Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

Temporal prediction of suicidal ideation in an ecological momentary assessment study with recurrent neural networks

INTRODUCTION

Ecological Momentary Assessment (EMA) holds promise for providing insights into daily life experiences when studying mental health phenomena. However, commonly used mixed-effects linear statistical models do not fully utilize the richness of the ultidimensional time-varying data that EMA yields. Recurrent Neural Networks (RNNs) provide an alternative data analytic method to leverage more information and potentially improve prediction, particularly for non-normally distributed outcomes.

METHODS

As part of a broader research study of suicidal thoughts and behavior in people with borderline personality disorder (BPD), eighty-four participants engaged in EMA data collection over one week, answering questions multiple times each day about suicidal ideation (SI), stressful events, coping strategy use, and affect. RNNs and mixed-effects linear regression models (MEMs) were trained and used to predict SI. Root mean squared error (RMSE), mean absolute percent error (MAPE), and a pseudo-R2 accuracy metric were used to compare SI prediction accuracy between the two modeling methods.

RESULTS

RNNs had superior accuracy metrics (full model: RMSE = 3.41, MAPE = 42 %, pseudo-R2 = 26 %) compared with MEMs (full model: RMSE = 3.84, MAPE = 56 %, pseudo-R2 = 16 %). Importantly, RNNs showed significantly more accurate prediction at higher values of SI. Additionally, RNNs predicted, with significantly higher accuracy, the SI scores of participants with depression diagnoses and of participants with higher depression scores at baseline.

CONCLUSION

In this EMA study with a moderately sized sample, RNNs were better able to learn and predict daily SI compared with mixed-effects models. RNNs should be considered as an option for EMA analysis.

National trends and correlates of treatment resistance in major depressive episode and associated suicidal ideation and behaviors among adults in the United States

OBJECTIVE

To examine recent 12-year trends in prevalence of suicidal ideation and behaviors (SIBs) among US adults experiencing a past-year treatment-resistant depression (TRD).

METHODS

Using data from the National Survey of Drug Use and Health, we estimated the annual percentage of individuals aged ≥18 with TRD who reported past-year SIBs, and estimated linear trends adjusting for potentially confounding factors from 2009 to 2020.

RESULTS

Of estimated 237.5 million US adults, 7.1 % met diagnostic criteria for a past-year major depressive episode (MDE) between 2009 and 2020. Of these, 9.7 % met criteria for TRD. The proportion reporting past-year suicidal ideation in TRD ranged from 39.5 % (95 % confidence interval [CI], 32.1-47.3 %) in 2009-2010 to 43.4 % (95 % CI, 36.7-503 %) in 2019-2020, with an average annual percent change (AAPC) of 1.3 % (95 % CI, -0.7 % to 3.3 %). The prevalence of past-year suicide attempts in TRD was 7.3 % across the study period (AAPC, 0.1 %; 95 % CI, -4.3 % to 4.7 %). Past-year SIBs were significantly associated with an increased likelihood of meeting criteria for TRD among adults with MDE (adjusted odds ratio [AOR], 1.53; 95 % CI, 1.35-1.75 for suicidal ideation; AOR, 2.17; 95 % CI, 1.79-2.62 for suicide attempts). No significant differences were observed between 2019 and 2020, reflecting the COVID-19 pandemic.

CONCLUSION

Among individuals with TRD, proportions of SIBs are high. These findings underscore an urgent need for suicide prevention efforts in this high-risk population, including preventive services across diverse settings and accessibility to evidence-based pharmacological and non-pharmacological interventions.

The impact of PTSD symptoms on suicide ideation in time of terror and war: A nationwide prospective study on the moderating role of loneliness

The terrorist attack of October 7, 2023, and its accompanying war have increased the risk for posttraumatic stress symptoms (PTSS) and suicide ideation (SI). In this national prospective cohort study, we examined the extent to which a sense of loneliness moderates the association between PTSS and SI in the wake of the October 7th attack and the Israel-Hamas war. A representative sample of 710 Israeli adults (362 female, 51.1 %) aged 18-85 (M = 41.01, SD = 13.72) participated in a longitudinal study assessing depression, current SI, and loneliness at two time points: T1, one month before the attack (August 2023) and T2 (November 2023), one month after the attack. We found two significant interactions in which a sense of loneliness at T2 moderated the link between both PTSS at T1 and T2 and current SI at T2. Specifically, the level of PTSS contributed to current SI at T2 more strongly among individuals reporting higher loneliness levels than those reporting low loneliness levels. Clinicians treating individuals coping with high PTSS levels should attend to their patients' sense of loneliness, as it comprises a significant risk factor for current SI and may be considered an important target in treatment.

Lifetime use of multiple substances and youth suicide risk: assessing the role of depressive symptoms using structural equation modeling

OBJECTIVES

This study assessed the direct and indirect effects (via depressive symptoms) of lifetime use of a broad range of substances on suicide risk among US adolescents.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data from the 2021 Youth Risk Behavior Survey were used (N = 12,303, 48.7% female). Associations between five types of substance use (cigarette, e-cigarette, alcohol, marijuana, and prescription pain medicine) and three dimensions of suicide risk (suicidal ideation, suicide plan, and suicide attempt) were measured by multivariate logistic regression models. The role of depressive symptoms was further examined by structural equation modeling.

RESULTS

Almost three in five (57.5%) adolescents had used one or more substances in their lifetime (18.1% one type, 12.2% two types, 13.1% three types, 10.2% four types, and 3.8% five types). Adolescents using five substances were up to 16 times more likely to experience suicidal ideation and behaviors. Depressive symptoms significantly linked the pathway from substance use to suicide risk, resulting in much stronger indirect effects than the direct effects. Collectively, the five substance use behaviors and depressive symptoms explained about 60.4% of variance in suicidal ideation, 53.6% of variance in suicide plan, and 55.0% of variance in suicide attempt.

CONCLUSIONS

Lifetime use of multiple substances is significantly correlated with suicidal ideation and behaviors among adolescents via the pathway of depressive symptoms. Routine screening for a broad range of substance use behaviors is needed to identify adolescents at risk for suicide and accessible mental health services could potentially attenuate the linkage between substance use and suicide risk.

Unintentional Intoxication or Injury and Risk for Self-Harm in Adolescents and Young Adults

This cohort study explores the risk of nonfatal self-harm in French adolescents and young adults hospitalized for unintentional intoxication or injury.

Disparities Among Pediatric Firearm Suicides in the United States: An Analysis of the National Violent Death Reporting System, 2014 to 2018

Suicide is a leading cause of death in the United States (U.S.), with firearms being the predominant method. This study examines the racial disparity and disproportionality of pediatric firearm suicide from 2014 to 2018 in 17 U.S. states. We used the National Violent Death Reporting System to quantify the burden of pediatric firearm suicide by race/ethnicity and gender and assessed themes among decedents aged 10 to 17 years. Racial disparity and disproportionality were measured using the Disparity Index and Disproportionality Representation Index, respectively. Decedents were primarily non-Hispanic White (NHW, 77.5%) and male (84.0%). NHW children died at a rate that was 1.3 times greater than expected based on their proportion in the general population and were 2.6 times more likely to die by firearm suicide than non-Hispanic Black (NHB) children. NHB children were less likely to disclose suicide intention, suggesting that this group may require more active screening intervention. Qualitative analysis revealed unsafe firearm storage as a common theme among these deaths. Differences in age with respect to social media use and precipitating factors such as bullying and arguments with parents were also identified as contributing factors. Results of this study support the expansion of interventions such as lethal means restriction counseling and implementation of safer firearm storage laws.

Validation of a Multivariable Model to Predict Suicide Attempt in a Mental Health Intake Sample

Importance

Given that suicide rates have been increasing over the past decade and the demand for mental health care is at an all-time high, targeted prevention efforts are needed to identify individuals seeking to initiate mental health outpatient services who are at high risk for suicide. Suicide prediction models have been developed using outpatient mental health encounters, but their performance among intake appointments has not been directly examined.

