An effective suicide prevention program in the Israeli Defense Forces: A cohort study

Acceptability and feasibility of video-based firearm safety education in a Colorado emergency department for caregivers of adolescents in firearm-owning households

BACKGROUND

Easy firearm access increases injury risk among adolescents. We evaluated the acceptability and feasibility of improving knowledge of a 3 min safe firearm storage education video in the paediatric emergency department.

METHODS

We conducted a single-centre block trial in a large paediatric emergency department (August 2020-2022). Participants were caregivers of adolescents (10-17 years) in firearm-owning households. First block participants (control) completed a baseline survey about child safety behaviours (including firearms). Second block participants (intervention) completed a baseline survey, watched the safe firearm storage video and evaluated acceptability. Participants completed a 3-month follow-up survey about firearm safety behaviours and knowledge recall. Demographic and clinical variables were compared between the intervention and control groups using Fisher's exact and χ2 tests. McNemar's test was used to compare firearm storage behaviours at the initial and 3-month visit within each group.

RESULTS

Research staff approached 1264 caregivers; 371 consented to participate (29.4%) and 144 (38.8%) endorsed firearm ownership. There were 95 participants in the control group and 62 in the intervention group. Follow-up was lower in the intervention group (53.7% vs 37.1%, p=0.04). Among participants viewing the video, 80.3% liked the video and 50.0% felt they learnt something new from the video.

CONCLUSIONS

Video-based firearm education in a paediatric emergency department is acceptable among a population of caregivers of adolescents with household firearms. This is a higher-risk group that may uniquely benefit from consistent education in the paediatric emergency department. Further study with larger populations is needed to evaluate intervention effectiveness.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov (NCT05168878).

Workplace interventions to prevent suicide: A scoping review

OBJECTIVES

To map organisational interventions for workplace suicide prevention, identifying the effects, mechanisms, moderators, implementation and economic costs, and how interventions are evaluated.

BACKGROUND

Suicide is a devastating event that can have a profound and lasting impact on the individuals and families affected, with the highest rates found among adults of work age. Employers have a legal and ethical responsibility to provide a safe working environment for their employees, which includes addressing the issue of suicide and promoting mental health and well-being.

METHODS

A realist perspective was taken, to identify within organisational suicide prevention interventions, what works, for whom and in what circumstances. Published and unpublished studies in six databases were searched. To extract and map data on the interventions the Effect, Mechanism, Moderator, Implementation, Economic (EMMIE) framework was used. Mechanisms were deductively analysed against Bronfenbrenner's socio-ecological model.

RESULTS

From 3187 records screened, 46 papers describing 36 interventions within the military, healthcare, the construction industry, emergency services, office workers, veterinary surgeons, the energy sector and higher education. Most mechanisms were aimed at the individual's immediate environment, with the most common being education or training on recognising signs of stress, suicidality or mental illness in oneself. Studies examined the effectiveness of interventions in terms of suicide rates, suicidality or symptoms of mental illness, and changes in perceptions, attitudes or beliefs, with most reporting positive results. Few studies reported economic costs but those that did suggested that the interventions are cost-effective.

CONCLUSIONS

It seems likely that organisational suicide prevention programmes can have a positive impact on attitudes and beliefs towards suicide as well reducing the risk of suicide. Education, to support individuals to recognise the signs and symptoms of stress, mental ill health and suicidality in both themselves and others, is likely to be an effective starting point for successful interventions.

Factors associated with self-harm behaviors during military service in the Israel Defense Forces, rates of such behaviors and their outcomes

The military environment involves stressful situations that may trigger or aggravate suicidal behaviors, such as suicide attempts (SAs), which significantly increase the likelihood of future suicide. This cross-sectional study aims to assess risk factors for severe SAs and non-suicidal self-injury (NSSI) among Israel Defense Forces (IDF) soldiers. Data were retrieved from an IDF computerized self-harm surveillance database and were based on the criteria of the Columbia Suicide Severity Rating Scale (C-SSRS) and the Suicide Attempt Self-Injury Interview (SASII). The cohort included all 1,238 occurrences of self-harm behavior, during 2017-2021. Other investigated variables included adjustment difficulty (AD, as per IDF definition) and psychiatric diagnosis (PD) as reported by mental health officers (MHOs) during recruitment. Higher rates of adjustment difficulties were found among soldiers who had conducted NSSIs. Higher rates of previous psychiatric diagnoses were found among individuals with SAs, and their risk of dying by suicide during military service was twice as high (OR = 2.356; p < .001). If the latter also served in a combat unit, the risk was almost fourfold (OR = .3.860; p < .001). The current study demonstrates a clear difference between IDF soldiers who conduct NSSI vs. those conducting SA with regard to adjustment difficulty (as per IDF definition) and PD.

A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial

STUDY OBJECTIVE

Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED).

METHODS

We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI).

RESULTS

Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1).

