Protocol for a stepped-wedge, cluster randomized controlled trial of the LifeSpan suicide prevention trial in four communities in New South Wales, Australia

Investigating the efficacy of a Dialectical behaviour therapy-based universal intervention on adolescent social and emotional well-being outcomes

There is increasing research interest as to whether Dialectical Behaviour Therapy (DBT), specifically the group skills training component, is an effective early intervention approach when delivered universally in schools. The current study aimed to provide the first large-scale examination of a universal DBT-based intervention and to also determine the extent to which home practice of DBT skills predicted changes in social and emotional outcomes over time. A non-randomised controlled trial design was employed whereby 1071 participants (51.30% Male; M age = 13.48 years) completed either an adapted eight-session DBT skills-training intervention ('WISE Teens) (n = 563) or class-as-per-usual (n = 508). On average, the 'WISE Teens' intervention did not improve outcomes with significant deteriorations or null effects observed across outcomes relative to class-as-per-usual immediately post-intervention. The largest deteriorations were observed for depressive (d = -0.22; 95% CI = -0.35, -0.08) and anxiety symptoms (d = -0.28; 95%CI - = -0.41, -0.14). Applying Bonferroni corrections, most group differences in outcomes had dissipated at follow-up, however, 'WISE Teens' participants continued to report significantly poorer quality of parent-child relationships relative to control (d = .16 for mother (95% CI = 0.01, 0.31); d = 0.17 for father (95% CI = 0.02, 0.33). While home practice was modest on average, further exploratory analyses nevertheless revealed that greater home practice was generally associated with more positive outcomes both immediately post-intervention and at follow-up. Based on these findings, the DBT-based 'WISE Teens' intervention is not recommended in its current format for universal dissemination amongst early adolescents in schools. Further research is needed to determine how to improve engagement and feasibility of delivery of DBT-based interventions universally in this context.

Early impacts of the 'National Suicide Prevention Trial' on trends in suicide and hospital admissions for self-harm in Australia

OBJECTIVES

The National Suicide Prevention Trial was announced by the Australian Government in 2016 and aimed to prevent suicidal behaviour in 12 trial sites (representing a population of ~8 million). This study investigated the early population-level impact of the National Suicide Prevention Trial activity on rates of suicide and hospital admissions for self-harm in comparison to control areas.

METHODS

Relative and absolute differences in monthly rates of suicide and hospital admissions for self-harm were compared in the period after the National Suicide Prevention Trial implementation (July 2017-November 2020) to the period prior to implementation (January 2010-June 2017) in (1) 'National Suicide Prevention Trial areas' and (2) 'Control areas', using a difference-in-difference method in a series of negative binomial models. Analyses also investigated whether associations for suicide and self-harm rates differed by key socio-demographic factors, namely sex, age group, area socio-economic status and urban-rural residence.

RESULTS

There were no substantial differences between 'National Suicide Prevention Trial areas' and 'Control areas' in rates of suicide (2% relative decrease, relative risk = 0.98, 95% confidence interval = [0.91, 1.06]) or self-harm (1% relative decrease, relative risk = 0.99, 95% confidence interval = [0.96, 1.02]), adjusting for sex, age group and socio-economic status. Stronger relative decreases in self-harm only were evident for those aged 50-64 years, high socio-economic status areas, metropolitan and remote geographic areas.

CONCLUSION

There was limited evidence that the National Suicide Prevention Trial resulted in reductions in suicide or hospital admissions for self-harm during the first 4 years of implementation. Continued monitoring of trends with timely data is imperative over the next 2-3 years to ascertain whether there are any subsequent impacts of National Suicide Prevention Trial activities.

Utilisation and application of implementation science in complex suicide prevention interventions: A systematic review

OBJECTIVES

Little is known about how complex, multilevel, and multicomponent suicide prevention interventions work in real life settings. Understanding the methods used to systematically adopt, deliver, and sustain these interventions could ensure that they have the best chance of unfolding their full effect. This systematic review aimed to examine the application and extent of utilisation of implementation science in understanding and evaluating complex suicide prevention interventions.