Objective

To assess the performance of a predictive model of suicide attempts among individuals seeking to initiate an episode of outpatient mental health care.

Design, Setting, and Participants

This prognostic study tested the performance of a previously developed machine learning model designed to predict suicide attempts within 90 days of any mental health outpatient visit. All mental health intake appointments scheduled between January 1, 2012, and April 1, 2022, at Kaiser Permanente Northern California, a large integrated health care delivery system serving over 4.5 million patients, were included. Data were extracted and analyzed from August 9, 2022, to July 31, 2023.

Main Outcome and Measures

Suicide attempts (including completed suicides) within 90 days of the appointment, determined by diagnostic codes and government databases. All predictors were extracted from electronic health records.

Results

The study included 1 623 232 scheduled appointments from 835 616 unique patients. There were 2800 scheduled appointments (0.17%) followed by a suicide attempt within 90 days. The mean (SD) age across appointments was 39.7 (15.8) years, and most appointments were for women (1 103 184 [68.0%]). The model had an area under the receiver operating characteristic curve of 0.77 (95% CI, 0.76-0.78), an area under the precision-recall curve of 0.02 (95% CI, 0.02-0.02), an expected calibration error of 0.0012 (95% CI, 0.0011-0.0013), and sensitivities of 37.2% (95% CI, 35.5%-38.9%) and 18.8% (95% CI, 17.3%-20.2%) at specificities of 95% and 99%, respectively. The 10% of appointments at the highest risk level accounted for 48.8% (95% CI, 47.0%-50.6%) of the appointments followed by a suicide attempt.

Conclusions and Relevance

In this prognostic study involving mental health intakes, a previously developed machine learning model of suicide attempts showed good overall classification performance. Implementation research is needed to determine appropriate thresholds and interventions for applying the model in an intake setting to target high-risk cases in a manner that is acceptable to patients and clinicians.

The moderating role of belongingness in the contribution of depression to suicide ideation following the October 7, 2023, terrorist attack in Israel: A nationwide prospective study

INTRODUCTION

With >1300 civilians murdered, the terrorist attack of October 7 is one of the deadliest terrorist attacks in modern history. Previous research documented a sharp increase in depression in the aftermath of the attacks and the military conflict that followed. In this national prospective cohort study, we examined to what extent perceived belongingness (PB) moderates the association between depression and suicide ideation (SI) in the wake of the October 7th terrorist attack.

METHODS

A representative sample of 710 Israeli adults (of them, 362 females, 51.1 %), Jews (557, 79.9 %), and Arabs (153, 20.1 %), aged 18-85 (M = 41.01, SD = 13.72) completed questionnaires assessing depression, current SI, and perceived belongingness at two timepoints: T1 (in August 2023) and T2 (in November 2023).

RESULTS

Perceived belongingness at T1 predicted SI at T2 beyond demographic and trauma-related characteristics. Importantly, we found a significant interaction in which a PB at T1 moderated the link between depression and current SI at T2. Specifically, the level of depression at T2 contributed to current SI-T2 more strongly for individuals with low PB levels than for individuals with high PB levels.

DISCUSSION

Our study highlights the impact of PB on SI following the October 7th terrorist attack. Clinicians treating individuals coping with depression should attend to their patients' sense of belongingness, as low PB comprises a significant risk factor for current SI. Moreover, community and national initiatives that could increase levels of PB among the citizens may help to diminish suicide risk in the aftermath of the attack.

Clinician Perspectives on Suicide Safety Planning and Its Implementation

OBJECTIVE

The safety planning intervention is an evidence-based practice shown to reduce suicide risk, but implementation of high-quality safety planning has proven challenging. We aimed to understand clinician perspectives on the safety planning intervention to inform future implementation efforts.

METHOD

This cross-sectional survey of clinicians who care for patients at risk of suicide in an academic medical center asked about comfort levels and fidelity to components of the safety planning intervention and assessed implementation barriers and facilitators. We used exploratory data analysis and regression analysis to explore clinician perspectives and assess the relationship between formal training and implementation.

RESULTS

Ninety-two clinicians responded to the survey. Two-thirds of participants (64.9%) endorsed using all six core elements of the safety planning intervention. Participants who reported receiving formal training in safety planning were significantly more likely to report being comfortable completing a safety plan (p < .001); those with higher levels of comfort were significantly more likely to endorse using all of the core elements of the safety planning intervention (p < .001).

CONCLUSIONS

Training in the evidence-based safety planning intervention is associated with clinician comfort and awareness of the core elements of the intervention. Our results suggest that there are gaps in clinician training and that formal safety planning intervention training could have a positive effect on clinician comfort and treatment fidelity.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation

OBJECTIVE

The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings.

METHODS

Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated.

RESULTS

In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care.

CONCLUSIONS

Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Why do adolescents attempt suicide? Insights from leading ideation-to-action suicide theories: a systematic review

Suicide is a leading cause of death among adolescents, and recent suicide theories have sought to clarify the factors that facilitate the transition from suicide ideation to action. Specifically, the Interpersonal Theory of Suicide (IPTS), Integrated Motivational-Volitional Model (IMV), and Three Step Theory (3ST) have highlighted risk factors central to the formation of suicidal ideation and suicidal behaviors, which is necessary for suicide death. However, these models were initially developed and tested among adults, and given core socioemotional and neurodevelopmental differences in adolescents, the applicability of these models remains unclear. Directly addressing this gap in knowledge, this systematic review aimed to (1) describe the evidence of leading ideation-to-action theories (i.e., IPTS, IMV, 3ST) as they relate to suicide risk among adolescents, (2) integrate ideation-to-action theories within prevailing biological frameworks of adolescent suicide, and (3) provide recommendations for future adolescent suicide research. Overall, few studies provided a complete test of models in adolescent samples, and empirical research testing components of these theories provided mixed support. Future research would benefit from integrating neurodevelopmental and developmentally sensitive psychosocial frameworks to increase the applicability of ideation-to-action theories to adolescents. Further, utilizing real-time monitoring approaches may serve to further clarify the temporal association among risk factors and suicide.

The Components and Characteristics of Safety Management Plans Used to Reduce the Risk of Self Harm: A PRISMA Scoping Review

BACKGROUND

The term "safety management planning" can be thought of as having evolved to constitute a number of different intervention types and components used across various clinical settings with various populations. This poses a challenge for effective communication between clinicians and likely variability in the clinical effectiveness of these interventions.

AIM

This PRISMA Scoping Review aims to review the literature to ascertain which intervention components and characteristics currently fall under this umbrella term as well as in which contexts the plans are delivered and who is involved in the process.

METHOD

Published research studies in PsycINFO, CINAHL Plus, MEDLINE, Science Direct and Web of Science were reviewed. Grey literature was searched using the databases Base and OpenGrey as well as through the search engine Google.

RESULTS

2853 abstracts were initially identified for screening and 74 pieces of literature informed the final review, with 54 derived from the published academic literature and 20 from the grey literature. Results indicated that the safety plans are used with a wide variety of populations and often include components related to identifying warning signs, internal coping strategies, accessing social professional support amongst other components.

CONCLUSION

Although most safety management plans described appeared to be based on specific interventions, there was a large amount of heterogeneity of components and characteristics observed. This was particularly the case with regards to safety management planning within the grey literature.

The association between ketamine and esketamine and suicidality: reports to the Food And Drug Administration Adverse Event Reporting System (FAERS)

INTRODUCTION

Replicated evidence indicates that ketamine and esketamine reduce measures of suicidality in persons with treatment-resistant depression (TRD). It remains uncertain whether individuals experience worsening of preexisting suicidality with either agent.

RESEARCH DESIGN AND METHODS

The Food and Drug Administration Adverse Event Reporting System (FAERS) database was searched from 1970 and 2019 to 30 September 2023 for reports of suicidal ideation, depression suicidal, suicidal behavior, suicidal attempt, and completed suicide in association with ketamine and esketamine exposure, respectively. We present reporting odds ratios (ROR) significance was determined when the lower limit of the 95% confidence interval (CI) exceeded 1.0. Lithium was used as the control agent.

