Most Individuals Are Seen in Outpatient Medical Settings Prior to Intentional Self-Harm and Suicide Attempts Treated in a Hospital Setting

Efficient Online Recruitment of Patients With Depressive Symptoms Using Social Media: Cross-Sectional Observational Study

BACKGROUND

Over 80% of trials worldwide fail to complete patient recruitment within the initially planned time frame. Over the past decade, the use of social media for recruitment in medical research has become increasingly popular. While Google and Facebook are well established, newer social media channels such as Instagram and TikTok garner less research attention as recruitment tools. Although some studies have investigated the advantages and disadvantages of using social media for recruitment, a considerable gap still exists in understanding the precise mechanisms and factors that make different social media platforms most effective and cost-efficient for patient recruitment in mental health studies.

OBJECTIVE

This study evaluates the effectiveness of recruitment strategies implemented during the investigative phase of a validation study for a new suicidality assessment questionnaire optimized for primary care.

METHODS

We describe how online recruitment contributed to the enrollment of patients with depressive symptoms for the validation of a suicidality questionnaire (Suicide Prevention in Primary Care), which required over 500 participants. To this end, we analyzed differences in sample demographics between traditionally recruited and online participants, compared advertising metrics and conversion rates, and conducted a cost-benefit analysis.

RESULTS

We found online recruitment to be a fast and efficient method of securing the required number of participants with depressive symptoms for the study and increasing patient diversity. Considering the distribution of gender, age, and Patient Health Questionnaire-9 scores, participants recruited offline and online were equally eligible for the study. Online recruitment demonstrated high advertising efficiency. For example, the study population responded well to video advertisements on social media; these performed 50% to 70% more cost-efficiently than the best image advertisements. Moreover, a long website copy proved slightly better than a short version. Pixel tracking for improved advertisement targeting reduced advertising costs per suitable participant by 83.3%, making the advertisements 6 times more cost-efficient.

CONCLUSIONS

Social media recruitment increased the diversity of patients in the studies and proved suitable for vulnerable and hard-to-reach populations. The total cost per patient recruited online was comparable to that achieved using offline methods, but overall recruitment progressed faster. In this study, implementing video advertisements and pixel tracking resulted in significant cost savings.

Preliminary validation of the Suicide Management Competency Scale in a Chinese nurse population: a cross-sectional study

BACKGROUND

Suicide represents a significant public health concern at the global level and is a major area of concern for mental health professionals. Nurses are positioned to identify and manage individuals at risk of suicide or suicidal ideation. It is widely acknowledged that ensuring nurses are adequately trained to assess and manage suicidal patients is of paramount importance in the prevention of suicide. The objective of this study was to examine the reliability and structural validity of the Suicide Management Competency Scale (SMCS) in clinical nurses population.

METHODS

A total of 452 clinical nurses in a third-class hospital in Liaoning Province were selected using convenience sampling. The survey was conducted using the general demographic questionnaire and the Suicide Management Competency Scale (SMCS). The reliability and acceptability of the scale were assessed by checking the consistency of the scale part, the split-half reliability coefficient, and the correlation between each item and the score of the total scale. Confirmatory factor analysis, convergent validity and discriminant validity were used to determine the dimensional structure and validity of the scale.

RESULTS

The internal consistency of the scale, as indicated by the Cronbach's α coefficient, was 0.902. The split-half reliability coefficient was 0.771. The results of the confirmatory factor analysis were as follows: CMIN/DF = 2.609, RMSEA = 0.060, RMR = 0.040, CFI = 0.957, GFI = 0.930, NFI = 0.933, TLI = 0.949, IFI = 0.958. All of the model fitting indexes were within the acceptable range. The average variance extracted (AVE) of the three subscales ranged from 0.500 to 0.583. The combined reliability values (CR) range from 0.848 to 0.888, indicating that the SMCS scale exhibits good convergence validity. The analysis of the correlation coefficient between the subscale and the total scale revealed that the AVE square root value of each subscale is between 0.707 and 0.763, which is greater than the correlation coefficient between the two indicators. This indicates that there are significant differences between the subscales of the SMCS, that the internal structure of the questionnaire is highly differentiated, and that the discrimination validity is good.

