A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

The COVID-19 pandemic of 2020 is a major global health challenge. At the time of writing, over 11.6 million people around the world had been registered as infected and 538,000 had died (Worldometers, 2020, accessed July 7, 2020). Public health responses to COVID-19 need to balance direct efforts to control the disease and its impact on health systems, infected people, and their families with the impacts from associated mitigating interventions. Such impacts include social isolation, school closure, health service disruption stemming from reconfiguring health systems, and diminished economic activity. The primary focus of both the United Nations (UN) and the World Health Organization (WHO) has been on addressing COVID-19 as a physical health crisis, but the need to strengthen mental health action, including suicide prevention, is increasingly recognized, as is the need for mental health research to be an integral part of the recovery plan (UN, 2020a). The impacts of the pandemic on physical and mental health will unfold differently over time and will vary depending on the duration and fluctuating intensity of the disease. Research is needed to help ensure that decision-making regarding all aspects of health, including mental health (Holmes et al., 2020), is informed by the best quality data at each stage of the pandemic. The pandemic poses a prolonged and unique challenge to public mental health, with major implications for suicide and suicide prevention (Gunnell et al., 2020; Reger, Stanley, & Joiner, 2020). A rise in suicide deaths in the wake of the pandemic is not inevitable. There is consensus, however, that the mitigation of risk will be contingent upon a proactive and effective response involving collaborative work between the state, NGOs, academia, and local governments and coordinated leadership across government ministries, including health, education, security, social services, welfare, and finance. Countries have responded in different ways to the pandemic, effectively creating a series of natural experiments. Thus, regions of the world affected later in the pandemic can draw on lessons from countries, such as China and Italy, affected in its early phase. Likewise, lessons learned early in the pandemic (e.g., on the impact of lockdown and physical distancing measures) can be used to inform responses to any future surges in the incidence of COVID-19. Although there are important parallels between countries in the course of the pandemic, some stressors, responses, and priorities are likely to differ between high- and low–middle-income countries and between cultures and regions. As COVID-19 appears to be disproportionately affecting Black, Asian, and minority ethnic communities, the response – and suicide prevention research carried out to inform the response – needs to be sufficiently granular and account for the complexity of risks in these groups (O'Connor et al., 2020). Throughout this editorial, when we refer to suicide and suicidal behavior, we mean to include both fatal and nonfatal suicidal behaviors and self-harm.

The Acceptability of Suicide Among Rural Residents, Urban Residents, and College Students from Three Locations in China

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

Help Seeking and Perceived Need for Mental Health Care Among Individuals in Canada With Suicidal Behaviors

Suicide Prevention in an International Context.

Each year approximately 1,000,000 people die by suicide, accounting for nearly 3% of all deaths and more than half (56%) of all violent deaths in the world (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Suicide ideation and suicide attempts are strongly linked to death by suicide and powerfully predict further suicidal behavior (Institute of Medicine, 2002). There are an estimated 100–200 suicide attempts for each completed suicide in young people, and 4 attempts for each completed suicide in the elderly (Institute of Medicine, 2002). Emergency departments (EDs) are the most important site, epidemiologically speaking, for treating those who make suicide attempts. EDs in the United States, for example, record over 500,000 suicide-related visits annually (Larkin, Smith, & Beautrais, 2008). The majority of suicide attempt patients are discharged after medical stabilization and psychosocial evaluation, but carry a significant risk of recidivism (Larkin, Smith, & Beautrais, 2008). Similarly, ED patients who present with suicide ideation (without attempt) have risks of returning to the ED with further ideation or with suicide attempts which are as high as those who present with attempts (Larkin, Beautrais, Gibb, & Laing, 2008). In addition, a significant fraction of those who present to EDs for nonmental health reasons often have occult or silent suicide ideation (estimated at 8–12%) (Claassen & Larkin, 2005). The worldwide economic tsunami and sky-rocketing healthcare costs have ensured that mental health-related visits and presentations for suicidal behavior will continue to rise in the foreseeable future. The closure of psychiatric inpatient facilities, reductions in inpatient beds, moves to treat people in the community, and increased costs of general practitioner visits have coincided with – and likely account for – increased ED attendances by psychiatric and suicidal patients who previously might have been admitted or seen in primary care. The ED is now the default, de facto option for urgent and acute contact for suicidal patients within the health system – and in many countries the ED is the only access to 24/7 healthcare (Fields et al., 2001).

