Suicide prevention: a study of patients' views

A preliminary investigation of the relationship between internalized stigma, experiential avoidance, and suicidal thoughts and behaviors in college students

Objective: Examine the relationship between internalized stigma, experiential avoidance (EA), and suicidal thoughts and behaviors (STBs) in a sample of college students, and explore whether EA accounts for part of the relationship between internalized stigma, EA, and STBs.Participants: College students (N=78) completed online questionnaires about demographic information, internalized stigma, EA, and STBs.Results: A simple mediation model evaluated the indirect effect of internalized stigma on STBs through EA, controlling for the presence of a mental health disorder diagnosis. Results: Internalized stigma, STBs, and EA were all positively correlated. EA partially mediated the relationship between internalized stigma and STBs.Conclusion: Despite decades of research and prevention efforts, STBs remain a pervasive problem. There is an urgent need to identify modifiable predictors of STBs. Internalized stigma is a risk factor for STBs, and recent research suggests EA might be a mechanism linking internalized stigma and STBs. Our findings suggest EA might represent a modifiable mechanism of change in the context of both anti-stigmatization and suicide prevention programs.

Living with suicidal thoughts: A scoping review

BACKGROUND

There is a significantly higher number of people experiencing severe levels of suicidal thoughts compared to that of suicidal deaths and suicide attempts. In suicide prevention research, there is a shift towards greater emphasis on people's experiences of living with suicidal thoughts. This can expand the existing evidence base, which is dominated by a biomedical approach. The aim of this review was to summarise and disseminate existing research on the lived experiences of living with suicidal thoughts.

METHODS

A scoping review by Arksey & O'Malley consisting of six stages: (1) formulating the research question, (2) identifying relevant studies, (3) selecting studies, (4) mapping data, (5) summarising the results and (6) consulting stakeholders. PubMed, PsycINFO and CINAHL were searched for studies in English, Danish, Swedish and Norwegian. Peer-reviewed articles examining people's experiences of living with suicidal thoughts using qualitative methods were included. The search was supplemented with a citation pearl search in the Web of Science database. Twenty-eight studies were included.

RESULTS

The findings were organised under two thematic headings: (a) the significance of social connections and (b) a loss of the personal self.

CONCLUSION

There is a need for further qualitative research of people's experiences of living with suicidal thoughts from an everyday life perspective. Awareness about social connections and attachment in mental health prevention and governance is crucial. Trauma-informed care could be a useful approach to prevent suicidal thoughts as the review found that many participants had traumatic experiences in both childhood and adulthood. As part of the treatment of suicidal thoughts, it might be useful to have a focus on narrative and communicative methods and their clinical application.

Finished with Life Anyway and Then Stigmatized for Attempting Suicide-An Overview

This article provides an overview of suicide and how society deals with it. Starting from early societal imprints through historical, religious and political influences, the origins of stigmatization are addressed. Even today, suicidal people experience stigmatization not only from society but also from the health system that treats suicidal people. This has far-reaching consequences for the people affected and runs counter to optimal treatment. Different approaches to a possibly improved handling of suicidality will be discussed.

Clinicians' Perspectives on Self-Harm in Pakistan: A Qualitative Study

Background: Suicide is a serious public health problem, ranked amongst the leading causes of death worldwide. There are no official data on self-harm and suicide in Pakistan; both are illegal acts, and are socially and religiously condemned. This study explored the views of clinicians, including general practitioners (GPs) and hospital physicians (HPs) on self-harm, about their management of people who self-harm and what interventions might be appropriate in Pakistan. Methods: This qualitative study, generating data using semi-structured interviews, was nested within a Randomized Controlled Trial (RCT) of a psychosocial intervention for people following self-harm. Clinicians (n = 18) with experience of treating people who self-harm were recruited from public hospitals and general practices. Results: Face-to-face interviews were conducted in Urdu and digitally recorded with consent, transcribed and translated into English. Transcripts were checked for cultural and interpretive interpretations by the research team, then analyzed thematically using the principles of constant comparison. The following themes will be presented: encountering people with self-harming behaviors; challenges encountered in managing people who self-harm; barriers to accessing care, and what ideal care might look like. Participants identified their lack of training and expertise in the management of people with self-harm behavior. Conclusions: This is the first study to explore clinicians' perspectives on self-harm in Pakistan. The study highlighted the need for training for doctors in the identification and management of mental health problems, including the management of people who self-harm.

Cultural Differences in Reactions to Suicidal Ideation: A Mixed Methods Comparison of Korea and Australia

There is evidence for cultural differences in mental health symptoms and help-seeking, but no past research has explored cultural differences in how people react to suicidal ideation communicated by others. Layperson reactions are critical, because the majority of people who experience suicidal ideation disclose to friends or family. Participants were 506 people aged 17-65 recruited from Australia and Korea who completed an experiment in which they responded to a friend who was experiencing either subclinical distress or suicidal ideation. Korean participants did not differentiate between the subclinical and suicidal targets, whereas Australian participants showed more concern for the suicidal target. For both targets, Korean participants were more likely to recommend passive coping strategies ("Time will solve everything" or "Cheer up"), while Australian participants were more likely to recommend active coping strategies ("Let's talk" or "See a doctor"). This study provides the first evidence of cultural differences in the way people typically respond to disclosures of suicidal ideation, and suggests that unhelpful and inappropriate recommendations are commonplace.

