Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Risk factors of passive suicidal ideation among outpatients in traditional medicine clinics: The case of Korean medicine in South Korea

Suicide is the leading cause of death worldwide, especially in South Korea. Individuals using Korean medicine (KM) clinics are common in this country, but KM doctor is not yet used in the country's suicide prevention policy. In this study, we investigated the prevalence and risk factors of passive suicidal ideation (SI) among outpatients at KM clinics, and attempted to develop a predictive model of SI through multivariate analysis. The Korea Health Panel Annual Data 2019, a nationally representative survey in South Korea, was analyzed. In this study, 1924 (weighted n:5,958,666) people aged 19 or older who used the KM outpatient service at least once in 2019 were set as study subjects. The authors calculated the weighted prevalence of passive SI and identified significant sociodemographic, physical, and mental factors using the Rao-Scott chi-square test and weighted logistic regression. A suicide risk scorecard was developed using the point to double the odds method to quantify individual risk, resulting in a score range of 0-100. We found high prevalence of passive SI among KM outpatients (7.5 %), and the annual prevalence of passive SI tended to be higher with increasing age (4.6 % in young adults, 6.7 % in middle-aged, and 12.4 % in old age). Also, the prevalence increased as stress worsened (2.0 % in hardly, 3.9 % in a little, 13.7 % in a lot, and 24.8 % in very much). By using multiple logistic regression analysis, SI risk prediction score model was developed, including basic livelihood security recipients, presence of chronic diseases, perceived stress, depression, and low quality of life. According to our findings, passive SI is not uncommon among KM outpatients. Based on current findings, the potential role of KMDs in the country's suicide prevention strategy can be discussed focusing on specific groups such as socioeconomically vulnerable groups, the elderly population, and those with physical illnesses.

Exploring adolescent suicidal trajectories: The intersection of race/ethnicity, gender, and social connectedness

INTRODUCTION

Understanding adolescent racial/ethnic and gender disparities in suicidal ideation and attempts longitudinally can help curb future suicidal risk.

METHODS

Survey data (1994-2008) from the Longitudinal Study of Adolescent to Adult Health (Add Health study, n = 18,887) examined racial/ethnic and gender ideation and attempt disparities over four waves of data from across the United States (51% female; 51% White; Mage = 17.43 years at Wave 1). Repeated-measures latent class analyses described how ideation and attempt patterns present longitudinally and how racial/ethnic minority groups predict different classes based on each wave and age-appropriate social supports (i.e., parents, peers).

RESULTS

Those most at-risk disclosed ideation and some attempt risk in early adolescence (Waves 1 and 2) and mostly identified as female. The second most prevalent group first disclosed ideation in their 20s and predominately identified as non-Hispanic White females. Peer connections were not significant for most groups except for non-Hispanic White males in Wave 3, while Black females who reported stronger school connections had decreased ideation and attempt rates in Wave 1 but not 2 (just 1 year later). A negative link between social supports and high-risk ideation and attempt classes was found among Black females, non-Hispanic Whites, and Latinos overall.

CONCLUSIONS

As the United States becomes more diverse, understanding the unique ideation and attempt disparities are crucial. Tailoring interventions to include risk and protective mechanisms among intersectional communities could eradicate disparities. Longitudinal studies can illuminate how protective and risk factors can change over time and even within and among racial/ethnic and gender groups.

Insights from primary care workers supporting people at risk of suicide in local communities in Japan: A qualitative descriptive study

AIM

To identify insights for supporting people at risk of suicide in the community based on primary healthcare workers' experiences.

DESIGN

Qualitative descriptive design.

METHODS

Semi-structured interviews were conducted with fifteen primary healthcare workers employed by Japanese municipalities between August and October 2019. The data were subjected to qualitative descriptive analysis.

RESULTS

The analysis revealed eleven subthemes, clustered under the following three themes: (1) fostering 'opportunities for discovery' for people at risk of suicide by encompassing strategies such as increasing access to services and promoting a holistic understanding of the life cycle; (2) fostering 'meaningful connections' by searching for channels to reach the heart and taking approaches from different objectives; and (3) engaging in 'risk management', by understanding and coping with real-life struggles and implementing timely crisis intervention.

CONCLUSION

Not only direct care targeting suicide prevention but also holistic care that includes atypical perspectives such as 'approaches from different objectives' may provide important insights for supporting people with suicide risk.

