A Population Health Perspective on Suicide Research and Prevention

Breaking Down Barriers to a Suicide Prevention Helpline: Web-Based Randomized Controlled Trial

Background

Every month, around 3800 people complete an anonymous self-test for suicidal thoughts on the website of the Dutch suicide prevention helpline. Although 70% score high on the severity of suicidal thoughts, <10% navigate to the web page about contacting the helpline.

Objective

This study aimed to test the effectiveness of a brief barrier reduction intervention (BRI) in motivating people with severe suicidal thoughts to contact the suicide prevention helpline, specifically in high-risk groups such as men and middle-aged people.

Methods

We conducted a fully automated, web-based, randomized controlled trial. Respondents with severe suicidal thoughts and little motivation to contact the helpline were randomly allocated either to a brief BRI, in which they received a short, tailored message based on their self-reported barrier to the helpline (n=610), or a general advisory text (care as usual as the control group: n=612). Effectiveness was evaluated using both behavioral and attitudinal measurements. The primary outcome measure was the use of a direct link to contact the helpline after completing the intervention or control condition. Secondary outcomes were the self-reported likelihood of contacting the helpline and satisfaction with the received self-test.

Results

In total, 2124 website visitors completed the Suicidal Ideation Attributes Scale and the demographic questions in the entry screening questionnaire. Among them, 1222 were randomized into the intervention or control group. Eventually, 772 respondents completed the randomized controlled trial (intervention group: n=369; control group: n=403). The most selected barrier in both groups was "I don't think that my problems are serious enough." At the end of the trial, 33.1% (n=122) of the respondents in the intervention group used the direct link to the helpline. This was not significantly different from the respondents in the control group (144/403, 35.7%; odds ratio 0.87, 95% CI 0.64-1.18, P=.38). However, the respondents who received the BRI did score higher on their self-reported likelihood of contacting the helpline at a later point in time (B=0.22, 95% CI 0.12-0.32, P≤.001) and on satisfaction with the self-test (B=0.27, 95% CI 0.01-0.53, P=.04). For male and middle-aged respondents specifically, the results were comparable to that of the whole group.

Conclusions

This trial was the first time the helpline was able to connect with high-risk website visitors who were hesitant to contact the helpline. Although the BRI could not ensure that those respondents immediately used the direct link to the helpline at the end of the trial, it is encouraging that respondents indicated that they were more likely to contact the helpline at a later point in time. In addition, this low-cost intervention provided greater insight into the perceived barriers to service. Follow-up research should be focused on identifying the added value of other components (eg, video or photo material) in the BRI and increasing its effectiveness, especially for men and middle-aged people.

Psychological Distress in Low-Income and Economically Marginalized Populations in India: Protective and Risk Factors

Studies at the juncture of development economics and public health take on considerable responsibility in addressing inequality and related mental health distress. Mental healthcare in economically marginalized populations requires depicting the linkages between socioeconomic status and psychological distress. In the present work, a sequential mixed-methods design was used to study 190 people in such communities in India. Gender-dependent psychological distress was found according to the Kessler Psychological Distress Scale (K-10) with moderate distress in women (M = 26.30, SD = 9.15) and mild distress in men (M = 21.04, SD = 8.35). Regression analysis indicated that gender significantly predicted psychological distress, followed by age, marital status, and the level of education of the head of the family. The Interpretative Phenomenological Analysis of semi-structured interviews of the six women who scored the highest on the distress scale unveiled three master themes: (1) manifestation of psychological distress, (2) contextual challenges, and (3) sources of strength and resilience. Overall, participants reported a lack of resources, community violence, gender discrimination, and widespread substance use as major contributors to the ongoing distress. These findings can pave the way for future studies to expand beyond independent economic indicators and curate clinical interventions for culturally competent mental healthcare.