RESULTS

Observed a higher ROR for suicidal ideation (ROR 7.58, 95% CI 6.34-9.07) and depression suicidal (ROR 14.19, 95% CI 1.80-112.07) with esketamine. Significantly lower RORs were observed for suicide attempt with ketamine (ROR 0.15, 95% CI 0.11-0.21) and esketamine (ROR 0.57, 95% CI 0.48-0.67).

CONCLUSIONS

Mixed RORs across aspects of suicidality were observed with ketamine and esketamine. Limitations of the FAERS database prevent any determination of causal effects new onset suicidality to either agent. The lower RORs for suicide attempt with ketamine and esketamine is noted but cannot be interpreted as a direct therapeutic effect.

Evaluating the Prevalence of Four Recommended Practices for Suicide Prevention Following Hospital Discharge

BACKGROUND

The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown.

METHODS

This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission-accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention.

RESULTS

Of 1,148 hospitals, 346 (30.1%) responded. The majority (n = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (n = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (n = 128 [37.0%)] or made follow-up contact with patients (n = 105 [30.3%]), and approximately a quarter (n = 97 [28.0%]) developed a plan for lethal means safety. Very few (n = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge.

CONCLUSION

The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap.

Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis

Importance

Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies.

Objective

To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts.

Design, Setting, and Participants

This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023.

Exposures

Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods.

Main Outcomes and Measures

Disclosure of recent intent, suicide note presence, and known psychotropic usage.

Results

Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged ≥71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%]).

Conclusions and Relevance

This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Mental Health in Elite Athletes: A Systematic Review of Suicidal Behaviour as Compared to the General Population

BACKGROUND AND OBJECTIVE

Previous systematic reviews on mental health in athletes have found athletes to be at a potentially increased risk for mental health diagnoses compared to the public. Multiple cross-sectional studies have examined suicide behaviour within different athlete populations, but there is a need for a comprehensive review to synthesize and identify risk factors and epidemiology regarding suicide behaviour in the elite athlete population, especially as it compares to the general population.

METHODS

A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science from 1990 to January 2023. Inclusion criteria included original peer-reviewed research articles examining suicidal ideation, suicide attempt, or suicide completion within elite athlete populations. Exclusion criteria included athletes participating in high-school or Paralympic level sports, studies that did not report results regarding elite athletes and non-athletes separately, and non-peer reviewed work. All studies were screened for inclusion by two independent reviewers. The primary outcome variables extracted from included studies included rates, risk factors, and protective factors for suicide behaviour. The study quality and risk of bias was evaluated for each study using the Joanna-Briggs Institute (JBI) critical appraisal tools.

RESULTS

Of the 875 unique studies identified, 22 studies, all of which were cross-sectional in nature, met the inclusion criteria. Seven studies evaluated previous athletes, 13 studies evaluated current athletes, and two studies included a combination of previous and current athletes. Seven studies involved varsity college athletes, nine involved professional athletes of various sports, and six focused on international or Olympic level athletes. The rate of suicidal ideation in professional athletes ranged from 6.9 to 18% across four studies, while the rate in collegiate athletes ranged from 3.7 to 6.5% across three studies. Ten studies compared athletes to the general population, the majority of which found athletes to be at reduced risk of suicidal ideation, suicide attempt, and suicide completion. Only one study found athletes to have increased rates of suicide compared to matched non-athletes. Risk factors for suicide behaviour identified across multiple studies included male sex, non-white race, older age, and depression. Player position, athletic level, sport played, and injuries showed trends of having limited effect on suicide behaviour risk.

CONCLUSION

This review suggests that elite athletes generally demonstrate reduced risk of suicidal ideation, suicide attempt, and suicide completion compared to the general population. Coaches should remain aware of specific factors, such as male sex, non-white race, and higher athletic level, in order to better identify at-risk athletes. Limitations of this review include the heterogeneity in the methodology and athlete populations across the included studies. Therefore, future targeted research is essential to compare suicide behaviour between sports and identify sport-specific suicide risk factors.

TRIAL REGISTRATION

PROSPERO Registration: CRD42023395990.

[Insomniac symptoms and suicidality-link and management]

BACKGROUND

A link between insomniac symptoms and suicidality has long been suspected and deserves specific attention.

OBJECTIVE

We examine the current evidence for this relationship from epidemiology and neurobiology in order to propose a targeted management.

MATERIAL AND METHOD

Clinical example and selective Medline-literature research for insomnia symptoms and suicidality.

RESULTS

Epidemiological data and statistical analysis show that symptoms of insomnia are independent risk factors for suicidality. Neurobiological factors associated with combined insomnia symptoms and suicidality are: serotonergic dysfunction and circadian rhythm disorder leading to hypofrontality with reduced problem solving capacity and impaired emotional and impulse-control. Social isolation, recurrent rumination, comorbid psychiatric disorders, access to potentially lethal drugs or weapons need urgent evaluation in patients with a combination of suicidality and symptoms of insomnia.

CONCLUSION

patients with insomnia and further risk factors for suicide need to be treated resolutely and at an early stage. Modern sleep-promoting antidepressants with low toxicity and antipsychotics must be preferred in the treatment of patients with insomniac sleep disorders and suicidality. Multimodal anti-insomnia and anti-depressive therapy adapted to the circadian rhythm can exert a favorable influence both on depressive-suicidal and insomnia symptoms and their inherent risks.

The Experience of Survivors of Firearm Suicide Attempts: A Retrospective Case Series

Objective

We sought to identify people who survived firearm suicide attempts to describe the acute stressors, substance use, and mental health conditions related to the attempt.

Background

Most firearm deaths in the United States are the result of suicide. Because firearm suicide attempts have a case fatality rate of approximately 90%, little is known about the precipitating factors that lead to firearm suicide attempts.

Methods

We conducted a retrospective case series of patients admitted to a large hospital system between 2000 and 2019 who survived intentional, self-inflicted gunshot wounds to the head. Through the electronic medical record, we collected information about acute stressors, substance use, and mental health diagnoses before or at the time of the suicide attempt.

Results

Thirty-four patients were included in the study cohort. Patients were predominantly White (74%) and male (88%), with a mean age of 44 (range, 14-82). Nineteen (56%) patients were acutely intoxicated with alcohol upon hospitalization and 17 (50%) patients had a positive urine drug screen. Acute stressors involving interpersonal relationships (53%), work/school (32%), and legal disputes (18%), among others, were documented in 82% of patients. Most patients (65%) had been diagnosed with depression before their index hospitalization. Most patients were discharged to an acute rehabilitation center (41%) or an inpatient psychiatric facility (41%).

Conclusions

Acute stress and alcohol intoxication were common in this cohort of patients who attempted suicide using firearms. These data offer an ability to learn from the experience of survivors of firearm suicide attempts, a rare population.

Lifetime Suicide Attempts in Otherwise Psychiatrically Healthy Individuals

Importance

Not all people who die by suicide have a psychiatric diagnosis; yet, little is known about the percentage and demographics of individuals with lifetime suicide attempts who are apparently psychiatrically healthy. If such suicide attempts are common, there are implications for suicide risk screening, research, policy, and nosology.

Objective

To estimate the percentage of people with lifetime suicide attempts whose first attempt occurred prior to onset of any psychiatric disorder.

Design, Setting, and Participants

This cross-sectional study used data from the US National Epidemiologic Study of Addictions and Related Conditions III (NESARC-III), a cross-sectional face-to-face survey conducted with a nationally representative sample of the US civilian noninstitutionalized population, and included persons with lifetime suicide attempts who were aged 20 to 65 years at survey administration (April 2012 to June 2013). Data from the NESARC, Wave 2 survey from August 2004 to September 2005 were used for replication. Analyses were performed from April to August 2023.

Exposure

Lifetime suicide attempts.

Main Outcomes and Measures

The main outcome was presence or absence of a psychiatric disorder before the first lifetime suicide attempt. Among persons with lifetime suicide attempts, the percentage and 95% CI of those whose first suicide attempt occurred before the onset of any apparent psychiatric disorders was calculated, weighted by NESARC sampling and nonresponse weights. Separate analyses were performed for males, females, and 3 age groups (20 to <35, 35-50, and >50 to 65 years).

