Lethal means reduction: what have we learned?

Veteran Suicide: Missed Opportunities for Suicide Prevention Within Concealed Pistol License Curriculum

Introduction

Veteran suicide is a growing topic for public health concern. Despite enhancements from the Department of Veterans Health Administration, clinicians continue to struggle to identify and engage veterans at risk for suicide.

Materials and Methods

Examining suicide prevention efforts, epidemiology, risk factors, and barriers to care; Substance Abuse and Mental Health Services Administration and the U.S. Department of Veterans Affairs Governor’s Challenges identified lethal means as one of 3 priority areas to focus on in during this agenda.

Results

The writers identified gaps within the current literature as an area for future research on lethal means within the veteran population and opportunity for intervention with concealed pistol license curriculum.

Conclusion

This article ends with recommendations for further research on veteran suicides, acquisition of concealed pistol licenses, and advocacy for legislative change to require suicide prevention resources and education to be included in the training curriculum for concealed pistol license holders.

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

Although global rates of suicide have dropped in the last 30 years, youth in low- and middle-income countries (LMICs) continue to be highly represented in suicide statistics yet underrepresented in research. In this review we present the epidemiology of suicide, suicidal ideation, and suicide attempts among youth in LMICs. We also describe population-level (attitudes toward suicide, socioeconomic, and societal factors) and individual-level clinical and psychosocial risk factors, highlighting specific considerations pertaining to youth in LMICs. These specific considerations in risk factors within this population can inform how multi-level prevention strategies may be targeted to meet their specific needs. Prevention and intervention strategies relying on the stepped-care framework focusing on population-, community-, and individual level targets while considering locally- and culturally relevant practices are key in LMICs. In addition, systemic approaches favoring school-based and family-based interventions are important among youth. Cross-culturally adapted multimodal prevention strategies targeting the heterogeneity that exists in healthcare systems, suicide rates, and risk factors in these countries should be accorded a high priority to reduce the burden of suicide among youth in LMICs.

[Suicides Among Adolescents in a Major German City]

Suicides Among Adolescents in a Major German City Abstract. Objective: Adolescent suicide is a major contributor to the overall mortality in this age group. This study examined sex and age differences in suicide methods. Method: The investigation is based on death certificates from the years 1996 to 2019 of the city of Leipzig and includes all suicides in the age group under 25 years. The impact of sex and age on the method and location of suicide was examined using chi square statistics. Moreover, we verified the association between suicides and death by drug overdose through statistical regression. Results: 140 suicides were included in the study. The suicide methods differed between the age groups (χ^² = 17,878; p = .022). Individuals under 21 years of age committed suicide almost exclusively by strangulation, jumping from heights, railway suicide, or deliberate intoxication. With the onset of early adulthood, the spectrum of methods expanded. Suicide methods were also different between the sexes (χ^² = 35,166; p < .001): Male adolescents preferred highly lethal methods such as strangulation, whereas in female adolescents intoxication was the leading method of suicide, with a predominance of antidepressants. The annual rates of suicide and death by drug overdose were found to correlate (Pearson correlation = 0,571, p = .004). Minors (χ² = 3.125, p = .077) tended to avoid their own residential environment as a place of suicides compared to adults. Conclusion: When assessing the individual suicide risk and weighing safeguarding measures in clinical practice, the differences shown in the choice of methods should be taken into account.

Rural Communities and Violence

Among US geographic regions classified as rural, death rates are significantly higher for children and teens as compared with their urban peers; the disparity is even greater for Alaskan Native/American Indian and non-Hispanic black youth. Violence-related injuries and death contribute significantly to this finding. This article describes the epidemiology of violence-related injuries, with a limited discussion on child abuse and neglect and an in-depth analysis of self-inflicted injuries including unintentional firearm injuries and adolescent suicide. Potential interventions are also addressed, including strategies for injury prevention, such as firearm safe storage practices.