The impact of the minimum wage on suicide rates in Hong Kong

Increases in minimum wages have been associated with reductions in suicide rates in the United States, but little evidence is available for Asia where social and contextual factors, as well as drivers of suicide, may be different. We investigated the impact of the introduction of the minimum wage in Hong Kong in May 2011 on suicide rates using an interrupted time series design for the period January 2006 to December 2016. We investigated both immediate and gradual changes in monthly suicide rates after the introduction of the minimum wage taking into account secular trends. We conducted stratified analyses by age and gender. In total 9396 suicides were recorded in Hong Kong during the 11-year study period. Introduction of the minimum wage was associated with an immediate decrease of 13.0% in the monthly suicide rate (95% confidence interval (CI) 5.4%-19.9%, P = 0.001). There was an immediate decrease of 15.8% in older working aged (25-64 years) men (95% CI: 4.2%-25.9%, P = 0.009). Point estimates of immediate effect for other subgroups were also in a negative direction, but were not statistically significant. There was no evidence of a gradual effect on suicide rates at the population level or by subgroup other than a small increase in younger working aged men. We estimate that 633 suicides were prevented by the minimum wage legislation for the period from May 2011 to December 2016, the majority in older working aged men. Our results provide new evidence that, similar to findings in Western settings, minimum wages may help to reduce suicide in Asia, particularly for working age men. Our study highlights the importance of examining the health impacts of government economic policy and suggests minimum wages may provide policy makers with an upstream population-based strategy to reduce suicide rates.

Perinatal adversity profiles and suicide attempt in adolescence and young adulthood: longitudinal analyses from two 20-year birth cohort studies

BACKGROUND

We aimed to identify groups of children presenting distinct perinatal adversity profiles and test the association between profiles and later risk of suicide attempt.

METHODS

Data were from the Québec Longitudinal Study of Child Development (QLSCD, N = 1623), and the Avon Longitudinal Study of Parents and Children (ALSPAC, N = 5734). Exposures to 32 perinatal adversities (e.g. fetal, obstetric, psychosocial, and parental psychopathology) were modeled using latent class analysis, and associations with a self-reported suicide attempt by age 20 were investigated with logistic regression. We investigated to what extent childhood emotional and behavioral problems, victimization, and cognition explained the associations.

RESULTS

In both cohorts, we identified five profiles: No perinatal risk, Poor fetal growth, Socioeconomic adversity, Delivery complications, Parental mental health problems (ALSPAC only). Compared to children with No perinatal risk, children in the Poor fetal growth (pooled estimate QLSCD-ALSPAC, OR 1.89, 95% CI 1.04-3.44), Socioeconomic adversity (pooled-OR 1.42, 95% CI 1.08-1.85), and Parental mental health problems (OR 1.74, 95% CI 1.27-2.40), but not Delivery complications, profiles were more likely to attempt suicide. The proportion of this effect mediated by the putative mediators was larger for the Socioeconomic adversity profile compared to the others.

CONCLUSIONS

Perinatal adversities associated with suicide attempt cluster in distinct profiles. Suicide prevention may begin early in life and requires a multidisciplinary approach targeting a constellation of factors from different domains (psychiatric, obstetric, socioeconomic), rather than a single factor, to effectively reduce suicide vulnerability. The way these factors cluster together also determined the pathways leading to a suicide attempt, which can guide decision-making on personalized suicide prevention strategies.

Evaluation of the impact and implementation of a national clinical programme for the management of self-harm in hospital emergency departments: study protocol for a natural experiment

BACKGROUND

A National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation.

METHODS

Employing a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity-adherence to the programme's core components-using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research.

ETHICS AND DISSEMINATION

This study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers.

Declining Life Expectancy in the United States: Missing the Trees for the Forest

In recent years, life expectancy in the United States has stagnated, followed by three consecutive years of decline. The decline is small in absolute terms but is unprecedented and has generated considerable research interest and theorizing about potential causes. Recent trends show that the decline has affected nearly all race/ethnic and gender groups, and the proximate causes of the decline are increases in opioid overdose deaths, suicide, homicide, and Alzheimer's disease. A slowdown in the long-term decline in mortality from cardiovascular diseases has also prevented life expectancy from improving further. Although a popular explanation for the decline is the cumulative decline in living standards across generations, recent trends suggest that distinct mechanisms for specific causes of death are more plausible explanations. Interventions to stem the increase in overdose deaths, reduce access to mechanisms that contribute to violent deaths, and decrease cardiovascular risk over the life course are urgently needed to improve mortality in the United States.

Contribution of birth weight to mental health, cognitive and socioeconomic outcomes: two-sample Mendelian randomisation

BACKGROUND

Low birth weight is associated with adult mental health, cognitive and socioeconomic problems. However, the causal nature of these associations remains difficult to establish owing to confounding.