God Bless You? The Association of Religion and Spirituality with Reduction of Suicide Ideation and Length of Hospital Stay among Psychiatric Patients at Risk for Suicide

OBJECTIVE

Religion and spirituality (R&S) were protective against suicidal behavior in the majority of studies. In prospective studies, R&S were associated with improved outcome for patients with depression, a main risk factor for suicide. Thus, R&S may also improve recovery from suicidal crisis, but related data is lacking.

METHOD

We explored how aspects of R&S were associated with reduction of suicide ideation and length of hospital stay among 351 patients admitted to a psychiatric crisis intervention ward specialized in suicide prevention. We analyzed the results separately by gender and sexual orientation due to the known specific effects of R&S in these groups.

RESULTS

Overall, there were only small and non-significant associations between R&S and reduction of suicide ideation and length of hospital stay. For heterosexual men, some R&S variables were associated with less optimal outcome. Contrary to our hypothesis, R&S were not less or even more beneficial for sexual minority than heterosexual patients.

CONCLUSIONS

Religion and spirituality were not or only weakly associated with improvement of suicide ideation and shorter hospital stay. Further studies are needed to account for selection biases and other limitations in our study. Based on our findings, R&S may not be major sources to recover from suicidal crisis in a psychiatric setting.

Understanding and Addressing the Treatment Gap in Mental Healthcare: Economic Perspectives and Evidence From China

A common challenge faced by the healthcare systems in many low- and middle-income countries is the substantial unmet mental healthcare needs, or the large gap between the need for and the provision of mental healthcare treatment. This paper investigates the potential causes of this treatment gap from the perspective of economics. Specifically, we hypothesize that people with mental illness face 4 major hurdles in obtaining appropriate healthcare, namely the high nonmonetary cost due to stigma, the high out-of-pocket payment due to insufficient public funds devoted to mental health, the high time costs due to low mental healthcare resource availability, and the low treatment benefit due to slow technology diffusion. We use China as a study setting to show country-specific evidence. Our analysis supports the above theoretical argument on the 4 barriers to access, which in turn sheds light on the effective approaches to mitigate the treatment gap. Four policy options are then discussed, including an information campaign for mental health awareness, increasing public investment in primary mental healthcare resources, transforming the healthcare system towards an integrated people-centered system and capitalizing on e-health technologies.

The relationship between post-traumatic stress disorder and suicidal ideation among shidu parents: the role of stigma and social support

BACKGROUND

Losing an only child is a particularly traumatic and heartbreaking event for parents, which can trigger a lot of emotional responses, including PTSD and suicidal ideation (SI). The objectives of this study were mainly to identify predictors of SI and examine the interactions of PTSD with stigma and social support on SI among shidu parents.

METHODS

A total of 507 shidu parents from Shenyang, China were included in this cross-sectional study. Bivariate logistic regression analyses were conducted to explore risk or protective factors associated with SI. Interactions of PTSD with stigma and social support on SI were also examined by bivariate logistic regression analyses.

RESULTS

The prevalence of SI among shidu parents was 11.24%. PTSD (OR = 2.23, p < 0.05) and stigma (OR = 4.66, p < 0.01) were positively associated with SI. Social support was negatively associated with SI (OR = 0.90, p < 0.01). For individuals with PTSD, the presence of stigma was more likely to lead to SI. For individuals with PTSD, an increased level of social support was less likely to lead to SI.

CONCLUSIONS

SI is a serious issue among shidu parents. Stigma aggravated the effect of PTSD on SI, while social support buffered the effect of PTSD on SI among shidu parents.

Suicide literacy predicts the provision of more appropriate support to people experiencing psychological distress

Mental health literacy has been hailed as a public health priority to reduce stigma and increase help seeking. We examined the effect of suicide literacy on the type of help provided to those experiencing suicidal ideation. A community sample of 363 Australians were randomly assigned to read one of three messages from a member of their social network (the target). The target reported symptoms consistent with either (1) subclinical distress, (2) clinical depression, or (3) suicidal ideation. Participants were most likely to recommend social support and least likely to recommend professional help. Suicide literacy interacted with the target's presentation, such that participants with higher suicide literacy who considered a suicidal target were less likely to recommend self-help or no action, and more likely to recommend professional help. Suicide literacy was also associated with lower suicide stigma, and unexpectedly, this indirectly predicted more reluctance to recommend professional help. Overall, results indicated that the relationship between mental health literacy, stigma, and provision of help is not straightforward. While suicide literacy was associated with greater sensitivity to a person's risk of suicide, it also predicted fewer recommendations for professional help overall, partly due to the stigma associated with seeking professional help.

Stigma Towards Depression in Rural Ireland: A Qualitative Exploration

The configuration of one's social environment influences the course and experience of depression. Research suggests that experiencing depression is associated with stigmatisation and the concomitant experiencing of discrimination across many facets of social life. This is identified as a particularly important factor in rural communities. Contemporary work is absent in relation to understanding the stigma towards depression in Ireland, and its manifestation in rural Ireland specifically. Evidence is presented which suggests that depression is a significant source of stigmatisation in this setting, and that entrenched views centring upon disability and fear are prevalent.

The Reciprocal Relationship between Suicidality and Stigma

INTRODUCTION

Although suicidality is frequently the cause of stigma, it is conversely true that stigma may be the cause of suicidality. The present paper focuses on the complex relationships that exist between suicidal behavior and stigmatizing attitudes.

METHODS

A narrative review of the topic will be presented on the basis of the relevant literature collected from an electronic search of PubMed, ISI Web of Knowledge, and Scopus databases, using stigma, public stigma, structural stigma, perceived stigma, self-stigma, suicide, attempted suicide, and suicidality as key words.