METHODS

The review adhered to updated PRISMA guidelines and was prospectively registered with PROSPERO (CRD42021247950). PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL were searched. All English-language records (1990-2022) with suicide and/or self-harm as the primary aims or targets of intervention were eligible. A forward citation search and a reference search further bolstered the search strategy. Interventions were considered complex if they consisted of three or more components and were implemented across two or more levels of socio-ecology or levels of prevention.

RESULTS

One hundred thirty-nine records describing 19 complex interventions were identified. In 13 interventions, use of implementation science approaches, primarily process evaluations, was explicitly stated. However, extent of utilisation of implementation science approaches was found to be inconsistent and incomprehensive.

LIMITATIONS

The inclusion criteria, along with a narrow definition of complex interventions may have limited our findings.

CONCLUSION

Understanding the implementation of complex interventions is crucial for unlocking key questions about theory-practice knowledge translation. Inconsistent reporting and inadequate understanding of implementation processes can lead to loss of critical, experiential knowledge related to what works to prevent suicide in real world settings.

Exploring Community-Based Suicide Prevention in the Context of Rural Australia: A Qualitative Study

Suicide rates in rural communities are higher than in urban areas, and communities play a crucial role in suicide prevention. This study explores community-based suicide prevention using a qualitative research design. Semi-structured interviews and focus groups asked participants to explore community-based suicide prevention in the context of rural Australia. Participants recruited ((n = 37; ages 29-72, Mean = 46, SD = 9.56); female 62.2%; lived experience 48.6%) were self-identified experts, working in rural community-based suicide prevention (community services, program providers, research, and policy development) around Australia. Data were thematically analysed, identifying three themes relating to community-based suicide prevention: (i) Community led initiatives; (ii) Meeting community needs; and (iii) Programs to improve health and suicidality. Implementing community-based suicide prevention needs community-level engagement and partnerships, including with community leaders; gatekeepers; community members; people with lived experience; services; and professionals, to "get stuff done". Available resources and social capital are utilised, with co-created interventions reflecting diverse lifestyles, beliefs, norms, and cultures. The definition of "community", community needs, issues, and solutions need to be identified by communities themselves. Primarily non-clinical programs address determinants of health and suicidality and increase community awareness of suicide and its prevention, and the capacity to recognise and support people at risk. This study shows how community-based suicide prevention presents as a social innovation approach, seeing suicide as a social phenomenon, with community-based programs as the potential driver of social change, equipping communities with the "know how" to implement, monitor, and adjust community-based programs to fit community needs.

Exploring Sociodemographic Correlates of Suicide Stigma in Australia: Baseline Cross-Sectional Survey Findings from the Life-Span Suicide Prevention Trial Studies

The risk of suicidal behaviour in Australia varies by age, sex, sexual preference and Indigenous status. Suicide stigma is known to affect suicide rates and help-seeking for suicidal crises. The aim of this study was to investigate the sociodemographic correlates of suicide stigma to assist in prevention efforts. We surveyed community members and individuals who had attended specific emergency departments for suicidal crisis. The respondents were part of a large-scale suicide prevention trial in New South Wales, Australia. The data collected included demographic characteristics, measures of help-seeking and suicide stigma. The linear regression analyses conducted sought to identify the factors associated with suicide stigma. The 5426 participants were predominantly female (71.4%) with a mean (SD) age of 41.7 (14.8) years, and 3.9% were Indigenous. Around one-third of participants reported a previous suicide attempt (n = 1690, 31.5%) with two-thirds (n = 3545, 65.3%) seeking help for suicidal crisis in the past year. Higher stigma scores were associated with Indigenous status (β 0.123, 95%CI 0.074-0.172), male sex (β 0.527, 95%CI 0.375-0.626) and regional residence (β 0.079, 95%CI 0.015-0.143). Lower stigma scores were associated with younger age (β -0.002, 95%CI -0.004--0.001), mental illness (β -0.095, 95%CI -0.139 to -0.050), male bisexuality (β -0.202, 95%CI -0.351 to -0.052) and males who glorified suicide (β -0.075, 95%CI -0.119 to -0.031). These results suggested that suicide stigma differed across the community, varying significantly by sex, sexual orientation and Indigenous status. Targeted educational programs to address suicide stigma could assist in suicide prevention efforts.