CONCLUSION

To the best of our knowledge, this is the inaugural study to report the utilisation of the Suicide Management Competency Scale (SMCS) in the context of clinical nursing. The findings offer preliminary support for the utilisation of the SMCS in clinical nurses. In the future, nursing managers will be able to effectively evaluate clinical nurses' ability to manage and prevent suicide, as well as train nurses in this area, with the ultimate goal of saving as many lives as possible.

Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol

BACKGROUND

The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth.

METHOD

This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys.

CONCLUSION

If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Self-harm and suicidal ideation among young people is more often recorded by child protection than health services in an Australian population cohort

OBJECTIVE

We investigated patterns of service contact for self-harm and suicidal ideation recorded by a range of human service agencies - including health, police and child protection - with specific focus on overlap and sequences of contacts, age of first contact and demographic and intergenerational characteristics associated with different service responses to self-harm.

METHODS

Participants were 91,597 adolescents for whom multi-agency linked data were available in a longitudinal study of a population cohort in New South Wales, Australia. Self-harm and suicide-related incidents from birth to 18 years of age were derived from emergency department, inpatient hospital admission, mental health ambulatory, child protection and police administrative records. Descriptive statistics and binomial logistic regression were used to examine patterns of service contacts.

RESULTS

Child protection services recorded the largest proportion of youth with reported self-harm and suicidal ideation, in which the age of first contact for self-harm was younger relative to other incidents of self-harm recorded by other agencies. Nearly 40% of youth with a health service contact for self-harm also had contact with child protection and/or police services for self-harm. Girls were more likely to access health services for self-harm than boys, but not child protection or police services.

CONCLUSION

Suicide prevention is not solely the responsibility of health services; police and child protection services also respond to a significant proportion of self-harm and suicide-related incidents. High rates of overlap among different services responding to self-harm suggest the need for cross-agency strategies to prevent suicide in young people.

Suicides among Children and Adolescents in Paraguay: An 18-year National Exploratory Study (2004-2022)

BACKGROUND

Suicide and suicide attempts are impacting events for patients and their relatives, and these behaviors are still taboo among adults and may be even more traumatic when involving children and adolescents.

AIM

In this study we aimed to describe suicide rates among children and adolescents in Paraguay over the last decades as well as associated factors such as sociodemographic characteristics and methods used for suicide.

METHODS

This was an observational and exploratory study describing the frequency and characteristics of suicide among children and adolescents in Paraguay between 2004 and 2022. Official records of all deaths by suicide were reviewed, and statistical analyses were performed. In addition, an attempt was made to predict the number of suicides in the next 5 years using a mathematical model based on simple linear regression.

RESULTS

In the 18-year period observed, 940 suicides among children and adolescents were recorded. The mean age was 15.05 ± 1.8 years old. Of these, 51.17% were male, 74.6% were from urban areas, and 22.2% were from the Greater Asunción and Central Department of Paraguay. The most frequently used method of suicide was intentional self-inflicted injury by hanging, strangulation, or suffocation, which all represented 75.3% of the cases. Our mathematical modeling based on simple linear regression determined that the expected yearly number of national suicides in the pediatric population for the following years, from 2023 to 2027, will range between 72 and 81.

CONCLUSION

This study is the first large national epidemiological report on the emerging issue of suicide among children and adolescents in Paraguay. It may be a relevant source of information for mental health professionals, health authorities, and decision makers to develop national prevention strategies and actions against suicide among youths.

