Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study

How people react to suicidal ideation: The effect of suicide literacy, suicide stigma, and expressive suppression

INTRODUCTION

The purpose of this study is to understand the role of suicide literacy and suicide stigma in laypeople's intention to recommend professional help in Korea. Additionally, the study focuses on the role of expressive suppression as a sociocultural factor.

METHODS

Participants read vignettes depicting either subclinical distress or suicidal ideation and answered questions measuring suicide literacy, stigma, and expressive suppression. Mediated moderation analyses were used to examine the interactions between these factors.

RESULTS

The result found the significant effect of expressive suppression. The mediating effect of suicide stigma on the relationship between suicide literacy and recommendation of professional help was significant for those who do not suppress their emotions. This result indicates that when individuals were not hesitant to express negative emotions, high suicide literacy lowered suicide stigma and led to more willingness to recommend professional help.

CONCLUSIONS

The results showed that expressive suppression acts as a barrier deterring Koreans from professional help for their mental health. The findings underscore the importance of sociocultural factors such as expressive suppression in developing suicide prevention strategies.

Case fatality of repeated suicidal acts among suicide attempters in rural China: a retrospective cohort study

Background

Individuals presenting to hospital due to suicide attempt are at high risk for repeated suicidal act, yet there are meager data on the extent to which repeated suicidal acts result in death.

Methods

This retrospective cohort study was based on a general hospital self-harm register system in a rural county in China. Identified individuals who attempted suicide were contacted and followed up for up to 8 years. Main outcomes over follow-up were: 1) suicide death, 2) nonlethal suicide attempt, and 3) suicidal acts including suicide death and nonlethal attempt. Incidence densities, correlates, and case fatality of repeated suicidal acts were estimated.

Findings

A total of 1086 individuals (two-thirds females, mean age 40.6 years) with a suicide attempt presenting to hospital (index attempt) were identified and followed up, with most of the index attempts by pesticide ingestion (79%). Over follow-up, there were 116 suicidal acts carried out by 108 individuals (69 females, 39 males), including 34 suicide deaths (21 females, 13 males), yielding a high case-fatality of 29.3%. During follow-up, suicide death rates were also high overall and in the first year of follow-up (846.7 and 1787.2 per 100,000 person years). Over follow-up, pesticide was the most common method (47/116) of repeated suicidal act and yielded a higher case-fatality than other methods (46.8% vs 17.4%, χ2 = 11.68, P < 0.001). The incidence densities of repeated suicidal acts and nonlethal attempts were low compared to rates reported in previous literature.

Interpretation

Incidence densities of repeated suicidal acts in a rural China cohort were low compared to previous studies. However, rates of suicide deaths over follow-up were high, a result driven by the high case-fatality of suicidal acts and attributable to the common use of pesticides. Reducing suicidal acts with pesticides is a key target for suicide prevention in rural China.

Funding

Beijing Municipal High Rank Public Health Researcher Training Program, Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support, and Beijing Hospitals Authority's Ascent Plan.

Clinical utility of depression measures and symptoms: Implications for suicide risk assessment in high risk, resource limited youth populations

OBJECTIVE

Suicide risk for youth in resource- limited settings has been largely underrepresented in the literature and requires targeted examination of practical ways to address this growing public health concern. The present study focuses on the clinical utility of depression risk assessment tools addressing how and for whom suicide prevention intervention is most beneficial within a low-middle-income-country, high suicide risk youth sample.

METHODS

Youth who reported a previous suicide attempt versus those who did not were criterion to test the validity of depression and hopelessness symptom assessment tools. We used item analyses to identify depressive symptom endorsements that most informed youth suicide risk, which will better equip rural practitioners for targeted intervention and monitoring of youth with an already high risk for suicide.

RESULTS

Findings demonstrated that practitioners may target symptoms of social anhedonia, depressed mood, concentration disturbance, feelings of worthlessness, sleep disturbance, and fatigue for suicide prevention-intervention efforts among high-risk youth.

CONCLUSIONS

Study implications are for clinicians' use of the BDI-II and CES-D for depression symptom identification and suicide risk monitoring in settings with limited mental health infrastructure.

Prevention of Re-attempt Suicide Through Brief Contact Interventions: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Controlled Trials

Brief contact intervention (BCI) is a low-cost intervention to prevent re-attempt suicide. This meta-analysis and meta-regression study aimed to evaluate the effect of BCI on re-attempt prevention following suicide attempts (SAs). We systematically searched using defined keywords in MEDLINE, Embase, and Scopus up to April, 2023. All randomized controlled trials (RCTs) were eligible for inclusion after quality assessment. Random-effects model and subgroup analysis were used to estimate pooled risk difference (RD) and risk ratio (RR) between BCI and re-attempt prevention with 95% confidence intervals (CIs). Meta-regression analysis was carried out to explore the potential sources of heterogeneity. The pooled estimates were (RD = 4%; 95% CI 2-6%); and (RR = 0.62; 95% CI 0.48-0.77). Subgroup analysis demonstrated that more than 12 months intervention (RR = 0.46; 95% CI 0.10-0.82) versus 12 months or less (RR = 0.67; 95% CI 0.54-0.80) increased the effectiveness of BCI on re-attempt suicide reduction. Meta-regression analysis explored that BCI time (more than 12 months), BCI type, age, and female sex were the potential sources of the heterogeneity. The meta-analysis indicated that BCI could be a valuable strategy to prevent suicide re-attempts. BCI could be utilized within suicide prevention strategies as a surveillance component of mental health since BCI requires low-cost and low-educated healthcare providers.

Suicide attempts and the factors that lead to suicidal ideation: A 3-year analysis

OBJECTIVE

We explored the epidemiological characteristics of suicide attempts and identified suicide trends and associated factors.

METHODS

This retrospective, cross-sectional, observational, and single-center study included consecutive 412 patients who were admitted to Emergency Department for follow-up and treatment after a suicide attempt between June 2019 and June 2022. We assessed patient demographics, suicidal behavior, previous suicide attempts, psychiatric disorders, drug use, visits to the psychiatry clinic within the past 6 months, the persistence of suicidal ideation, and clinical outcomes.

RESULTS

The study population consisted of 259 females (62.86%) and 153 males (37.14%), with a mean age of 29.50±11.51 (range: 13-72) years. Females attempted suicide more often than males, but suicide completion was more common in males. Overall, 79.37% (n=327) of the suicide attempters were aged <40 years and most were 20-29 years old (n=147, 35.68%). Non-fatal suicide attempts were more common in single, unemployed, and poorly educated individuals, but this was not the case for suicide completers. However, there was no significant difference in marital status, education, and occupation among suicide completers. Drug poisoning was the major form of suicide attempt (n=345, 83.74%). Mental disorders, family or relationship conflicts, and separation from a partner were common causes of suicidal ideation. Patient numbers were particularly high in the autumn (i.e., September), and at night.

CONCLUSION

Females, young adults, singletons, the unemployed, and individuals with psychiatric disorders and low education levels are more likely to attempt suicide, particularly during hours when they are likely to be alone.

Comparative Epidemiology of Attempted and Fatal Suicide in a Defined Catchment Area in Israel

BACKGROUND

Both attempted and fatal suicides are important public health issues and the relationship between these behaviors has great relevance to clinical practice.

AIMS

To determine how the epidemiology of attempted and fatal suicide relate to each other over time.

METHOD

In an 18-year period consecutive admissions for suicide attempts (n = 4,645) to the emergency room of the central hospital of a well-defined catchment area were assessed using a structured interview. Data were compared with records of 425 fatal suicides from the same catchment area.

RESULTS

The relative rates of attempted and fatal suicide changed over time independent of both age and gender up to age 64. Rates of suicide and attempted suicide did not correlate over time in this age group. This was not true for the over 65 age group where attempted suicide and fatal suicide were significantly correlated over time in both men and women.