Co-creating safe spaces: Study protocol for translational research on innovative alternatives to the emergency department for people experiencing emotional distress and/or suicidal crisis

INTRODUCTION

Safe spaces are an alternative to emergency departments, which are often unable to provide optimum care for people experiencing emotional distress and/or suicidal crisis. At present, there are several different safe space models being trialled in Australia. However, research examining the effectiveness of safe space models, especially in community settings, is rare. In this paper, we present a protocol for a study in which we will investigate the implementation, effectiveness, and sustainability of safe space models as genuine alternatives for people who might usually present to the emergency department or choose not to access help due to past negative experiences.

MATERIAL AND METHODS

We will use a mixed methods, co-designed study design, conducted according to the principles of community-based participatory research to obtain deep insights into the benefits of different safe space models, potential challenges, and facilitators of effective practice. We developed the study plan and evaluation framework using the RE-AIM framework, and this will be used to assess key outcomes related to reach, effectiveness, adoption, implementation, and maintenance. Data collection will comprise quantitative measures on access, use, satisfaction, (cost) effectiveness, distress, and suicidal ideation; and qualitative assessments of service implementation, experience, feasibility, acceptability, community awareness, and the fidelity of the models to service co-design. Data will be collected and analysed concurrently throughout the trial period of the initiatives.

DISCUSSION

This study will enable an extensive investigation of safe spaces that will inform local delivery and provide a broader understanding of the key features of safe spaces as acceptable and effective alternatives to hospital-based care for people experiencing emotional distress and/or suicidal crisis. This study will also contribute to a growing body of research on the role and benefits of peer support and provide critical new knowledge on the successes and challenges of service co-design to inform future practice.

Profiles of Passive and Active Suicidal Ideation and Attempts Among Secondary School Students in Australia: A Cross-Sectional Analysis

INTRODUCTION

Suicide is a leading cause of death among young people (aged 15-24 years), and as such, identifying targets for early intervention is essential to reducing this risk. Using baseline data from a school-based universal suicide prevention trial, we investigate factors associated with different types of suicidal ideation in secondary school students with implications for youth suicide preventive efforts.

METHODS

A self-report questionnaire was administered to students aged 13-16 years (Year 9) before program delivery in four regions across New South Wales, Australia (N = 556). Multinomial logistic regression was used to identify correlates of suicidal ideation type (passive vs. active).

RESULTS

Approximately half the total sample reported recent suicidal ideation (51.6% in the previous two weeks), which included almost one-third reporting active suicidal ideation (32.2% seriously considered suicide or made plans). Participants that were significantly more likely to report active suicidal ideation compared to passive suicidal ideation identified as female (OR = 1.91, 95% CI = 1.02-3.59), Indigenous (OR = 0.21, 95% CI = 0.05-0.80), as sexual minorities (OR = 0.36, 95% CI = 0.13-0.97), and had greater depression severity (OR = 1.11, 95% CI = 1.04-1.19).

CONCLUSIONS

Suicidal thoughts are prevalent among young people. Universal and indicated preventive interventions that address depression, as well as bullying and discrimination of minority groups would benefit all young people, particularly those more vulnerable to severe suicidal ideation and suicide attempts.HighlightsActive suicidal ideation (SI) was reported by 32.2% of our student sample aged 13-16 years.Active SI is linked to sex (female), Indigeneity status, sexual minority status, and greater depression severity.Improved bullying and discrimination policy within schools, and well-being programs targeting depression and promoting help-seeking, would benefit youth.

