The hypothesis of a continuum in suicidality: a discussion on its validity and practical implications

Tiredness of Life - Conceptualizing a Complex Phenomenon

A phenomenon referred to as 'tiredness of life' or 'weariness of life' appears in current discussions on the legitimacy of euthanasia for relatively healthy older adults as well as in research on suicidality more broadly. However, a consensus conceptualization of the phenomenon is lacking. In the current paper, we offer such a conceptualization by reviewing and integrating knowledge from terminology, available descriptions, and first qualitative findings. Boredom with life, aversion towards life, meaninglessness, and fatigue are identified as central components of the phenomenon. Per component, we describe how the component was identified, our definition of the component and its foundation in descriptions in the literature, and empirical studies on how the component relates to euthanasia requests and suicidality. Moreover, hypotheses on the structure of the phenomenon are outlined, such as on interactions among and the importance of the different components.

Internet addiction and suicidal ideation in Chinese children with migrant parents: Mediating role of anxiety and moderating role of social support

INTRODUCTION

The prevalence of internet addiction among Chinese left-behind children, coupled with its potential to exacerbate anxiety and suicidal ideation, has become a critical issue. This study seeks to address the dearth of research on the psychological underpinnings of this phenomenon, particularly the mediating role of anxiety and the moderating effect of social support across different parental migration statuses. Understanding these relationships is crucial for developing targeted interventions and informing policy decisions.

METHODS

In a cross-sectional study, we administered Young's Internet Addiction Test, alongside scales for anxiety, social support, and suicidal ideation, to 2882 middle school students in China with diverse parental migration backgrounds. Utilizing an online survey approach, we ensured broad participation and participant anonymity. Advanced statistical analyses, including regression models for mediation and moderation effects, were employed to rigorously test our hypotheses.

RESULTS

Among all participants, a significant positive correlation was observed between Internet addiction and suicidal ideation. Anxiety mediated the relationship between Internet addiction and suicidal ideation across all groups, including those with mother-only migration (Effect = 0.383, 95%CI: 0.107,0.943), father-only migration (Effect = 0.806, 95%CI: 0.487-1.230), both-parent migration(Effect = 0.289, 95%CI: 0.105-0.521), and non-left-behind children (Effect = 0.469, 95%CI: 0.342-0.630). Particularly in families where only the mother was absent, the moderating role of social support was especially prominent (B = 1.174, t = 6.446, p < 0.001 for low social support), underscoring the importance of family structure in the context of Internet addiction.

CONCLUSION

Internet addiction has both direct and indirect effects on suicidal ideation, with anxiety playing a mediating role in the indirect effects. Social support moderates and alleviates the relationship between Internet addiction and anxiety specifically in the mother-only migration group. Therefore, clarifying these relationships helps in developing and implementing effective interventions to specifically improve the mental health and living conditions of left-behind children.

Exploration-Exploitation and Suicidal Behavior in Borderline Personality Disorder and Depression

Importance

Clinical theory and behavioral studies suggest that people experiencing suicidal crisis are often unable to find constructive solutions or incorporate useful information into their decisions, resulting in premature convergence on suicide and neglect of better alternatives. However, prior studies of suicidal behavior have not formally examined how individuals resolve the tradeoffs between exploiting familiar options and exploring potentially superior alternatives.

Objective

To investigate exploration and exploitation in suicidal behavior from the formal perspective of reinforcement learning.

Design, Setting, and Participants

Two case-control behavioral studies of exploration-exploitation of a large 1-dimensional continuous space and a 21-day prospective ambulatory study of suicidal ideation were conducted between April 2016 and March 2022. Participants were recruited from inpatient psychiatric units, outpatient clinics, and the community in Pittsburgh, Pennsylvania, and underwent laboratory and ambulatory assessments. Adults diagnosed with borderline personality disorder (BPD) and midlife and late-life major depressive disorder (MDD) were included, with each sample including demographically equated groups with a history of high-lethality suicide attempts, low-lethality suicide attempts, individuals with BPD or MDD but no suicide attempts, and control individuals without psychiatric disorders. The MDD sample also included a subgroup with serious suicidal ideation.

Main Outcomes and Measures

Behavioral (model-free and model-derived) indices of exploration and exploitation, suicide attempt lethality (Beck Lethality Scale), and prospectively assessed suicidal ideation.

Results

The BPD group included 171 adults (mean [SD] age, 30.55 [9.13] years; 135 [79%] female). The MDD group included 143 adults (mean [SD] age, 62.03 [6.82] years; 81 [57%] female). Across the BPD (χ23 = 50.68; P < .001) and MDD (χ24 = 36.34; P < .001) samples, individuals with high-lethality suicide attempts discovered fewer options than other groups as they were unable to shift away from unrewarded options. In contrast, those with low-lethality attempts were prone to excessive behavioral shifts after rewarded and unrewarded actions. No differences were seen in strategic early exploration or in exploitation. Among 84 participants with BPD in the ambulatory study, 56 reported suicidal ideation. Underexploration also predicted incident suicidal ideation (χ21 = 30.16; P < .001), validating the case-control results prospectively. The findings were robust to confounds, including medication exposure, affective state, and behavioral heterogeneity.

Conclusions and Relevance

The findings suggest that narrow exploration and inability to abandon inferior options are associated with serious suicidal behavior and chronic suicidal thoughts. By contrast, individuals in this study who engaged in low-lethality suicidal behavior displayed a low threshold for taking potentially disadvantageous actions.

The implementation of a zero-suicide framework in a child and youth mental health service in Australia: processes and learnings

Suicide in children is a significant and growing problem. The "zero suicide" framework (ZSF) is one approach to suicide prevention used in health services for adults and children. This paper reports on the introduction of the first suicide prevention pathway (SPP) based on ZSF at a Child and Youth Mental Health Service (CYMHS) in Australia. It begins by describing the adaptations made to elements of the SPP originally designed for adults to meet the needs of children. Lessons learned in applying the SPP in the service are then discussed. The aim is to inform and improve practice in the use of zero suicide approaches in child and youth mental health settings in Australia and worldwide.

A comparison of the social cognition and neurocognitive characteristics of adolescents with suicide behavior, adolescent with depression and healthy controls

INTRODUCTION

Deficits in neurocognition and social-cognition have been suggested to be an endophenotype for suicidal behavior. We aimed to compare the social-cognition and neurocognitive characteristics of adolescents diagnosed with depression with and without suicidal behavior and to investigate whether these functions predict suicide.

METHOD

Adolescents diagnosed with Major Depressive Disorder (MDD) with suicidal behavior (n = 42); MDD without suicidal behavior (n = 44) and age- and sex-matched controls (n = 43) were included. The University of Pennsylvania Computerized Neurobehavioral Test Battery and Autism Spectrum Screening Questionnaire (ASSQ) were used to evaluate social-cognition and neurocognitive characteristics.

RESULTS

Several neurocognitive domain values of MDD groups, were significantly different from the control group. Neutral emotion recognition task (p = 0.025) and ASSQ scores were found to be significantly impaired in the patient groups (p < 0.001). Logistic regression analysis showed that, only the increase in the Suicide Probability Scale score was found to be significant as a risk factor predicting suicide (p = 0.007, OR: 1.246).

CONCLUSION

While the neurocognitive and social-cognitive performances of adolescents with MDD were significantly lower than the control group, these performances in the two depression groups were similar. When the predictors of suicidal behavior were examined, it was found that only the increase in suicidal ideation scores predicted suicide.

Risk and protective factors of a wish to die and suicidal ideation in community-dwelling, older, Flemish adults: results of the Belgian ageing studies

OBJECTIVES

This study aims to increase the understanding of suicidality in older adults by investigating the prevalence, characteristics, risk and protective factors of suicidal phenomena in community-dwelling older adults (60+) in Flanders, specifically of a current wish to die (WTD) and lifetime suicidal ideation and behaviour (LSIB).

METHOD

Cross-sectional data from the Belgian Ageing Studies (BAS) is used (N = 3050). The BAS aims to monitor the needs and quality of life of community-dwelling older adults through a standardised survey. Statistical methods used are bivariate analyses and binary logistic regression.

RESULTS

Prevalence rates of 4.8% for WTD and 8.2% for LSIB are found. LSIB is the biggest predictor of a current WTD, followed by requiring support on three domains, elder abuse, depression and subjective cognitive complaints, and elder abuse were significant risk factors for both WTD and LSIB. Limited effects of protective factors were found.

CONCLUSION

Previous research regarding risk factors to be confirmed in this study, and new insights on the effect of elder abuse, subjective indicators of cognitive complaints and requiring support are added. Further research into protective factors and underlying mechanisms is required.

Factors Associated With Suicide Risk Behavior Outcomes Among Black Middle School Adolescents

OBJECTIVE

Early adolescent self-identifying Black youth present with high rates of suicidality. This study assesses associations among 7 explanatory variables (sex, weapon carrying, weight perceptions, grades, grade level, bullying at school, and cyberbullying) and suicide ideation, planning, and attempts, and identifies associations with suicidality as a composite measure among a sample of Black middle school adolescents (BMSA) in the United States.