AIMS

To estimate the contribution of birth weight to adult mental health, cognitive and socioeconomic outcomes using two-sample Mendelian randomisation, an instrumental variable approach strengthening causal inference.

METHOD

We used 48 independent single-nucleotide polymorphisms as genetic instruments for birth weight (genome-wide association studies' total sample: n = 264 498) and considered mental health (attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), schizophrenia, suicide attempt), cognitive (intelligence) and socioeconomic (educational attainment, income, social deprivation) outcomes.

RESULTS

We found evidence for a contribution of birth weight to ADHD (OR for 1 s.d. unit decrease (~464 g) in birth weight, 1.29; 95% CI 1.03-1.62), PTSD (OR = 1.69; 95% CI 1.06-2.71) and suicide attempt (OR = 1.39; 95% CI 1.05-1.84), as well as for intelligence (β = -0.07; 95% CI -0.13 to -0.02) and socioeconomic outcomes, i.e. educational attainment (β = -0.05; 95% CI -0.09 to -0.01), income (β = -0.08; 95% CI -0.15 to -0.02) and social deprivation (β = 0.08; 95% CI 0.03-0.13). However, no evidence was found for a contribution of birth weight to the other examined mental health outcomes. Results were consistent across a wide range of sensitivity analyses.

CONCLUSIONS

These findings support the hypothesis that birth weight could be an important element on the causal pathway to mental health, cognitive and socioeconomic outcomes.

Study designs and outcomes used in evaluation studies of hospital-presenting self-harm: protocol for a methodological systematic review

INTRODUCTION

Self-harm is the most common risk factor for suicide, and so those who present to hospital following self-harm provide an opportunity for targeted clinical care interventions. Observational studies evaluating such interventions may be useful in overcoming limitations of controlled trials, but study design, statistical analyses and outcomes used must be appropriate. This methodological systematic review will describe, categorise, synthesise and compare the methodological aspects of studies evaluating interventions and aspects of clinical management following hospital-presenting self-harm in both observational and experimental (ie, controlled trials or quasi-experimental studies) study designs.

METHODS AND ANALYSIS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocol guidelines were followed in drafting this protocol. Search terms were developed (related to self-harm, hospital presentation and evaluation studies) and adapted for MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and grey literature databases. Two reviewers will independently screen 100 titles/abstracts until consensus is reached, with the remaining screened by one reviewer. Full-text screening will be conducted independently by two reviewers. Data will be extracted by one reviewer, and a second will check all data extracted. Validated risk of bias tools will be used. Data synthesis will focus on the heterogeneity of outcomes used in individual studies. Descriptive summary statistics of the data (eg, key study characteristics, type and frequency of outcomes) will be provided in categorical format, using frequencies and percentages. Outcomes will be reported separately for trials (both randomised and non-randomised trials), observational and quasi-experimental studies. Categorisation of outcomes will be guided by Cochrane Effective Practice and Organisation of Care resources for reviews of health systems interventions.

ETHICS AND DISSEMINATION

Results will be disseminated at national and international conferences and published in a peer-reviewed journal. Findings will be used to inform future studies in the area of hospital-presenting self-harm. Ethical approval is not required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208714.

Sociodemographic characteristics associated with hospital contact in the year prior to suicide: A data linkage cohort study in Victoria, Australia

Aims

The aims of this study were to examine the prevalence of hospital contact in the year prior to suicide in Victoria, Australia, and to compare characteristics among those who did and did not have contact in the year prior to suicide.

Methods

The study was a data linkage cohort study of 4348 Victorians who died by suicide over the period 2011–2017. Data from the Victorian Suicide Register (VSR) was linked with hospital separations and Emergency Department (ED) presentations datasets by the Centre for Victorian Data Linkages (CVDL). The main outcomes were: (1) hospital contact for any reason, (2) hospital contact for mental-health-related reasons, and (3) hospital contact for intentional self-harm. Unadjusted and adjusted odds ratios were calculated as the measures of association.

Results

In the year prior to suicide, half of the decedents (50.0%) had hospital contact for any reason (n = 2172), 28.6% had mental-health-related hospital contact (n = 1244) and 9.9% had hospital contact for intentional self-harm (n = 432).