CONCLUSIONS

In subjects over 65 attempted suicide is highly associated with eventual suicide. This relationship is much less clear in younger age groups. Thus age of attempt is of great importance when considering the prognostic import of a suicide attempt.

Development and validation of a nomogram to predict suicidal behavior in female patients with mood disorder

Introduction

This study aims to explore the risk factors associated with suicidal behavior and establish predictive models in female patients with mood disorders, specifically using a nomogram of the least absolute shrinkage and selection operator (LASSO) regression.

Methods

A cross-sectional survey was conducted among 396 female individuals diagnosed with mood disorders (F30-F39) according to the International Classification of Diseases and Related Health Problems 10th Revision (ICD-10). The study utilized the Chi-Squared Test, t-test, and the Wilcoxon Rank-Sum Test to assess differences in demographic information and clinical characteristics between the two groups. Logistic LASSO Regression Analyses were utilized to identify the risk factors associated with suicidal behavior. A nomogram was constructed to develop a prediction model. The accuracy of the prediction model was evaluated using a Receiver Operating Characteristic (ROC) curve.

Result

The LASSO regression analysis showed that psychotic symptoms at first-episode (β = 0.27), social dysfunction (β = 1.82), and somatic disease (β = 1.03) increased the risk of suicidal behavior. Conversely, BMI (β = -0.03), age of onset (β = -0.02), polarity at onset (β = -1.21), and number of hospitalizations (β = -0.18) decreased the risk of suicidal behavior. The area under ROC curve (AUC) of the nomogram predicting SB was 0.778 (95%CI: 0.730-0.827, p < 0.001).

Conclusion

The nomogram based on demographic and clinical characteristics can predict suicidal behavior risk in Chinese female patients with mood disorders.

Alcohol use, self-harm and suicide: a scoping review of its portrayal in the Sri Lankan literature

Background

Suicide is a global public health problem. Compared to other middle-income countries, much literature has been generated on the topic of self-harm and suicide in Sri Lanka. Harmful use of alcohol is a well-known risk factor to self-harm and suicide, however the connection needed further exploration.

Aim

The aim was to investigate alcohol's role in self-harm and suicide in Sri Lanka to inform policy and prevention programs and future research priorities.

Methods

We performed a scoping review exploring how the association between alcohol use, self-harm and suicide in Sri Lanka is presented in scientific literature from August 1, 2008 to December 31, 2022. Thematic analysis was used to explore emerging themes.

Results

Altogether 116 peer-reviewed articles were included. Three themes emerged: (i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. The articles' recommendations for policy, prevention and research priorities included: Family- and community-based alcohol, self-harm and suicide reduction interventions; viewing self-harm as a window of opportunity for health personnel to intervene in families affected by harmful alcohol consumption; and introduction of and increased access to treatment of alcohol use disorder at the individual level.

Conclusion

Suggestions for alcohol, self-harm, and suicide prevention interventions were primarily targeted at the community, though this might also reflect the limited treatment, mental health, and alcohol support available in the country. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm prevention and treatment.

Establishing Self-Harm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally

Self-harm registers (SHRs) are an essential means of monitoring rates of self-harm and evaluating preventative interventions, but few SHRs exist in countries with the highest burden of suicides and self-harm. Current international guidance on establishing SHRs recommends data collection from emergency departments, but this does not adequately consider differences in the provision of emergency care globally. We aim to demonstrate that process mapping can be used prior to the implementation of an SHR to understand differing hospital systems. This information can be used to determine the method by which patients meeting the SHR inclusion criteria can be most reliably identified, and how to mitigate hospital processes that may introduce selection bias into these data. We illustrate this by sharing in detail the experiences from a government hospital and non-profit hospital in south India. We followed a five-phase process mapping approach developed for healthcare settings during 2019-2020. Emergency care provided in the government hospital was accessed through casualty department triage. The non-profit hospital had an emergency department. Both hospitals had open access outpatient departments. SHR inclusion criteria overlapped with conditions requiring Indian medicolegal registration. Medicolegal registers are the most likely single point to record patients meeting the SHR inclusion criteria from multiple emergency care areas in India (e.g., emergency department/casualty, outpatients, other hospital areas), but should be cross-checked against registers of presentations to the emergency department/casualty to capture less-sick patients and misclassified cases. Process mapping is an easily reproducible method that can be used prior to the implementation of an SHR to understand differing hospital systems. This information is pivotal to choosing which hospital record systems should be used for identifying patients and to proactively reduce bias in SHR data. The method is equally applicable in low-, middle- and high-income countries.

The engaged community action for preventing suicide (ECAPS) model in Latin America: development of the ¡PEDIR! program

PURPOSE

It is estimated that someone dies by suicide every 40 s globally and that 3000 people end their lives daily. Of these deaths, 79% occur in low-resource settings. The very nature of the low-resource settings often serves as a barrier to the adoption and implementation of evidence-based suicide prevention models that have demonstrated success in high-resource countries. As such rates of suicide continue to increase, the workforce of trained mental health providers equipped to effectively engage, assess, and treat individuals struggling with suicidal thoughts and behaviors remains relatively stagnant. This paper aims to illustrate the implementation of the Engaged Community Action for Preventing Suicide (ECAPS) model as a means of developing a culturally relevant and responsive model of suicide prevention that is acceptable and sustainable in low-resource settings.

METHODS

University faculty and staff (n=34) and psychology students (n=25), and community-based mental health providers (n=41) providing mental health services to at-risk individuals in highly vulnerable communities in Lima, Peru participated in the implementation of ECAPS process.

RESULTS

The resulting program, ¡PEDIR!, demonstrates the acceptability, feasibility, and effectiveness of the ECAPS model.

CONCLUSION

The ECAPS model is a feasible and effective framework for use in low-resource settings to guide the development of a culturally relevant community-level intervention to address the systemic, societal, and individual level factors that serve as barriers to suicide prevention.

Identifying Youth at Risk for Suicidal Thoughts and Behaviors Using the "p" factor in Primary Care: An Exploratory Study

Suicide is a major, preventable public health problem. The general factor of psychopathology ("p" factor) might help improve detection and prediction of individuals at risk for suicide. This cross-sectional proof-of-concept study tests whether the p-factor score is associated with suicidal thoughts and behaviors (STB) better than a depression scale alone. Youth (N = 841; mean age 18.02, SD = 3.36) in primary care were universally screened using the Behavioral Health Screen (BHS). Factor analysis and ROC results showed the BHS assesses the p-factor, and the p-factor score demonstrates higher classification accuracy of several types of STB than a depression scale. The p-factor could help clinicians in the identification of youths with STB.

Effectiveness of distance-based suicide interventions: multi-level meta-analysis and systematic review

BACKGROUND

The use of distance-based interventions (DBIs) to reduce suicidal ideation and behaviours are an increasingly relevant form of intervention. DBIs are more affordable, scalable and available than traditional face-to-face interventions, helping to narrow the gap between needed and provided care.

AIMS

To evaluate the overall effectiveness of DBIs against suicidal ideation and behaviours.

METHOD

We systematically searched Web of Science, Scopus and PubMed for all DBIs primarily aimed at reducing suicidal ideation and behaviours. Data were analysed with a robust variance estimation corrected, multi-level meta-analysis.

RESULTS

We found 38 studies, reporting 110 outcomes. Effectiveness in reducing suicidal ideation was low (standardised mean difference -0.174, 95% CI -0.238 to -0.110). DBIs were significantly less effective against suicidal behaviours than against suicidal ideation, although still effective (standardised mean difference -0.059, 95% CI -0.087 to -0.032). Human involvement had no significant effect on effectiveness.

CONCLUSIONS

Despite low effectiveness, DBIs might play a role in large-scale prevention efforts against suicidal ideation within a stepped care approach. Further, DBIs may be helpful in expanding mental health services in low- and middle-income countries with otherwise limited access to mental healthcare. Although the evidence for DBIs efficacy is well grounded, the technical and scientific evaluation of DBIs regarding their set up, functionality and components needs to be addressed in future studies.