METHOD

Data were extracted from the 2019 Middle School Youth Risk Behavior Survey. Descriptive statistics were calculated, and associations between suicide ideation, planning, and attempts were explored. A network graphical representation of polychoric and tetrachoric correlations across suicidality outcomes and explanatory variables was performed. A multivariable, multinomial logistic regression model estimated associations among explanatory variables and suicide ideation (with and without planning) and planning (with and without ideation). Both suicide attempt and a composite suicidality metric were explored using independent logistic models with multiple imputation.

RESULTS

The sample included 7,643 self-identifying BMSA. Our findings indicate that approximately 28% reported suicidality. Prevalence rates were found of about 1 in 4 BMSA for suicidal ideation, 1 in 6 for suicidal planning, and 1 in 10 for attempting suicide. Female BMSA, victims of cyberbullying, and BMSA carrying a weapon experienced significantly higher odds of all suicidality outcome measures.

CONCLUSION

Practical implications for identifying and screening suicidality among BMSA to guide suicide prevention efforts are necessary. Findings validate the need for informed cultural approaches to suicide screening and prevention efforts to reduce suicide risk outcomes, especially when identifiable environmental factors are strongly associated with those outcomes.

DIVERSITY AND INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list.

Differences in resting-state brain activity in first-episode drug-naïve major depressive disorder patients with and without suicidal ideation

Despite altered brain activities being associated with suicidal ideation (SI), the neural correlates of SI in major depressive disorder (MDD) have remained elusive. We enrolled 82 first-episode drug-naïve MDD patients including 41 with SI and 41 without SI, as well as 41 healthy controls (HCs). Resting-state functional and structural MRI data were collected. The measures of fractional amplitude of low-frequency fluctuation (fALFF) and grey matter volume (GMV) were calculated and compared. Compared with HCs, patients with SI exhibited increased fALFF values in the right rectus gyrus and left medial superior frontal gyrus, middle frontal gyrus and precuneus. Decreased GMV in the right parahippocampal gyrus, insula and middle occipital gyrus and increased GMV in the left superior frontal gyrus were detected in patients with SI. In addition, patients without SI demonstrated increased fALFF values in the right superior frontal gyrus and decreased fALFF values in the right postcentral gyrus. Decreased GMV in the left superior frontal gyrus, right medial superior frontal gyrus, opercular part of inferior frontal gyrus, postcentral gyrus, fusiform gyrus and increased left supplementary motor area, superior occipital gyrus, right anterior cingulate gyrus and superior temporal gyrus were revealed in patients with SI. Moreover, in comparison with patients without SI, increased fALFF values were identified in the left precuneus of patients with SI. However, no significant differences were found in GMV between patients with and without SI. These findings might be helpful for finding neuroimaging markers predicting individual suicide risk and detecting targeted brain regions for effective early interventions.

Users' Perspectives on Crisis Helplines in Relation to Professional Mental Health Services

Background: Crisis helplines aim to provide a short-term intervention or guide users to professional mental health services, but many users return to helplines despite having professional mental health contacts. Aims: To contribute knowledge on users' perspectives on the role of crisis helplines in relation to their professional mental health contacts, we aimed to investigate how online helpline users describe such services. Methods: We used thematic analysis of 100 naturally occurring interactions from a Swedish online crisis helpline. Results: The users viewed the helpline as a safe space, a partner, or an alternative to bad professional services. Users oriented to ongoing helpline usage as crucial for their well-being while they described using professional mental health services to be able to stay alive. Limitations: The findings are limited to the nature of the different themes. Conclusion: The view on crisis helplines as a short-term intervention relies on an idealized view on crisis intervention that does not represent users' views. User control is at the core of the appeal of helplines, but it is also a key challenge for organizations and volunteers.

Mobile phone addiction and suicide behaviors among Chinese adolescents: The mediation of poor sleep quality

Background and aims

Mobile phone addiction (MPA) is emerging among adolescents, especially during the COVID-19 pandemic. Nevertheless, there is a dearth of knowledge regarding the correlation between MPA and suicide behaviors and its mechanism. The objective of the current study is exploring the direct effect of MPA on suicide behaviors and the indirect effect through poor sleep quality.

Methods

A total of 18,900 Chinese adolescents aged 12 to 18 were recruited via a multi-stage cluster sampling method.

Results

The prevalence of MPA and poor sleep quality was 26.2 and 23.1%, respectively. During the past year, 24.4% participants were involved in suicide behaviors. Specifically, suicide ideators, suicide planners, and suicide attempters were 10.7, 8.4, and 5.3%, respectively. Particularly, rural females had the highest prevalence of suicide behaviors, MPA, and poor sleep quality. Logistic regression analysis showed that MPA was significantly associated with suicide ideators (OR = 1.22, 95% CI: 1.09-1.37, p < 0.001) and planners (OR = 1.18, 95% CI: 1.04-1.34, p < 0.05), but not for suicide attempters (p > 0.05). Structural equation modelling demonstrated that MPA had direct effect on suicide behaviors (β = 0.145, 95% CI = 0.127-0.160), and poor sleep quality partially mediated the relationship (the mediating ratio was 46.7%). The mediating ratio of poor sleep quality was the highest in urban males.

Conclusions

MPA has both direct and indirect effects on suicide behaviors. For suicide prevention, limited mobile phone use and improvement sleep quality may be practical for adolescents. Additionally, more efforts of intervention could give priority to rural girls.

Social anxiety and suicidal ideation among middle-school students in China: a mediation model of internet addiction

Background

Suicide is a fatal public health issue for adolescents, and it is of great significance to explore the precursors of suicidal behaviors, especially suicidal ideation. However, the relationship between social anxiety and suicidal ideation and its mechanism are still unclear. The study aims to examine the association between social anxiety and suicidal ideation and the mediating effect through Internet addiction.

Methods

A total of 2,278 middle-school students aged 12 to 16 years were recruited through a multistage cluster sampling method in this cross-sectional study. Logistical regression analysis and structural equation modeling (SEM) were conducted to examine the direct and indirect effects of social anxiety.

Results

During the past year, 262 (11.50%) participants reported suicidal ideation. Females had a higher prevalence of suicidal ideation than males (12.9% vs. 10.0%, p = 0.034), and urban adolescents reported a higher prevalence than their rural counterparts (13.4% vs. 9.6%, p = 0.006). In the total sample, social anxiety and Internet addiction were independently associated with suicidal ideation (p < 0.05). In the subgroup analysis, the association between social anxiety and suicidal ideation was significant only among rural females and urban males (p < 0.05). SEM demonstrated that social anxiety had direct and indirect effects on suicidal ideation, and Internet addiction partially mediated the relationship, with a mediating ratio of 30.53%. The partial mediating effect was also significant only in rural females and urban males.

Conclusion

Adolescents may overuse the Internet to cope with social anxiety and further have suicidal ideation. Limiting Internet use and improving interpersonal skills in real life may be efficient for suicide prevention. In addition, targeted interventions should be tailored by different sexes across urban and rural regions.

Risk of Suicidal Ideation and Behavior in Individuals With Parkinson Disease: A Systematic Review and Meta-Analysis

Importance

Suicide risk may be increased in patients with Parkinson disease (PD), a common neurodegenerative condition. Mood disorders, especially depression, are prevalent in patients with PD who report suicidality.

Objective

To address inconsistent results from studies of suicidal ideation and behavior in patients with PD.

Data Sources

The study team searched MEDLINE and Embase from inception to June 14, 2023, and further screened the bibliographies of relevant studies to ensure a comprehensive search.

Study Selection

Original studies, published in English, discussing either suicidal ideation, behavior, or both in adults with PD were included. Accepted study designs included cross-sectional, case-control, and cohort studies. Studies that only included patients with PD after deep brain stimulation were excluded.

Data Extraction and Synthesis

This meta-analysis was conducted in line with the PRISMA guidelines. Two authors reviewed each study and extracted the data independently, with discrepancies referred to a third independent author.

Main Outcomes and Measures

Outcomes included the prevalence of suicidal ideation and behavior, measured as proportions, and the risk of suicidal behavior in patients with PD relative to controls, measured in both odds ratio (OR) and hazards ratio (HR).

Results

A total of 28 studies comprising 505 950 PD patients were included in the final analysis. The prevalence of suicidal ideation was evaluated in 14 studies (22.2%; 95% CI, 14.6-32.3) and suicidal behavior in 21 studies (1.25%; 95% CI, 0.64-2.41). Excluding 4 outliers, prevalence of suicidal behavior was significantly higher in prospective studies (1.75%; 95% CI, 1.03-2.95) than retrospective studies (0.50%; 95% CI, 0.24-1.01). Excluding 1 outlier, OR of suicidal behavior was pooled across 10 studies and significant (OR, 2.15; 95% CI, 1.22-3.78; P = .01). HR of suicidal behavior was assessed in 9 studies (HR, 1.73; 95% CI, 1.40-2.14; P < .001).