A Suicide-Specific Diagnosis – The Case Against

A Suicide-Specific Diagnosis – The Case For

A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies

Suicide risk in adults with Asperger's syndrome

Suicide research and prevention in developing countries in Asia and the Pacific

The World Health Organization's report on suicide: a fundamental step in worldwide suicide prevention.

Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.

The developmental hypothesis that maladaptive personality traits mediate the association of childhood adversities with long-term risk for depressive disorders and other adverse mental health outcomes is an etiological component of several leading theories of psychopathology. Two personality traits pertaining to depressive disorders, interpersonal dependency and low self-esteem, have been hypothesized to develop in the context of childhood adversities, and to contribute to increased risk for the onset of depressive symptoms. Individuals with these and related traits have been hypothesized to be particularly vulnerable for depression following significant losses, such as the death of a loved one. Jeffrey Johnson, et al. used data from a community-based multi-wave investigation to examine a developmental model of risk for depression and suicidality following the death of a spouse. Measures of perceived parental affection and control during childhood were administered to 218 widowed adults 11 months after the death of the spouse. Self-esteem, spousal dependency, depression, and suicidality were assessed 9 months later. Dependency on the deceased spouse mediated a significant association between retrospectively reported parental control during childhood and post-loss depressive symptoms. Depressive symptoms mediated significant associations of dependency on the deceased spouse and low self-esteem with suicidal ideation and behavior. Carl-Aksel Sveen and Fredrik Walby conducted the first systematic review of suicide survivors' reactions compared with survivors after other modes of death. A qualitative data analysis was performed on forty-one studies. They found that there were no significant differences between survivors of suicide and other bereaved groups regarding general mental health, depression, PTSD symptoms, anxiety, and suicidal behavior. The results regarding the overall level of grief are less clear, depending on whether general grief instruments or suicide-specific instruments are used. Considering specific grief variables, suicide survivors report higher levels of rejection, shame, stigma, need for concealing the cause of death, and blaming than all other survivor groups. While data do not exist on the number of survivors following each suicide, rough estimates label one in every 64 Americans as a survivor of suicide. Survivors of suicide thus represent a significant portion of the population and are often recognized by mental health professionals as a high-risk group for mental health difficulties including future suicidal behavior. Stigma and societal norms regarding suicide create barriers for survivors that could decrease the likelihood that they reach out for social support or mental health services. Traditional passive models of postvention require survivors themselves to find out about resources which are available in their community. In 1999, the Baton Rouge (LA) Crisis Intervention Center (BRCIC) established a program of active postvention for suicide survivors which supplements services from traditional first responders (e.g. police, emergency medical personnel, coroner). Julie Cerel and Frank Campbell used archival data from suicide survivors presenting for treatment from 1999–2005 at the BRCIC to examine differences in those who received an active model of postvention (APM) compared to those who received traditional passive postvention (PP). They found that APM survivors presented sooner for treatment (48 days) than PP survivors (97 days). APM survivors were more likely to have been the survivor of a violent suicide. APM survivors were more likely than PP survivors to attend survivor support group meetings and APM survivors attended more groups. It is yet to be determined if presenting earlier for treatment results in less development of chronic problems. Although childhood suicidal behaviors have been found to be prognostic of future suicide risk, it is not clear what are the risk factors that explain the development of suicidal behaviors in prepubertal children. Leilani Greening, et al. applied path analyses to test a model that includes internalizing and externalizing behavior problems as predictors of suicidal behaviors in children. Parents of an inpatient sample of boys rated the frequency of suicidal ideation and completed standardized measures of behavior problems. Blind raters rated the severity of the children's suicidal behaviors. Their results revealed a significant direct effect for suicidal ideation on suicide attempt and for depressive symptoms