CONCLUSIONS

We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Practical Capability Among Veterinarians: Preliminary Evidence of the Importance of Access to Lethal Medications in the Workplace

OBJECTIVE

Veterinarians die by suicide at elevated rates. Higher levels of capability for suicide among veterinarians, including access to lethal medications, may account for this discrepancy. This study aimed to determine the importance of accessibility of lethal medications in veterinary workplaces in the relationship between recent suicidal ideation and perceived likelihood of making a future suicide attempt.

METHOD

Participants identifying with one or more groups at high-risk for suicide (e.g., veterinarians, firearm owners) were recruited via social media to complete online self-report questionnaires examining demographic, work-related, and suicide-related risk factors. The sample of veterinarians (n = 310) was primarily female, White, and worked in small animal practices.

RESULTS

Method of lethal medication storage in the workplace moderated the relationship between past week ideation and perceived likelihood of a future suicide attempt such that the relationship became stronger among those storing medications unlocked during business hours and weaker among those storing medications locked during business hours.

CONCLUSION

Secure storage of lethal medications in the workplace may protect against suicide risk. Barriers to lethal medications, when not actively in use, may reduce both physical and cognitive accessibility. Future research should determine the impact of workplace lethal medication storage on suicidal behavior among veterinarians.HIGHLIGHTSLethal med storage moderates link between suicidal thoughts and belief suicide is likelyStoring unlocked may increase physical and cognitive accessibility of this methodWorking with vets to develop and implement means safety strategies will be important.

Are intelligent people more likely to get vaccinated? The association between COVID-19 vaccine adherence and cognitive profiles

INTRODUCTION

Since vaccination adherence is crucial in reducing morbidity and mortality during a pandemic, we characterized the association between demographic, intelligence, and personal attributes and COVID-19 vaccination adherence among young adults.

METHODS

Cohort study including vaccination data of 185,061 personnel, collected during 13 months of COVID-19 vaccination campaign, while a wide array of vaccination incentives were offered. The effect of demographic data (age, gender and socioeconomic status), military medical fitness - fit for combat service, administrative service, or unfit (volunteering), general intelligence score (GIS) and military social score (MSS) assessing social abilities, on vaccine adherence (allocating by IMOH guidelines) was examined.

RESULTS

Adherent (vs. nonadherent) personnel presented higher GIS (mean 5.68 ± 1.84 vs. 4.72 ± 1.91) and MSS (median 26 (IQR 23-29) vs. 24 (IQR 19-26)), p < 0.001 for both. Higher intelligence was the strongest predictor for vaccine adherence (OR = 5.38, 95 %CI 5.11-5.67, p < 0.001). The probability for vaccine adherence increased in association with escalating GIS scores, with highest GIS females more likely to adhere to vaccination than same-level males (OR = 5.66, 95 %CI 5.09-6.28 vs. OR = 3.69, 95 %CI 3.45-3.94, respectively, p < 0.001 for both). Medically fit service-members were approximately three times as likely to be adherent than volunteering personnel (OR = 2.90 (95 %CI 2.65-3.17) for administrative and OR = 2.94 (95 %CI 2.70-3.21) for combative fitness, p < 0.001 for both).

CONCLUSIONS

During a COVID-19 vaccination campaign, addressing vaccine hesitancy contributing factors and providing wide vaccine availability, GIS and physical fitness had the strongest association with vaccination adherence among young adults. When planning future vaccination campaigns, implementing these insights should be considered to improve adherence.

Firearms Availability Among High-School Age Youth With Recent Depression or Suicidality

BACKGROUND AND OBJECTIVES

Limiting firearm access is essential to decreasing teen suicide. Previous efforts have focused on household firearms; however, less is known about firearm access and possession among teens at increased suicide risk. Our objective was to estimate prevalence of firearm possession and access among high school-aged teens with recent depression and/or lifetime history of suicidality (DLHS).

METHODS

We conducted a probability-based, cross-sectional Web survey of 1914 parent-teen dyads between June 24, 2020, and July 22, 2020, with data weighted to generate a nationally representative sample of US teenagers (aged 14-18). Logistic regression analyses examined the difference between teens with and without DLHS for: (1) personal firearm possession, (2) perceived firearm access, and (3) method of firearm attainment.

RESULTS

Among high school-aged teens, 22.6% (95% confidence interval [CI], 19.4-25.8) reported DLHS, 11.5% (95% CI, 8.7-14.3) reported personal firearm possession, and 44.2% (95% CI, 40.2-48.2) endorsed firearm access. Teens experiencing DLHS had increased perceived access (adjusted odds ratio, 1.56; 95% CI, 1.07-2.28) compared with non-DLHS peers. There was no association between DLHS and personal firearm possession (adjusted odds ratio, 0.97; 95% CI, 0.47-2.00). Among teens reporting firearm possession, those with DLHS were more likely to have acquired it by buying/trading for it (odds ratio, 5.66; 95% CI, 1.17-27.37) and less likely receiving it as a gift (odds ratio, 0.06; 95% CI, 0.01-0.36).