In the year prior to suicide, when compared with males aged 25–49 years (the reference group):

males aged 75+ years and females of all ages were significantly more likely to have hospital contact for any reason

females aged 10–24 years and 25–49 years were significantly more likely to have mental-health-related hospital contact

females aged 10–24 years and 25–49 years had 3.5 times and 2.4 times the odds of having hospital contact for intentional self-harm.

Conclusions

The comparatively high proportion of female decedents with mental-health related hospital contact in the year prior to suicide suggests improving the quality of care for those seeking help is an essential prevention initiative; this could be explored through programs such as the assertive outreach trials currently being implemented in Victoria and elsewhere in Australia. However, the sizeable proportion of males who do not have contact in the year prior to suicide was a consistent finding and represents a challenge for suicide prevention. Programs to identify males at risk in the community and engage them in the health care system are essential. In addition, promising universal and selective interventions to reduce suicide in the cohort who do not have hospital contact, include restricting access to lethal means and other public health interventions are also needed.

The association between self-reported mental health, medication record and suicide risk: A population wide study

Suicide mortality and mental ill health are increasing globally. Mental ill health can be measured in multiple ways. It is unclear which measure is most associated with suicide risk. This study explored the association between self-rated mental health and medication record and death by suicide. The 2011 Northern Ireland Census records of adults aged 18-74 years (n=1,098,967) were linked to a centralised database of dispensed prescription medication and death registrations until the end of 2015. Mental health status was ascertained through both a single-item self-reported question in the Census and receipt of psychotropic medication. Logistic regression models examined the association between indicators of mental ill health and likelihood of suicide mortality. Of the 1,098,967 cohort members, 857 died by suicide during the study period. Just over half of these deaths (n=429, 50.1%) occurred in individuals with neither indicator of mental ill health. Cohort members with both self-reported mental ill health and receipt of psychotropic medication had the highest risk of suicide (OR=6.13, 95%CI: 4.94–7.61), followed by those with psychotropic medication record only (OR=4.00, 95%CI: 3.28–4.88) and self-report only (OR=2.88, 95%CI: 2.16–3.84). Individuals who report mental ill health and have a history of psychotropic medication use are at a high risk of suicide mortality. However, neither measure is particularly sensitive, as both failed to signal over half of subsequent suicides. Some individuals who report poor mental health but are not in receipt of psychotropic medication are at increased risk of suicide, indicating possible unmet treatment need. The combination of the two indicators offers more precision for identifying those most at risk for targeted interventions.

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Mental ill health is associated with an increased risk of suicide, but measuring population mental health is difficult.

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The suicide risk associated with both subjective and objective indicators of mental ill health have not been examined.

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Most individuals who die by suicide have no indicator of mental ill health.

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Having both self-reported poor mental health and psychotropic medication record carried the highest risk of suicide death.

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Increased risk of suicide in individuals who report poor mental health but are not on medication may indicate unmet need.

Suicide prevention from a public health perspective. What makes life meaningful? The opinion of some suicidal patients

BACKGROUND AND AIM OF THE WORK

Suicide is a worldwide phenomenon, with a relevant number of victims. Moreover, repercussions of suicidality-across its entire spectrum-involve not only the individual but also survivors and communities, in a profound and lasting way. As such, suicidality represents a crucial public mental health concern, in which risk/protection factors' study represent a key issue. However, research primarily focused on suicidality risk factors. This study, moving from Frankl's first observations on "Meaning in Life" (MiL) as protective against suicidality, aimed to identify the main themes that suicidal patients identified as MiL carriers, or potential carriers, in their existences.

METHODS

Qualitative study on 144 patients admitted to the Geneva University Hospital's emergency department for suicidal ideation (SI) and suicide attempt (SA).  Results: Interpersonal/affective relationships constituted the main theme (71.53%), with emphasis on family (39.80%), children/grandchildren (36.89%). Profession/education, intellectual/non-intellectual pleasures, and transcendental dimension also emerged.

CONCLUSIONS

These aspects could be considered among a public health agenda's points for suicide prevention programs taking into account also protective factors promotion/support, including community's mental health resources. Reconnecting to introduction's historical part, our findings are consistent with Frankl's observations. Even if exposed to "absurd" and reluctant to deliberate on this, he seems approach Camus conceptualization who, confronted to the necessity of predictable and conform to recognizable personal patterns transcending chaos for a sense-giving perspective, invited to imagine that a meaning, even a "non-absolute meaning", may lie in apparent smallest things and that Sisyphus can have "the possibility to revolt by trying to be happy".