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap-proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision-making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low- and middle-income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low-resource settings may lead to wider learning from locally embedded strategies.

Nursing students' attitudes towards suicide and suicidal patients: A multicentre cross-sectional survey

BACKGROUND

Education of nursing students can be a valuable resource in contributing to suicide prevention in mental health service users. The evaluation of students' attitudes towards a complex clinical issue is an important aspect of education that can expand traditional paths to acquisition of competence. Thus far, very few studies investigated attitudes towards suicidal risk among nursing students, and no data are available on Italian settings.

OBJECTIVES

The aim of this study was to explore nursing students' attitudes towards suicidal risk across the Nursing schools in three Italian universities.

DESIGN

Multicentre cross-sectional survey incorporating a before-after design.

SETTING AND PARTICIPANTS

A non-randomized sample of nursing students of the bachelor's degree in Nursing in three University hospitals was recruited.

METHODS

Nursing students completed "Suicide Behaviour Attitude questionnaire-Italian version" (SBAQ-ita scale); second-year nursing students of the University of Milan completed the scale before (T0) and 2 months after (T1) a specific lecture on suicide and suicidal risk.

RESULTS

Three hundred and fourteen students were enrolled (response rate 76.77%). The overall score of sample attitudes had a Median (Me) of 3.5[2.5;4] for the domain "Feeling towards the patient", 3[2;4] for the domains "Professional ability", 5[3;7] for the domain "Right to suicide", 5[4;6] for the domain "Knowledge". Improved median score regarding the domain "Professional ability" (0.015), and decreased median score on the "Knowledge" (0.021) domain were observed at T1.

CONCLUSIONS

The study highlights the impact of an educational intervention on nursing students' attitudes, supporting its implementation to improve academic education programmes.

Discordance between family report and clinical assessment of suicide attempts: a prospective study from the emergency department

Background

Developing accurate identification methods for individuals with suicide attempts and providing them with follow-up care and supports can be a vital component of all comprehensive suicide prevention strategies. However, because of the difficulties concerning one’s intentions behind injurious behaviour, identifying suicide attempts is a challenge for families and clinicians.

Aims

The aim of this study was to investigate the differences between family report and clinical assessment for suicide attempts in the emergency department (ED).

Methods

A total of 148 patients with suspected suicide attempts (SSAs) and 148 family caregivers in the ED were enrolled. The suicide risk module of the Chinese version of the MINI International Neuropsychiatric Interview and the self-report measure were used to assess those with SSA’s suicidal behaviours. The Family Adaptability and Cohesion Evaluation Scales and semi-structured interviews were used to investigate the characteristics of suicide risk and demographics of patients with SSA, as well as the rate and influencing factors of omitted suicide attempts reported by family caregivers.

Results

The underreporting rate for family reported suicide attempts in the ED was 69.0%. The suicide attempts group indicated lower mean scores on perceptions of family resources, adaptability and cohesion. Patients' suicide risk rating (OR=0.152, 95% CI: 0.037 to 0.620, p=0.009), adult-children relationship (OR=5.037, 95% CI: 1.478 to 17.167, p=0.010) and caregiver’s age (OR=0.279, 95% CI: 0.103 to 0.757, p=0.012) might be associated with underreporting by families. If patients committed suicide attempts through a falling injury or medication overdose, their families may have misreported the suicide attempt.

Conclusions

The discordance of suicide attempt records between family report and clinical assessment reveals the limitations of family self-reports when identifying suicide attempts. Interviews and observations, together with information from certain diagnoses, should be combined to accurately identify suicide attempters in the ED.

FASE-family and social engagement model for prevention and management of self harm behavior-a study protocol for cluster randomized control trial in India

BACKGROUND

Suicide is a substantial public health concern for countries worldwide. Effective preventive and curative interventions for self-harm behavior (SHB) are imperative for nations with an alarmingly high rate of suicide and self-harm behaviors. The intervention protocol named FASE (Family and Social Engagement) consists of comprehensive assessment, Attachment-Based Family Therapy (ABFT), and community linkages for people presenting with suicide or self-harm in emergency departments of tertiary hospitals.

METHODS

This article reports the design and protocol for a cluster randomized control trial for suicide prevention and management. After the developed intervention is pilot tested in a tertiary hospital in Kerala, the intervention will be scaled up to be implemented in various tertiary hospitals in Kerala. Each hospital emergency department will be considered a cluster, and these clusters will be randomized to the intervention group and control group in a 1:1 ratio. The eligible people from the intervention clusters will undergo a baseline assessment, a structured moderate intense intervention with twelve sessions spread across 6 months by the trained social workers supervised by the Mental health team, and a follow-up assessment at the end. Participants will be recruited after obtaining consent and explaining the study. The primary outcome includes suicidality measured by the Depressive Symptom Inventory-Suicidality Subscale (DSI-SS), Depression, Anxiety and Stress Scale (DASS), MOS Social Support Survey, and Brief resilience scale (BRS).

DISCUSSION

Knowledge generated from this trial can significantly affect new programmatic policy and clinical guidelines that will improve the reduction of suicide rates in the country.

TRIAL REGISTRATION

Prospectively registered in Clinical Trial Registry India (ICMR-NIMS) on 18/10/2021 (ref number- REF/2021/10/048264).

Organophosphate pesticide exposure as a risk factor for attempted suicide in Cape Town, South Africa: A case-control study

Pesticides are a commonly used agent for suicide in many Low- and Middle-Income countries (LMICs). However, accumulating evidence suggests that exposure to organophosphate (OP) pesticide may also increase the risk of suicide. We conducted a hospital-based case-control study to investigate whether prior household, garden or occupational OP exposure were associated with attempted suicide using conditional logistic regression modeling. Participants who attempted suicide with any means and were admitted to two Western Cape Province hospitals in South Africa were compared to a sample of controls matched by age, sex and time of admission with unrelated conditions, between August 2015 and August 2017. The means of attempted suicide was not recorded. OP exposure was determined by dialkyl phosphate (DAP) metabolites detected in hair and by environmental and occupational history. Approximately 85% of participants reported using pesticides in the home or garden and 15% of participants reported current or past occupational exposure while working on a farm. Attempted suicide was not associated with reported home or garden OP use (Odds ratio [OR] = 0.59, 95%CI 0.33-1.04), hair DAP metabolites (OR = 1.00, 95%CI 0.98-1.02) or current or past agricultural work (OR = 1.08, 95%CI 0.62-1.87), but was associated with hazardous drinking and unemployment with no household income. We found no evidence that attempted suicide was associated with environmental or occupational pesticide use in an urban South African population attending an emergency center.

Effectiveness of a telephone prevention programme on the recurrence of suicidal behaviour. One-year follow-up

People who have attempted suicide are considered a risk population for repeating the behaviour. Therapeutic interventions, such as telephone follow-up programmes (TFPs), are promising but more evidence for its efficacy is needed. In this multicentre, open, ex-post-facto, pre/post, one year prospective study, a previous cohort discharged from the emergency department for a suicide attempt (SA) and given routine treatment (n=207) was compared with a similar group who received the same intervention plus a structured TFP of six calls (n=203). At one year of follow-up, the efficacy of the TFP at preventing SA was assessed. A total of 53.2% (n=108) of the patients finished the TFP. A total of 20.3% (n=42) of the routine treatment group and 23.6% (n=48) of the TFP group re-attempted at least once in the follow-up period (χ²=0.7;df=1;p=.412). However, in both groups, different subsamples of patients who presented extreme risk of SA at follow-up (0-57%) were identified. In the TFP group, the recurrence of suicidal behaviour was lower in patients admitted after the index attempt and in those who had more severe psychopathological symptoms, but not in the other profiles. Thus, this study has identified a specific profile of patients who could benefit from a brief-contact intervention.