Results

In the total sample of 36 309 respondents, 1948 persons had lifetime suicide attempts; 66.8% (95% CI, 64.1%-69.4%) were female, and 6.2% (95% CI, 4.9%-7.4%) had no apparent lifetime psychiatric diagnoses when surveyed. In addition, 13.4% (95% CI, 11.6%-15.2%) made their first suicide attempt prior to psychiatric disorder onset. Thus, an estimated 19.6% of respondents first attempted suicide without an antecedent psychiatric disorder. No significant age or sex differences were detected in the percentage of those with lifetime suicide attempts absent psychiatric disorders, although females were more likely than males to attempt suicide in the year of psychiatric disorder onset (14.9% [95% CI, 12.5%-17.3%] vs 8.6% [95% CI, 6.0%-11.2%]; P < .001), and attempts were less frequent among those older than 50 to 65 years (3.9% [95% CI, 3.5%-4.4%] vs 6.1% [95% CI, 5.4%-6.8%] for 35-50 years and 6.2% [95% CI, 5.6%-6.9%] for 20 to <35 years; P < .001).

Conclusions and Relevance

In this study, an estimated 19.6% of individuals who attempted suicide did so despite not meeting criteria for an antecedent psychiatric disorder. This finding challenges clinical notions of who is at risk for suicidal behavior and raises questions about the safety of limiting suicide risk screening to psychiatric populations.

Suicide Prevention Programming: Comparing Four Prominent Frameworks

OBJECTIVE

Suicide is a significant public health concern. About 48,000 individuals died by suicide in 2021 in the United States, and approximately one in 100 deaths globally are due to suicide. Continuing efforts in program development and evaluation are vital to preventing suicide. Multiple frameworks have been developed to reduce suicide rates, but they have not been compared to assess their comprehensiveness, nor have their components been classified.

METHODS

In 2019, the authors conducted a narrative review of the literature and identified four major frameworks for suicide prevention: the U.S. Department of Veterans Affairs (VA) Suicide Prevention Program, the Defense Suicide Prevention Program of the U.S. Department of Defense, Zero Suicide in Health and Behavioral Health Care, and the technical package developed by the Centers for Disease Control and Prevention. Program components for these frameworks were identified and classified by using two prevention strategy classification systems: the National Academy of Medicine's (NAM's) continuum-of-care model and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) prevention model.

RESULTS

The cross-program comparison revealed that no single program included all components of suicide prevention programs. However, the VA program was the most comprehensive in terms of the number of components and their spread across prevention strategy classifications. The programs used few components categorized under NAM's promotion or selective prevention strategy classifications. The SAMHSA prevention strategy classifications of information dissemination, community-based processes, and positive alternatives were also used infrequently.

CONCLUSIONS

Organizations, health care systems, and policy makers may use these findings as they develop, improve, and implement suicide prevention programs.

Recognising and Responding to Suicide-Risk Factors in Primary Care: A Scoping Review

The cost of one suicide is estimated to be £1.67 million (2 million euros) to the UK economy. Most people who die by suicide have seen a primary care practitioner (PCP) in the year prior to death. PCPs could aim to intervene before suicidal behaviours arise by addressing suicide-risk factors noted in primary care consultations, thereby preventing suicide and promoting health and wellbeing. This study aimed to conduct a rapid, systematic scoping review to explore how PCPs can effectively recognise and respond to suicide-risk factors. MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: suicide prevention, mental health and primary care. Two reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analysing study characteristics and findings. Forty-two studies met the eligibility criteria and were cited in this scoping review. Studies were published between 1990 and 2020 and were of good methodological quality. Six themes regarding suicide risk assessment in primary care were identified: Primary care consultations prior to suicide; Reasons for non-disclosure of suicidal behaviour; Screening for suicide risk; Training for primary care staff; Use of language by primary care staff; and, Difference in referral pathways from general practitioners or primary care practitioners. This review focused on better recognition and response to specific suicide-risk factors more widely such as poor mental health, substance misuse and long-term physical health conditions. Primary care is well placed to address the range of suicide-risk factors including biological, physical-health, psychological and socio-economic factors and therefore these findings could inform the development of person-centred approaches to be used in primary care.

Advancing Global Health Through Primary Care Physician Education on Suicide Prevention

The rising global suicide rate presents a major public health concern, resulting in the loss of over 700,000 lives annually. Discrepancies in the impact of suicide among diverse populations underscore the necessity for targeted prevention strategies. Primary care providers (PCPs) play a crucial role in identifying and managing suicide risk, particularly in underserved areas with limited access to mental health care. Educating PCPs about evidence-based interventions and suicide prevention strategies has demonstrated effectiveness in reducing suicide rates. Landmark initiatives in Australia, Sweden, and Hungary have successfully lowered suicide rates by implementing educational programs for PCPs focused on suicide prevention. Denmark, previously afflicted by some of the highest rates globally in the 1980s, has significantly reduced its figures and now ranks among countries with the lowest rates in high-income nations. Collaborative programs involving PCPs and health workers in low-resource regions have also shown promising outcomes in suicide prevention efforts. Enhancing the expertise of PCPs in suicide prevention can fortify healthcare systems, prioritize mental health, and ultimately save lives, contributing to global health endeavors aimed at addressing the pervasive issue of suicide.

Analysis of health services use and clinical profiles in the year prior to suicide between 2010 and 2018: An opportunity to improve its prevention

INTRODUCTION

Suicide is the first cause of external death in Spain. International studies show frequent and varied health contacts in the months prior to suicide. There are hardly any studies on that phenomenon in this country.

OBJECTIVE

To analyze health care use in the year prior to suicide between 2010 and 2018 in the Basque Country, as well as pharmacological prescriptions and psychiatric diagnoses received.

METHODS

Retrospective descriptive study with all suicides registered by the Basque Institute of Legal Medicine (BILM) between 2010 and 2018. The records of the BILM and the Basque Health Service (Osakidetza) were cross-checked.

RESULTS

1526 suicides were analyzed. 74% had health contacts in the previous year. The use was higher in women (p<0.05) and in older ages (p<0001). Primary care was the most used specialty (58.8% the previous year and 7.1% the previous week), followed by Hospital Emergencies (50.3% and 10.2%) and Outpatient Medical Specialties (49% and 11.6%), especially Radiology. Outpatient psychiatry only contacted 29.6% that year, although it had the highest average number of visits (15.1 SD22.6). The most frequent diagnostic category among psychiatric patients was F30-39 (26.7%), with differences between sexes and ages. 49.7% received psychotropic drugs.

CONCLUSIONS

The results are aligned with international evidence, which they also extend, and reinforce the need to extend prevention beyond psychiatric services. It seems advisable to increase proactivity in the search for risk by sensitizing and training different professional profiles, but also to work from non-health settings to improve assistance to highly vulnerable profiles (young men) with low health links.

Machine Learning-Based Prediction of Suicidal Thinking in Adolescents by Derivation and Validation in 3 Independent Worldwide Cohorts: Algorithm Development and Validation Study

BACKGROUND

Suicide is the second-leading cause of death among adolescents and is associated with clusters of suicides. Despite numerous studies on this preventable cause of death, the focus has primarily been on single nations and traditional statistical methods.

OBJECTIVE

This study aims to develop a predictive model for adolescent suicidal thinking using multinational data sets and machine learning (ML).

METHODS

We used data from the Korea Youth Risk Behavior Web-based Survey with 566,875 adolescents aged between 13 and 18 years and conducted external validation using the Youth Risk Behavior Survey with 103,874 adolescents and Norway's University National General Survey with 19,574 adolescents. Several tree-based ML models were developed, and feature importance and Shapley additive explanations values were analyzed to identify risk factors for adolescent suicidal thinking.