Preliminary Evaluation of Lived Experience of Suicide Training: Short-, Medium- and Longer-Term Impacts of Our Voices in Action Training

Despite increased participation and multiple workforce roles of those with lived experience in suicide prevention, there are no evaluated training programs to support this population. This study evaluated a training program aimed to prepare people for these important roles. Survey data at pre-, post- and at three- and 12-month follow-up were used measuring knowledge, attitudes, and self-efficacy, as well as psychological distress as a safety measure. Participants experienced significant gains in knowledge after training, although not all aspects of knowledge were maintained at follow-up. Self-efficacy was examined through confidence and empowerment. Confidence gains were significant at immediate and longer-term follow-up but gains in empowerment were not maintained over time. Participants' positive attitudes improved but this was not significant. There was no indication of increases in psychological distress in participants throughout the training and follow-up periods. Implications of these outcomes are discussed.

A decline in Australian suicide during COVID-19? A reflection on the 2020 cause of death statistics in the context of long-term trends

This correspondence considers the overall decline in suicide in 2020 in the context of longer-term sex and age-specific trends over the period 1907–2020. When considering suicide rates from the beginning of the 20th century, the decrease in the total suicide rate from 2019 to 2020 is less noteworthy.

Networks to strengthen community social capital for suicide prevention in regional Australia: the LifeSpan suicide prevention initiative

Introduction

Mental health services are fragmented in Australia leading to a priority being placed on whole-of-community approaches and integration. We describe the LifeSpan suicide prevention intervention developed by the Black Dog Institute that draws upon nine evidence-based community-wide strategies. We examined the suicide prevention Collaborative group at each site. We evaluated how the social capital of the community and service providers changed, and how the brokerage roles of the Collaborative affected integration of effort.

Methods

This was a two phase, explanatory mixed methods study. Participants were LifeSpan Coordinators, The Collaborative and working group members at four LifeSpan sites in New South Wales (three metropolitan/regional, one regional/rural). Quantitative social network data was collected through an online survey and analysed using Gephi software. Qualitative data through focus groups and interviews with Lifespan Coordinators and community stakeholders.

Results

The social network survey was administered in three sites and was completed by 83 people. Data gave quantitative evidence of increased engagement across key stakeholders in each region who had not previously been working together. Nominations of other collaborators showed this network extended beyond the formal structures of The Collaborative. LifeSpan Coordinators were empirically identified as key players in the networks. Qualitative data was collected from 53 individuals (18 interviews and five focus groups) from across all sites. Participants identified benefits of this collaborative approach including greater capacity to run activities, better communication between groups, identification of “who’s who” locally, improvement in the integration of priorities, services and activities, and personal support for previously isolated members. LifeSpan Coordinators were key to the smooth running of The Collaborative. This may represent a risk to sustainability if they left. The collaboration model that suited metropolitan sites was difficult to sustain in rural sites, but gains were seen in better coordinated postvention efforts.

Conclusion

LifeSpan Coordinators were noted to be exceptional people who magnified the benefits of collaboration. Geographic proximity was a potent driver of social capital. Initial engagement with local stakeholders was seen as essential but time-consuming work in the implementation phase. Coordinators reported this important work was not always acknowledged as part of their formal role.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00524-z.

Developing a tailored implementation action plan for a suicide prevention clinical intervention in an Australian mental health service: A qualitative study using the EPIS framework