Innovating Technology-Enhanced Interventions for Youth Suicide: Insights for Measuring Implementation Outcomes

Technology is one medium to increase youth engagement, especially among underserved and minority groups, in suicide preventive interventions. Technology can be used to supplement or adjunct an in-person intervention, guide an in-person intervention, or be the stand-alone (automated) component of the intervention. This range in technological use is now called the continuum of behavioral intervention technologies (BITs). Overall, suicide intervention researchers do not use this terminology to categorize how the role of technology differs across technology-enhanced youth interventions. There is growing recognition that technology-enhanced interventions will not create substantial public health impact without an understanding of the individual (youth, families, and providers), mezzo (clinics and health systems of care), and contextual factors (society, culture, community) that are associated with their implementation. Implementation science is the study of methods to promote uptake of evidence-based practices and policies into the broader health care system. In this review, we incorporate work from implementation science and BIT implementation to illustrate how the study of technology-enhanced interventions for youth suicide can be advanced by specifying the role of technology and measuring implementation outcomes.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Effects of psychosocial interventions among people cared for in emergency departments after a suicide attempt: a systematic review protocol

BACKGROUND

The care of the emergency department (ED) for a person after a suicide attempt can act as a protector against future suicidal behavior. For this reason, it is essential that the ED ensure an assistance that involves effective interventions in preventing suicidal behaviors. Among suicidal behaviors, it is known that suicide attempt is one of the most lethal risk factors for consummated suicide. In addition, the risk for further attempts is greater in the period from the immediate post-discharge up to 12 months after the last attempt. This makes the ED a key link in the suicide prevention chain. The purpose of this review is to investigate the effects of psychosocial interventions on suicide prevention, when applied in the ED after a suicide attempt.

METHODS

This systematic review protocol was built and registered with the collaboration of a multidisciplinary scientific team. The review will include randomized clinical studies, quasi-experimental trials, and comparative observational studies, all conducted with people (11 years old or more) who have received a psychosocial suicide prevention intervention initiated in the ED after a suicide attempt. The research will be conducted across databases such as Cochrane Library, PubMed, EMBASE, PsycINFO, and DARE. The repetition of a suicide attempt and death by suicide as primary outcomes will be analyzed. The eligibility of the studies and data extraction will be carried out by matched and blind researchers. The risk of bias will be addressed using appropriate instruments. The analyses and synthesis of the results will be both qualitative and quantitative.

DISCUSSION

From a public health point of view, suicide is in itself a public health problem and requires appropriate interventions at different levels of care in order to be prevented. Taking into account that a high percentage of people who died by suicide sought the ED for suicide attempt in the year before their death, the ED is a clinical context with a privileged potential to implement these interventions. Presently, several clinical studies seek to validate interventions to be adopted regarding the prevention of suicidal behavior. Current evidence indicates that different interventions must be strategically combined to reduce suicide attempts and their mortality.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42019131040.

Suicide Prevention in the Western Pacific Region

This chapter draws on internationally available data to describe the epidemiology of suicide and self-harm in the World Health Organization (WHO) Western Pacific Region. It then describes the suicide prevention activities in the region, using in-depth case studies to highlight some key suicide prevention activities in certain countries/areas and the Global Survey on Suicide Prevention conducted in 2013 by the International Association for Suicide Prevention (IASP) and WHO. It demonstrates that there is considerable variability both between and within low and middle income countries and high income countries, both in terms of rates of suicide and self-harm and in terms of the preventive efforts that have been mobilised to address them. Adequate funding for suicide prevention efforts in the region should be a priority, as should the delivery of a range of suicide prevention approaches. Evaluation and monitoring efforts are also crucial.

Suicidality in Epilepsy: Does It Share Common Pathogenic Mechanisms with Epilepsy?

Suicidality presents a major global health concern and its association with epilepsy has been suggested. The body of evidence is growing due to targeted epidemiological studies, genetic findings, and neuroimaging data, use of specific neuropsychiatric inventories, neuropsychological tests, and metabolic and immunological studies.Suicide tendencies and psychiatric comorbidity such as depression are not uncommon in chronic diseases, especially in epilepsy. Suicide is an important cause of death in epilepsy, and is usually underestimated. Persons with epilepsy have higher risk for suicide than healthy controls. It appears that some epilepsy types have stronger tendencies for suicide, in particular temporal lobe epilepsy. The suicidal risk factors in persons with epilepsy include difficult to treat epilepsies, onset of epilepsy at an earlier age, and comorbid depression.This clinical evidence is mostly based on observational studies in which we found an increased risk of suicidal ideation, suicidal attempts, and completed suicides in persons with epilepsy. However, we lack prospective and longitudinal studies on suicide in epilepsy. In this chapter we will examine recent research in neurobiological mechanisms between suicidality and epilepsy, and comorbid depression.

The Role of Technology and the Continuum of Care for Youth Suicidality: Systematic Review

Background

Youth suicide is a global public health issue, and using technology is one strategy to increase participation in preventive interventions. However, there is minimal knowledge on how technology-enhanced interventions for youth correspond to the stages of care, from illness or risk recognition to treatment follow-up.

Objective

This systematic review aims to examine the efficacy of technology-enhanced youth suicide prevention and interventions across the continuum of care.

Methods

Four electronic databases were searched up to spring 2019 for youth suicide preventive interventions that used technology. The review was not restricted by study design and eligible studies could report outcomes on suicidality or related behaviors, such as formal treatment initiation. An adapted version of the Methodological Quality Ratings Scale was used to assess study quality.

Results

A total of 26 studies were identified. The findings support the emerging efficacy of technology-enhanced interventions, including a decline in suicidality and an increase in proactive behaviors. However, evidence suggests that there are gaps in the continuum of care and recent study samples do not represent the diverse identities of vulnerable youth.

Conclusions

The majority of identified studies were conducted in school settings and were universal interventions that aligned with the illness and risk recognition and help-seeking stages of the continuum of care. This field could be strengthened by having future studies target the stages of assessment and treatment initiation, include diverse youth demographics, and examine the varying roles of providers and technological components in emerging interventions.

Suicidal behaviors and depression "among adolescents in Hanoi, Vietnam: A multilevel analysis of data from the Youth Risk Behavior Survey 2019

This study described the prevalence of suicidal behaviors and depression among adolescents in Hanoi, Vietnam, and examines the associated factors. In 2019, a school-based survey was conducted in three high schools in Hanoi and 661 high students were included into the study. We found that the prevalence of 12-month suicidal thoughts, suicide plans, and suicide attempts were 14.2%, 5.5%, and 3.0% respectively. Notably, the depression score mean was 16.1±4.9, among major predictors of suicidal ideation. Therefore, developing psychological care services in school is imperative to the early detection of mental disorders and the prevention of suicidal behaviors for the students.

Recruitment of adolescents with suicidal ideation in the emergency department: lessons from a randomized controlled pilot trial of a youth suicide prevention intervention

BACKGROUND

Emergency Departments (EDs) are a first point-of-contact for many youth with mental health and suicidality concerns and can serve as an effective recruitment source for randomized controlled trials (RCTs) of mental health interventions. However, recruitment in acute care settings is impeded by several challenges. This pilot RCT of a youth suicide prevention intervention recruited adolescents aged 12 to 17 years presenting to a pediatric hospital ED with suicide related behaviors.

METHODS

Recruitment barriers were identified during the initial study recruitment period and included: the time of day of ED presentations, challenges inherent to study presentation, engagement and participation during an acute presentation, challenges approaching and enrolling acutely suicidal patients and families, ED environmental factors, and youth and parental concerns regarding the study. We calculated the average recruitment productivity for published trials of adolescent suicide prevention strategies which included the ED as a recruitment site in order to compare our recruitment productivity.