RESULTS

When trained on the Korea Youth Risk Behavior Web-based Survey data from South Korea with a 95% CI, the XGBoost model reported an area under the receiver operating characteristic (AUROC) curve of 90.06% (95% CI 89.97-90.16), displaying superior performance compared to other models. For external validation using the Youth Risk Behavior Survey data from the United States and the University National General Survey from Norway, the XGBoost model achieved AUROCs of 83.09% and 81.27%, respectively. Across all data sets, XGBoost consistently outperformed the other models with the highest AUROC score, and was selected as the optimal model. In terms of predictors of suicidal thinking, feelings of sadness and despair were the most influential, accounting for 57.4% of the impact, followed by stress status at 19.8%. This was followed by age (5.7%), household income (4%), academic achievement (3.4%), sex (2.1%), and others, which contributed less than 2% each.

CONCLUSIONS

This study used ML by integrating diverse data sets from 3 countries to address adolescent suicide. The findings highlight the important role of emotional health indicators in predicting suicidal thinking among adolescents. Specifically, sadness and despair were identified as the most significant predictors, followed by stressful conditions and age. These findings emphasize the critical need for early diagnosis and prevention of mental health issues during adolescence.

The association between county-level mental health provider shortage areas and suicide rates in the United States during the COVID-19 pandemic

OBJECTIVE

Prior literature has shown that mental health provider Health Professional Shortage Areas (MHPSAs) experienced a greater increase in suicide rates compared to non-shortage areas from 2010 to 2018. Although suicide rates have been on the rise, rates have slightly decreased during the COVID-19 pandemic. This study sought to characterize the differences in suicide rate trends during the pandemic by MHPSA status.

METHOD

We used generalized estimating equation regression to test the associations between MHPSA status and suicide rates from 2018 to 2021. Suicide deaths were obtained from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.

RESULTS

MHPSA status was associated with higher suicide rates (adjusted IRR:1.088 [95% CI, 1.024-1.156]). Furthermore, there was a significant interaction between MHPSA status and year (adjusted IRR:1.056 [95% CI, 1.022-1.091]), such that suicide rates did not significantly change among MHPSAs but slightly decreased among non-MHPSAs from 2018 to 2021.

CONCLUSIONS

During the COVID-19 pandemic, there was a slight decrease in suicide rates among non-MHPSAs, while those with shortages experienced no significant changes in suicide rates. It will be important to closely monitor MHPSAs as continued at-risk regions for suicide as trendlines return to their pre-pandemic patterns.

Adherence to Masculinity Norms and Depression Symptoms Among Israeli Men: The Moderating Role of Psychological Flexibility

Being a man has been recognized as a salient risk factor for suicide. Adopting uncompromised masculine perceptions (i.e., conforming to the masculine gender role norms) may restrict emotional expressiveness in men, which, in turn, may contribute to depression and somatization symptoms. We examined the moderating role of psychological flexibility and alexithymia in the relationship of masculinity with depression and somatization symptoms. A sample of 119 men completed measures of masculinity, alexithymia (difficulty identifying and delivering subjective feelings), psychological flexibility, depression, and somatization symptoms in a cross-sectional design study. Psychological flexibility levels moderated the relationship between masculinity and depression symptoms: Masculinity contributed as positively associated with depression symptoms when psychological flexibility was low, but no such association was found at moderate or high levels of psychological flexibility. As a cognitive factor promoting adaptive emotional regulation, psychological flexibility might reduce depression symptoms among inflexible masculine men. Clinical implications relate to diagnosing at-risk subgroups and their treatment.

Exploring the Association Between Help-Seeking Intentions and Suicidal Ideation in Australian Adult Men

Background: Men account for three-quarters of suicide deaths in Australia. Self-reliant masculine norms may act as barriers to men's help-seeking and contribute to suicidal ideation. Men who seek help may be less likely to experience suicidal ideation. Aim: We evaluated the association between help-seeking intentions and suicidal ideation in Australian adult men using data from Wave 2 of the Australian Longitudinal Study on Male Health (Ten to Men). Method: Using scores on the General Help-Seeking Questionnaire, we explored the association between informal help-seeking intentions (e.g., friend, family), formal help-seeking intentions (e.g., psychologist), overall help-seeking intentions (all sources), and new-onset suicidal ideation. We conducted logistic regression analyses using a sample of 7,828 men aged 18-60 years. Results: Increased overall help-seeking intentions and informal help-seeking intentions were significantly associated with lower odds of new-onset suicidal ideation, whereas formal help-seeking intentions were not significantly associated. Limitations: The cross-sectional design limits inferences about causality. Conclusion: Men who have greater informal help-seeking intentions may be less likely to experience a new onset of suicidal ideation; however, more longitudinal research is needed.

A special type of homicide-suicide: A retrospective study of the characteristics of extended suicide

Extended suicide, a specific type of homicide-suicide event, has severe social consequences yet remains lacking systematic research. This retrospective study investigated 51 cases of extended suicide involving mental disorders in central China with aim of better understanding risk factors for such events and guiding prevention strategies. Over an 8-year period from 2015 to 2022, cases were collected from forensic institutions, and demographic characteristics, case details, and psychiatric data were recorded. The 51 incidents involved 51 perpetrators and 79 victims, with more female perpetrators (58.8%) and more female victims (54.4%). The average age of the perpetrators was 36.1, and most were married (88.2%). Almost all of the victims were family members of the perpetrator, like the most numerous children (64.6%), followed by spouses (24.1%). The most common homicide mode of death was mechanical asphyxia (38.0%), followed by sharp devices (36.7%) and drug poisoning (16.5%). Depressive disorders (76.5%) were the most common diagnosis of mental disorder for perpetrators. The study analyzed the unique characteristics of extended suicide to enrich such data. These findings help strengthen the screening and identification of potential perpetrators and victims to prevent such cases from occurring.

Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study

Background

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety.

Objective

We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.

Methods

This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.

Results

Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002).

Conclusions

Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

The Veterans Crisis Line: Relations among immediate call outcomes and treatment contact and utilization following the call

OBJECTIVE

Crisis line callers experience reductions in distress and suicidal ideation and utilize more health care following calls. The purpose of this study was to determine whether changes in distress and suicidal ideation during a call are associated with later healthcare contact and utilization.

METHOD

Veterans Crisis Line calls from 599 veterans were extracted with call dates between 12/1/2018 and 11/30/2019. Calls were coded for changes in distress and suicidal ideation and linked with VA medical records to obtain healthcare data. Generalized Linear Mixed Modeling was used to examine the associations of changes in distress and suicidal ideation with healthcare contact (yes/no) and utilization (days of treatment) in the month (30 days) following the call.

RESULTS

Reductions in distress were associated with behavioral (i.e., mental and substance use) healthcare utilization, F(1, 596) = 4.52, p = 0.03, and reductions in suicidal ideation were associated with any healthcare utilization, F(1, 596) = 6.45, p = 0.01. Changes in distress and suicidal ideation were not associated with healthcare contact.

CONCLUSION

Responders need to help resolve distress and suicidal ideation and link callers with treatment. Unresolved distress and suicidal thoughts may signify later problems with treatment utilization. Research is needed to determine causality.

Suicide risk, related factors and the impact of COVID-19 amongst suicide prevention helpline callers: A network analysis

BACKGROUND

The COVID-19 pandemic brought along many known risk factors for suicide. It is important to map out contributing and protective factors for suicide risk and examine possible changes in these associations during pandemics such as COVID-19. The current study aimed to examine how information on risk and protective factors obtained through a suicide prevention helpline is linked to the assessed suicide risk and the possible impact of the COVID-19 pandemic.

METHODS

Data on 9474 calls registered by operators of the suicide prevention helpline of Flanders (i.e., part of Belgium) were analysed using network analysis. Using network analyses allowed for a data-driven examination of direct and indirect pathways through which risk and protective factors are associated to perceived suicide risk. The network before and during COVID-19 were compared to examine the possible impact of the pandemic.

RESULTS

Our findings suggest that different vulnerability and protective factors contribute to perceived suicide risk. Experiencing a break-up, abuse, previous attempt(s), experienced difficulties with the healthcare system and availability of resources were directly and uniquely associated with perceived suicide risk before and during COVID-19.