IMPLICATIONS FOR PRACTICE

Beyond the limitations of existing suicide risk screening methods, this study highlights the importance of a holistic approach that sees people at risk of suicide in the context of their daily lives and aims to alleviate the difficulties in their lives that have brought them to the point of considering suicide.

IMPACT

By describing support focused on the difficulties that people at risk of suicide face in their daily lives, this study identified insights for supporting people at risk of suicide in communities where screening and intervention are difficult. These findings will contribute to the relief of people at risk of suicide by stimulating suicide prevention measures in primary healthcare settings.

REPORTING METHOD

This study complied with the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Circumstantial variables preceding firearm suicide among females with and without mobility disability in the USA: comparative analysis using data from the National Violent Death Reporting System

BACKGROUND

Mobility disability impacts approximately 12% of the US population; females are overrepresented among persons with mobility disability. Those with mobility disability are at increased risk of suicide compared with their non-disabled counterparts. Suicide using a firearm has increased among females in the last two decades. This study aims to describe and explore significant circumstantial variables (eg, socio-demographic, health indicators) preceding firearm suicide among females with mobility disability as compared with females without mobility disability.

METHODS

This is a secondary comparative, retrospective analysis of the narrative data from the National Violent Death Reporting System Restricted Access Database. Persons with mobility disability were identified through text mining and manual review and subsequently analysed with a summative form of content analysis. Pearson/Fisher's X2 or t-tests were used to assess differences in the circumstantial variables between those with and without mobility disabilities.

RESULTS

Among female firearm suicide decedents, persons with mobility disability were more commonly older (p<0.001), identified as a homemaker (p<0.001), were perceived to be in a depressed mood before death (p<0.05), had a history of suicidal thoughts (p<0.05) and were perceived to have physical pain (p<0.001); they less commonly had relationship problems (p<0.05).

CONCLUSIONS

Females with mobility disability who die by firearm suicide may be differentiated from suicide decedents without mobility disability by age, employment status, depressive mood, relationship problems and physical pain. The significance of these variables as independent risk factors for firearm suicide may be tested with prospective study designs, which in turn may inform the development of targeted or disability-inclusive prevention strategies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

The impact of history of depression and access to weapons on suicide risk assessment: a comparison of ChatGPT-3.5 and ChatGPT-4

The aim of this study was to evaluate the effectiveness of ChatGPT-3.5 and ChatGPT-4 in incorporating critical risk factors, namely history of depression and access to weapons, into suicide risk assessments. Both models assessed suicide risk using scenarios that featured individuals with and without a history of depression and access to weapons. The models estimated the likelihood of suicidal thoughts, suicide attempts, serious suicide attempts, and suicide-related mortality on a Likert scale. A multivariate three-way ANOVA analysis with Bonferroni post hoc tests was conducted to examine the impact of the forementioned independent factors (history of depression and access to weapons) on these outcome variables. Both models identified history of depression as a significant suicide risk factor. ChatGPT-4 demonstrated a more nuanced understanding of the relationship between depression, access to weapons, and suicide risk. In contrast, ChatGPT-3.5 displayed limited insight into this complex relationship. ChatGPT-4 consistently assigned higher severity ratings to suicide-related variables than did ChatGPT-3.5. The study highlights the potential of these two models, particularly ChatGPT-4, to enhance suicide risk assessment by considering complex risk factors.

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

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

Perceptions of key stakeholders on peer led strength building program for suicide prevention among young adolescents: A qualitative study from Karnataka, India

Context

Adolescent suicides are a significant public health concern in India and understanding the intersecting perspectives becomes imperative for the prevention of various mental health concerns.

Aim

Assessing perceptions of various key stakeholders, that is, mental health experts, school and college teachers, and District Mental Health Program staff about peer-led strength building programs for suicide prevention.

Settings and Design

A cross-sectional qualitative design using two Focus Group Discussions (FGDs) with mental health experts and teachers and one FGD with DMHP staff was conducted. The sample comprised 45 participants from Bengaluru urban district.

Materials and Methods

The data were analyzed manually by the method of direct content analysis, and themes were determined using existing literature.

Results

The teachers and the DMHP highlighted the need for an intensive training program/module that is necessary to be developed in order to train the peer leaders first. The mental health experts opined that creating a network will help in easy identification of the cases and appropriate treatment could be provided without delays.

Conclusions

This study indicated that suicide is a preventable public health emergency and inaccessibility to existing as well as proper support systems was perceived as a major concern. Therefore, peer-led programs are beneficial in steering and improving help seeking behavior in suicidal adolescents.