Conclusions and Relevance

This meta-analysis involving more than 500 000 patients with PD found 22.2% and 1.25% of patients with PD to have suicidal ideation and behavior, respectively. Patients with PD had 2 times the risk of suicidal behavior than controls. Early recognition and management of suicidality in PD can help reduce mortality.

Psychosocial interventions for suicidal and self-injurious-related behaviors among adolescents: a systematic review and meta-analysis of Chinese practices

Background

Suicidal and self-injurious-related behaviors (SSIRBs) are a serious public health challenge in China. However, a comprehensive systematic review of psychosocial interventions for SSIRBs among Chinese adolescents has not been performed. To fill this gap, this systematic review and meta-analysis aimed to examine psychosocial interventions for SSIRBs among Chinese adolescents.

Methods

Eight international (PubMed, EMBASE, Cochrane Library, ScienceDirect, Clinical Trial, CINAHL, PsycINFO, and Web of Science) and four Chinese (Wanfang, SinoMed, CEPS, and CNKI) databases were searched from inception to 31 January 2023. Data extraction and quality assessment were independently conducted by two groups of researchers. Qualitative synthesis and meta-analysis were both used.

Results

The initial search yielded 16,872 titles. Of the 649 full texts reviewed, 19 intervention articles focusing on SSIRBs met the inclusion criteria. Thirteen out of the 19 included studies involved cognitive-behavioral therapy (CBT). Seven non-suicidal self-injury (NSSI) studies assessing self-injurious behaviors were included (six short-term studies and three long-term studies). Compared with long-term interventions [-1.30 (95% CI: -1.84, -0.76)], short-term psychosocial interventions had a higher standardized mean difference (SMD) value [1.86 (95% CI: -2.72, -0.99)]. Meta-regression showed an inverse relationship between the treatment response and sample size (slope = 0.068, Z = 2.914, p = 0.004) and proportion of females (slope = 1.096, Z = 5.848, p < 0.001). Subgroup analyses showed that compared with the "less than 1 month" group [-0.494 (-0.783, -0.205)], in the "immediate postintervention" group, the pooled estimate was significantly lower [-2.800 (-4.050, -1.550), p < 0.001].

Conclusion

Our review systematically summarized the key characteristics and effectiveness of existing psychosocial interventions for SSIRBs among Chinese adolescents. Short-term psychosocial interventions for NSSI were significantly effective in reducing self-injurious behavior scores, especially in the immediate postintervention period. More favorable treatment responses could be observed in both male and small samples.

Molecular Changes Associated with Suicide

Suicide is a serious global public health problem, with a worrying recent increase in suicide rates in both adolescent and adult populations. However, it is essential to recognize that suicide is preventable. A myriad of factors contributes to an individual's vulnerability to suicide. These factors include various potential causes, from psychiatric disorders to genetic and epigenetic alterations. These changes can induce dysfunctions in crucial systems such as the serotonergic, cannabinoid, and hypothalamic-pituitary-adrenal axes. In addition, early life experiences of abuse can profoundly impact an individual's ability to cope with stress, ultimately leading to changes in the inflammatory system, which is a significant risk factor for suicidal behavior. Thus, it is clear that suicidal behavior may result from a confluence of multiple factors. This review examines the primary risk factors associated with suicidal behavior, including psychiatric disorders, early life adversities, and epigenetic modifications. Our goal is to elucidate the molecular changes at the genetic, epigenetic, and molecular levels in the brains of individuals who have taken their own lives and in the plasma and peripheral mononuclear cells of suicide attempters and how these changes may serve as predisposing factors for suicidal tendencies.

A multimodal prediction model for suicidal attempter in major depressive disorder

Background

Suicidal attempts in patients with major depressive disorder (MDD) have become an important challenge in global mental health affairs. To correctly distinguish MDD patients with and without suicidal attempts, a multimodal prediction model was developed in this study using multimodality data, including demographic, depressive symptoms, and brain structural imaging data. This model will be very helpful in the early intervention of MDD patients with suicidal attempts.

Methods

Two feature selection methods, support vector machine-recursive feature elimination (SVM-RFE) and random forest (RF) algorithms, were merged for feature selection in 208 MDD patients. SVM was then used as a classification model to distinguish MDD patients with suicidal attempts or not.

Results

The multimodal predictive model was found to correctly distinguish MDD patients with and without suicidal attempts using integrated features derived from SVM-RFE and RF, with a balanced accuracy of 77.78%, sensitivity of 83.33%, specificity of 70.37%, positive predictive value of 78.95%, and negative predictive value of 76.00%. The strategy of merging the features from two selection methods outperformed traditional methods in the prediction of suicidal attempts in MDD patients, with hippocampal volume, cerebellar vermis volume, and supracalcarine volume being the top three features in the prediction model.

Conclusions

This study not only developed a new multimodal prediction model but also found three important brain structural phenotypes for the prediction of suicidal attempters in MDD patients. This prediction model is a powerful tool for early intervention in MDD patients, which offers neuroimaging biomarker targets for treatment in MDD patients with suicidal attempts.

Tinnitus, Suicide, and Suicidal Ideation: A Scoping Review of Primary Research

Tinnitus (the perception of sound in the absence of any corresponding external source) is highly prevalent and can be distressing. There are unanswered questions about how tinnitus, suicidal thoughts, and suicidal behaviours co-occur and interact. To establish the extent of scientific literature, this scoping review catalogued primary reports addressing the associations between tinnitus, suicidal ideation, attempted suicide, and death by suicide. We searched OvidSP, Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, EThoS, and ProQuest for all studies and case reports on ideation and/or attempted and/or completed suicide in the context of tinnitus. Twenty-three studies were included, and data were charted according to study type. Several epidemiological and other observational studies gave evidence of risk factors and an association between suicidal ideation, suicidal behaviour, and tinnitus. However, there was no evidence of the direction of causality. Qualitative studies are indicated to explore the patient's experience and understand the dynamics of any interaction between tinnitus and suicidal thoughts and behaviours. A theory-informed model of tinnitus and suicide needs to be developed to inform the development of interventions and how tinnitus patients are supported clinically.

An exploration of suicidal ideation and attempts, and care use and unmet need among suicide-ideators in a Belgian population study

BACKGROUND

Suicidal ideation, or thinking about death and suicide, is common across all layers of society. The aim of this paper is to add to the understanding of suicidal ideation in the general population, as well as help-seeking behaviors and perceived unmet mental health needs among those who report suicidal thoughts.

METHODS

The research is part of a representative population-based survey study of mental wellbeing in Antwerp (Flanders, Belgium) carried out in 2021. A total of 1202 participants between 15 and 80 years old answered the Ask Suicide-Screening Questions (ASQ), and an additional question about suicide plans. Participation was by invitation only and possible online or via a postal paper questionnaire. Univariate and multivariate logistic regression analyses were used to explore the association between both current suicidal ideation and self-reported lifetime suicide attempt with the sociodemographic factors age, gender, educational level, origin and financial distress. Moreover, formal care use for mental health was examined among those experiencing suicidal ideation, and logistic regression analyses were used to assess associated sociodemographic factors. Finally, perceived unmet mental health needs were assessed among suicide ideators.

RESULTS

The point-prevalence of suicidal ideation was 8.6% and was higher among younger age groups and individuals reporting financial distress. The lifetime-prevalence of suicide attempts is 6.5% and was higher in younger people and individuals with a primary educational level and with financial distress. About half (45.6%) of those with suicidal ideation consulted a professional for mental health problems in the past twelve months. Men and those with a primary educational level were less likely to seek help. Half of suicide ideators without care use perceived some need for mental health care, and a third of suicide ideators who used care perceived the obtained help as insufficient, resulting in a population prevalence of 3.6% suicide ideators with a fully or partially perceived unmet need.

CONCLUSIONS

The prevalence of suicide attempts, suicidal ideation and unmet needs among suicide-ideators is high in this Belgian sample. Mental health care need perception in suicide ideators needs further investigation.

Racial and ethnic differences in suicidal behavior and mental health service use among US adults, 2009-2020

BACKGROUND

While suicide rates have recently declined for White individuals, rates among Black and Hispanic individuals have increased. Yet, little is known about racial/ethnic differences in precursors to suicide, including suicidal ideation (SI) and suicide attempts (SA).

METHODS

Data from 2009-2020 National Survey of Drug Use and Health (NSDUH) consisted of non-institutionalized US civilians aged ⩾18 (n = 426 008). We compared proportions of White, Black, and Hispanics among adults reporting no past-year suicidal thoughts/behavior, SI, and SA. Multivariable-adjusted analyses were used to evaluate the independence of observed racial/ethnic differences in past-year SI, SA, and mental health service use.