RESULTS

In response to identified barriers, an enhanced ED-centered recruitment strategy was developed to address low recruitment rate, specifically (i) engaging a wider network of ED and outpatient psychiatry staff (ii) dissemination of study pamphlets across multiple areas of the ED and relevant outpatient clinics. Following implementation of the enhanced recruitment strategy, the pre-post recruitment productivity, a ratio of patients screened to patients randomized, was computed. A total of 120 patients were approached for participation, 89 (74.2%) were screened and 45 (37.5%) were consented for the study from March 2018 to April 2019. The screening to randomization ratio for the study period prior to the introduction of the enhanced recruitment strategies was 3:1, which decreased to 1.8:1 following the implementation of enhanced recruitment strategies. The ratio for the total recruitment period was 2.1:1. This was lower than the average ratio of 3.2:1 for published trials.

CONCLUSIONS

EDs are feasible sites for participant recruitment in RCTs examining new interventions for acute mental health problems, including suicidality. Engaging multi-disciplinary ED staff to support recruitment for such studies, proactively addressing anticipated concerns, and creating a robust recruitment pathway that includes approach at outpatient appointments can optimize recruitment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03488602 , retrospectively registered April 4, 2018.

Supportive effect of body contact care with ylang ylang aromatherapy and mobile intervention team for suicide prevention: A pilot study

OBJECTIVES

To assess understudied, alternative suicide prevention modalities in a mental health care setting.

METHODS

This was a prospective study of patients (n = 140, 68 cases and 72 controls) who were admitted to hospital or who contacted an SOS suicide crisis line for suicidal ideation or attempts. Psychiatric diagnoses (Mini-International Neuropsychiatric Interview) and intensity of anxiety/depression/suicidality (Hamilton Anxiety Rating Scale, Montgomery-Åsberg Depression Rating Scale, and Beck Scale for Suicidal Ideation) were assessed. All intervention group subjects received a crisis card with a crisis line number, interviews with psychologists or volunteers and a telephone call on days 10 to 21, then 6 months later. These subjects also had a choice between two further 4-month interventions: body contact care or mobile intervention team visits.

RESULTS

The interventions significantly reduced the number of suicide attempts and suicide (3%) at 6 months compared with the control condition (12%). There were fewer losses to follow-up in the intervention group (7.35%) than in the control group (9.72%).

CONCLUSIONS

The results favour the implementation of integrated care and maintaining contact in suicide prevention.

Suicide during Transition of Care: a Review of Targeted Interventions

The risk of suicide is significant during the transition of care; the highest in the first few weeks after discharge from a healthcare facility. This systematic review summarizes the evidence for interventions providing care during this high-risk period. In January 2019, PubMed and Scopus were systematically searched using the search terms: Suicide AND (Hospital OR Emergency department) AND Discharge. Articles relevant to interventions targeting suicidal behaviors during the transition of care were selected after the title and abstract screening followed by full-text screening. This review article included 40 articles; with a total patient population of 24,568. The interventions included telephone contacts, letters, green cards, postcards, structured visits, and community outreach programs. An improvement in the engagement of patients in outpatient services was observed but the evidence for suicidal behaviors was conflicting. The reviewed interventions were efficacious in linking patients to outpatient services, reducing feelings of social isolation and helping patients in navigating the available community resources. For patients with repetitive suicidal behaviors, psychosocial interventions such as dialectical behavioral therapy can be helpful. Patients should be followed by targeted interventions based on risk categorization of the patients by using evidence-based tools.

Prevention of Suicidal Behavior with Telemedicine in Patients with a Recent Suicide Attempt: Is a 6-month Intervention Long Enough?

OBJECTIVE

To analyze the results of a 6-month telephone follow-up program for the prevention of suicidality in adult patients discharged from three general hospitals after a suicide attempt. Results are compared with traditional programs lasting 12 months or more.

METHODS

This is a prospective, multicenter, study with the control group. Patients in the intervention group received five protocolized telephone calls which were added to their usual treatment. Those in the control group only received usual treatment. Each patient was followed up for 12 months.

RESULTS

A total of 123 patients were included in the intervention group and 463 in the control group. 57.7% received at least three calls. Patients in the intervention group took longer to perform a reattempt (p = .05). The percentage of those who did a reattempt (p = .67) and the number of reattempts per patient (p = .66) did not differ between groups. Those in the intervention group showed higher percentages of adherence to the outpatient follow-up (p < .001).

CONCLUSION

The intervention was well accepted and showed improved percentages of adherence to outpatient follow-up; however, the results in the prevention of suicidality were worse than those obtained by programs lasting 12 months or more. It is advisable to maintain the telephone follow-up for a minimum of 12 months.

Suicide Attempts Among French and Brazilian Adolescents Admitted to an Emergency Room. A Comparative Study of Risk and Protective Factors

BACKGROUND

Suicide is the second most common cause of preventable mortality among Brazilian and French adolescents. The aim of the current study was to compare the main risk and protective factors associated with a suicide attempt (SA) and to highlight differences based on geographical characteristics.

METHOD

We compared a Brazilian sample (N = 45) of adolescents admitted to the emergency room of a public hospital in São Paulo for SA to a French sample (N = 320) of adolescents hospitalized for SA across 5 paediatric departments. Then, we ran several multivariate models to examine how each selected variable was related to geographic origin and to the other selected variables linked to geographic origin.

RESULTS

The two samples presented no significant differences regarding gender, age or schooling. Both samples had high rates of depressive disorders, anxiety disorders, substance use, disruptive disorders, borderline psychopathology, and lifetime SAs. However, the Brazilian sample presented significantly higher levels of psychopathology and had more insecure attachment relationships (fearful and detached), whereas the French sample had a more secure attachment style. Brazilian adolescents had more recourse to spiritual beliefs and spiritual support, whereas the French adolescents had higher scores on the Reasons for Living Inventory and used more help-seeking strategies from their social network, mainly close friends. Multivariate models showed that two productive coping strategies (seeking spiritual support and social action) and the dependence score were significantly associated with membership in the Brazilian cohort, whereas a secure attachment style and depression severity (evaluated by the Beck Depression Inventory) were significantly associated with membership in the French cohort.

CONCLUSION

Despite presenting similar psychopathologies, Brazilian adolescents presented a more insecure attachment style and used the religious kind of coping more commonly than their French counterparts. We hypothesize that religion may compensate for the social vulnerabilities present in a middle-income country such as Brazil. More transcultural studies may help to elucidate this phenomenon.

Identifying alcohol problems among suicide attempters visiting the emergency department

BACKGROUND

Many suicide attempters brought to our emergency department (ED) have been found to have alcohol problems, and this should be taken serious consideration because alcohol use disorder is a risk factor for suicide reattempt. In this study, we aimed to estimate the effectiveness of alcohol-related biochemical markers and Alcohol Use Disorder Identification Test Consumption (AUDIT-C) in suicide attempters who visited our ED based on the gold standard for clinical diagnosis used by psychiatrists for alcohol use disorder. Moreover, we aimed to search for a significant standard when clinicians make correct predictions about alcohol use disorder using these markers.

METHODS

Among the subjects who visited ED following a suicide attempt, a total of 203 subjects were selected. Following a psychiatric interview, the subjects who met the criteria for alcohol abuse or alcohol dependence according to DSM-IV-TR in the past year were defined as the "alcohol use disorder" group. Although some subjects did not meet these criteria, men with a weekly alcohol intake of ≥14 drinks and women with a weekly alcohol intake of ≥7 drinks were classified as the "risky drinking" group. AUDIT-C was used as a self-report; further, aspartate aminotransferase, gamma-glutamyltransferase (GGT), and carbohydrate-deficient transferrin (CDT) were assayed using standard methods, and GGT-CDT was calculated using this formula: 0.8 × ln(GGT) + 1.3 × ln(%CDT).