In-utero and perinatal influences on suicide risk: a systematic review and meta-analysis

BACKGROUND

Adverse in-utero and perinatal conditions might contribute to an increased suicide risk throughout the lifespan; however, existing evidence is sparse and contradictory. We aimed to investigate in-utero and perinatal exposures associated with suicide, suicide attempt, and suicidal ideation.

METHODS

We did a systematic review and meta-analysis and searched MEDLINE, Embase, and PsycINFO from inception to Jan 24, 2019, for population-based prospective studies that investigated the association between in-utero and perinatal factors and suicide, suicide attempt, and suicidal ideation. Only papers published in English in peer-reviewed journals were considered. Two researchers independently extracted formal information (eg, country, year, duration of follow-up) and number of cases and non-cases exposed and non-exposed to each risk factor. We calculated pooled odds ratios (ORs) with 95% CIs using random-effects models and used meta-regression to investigate heterogeneity. This study was registered with PROSPERO, number CRD42018091205.

FINDINGS

We identified 42 eligible studies; they had a low risk of bias (median quality score 9/9 [IQR 8-9]). Family or parental characteristics, such as high birth order (eg, for fourth-born or later-born vs first-born, pooled OR 1·51 [95% CIs 1·21-1·88]), teenage mothers (1·80 [1·52-2·14]), single mothers (1·57 [1·31-1·89]); indices of socioeconomic position, such as low maternal (1·36 [1·28-1·46]) and paternal (1·38 [1·27-1·51]) education; and fetal growth (eg, low birthweight 1·30 [1·09-1·55] and small for gestational age 1·18 [1·00-1·40]) were associated with higher suicide risk. Father's age, low gestational age, obstetric characteristics (eg, caesarean section), and condition or exposure during pregnancy (eg, maternal smoking or hypertensive disease) were not associated with higher suicide risk. Similar patterns of associations were observed for suicide attempt and suicidal ideation; however, these results were based on a lower number of studies. In meta-regression, differences in length of follow-up explained most between-study heterogeneity (inital I² ranged from 0 to 79·5).

INTERPRETATION

These findings suggest that prenatal and perinatal characteristics are associated with increased suicide risk during the life course, supporting the developmental origin of health and diseases hypothesis for suicide. The low number of studies for some risk factors, especially for suicide attempt and ideation, leaves gaps in knowledge that need to be addressed. The mechanisms underlying the reported associations and their causal nature still remain unclear.

FUNDING

Horizon 2020 (EU).

Interactions between youth and mental health professionals: The Youth Aware of Mental health (YAM) program experience

THE YOUTH AWARE OF MENTAL HEALTH (YAM) EXPERIENCE

Youth stand at the core of much mental health promotion, yet little is written about their experiences of such efforts. We aimed to take this on by interviewing youth after they participated in Youth Aware of Mental Health (YAM), a universal mental health promotion program. YAM has a non-anticipatory methodology that provides youth with a safe space for reflection, role-play, and discussion. Addressing everyday mental health, YAM invites the experiences and issues relevant to the youth present to influence the program in a slightly different direction every time. The YAM instructor guides the participants but does not present the youth with given formulas on how to solve their problems. Like any mental health promotion, YAM appeals to some more than others in its intended audience and individuals engage with the program in many different ways. We set out to learn more about these experiences.

CONVERSATIONS ABOUT MENTAL HEALTH

Thirty-two semi-structured interviews were conducted with 15-17 year olds in Estonia, Italy, Romania and Spain. In these interviews, the researchers made an effort to discuss mental health in terms relevant to youth. Still, wide-ranging levels of motivation, ease with engaging in dialogue with mental health professionals, and comfort with the format and content of YAM were detected. The youth were clustered in five different groups relating to their positioning vis-à-vis the researcher during the interview. The following evocative labels were used: "interested", "foot in the door", "respect for authority", "careful", and "not my topic". Corresponding labels were devised for their YAM experience: "engaged", "initially hesitant", "cautious", "eager to please", or "disengaged". We also observed that the researchers brought their own expectations and employed a variety of approaches that led to anticipating answers, stating the obvious, or getting along better with some of the youth. These modes of interaction were categorized under: "favoritism", "familiarity", "frustration", "out of sync", and "insecurity". Similar power dynamics likely transpire in other encounters between youth and researchers, including interventions such as YAM.