RESULTS

In the entire sample, 20 791 (4.9%) reported past-year SI only and 3661 (0.9%) reported a SA. Compared to White individuals, Black and Hispanic individuals were significantly less likely to report past-year SI [OR 0.73 (95% CI 0.69-0.77); OR 0.75 (95% CI 0.71-0.79), respectively], but more likely to report a past-year SA [OR 1.45 (95% CI 1.28-1.64); OR 1.19 (95% CI 1.04-1.37), respectively] even after multivariable adjustment. Black and Hispanic individuals were significantly less likely to use mental health services, but the lack of significant interactions between race/ethnicity and SI/SA in association with service use suggests differences in service use do not account for differences in SI or SA.

CONCLUSIONS

Black and Hispanic individuals are significantly less likely than White individuals to report SI but more likely to report SAs, suggesting differences in suicidal behavior across race/ethnicity that may be impacted by socio-culturally acceptable expressions of distress and structural racism in the healthcare system.

Active involvement of people with lived experience of suicide in suicide research: a Delphi consensus study

BACKGROUND

The importance and value of involvement of people with lived experience of suicide has been recognized in suicide research and prevention. Nonetheless, clear guidance on research collaboration and co-production is lacking. This study aimed to address this gap by developing a set of guidelines on active involvement of people with lived experience of suicide in suicide studies., i.e., conducting research with or by people with lived experience, rather than to, about or for them.

METHODS

The Delphi method was used to determine statements on best practice for the active involvement of people with lived experience of suicide in suicide research. Statements were compiled through a systematic search of the scientific and grey literature, and reviewing qualitative data from a recent related study conducted by the authors. Two expert panels: people with lived experience of suicide (n = 44) and suicide researchers (n = 29) rated statements over three rounds of an online survey. Statements endorsed by at least 80% of panellists of each panel were included in the guidelines.

RESULTS

Panellists endorsed 96 out of 126 statements in 17 sections covering the full research cycle from deciding on the research question and securing funding, to conducting research and disseminating and implementing outcomes. Overall, there was a substantial level of agreement between the two panels regarding support from research institutions, collaboration and co-production, communication and shared decision making, conducting research, self-care, acknowledgment, and dissemination and implementation. However, panels also disagreed on specific statements regarding representativeness and diversity, managing expectations, time and budgeting, training, and self-disclosure.

CONCLUSIONS

This study identified consensus recommendations on active involvement of people with lived experience of suicide in suicide research, including co-production. Support from research institutions and funders, and training on co-production for researchers and people with lived experience, are needed for successful implementation and uptake of the guidelines.

The importance of clinicians' and parents' awareness of suicidal behaviour in adolescents reaching the upper age limit of their mental health services in Europe

BACKGROUND

To study clinicians' and parents' awareness of suicidal behaviour in adolescents reaching the upper age limit of their Child and Adolescent Mental Health Service (CAMHS) and its association with mental health indicators, transition recommendations and mental health service (MHS) use.

METHODS

763 CAMHS users from eight European countries were assessed using multi-informant and standardised assessment tools at baseline and nine months follow-up. Separate ANCOVA's and pairwise comparisons were conducted to assess whether clinicians' and parents' awareness of young people's suicidal behaviour were associated with mental health indicators, clinician's recommendations to continue treatment and MHS use at nine months follow-up.

RESULTS

53.5 % of clinicians and 56.9 % of parents were unaware of young people's self-reported suicidal behaviour at baseline. Compared to those whose clinicians/parents were aware, unawareness was associated with a 72-80 % lower proportion of being recommended to continue treatment. Self-reported mental health problems at baseline were comparable for young people whose clinicians and parents were aware and unaware of suicidal behaviour. Clinicians' and parents' unawareness were not associated with MHS use at follow-up.

LIMITATIONS

Aspects of suicidal behaviour, such as suicide ideation, -plans and -attempts, could not be distinguished. Few young people transitioned to Adult Mental Health Services (AMHS), therefore power to study factors associated with AMHS use was limited.

CONCLUSION

Clinicians and parents are often unaware of suicidal behaviour, which decreases the likelihood of a recommendation to continue treatment, but does not seem to affect young people's MHS use or their mental health problems.

Peer Intervention following Suicide-Related Emergency Department Presentation: Evaluation of the PAUSE Pilot Program

The risk for future suicidal behaviours is elevated following suicide attempts, particularly for those with complex needs or those who are disconnected from healthcare systems. The PAUSE program was designed to address this gap using peer workers to provide continuity and coordination of care following suicide-related emergency presentations. This study aimed to evaluate the pilot program's effect on suicidal ideation and hope, and to explore the acceptability and participants' experiences. A mixed-methods design was employed with pre- and post-evaluation questionnaires, including the GHQ-28-SS (general health questionnaire suicide scale), AHS (adult hope scale), and K10 (Kessler psychological distress scale). Participant engagement rates and semi-structured interviews were used to explore program acceptability. In total, 142 people were engaged with the PAUSE pilot between 24 August 2017 and 11 January 2020. There were no significant gender differences in engagement. The suicidal ideation scores decreased, and the hope scores increased after participation in PAUSE. A thematic analysis revealed that participants identified that the key program mechanisms were holistic and responsive support, ongoing social connectedness, and having peer workers who understood their experiences and treated them like people rather than clients. The small number of participants and lack of a control group limited the result generalizability. The findings suggest that PAUSE was an effective and acceptable model for supporting people following suicide-related hospitalisations in this pilot sample.

The shared genetic architecture of suicidal behaviour and psychiatric disorders: A genomic structural equation modelling study

Background: Suicidal behaviour (SB) refers to behaviours, ranging from non-fatal suicidal behaviour, such as suicidal ideation and attempt, to completed suicide. Despite recent advancements in genomic technology and statistical methods, it is unclear to what extent the spectrum of suicidal behaviour is explained by shared genetic aetiology. Methods: We identified nine genome-wide association statistics of suicidal behaviour (sample sizes, n, ranging from 62,648 to 125,844), ten psychiatric traits [n up to 386,533] and collectively, nine summary datasets of anthropometric, behavioural and socioeconomic-related traits [n ranging from 58,610 to 941,280]. We calculated the genetic correlation among these traits and modelled this using genomic structural equation modelling, identified shared biological processes and pathways between suicidal behaviour and psychiatric disorders and evaluated potential causal associations using Mendelian randomisation. Results: Among populations of European ancestry, we observed strong positive genetic correlations between suicide ideation, attempt and self-harm (rg range, 0.71-1.09) and moderate to strong genetic correlations between suicidal behaviour traits and a range of psychiatric disorders, most notably, major depression disorder (rg = 0.86, p = 1.62 × 10^-36). Multivariate analysis revealed a common factor structure for suicidal behaviour traits, major depression, attention deficit hyperactivity disorder (ADHD) and alcohol use disorder. The derived common factor explained 38.7% of the shared variance across the traits. We identified 2,951 genes and 98 sub-network hub genes associated with the common factor, including pathways associated with developmental biology, signal transduction and RNA degradation. We found suggestive evidence for the protective effects of higher household income level on suicide attempt [OR = 0.55 (0.44-0.70), p = 1.29 × 10^-5] and while further investigation is needed, a nominal significant effect of smoking on suicide attempt [OR = 1.24 (1.04-1.44), p = 0.026]. Conclusion: Our findings provide evidence of shared aetiology between suicidal behaviour and psychiatric disorders and indicate potential common molecular mechanisms contributing to the overlapping pathophysiology. These findings provide a better understanding of the complex genetic architecture of suicidal behaviour and have implications for the prevention and treatment of suicidal behaviour.

Revised Attentional Fixation on Suicide Experiences Questionnaire and its relationship with suicidal ideation and behavior: A cross-sectional study

INTRODUCTION

The Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) was developed to measure attentional fixation on suicide, a cognitive process characterized by a preoccupation with suicide as a solution. This study investigated a revised version (AFSEQ-R) and examined differences between those who made a recent suicide attempt and those with suicidal ideation (SI).

METHOD

Participants were 57 inpatients who attempted suicide within 14 days of study participation and 57 inpatients who presented with SI but no suicidal behavior within the past year. Analyses examined the internal reliability, multidimensionality, and construct validity of the AFSEQ-R, and whether attentional fixation moderated the correlation between SI and attempt status.

RESULTS

Exploratory factor analysis revealed a two-factor structure, and subscale and total scores demonstrated excellent internal consistency. Cognitive Stuckness (and total score) correlated with SI, anxiety, impulsivity, and specific problem-solving deficits, while Cognitive Dysfunction correlated with anxiety and acted as a moderator of the correlation between Stuckness and SI. AFSEQ-R scores did not moderate the relationship between SI and attempt status.

CONCLUSION

AFSEQ-R is a psychometrically sound and valid measure of attentional fixation. Attentional fixation on suicide is correlated with SI, and prospective studies are needed to uncover its directional effect on suicidal crises.