RESULTS

In total, 88 subjects met the criteria for alcohol use disorder and 115 were included in the reference group. In the screening for alcohol use disorder, the AUC of AUDIT-C was 0.89 for men and 0.87 for women. In the screening for risky drinking, the AUC of AUDIT-C was 0.99 for men and 0.93 for women. Compared with other biochemical markers, AUDIT-C showed the highest AUC value for screening for both alcohol use disorder and risky drinking, with the trend being more prominent in men.

CONCLUSIONS

Among the biochemical markers, AUDIT-C yielded the highest sensitivity, specificity, and accuracy in diagnosing alcohol use disorder among suicide attempters in ED. Comparison of results revealed that the use of AUDIT-C with biochemical markers or its use alone can help screen for alcohol use disorder or risky drinking in clinical settings.

Family-based analyses reveal novel genetic overlap between cytokine interleukin-8 and risk for suicide attempt

BACKGROUND

Suicide is major public health concern. It is imperative to find robust biomarkers so that at-risk individuals can be identified in a timely and reliable manner. Previous work suggests mechanistic links between increased cytokines and risk for suicide, but questions remain regarding the etiology of this association, as well as the roles of sex and BMI.

METHODS

Analyses were conducted using a randomly-ascertained extended-pedigree sample of 1882 Mexican-American individuals (60% female, mean age = 42.04, range = 18-97). Genetic correlations were calculated using a variance components approach between the cytokines TNF-α, IL-6 and IL-8, and Lifetime Suicide Attempt and Current Suicidal Ideation. The potentially confounding effects of sex and BMI were considered.

RESULTS

159 individuals endorse a Lifetime Suicide Attempt. IL-8 and IL-6 shared significant genetic overlap with risk for suicide attempt (ρg = 0.49, pFDR = 7.67 × 10-03; ρg = 0.53, pFDR = 0.01), but for IL-6 this was attenuated when BMI was included as a covariate (ρg = 0.37, se = 0.23, pFDR = 0.12). Suicide attempts were significantly more common in females (pFDR = 0.01) and the genetic overlap between IL-8 and risk for suicide attempt was significant in females (ρg = 0.56, pFDR = 0.01), but not in males (ρg = 0.44, pFDR = 0.30).

DISCUSSION

These results demonstrate that: IL-8 shares genetic influences with risk for suicide attempt; females drove this effect; and BMI should be considered when assessing the association between IL-6 and suicide. This finding represents a significant advancement in knowledge by demonstrating that cytokine alterations are not simply a secondary manifestation of suicidal behavior, but rather, the pathophysiology of suicide attempts is, at least partly, underpinned by the same biological mechanisms responsible for regulating inflammatory response.

Reduction of Postdischarge Suicidal Behavior Among Adolescents Through a Telephone-Based Intervention

OBJECTIVE

Brief telephone follow-up for a patient with suicidal tendencies after he or she has been discharged from an emergency room or hospital has been shown to decrease subsequent suicide attempts. However, despite the high rate of suicidal behavior in adolescents, this intervention has not been examined in this population. As part of a quality improvement intervention, postdischarge telephone contacts were used to attempt to reduce suicidal behavior and inpatient rehospitalizations among adolescents.

METHODS

Adolescents who were hospitalized for suicidal ideation or attempt (N=142) were randomly assigned to one of two telephone interventions delivered over a 90-day period: either a single call intervention (SCI) or a multiple calls intervention (MCI). The intervention consisted of assessment of suicidality, review of safety plan, and discussion of medication and weapon safety, with up to six telephone contacts in the MCI and up to one contact in the SCI. Primary outcome measures included suicidal behavior and inpatient rehospitalizations; secondary outcome measures included adolescents' confidence in their safety plan.

RESULTS

Adolescents receiving the MCI had a significantly lower rate of suicidal behavior (6%) compared with adolescents receiving SCI (17%; odds ratio [OR]=0.28, p=0.037); results persisted while the analysis controlled for relevant covariates (OR=0.25, p=0.032). Similarly, adolescents receiving the MCI reported significantly greater confidence in their safety plan at 90 days (95%vs. 74%; p=0.001), which, in turn, was associated with a lower rate of suicidal behavior (OR=0.95, p=0.019).

CONCLUSIONS

A telephone-based intervention for providing recurrent follow-up soon after discharge is feasible in the adolescent population and may be effective in reducing postdischarge suicidal behavior.

The relationship between an electronic mental health stigma campaign and suicidal thoughts and behaviours: a two-arm randomized controlled trial in the Australian construction industry

Males employed in the construction industry are at greater risk of suicide than other employed males. It is plausible that a high level of stigma against mental health problems explains the elevated rates of suicide among this group. This study sought to test the effectiveness of an electronic mental health stigma intervention on suicide ideation, communication about suicide and attempts. Participants were randomly assigned to receive either a series of brief contact interventions over a 6-week period or a wait list control. Suicidal ideation, communication about suicide and suicide attempts were assessed using the Suicidal Behaviors Questionnaire-Revised at post-intervention. We used linear regression to assess effectiveness at post-intervention, adjusting for relevant covariates using both conventional methods and a propensity score approach. Results indicate that the intervention had no significant impact on suicidal thoughts, communication or suicide attempts. There was some indication that individuals in the intervention group reported a slight increase in attempts and communication about suicide. These observations underscore an urgent need for more research to understand the complex and nuanced relationship between stigma and suicide in non-clinical populations.

Practical implications of Mental Healthcare Act 2017: Suicide and suicide attempt

The prevalence of suicides has been increasing in recent years. The number of persons who attempt to die by suicide is 25 times that of the number of those who die by suicide every year. Indian Government passed the Mental Healthcare Act (MHCA), 2017 in the middle of 2018. Section 115 of the act decriminalized the attempt to die by suicide, thereby reducing further stress on the victim. This has legal implications with regard to abetment laws of Sections 109, 116, 306, and 309 of Indian Penal Code. Regarding mental healthcare delivery, this act enables the person who attempted to die by suicide, to access free healthcare, treatment, and rehabilitation. The cost implications for the government are enormous. Medical professionals, mental health professionals, and general and mental health establishments involved in the care of persons who attempted to die by suicide need to update their knowledge to enhance their assessment and management skills to align with the provisions of the act. Massive public awareness programs need to be conducted to enable persons who attempted to die by suicide, to access mental healthcare as per the provisions of the MHCA 2017.

Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis

BACKGROUND

There is evidence that several intervention types, including psychotherapy, reduce repeat suicide attempts. However, these interventions are less applicable to the heterogeneous patients admitted to emergency departments (EDs). The risk of a repeat suicide attempt is especially high in the first 6 months after the initial attempt. Therefore, it is particularly important to develop effective ED interventions to prevent repeat suicide attempts during this 6-month period.

METHODS

We systematically reviewed randomized controlled trials of ED-initiated interventions for suicidal patients admitted to EDs using the databases MEDLINE, PsychoINFO, CINAHL, and EMBASE up to January 2015 in accordance with an a priori published protocol (PROSPERO: CRD42013005463). Interventions were categorized into four types, including active contact and follow-up interventions (intensive care plus outreach, brief interventions and contact, letter/postcard, telephone, and composite of letter/postcard and telephone), and a meta-analysis was conducted to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of a repeat suicide attempt within 6 months.

RESULTS

Of the 28 selected trials, 14 were active contact and follow-up interventions. Two of these trials (n = 984) reported results at 6 months (pooled RR = 0.48; 95% CI: 0.31 to 0.76). There were not enough trials of other interventions to perform meta-analysis. Some trials included in the meta-analysis were judged as showing risk of bias.

CONCLUSION

Active contact and follow-up interventions are recommended for suicidal patients admitted to an ED to prevent repeat suicide attempts during the highest-risk period of 6 months.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005463 (27 August 2013).