A Systematic Review of Factors Impacting Suicide Risk Among Rural Adults in the United States

PURPOSE

Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk.

METHODS

OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment.

FINDINGS

Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use.

CONCLUSIONS

Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

Predictors of Traumatic Suicide Attempts in Youth Presenting to Hospitals with Level I Trauma Centers

BACKGROUND

Limited research exists examining the predictors of suicide attempts by mechanism.

OBJECTIVE

The purpose of this study was to examine predictors of traumatic suicide attempts in youth.

METHODS

Data came from patients 5-18 years of age presenting because of a suicide attempt at 2 hospitals in Central Texas with level I trauma centers. Univariate logistic regression examined the association between traumatic suicide attempts and variables describing the patient's demographic, mental health, and social information. We used the Mann-Whitney U test to examine the association between traumatic suicide attempts and the continuous variable of age.

RESULTS

Of 231 patients included in this study, most were female (75.8%), non-Hispanic white (48.1%), and had a median age of 15.0 years (interquartile range 14-16). Compared with patients presenting because of an intentional overdose, patients presenting because of traumatic suicide attempts were associated with a reported criminal history (odds ratio [OR] 14.50 [95% confidence interval {CI} 3.84-54.82]), reported Child Protective Services history (OR 3.26 [95% CI 0.99-10.77]), being publicly insured or uninsured (OR 1.80 [95% CI 1.02-3.19]), male (OR 2.37 [95% CI 1.28-4.38]), and identifying as Hispanic (OR 2.01 [95% CI 1.10-3.68).

CONCLUSIONS

Our findings inform targeted preventative resources and education efforts to populations of greatest need.

Deaths of Despair: Conceptual and Clinical Implications

Since the late 1990s, mortality rates for middle-aged (45-55), White non-Hispanic (WNH) Americans began to rise while rates declined for all other demographic and age groups. Coinciding with the rise in mortality, rates of death due to suicide, drug- and alcohol-related overdoses, and alcohol-related liver diseases increased as well for this demographic. Research suggests these causes of death (i.e., suicide, poisoning, alcohol-related liver disease) are driving the overall mortality rate for middle-aged WNHs and have been described as "deaths of despair" in the literature. In the current paper, we describe the social and clinical features of "deaths of despair," explore theoretical models of psychopathology (e.g., depression, posttraumatic stress disorder) that may inform our understanding of mechanisms of risk for negative mental health outcomes, and propose an initial conceptual model of "deaths of despair" to identify intervention targets. We then review an applied case example demonstrating how this model could be used for clinical application. We conclude our paper by describing how current cognitive-behavioral interventions may address these mechanisms of "despair."

Alcohol misuse, firearm violence perpetration, and public policy in the United States

OBJECTIVE

Firearm violence is a significant public health problem in the United States, and alcohol is frequently involved. This article reviews existing research on the relationships between alcohol misuse; ownership, access to, and use of firearms; and the commission of firearm violence, and discusses the policy implications of these findings.

METHOD

Narrative review augmented by new tabulations of publicly-available data.

RESULTS

Acute and chronic alcohol misuse is positively associated with firearm ownership, risk behaviors involving firearms, and risk for perpetrating both interpersonal and self-directed firearm violence. In an average month, an estimated 8.9 to 11.7 million firearm owners binge drink. For men, deaths from alcohol-related firearm violence equal those from alcohol-related motor vehicle crashes. Enforceable policies restricting access to firearms for persons who misuse alcohol are uncommon. Policies that restrict access on the basis of other risk factors have been shown to reduce risk for subsequent violence.

CONCLUSION

The evidence suggests that restricting access to firearms for persons with a documented history of alcohol misuse would be an effective violence prevention measure. Restrictions should rely on unambiguous definitions of alcohol misuse to facilitate enforcement and should be rigorously evaluated.