CONCLUSIONS

High school-aged teens experiencing DLHS have higher perceived firearm access compared with lower-risk peers. Providers should speak directly to high school-aged teens at increased suicide risk about firearm access, in addition to counseling parents.

Engaging stakeholders to develop a suicide prevention learning module for Louisiana firearm training courses

BACKGROUND

Firearm suicide is a significant public health problem in the United States of America among the general and veteran populations. Broad-based preventive strategies, including lethal means safety, have been emphasized as a key approach to suicide prevention. Prior research has identified ways to improve the reach and uptake of lethal means safety messages. However, few resources have been created with these lessons in mind.

METHODS

Louisiana firearm owners and instructors were recruited through a larger project, Veteran-Informed Safety Intervention and Outreach Network, as well as a publicly available database of firearm instructors to participate in focus groups to provide feedback on an existing suicide prevention learning module (developed in Utah) for use by firearm instructors. Their feedback was used to adapt the module, which included a brief video and PowerPoint presentation. Firearm owners and instructors were then invited back for another round of focus groups to provide feedback on this adapted learning module. Team-based rapid qualitative analysis was conducted to identify themes across transcripts from these four focus groups.

RESULTS

Firearm owners and instructors agreed on several key themes, including the importance of messenger relatability and aligning the lethal means safety message with firearm owner values. Feedback suggested these themes were adequately addressed in the adapted learning module and contributed to overall module acceptability. The final theme, present across the original and adapted learning modules (i.e., Utah and Louisiana), was openness to further information and training on firearm suicide prevention.

CONCLUSION

Consistent with a public health approach to suicide prevention, the current study used stakeholder engagement to develop a suicide prevention learning module perceived as representative, accurate, and acceptable to Louisiana firearm owners and instructors. These findings can be used to inform firearm suicide prevention efforts in other states.

Population- and Community-Based Interventions to Prevent Suicide

Background: Suicide is estimated to account for 1.4% of deaths worldwide, making it among the leading causes of premature death. Public health approaches to reduce suicide have the potential to reach individuals across the spectrum of suicide risk. Aims: To review the effectiveness of newer community-based or population-level suicide prevention strategies. Methods: We conducted a systematic review of literature published from January 2010 to November 2020 to evaluate the effectiveness of community- and population-level interventions. The US Center for Disease Control framework was used for grouping studies by strategy. Results: We included 56 publications that described 47 unique studies. Interventions that reduce access to lethal means, implement organizational policies and culture in police workplace settings, and involve community screening for depression may reduce suicide deaths. It is unclear if other interventions such as public awareness and education campaigns, crisis lines, and gatekeeper training prevent suicide. Evidence was inconsistent for community-based, multistrategy interventions. The most promising multistrategy intervention was the European Alliance Against Depression. Limitations: Most eligible studies were observational and many lacked concurrent control groups or adjustment for confounding variables. Conclusions: Community-based interventions that may reduce suicide deaths include reducing access to lethal means, implementing organizational policies in workplace settings, screening for depression, and the multistrategy European Alliance Against Depression Program. Evidence was unclear, inconsistent, or lacking regarding the impact of many other single- or multistrategy interventions on suicide deaths.

A Systematic Review of Suicide Prevention Interventions in Military Personnel

OBJECTIVE

In response to the increasing rates of suicide in military personnel throughout the world, there is an increasing focus on the development and implement of interventions aimed at preventing suicide among this group. Therefore, the goal of the present systematic review was to examine the effectiveness of interventions focused on preventing suicidal ideation and behavior in military personnel.

METHOD

Search for articles was conducted in PsycINFO, PubMed, Web of Science, EMBASE, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), IranMedex, Scientific Information Database (SID), and MagIran. International databases were searched from June 2008 to May 2019, and Iranian databases were searched from their inception to May 2019. RCT and non-RCT studies focused on the effectiveness of preventive interventions for suicide in military personnel were included in the analysis. Narrative synthesis of results was the main strategy for data analysis.

RESULTS

According to the inclusion and exclusion criteria, 18 articles were selected. Interventions were divided into four categories according to their nature: interventions based on psychotherapy, interventions based on crisis management, interventions based on pharmacotherapy, and community-based interventions. In addition, most studies had moderate methodological quality.

CONCLUSION

Most of the preventive interventions were effective in reducing suicidal ideation and behavior in military personnel; however, in some cases, there were serious challenges in terms of effectiveness. Interventions based on cognitive-behavioral approaches constitute a significant portion of the interventions. Overall, RCTs and non-RCTs, especially community-based studies, need to use more rigorous examinations in order to gain research and clinical support. HIGHLIGHTSInterventions based on psychotherapy and community-based interventions were the most commonly used interventions, respectively.The majority of interventions based on psychotherapy came from cognitive-behavioral approaches.There are few evidence-based studies on prevention of suicide in military personnel.