Background: Tailoring implementation strategies to local contexts is a promising approach to supporting implementation and sustainment of evidence-based practices in health settings. While there is increasing research on tailored implementation of mental health interventions, implementation research on suicide prevention interventions is limited. This study aimed to evaluate implementation and subsequently develop a tailored action plan to support sustainment of an evidence-based suicide prevention intervention; Collaborative Assessment and Management of Suicidality (CAMS) in an Australian public mental health service. Methods: Approximately 150 mental health staff working within a regional and remote Local Health District in Australia were trained in CAMS. Semi-structured interviews and focus groups with frontline staff and clinical leaders were conducted to examine barriers and facilitators to using CAMS. Data were analysed using a reflexive thematic analysis approach and mapped to the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and followed by stakeholder engagement to design a tailored implementation action plan based on a ‘tailored blueprint’ methodology. Results: A total of 22 barriers to implementing CAMS were identified. Based on the perceived impact on implementation fidelity and the feasibility of addressing identified barriers, six barriers were prioritised for addressing through an implementation action plan. These barriers were mapped to evidence-based implementation strategies and, in collaboration with local health district staff, goals and actionable steps for each strategy were generated. This information was combined into a tailored implementation plan to support the sustainable use of CAMS as part of routine care within this mental health service. Conclusions: This study provides an example of a collaborative approach to tailoring strategies for implementation on a large scale. Novel insights were obtained into the challenges of evaluating the implementation process and barriers to implementing an evidence-based suicide prevention treatment approach within a geographically large and varied mental health service in Australia. Plain language abstract: This study outlines the process of using a collaborative stakeholder engagement approach to develop tailored implementation plans. Using the Exploration Preparation Implementation Sustainment Framework, findings identify the barriers to and strategies for implementing a clinical suicide prevention intervention in an Australian community mental health setting. This is the first known study to use an implementation science framework to investigate the implementation of the clinical suicide prevention intervention (Collaborative Assessment and Management of Suicidality) within a community mental health setting. This work highlights the challenges of conducting implementation research in a dynamic public health service.

Understanding Emergency Department Healthcare Professionals' Perspectives of Caring for Individuals in Suicidal Crisis: A Qualitative Study

Help seekers regularly present to Emergency Departments (EDs) when in suicidal crisis for intervention to ensure their immediate safety, which may assist in reducing future attempts. The emergency health workforce have unique insights that can inform suicide prevention efforts during this critical junction in an individual's experience with suicide. This paper explores the treatment and care delivery experiences of 54 health professionals working in EDs within one of the LifeSpan suicide prevention trial sites in Australia. Data was collected via six focus groups and six interviews. Thematic analysis resulted in three themes: (1) physicality of the emergency department, (2) juggling it all-the bureaucracy, practicalities, and human approach to care, and (3) impact of care delivery on ED staff. Findings highlight the need for workplace training that incorporates responding to the uncertainty of suicidal crisis, to compliment the solution-focused medical model of care. Broader policy changes to the ED system are also considered to ensure better outcomes for health professionals and help-seekers alike.

Promoting Healthier Masculinities as a Suicide Prevention Intervention in a Regional Australian Community: A Qualitative Study of Stakeholder Perspectives

Regionally-based Australian men have a higher risk of suicide than those in urban centers, with similar trends observed internationally. Adopting a place-based approach to understanding men's suicide and harm prevention provides contextual insights to guide localised opportunities for the development of tailored gender-specific interventions. Men in rural Australia are typically portrayed as embodying idealized masculinity-dominant and tough, upholding strength and stoicism in the face of hardship. Such values can increase suicide risk in men by reducing help-seeking. The Macedon Ranges Shire is an inner regional municipality with a population of approximately 50,000 people spanning across 10 regional towns and surrounding farming areas in Victoria, Australia. Understanding the influence of masculinities on men's wellbeing and help seeking behaviours in a regional context is vital in order to inform effective local suicide prevention efforts. The present research involved in-depth qualitative interviews with 19 community stakeholders (M = 49.89 years, SD = 11.82) predominantly working in healthcare and community services including emergency services and education. Using thematic analysis, interview transcripts were coded and themes inductively derived. Stakeholders identified three key areas for understanding suicide risk and wellbeing for local men; 1) localizing masculinities, 2) belonging in community, and 3) engaging men. Findings illustrate that addressing men's wellbeing in regional areas requires a multifaceted whole-of-community approach. While diverse, local expressions of masculinities were seen as contributors to men's challenges understanding their emotional worlds and reticence for help-seeking. Of vital need is to provide diverse opportunities for men to connect with others in the region, and offer inclusive spaces where men feel accepted, welcomed and able to meaningfully contribute to the community. Not only will this assist by bolstering men's sense of self, identity, and mental wellbeing, it may also provide valuable informal inroads to normalizing healthy communication around mental health and seeking mental health care. These findings offer important suggestions for the promotion of healthier masculinities in regionally-based Australian men, which may help to improve wellbeing of these men and their entire communities.