LIMITATIONS

Main limitations of this study are the possible bias of operator assessment accuracy, absence of several important psychological risk factors and the use of cross-sectional data.

CONCLUSIONS

The current study provides insight in the effect of COVID-19 on suicidality and its risk and protective factors amongst suicide prevention helpline users, a population with high risk of suicide. Implications for suicide prevention helplines are discussed.

The effectiveness of a suicide prevention program in primary care clinics supported by community public health resources: A difference-in-differences analysis

The importance of appropriate and intensive follow-up management for individuals identified with suicide risk through screening is highlighted. The Link between Primary Care Clinic and Public Health Resources Intervention(LinkPC-PH), a suicide prevention program in primary care clinics supported by community public health resources, was implemented at the district level in 2017. The purpose of the present study is to evaluate the effectiveness of the LinkPC-PH intervention by comparing suicide rates before(2014-2016) and after(2017-2019) implementation of the intervention using a difference-in-differences design. The LinkPC-PH comprises several dimensions of intervention including screening, risk assessment of suicidality, and referral in primary care clinics and crisis contact within 24 hours, case management, and safety planning led by public health professionals. After adjustment for district-level confounders, an intervention-implemented district had 2.87 fewer suicide deaths per 100,000 people in a population sample at post-intervention than would have been expected from the same trend in suicide rates as non-implemented intervention districts. In other words, the suicide rate in the intervention area decreased by 25% following the intervention. These results empirically substantiate suicide prevention programs in primary care clinics by community public health resources for reduced suicide rates to support effective community-based suicide prevention interventions.

Predicting adolescent suicidal behavior following inpatient discharge using structured and unstructured data

BACKGROUND

The objective was to develop and assess performance of an algorithm predicting suicide-related ICD codes within three months of psychiatric discharge.

METHODS

This prognostic study used a retrospective cohort of EHR data from 2789 youth (12 to 20 years old) hospitalized in a safety net institution in the Northeastern United States. The dataset combined structured data with unstructured data obtained through natural language processing of clinical notes. Machine learning approaches compared gradient boosting to random forest analyses.

RESULTS

Area under the ROC and precision-recall curve were 0.88 and 0.17, respectively, for the final Gradient Boosting model. The cutoff point of the model-generated predicted probabilities of suicide that optimally classified the individual as high risk or not was 0.009. When applying the chosen cutoff (0.009) to the hold-out testing set, the model correctly identified 8 positive cases out of 10, and 418 negative cases out 548. The corresponding performance metrics showed 80 % sensitivity, 76 % specificity, 6 % PPV, 99 % NPV, F-1 score of 0.11, and an accuracy of 76 %.

LIMITATIONS

The data in this study comes from a single health system, possibly introducing bias in the model's algorithm. Thus, the model may have underestimated the incidence of suicidal behavior in the study population. Further research should include multiple system EHRs.

CONCLUSIONS

These performance metrics suggest a benefit to including both unstructured and structured data in design of predictive algorithms for suicidal behavior, which can be integrated into psychiatric services to help assess risk.

Longitudinal associations between exposure to potentially morally injurious events and suicidal ideation among recently discharged veterans - The mediating roles of depression and loneliness

BACKGROUND

Exposure to potentially morally injurious events (PMIEs) during military service is associated with heightened suicidal ideation (SI). However, no longitudinal study has established temporal associations between these variables and examined the possible mediating roles of depression and loneliness in this effect.

METHODS

Participants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following their discharge (T3 and T4, respectively). Data were assessed through semi-structured interviews and validated self-report questionnaires.

RESULTS

Above and beyond pre-enlistment personal characteristics (T1) and combat exposure (T2), PMIEs-'betrayal' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of depression. Moreover, both PMIEs-'betrayal' and 'self' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of loneliness.

LIMITATIONS

We used self-report measures to assess PMIEs and SI, which may suffer from various biases.

CONCLUSIONS

Our findings are the first to provide evidence of longitudinal, temporal associations between exposure to PMIEs and SI. Notably, potential interventions might consider addressing the loneliness experienced following exposure to PMIEs during military service, among recently discharged traumatized veterans.

Classifying coping strategies from suicide prevention safety plans

INTRODUCTION

Understanding the specific strategies individuals use to cope with their suicidal thoughts may have implications for suicide prevention. This study developed a classification system of coping strategies and applied this system to individual coping behaviors documented in a safety planning intervention smartphone application called Beyond Now.

METHOD

725 Beyond Now safety planning app users, aged 16 to over 55 years, entered coping strategies that were used to develop a classification system through content analysis. Entries were either user generated or selected from a list of suggested coping strategies, and 2960 entries were classified using the system.

RESULTS

Our classification system featured 11 distinct descriptive categories, with media consumption being the most popular coping strategy among Beyond Now users, followed by relaxation and self-care activities, exercise and creative activities. More than half (57%) of the entries were suggested coping strategies with the remainder being user-generated entries (43%).

CONCLUSION

A wide range of coping strategies were entered into safety plans, with activities that aim to either distract or provide reductions in emotional arousal common. Future research is needed to evaluate the efficacy of the coping strategies listed in safety plans.

Advancing early detection of suicide? A national study examining socio-demographic factors, antecedent stressors and long-term history of self-harm

BACKGROUND

A range of factors including mental disorders, adverse events and history of self-harm are associated with suicide risk. Further examination is needed of the characteristics of suicides which occur without established risk factors, using national surveillance systems.

METHODS

Data on all suicides in Ireland from 2015 to 2017 were drawn from the Irish Probable Suicide Deaths Study (IPSDS). Variables examined included socio-demographics, psychiatric history and precipitant stressors. Suicide data were linked with data on prior self-harm from the National Self-Harm Registry Ireland (NSHRI). Latent Class Analysis (LCA) was used to identify sub-groups of suicide cases.

RESULTS

Of the 1809 individuals who died by suicide, 401 (22.2 %) had a history of hospital-treated self-harm. Four distinct profiles of suicides were identified. One group was marked by high levels of prior self-harm and mental health conditions. Two of the groups included few individuals with a history of self-harm but had notably high levels of mental health conditions. These two groups had relatively high levels of reported chronic pain or illness but differed in terms of socio-demographics. The final group, predominantly male, had markedly low levels of mental health conditions or self-harm but high levels of personal stressors and substance use.

LIMITATIONS

The use of coronial data may be limited by bias in the collecting of information from the deceased's family members.

CONCLUSIONS

A sub-group of suicide cases exists without any psychiatric or self-harm history but with salient occupational or health-related proximal stressors. Suicide prevention interventions should include occupational settings and should promote mental health literacy.

Effect of next-step antidepressant treatment on suicidal ideation: findings from the VAST-D trial

BACKGROUND

Major depressive disorder (MDD) contributes to suicide risk. Treating MDD effectively is considered a key suicide prevention intervention. Yet many patients with MDD do not respond to their initial medication and require a 'next-step'. The relationship between next-step treatments and suicidal thoughts and behaviors is uncharted.

METHOD

The VA Augmentation and Switching Treatments for Depression trial randomized 1522 participants to one of three next-step treatments: Switching to Bupropion, combining with Bupropion, and augmenting with Aripiprazole. In this secondary analysis, features associated with lifetime suicidal ideation (SI) and attempts (SA) at baseline and current SI during treatment were explored.

RESULTS

Compared to those with SI only, those with lifetime SI + SA were more likely to be female, divorced, or separated, unemployed; and to have experienced more childhood adversity. They had a more severe depressive episode and were more likely to respond to 'next-step' treatment. The prevalence of SI decreased from 46.5% (694/1492) at baseline to 21.1% (315/1492) at end-of-treatment. SI during treatment was associated with baseline SI; low positive mental health, more anxiety, greater severity and longer duration of current MDD episode; being male and White; and treatment with S-BUP or C-BUP as compared to A-ARI.