What is "safety"?: Lethal means counseling as a cross-cultural communication

U.S. suicide rates have risen every year over the past two decades with self-directed firearm use as the method accounting for the highest proportion of deaths. This pattern is particularly pronounced among veterans and members of the U.S. Armed Forces. The numerical burden of firearm-related suicide accompanied by characteristics of self-directed firearm injury have motivated the development of lethal means safety initiatives focused on firearms. Simultaneously, research has sought to characterize patterns of firearm ownership and use among veterans as well as optimal strategies for clinicians to deliver suicide prevention messages to firearm owners. Increasingly, findings from research have been understood as cultural factors that warrant greater attention to improve the quality of lethal means counseling. Here, we review and interpret selected research on cultural aspects of firearm ownership and suggest that cultural differences between health care practitioners and firearm owners may result in health care practitioners delivering clinical interventions that are broadly divergent from perspectives within the cultural frameworks of firearm owners. We follow by organizing these cultural factors into existing frameworks of cultural competency training as a basis for developing curriculum for health care practitioners to improve clinical care.

Public Perception of Gun Violence-related Headline Accuracy and the Credibility of Media Sources

The present study sought to determine the extent to which the message or messenger is more important for news media portrayal of gun violence prevention. Exploratory analyses also examined factors related to Fox News and MSNBC credibility. Participants (N = 3,500) were US adults matched to the 2010 US Census on several demographic variables. Two mock headlines were presented: "Gun violence is result of mental health problems" and "Storing firearms in a safe can help prevent suicides." Headlines were reported to be from either Fox News or MSNBC. Participants then rated accuracy of the headline and credibility of the news source. Headline content did not predict perceived accuracy of the headline. Perceived credibility of the messenger was associated with perceived accuracy for both mock headlines. Exploratory analyses indicated several demographic factors related to Fox News and MSNBC credibility. Regardless of the content of a headline, the degree to which participants perceived it as accurate was associated with how credible they believed the source to be. These findings highlight the importance of credible media portrayal of accurate information on gun violence prevention.

Risk Factors Associated With Various Severities of Suicidal and Non-Suicidal Self-Harm Among Israel Defense Forces Soldiers-A Nested Case-Control Study

OBJECTIVE

Severe suicide attempt is a major risk factor for completed suicide. The aim of the present study was to focus on suicide behavior and timing to gain better understanding of these populations.

METHOD

The nested case-control retrospective study based on medical records of 246,866 soldiers, who demonstrated suicide attempts of varying severity, including death by suicide were compared with soldiers who did not demonstrate such behavior.

RESULTS

Risk for death by suicide was associated with males, military seniority of less than 12 months. High frequency of visits with mental health care professionals was associated with being severe suicide attempters (SAs). Moderate suicide attempts were associated with being a male, visiting a primary care physician frequently, and belonging to one of the two latest immigrant groups in Israel (Ethiopians and former Soviet Union). Mild suicide attempts were associated with having a psychiatric diagnosis on the enlistment day, visiting a mental health care professional at high or average frequency, visiting a primary care physician at high or average frequency, being a male, and being born in the former Soviet Union. While the proportion of males demonstrating suicidal behavior was higher than the females', severe SAs were higher among females. There was a clear tendency of female suicide attempters at all levels to act toward the end of their military service.

CONCLUSIONS

Although half of the SAs were females, their characteristics may be similar to those of the male SAs, contrary to the sex differences in suicide behavior among civilians.

Differentiating suicide decedents who died by firearm verse hanging

This present study sought to examine how demographics and the availability of means for suicide converge to impact method selection between firearms and hanging, which are the two most lethal and commonly used methods for suicide in the United States. Data were collected as part of a larger online study that gathered information about suicide decedents and the circumstances around their death from family members and friends; the most common sources being parents, friends, and other family members. This study used data from those who died by suicide by firearm or hanging (n = 149); and was restricted to those who identified as male and white. The study examined if age, education, marital status, military affiliation, and firearm ownership impacted method selection. Results indicated that age and owning a firearm were associated with using a firearm in a suicide death. Additionally, those who used a firearm were significantly younger and more likely to own a firearm than those who used another method; and those who died by hanging were significantly younger than those who used another method. Findings from this study can be leveraged to improve the effectiveness of means safety efforts and create more personalised public health messages on firearm safe storage.

Veterans, Firearms, and Suicide: Safe Storage Prevention Policy and the PREVENTS Roadmap

BACKGROUND

US veterans die by suicide at a higher rate than that of the civilian population and are more likely to use a firearm as their method. Systemic efforts to address the use of firearms in suicide had been largely evaded. In June 2020, the White House published the Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, which verified the link between, and the need to address, at-risk veterans and their access to firearms. This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans' access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

OBSERVATIONS

The PREVENTS report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely and the expansion of free or affordable options for storing weapons. Recommended policy actions to accomplish this goal include delaying access to firearms for at-risk veterans, facilitating temporary storage out of the home, improving in-home safe storage options, requiring that health care providers who care for high-risk veterans are trained in lethal means safety counseling, and creating campaigns to shift cultural norms for firearms' storage during crises.