RESULTS

A negative perception is frequently held of suicidal people, labeling them as weak and unable to cope with their problems, or selfish. Individuals who have attempted suicide are subject to similar processes of stigmatization and "social distancing"; insurance policies include an exclusion clause against death by suicide. Subjects with a direct personal experience of depression or suicide strongly endorse a feeling of self-stigma; those who have attempted suicide are often ashamed and embarrassed by their behavior and tend to hide the occurrence as much as possible. Similar processes are observed among family members of subjects who have committed suicide or made a suicide attempt, with a higher perceived stigma present in those bereaved by suicide. Perceived or internalized stigma produced by mental or physical disorders, or through belonging to a minority group, may represent a significant risk factor for suicide, being severely distressing, reducing self-esteem and acting as a barrier in help-seeking behaviors.

CONCLUSION

With the aim of preventing suicide, greater efforts should be made to combat the persisting stigmatizing attitudes displayed toward mental disorders and suicide itself. Indeed, the role of stigma as a risk factor for suicide should further motivate and spur more concerted efforts to combat public stigma and support those suffering from perceived or internalized stigma. Experts and scientific societies should form an alliance with the media in an effort to promote a marked change in the societal perception of mental health issues and suicide. As stigma may result in severe consequences, specialist care and psychological interventions should be provided to populations submitted to stigma.

Patients' Experiences After Attempted Suicide: A Literature Review

The aim of this study has been to synthesize research on suicidal patients' experiences of the suicide process. A literature search was performed in CINAHL, PubMed, and PsycINFO, and the analysis of the 15 articles covered was based on meta-synthesis. Patients experience a wide variety of feelings regarding their situation during the suicide process, and these exist on two levels: they relate to the different aspects of care that the patients receive and the patients' need to communicate with others and regain hope. The patients in this study described the struggle to maintain hope when life became too difficult and their suffering despite a sense of security, and they sought to achieve emotional balance. A good understanding of how suicidal individuals live with and manage suicidal ideation, while maintaining hope is important for planning effective nursing care. Further research from the patient perspective is needed to further develop psychiatric care for people at risk of suicide.

Stigma and suicidal ideation among young people at risk of psychosis after one year

Suicidality is common among individuals at risk of psychosis. Emerging findings suggest that mental illness stigma contributes to suicidality. However, it is unclear whether stigma variables are associated with suicidality among young people at risk of psychosis. This longitudinal study assessed perceived public stigma and the cognitive appraisal of stigma as a stressor (stigma stress) as predictors of suicidal ideation among individuals at risk of psychosis over the period of one year. One hundred and seventy-two participants between 13 and 35 years of age were included who were at high or ultra-high risk of psychosis or at risk of bipolar disorder. At one-year follow-up, data were available from 73 completers. In multiple logistic regressions an increase of stigma stress (but not of perceived stigma) over one year was significantly associated with suicidal ideation at one-year follow-up, controlling for age, gender, symptoms, comorbid depression and suicidal ideation at baseline. Interventions to reduce public stigma and stigma stress could therefore improve suicide prevention among young people at risk of psychosis.

Supporting young people who repeatedly self-harm

This paper explores the views and experiences of a group of 74 young people aged 16-22 who were interviewed following presentation in accident and emergency (A&E) departments after intentionally harming themselves. It focuses on a sub-group of 38 young people with a history of self-harm behaviour that extended from when they were under the age of 16, one-third of whom had been or were currently in care. Whilst some had kept their self-harming hidden and had not received any professional intervention until they reached adulthood, others had been in touch with services, although their treatment had not prevented them from continuing to self-harm. Medication was perceived as ‘fobbing off’, particularly when unaccompanied by other treatments. The young people described their encounters with counsellors and clinicians, some of whom they perceived not to understand or to listen to their perspective. Whilst not representative of all young people who self-harm, these views are important and deserve attention if interventions for children and adolescents are to prevent repetition of self-harm.

Experiences that inspire hope: Perspectives of suicidal patients

Background:

Suffering in a suicidal crisis includes feelings such as despair, loneliness, anxiety, fear, shame, guilt and hopelessness. This study highlights the experiences of patients in the aftermath of suicide attempts. The research question was, what do suicidal patients see as meaningful help in care and treatment situations?

Methodology:

The methodology is inspired by Gadamer’s hermeneutics, where the parts are understood in light of the whole, and the whole is understood in light of the parts. Qualitative interviews were employed.

Participants and research context:

A total of 10 persons, 4 women and 6 men 21–52 years old, were informed and asked to participate by specialists in psychology at two emergency psychiatric wards and by one crisis resolution team. Nine of the participants had experienced one or more suicide attempts using drugs and alcohol. Forced hospitalization prevented one of the 10 participants from attempting suicide.

Ethical considerations:

Before the participants signed an informed consent form, the interviewer met all participants to provide the written information, talking about the interview. A meeting to terminate contact was arranged after the participants had read their own interviews.

Findings:

Three themes were generated by the methodology we applied: (1) experiencing hope through encounters, (2) experiencing hope through the atmosphere of wisdom and (3) experiencing a ray of hope from taking back responsibility.

Discussion:

The findings are discussed in the light of Eriksson’s suffering theory and Lindström’s theory about psychiatric care, as well as earlier research and theories about suicidality.

Conclusion:

The study reinforces possibilities that hope in suicidal patients can be inspired in encounters with healthcare personnel and within caring cultures. Through dialogue and cooperation, patients’ safety and ability to cope with suffering is created and thereby the hope and will to struggle for life.