CONCLUSION

SI declines for most patients during next-step medication treatments. But about 1 in 5 experienced emergent or worsening SI during treatment, so vigilance for suicide risk through the entire 12-week acute treatment period is necessary. Treatment selection may affect the risk of SI.

Developing a clinical decision support system software prototype that assists in the management of patients with self-harm in the emergency department: protocol of the PERMANENS project

BACKGROUND

Self-harm presents a significant public health challenge. Emergency departments (EDs) are crucial healthcare settings in managing self-harm, but clinician uncertainty in risk assessment may contribute to ineffective care. Clinical Decision Support Systems (CDSSs) show promise in enhancing care processes, but their effective implementation in self-harm management remains unexplored.

METHODS

PERMANENS comprises a combination of methodologies and study designs aimed at developing a CDSS prototype that assists clinicians in the personalized assessment and management of ED patients presenting with self-harm. Ensemble prediction models will be constructed by applying machine learning techniques on electronic registry data from four sites, i.e., Catalonia (Spain), Ireland, Norway, and Sweden. These models will predict key adverse outcomes including self-harm repetition, suicide, premature death, and lack of post-discharge care. Available registry data include routinely collected electronic health record data, mortality data, and administrative data, and will be harmonized using the OMOP Common Data Model, ensuring consistency in terminologies, vocabularies and coding schemes. A clinical knowledge base of effective suicide prevention interventions will be developed rooted in a systematic review of clinical practice guidelines, including quality assessment of guidelines using the AGREE II tool. The CDSS software prototype will include a backend that integrates the prediction models and the clinical knowledge base to enable accurate patient risk stratification and subsequent intervention allocation. The CDSS frontend will enable personalized risk assessment and will provide tailored treatment plans, following a tiered evidence-based approach. Implementation research will ensure the CDSS' practical functionality and feasibility, and will include periodic meetings with user-advisory groups, mixed-methods research to identify currently unmet needs in self-harm risk assessment, and small-scale usability testing of the CDSS prototype software.

DISCUSSION

Through the development of the proposed CDSS software prototype, PERMANENS aims to standardize care, enhance clinician confidence, improve patient satisfaction, and increase treatment compliance. The routine integration of CDSS for self-harm risk assessment within healthcare systems holds significant potential in effectively reducing suicide mortality rates by facilitating personalized and timely delivery of effective interventions on a large scale for individuals at risk of suicide.

Considering the importance of 'Communities of Practice' and Health Promotion Constructs for Upstream Suicide Prevention

Background

Suicide is a serious and growing health inequity for Alaska Native (AN) youth (ages 15-24), who experience suicide rates significantly higher than the general U.S. youth population. In low-resourced, remote communities, building on the local and cultural resources found in remote AN communities to increase uptake of prevention behaviors like lethal means reduction, interpersonal support, and postvention can be more effective at preventing suicide than a risk-referral process. This study expands the variables we hypothesize as important for reducing suicide risk and supporting wellbeing. These variables are: 1) perceived suicide prevention self-efficacy, 2) perceived wellness self-efficacy, and 3) developing a 'community of practice' (CoP) for prevention/wellness work.

Method

With a convenience sample (N = 398) of participants (ages 15+) in five remote Alaska Native communities, this study characterizes respondents' social roles: institutional role if they have a job that includes suicide prevention (e.g. teachers, community health workers) and community role if their primary role is based on family or community positioning (e.g. Elder, parent). The cross-sectional analysis then explores the relationship between respondents' wellness and prevention self-efficacy and CoP as predictors of their self-reported suicide prevention and wellness promotion behaviors: (1) working together with others (e.g. community initiatives), (2) offering interpersonal support to someone, (3) reducing access to lethal means, and (4) reducing suicide risk for others after a suicide death in the community.

Results

Community and institutional roles are vital, and analyses detected distinct patterns linking our dependent variables to different preventative behaviors. Findings associated wellness self-efficacy and CoP (but not prevention self-efficacy) with 'working together' behaviors, wellness and prevention self-efficacy (but not CoP) with interpersonal supportive behaviors; both prevention self-efficacy and CoP with higher postvention behaviors. Only prevention self-efficacy was associated with lethal means reduction.

Conclusions

The study widens the scope of suicide prevention. Promising approaches to suicide prevention in rural low-resourced communities include: (1) engaging people in community and institutional roles, (2) developing communities of practice for suicide prevention among different sectors of a community, and (3) broadening the scope of suicide prevention to include wellness promotion as well as suicide prevention.

A 'Vocal Locals' social network campaign is associated with increased frequency of conversations about mental health and improved engagement in wellbeing-promoting activities in an Australian farming community

BACKGROUND

Farmers face numerous barriers to accessing professional mental health services and instead report a preference for informal support systems, such as lay or peer networks. Farmers also experience barriers to investing time in maintaining or improving their wellbeing, stemming from sociocultural norms and attitudes that are widespread in agricultural communities. The Vocal Locals social network campaign is an ifarmwell initiative that aims to promote conversations about wellbeing and challenge attitudes and behaviours that contribute to farmers' poor mental health.

METHODS

The Vocal Locals campaign was underpinned by the socio-ecological model which explains human behaviour as stemming from interactions between the individual, their closest social circle, the community, and broader society. The campaign ran in Loxton, South Australia, from June to August 2022. Ten community members (8/10 farmers) became 'Vocal Locals' and were supported to share 'calls-to-action' to encourage people in their social networks to engage in wellbeing-promoting activities. A broader communications campaign reinforced key messages and amplified Vocal Locals' activities in the community. The intrapersonal and community-level impacts of the campaign were evaluated via pre- and post-campaign surveys of Vocal Locals and community members respectively.

RESULTS

Vocal Locals reported significantly lower psychological distress (p = .014), and higher positive mental wellbeing (p = .011), levels of general mental health knowledge (p = .022), and confidence helping someone with poor mental health (p = .004) following the intervention. However, changes in stigmatising beliefs about mental illness, confidence recognising poor mental health, and confidence and comfort speaking to others about mental health were non-significant. Community members who were familiar with the campaign reported having significantly more wellbeing-related conversations post-campaign compared to before (p = .015). Respondents also reported being more comfortable speaking to others about mental health or wellbeing (p = .001) and engaging more in activities to maintain or improve their wellbeing (p = .012) following the campaign.

CONCLUSIONS

The Vocal Locals social network campaign is an example of how science and community can be brought together to achieve meaningful outcomes. The campaign may serve as a model for others who wish to challenge attitudinal or knowledge-related barriers to help-seeking and improve engagement in wellbeing-promoting activities in difficult-to-reach communities.

The Cost-Effectiveness of Psychosocial Interventions Following Self-Harm in Australia

Background: Psychosocial interventions following self-harm in adults, in particular cognitive behavioral therapy (CBT), can be effective in lowering the risk of repeated self-harm. Aims: To evaluate the cost-effectiveness of CBT for reducing repeated self-harm in the Australian context. Method: The current study adopted the accessing cost-effectiveness (ACE) approach using return-on-investment (ROI) analysis. Uncertainty and sensitivity analyses (Sas) tested the robustness of the model outputs to changes in three assumptions: general practitioner referral pathway (SA1), private setting intervention delivery (SA2), and training costs (SA3). Results: The intervention produced cost savings of A$ 46M (95% UI -223.7 to 73.3) and A$ 18.3M (95% UI -86.2 to 24.6), subject to the effect of intervention lasting 2- or 1-year follow-up. The ROI ratio reduced to 5.22 in SA1 (95% UI -10.1 to 27.9), 2.5 in SA2 (95% UI -4.8 to 13.3), and 5.1 in SA3 (95% UI -9.8 to 27.8). Limitations: We assumed that the effectiveness would reduce 50% within 5 years in the base case, and we used Australian data and a partial social perspective. Conclusions: The current study demonstrated cost-effectiveness of CBT for adults who have self-harmed with the return-on-investment ratio of A$ 2.3 to $6.0 for every A$ 1 invested.

What Now?: Experiences of VHA patients following disclosure of suicidal ideation in primary care and mental health settings

OBJECTIVE

While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings.

METHOD

Qualitative thematic analysis using a conventional/directed hybrid approach.