CONCLUSIONS

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels.

Suicide among Ethiopian origin soldiers in the IDF - A qualitative view of risk factors, triggers, and life circumstances

BACKGROUND

Ethiopian soldiers in the IDF comprise an at-risk group for suicide. The study investigated the unique characteristics of these soldiers, compared with other suicides in the Israel Defense Forces (IDF).

METHOD

The research group included all (n = 36) male soldiers born an Ethiopian family, who died by suicide during their compulsory military service in the years 1990-2017. The control group included all (n = 55) non-Ethiopian soldiers who died by suicide during their military service in the years 2009-2013. Socio-demographic, military-service, and suicide-related variables were examined.

RESULTS

Logistic regression analysis revealed that risk for suicide among Ethiopian soldiers were being incarcerated in a military prison, belonging to a bereaved family, seniority in the military service, and avoidance of help-seeking (explaining 87.8% of the variance).

DISCUSSION

Ethiopian suicide soldiers have endured heavy environmental pressure, such as financial problems and family bereavement. These circumstances could lead to conflict with the soldier's military service, resulting in absence from service or even imprisonment. When the Ethiopian soldier's distress goes un-expressed in words or actions with others, the psychological crisis signs remain unapparent to those around him, and the risk for eventual suicide is high.

LIMITATIONS

The case analysis did not include retrieving information from family and relatives outside the military but was derived from archived material, collected primarily for legal purposes. This limitation was addressed by assembling objective variables and information collected prior to the suicide, along with post-mortem information collected by mental health personnel in their assessments.

Risk factors for suicide in the Israeli army between the years 1992–2012: A case-control study

Objective

Young age, availability of weapons, and stressful life events, increase the risk of suicide. The aim of the present study was to assess additional risk factors for suicide in the Israeli army.

Methods

We conducted a case-control study, to assess risk factors for suicide. The cases comprised soldiers who died by suicide during their military service (n = 462; 0.039% of all soldiers in the cohort). The control group consisted of soldiers who did not commit suicide but were in active service during the investigated period (n = 1,170,895; 99.96%). Predictor variables, including socio-demographic and psychiatric diagnoses, were considered.

Results

Using a Generalized Linear Model with a Binary Logistic dependent variable to predict suicide, while controlling the effect of intervening variables, we found the following variables enhanced the risk for committing suicide: male (RR = 6.703; P < 0.001), country of origin: Ethiopia (RR = 4.555; P = 0.014), low socioeconomic status (RR = 1.448; P = 0.016) and low adjustment difficulties (RR = 2.324; P < 0.001). In addition, we found that in males only, Cluster B Personality Disorder (RR = 2.548; P = 0.027), low (RR = 1.657; P = 0.002), to average motivation to serve in a combat unit (RR = 1.322; P = 0.046) increased the risk for suicide.

Conclusions

IDF Soldiers bearing a psychiatric diagnosis or severe adjustment difficulties remained tightly monitored through their military service, and were found to be at a lower risk for suicide. However, those enlisted with mild (low) difficulties, were found to be at greater risk for suicide, as well as soldiers whose country of origin is Ethiopia. Suicide prevention program should focus on monitoring soldiers with these risk factors, together with soldiers’ guidance regarding help seeking and de-stigmatizing suicide.

Effectiveness of a village-based intervention for depression in community-dwelling older adults: a randomised feasibility study

Background

Although a focus on late-life depression may help preventing suicide in older adults, many older people, especially those living in rural areas, have relatively low accessibility to treatment. This study examined the feasibility and effectiveness of a village-based intervention for depression targeting older adults living in rural areas.

Methods

A community-based randomised pilot trial was performed in two small rural villages in South Korea. Two villages were randomly selected and assigned to the intervention or active control group; all older adults living in the two villages (n = 451) were included in the intervention program or received standard Community Mental Health Service (CMHS) care, and the effectiveness of the program was examined using representative samples from both groups (n = 160). The 12-week intervention included case management according to individual risk level and group-based activities. Healthy residents living in the intervention village who played major roles in monitoring at-risk older individuals were supervised by CMHS staff. The score on the Korean version of the Geriatric Depression Scale-Short Form (SGDS-K) was the primary outcome, while social network, functional status, and global cognitive function were secondary outcomes. Linear mixed models including the factors of intervention group, time, and their interaction were used to examine group differences in changes in primary and secondary outcomes from baseline to follow up.

Results

Overall, there was no significant group × time interaction with respect to the SGDS-K score, but older individuals with more depressive symptoms at baseline (SGDS-K ≥ 6) tended to have a lower likelihood of progressing to severe depression at post-intervention. The social network was strengthened in the intervention group, and there was a significant group × time interaction (F[df1, df2], 5.29 [1, 153], p = 0.023).