The Paradox of Suicide Prevention

The recognition that we cannot use risk stratification (high, medium, low) to predict suicide or to allocate resources has led to a paradigm shift in suicide prevention efforts. There are challenges in adapting to these new paradigms, including reluctance of clinicians and services to move away from traditional risk categorisations; and conversely, the risk of a pendulum swing in which the focus of care swings from one approach to determining service priority and focus (e.g., diagnosis, formulation, risk and clinical care) to a new focus (e.g., suicide specific and non-clinical care), potentially supplanting the previous approach. This paper argues that the Prevention Paradox provides a useful mental model to support a shift in paradigm, whilst maintaining a balanced approach that incorporates new paradigms within the effective aspects of existing ones. The Prevention Paradox highlights the seemingly paradoxical situation where the greatest burden of disease or death is caused by those at low to moderate risk due their larger numbers. Current planning frameworks and resources do not support successful or sustainable adoption of these new approaches, leading to missed opportunities to prevent suicidal behaviours in healthcare. Adopting systems approaches to suicide prevention, such as the Zero Suicide Framework, implemented in a large mental health service in Australia and presented in this paper as a case study, can support a balanced approach of population- and individual-based suicide prevention efforts. Results demonstrate significant reductions in re-presentations with suicide attempts for consumers receiving this model of care; however, the increasing numbers of placements compromise the capacity of clinical teams to complete all components of standardised pathway of care. This highlights the need for review of resource planning frameworks and ongoing evaluations of the critical aspects of the interventions.

Childhood maltreatment and suicidal ideation in Chinese children and adolescents: the mediating role of mindfulness

BACKGROUND

Childhood maltreatment (CM) has been associated with suicidal ideation (SI) in children and adolescents, yet the mediating role of mindfulness in this association remains unclear. This study aims to test the mediation of mindfulness in CM-SI association among a large sample of Chinese children and adolescents.

METHODS

A population-based cross-sectional study of 3455 children and adolescents aged 10-17 years from southwest China Yunnan province was conducted. Information from the participants was collected by using a comprehensive self-administered questionnaire. The Chinese version of the Childhood Trauma Questionnaire (CTQ), Five Facet Mindfulness Questionnaire (FFMQ), and the Beck Scale for Suicidal Ideation (BSSI) were used to measure CM, mindfulness and SI. Univariate and multivariate binary logistic regression models were used to estimate the crude and adjusted associations between CM, mindfulness and SI (one-week, one-year, lifetime). Pathway analysis was subsequently performed to test the mediation of mindfulness in CM-SI association.

RESULTS

The findings showed that mindfulness, CM and SI were significantly correlated with each other (p &lt; 0.05). Mindfulness is a significant mediator in CM-SI association, accounted for 7.5, 11.4, and 17.6% of the total associations for one-week SI, one-year SI, and lifetime SI, respectively. For the five types of CM, the highest level of mediation via mindfulness had been found for physical neglect (PN) and one-year SI (34.3%), followed by emotional neglect (EN) and one-year SI (30.2%), sexual abuse (SA) and one-year SI (25.4%).

CONCLUSIONS

Our study findings highlight the intervention potential of mindfulness in preventing CM associated suicidal risk. Future longitudinal studies are warranted to corroborate the effectiveness of mindfulness-based intervention for Chinese children and adolescents.

Relationship between parental psychological control and suicide ideation in Chinese adolescents: Chained mediation through resilience and maladjustment problems

Suicide ideation is an essential predictor of suicide deaths and is highly prevalent among Chinese adolescents. Several studies have highlighted the significant association between parental psychological control and suicide ideation. However, few studies have focused on the potential mechanisms underlying this relationship. This study investigated the chained mediating effects of resilience and maladjustment problems on the relationship between parental psychological control and suicide ideation among Chinese adolescents. A total of 2,042 students in junior high school completed measurements. The results revealed significant correlations among parental psychological control, resilience, maladjustment problems and suicide ideation. Even after controlling for the effects of gender and grade, parental psychological control positively predicted a significant effect of suicide ideation. Furthermore, suicide ideation was linked with parental psychological control through three pathways: the mediating role of resilience, the mediating role of maladjustment problems, and the chained mediating roles of resilience and maladjustment problems. These findings have broad implications for the field of suicide studies. High levels of parental psychological control, low levels of resilience, and high levels of maladjustment problems may increase the occurrence of suicide ideation.

Associations between lifetime mental disorders and suicidal behaviors: findings from the Taiwan psychiatry morbidity survey

BACKGROUND

East Asia has high suicide rates but low prevalence of mental disorders. We examined the associations between prior lifetime mental disorders (mood disorders, anxiety disorders, substance use disorders, and impulse control disorders) and subsequent suicidal behaviors (suicidal ideation and attempts in the general population and suicide plans, planned attempts, and unplanned attempts in suicidal ideators) in Taiwan.

METHODS

This survey applied the World Mental Health Survey Composite International Diagnostic Interview to a population representative sample of noninstitutionalized adults between 2003 and 2005. Odds ratios (ORs) obtained using discrete-time survival analysis were used to estimate population attributable fractions (PAFs) of suicidal behaviors due to lifetime mental disorders.

RESULTS

Lifetime mental illness was a significant risk factor for subsequent suicidal behaviors (except unplanned attempts among ideators) despite the relatively low prevalence of mental disorders in people with suicidality (16.1%-35.0%). Each diagnosis increased the odds of suicidal ideation. In terms of acting on suicidal ideation, mood disorders were most strongly associated with having plans (OR = 10.0; 95% confidence interval, CI 4.3-21.1), whereas substance use disorders most strongly with either planned (OR = 27.3; 95% CI 6.3-118.5) or unplanned attempts (OR = 14.5; 95% CI 1.7-121.5). PAFs of all mental disorders on suicidality lay between 20 and 30% (except 11% of unplanned attempts among ideators). Mood, anxiety, and substance use disorders had higher PAFs than impulse control disorders.

CONCLUSIONS

In addition to mood disorders, considering anxiety and substance use disorders is essential in devising population-based suicide prevention strategies.

Suicidality in clinically stable bipolar disorder and schizophrenia patients during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has a disproportionate impact on vulnerable subpopulations, including those with severe mental illness (SMI). This study examined the one-year prevalence of suicidal ideation (SI), suicide plans (SP), and suicide attempts (SA) in bipolar disorder (BD) and schizophrenia (SCZ) patients during the pandemic. Prevalence rates were compared between the two disorders and associated factors were examined. A survey was conducted in six tertiary psychiatric hospitals and psychiatric units. People with a diagnosis of BD or SCZ were invited to participate. SI, SP, and SA (suicidality for short) were assessed and associated factors were examined using binary logistical regression. The 1-year prevalence of SI, SP and SA in BD patients were 58.3%, (95% CI: 54.1-62.6%), 38.4% (95% CI: 34.3-42.6%) and 38.6% (95% CI: 34.5-42.8%), respectively, which were higher than the corresponding figures in SCZ patients (SI: 33.2%, 95% CI: 28.6-37.8%; SP: 16.8%, 95% CI: 13.2-20.5%; SA: 19.4%, 95% CI: 15.5-23.3%). Patients with younger age, experience of cyberbullying, a history of SA among family or friends, a higher fatigue and physical pain score, inpatient status, and severe depressive symptoms were more likely to have suicidality. The COVID-19 pandemic was associated with increased risk of suicidality, particularly in BD patients. It is of importance to regularly screen suicidality in BD and SCZ patients during the pandemic even if they are clinically stable.

Prevalence and Correlational Factors of Suicidal Ideation and Suicide Attempts Among Chinese Adolescents

This study’s purpose was to (1) determine the prevalence of suicidality (i.e., suicidal ideation or suicide attempts) among adolescents in a city in Northeast China and (2) identify the correlational factors among adolescents with suicidality. A total of 69,519 adolescents from grades 5 to 12 in a city in Northeast China participated in the online investigation. Students completed a structured questionnaire to report their demographic information, psychological characteristics, and suicidality. Univariable and multivariable logistic regressions were applied to determine significant correlational factors associated with suicidal ideation (SI) and suicide attempts (SA). The prevalence of SI and SA among adolescents in the past 12 months was 13 and 4.8%, respectively. Multivariable logistic regression analyses found that the potential risk factors for SI and SA included female, non-nuclear family, higher subjective socioeconomic status, meaningless in life, depression, bullying perpetrator, negative parental rearing styles, lower self-esteem scores, hopelessness, and stressful life events. In order to improve the accuracy of suicide risk identification, a cumulative risk index was used. With the increase in the number of cumulative risks, the risk of SI and SA also increased. So the cumulative risk index was very valuable. The total prevalence of SI and SA among primary and middle school students was high. Preventive measures could be implemented according to the risk factors.

Effect of Attitude Toward Suicide on Suicidal Behavior: Based on the Korea National Suicide Survey

OBJECTIVE

Suicide is a complex phenomenon; therefore, it should be approached in light of sociocultural perspectives and the general attitude toward suicide. This study aimed to extract factors from the Attitude Toward Suicide Scale (ATTS) and investigate the relationship between attitudes toward suicide and suicidal behavior (i.e., suicidal idea, plan, and attempt) by using a representative sample of Korean adults.