Comparing Self-stigma Between People With Different Mental Disorders in Taiwan

Internalized stigma (or self-stigma), one of the most painful effects of stigma, causes people with mental health problems profound negative consequences, for example, psychological adversity, demoralization, and feelings of hopelessness. However, knowledge about self-stigma in people with different mental disorders is insufficient. We hypothesized that people with different psychiatric diagnoses have different levels of self-stigma. Through convenience sampling, we used the Internalized Stigma of Mental Illness Scale to compare people diagnosed with schizophrenia (n = 161), depressive disorder (n = 98), bipolar disorder (n = 43), and anxiety disorder (n = 45) in southern Taiwan. We found that people with schizophrenia (mean, 2.09-2.30) and those with bipolar disorder (mean, 2.16-2.38) had significantly higher levels of self-stigma, except for the Stigma Resistance, than did those with anxiety disorder (mean, 1.74-1.87). Our results suggest that clinicians should use different interventions to reduce self-stigma for populations with different psychiatric diagnoses.

Cognitive therapy for internalised stigma in people experiencing psychosis: A pilot randomised controlled trial

We aimed to evaluate the feasibility of Cognitive Therapy (CT) as an intervention for internalised stigma in people with psychosis. We conducted a single-blind randomised controlled pilot trial comparing CT plus treatment as usual (TAU) with TAU only. Participants were assessed at end of treatment (4 months) and follow-up (7 months). Twenty-nine participants with schizophrenia spectrum disorders were randomised. CT incorporated up to 12 sessions over 4 months (mean sessions=9.3). Primary outcome was the Internalised Stigma of Mental Illness Scale - Revised (ISMI-R) total score, which provides a continuous measure of internalised stigma associated with mental health problems. Secondary outcomes included self-rated recovery, internalised shame, emotional problems, hopelessness and self-esteem. Recruitment rates and retention for this trial were good. Changes in outcomes were analysed following the intention-to-treat principle, using ANCOVAs adjusted for baseline symptoms. There was no effect on our primary outcome, with a sizable reduction observed in both groups, but several secondary outcomes were significantly improved in the group assigned to CT, in comparison with TAU, including internalised shame, hopelessness and self-rated recovery. Stigma-focused CT appears feasible and acceptable in people with psychosis who have high levels of internalised stigma. A larger, definitive trial is required.

Pathways between stigma and suicidal ideation among people at risk of psychosis

Mental illness stigma may contribute to suicidality and is associated with social isolation and low self-esteem among young people at risk of psychosis. However, it is unclear whether mental illness stigma contributes to suicidality in this population. We therefore examined the associations of self-labeling and stigma stress with suicidality among young people at risk. Self-labeling as "mentally ill", stigma stress, social isolation, self-esteem, symptoms and suicidal ideation were assessed in 172 individuals at risk of psychosis. Self-labeling and stigma stress were examined as predictors of suicidality by path analysis. Increased self-labeling as "mentally ill" was associated with suicidality, directly as well as indirectly mediated by social isolation. More stigma stress was related to social isolation which in turn was associated with low self-esteem, depression and suicidal ideation. Social isolation fully mediated the link between stigma stress and suicidal ideation. Interventions to reduce the public stigma associated with risk of psychosis as well as programs to facilitate non-stigmatizing awareness of at-risk mental state and to reduce stigma stress among young people at risk of psychosis might strengthen suicide prevention in this population.

Social Stigma Toward Suicide: Effects of Group Categorization and Attributions in Korean Health News

The purpose of this study is to examine the influence of health news content on the stigma of suicide. In particular, this study tested whether the onset controllability and group categorization had a causal effect on people's stigma toward suicide. The results indicated that stigma scores were lower for those who read an article explaining the causes of suicide as uncontrollable than for those who read an article explaining the causes as controllable. Also, lower stigma scores were observed for those who read an article depicting suicidal people as the in-group compared to those who read an article depicting suicidal people as the out-group. Furthermore, stigma scores were the highest for those exposed to an article with the out-group categorization combined with the controllable causes of suicide.

The link between mental health-related discrimination and suicidality: service user perspectives

BACKGROUND

Suicide is a major global public health issue. Mental illness is a risk factor for suicide, but as many individuals with a diagnosed mental health problem do not experience suicidal ideation or attempt suicide, other individual and societal factors must be considered. Mental illness-related discrimination is one potential risk factor.

METHOD

Using mixed methods, the influence of discrimination on suicidality amongst 194 individuals diagnosed with depression, bipolar or schizophrenia spectrum disorders was investigated. Qualitative interviews with a sub-sample of 58 individuals who reported a link between experience of discrimination and suicidality were analysed using framework analysis. Quantitative methods were used to examine the model derived from qualitative analyses.

RESULTS

Results indicate that the experience of discrimination led 38% of the overall sample of 194 participants, to suicidal feelings and 20% reported that it contributed to making a suicide attempt. The qualitative model derived from interviews with a sub-sample of 58 participants suggested that the experience of discrimination is experienced as a stressor that exceeds coping resources, leading to a negative self-image and a perception of decreased supportive networks/social structure. The anticipation of further negative events and treatment, and the perception of a lack of supportive networks led individuals in this study to feelings of hopelessness and suicidality. Quantitative analyses provided support for the model.

CONCLUSIONS

These data suggest that both psychological therapies aimed at improving coping skills and population-level anti-stigma interventions that reduce the occurrence of discrimination may provide some protection against suicide amongst individuals with mental health problems.