Conclusion

This study examined a 12-week village-based intervention for late-life depression in which the CMHS helped village-dwellers deal with late-life depression in their communities. Although the intervention improved social interactions among older adults, it did not reduce depressive symptoms. Further studies including more rural villages and long-term follow up are needed to confirm the effectiveness of this prevention program.

Trial registration

NCT04013165 (date: 9 July 2019, retrospectively registered).

Development of the U.S. Army’s Suicide Prevention Leadership Tool: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4)

Introduction

Although numerous efforts have aimed to reduce suicides in the U.S. Army, completion rates have remained elevated. Army leaders play an important role in supporting soldiers at risk of suicide, but existing suicide-prevention tools tailored to leaders are limited and not empirically validated. The purpose of this article is to describe the process used to develop the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) tools for Army leaders that are currently undergoing empirical validation with two U.S. Army divisions.

Materials and Methods

Consistent with a Secretary of the Army directive, approximately 76 interviews and focus groups were conducted with Army leaders and subject matter experts (SMEs) to obtain feedback regarding existing practices for suicide risk management, leader tools, and institutional considerations. In addition, reviews of the empirical literature regarding predictors of suicide and best practices for the development of practice guidelines were conducted. Qualitative feedback, empirical predictors of suicide, and design considerations were integrated to develop the R4 tools. A second series of 11 interviews and focus groups with Army leaders and SMEs was also conducted to validate the design and obtain feedback regarding the R4 tools.

Results

Leaders described preferences for tool processes (eg, incorporating engaged leadership, including multiple risk identification methods), formatting (eg, one page), organization (eg, low-intermediate-high risk scoring system), content (eg, excluding other considerations related to vehicle safety, including readiness implications), and implementation (eg, accounting for leadership judgment, tailoring process to specific leadership echelons, consideration of institutional barriers). Evidence-based predictors of suicide risk and practice guideline considerations (eg, design) were integrated with leadership feedback to develop the R4 tools that were tailored to specific leadership echelons. Leaders provided positive feedback regarding the R4 tools and described the importance of accounting for potential institutional barriers to implementation. This feedback was addressed by including recommendations regarding the implementation of standardized support meetings between different echelons of leadership.

Conclusions

The R4 development process entailed the simultaneous integration of leadership feedback with evidence-based predictors of suicide risk and design considerations. Thus, the development of these tools builds upon previous Army leadership tools by specifically tailoring elements of those tools to accommodate leader preferences, accounting for potential implementation barriers (eg, institutional factors), and empirically evaluating the implementation of those tools. Future studies should consider utilizing a similar process to develop empirically based resources that are more likely to be incorporated into the routine practice of leaders supporting soldiers at risk of suicide, very often located at the company level and below.

The effect of the Suicide Prevention Program (SPP) on the characteristics of Israeli soldiers who died by suicide after its implementation

BACKGROUND

Suicide is major cause of death in the IDF. The Suicide Prevention Program (SPP) led to significant reduction in yearly rates of suicide. A study regarding demographic changes of those who died by suicide was done to further investigate its affect.

METHOD

Nested case control retrospective study based on medical and HR data gathered between 1992 and 2016. Participants were divided into four groups: soldiers who died by suicide and non-suicidal soldiers, before and after SPP implementation.

RESULTS

Multivariate analysis with suicide as the binary logistic dependent variable before and after implementation of the SPP among four groups revealed that before SPP the OR was higher for males (OR, 7.885; 95% CI, 5.071-12.259;p < 0.001) compared to after (OR, 3.281; 95% CI, 1.600-6.726; p = 0.001). For support unit soldiers the values before SPP were OR, 14.962 and 95% CI, 8.427-26.563 (p < 0.001) while after SPP they were OR, 6.304 and 95% CI, 3.334-11.919 (p < 0.001). After SPP, OR was higher for psychiatric diagnosis at recruitment (OR, 5.830; 95% CI, 2.046-16.612; p =  0.001) than before SPP (OR, 2.422; 95% CI, 1.526-3.842; p < 0.001).For soldiers from Ethiopian ethnicity, after SPP values were higher (OR, 8.130 and 95% CI, 2.868-23.047 (p < 0.001) compared to before (OR, 3.522; 95% CI, 1.2891-6.650; p < 0.001). For those of Druse religion before values (OR, 4.027; 95% CI, 2.211-7.331; p < 0.001) were significant but not after.

CONCLUSIONS

While the SPP succeeded in reducing risk of suicide in situational factors, dispositional risk factors were not affected by the SPP. The OR decreased in critical masses and rose in unique and smaller groups.

Personal and psychiatric characteristics among Druze soldiers attempting suicide during military service

BACKGROUND

A non-fatal suicide attempt is a strong predictor of suicide. This study aimed to examine personal characteristics and psychiatric diagnoses among Druze soldiers who attempted suicide during their military service.