The Colorado National Collaborative: A public health approach to suicide prevention

OBJECTIVE

Suicide rates in the United States have risen dramatically during the 21st century despite national, state and local level commitments to prevention, improvements in the development and delivery of evidence-informed prevention approaches, and advances in epidemiological capacity to identify areas for targeted intervention. Complex problems require comprehensive solutions. In Colorado, that solution is a comprehensive, integrated public health collaboration that aligns diverse community and programmatic efforts across the prevention continuum. The Colorado National Collaborative (CNC) is pursuing a real-world test of the public health approach to suicide prevention by helping community coalitions deliver a package of evidence-informed activities in geographically defined community systems.

METHODS

The CNC began by identifying six diverse Colorado counties with high suicide rates or number of deaths. Working closely with community, state, and national partners, CNC identified existing community-level risk and protective factors, programs, and policies. This process provided insight on the overlay between existing efforts and identified burden centers and drivers.

RESULTS

The CNC team identified six components for strategic implementation: (1) connectedness, (2) economic stability and supports, (3) education and awareness, (4) access to suicide safer care, (5) lethal means safety, and (6) postvention. Evaluation is being conducted through a collaborative, participatory, and empowerment approach that incorporates stakeholders as leaders in all aspects of the process.

CONCLUSION

The CNC includes data-driven identification of populations at risk of suicide, community identification of protective factors, and true collaboration between prevention experts at the national, state, and local level in implementing a comprehensive approach to prevention. Lessons learned are discussed.

The Youth Aware of Mental Health program in Australian Secondary Schools: 3- and 6-month outcomes

OBJECTIVE

The evidence base for suicide prevention programs in Australian schools is limited. The aim of this study was to examine the impact of a universal, mental health promotion and suicide prevention program-Youth Aware of Mental Health (YAM)-on suicidal ideation, mental health, and help-seeking in Australian secondary school students from baseline to post-intervention and 6-month follow up.

METHODS

Using a single-arm design, the YAM program was delivered to Year 9 students (13-16 years) in secondary schools located within four regions across New South Wales, Australia. A structured self-report questionnaire using validated scales was administered at each time point. Linear mixed-effects modelling was used to examine differences in suicidal ideation scores across time, while accounting for random effects of individual schools.

RESULTS

Suicidal ideation reduced significantly from baseline to post, and from baseline to follow-up (p < 0.001). Depression severity declined (p < 0.001) and help-seeking intentions increased (p < 0.001) at post-intervention and 6- months following the intervention period. No suicide deaths were reported for any study participants.

CONCLUSION

The current findings provide preliminary evidence that the YAM program is a promising preventive intervention for Australian schools, particularly for reducing suicidal ideation, depression and increasing help-seeking intentions in young people. The implementation of YAM in a large number of schools across New South Wales demonstrates the feasibility, and acceptability by schools, of implementing this program at scale.

TRIAL REGISTRATION

ANZCTR, ACTRN12619000338167. Registered 5 March 2019-Retrospectively registered, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376989&isReview=true .

"A Sustained, Productive, Constructive Relationship with Someone Who Can Help"-A Qualitative Exploration of the Experiences of Help Seekers and Support Persons Using the Emergency Department during a Suicide Crisis

For Australians experiencing a suicide crisis, the emergency department (ED) is the recommended point of contact for intervention and to ensure personal safety. However, negative ED experiences can deter individuals from returning, thus impacting future suicide risk. In order to improve the ED environment for individuals in suicidal crisis, an in-depth understanding of this experience is needed. In-depth semi-structured interviews with 17 help seekers and 16 support persons were conducted. A grounded theory approach uncovered a core organising concept—all participants wanted a “a sustained, productive, constructive relationship with someone who can help” during the ED visit—which guided analysis. Thematic analysis resulted in two themes and four subthemes exploring the systemic and interpersonal aspects of the ED visit and the roadblocks and pathways to development of the relationship. Interpersonal factors included aspects of staff interaction and presence of a support person. Systemic factors related to aspects controlled by the physical space and internal policies and procedures and included aspects such as the chaotic environment, long waiting times, and access to staff. Overwhelmingly, there were more roadblocks than pathways reported by participants. Improving the ED environment, increasing staff training and encouraging the presence of support persons may help mitigate some of these roadblocks.