RESULTS

A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options.

CONCLUSIONS

While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care.

Association between insurance type and suicide-related behavior among US adults: The impact of the Affordable Care Act

This study examined the association between insurance type and suicidal ideation and attempts among adults in the United States, incorporating a comparative analysis of the pre- and post-Affordable Care Act (ACA) periods. We used a nationally representative, cross-sectional, population-based survey of individuals aged 18 years and older from the 2010-2019 National Survey on Drug Use and Health. The higher rates of suicidal ideation and attempts among Medicaid and uninsured groups compared with those with private insurance. After implementation of the ACA policy, the difference-in-differences analysis showed a significantly reduced risk of suicide in the Medicare group compared with the privately insured group, with no significant differences observed in the other groups. These findings highlight the importance of improving access to mental health services, particularly for those with lower levels of insurance coverage, such as Medicaid and Medicare.

Suicide prevention during disasters and public health emergencies: a systematic review

Background

Disasters and public health emergencies increasingly affect populations around the world, posing significant wide-ranging challenges for societies as well as for effective public health and suicide prevention. Intervention research is essential to inform evidence-based responses. Yet, despite evident public concern and growing research interest in heightened suicide risks and impacts, little is known about effective suicide prevention interventions in these contexts. We conducted a systematic review to examine the outcomes of suicide prevention strategies implemented in disasters and public health emergencies.

Methods

We searched five databases (Medline, Embase, PsycINFO, Web of Science, PTSDpubs) from inception to December 2022 for peer-reviewed quantitative studies that reported relevant intervention outcomes (changes in the frequency of suicide, suicide attempts, self-harm) for populations affected by disasters and public health emergencies. We assessed the quality of eligible studies using the Quality Assessment Tool for Quantitative Studies, and distilled review findings through narrative synthesis. The study protocol was registered with PROSPERO (CRD42021276195).

Results

Ten eligible and mostly observational studies were included in this review, which examined a range of universal, selective, and indicated interventions. Three of five studies of interventions in public health emergencies indicated the potential effectiveness and buffering effects of generic disaster related mental health support, access to urban parks, as well as the beneficial role of video-enabled tablets in facilitating treatment access and outcomes. Similarly, three of five studies of interventions in disaster contexts provided evidence of the beneficial role of universal economic security measures, national gun laws and buy back schemes, and volunteer-delivered mental health support. Overall, four of six studies with favorable outcomes examined interventions specifically deployed in disaster or public health emergency contexts, whereas two studies examined ongoing existing interventions. Three studies, respectively, of suicide prevention focused interventions or generic interventions reported favorable outcomes. The quality of included studies was variable, with two studies being rated as 'strong', four studies rated as 'moderate', and four studies rated as 'weak'.

Conclusion

Notwithstanding the limited scope and variable quality of published evidence, our review findings highlight the breadth of interventions that have been applied in such contexts with some success. There is a need for further research on effective interventions and intervention adaptations to inform evidence-based suicide prevention responses to disasters and public health emergencies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276195, PROSPERO ID CRD42021276195.

Whole-brain structural and functional neuroimaging of individuals who attempted suicide and people who did not: A systematic review and exploratory coordinate-based meta-analysis

Suicide is the cause of death of approximately 800,000 people a year. Despite the relevance of this behaviour, risk assessment tools rely on clinician experience and subjective ratings. Given that previous suicide attempts are the single strongest predictors of future attempts, we designed a systematic review and coordinate-based meta-analysis to demonstrate whether neuroimaging features can help distinguish individuals who attempted suicide from subjects who did not. Out of 5,659 publications from PubMed, Scopus, and Web of Science, we summarised 102 experiments and meta-analysed 23 of them. A cluster in the right superior temporal gyrus, a region implicated in emotional processing, might be functionally hyperactive in individuals who attempted suicide. No statistically significant differences in brain morphometry were evidenced. Furthermore, we used JuSpace to show that this cluster is enriched in 5-HT1A heteroreceptors in the general population. This exploratory meta-analysis provides a putative neural substrate linked to previous suicide attempts. Heterogeneity in the analytical techniques and weak or absent power analysis of the studies included in this review currently limit the applicability of the findings, the replication of which should be prioritised.

Review of Australia's funding commitments for suicide prevention from 2021-22 to 2026-27

Objective Examine the distribution of funding for suicide prevention in Australia from 2021-22 to 2026-27. Methods Government websites were reviewed to locate budget documents related to suicide prevention funding. Information was extracted on the program/service to be funded, and the funder entity, duration, and year allocation. Extracted data was reviewed to identify commonly targeted sub-populations. Results The majority of suicide prevention-related funding was allocated to aftercare for persons who have attempted suicide, consistent with the effectiveness of these services, followed by programs targeting the general population. Little funding was allocated to other specific sub-populations, such as young people and Aboriginal and Torres Strait Islander peoples. The amount of funding allocated to suicide prevention varied across jurisdictions, which is only partially explained by suicide rates. Conclusions There is a need for greater investment in care for specific sub-populations who are at higher risk of suicide. This study provides a baseline for comparing future investments in suicide prevention in Australia.

Lack of Identity and Suicidality: The Mediating Role of Emotion Regulation Difficulties

ABSTRACT

Identity disturbance has been connected to both psychological distress and suicidality, and associated with emotion dysregulation. However, despite empirical evidence of a relationship between lack of identity and poor psychiatric outcomes, the link between impaired identity and emotion dysregulation in suicide risk remains underexplored, particularly among individuals seeking outpatient mental health services. Using data from a large clinical sample (n = 246), the present study examined the association between lack of identity and suicidality and the role of emotion dysregulation within this process. Findings indicated that the mediation model was significant, with emotion regulation difficulties significantly mediating the association between lack of identity and future suicidal behavior. Furthermore, the indirect effect of lack of identity on anticipated suicidality remained significant beyond general distress and past suicide attempt. Our findings add to the literature examining the complex relationship among lack of identity, emotion regulation, and suicidality.

Prototyping the implementation of a suicide prevention protocol in primary care settings using PDSA cycles: a mixed method study

Introduction

In Canada, approximately 4,500 individuals die by suicide annually. Approximately 45% of suicide decedents had contact with their primary care provider within the month prior to their death. Current versus never smokers have an 81% increased risk of death by suicide. Those who smoke have additional risks for suicide such as depression, chronic pain, alcohol, and other substance use. They are more likely to experience adverse social determinants of health. Taken together, this suggests that smoking cessation programs in primary care could be facilitators of suicide prevention, but this has not been studied.

Study objectives

The objectives of the study are to understand barriers/facilitators to implementing a suicide prevention protocol within a smoking cessation program (STOP program), which is deployed by an academic mental health and addiction treatment hospital in primary care clinics and to develop and test implementation strategies to facilitate the uptake of suicide screening and assessment in primary care clinics across Ontario.

Methods

The study employed a three-phase sequential mixed-method design. Phase 1: Conducted interviews guided by the Consolidated Framework for Implementation Research exploring barriers to implementing a suicide prevention protocol. Phase 2: Performed consensus discussions to map barriers to implementation strategies using the Expert Recommendations for Implementing Change tool and rank barriers by relevance. Phase 3: Evaluated the feasibility and acceptability of implementation strategies using Plan Do Study Act cycles.

Results

Eleven healthcare providers and four research assistants identified lack of training and the need of better educational materials as implementation barriers. Participants endorsed and tested the top three ranked implementation strategies, namely, a webinar, adding a preamble before depression survey questions, and an infographic. After participating in the webinar and reviewing the educational materials, all participants endorsed the three strategies as acceptable/very acceptable and feasible/very feasible.

Conclusion

Although there are barriers to implementing a suicide prevention protocol within primary care, it is possible to overcome them with strategies deemed both acceptable and feasible. These results offer promising practice solutions to implement a suicide prevention protocol in smoking cessation programs delivered in primary care settings. Future efforts should track implementation of these strategies and measure outcomes, including provider confidence, self-efficacy, and knowledge, and patient outcomes.