METHOD

The research group (n = 180) included all Druze soldiers who had attempted suicide between the years 2008-2012 (This number encompassed 18.4% of all suicide attempts in the IDF during those years). Three control groups were examined: Jewish soldiers who had attempted suicide (n = 155), and two additional groups comprising Druze and Jewish combat soldiers who had not attempted suicide (n = 5,255 and n = 205,819, respectively).

RESULTS

While Druze soldiers were diagnosed with psychiatric conditions less frequently than their Jewish counterparts, the more prolonged time to diagnosis among Druze may account for increased severity at time of diagnosis, thus increasing the risk of suicide attempt. A multivariate analysis revealed that the odds of a suicide attempt among Druze soldiers were much higher than among Jewish soldiers (OR 20.53; p < .001). In addition, it was found that average and high socioeconomic levels, strong Hebrew language skills, and high intelligence levels were protective factors against attempted suicide (p < .001, R² = 0.217).

LIMITATIONS

The three control groups were samples, while the research group (Druze attempters) consisted of all instances of attempted suicide during the study period. Comparing only samples would have offered less statistical power; therefore, using all the records in the research group improved accuracy.

Suicide ideation severity is associated with severe suicide attempts in a military setting

BACKGROUND

There is an ongoing debate on the effectiveness of suicidal behavior prevention measures in the military. The association of three widely used tools with severe suicide attempts was assessed in this setting.

METHODS

Thirty-nine Israeli soldiers (59% males), mean age 19 yrs., who attempted suicide during military service were divided into two groups: severe (n = 14; 35.9%) and moderate suicide attempts, and were assessed using the Scale for Suicide Ideation (SSI), Suicide Intent Scale (SIS) and the Columbia Suicide Severity Rating Scale (C-SSRS).

RESULTS

Seven items from the SSI (p = 0.008), two items from SIS and one item from C-SSRS were associated with severe suicide attempts. Kendall's tau-b correlation with bootstrap demonstrated stability of these correlations.

CONCLUSION

Greater severity of suicidal ideation was associated with more severe suicide attempts. The combination of male gender, available firearms and current severe suicide ideation is high-risk danger sign in a military setting, even when reported intent to die is low.

Men and suicide prevention: a scoping review

BACKGROUND

Male suicide rates are higher than their female counterparts in almost every country around the world. Several developed countries have attempted to implement suicide prevention programmes, but few have specifically targeted men.

AIMS

To identify what is currently known about suicide prevention strategies, programmes, and interventions of relevance to men.

METHOD

A scoping review guided by Arksey and O'Malley's five-stage framework.

RESULTS

Twenty-two studies were included. Thematic analysis identified three categories: (i) male suicide prevention interventions; (ii) factors or coping strategies that interrupt the suicidal process in men; (iii) men's perspectives on service provision. Interventions included awareness campaigns; training of community "gatekeepers"; psychological support; and educational initiatives targeted to either GPs or depressed or suicidal men. Men emphasised the need to receive support from a trusted and respected individual, preferably in an informal setting. Connecting with others, reframing help-seeking as masculine, and the use of emotional regulation techniques were all identified as factors with potential to interrupt the suicidal process.

CONCLUSIONS

This review demonstrates the need for further research examining the perspectives of suicidal middle-aged men and their close family and friends.

Acceptability of potential interventions to increase firearm safety among patients in VA mental health treatment

OBJECTIVE

Veterans in mental health care have high rates of firearm-related suicide; reducing firearm access during high-risk periods could save lives. We assessed veteran patients' attitudes towards voluntary interventions to reduce access.

METHODS

Descriptive data came from surveys mailed to random samples of veterans receiving mental health care in five geographically diverse VA facilities. Survey items inquired about the acceptability of seven voluntary health system interventions to address firearm access, ranging from lower-intensity interventions that addressed safety but might not reduce access (i.e., clinician screening; distribution of gunlocks) to interventions substantially limiting access (i.e., storage of firearms offsite; gun disposal). Mailings occurred between 5/11/15 and 10/19/15; 677 of 1354 veterans (50%) returned the surveys.

RESULTS

93.2% of respondents endorsed one or more health system interventions addressing firearm access; 75.0% endorsed interventions substantially limiting access. Although veterans with household firearms were less likely to endorse interventions, fully 50.4% would personally participate in at least one intervention that substantially limited access.

DISCUSSION

A majority of veterans in VA mental health care endorse voluntary health system interventions addressing firearm access during high-risk periods for suicide. Approximately half of veterans with firearms would personally participate in an intervention that substantially limited firearm access.

What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis

BACKGROUND

Young people require specific attention when it comes to suicide prevention, however efforts need to be based on robust evidence.

METHODS

We conducted a systematic review and meta-analysis of all studies examining the impact of interventions that were specifically designed to reduce suicide-related behavior in young people.