METHODS

Three thousand Koreans aged 19 to 75 years were surveyed cross-sectionally in 2013 and 2018. The data collected were subjected to exploratory factor analysis. Extracted attitude factors were compared using a suicidal behavior continuum. Univariate and multivariate logistic models were constructed to compare the association between attitude factors and suicidal behaviors.

RESULTS

Among the participants, 477 (15.9%) experienced suicidal idea only, 85 (2.8%) had a suicidal plan without attempt, and 58 (1.9%) attempted suicide. Four meaningful factors were extracted from the factor analysis: "permissiveness," "unjustified behavior," "preventability/readiness to help," and "loneliness." "Permissiveness," "unjustified behavior," and "loneliness" factors showed significant trends across the suicidal behavior continuum. Permissive attitude toward suicide increased the odds of suicidal idea, suicidal plan, and suicide attempt (adjusted odds ratio [aOR]=1.49, 95% confidence interval [CI]=1.25-1.79; aOR=2.79, 95% CI=1.84-4.25; aOR=2.67, 95% CI=1.65-4.33), while attitude toward suicide as unjustified behavior decreased the odds of suicidal ideation and attempt (aOR=0.79, 95% CI=0.67-0.94; aOR=0.64, 95% CI=0.42-0.99).

CONCLUSION

A significant association was found between attitude toward suicide and suicidal behaviors. Attitude toward suicide is a modifiable factor that can be used to develop prevention policies.

Peripheral and neural correlates of self-harm in children and adolescents: a scoping review

BACKGROUND

Self-harm in children and adolescents is difficult to treat. Peripheral and neural correlates of self-harm could lead to biomarkers to guide precision care. We therefore conducted a scoping review of research on peripheral and neural correlates of self-harm in this age group.

METHODS

PubMed and Embase databases were searched from January 1980-May 2020, seeking English language peer-reviewed studies about peripheral and neural correlates of self-harm, defined as completed suicide, suicide attempts, suicidal ideation, or non-suicidal self-injury (NSSI) in subjects, birth to 19 years of age. Studies were excluded if only investigating self-harm in persons with intellectual or developmental disability syndromes. A blinded multi-stage assessment process by pairs of co-authors selected final studies for review. Risk of bias estimates were done on final studies.

RESULTS

We screened 5537 unduplicated abstracts, leading to the identification of 79 eligible studies in 76 papers. Of these, 48 investigated peripheral correlates and 31 examined neural correlates. Suicidality was the focus in 2/3 of the studies, with NSSI and any type of self-harm (subjects recruited with suicidality, NSSI, or both) investigated in the remaining studies. All studies used observational designs (primarily case-control), most used convenience samples of adolescent patients which were predominately female and half of which were recruited based on a disorder. Over a quarter of the specific correlates were investigated with only one study. Inter-study agreement on findings from specific correlates with more than one study was often low. Estimates of Good for risk of bias were assigned to 37% of the studies and the majority were rated as Fair.

CONCLUSIONS

Research on peripheral and neural correlates of self-harm is not sufficiently mature to identify potential biomarkers. Conflicting findings were reported for many of the correlates studied. Methodological problems may have produced biased findings and results are mainly generalizable to patients and girls. We provide recommendations to improve future peripheral and neural correlate research in children and adolescents, ages 3-19 years, with self-harm.

Few Do and To Few: Disclosure of Suicidal Thoughts in Friendship Networks of Young Adults Experiencing Homelessness

Disclosure of one's suicidal thoughts is a pivotal but under-investigated mechanism for preventing suicide among young adults experiencing homelessness (YAEH). In a sample of 527 YAEH, we adopted a multi-level perspective to assess patterns and correlates of disclosure in their friendship networks. Less than one-third of YAEH disclosed their suicidal thoughts-half of them doing so during a suicidal crisis-and only disclosed to 21% of their friends. Multilevel modeling showed that YAEH who reported a history of unmet mental health needs were more likely to have disclosed to a friend, and friends who were sources of social support were most highly sought out for disclosures. Our findings highlight the need for cultivating safe environments that promote disclosures among YAEH.

Suicide attempts among Greenlandic forensic psychiatric patients - prevalence and determinants

This nationwide cross-sectional study of the lifetime prevalence and determinants of suicide attempts includes 90% of Greenlandic forensic psychiatric patients. Retrospective data were collected from electronic patient files, court documents, and forensic psychiatric assessments using a coding form from a similar study. We used unpaired t-tests and chi² or Fisher's exact test. The lifetime prevalence of suicide attempts was 36% (n = 32), and no difference in prevalence was found between male and female patients (p = 0.95). Patients having attempted suicide had a higher rate of physical abuse in childhood (p = 0.04), family history of substance misuse (p = 0.007), and criminal convictions among family members (p = 0.03) than patients who had never attempted suicide. Women primarily used self-poisoning in their latest suicide attempts (67%), whereas men more often used sharp objects or a firearm (42%). Over a third of Greenlandic forensic patients have attempted suicide at some point in their life, and patients with traumatic childhood experiences are at higher risk of suicidal behaviour. It is not possible to conclude whether the lifetime prevalence of suicide attempts among Greenlandic forensic patients is comparable to that of other high-risk groups in other Arctic regions due to methodological differences among the very few other comparable studies.

Predicting risk along the suicidality continuum: A longitudinal, nationally representative study of the Irish population during the COVID-19 pandemic

INTRODUCTION

Little is known about the lifetime prevalence of different indicators of suicidality in the Irish general population; whether suicidality has increased during the COVID-19 pandemic; and what factors associated with belonging to different points on a continuum of suicidality risk.

METHODS

A nationally representative sample of Irish adults (N = 1,032) completed self-report measures in May 2020 and a follow-up in August 2020 (n = 715).

RESULTS

Lifetime prevalence rates were 29.5% for suicidal ideation, 12.9% for non-suicidal self-injury (NSSI), and 11.2% for attempted suicide. There were no changes in past two-week rates of NSSI and attempted suicide during the pandemic. Correlations between the indicators of suicidality supported a progression from ideation to NSSI to attempted suicide. Suicidal ideation alone was associated with being male, unemployed, higher loneliness, and lower religiosity. NSSI (with no co-occurring attempted suicide) was associated with a history of mental health treatment. Attempted suicide was associated with ethnic minority status, lower education, lower income, PTSD, depression, and history of mental health treatment.

CONCLUSION

Suicidal ideation, NSSI, and attempted suicide are relatively common phenomena in the general adult Irish population, and each has unique psychosocial correlates. These findings highlight important targets for prevention and intervention efforts.

Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional

BACKGROUND

Prevalence of suicidal ideation increases rapidly in adolescence, and many choose not to seek help and disclose their ideation. Young people who do disclose suicidal ideation, prefer to do so with peers and family compared to mental health professionals, who are best placed to provide evidence-based treatment. This study aimed to identify key factors associated with young people's decision to, or not to disclose suicidal thoughts to their mental health practitioner.

METHODS

A community-based sample of young Australians (16 - 25 years), who had experienced suicidal ideation and engaged with a mental health professional, completed an online questionnaire (N=513) which assessed demographic characteristics, severity of depression, anxiety, psychological distress, and suicidal ideation, lifetime suicide attempts, exposure to suicide loss, personal suicide stigma, prioritisation of mental health issues, and therapeutic alliance. Logistic regression analyses were used to identify factors associated with disclosure.

RESULTS

Though the full sample had engaged in therapy, 39% had never disclosed suicidal ideation to their clinician. Those who had disclosed were more likely to report greater therapeutic alliance (OR=1.04, 95% CI=1.02-1.06), personal suicide stigma (OR=1.04, 95% CI=1.01-1.06), prioritisation of suicidal ideation (OR=.24, 95% CI=0.14-0.42), and lifetime history of suicide attempt (OR=.32, 95% CI=0.18-0.57). The most common reason for not disclosing was concern that it would not remain confidential.

CONCLUSION

These findings provide new insights into why young people may not seek help by disclosing suicidal ideation, despite having access to a mental health professional, and establish evidence to inform practice decisions and the development of prevention strategies to support young people for suicide.

Prevalence and correlates of suicidal behaviors in the Taiwan Psychiatric Morbidity Survey

BACKGROUND/PURPOSE

Suicide is a huge global health burden. High suicide rates with a low prevalence of major depressive disorder were reported in East Asia. This study aimed to investigate the prevalence of suicidal behaviors in relation to the demographic characteristics and major depressive disorder in Taiwan.

METHODS

This study was based on the Taiwan Psychiatric Morbidity Survey, conducted between 2003 and 2005, a survey of common psychiatric disorders in a nationally representative sample of non-institutionalized civilians aged 18 or above. Demographic data, major depressive disorder, and suicidal behaviors were ascertained by a face-to-face interview using the paper version of the World Mental Health Survey Composite International Diagnostic Interview.

RESULTS

According to the total sample of 10,135 participants, the lifetime prevalence of suicidal ideation, plans and attempts was 7.52% (S.E = 0.46%), 1.31% (S.E. = 0.16%) and 1.29% (S.E. = 0.16%), respectively. Among suicide ideators, the conditional probability of making a suicide plan was 17.39% (S.E. = 1.92%), and a suicide attempt 17.16% (S.E. = 2.15%). Age ≤ 40, female sex, and major depressive disorder were related to a higher risk of suicidal behaviors in the general population; the former two were associated with further developing suicide attempts and the latter one developing plans among ideators.