"It's Either Do It or Die"

Abstract. Background: The role of self-management of suicidality was investigated as part of a larger qualitative study of suicidality among people with experience of mental illness in New Zealand. Aims: To understand how people self-manage suicidality, why they self-manage, and the effects that self-management may have on suicidal thoughts and behavior. Method: Twenty seven people with experience of mental illness and suicidality were interviewed. A narrative thematic analysis was performed. Results: People had either drifted into self-management (while still using or instead of using mental health services) or chosen self-management because they were unhappy with mental health services, desired independence, or had difficulty accessing services. Self-management of suicidality included: using active ways to reduce, distract, and protect themselves from suicidal thoughts and feelings; practical ways of looking after themselves; reframing thoughts; getting to know themselves better; and peer support. Conclusion: Self-management of suicidality can encourage independence and resilience, a sense of citizenship, mutuality, and achievement.

A qualitative investigation into the relationships between social factors and suicidal thoughts and acts experienced by people with a bipolar disorder diagnosis

BACKGROUND

The prevalence rate of completed suicide in bipolar disorder is estimated to be as high as 19%. Social factors or influences, such as stigmatisation and family conflict, contribute to the development of suicidal ideation in clinical and non-clinical populations. Yet, there is a lack of studies examining suicidality from a psychosocial perspective in people who experience bipolar disorder.

METHOD

Semi-structured interviews were used to collect qualitative data from 20 participants with bipolar disorder. The interview focused on the effects of social factors upon participants׳ experiences of suicidality (suicidal thoughts, feelings or behaviours). A thematic analysis was used to understand the data.

RESULTS

Social or interpersonal factors which participants identified as protective against suicidality included, 'the impact of suicide on others' and, 'reflecting on positive social experiences'. Social factors which triggered suicidal thoughts included, 'negative social experiences' and, 'not being understood or acknowledged'. Social factors which worsened suicidal thoughts or facilitated suicidal behaviour were, 'feeling burdensome,' and 'reinforcing negative self-appraisals'.

LIMITATIONS

Some participants had not experienced suicidal thoughts for many years and were recalling experiences which had taken place over ten years ago. The accuracy and reliability of these memories must therefore be taken into consideration when interpreting the results.

CONCLUSIONS

The themes help to enhance current understanding of the ways in which social factors affect suicidality in people who experience bipolar disorder. These results highlight the importance of considering the social context in which suicidality is experienced and incorporating strategies to buffer against the effects of negative social experiences in psychological interventions which target suicide risk in bipolar disorder.

Crucial resources to strengthen the desire to live

Background:

Suicidality is a life-and-death struggle in deep loneliness and psychological pain. There is a lack of knowledge about what could help the suicidal patients’ struggle for continued life. The aim of this study was to develop a deeper understanding of suicidal patients in the aftermath of suicidal attempts. The research question was ‘What resources in the person himself or herself and his or her surroundings are crucial in a suicidal crisis to maintaining the will to live and hope for life’?

Methodology:

The study has a hermeneutic approach and an explorative design. Data were collected using semi-structured interviews with 10 participants: men and women 21–52 years of age. The context was two emergency psychiatric units and one crisis resolution team.

Ethical considerations:

The participants signed an informed consent before the interviews were conducted.

Findings:

This article presents three themes: (a) becoming aware of the desire to live, (b) an experience of connectedness and (c) someone who cares.

Discussion:

The suicidal person’s awareness of wishes, dreams, hopes and will, but also of their feelings in the aftermath of the suicide attempt, seemed to play a crucial role in a suicidal crisis. Experiences of connectedness remind the person of the responsibility in his or her own life and in the lives of others and seemed to strengthen the urge to go on. Private and professional relationships seem to be crucial in stimulating the desire and hope to go on living.

Conclusion:

Becoming aware of the desire to live, being connected to others and experiencing someone who cares is necessary for life. Both private and professional networks seemed to be important resources that could remind the suicidal person of his or her own dignity as part of being human.

Does the stigma of mental illness contribute to suicidality?

Mental disorders are associated with suicidality and with stigma. Many consequences of stigma, such as social isolation, unemployment, hopelessness or stress, are risk factors for suicidality. Research is needed on the link between stigma and suicidality as well as on anti-stigma interventions and their effects on suicidality.

Suicide prevention as a prerequisite for recovery from severe mental illness

For a significant number of people suffering from severe mental illness (SMI) prevention of suicide is a prerequisite for their recovery. This review summarises and interprets risk/protective factors for suicide in the context of schizophrenia and bipolar disorder, thereby enabling evidence-based suicide risk assessment and management. A history of self-harm greatly increases suicide risk among people with schizophrenia or bipolar disorder. Suicide prevention for patients with SMI necessitates constant vigilance by (mental) health and social care professionals in contact with them, particularly those with a history of self-harm, males, young people, those near illness onset, people with a family history of suicidal behaviour (especially suicide), victims of childhood abuse, those challenged by recent adverse life events (notably interpersonal conflict), people with aggressive/impulsive personality features, and those who have expressed hopelessness. Research suggests that suicide risk associated with SMI should be reduced by early intervention, restricting access to lethal means, improvement of treatment adherence, treating more patients with clozapine and lithium, assertive outreach, treating psychiatric comorbidity (depression, alcohol/drug misuse, etc.), 24-hour crisis care, timely (compulsory) hospitalization (sufficient bed provision imperative), improving psychiatric inpatient ward safety, lowering the risk of absconding from wards, appropriate use of electroconvulsive therapy, intensive follow-up postdischarge, and improving access to psychological/psychosocial interventions, notably cognitive behavioural therapy. The clinical interview is the optimum method of suicide risk assessment and locally developed risk assessment tools should not be used. Evidence-based suicide risk assessment/management within primary care and secondary mental health services warrants recurrent, mandatory training.