Suicide risk in skin disorders

Suicide accounts for about 1,000,000 deaths worldwide every year and is among the leading causes of death in young adults. Reports of high prevalence of suicidal ideation and increased suicide risk in several skin diseases raised concerns about deliberate self-harm in dermatological patients. The literature consistently points to an increased suicide risk in patients with psoriasis, atopic dermatitis, and acne, with higher risk in patients in whom the skin condition is associated with clinically significant emotional distress, changes in body image, difficulties in close relationships, and impaired daily activities. Other risk factors for suicide include a history of suicide attempts, severe mental or physical disorders, alcoholism, unemployment, bereavement or divorce, and access to firearms or other lethal means. Dermatologists may play an important role in recognizing suicidal ideation and preventing fatal self-harm in their patients. Increasing dermatologists' awareness of the issue of suicide and developing mental health consultation-liaison services within dermatology settings would be instrumental in contributing to suicide prevention in this population.

Controlling access to suicide means

Background: Restricting access to common means of suicide, such as firearms, toxic gas, pesticides and other, has been shown to be effective in reducing rates of death in suicide. In the present review we aimed to summarize the empirical and clinical literature on controlling the access to means of suicide. Methods: This review made use of both MEDLINE, ISI Web of Science and the Cochrane library databases, identifying all English articles with the keywords “suicide means”, “suicide method”, “suicide prediction” or “suicide prevention” and other relevant keywords. Results: A number of factors may influence an individual’s decision regarding method in a suicide act, but there is substantial support that easy access influences the choice of method. In many countries, restrictions of access to common means of suicide has lead to lower overall suicide rates, particularly regarding suicide by firearms in USA, detoxification of domestic and motor vehicle gas in England and other countries, toxic pesticides in rural areas, barriers at jumping sites and hanging, by introducing “safe rooms” in prisons and hospitals. Moreover, decline in prescription of barbiturates and tricyclic antidepressants (TCAs), as well as limitation of drugs pack size for paracetamol and salicylate has reduced suicides by overdose, while increased prescription of SSRIs seems to have lowered suicidal rates. Conclusions: Restriction to means of suicide may be particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods. However, since there is some risk of means substitution, restriction of access should be implemented in conjunction with other suicide prevention strategies.

Suicide prevention in military organizations

Suicide is an important public health problem in the demographic group that forms the bulk of military populations, namely young and middle-aged men. Suicide in the military also has special significance: certain aspects of military service can lead to serious mental disorders that increase the risk of suicidal behaviour. Moreover, military organizations have control over a broad range of factors (notably the direct delivery of mental health care) that could mitigate suicide risk. This article will review the literature on suicide risk in military organizations to answer the important question: Are military personnel at increased risk for suicide? Next, Mann et al.'s (2005) model for specific suicide preventive interventions in civilian settings will be reviewed and then expanded, with an emphasis on identifying special opportunities for suicide prevention in military organizations, including: 1) organizational interventions to mitigate work stress; 2) selection, resilience training, and risk factor reduction; 3) interventions to overcome barriers to care; and 4) systematic quality improvement efforts in mental health care. Finally, the evidence behind comprehensive suicide prevention programmes will be reviewed, with a special focus on the US Air Force's benchmark programme.

Training mental healthcare providers to reduce at-risk patients' access to lethal means of suicide: evaluation of the CALM Project

The objective of this study was to evaluate the "CALM" (Counseling on Access to Lethal Means) training, in which community-based mental health care providers were trained to work with at-risk clients and their families to assess and reduce access to lethal means of suicide, including firearms. In 2006, CALM trainers conducted workshops in 7 community-based mental health care centers in New Hampshire towns. Participants completed a post-test immediately after the workshop and a follow-up questionnaire approximately 6 weeks later. At follow-up, 65% reported that they had counseled clients' parents about access to lethal means (n = 111). Findings also indicate that the workshop influenced participants' attitudes, beliefs, and skills regarding conducting lethal means counseling.