CONCLUSION

Despite low prevalence, major depressive disorder remained a significant risk factor for suicidal behaviors in Taiwan.

Resilience mediates the association between self-harm and suicidal ideation in Chinese left-behind children

Background

A significant association between self-harm (SH) and suicide ideation (SI) has been found in Chinese left-behind children (LBC). Existing literature suggests that resilience might be a mediator in this association. However, this hypothesis has not been effectively discussed. The major aim of our study is to analyze the possible mediation of resilience in SH-SI association in Chinese LBC.

Methods

A population-based clustering sampling survey of 2619 LBC was conducted in southwestern China Yunnan province. Self-developed structured questionnaire was used to collect relevant information. Univariate and multivariate Logistic regression models were applied to estimate the associations between SH and SI, resilience and SI, and SH and resilience. Path analysis was adopted to measure the mediation of resilience, as well as its 5 dimensions, in the association between SH and SI. A subgroup analysis was further done to explore the mediation of resilience in the associations between SH severity and SI, SH repetition and SI, among self-harmed LBC.

Results

Compared with LBC who reported no SH behaviors, the odds ratio (OR) for SI was 3.37 (95% CI: 2.63–4.31) among self-harmed LBC. Based on the path model, resilience significantly mediated a quarter of the total association between SH and SI. Among the 5 dimensions of resilience, emotion regulation, interpersonal assistance, and family support were the strongest mediators. Subgroup analysis revealed that, the mediation of resilience was only significant for SH severity and SI.

Conclusions

Resilience played as a prominent mediator in SH-SI association among Chinese LBC. Resilience-centered intervention measures could be considered to reduce suicidal risk of this disadvantageous group.

Analyzing suicide life stories on Wikipedia with Highway_star and other textual visualization tools

Being responsible for a death every 40s, suicide is a major public health concern (Brunier et al. 2019). Even if many of its risk factors are social (Van Orden et al. 2010), there are surprisingly few qualitative sociological studies about the phenomenon. This study aim is to provide a life-story sociological analysis of suicidal trajectories. Two challenges are identified: gathering suicidal narrative and maintaining a quantitative foreground in order to deepen and rationalize the interpretation of data. They are both faced using a self-made, free to use, open access, algorithm: Highway_star (https://github.com/matheo-daly/highway_star). Two corpora of Wikipedia biographies of people who died by suicide in the 1920s (N = 82) and 2020s (N = 49) are gathered. Following an application of Fritze Schütze's methodology (Schütze, 2014), classical textual visualizations are produced. A Hierarchical Descending Classification, a Factorial Correspondence Analysis and a Similarity Analysis reveal five narration categories centered around different topics: cinema, death, family, poetry and politics. As none of those visualizations focuses on the developmental aspect of the biography, they offer limited interest for a life-story investigation. The second functionality of the Highway_star tool, which represents a narrative's unfolding with a Sankey Diagram, allows completing the analysis. It shows interesting differences between decades or gender. An example of the last being that men narratives tend to be more complex and achievement focused, while the women ones are more linear and family centered. The study's range has limitations. A major one is related to the corpus and the inability to identify clearly which parts of the narratives are associated to fame and which to suicide. Another one is linked to the Highway_star tool that sometimes lack of flexibility.

The mediating role of tolerance for psychological pain in the relationship of childhood trauma to suicidal ideation in individuals with a substance use disorder

OBJECTIVES

The association between childhood trauma and suicidal ideation has been well documented in several populations, including individuals with a substance use disorder (SUD). However, a gap still exists in the literature regarding the mechanisms by which childhood trauma later impacts suicide risk. This cross-sectional study tested the effect of childhood trauma on suicidal ideation, as well as the mediating effect of tolerance for psychological pain (managing the pain and enduring the pain) in that relationship, controlling for the effect of depressive symptoms, in individuals with a SUD.

METHODS

A sample of 102 adults with a SUD participated in the study. Path analysis by structural equation␣modelling tested a mediation model.

RESULTS

Depressive symptoms and lower levels of managing the pain were found to fully mediate the association between childhood trauma and suicidal ideation.

CONCLUSIONS

Our results suggest that depressive symptoms and a lack of ability to manage psychological pain contribute towards explaining why traumatic childhood experiences may result in suicidal cognitions in individuals with SUDs. Moreover, they have relevant implications for prevention and clinical interventions regarding suicidal ideation in this population.

PRACTITIONER POINTS

Childhood trauma relates to suicidal ideation in individuals with a substance use disorder. Depressive symptoms contribute towards explaining why traumatic childhood experiences may result in suicidal cognitions. A lack of ability to manage psychological pain also contributes towards explaining this relationship. The obtained results have relevant implications for the prevention of and clinical intervention for suicidal ideation in SUD individuals.

Mediation of Internet addiction on association between childhood maltreatment and suicidal behaviours among Chinese adolescents

Aims

The associations between suicidal behaviours and childhood maltreatment (CM), as well as Internet addiction (IA) have been extensively examined. However, few studies pay attention to different types of CM and all stages of suicidality, including suicidal ideation (SI), suicidal plans (SP) and suicidal attempts (SA). Moreover, little is known regarding the mediation of IA on the relationship between CM and suicidal behaviours. The study aims to explore the direct effect of CM and IA on three stages of suicidal behaviours, and the indirect effect of CM on suicidality via IA.

Methods

A total of 16 130 high-school students aged 12–18 were recruited using a stratified cluster sampling strategy across five representative provinces in China. Relevant information was collected by a self-administered anonymous questionnaire. Multinomial logistic regression analysis and structural equation model were used to examine the associations.

Results

During the last year, 16.0% of participants reported suicidal behaviours. Specifically, 7.9% reported SI only, 4.6% reported SP but no SA, and 3.5% reported SA. The prevalence of neglect, physical abuse and IA in moderate to severe were 28.9, 19.9 and 33.1%, respectively. After controlling for demographic characteristics and confounding factors, such as loneliness, psychological resilience, and social support, moderate and severe neglect, physical abuse and IA were associated with an increased risk of SI, SP and SA (p < 0.01). The total effect of neglect and physical abuse on suicidal behaviours were 0.152 and 0.172, respectively (p < 0.001). The mediation proportion of IA on the association between neglect and suicidal behaviours, as well as physical abuse and suicidal behaviours were 22.4 and 18.0%, respectively.

Conclusions

CM and IA are independently associated with suicidal behaviours among Chinese adolescents. Moreover, IA plays a mediating role on the relationship between CM and suicidality. Targeted interventions for adolescents’ suicidal behaviours should focus on those who have experience of CM and IA.

Relationships between neighborhood collective efficacy and adolescent suicidal ideation

INTRODUCTION

Until now, South Korean adolescent suicidal ideation literature has focused mainly on individual-level characteristics. Little is known about the contextual effects of social integration and social regulation on an individual's suicide behavior in South Korea as identified through the use of Durkheim's sociological insights. This study drew on Durkheim's suicide and collective efficacy theories and analyzed the effects of the structural characteristics and collective efficacy of neighborhoods on adolescents' suicidal ideation.

METHODS

The data analyzed was from three sources: the 2013 Korean National Survey of the Present Status of Children (n = 1,915; 50.41% girls; mean age = 13.04 years), government census data from the Korea Statistical Information System, and administrative data from the Korea Ministry of Health and Welfare. The Hierarchical Generalized Linear Model was used to investigate the effects of neighborhood structural characteristics and collective efficacy on adolescent suicidal ideation.

RESULTS

There were no significant associations between neighborhood characteristics such as concentrated poverty, divorce rate, and residential instability; however, adoles cents' perceptions of collective efficacy in neighborhoods was associated with lower suicidal ideation after accounting for individual adolescent differences.

CONCLUSION

The findings provide significant implications for the prevention of suicide in adolescents and suggest that enhancing the collective efficacy of neighborhoods through community-based intervention may be an important target of future suicide prevention strategies in South Korea.

The role of meaning in life as a protective factor in suicidal ideation among elderly men with physical illnesses

The highest suicide rates are among elderly men. The aim of the present study is to extend previous findings by focusing on meaning in life as a protective factor for suicidal ideation among elderly men. Self-report measures were administered to 170 elderly men aged 65 and over in community. Meaning in life and physical illness predicted suicidal ideation among elderly men. Physical illness moderated the association between meaning in life and suicidal ideation. In the young-old group (ages 65-74), meaning in life predicted suicidal ideation among those who reported higher rates of physical illness. This moderation effect was not found among the older group (aged 75 years and older). The findings of this study highlight the importance of age-differences in studying suicidal ideation among elderly men. Our findings emphasize the importance of cultivating and maintaining meaning in life when coping with chronic illnesses and point at meaning in life as a goal in therapeutic interventions designed to reduce suicidal ideation among elderly.