Relationship of being threatened or injured with a weapon in school with suicidal ideation and attempt among school students: a school-based study in Zhejiang Province, China

BACKGROUND

Suicide is the second leading cause of death among 15-29 year old youths globally, and the third most common external cause of death in China. School bullying can cause serious consequences among adolescents, including psychosocial problems, low self-esteem and post-traumatic stress disorder. Most studies examining the associations between being bullied in school and suicide are from Western, developed countries. Moreover, few studies focus on being threatened or injured with a weapon, which may cause serious body injury. Our study aimed to explore the relationship of being threatened or injured with a weapon in school with suicidal ideation and attempt among middle and high school students in Zhejiang Province, China.

METHODS

A cross-sectional study of 23,543 students in grades 7-12 from 442 schools was carried out through an anonymous self-administered questionnaire between April and May 2017. Multivariable logistic regression models were used to examine the relationship of being threatened or injured with a weapon in school with suicidal ideation and attempt.

RESULTS

51.3% of participants were boys, and mean (SD) age was 15.6 (1.7) years. The overall prevalence of suicidal ideation and attempt were 16.1% (95%CI: 15.3-16.9) and 3.6% (95%CI: 3.3-4.0), respectively. Prevalence was higher among girls than boys (ideation: 19.1% vs. 13.3%. attempt: 4.4% vs. 2.9%). 13.2% of students reported being threatened or injured with a weapon in school in the past 12 months (95%CI: 11.9-14.5), higher among boys than girls (15.7% vs. 10.5%), and among rural students than urban students (13.9% vs. 11.6%). After adjustment for socio-demographic status, lifestyle factors, academic performance, self-reported health and mental health, the odds ratios for suicidal ideation and attempt among students who reported being threatened or injured with a weapon were 1.46 (1.31-1.61) and 1.68 (1.31-2.13) respectively, as compared with those who did not report being threatened or injured.

CONCLUSIONS

Preventive measures for physical bullying in school need to be reinforced in China. Being threatened or injured with a weapon is associated with both suicidal ideation and attempt among middle and high school students. Suicide prevention should be an important component of psychological interventions for threatened or injured students.

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.

A Scoping Review of Emergency Department Discharge Instructions for Children and Adolescents With Mental Disorders

BACKGROUND

Although most young people under the age of 25 years with mental health presentations to the emergency department (ED) are discharged home, several studies suggest discharge instructions are inadequate. We conducted a scoping review to characterize and map the literature, identify research gaps, and prioritize targeted areas for future reviews for ED discharge instructions for young people with mental disorders.

METHODS

Our review was conducted in an iterative approach with 6 stages including identifying the research question, identifying relevant studies, study selection, data extraction, collaring and summarizing, and stakeholder engagement. We characterized the available information on discharge instruction interventions using the Behavior Change Wheel.

RESULTS

Of the 805 potential publications screened, 25 were included for extraction. Nine of the 25 articles focused on suicide or self-harm, 6 were on mental health in general or mixed groups, and 9 focused on alcohol, tobacco, or substance use in general. Five studies included younger children (ie, less than 12 years) but ages ranged significantly among studies. Education and persuasion were intervention functions most commonly reported in publications (n = 13 and n = 12, respectively). From the policy categories, recommendations regarding service provision were most frequently made from four publications. Descriptions of theory were limited in publications.

CONCLUSIONS

The available literature regarding discharge instructions in the ED for youth with mental disorders is focused on certain content areas (eg, self injurious behaviors, substance use) with more work required in chronic mental disorders that make up a significant proportion of ED visits. Research that extends beyond education and with theoretical underpinnings to explain how and why various interventions work would be useful for clinicians, policy-makers, and other researchers.

Epidemiology of Suicide and the Psychiatric Perspective

Suicide is a worldwide phenomenon. This review is based on a literature search of the World Health Organization (WHO) databases and PubMed. According to the WHO, in 2015, about 800,000 suicides were documented worldwide, and globally 78% of all completed suicides occur in low- and middle-income countries. Overall, suicides account for 1.4% of premature deaths worldwide. Differences arise between regions and countries with respect to the age, gender, and socioeconomic status of the individual and the respective country, method of suicide, and access to health care. During the second and third decades of life, suicide is the second leading cause of death. Completed suicides are three times more common in males than females; for suicide attempts, an inverse ratio can be found. Suicide attempts are up to 30 times more common compared to suicides; they are however important predictors of repeated attempts as well as completed suicides. Overall, suicide rates vary among the sexes and across lifetimes, whereas methods differ according to countries. The most commonly used methods are hanging, self-poisoning with pesticides, and use of firearms. The majority of suicides worldwide are related to psychiatric diseases. Among those, depression, substance use, and psychosis constitute the most relevant risk factors, but also anxiety, personality-, eating- and trauma-related disorders as well as organic mental disorders significantly add to unnatural causes of death compared to the general population. Overall, the matter at hand is relatively complex and a significant amount of underreporting is likely to be present. Nevertheless, suicides can, at least partially, be prevented by restricting access to means of suicide, by training primary care physicians and health workers to identify people at risk as well as to assess and manage respective crises, provide adequate follow-up care and address the way this is reported by the media. Suicidality represents a major societal and health care problem; it thus should be given a high priority in many realms.

Who are likely to attempt suicide again? A comparative study between the first and multiple timers

BACKGROUND

Various explanations account for suicide incidents, and some patients continue to attempt afterwards and others never again. The suicide mortality rate increases with the number of serious attempts. The prevention of secondary attempt of suicide should be an important approach to reduce suicide mortality. However, the characteristics of the targeted population of repeated suicide attempters are understudied.

METHODS

This was a cross-sectional data collection from hospital emergency room from patients who had either attempted suicide for the first time (n=721) or for two or more times (n=70). The subjects were between 14 and 53years old and comprised 293 males and 498 females. In-depth interview was conducted for each suicide attempter with a semi-structural protocol. Demographic and social-psychological characteristics were compared between the two groups of suicide attempters. Logistic regression was used to identify independent predictors of multiple attempts.

FINDINGS

The two groups only differed in religion factor among demographic characteristics and multiple suicide attempters group have a higher percentage of subjects who reported to have a religion affiliation than first time suicide attempters. Multiple attempters were more likely to have family suicide history, physical illness, mental disorder, higher scores on Beck Hopelessness Scale (BHS) and Suicide Intent Scale (SIS) and lower scores on Duke Social Support Scale (DSSI). In the final regression model, family history of suicide, mental disorder, hopelessness and social support emerged as significant predictors of multiple suicide attempts.

CONCLUSION

Suicide attempters that have mental disorder, family history of suicide, higher level of hopelessness and lower level of social support are more likely to re-attempt suicide again. Social and clinical interventions may have to also focus on this sub-group of patients with these characteristics to effectively reduce suicide mortality rate.

Taking care of suicidal patients with new technologies and reaching-out means in the post-discharge period

Suicide is a global public health problem with over one million people dying by suicide each year worldwide. Research efforts have focused on developing and testing novel suicide prevention strategies employing recent technological advances. In order to provide a review regarding the role of new technologies (e.g., postcards/letters, text messages, crisis cards, telephone contacts, online interventions) in suicide prevention, we searched PubMed, ScienceDirect, ResearchGate, and Crisis to identify all papers in English from 1977 to 2016. Our results indicated that brief contact interventions show promise in reducing the number of episodes of repeated self-harm and/or suicide attempts following discharge from the Emergency Department or psychiatric units. Innovative methods of contact (e.g., text messages) are easily implemented by clinicians and received by patients in the period of post discharge and have been shown to be beneficial. However, more research employing randomized clinical trials investigating the potential benefits of these novel suicide prevention methods is warranted. Future researchers should continue improving and testing new technologies in the prevention of suicide.