'Individualism-collectivism' as an explanatory device for mental illness stigma

The aim of this study is investigate whether the cross-cultural value paradigm 'individualism-collectivism' is a useful explanatory model for mental illness stigma on a cultural level. Using snowball sampling, a quantitative questionnaire survey of 305 individuals from four UK-based cultural groups (white-English, American, Greek/Greek Cypriot, and Chinese) was carried out. The questionnaire included the 'Community Attitudes to Mental Illness scale' and the 'vertical-horizontal individualism-collectivism scale'. The results revealed that the more stigmatizing a culture's mental illness attitudes are, the more likely collectivism effectively explains these attitudes. In contrast, the more positive a culture's mental illness attitudes, the more likely individualism effectively explains attitudes. We conclude that a consideration of the individualism-collectivism paradigm should be included in any future research aiming to provide a holistic understanding of the causes of mental illness stigma, particularly when the cultures stigmatization levels are particularly high or low.

Callers' experiences of contacting a national suicide prevention helpline: report of an online survey

BACKGROUND

Helplines are a significant phenomenon in the mixed economy of health and social care. Given the often anonymous and fleeting nature of caller contact, it is difficult to obtain data about their impact and how users perceive their value. This paper reports findings from an online survey of callers contacting Samaritans emotional support services.

AIMS

To explore the (self-reported) characteristics of callers using a national suicide prevention helpline and their reasons given for contacting the service, and to present the users' evaluations of the service they received.

METHODS

Online survey of a self-selected sample of callers.

RESULTS

1,309 responses were received between May 2008 and May 2009. There were high incidences of expressed suicidality and mental health issues. Regular and ongoing use of the service was common. Respondents used the service for complex and varied reasons and often as part of a network of support.

CONCLUSIONS

Respondents reported high levels of satisfaction with the service and perceived contact to be helpful. Although Samaritans aims to provide a crisis service, many callers do not access this in isolation or as a last resort, instead contacting the organization selectively and often in tandem with other types of support.

Social injury: An interpretative phenomenological analysis of the attitudes towards suicide of lay persons in Ghana

One way of furthering our understanding of suicidal behaviour is to examine people's attitudes towards it and how they conceive the act. The aim of this study was to understand how lay persons conceive the impact of suicide on others and how that influences their attitudes towards suicide; and discuss the implications for suicide prevention in Ghana. This is a qualitative study, using a semi-structured interview guide to investigate the attitudes and views of 27 lay persons from urban and rural settings in Ghana. Interpretative Phenomenological Analysis was used to analyse the data. Findings showed that the perceived breach of interrelatedness between people due to suicidal behaviour influenced the informants' view of suicide as representing a social injury. Such view of suicide influenced the negative attitudes the informants expressed towards the act. The negative attitudes towards suicide in Ghana are cast in consequential terms. Thus, suicide is an immoral act because it socially affects others negatively. The sense of community within the African ethos and The Moral Causal Ontology for Suffering are theoretical postulations that are used to offer some explanations of the findings in this study.

The meanings of suicidal behaviour to psychology students in Ghana: a qualitative approach

The objective of this study was to examine psychology students' attitudes toward suicidal behaviour and the meanings they assign to the act. In-depth interviews were conducted with 15 final year psychology students at a university in Ghana. Interpretative Phenomenological Analysis (IPA) was used to analyze the data. The results indicated that the students had a generalized negative attitude toward suicide. Religious beliefs and family harmony are cultural contexts influencing the interpretation of suicidal behaviour as breach of divine and communal moralities. The implications of these meanings of suicidal behaviour for suicide prevention in Ghana are discussed.

A two-year cross-sectional study on the information about schizophrenia divulged by a prestigious daily newspaper

Media is an important source of information about mental health for the public. The current study analyzed the information about schizophrenia divulged by the largest Brazilian newspaper. A content analysis examined articles on health and news involving affected individuals or suspected cases. The articles were rated against indicators of poor quality reporting and of effective health communication. The presence of myths was examined. The search identified 687 articles, 75 of which fulfilled the inclusion/exclusion criteria and were selected. The themes with the highest number of articles were mental disorders and violence, treatment, and etiology. Three articles described the social inclusion stories of affected individuals. The coverage addressed genetic factors, drug-induced psychosis risk, and antipsychotic benefits, which may contribute to stigma reduction toward treatment. However, the articles divulged stigmatizing messages, and the entire complexity of the disorder was not discussed. Dangerousness was a common theme, which may invalidate positive messages about social inclusion.

Suicide in later life: public health and practitioner perspectives

OBJECTIVES

Suicide in later life is a public health concern. Given the need for practical guidance and policy implementation, this paper aims to provide a critical interpretive synthesis approach to prioritize the likely relevance of publications and the contribution that they make to understanding of the problem.

METHODS

A selective review of the English language literature focusing on the epidemiology of suicide among older people was conducted; the search strategy built on that of a previous review. Papers were selected for their ability to shed light on the potential for prevention and practice from public health perspectives.

RESULTS

Whilst the majority of older people who commit suicide have major depression, suicide seems to be due to a combination of personality factors and co-morbidities, including chronic pain and disablement. Complex multi-component public health studies are underway and are likely to provide useful knowledge to guide practice more precisely, but there is remarkably little information about the involvement of older people in risk reduction or about harm minimization approaches at patient and public participation levels.