Differential associations of phasic and tonic irritability to suicidality among U.S. adults

Research on the relations between irritability and suicidality among adults has rarely compared or differentiated between tonic versus phasic irritability. The current cross-sectional study investigated the role of both tonic and phasic irritability in relation to lifetime suicidal ideation, plans, and attempts. The study included adult participants who completed the suicidality module from the National Comorbidity Survey - Replication (NCS-R) (N = 7683 for suicidal ideation and N = 1223 for suicidal plan and attempt). The NCS-R used lay-administered, standardized diagnostic interviews. Phasic and tonic irritability were assessed with individual screener items from the World Health Organization Composite International Diagnostic Interviews (CIDI). The current study used logistic regression, weighted Cox proportional hazard model, and multinomial logit regression, adjusting for sex, race/ethnicity, age, education, and marital status. Both types of irritability were included simultaneously in the models. Results indicated that both types of irritability were significantly associated with increased odds of suicidal ideation (phasic: Odds Ratio 2.72 [2.35,3.14]); tonic: OR 2.34 [2.04,2.68]), age of first-time suicidal ideation (phasic: Adjusted Hazard Ratio 2.87 [2.27, 3.63]; tonic: AHR 2.12 [1.76,2.54]), and suicide attempt (phasic: OR 1.53 [1.13,2.07]); tonic: OR 1.44 [1.11,1.89]). Only tonic but not phasic irritability was associated with suicide plans (OR 1.39 [1.08,1.79]). When suicide attempts were divided into those that were impulsive versus planned and compared them to no suicide attempt, both types of irritability were associated planned attempts, (phasic: OR 1.53 [1.13,2.07]); tonic: OR 1.44 [1.11,1.89]) but only phasic irritability was related to impulsive attempts (OR 1.70 [1.10,2.64]). Phasic and tonic irritability show differential relations to and can serve as differential markers for suicide-related outcomes in adults.

Exposure to suicide in the family and suicidal ideation in Portugal during the Covid-19 pandemic: The mediating role of unbearable psychache

Objectives

This study tested the mediation effects of two facets of psychache – bearable and unbearable – in the relationship between exposure to suicide in the family and suicidal ideation in Portugal during the Covid‐19 pandemic.

Methods

Two hundred and forty‐four adults aged between 19 and 64 participated. Two groups were defined: one exposed to suicide in the family (n = 42) and a control group (n = 192).

Results

Path analysis using structural equation modelling tested a mediation model. Results demonstrated that unbearable psychache fully mediated the relationship between exposure to suicide and suicidal ideation, even when controlling for the mediation effects of depressive symptoms, the presence of a psychiatric diagnosis, and years of education.

Conclusions

These results suggest that rather than considering just the global experience of psychache in individuals exposed to suicide, researchers and clinicians should look to the presence of unbearable psychache given its contribution to suicidal ideation.

Practitioner points

Unbearable psychache fully mediated the relationship between exposure to suicide in the family and suicidal ideation

It is not the global experience of psychache that contributes to suicide ideation in individuals exposed to suicide in the family rather the presence of unbearable psychache

Childhood maltreatment and suicidal ideation in Chinese children and adolescents: the mediation of resilience

Background

Childhood maltreatment could increase the risk of suicidal ideation (SI) in adolescents. However, the mediation of resilience in this association remains unclear.

Methods

A population-based cross-sectional study has been done among 3,146 Chinese adolescents. We collected relevant information from the study participants by using self-administered questionnaire. Chinese version of the Childhood Trauma Questionnaire (CTQ), the Resilience Scale for Chinese Adolescents (RSCA), and the Beck Scale for Suicide Ideation (BSSI) were used to measure childhood maltreatment, resilience, and SI, respectively. Univariate and multivariate binary Logistic regression models were employed to estimate crude and adjusted associations between childhood maltreatment, resilience, and SI. Path analysis has subsequently been performed to measure the mediation of resilience in this association.

Results

Multivariate Logistic regression models revealed that compared to non-abused counterparts, adolescents who had ever experienced any type of childhood maltreatment was 1.74 times likely to report SI. Among the specific types of childhood maltreatment, emotional abuse showed the strongest association with SI (adjusted OR = 3.01, 95% CI [2.37–3.82]). Path model suggested that over one-third (39.8%) of the total association between childhood maltreatment and SI was mediated via resilience. Emotion regulation and interpersonal assistance were the most prominent mediators among all dimensions of resilience.

Conclusions

Resilience played as a significant mediator in the association between childhood maltreatment and SI. Resilience-oriented intervention measures could be considered for suicidal risk prevention among abused Chinese adolescents.

Suicide ideation, suicide plan, and suicide attempt among left-behind children and adolescents: A systematic review and meta-analysis

OBJECTIVE

There are an increasing number of studies that discussed suicide ideation (SI), suicide plan (SP), and suicide attempt (SA) among left-behind children (LBC). However, the prevalence of these indicators of LBC has not been synthesized and the true correlation between these indicators and left-behind status remains unclear.

METHODS

Electronic databases were comprehensively searched, and eligible observational studies were selected to extract useful data. We pooled the rates and their 95% confidence intervals (95% CIs) to determine the prevalence of SI, SP, and SA among LBC. The odds ratios (ORs) and 95% CIs were calculated to reflect the association between left-behind status and risk of SI, SP, and SA.

RESULTS

Among LBC, the pooled prevalence was 18.7% (95% CI: 15.4-21.9) for SI, 6.4% (95% CI: 4.7-8.1) for SP, and 3.1% (95% CI: 2.6-3.6) for SA. Compared to non-LBC, LBC was at higher risk of SI (OR = 1.26), SP (OR = 1.20), and SA (OR = 1.14), but only the effect for SI achieved statistical significance.

CONCLUSION

Overall, the prevalence of SI, SP, and SA is common among LBC, and parental migration has a significant impact on the SI of LBC. Intervention plans and programs are urgently needed to prevent suicidality of this vulnerable group.

Analysis of Suicides Reported as Adverse Events in Psychiatry Resulted in Nine Quality Improvement Initiatives

Background: The majority of persons who die by suicide have a mental disorder. Preventive strategies should include addressing social and psychological factors and the treatment of the mental disorder. Aim: We aimed to identify breaches in clinical care and identify areas for quality improvement initiatives. Method: An aggregate analysis of suicides reported as adverse events during 2012-2016 to Psychiatry, North Denmark Region was carried out. We developed an audit chart and identified items through (a) medical chart review and (b) consensus meetings in an expert panel. Results: A total of 35 cases were analyzed. Suicide risk assessments were adequately documented in the medial chart in six of 35 cases. Risk assessments emphasized suicidal ideation rather than well-known risk factors such as previous suicide attempts, substance abuse, physical illness, or job loss. Relatives were involved in four of 35 of the risk assessments. The panel suggested nine areas for quality improvement. Limitations: Most people who die by suicide are not seen in mental health facilities prior to suicide, and hence conclusions can only be generalized to these patients. Information on the gap between "Work-as-Done" and "Work-As-Imagined" was not recognized. Conclusion: Most of the risk assessments among suicides reported as adverse events to our mental health facilities were insufficient. Quality improvement initiatives focusing on training, documentation, involving relatives, communication, and data sharing must be planned to improve clinical care.

Prevalence and correlates of non-suicidal self-injury, suicidal ideation, and suicide attempt among children and adolescents: Findings from Uganda and Jamaica

BACKGROUND

Youth non-suicidal self-injury (NSSI) and suicide are major public health concerns, but limited data are available on the prevalence and correlates of these problems in developing countries. The aim of this study is to describe experiences of three suicidal phenomena (NSSI, suicidal ideation [SI], and suicide attempt [SA]) among children and adolescents from two developing countries. We also examine how depression, anxiety, sleep problems, child maltreatment, and other socio-demographic variables associate with the risk of NSSI only, SI only, SA only, and co-occurring NSSI/SI/SA.

METHODS

We conducted a population-based cross-sectional study of school-based Ugandan and Jamaican children and adolescents. Participants were 11,518 (52.4% female) Ugandan and 7,182 (60.8% female) Jamaican youths aged 9-17 years.

RESULTS

The estimated lifetime prevalence of NSSI, SI, and SA was 25.5%, 25.6%, and 12.8% respectively among Ugandan boys and 23.2%, 32.5%, and 15.3% respectively among Ugandan girls. As for the Jamaican sample, the estimated lifetime prevalence of NSSI, SI, and SA was 21%, 27.7%, and 11.9% respectively among boys and 32.6%, 48.6%, and 24.7% respectively among girls. The odds of experiencing SI only, SA only, and co-occurring NSSI/SI/SA were significantly elevated among participants with mild, moderate, and severe depression in both countries.

LIMITATIONS

The current study relied on retrospective data.

CONCLUSIONS

This study found that suicidal phenomena are common among youths from Uganda and Jamaica, with rates substantially higher than among youths from high-income countries. The risk of suicidal phenomena was especially high among youths with severe depression.