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

Introduction

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

Study objectives

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

Methods

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

Results

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

Conclusion

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

Freely Available Training Videos for Suicide Prevention: Scoping Review

BACKGROUND

Freely available and asynchronous implementation supports can reduce the resource burden of evidence-based practice training to facilitate uptake. Freely available web-based training videos have proliferated, yet there have been no efforts to quantify their breadth, depth, and content for suicide prevention.

OBJECTIVE

This study presents results from a scoping review of freely available training videos for suicide prevention and describes a methodological framework for reviewing such videos.

METHODS

A scoping review of freely available training videos (≥2 minutes) for suicide prevention practices was conducted using 4 large video-sharing platforms: YouTube, Vimeo, Bing Video, and Google Video. Identified suicide prevention training videos (N=506) were reviewed and coded.

RESULTS

Most content was targeted toward gatekeepers or other lay providers (n=370) versus clinical providers (n=136). Videos most commonly provided content related to suicidal thoughts or behaviors (n=420). Many videos (n=274, 54.2%) included content designed for certain communities or organizations. Less than half (n=232, 45.8%) of training videos included formal clinical content pertaining to assessment or intervention for suicide prevention.

CONCLUSIONS

Results suggested an abundance of videos providing broad informational content (eg, "signs and symptoms of someone at risk for suicide") and a limited portion of videos with instructional content aimed at clinical providers delivering formal evidence-based assessments or interventions for suicide prevention. Development of resources to address identified gaps may be needed. Future work may leverage machine learning techniques to expedite the review process.

Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

Ketamine's rapid antidepressant effects are mediated by Ca2+-permeable AMPA receptors

Ketamine is shown to enhance excitatory synaptic drive in multiple brain areas, which is presumed to underlie its rapid antidepressant effects. Moreover, ketamine's therapeutic actions are likely mediated by enhancing neuronal Ca2+ signaling. However, ketamine is a noncompetitive NMDA receptor (NMDAR) antagonist that reduces excitatory synaptic transmission and postsynaptic Ca2+ signaling. Thus, it is a puzzling question how ketamine enhances glutamatergic and Ca2+ activity in neurons to induce rapid antidepressant effects while blocking NMDARs in the hippocampus. Here, we find that ketamine treatment in cultured mouse hippocampal neurons significantly reduces Ca2+ and calcineurin activity to elevate AMPA receptor (AMPAR) subunit GluA1 phosphorylation. This phosphorylation ultimately leads to the expression of Ca2+-Permeable, GluA2-lacking, and GluA1-containing AMPARs (CP-AMPARs). The ketamine-induced expression of CP-AMPARs enhances glutamatergic activity and glutamate receptor plasticity in cultured hippocampal neurons. Moreover, when a sub-anesthetic dose of ketamine is given to mice, it increases synaptic GluA1 levels, but not GluA2, and GluA1 phosphorylation in the hippocampus within 1 hr after treatment. These changes are likely mediated by ketamine-induced reduction of calcineurin activity in the hippocampus. Using the open field and tail suspension tests, we demonstrate that a low dose of ketamine rapidly reduces anxiety-like and depression-like behaviors in both male and female mice. However, when in vivo treatment of a CP-AMPAR antagonist abolishes the ketamine's effects on animals' behaviors. We thus discover that ketamine at the low dose promotes the expression of CP-AMPARs via reduction of calcineurin activity, which in turn enhances synaptic strength to induce rapid antidepressant actions.

Health Service Protection vis-à-vis the Detection of Psychosocial Risks of Suicide during the Years 2019-2021

Health services are especially relevant in suicide prevention and intervention, representing a favourable environment in which to implement specific strategies to detect and address suicidal behaviours. Indeed, a significant proportion of people who die by suicide (DBS) present at primary care and mental health services during the last year, month, or even days before committing suicide. The objective of this descriptive and cross-sectional study of all registered cases of death by suicide (N = 265) in Extremadura (Spain) was to determine which of those people who died by suicide had mental health problems (MHP) and what type of assistance they had requested. Diagnoses, previous suicide attempts, type of health service, and last visit before death were explored with univariate analyses and logistic regressions. The proportion of people without MHP was found to be high, and these people had hardly visited the health services at all in their last year. People with MHP, between the ages of 40 and 69, and with previous suicide attempts were more likely to have visited the mental health service in the three months prior to their death. It is, thus, necessary to provide health professionals with tools and training in the prevention of and approach to suicide. Efforts must be directed towards effectively assessing mental health and the risk of suicide since a large proportion of people who die by suicide may go unnoticed.