CONCLUSIONS

For lack of sufficient evidence from intervention trials that are specific to older people, practitioners need to extrapolate from studies of younger adults and be aware of risk factors for suicide in later life. Public health approaches combined with practitioners' experiences of older people at risk may help minimize the risks of suicide in later life. These are fruitful areas for collaborative practice development, service initiatives, evaluation, and research.

Relations of internalized stigma with temperament and character in patients with schizophrenia

OBJECTIVE

The aim of the study was to assess the associations between self-stigma and temperament and character dimensions.

METHODS

One hundred twenty outpatients with diagnosis of schizophrenia, established with Mini International Neuropsychiatric Interview were consecutively included in the study. Self-stigma was assessed with Internalized Stigma of Mental Illness (ISMI), personality dimensions with Temperament and Character Inventory, and psychopathology with Positive and Negative Symptom Scale.

RESULTS

The results showed that higher level of harm avoidance, lower self-directedness, and persistence correlated with ISMI and all its subscales. Self-transcendence correlated with ISMI subscales alienation, discrimination, and stigma resistance. Regression analyses controlling for psychopathology, age, length of illness, and number of hospitalizations revealed that higher level of harm avoidance and low self-directedness predicted internalized stigma.

CONCLUSION

The finding suggests that the experience of self-stigma is related to personality dimensions. Interpretations of these findings include the possibility that, irrespective of patients' psychopathology or functional characteristics, experience of self-stigma and its consequences might depend on personality dimensions. Further studies are needed.

Suicide Prevention Public Service Announcements

Background: Determining optimal methods for preventing suicide continues to be an elusive goal. Aims: The study examines benefits and possible untoward effects of public service announcements (PSAs) for young adults. Methods: Young adult participants (N = 279) were randomly assigned to one of three conditions: (a) a billboard simulation, (b) a 30-s TV ad simulation, and (c) a no-information condition. Results: Largely replicating a study previously conducted with adolescents, the results provided some evidence of the benefit of the simulated TV ad (e. g., increased knowledge, perceived as useful), but it also provided some evidence of untoward effects for the billboard (e. g., viewers were less likely to endorse help-seeking strategies, normative beliefs were altered for high-risk participants). Conclusions: These results are preliminary but nevertheless highlight the need for carefully researching existing messages prior to market diffusion, so that the well-intended efforts of preventionists can meet their desired goals.

Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom

BACKGROUND

Little is known about variables associated with suicidality in veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF).

METHODS

A total of 272 OEF/OIF veterans completed a survey containing measures of psychopathology, resilience, and social support. Thirty-four respondents (12.5%) reported contemplating suicide in the two weeks prior to completing the survey.

RESULTS

Suicide contemplators were more likely to screen positive for posttraumatic stress disorder (PTSD), depression, and an alcohol problem, and scored higher on measures of psychosocial difficulties, stigma, and barriers to care, and lower on measures of resilience and social support. Logistic regression analysis revealed that positive PTSD and depression screens, and increased psychosocial difficulties were associated with suicidal ideation, and that increased postdeployment social support and sense of purpose and control were negatively associated with suicidal ideation.

CONCLUSIONS

Interventions for PTSD, depression, and psychosocial difficulties, and to bolster postdeployment social support and resilience may be helpful in preventing suicidal ideation in OEF/OIF veterans.

Stigmatization of eating disorders: a controlled study of the effects of the television show Starved

Starved is a situational comedy ("sitcom") that depicted individuals with eating disorders that was feared to increase stigma. Our study directly examined this possibility by randomly assigning participants to watch Starved or The Comeback (a sitcom unrelated to eating disorders) and measuring eating disorder stigma/stereotypes before and after viewing. Participants who viewed Starved did not show increased levels of stigma, suggesting that short-term exposure to an extreme portrayal of eating disorder stereotypes may not increase stigma. Future research should examine prolonged exposure and other potential sources of these negative attitudes.

How people live with or get over being suicidal: a review of qualitative studies

AIM

To systematically review qualitative research which addresses how people live with suicidality or recover a desire to live.

BACKGROUND

Suicide is a pressing social and public health problem. Much emphasis in suicide research has been on the epidemiology of suicide and the identification of risk and protective factors. Relatively little emphasis has been given to the subjective experiences of suicidal people, but this is necessary to inform the care and help provided to individuals.

DATA SOURCES

Electronic searches of CINAHL Plus with full text, Medline and PsychArticles (included PsycINFO, Social Services Abstracts and Sociological abstracts) were undertaken for the period from 1997 to April 2007. In addition, the following journals were hand searched (1997-2007): 'Mortality', 'Death Studies', 'Archives of Suicide Research' and 'Crisis: The Journal of Crisis Intervention and Suicide Prevention'.

METHOD

A systematic review of the literature and thematic content analysis of findings. The findings were extracted from selected papers and synthesized by way of content analysis in narrative and tabular form.

FINDINGS

Twelve studies were identified. Analysis revealed a number of interconnected themes: the experience of suffering, struggle, connection, turning points and coping.

CONCLUSIONS

Living with or overcoming suicidality involves various struggles, often existential in nature. Suicide may be seen as both a failure and a means of coping. People may turn away from suicide quite abruptly through experiencing, gaining or regaining the right kind of connection with others. Nurses working with suicidal individuals should aspire to be identified as people who can turn people's lives around.

Perception of stigmatization in forensic patients with schizophrenia

BACKGROUND

The literature about perceived stigmatization of forensic patients with schizophrenia is sparse.