Role of Inflammation in Suicide: From Mechanisms to Treatment

Suicidal behavior is complex and manifests because of a confluence of diverse factors. One such factor involves dysregulation of the immune system, which has been linked to the pathophysiology of suicidal behavior. This review will provide a brief description of suicidality and discuss the contribution of upstream and downstream factors in the etiology of suicidal behavior, within the contextual framework of inflammation. The contribution of inflammatory conditions such as traumatic brain injury, autoimmune disorders, and infections to neuropsychiatric symptoms and suicidality is only beginning to be explored. We will summarize studies of inflammation in the etiology of suicide, and provide a neurobiological basis for different mechanisms by which inflammation might contribute to the pathophysiology. Finally, we will review treatments that affect upstream and downstream pathways related to inflammation in suicidality.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

[Follow-up interventions after suicide attempt. What tools, what effects and how to assess them?]

After attempting suicide, 60 to 70% of patients are discharged from emergency departments and referred to outpatient treatment which entails psychosocial strategies, pharmacological strategies or a combination. The main objective of outpatient care consists in preventing recurrent suicidal behavior. Yet suicide attempters have been found to be very difficult to engage in treatment. Between 11% and 50% of attempters refuse outpatient treatment or drop out of outpatient therapy very quickly. In order to address this extremely serious issue, for the past 20 years monitoring or follow up interventions has been presented as a promising approach. Follow-up intervention is defined as a service that aims at both increased access to and engagement in care as well as to prevent suicide and related behaviors. This approach consists in "stay in contact" or "connectedness" protocols using phone calls or tele-assistance, sending letters, email or mobile phone messages and medical visits or nursing at home. From one study to another these tools have been used separately, associated to one another or reinforced by motivational interviewing or brief psychotherapy. To our knowledge, since 1993 16 controlled and randomized controlled studies assessed the effectiveness of diverse follow-up. Four studies assessing telephone follow up reported a significant decrease in suicide reattempt while one study evaluating a sending letters strategy reported positive results. Among five studies assessing engagement in healthcare, only two (one using phone follow up and the other sending letters reported significantly positive results. The refusal rate of monitoring strategies has not exceeded 11% attesting to the high applicability of these methods. Despite several positive results, we cannot draw firm conclusions on replicability of these results. This is largely due to methodological issues: lack of standardization of interventions, lack of consensus on definition of the main measured variables (recurrent suicidal behavior, engagement in healthcare) but also to the confounding effect of other care approaches frequently associated with follow up intervention services. Further studies and research should be conducted as follow-up intervention services are increasingly used in suicide prevention because of their good acceptability and usefulness.

Suicide prevention strategies revisited: 10-year systematic review

BACKGROUND

Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.

METHODS

We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.

FINDINGS

We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.

INTERPRETATION

In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.

FUNDING

The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

Benefits of a Secondary Prevention Program in Suicide

Abstract. Background: The effectiveness of suicide intervention programs has not been assessed with experimental designs. Aim: To determine the risk of suicide reattempts in patients engaged in a secondary prevention program. Method: We included 154 patients with suicidal behavior in a quasi-experimental study with a nontreatment concurrent control group. In all, 77 patients with suicidal behavior underwent the Suicide Behavior Prevention Program (SBPP), which includes specialized early assistance during a period of 3–6 months. A matched sample of patients with suicidal behavior (n = 77) was selected without undergoing any specific suicide prevention program. Data on sociodemographics, clinical characteristics, and suicidal behavior were collected at baseline (before SBPP) and at 12 months. Results: After 12 months, SBPP patients showed a 67% lower relative risk of reattempt (χ2 = 11.75, p = .001, RR = 0.33 95% CI = 0.17–0.66). Cox proportional hazards models revealed that patients under SBPP made a new suicidal attempt significantly much later than control patients did (Cox regression = 0.293, 95% CI = 0.138–0.624, p = .001). The effect was even stronger among first attempters. Limitations: Sampling was naturalistic and patients were not randomized. Conclusion: The SBPP was effective in delaying and preventing suicide reattempts at least within the first year after the suicide behavior. In light of our results, implementation of suicide prevention programs is strongly advisable.

Mechanisms of brief contact interventions in clinical populations: a systematic review

BACKGROUND

Brief Contact Interventions (BCIs) have been of increasing interest to suicide prevention clinicians, researchers and policy makers. However, there has been no systematic assessment into the mechanisms underpinning BCIs. The aim of the current paper is to provide a systematic review of the proposed mechanisms underpinning BCIs across trial studies.

METHOD

A systematic review was conducted of trials using BCIs (post-discharge telephone contacts; emergency or crisis cards; and postcard or letter contacts) for suicide or self-harm. Following PRISMA guidelines, we searched CENTRAL, MEDLINE, EMBASE, and the reference lists of all past reviews in the area. Secondary searches of reference lists were undertaken.

RESULTS

Sixteen papers provided a description of possible mechanisms which we grouped into three main areas: social support; suicide prevention literacy, and; learning alternative coping behaviours. After assessment of the studies and considering the plausibility of mechanisms, we suggest social support and improved suicide prevention literacy are the most likely mechanisms underpinning BCIs.

CONCLUSION

Researchers need to better articulate and measure the mechanisms they believe underpin BCIs in trial studies. Understanding more about the mechanisms of BCIs' will inform the development of future interventions for self-harm and suicide.

Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: a systematic review and meta-analysis

BACKGROUND

Psychosocial and behavioural interventions that address suicidal thoughts and behaviour during treatment (direct interventions) might be more effective in preventing suicide and suicide attempts than indirect interventions that address symptoms associated with suicidal behaviour only (eg, hopelessness, depression, anxiety, quality of life). To test this hypothesis, we did a systematic review and meta-analysis of psychosocial and behavioural interventions aimed at preventing suicide and suicide attempts.

METHODS

For this systematic review and meta-analysis, we searched MEDLINE and PsycINFO from inception to Dec 25, 2015, for randomised controlled trials that reported suicides or suicide attempts as an outcome, irrespective of participants' diagnoses or the publication language. We excluded studies with pharmacological or device-based interventions, those that targeted communities or clinicians, primary prevention trials, and trials that reported events of non-suicidal self-injury as suicide attempts. Trials that had no suicides or suicide attempts in both groups were also excluded. Data were extracted by one investigator and independently verified by a second investigator. We used random-effects models of the odds ratio (OR) based on a pooled measure of suicides and the number of individuals who attempted suicide, immediately post-treatment and at longer-term follow-up.

FINDINGS

Of 2024 unique abstracts screened, 53 articles met eligibility criteria and reported on 44 studies; 31 studies provided post-treatment data with 6658 intervention group participants and 6711 control group participants at baseline, and 29 studies provided follow-up data. The post-treatment difference between direct interventions and indirect interventions did not reach statistical significance at the 0·05 level (OR 0·62 [95% CI 0·45-0·87] vs 0·93 [0·77-1·12], p=0·06) and represented a large effect size (Cohen's d=0·77). At longer-term follow-up, the difference was not significant (OR 0·65 [0·46-0·91] vs 0·82 [0·70-0·96], p=0·25) but still represented a medium effect size (Cohen's d=0·47). These effect sizes emphasise the clinical importance of direct interventions. Post-hoc subgroup and sensitivity analyses showed that our results are robust and unlikely to be notably affected by between-study heterogeneity or publication bias.

INTERPRETATION

Psychosocial and behavioural interventions that directly address suicidal thoughts and behaviour are effective immediately post-treatment and long term, whereas treatments indirectly addressing these components are only effective long term. Moreover, although the differences shown between direct and indirect strategies were non-significant, the difference in favour of direct interventions represented a large post-treatment improvement and medium improvement at longer-term follow-up. On the basis of these findings, clinicians working with patients at risk of suicide should address suicidal thoughts and behaviours with the patient directly. Although direct interventions are effective, they are not sufficient, and additional efforts are needed to further reduce death by suicide and suicide attempts. Continued patient contact might be necessary to retain long-term effectiveness.

FUNDING

National Institute of Nursing Research.