FINDINGS

Ninety-nine studies were identified, of which 52 were conducted in clinical settings, 31 in educational or workplace settings, and 15 in community settings. Around half were randomized controlled trials. Large scale interventions delivered in both clinical and educational settings appear to reduce self-harm and suicidal ideation post-intervention, and to a lesser extent at follow-up. In community settings, multi-faceted, place-based approaches seem to have an impact. Study quality was limited.

INTERPRETATION

Overall whilst the number and range of studies is encouraging, gaps exist. Few studies were conducted in low-middle income countries or with demographic populations known to be at increased risk. Similarly, there was a lack of studies conducted in primary care, universities and workplaces. However, we identified that specific youth suicide-prevention interventions can reduce self-harm and suicidal ideation; these types of intervention need testing in high-quality studies.

Depression and impulsiveness among soldiers who died by suicide: A psychological autopsy study

INTRODUCTION

Despite the accumulated knowledge about suicide, suicidal acts remain difficult to predict, and many suicides are acted out impulsively.

METHODS

We performed a psychological autopsy study based on inquiries about the deaths of all male soldiers aged 18-21 years who served in the Israeli army and died by suicide between 2009 and 2013 (n = 69). The study population was first divided into two groups: those who had depressive disorder (n = 31); and those who did not (n = 38). Socio-demographic characteristics of the subjects and the characteristics of the suicidal act were compared. Afterwards, the study population was re-divided by the presence or absence of impulsive personality traits (n = 22, and n = 47, respectively), and investigated for distinct suicidal behavior features.

RESULTS

No significant socio-demographic differences were found between the depressed and non-depressed suicide victims. The depressed group had showed more signs of planning the act (47% vs. 23%), and had expressed suicidal ideation in the days preceding the suicide (51.6% vs. 21%). One third of the subjects were found to have an impulsive personality trait, with significantly more histories of disciplinary issues, violence and cluster B personality disorders. Alcohol use during the act was significantly more prevalent among impulsive than non-impulsive subjects (45.4% vs. 14.9%).

CONCLUSION

Identification of distinct clinical groups of suicide victims among young males might help clinicians evaluate high risk cases, and may provide valuable opportunities to alleviate and prevent these events in the future.

Addressing the Cultural Challenges of Firearm Restriction in Suicide Prevention: A Test of Public Health Messaging to Protect Those at Risk

OBJECTIVES

Reducing access to firearms as a suicide prevention strategy is limited in the US today because of divergent cultural attitudes and political contentiousness surrounding gun restrictions. This research examined the effects of culturally-specific suicide prevention messages on the likelihood of restricting firearm access during periods of suicide risk.

METHODS

Focus groups and key informant interviews were conducted with rural gun owners in order to develop a suicide prevention message that highlighted the importance of restricting access to firearms during periods of risk without threatening second amendment concerns. The effectiveness of this gun culture message, relative to standard suicide prevention messaging and a control condition, was then tested with a national sample of gun owners.

RESULTS

Relative to all other conditions, respondents who received our culturally-specific message in conjunction with standard suicide prevention content reported the greatest likelihood of taking steps to restrict access to firearms. This tendency was enhanced for individuals who were more politically conservative, lived in more rural areas, and supported gun rights to a stronger degree.

CONCLUSIONS

Findings underscore the importance of attending to cultural factors in public health messaging. Messaging that respects the values of gun owners could hold promise in promoting firearm restriction for suicide prevention.

Immediate and brief intervention after suicide attempts on patients without major psychiatric morbidity-A pilot study in northern Israel

BACKGROUND

Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events.

METHODS

Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8-12 meetings with a therapist that focused on "crisis intervention" techniques.

RESULTS

212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program's population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts.

CONCLUSIONS

The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

Characteristics of the suicidal soldier in the Israeli Defense Force-a review of literature

Suicide is the third leading cause of death among adolescents in most Western world countries. Similar findings have been reported among adolescents in Israel (including the Israeli army) in times of peace; nonetheless, suicide rate has decreased significantly in recent years.

In Israel, IDF service is mandatory and adolescents are obligated to serve by law. Therefore, the IDF is responsible under state and moral law to care for the physical and mental health of its soldiers. Additionally, there is an understanding that the Israeli soldiers represent a mentally healthy population as prior to their enlistment they undergo a series of tests and evaluations to determine their suitability for service. The IDF is one of the few organizations in the world that is comprised of the majority of a country’s healthy adolescent population. International literature defines this population (i.e., the adolescent population) as having the highest risk of suicidality. Moreover, the risk of suicide increases in the face of two additional circumstances within the context of military service: the army service as a stressor and the availability of weapons.

The IDF invests significant resources in delineating the characteristics of suicidal soldiers, realizing its importance for suicide prevention during military service. This article reviews studies regarding complete suicide cases of Israeli soldiers in the aim of characterising a ‘suicidal soldier’s profile’ to inform better screening and prevention policies.