YOUTH AND MENTAL HEALTH PROFESSIONALS: NOTICING THE DYNAMICS AT PLAY

As mental health professionals, we need to be aware of the professional habits and biases that sometimes obstruct us in understanding the experiences of youth. By initiating dialogue and listening closely to youth we can find a way to those experiences. Qualitative research can help bring the underlying interplay between mental health professionals and youth to the surface while also orienting the conversation towards topics that matter to youth. Some youth are more interested or feel more at ease in speaking openly with mental health professionals, while others find such exchanges less appealing or almost intolerable. Future mental health promotion initiatives would benefit from involving youth in the design of interventions to create an inclusive atmosphere and engage with topics that appeal to youth with diverse experiences of mental health.

Barriers toward help-seeking among young men prior to suicide

This study explores barriers to help-seeking among young men prior to suicide. We analyzed 61 in-depth interviews with parents, siblings, friends, and ex-partners of 10 young men (aged 18-30) with no record of mental illness, as well as 6 suicide notes, using interpretative phenomenological analysis. Three barriers emerged: (a) a total defeat; (b) no room for weakness; and (c) fear of mental disorder. The shame from falling short of standards (own/significant male others') could be a considerable barrier to help-seeking in a suicidal crisis.

Psychosocial characteristics as potential predictors of suicide in adults: an overview of the evidence with new results from prospective cohort studies

In this narrative overview of the evidence linking psychosocial factors with future suicide risk, we collected results from published reports of prospective studies with verified suicide events (mortality or, less commonly, hospitalisation) alongside analyses of new data. There is abundant evidence indicating that low socioeconomic position, irrespective of the economic status of the country in question, is associated with an increased risk of suicide, including the suggestion that the recent global economic recession has been responsible for an increase in suicide deaths and, by proxy, attempts. Social isolation, low scores on tests of intelligence, serious mental illness (both particularly strongly), chronic psychological distress, and lower physical stature (a marker of childhood exposures) were also consistently related to elevated suicide rates. Although there is some circumstantial evidence for psychosocial stress, personality disposition, and early-life characteristics such as bullying being risk indices for suicide, the general paucity of studies means it is not currently possible to draw clear conclusions about their role. Most suicide intervention strategies have traditionally not explored the modification of psychosocial factors, partly because evidence linking psychosocial factors with suicide risk is, as shown herein, largely in its infancy, or, where is does exist, for instance for intelligence and personality disposition, the characteristics in question do not appear to be easily malleable.

Suicide by gassing in Hong Kong 2005-2013: Emerging trends and characteristics of suicide by helium inhalation

BACKGROUND

Increased use of lethal suicide methods can have a profound impact on overall suicide incidence; the epidemic of suicide by barbecue charcoal gas poisoning in some East Asian countries is a recent example. There have been concerns about recent rises in suicide using gases in some Western countries.

METHODS

We investigated suicide by gassing in Hong Kong (2005-2013) using Coroner's files data. The characteristics were compared between suicide by helium inhalation, charcoal gas poisoning, and other methods.

RESULTS

About one sixth (1407/8445, 16.7%) of all suicides used gases. Charcoal-burning suicides constituted the majority (97.5%) of them but showed a reduction over the 9-year period (-33%). Helium suicide was not recorded in 2005-2010 but increased from one in 2011 to three in 2012 and 11 in 2013, accounting for 1.2% of all suicides in 2013. Similar to the profile of charcoal-burning suicides, helium suicides were younger and more likely to have debt problem and less likely to receive psychiatric treatment than other suicides. Internet involvement related to the method was found in one third of cases of helium suicide.

LIMITATIONS

The small number of helium suicides (n=15) limits the power to examine their characteristics.

CONCLUSION

Suicide by charcoal burning showed a downward trend whilst there was an alarming increase in helium suicide in Hong Kong. Public health measures to prevent an epidemic of helium suicide similar to that of charcoal-burning suicide may include close monitoring of trend, responsible media reporting, and restricting online information about and access to this method.