AIMS

To examine relations between the perceived stigmatization of forensic patients with schizophrenia and the intensity of the symptoms, age, regular home visiting, kind of offence, perceived family support and duration of hospitalization.

METHOD

Sixty-two male forensic patients with schizophrenia were included. Perceived stigmatization was measured by the modified questions from the World Health Organization Disability Assessment Schedule II. Symptomatology was assessed with the Positive and Negative Syndrome Scale. Perception of family support was assessed with a visual-analogue scale. Due to different characteristics of offences and possibilities for home visiting, patients were divided into groups of those who had committed violent and non-violent offences, and those with and without the possibility of regular home visiting.

RESULTS

Symptoms have an impact on the perception of stigma. The kind of offence committed does not have a significant role in the perception of discrimination. Age was negatively correlated with the perception of stigma.

CONCLUSION

Results might have significance for a better understanding of social relations between forensic patients and their environment and provide us with information about institutionalized forms of stigma. Results might have implications for the treatment and the quality of life of these patients.

Subjective experience and suicidal ideation in schizophrenia

Suicidal ideation and behavior are a frequent complication of schizophrenia. Although a number of risk factors have been identified, specific features of suicidality in schizophrenia remain poorly understood. In this study, 19 patients with schizophrenia were interviewed in depth on their suicidal ideation and intentions, followed by a qualitative phenomenological analysis of the material. Solitude with inability to participate in human interactions and feelings of inferiority were found to be the main sources of suicidal ideation. These experiences seem to resemble ordinary depressive reactions, yet we found them to be reflective of a more basic self-alienation and incapacity for immersion in the shared world. Ignoring this experiential level of patients' disturbances may lead to trivialization (and misjudgment) of the experiences at the root of suicidality in schizophrenia.

Mental illness stigma in the Israeli context: deliberations and suggestions

BACKGROUND

In this paper we deliberate mental illness stigma in the Israeli context and suggest ways to reduce it, emphasizing the community's role in the rehabilitation of persons with mental illness.

MATERIAL

A literature review of Israeli and international literature of mental illness stigma.

DISCUSSION

Community mental health, in addition to its traditional focus on developing community-based services, should focus also on community-based interventions such as the delivery of anti-stigma interventions.

CONCLUSIONS

Providing individualized rehabilitation services in the community while addressing stigma-induced social barriers may create a better recovery ground for Israelis with mental illness.

Can hopelessness and adolescents' beliefs and attitudes about seeking help account for help negation?

Avoidance of appropriate help is common in acutely suicidal samples and has been confirmed in nonclinical samples but factors that contribute to this help negation effect remain unclear. In a sample of 269 nonclinical Australian high school students, the current study examines the impact of hopelessness, previous mental health care, beliefs, and attitudes toward professional psychological help on the help negation relationship. Results revealed that suicidal ideation significantly predicted lower help seeking intentions and that although hopelessness could not explain the help negation effect, it moderated the effect for seeking help from family. They also revealed that although previous mental health care was unable to explain the effect fully for professional mental health sources, beliefs and attitudes about professional psychological help could. Implications of the findings for prevention, primary health care, and professional psychological practice are discussed.

Self-harm

The term self-harm is commonly used to describe a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning, and superficial cutting in response to intolerable tension. As with suicide, rates of self-harm vary greatly between countries. 5-9% of adolescents in western countries report having self-harmed within the previous year. Risk factors include socioeconomic disadvantage, and psychiatric illness--particularly depression, substance abuse, and anxiety disorders. Cultural aspects of some societies may protect against suicide and self-harm and explain some of the international variation in rates of these events. Risk of repetition of self-harm and of later suicide is high. More than 5% of people who have been seen at a hospital after self-harm will have committed suicide within 9 years. Assessment after self-harm includes careful consideration of the patient's intent and beliefs about the lethality of the method used. Strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk. Management after self-harm includes forming a trusting relationship with the patient, jointly identifying problems, ensuring support is available in a crisis, and treating psychiatric illness vigorously. Family and friends may also provide support. Large-scale studies of treatments for specific subgroups of people who self-harm might help to identify more effective treatments than are currently available. Although risk factors for self-harm are well established, aspects that protect people from engaging in self-harm need to be further explored.

Suicidal ideation and attempted suicide among women living with HIV/AIDS

The prevalence, timing, and predictors of suicidal ideation and attempted suicide were evaluated in a sample of 207 HIV-positive women in New York City. Twenty-six percent of the women reported attempting suicide since their HIV diagnosis. Of those who made an attempt, 42% acted within the first month after diagnosis and 27% acted within the first week. AIDS diagnosis, psychiatric symptoms, and physical or sexual abuse were significant positive predictors of both suicidal ideation and attempts. Contrary to expectations, having children and being employed were also significant positive predictors. Spirituality was significantly negatively associated with suicidal ideation only. These results suggest that suicide prevention measures should be implemented for HIV-positive women immediately after diagnosis. Specifically, interventions should target those with an AIDS diagnosis, psychiatric symptoms, an abuse history, children, or employment. The encouragement of spiritual connection seems to be a deterrent to suicidal thoughts and is a possible avenue for intervention.

Suicide and awareness of illness in schizophrenia: an overview

Suicide is the first cause of premature death in patients with schizophrenia. Numerous studies have identified risk factors for suicide among these patients. This study reviews available literature focusing on awareness of illness in patients with schizophrenia. Insight, or awareness of illness, has been considered a risk factor for suicide in schizophrenic patients. In assessing insight, many issues have to be taken into account, because a high degree of insight is not desirable in some conditions.