A Qualitative Analysis of Motivators to Participation in Suicide-Focused Research from a Community-Based Australian Sample

Suicide prevention strategies internationally appear to be falling short of making a meaningful impact on global suicide deaths. Increasing the rates of general community participation in suicide research may improve knowledge generalisability as it relates to suicidal behaviour and leads to new suicide prevention approaches. This study aims to explore the motivations of a community-based sample to participate in suicide research. A subsample of the Australian general population took part in an online survey which is part of a multilevel suicide prevention trial. The survey concluded with an optional open-text question asking about peoples’ motivations for participating in the study; 532 participants left a response to this question. These responses were qualitatively analysed using Thematic Network Analysis. Motivations to participate in suicide research were represented by four global themes: altruism, solve systemic problems, lived experience, and personal benefit. Of these themes, three were focused on the benefit of others, while only the final theme articulated motivation to participate that was self-focused. The impact of suicide is felt throughout the wider community. This new understanding of the motivations of community-based samples to participate in suicide research should be used to increase participation rates and reach people who would not normally contribute their voice to suicide research.

Acceptability, Safety, and Resonance of the Pilot Digital Suicide Prevention Campaign "Better Off With You": Qualitative Study

Background

The Interpersonal Theory of Suicide posits that there are three key elements of suicidal behavior: perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide. The digital campaign Better Off With You was developed to directly challenge the idea of perceived burdensomeness among people who are contemplating suicide in 2 communities within Australia.

Objective

The aim of this study is to explore the needs and preferences of people with lived experience of suicidal thoughts and actions to inform the development of Better Off With You.

Methods

This study involved a series of focus groups that aimed to discuss campaign messaging, scope, and approach. People with lived experience of suicidal thoughts and actions attended the focus groups. After the completion of initial focus groups, the results informed the creation of campaign collateral by creative agencies. Early versions of the campaign collateral were then presented in the user testing sessions. Transcriptions were analyzed via thematic analysis.

Results

In total, 13 participants attended the focus groups and 14 attended the user testing sessions. The following three overarching themes were presented: acceptability, safety, and resonance. Participants believed that suicide is a serious and ongoing issue in their communities and welcomed a localized suicide prevention focus via peer-to-peer storytelling. The idea of perceived burdensomeness required clarification but was perceived as acceptable and relevant. Participants seemed drawn toward peer narratives that they perceived to be authentic, genuine, and believable as given by real people with lived experience. Campaign messaging needs to be clear and empathetic while directly talking about suicide. Participants did not anticipate any significant negative or harmful impact from any campaign videos and highlighted the importance of providing appropriate help-seeking information.

Conclusions

This iterative study provided important insights and knowledge about peer-to-peer storytelling in suicide prevention campaigns. Future campaigns should involve simple messaging, be validating and empathetic, and consider including a lived experience perspective.

Can Government Responses to Unemployment Reduce the Impact of Unemployment on Suicide?

Background: Unemployment is a well-documented risk factor for suicide. Findings from a number of studies suggest that government policy plays a crucial role in mediating the unemployment-suicide relationship. Aims: Our review was designed to assess whether government policies aimed at managing unemployment can moderate the impact of unemployment on suicide and self-harm. Method: A systematic search of the Medline, ProQuest, Scopus, and Web of Science databases was conducted. All original, English-language, peer-reviewed studies examining the impact of unemployment policy on rates of suicide or self-harm were eligible for inclusion. Results: Six unique studies were identified, each using an ecological design and suicide deaths as the outcome. Three of five studies looking at unemployment benefits found a negative association with suicide rates. Studies examining the impact of active unemployment policy and employment protection legislation found evidence of beneficial effects. The effects of the policies were small and had particular benefit in reducing suicide rates among men. Limitations: The ecological designs used may limit conclusions around causality. It is unclear whether the findings generalize to those in lower- and middle-income countries. Conclusion: The findings suggest that unemployment policies can mitigate the relationship between unemployment and suicide, particularly among men.