Validation of the German Version of the P4 Suicidality Tool

For general practitioners (GPs), it may be challenging to assess suicidal ideation (SI) in patients. Although promising instruments exist for the use in primary care, only a few have been validated in German. The objectives of this study were to examine the validity of the brief P4 screener for assessing SI in a cross-sectional study including outpatients. Inclusion criteria were a PHQ-9 score ≥ 10 or an affirmative answer to its SI item. Construct validity of the P4 was examined by comparison with the four-item Suicide Behaviors Questionnaire-Revised (SBQ-R), the PHQ-9 (convergent), and the positive mental health (PMH) scale (divergent). The study sample included 223 patients (mean age 47.61 ± 15 years; 61.9% women) from 20 primary care practices (104 patients) and 10 psychiatric/psychotherapeutic clinics (119 patients). The first three items of the P4 correlate positively with most of the four items of the reference standard SBQ-R (convergent validity); the fourth item of the P4 (preventive factors) correlates significantly with the PMH scale. The most common preventive factor (67%) is family or friends. The German P4 screener can be used to assess SI in outpatient care. It explores preventive or protective factors of suicide, which may support the GP's decision on treatment. We recommend a further clinical interview for patients flagged by P4 assessment in order to more formally assess suicidal risk.

National estimates of emergency department visits for medication-related self-harm: United States, 2016-2019

BACKGROUND

Medication poisoning is a common form of self-harm injury, and increases in injuries due to self-harm, including suicide attempts, have been reported over the last two decades.

METHODS

Cross-sectional (2016-2019) data from 60 emergency departments (EDs) participating in an active, nationally representative public health surveillance system were analysed and US national estimates of ED visits for medication-related self-harm injuries were calculated.

RESULTS

Based on 18 074 surveillance cases, there were an estimated 269 198 (95% CI 222 059 to 316 337) ED visits for medication-related self-harm injuries annually in 2016-2019 compared with 1 404 090 visits annually from therapeutic use of medications. Population rates of medication-related self-harm ED visits were highest among persons aged 11-19 years (58.5 (95% CI 45.0 to 72.0) per 10 000) and lowest among those aged ≥65 years (6.6 (95% CI 4.4 to 8.8) per 10 000). Among persons aged 11-19 years, the ED visit rate for females was four times that for males (95.4 (95% CI 74.2 to 116.7) vs 23.0 (95% CI 16.4 to 29.6) per 10 000). Medical or psychiatric admission was required for three-quarters (75.1%; 95% CI 70.0% to 80.2%) of visits. Concurrent use of alcohol or illicit substances was documented in 40.2% (95% CI 36.8% to 43.7%) of visits, and multiple medication products were implicated in 38.6% (95% CI 36.8% to 40.4%). The most frequently implicated medication categories varied by patient age.

CONCLUSIONS

Medication-related self-harm injuries are an important contributor to the overall burden of ED visits and hospitalisations for medication-related harm, with the highest rates among adolescent and young adult females. These findings support continued prevention efforts targeting patients at risk of self-harm.

Predictors of Intentional Self -Harm Among Medicaid Mental Health Clinic Clients In New York

BACKGROUND

Behavioral health outpatients are at risk for self-harm. Identifying individuals or combination of risk factors could discriminate those at elevated risk for self-harm.

METHODS

The study population (N = 248,491) included New York State Medicaid-enrolled individuals aged 10 to 64 with mental health clinic services between November 1, 2015 to November 1, 2016. Self-harm episodes were defined using ICD-10 codes from emergency department and inpatient visits. Multi-predictor logistic regression models were fit on a subsample of the data and compared to a testing sample based on discrimination performance (Area Under the Curve or AUC).

RESULTS

Of N = 248,491 patients, 4,224 (1.70%) had an episode of intentional self-harm. Factors associated with increased self-harm risk were age 17-25, being female and having recent diagnoses of depression (AOR=4.3, 95%CI: 3.6-5.0), personality disorder (AOR=4.2, 95%CI: 2.9-6.1), or substance use disorder (AOR=3.4, 95%CI: 2.7-4.3) within the last month. A multi-predictor logistic regression model including demographics and new psychiatric diagnoses within 90 days prior to index date had good discrimination and outperformed competitor models on a testing sample (AUC=0.86, 95%CI:0.85-0.87).

LIMITATIONS

New York State Medicaid data may not be generalizable to the entire U.S population. ICD-10 codes do not allow distinction between self-harm with and without intent to die.

CONCLUSIONS

Our results highlight the usefulness of recency of new psychiatric diagnoses, in predicting the magnitude and timing of intentional self-harm risk. An algorithm based on this finding could enhance clinical assessments support screening, intervention and outreach programs that are at the heart of a Zero Suicide prevention model.