Performance, Cost-Effectiveness, and Representativeness of Facebook Recruitment to Suicide Prevention Research: Online Survey Study

BACKGROUND

Researchers are increasingly using social media advertisements to recruit participants because of their many advantages over traditional methods. Although there is growing evidence for the effectiveness and cost-effectiveness of social media recruitment in the health sciences, no studies have yet examined this in the context of suicide prevention, which remains to be a highly stigmatized and sensitive topic.

OBJECTIVE

This study aims to recruit a general community sample to complete a survey on suicide literacy, stigma, and risk via Facebook advertisements. Specifically, we aim to establish the performance of the advertisements, cost-effectiveness, sample representativeness, and the impact of gender-specific advertising on recruiting men into the study.

METHODS

From June 2017 to March 2019, we released Facebook advertisements targeted at adults 18 years or older, residing in the New South Wales (NSW) trial or control regions, and involved in the LifeSpan suicide prevention trial. Cost-effectiveness was examined descriptively using metrics provided by Facebook. Chi-square analyses were conducted to determine demographic differences between our sample and the general NSW population as well as the impact of gender-specific advertisements on gender engagement.

RESULTS

The 14 Facebook advertisement campaigns reached a total of 675,199 people, yielding 25,993 link clicks and resulting in 9603 individuals initiating the survey (7487 completions) at an overall cost of Aus $2.81 (US $2.01) per participant. There was an overrepresentation of younger (P=.003), female (P=.003), highly educated (P<.001) participants and mental health conditions (P<.001) compared with the total NSW population. The use of male-specific advertisements resulted in a significantly higher proportion of men completing the survey relative to gender-neutral advertisements (38.2% vs 24.6%; P<.001).

CONCLUSIONS

This study demonstrates the potential of Facebook to be an effective, low-cost strategy for recruiting a large sample of general community participants for suicide prevention research. Strategies to improve sample representativeness warrant further investigation in future research.

Study protocol for a mixed methods prospective cohort study to explore experiences of care following a suicidal crisis in the Australian healthcare system

INTRODUCTION

For individuals presenting to the emergency department (ED) for a suicide attempt, the period after discharge from hospital is marked by heightened vulnerability for further suicide attempts. Effective care following a suicidal crisis has the potential to significantly decrease this risk. The current study aims to examine the impact of the LifeSpan multilevel suicide prevention model on experiences of care following a suicidal crisis. Perspectives from healthcare consumers (individuals who have presented to the ED following a suicidal crisis), carers, and health professionals will be explored. The LifeSpan model is currently being evaluated as a high-fidelity trial in four geographically defined regions in New South Wales, Australia.

METHODS AND ANALYSIS

This study will use a mixed methods prospective cohort design. Quantitative data collection includes a structured survey, administered to healthcare consumers from LifeSpan sites and control sites. Two cohorts of healthcare consumers will be recruited 12 months apart with baseline assessment occurring within 18 months of the ED presentation, and follow-up 12 months after the initial assessment. Survey participants will be recruited online and through participating EDs, mental health organisations and aftercare services. Qualitative interview data from healthcare consumers, carers who have accompanied a loved one to the ED following a suicidal crisis and health professionals who provide care to people at risk of suicide will be collected concurrently with the recruitment of the first cohort of survey participants. Purposive and convenience sampling techniques will be used for recruitment of interview participants. The primary outcome for this study will be healthcare consumers' experiences of service provided at the ED. Analysis will be undertaken of the change over time within LifeSpan sites, as well as between LifeSpan sites and control sites, using mixed effects repeated measures models as principal means of data analysis.

ETHICS AND DISSEMINATION

This research has been approved by the Hunter New England Human Research Ethics Committee (HREC/17/HNE/144). Results will be disseminated via conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000457347.