on suicidal ideation. There was also a significant indirect path from impulsivity to suicidal ideation through aggressive and depressive symptoms. These findings suggest that, in addition to depressed mood increasing risk for suicidal ideation, children exhibiting poor impulse control and aggressive behavior may also be vulnerable to suicidal ideation through depressive symptoms. Geoff Goodman, et al. assessed 43 psychiatrically hospitalized prepubertal children regarding their assaultive and suicidal behaviors. These children were subsequently classified into two groups, assaultive/suicidal (AS) and assaultive-only (AO). AS children had higher aggression and suicidal-scale scores, but not higher depression scores, and were more likely to be diagnosed with ADHD. ADHD, child's aggression, and maternal depression and state anger accounted for 33% of the variance in suicidal-scale scores. Aggression mediated the relation between ADHD and suicidal behavior. Differences in symptom pattern between these two subtypes of assaultive inpatient children are interpreted as a basis for distinctive screening procedures. Little is known about parental detection of self-harm behavior in youth. Ramin Mojtabai and Mark Olfson examined the rate and predictors of parental detection of youth self-harm behavior and help seeking in 7,036 parent-child dyads from the 1999 and 2004 surveys of Mental Health of Children and Young People in Great Britain. Youth self-harm behavior was reported by 6.6% of children and adolescents, but only by 2.7% of the parents. Reports were more accurate if parents were from majority white ethnicity, were mothers of girls, experienced psychological distress themselves, or if children were older or had emotional/behavioral problems. They found that parental detection of youth self-harm was associated with increased likelihood of professional help-seeking. Most current school-based suicide prevention education programs have focused on teaching adolescents how to provide an appropriate initial response when they come into contact with suicidal peers, and how to seek help from a responsible adult. Konstantin Cigularov, et al. examined perceived barriers to help-seeking among adolescents attending a suicide education program. Over 850 high school students in Colorado completed one of two questionnaires, measuring barriers to help-seeking for self or friend. The most prominent barriers for self were: inability to discuss problems with adults, self-overconfidence, fear of hospitalization, and lack of closeness to school adults. The most prominent barriers for troubled friends were: friendship concerns, inapproachability of school adults, fear of friend's hospitalization, and underestimating friend's problems. These findings reveal multiple constraints limiting suicide education program utilization, and supporting the need for comprehensive system approaches to suicide prevention. In the fall of 1984, the University of Illinois instituted a formal program to reduce the rate of suicide among its enrolled students. At the core of the program is a policy that requires any student who threatens or attempts suicide to attend four sessions of professional assessment. The consequences for failing to comply with the program include withdrawal from the university. Paul Joffe reports that in the 21 full years that the program has been in effect, reports on 2,017 suicide incidents have been submitted to the Suicide Prevention Team. The rate of suicide at locations within Champaign County, IL decreased from a rate of 6.91 per 100,000 enrolled students during the eight years before the program started to a rate of 3.78 during the first 21 years of the program. This represents a reduction of 45.3 percent. This reduction occurred against a backdrop of stable rates of suicide both nationally and among 11 peer institutions within the Big Ten Universities. The implications of instituting a similar reporting system and mandated assessment at other institutions of higher education are discussed. I believe the full implementation of this program at other universities will continue to be debated well into the future. Understanding the reasons for self-harm may be important in developing efficacious treatments for the identification and treatment of self-harm behavior. Presently, the psychometric properties for self-harm questionnaires are generally unknown or untested in non-inpatient samples. Existing inpatient measures may have limited generalizability and do not examine self-harm apart from an explicit intent to die. Stephen Lewis and Darcy Santor examined a newly developed, self-report measure of reasons for self-harm in a college student population. Results indicated that reasons for self-harm co-varied in meaningful and internally consistent ways, with subgroups of self-harm reasons correlating with hypothesized concomitants of self-harm, such as depressive symptoms. Findings have implications for prevention and intervention and this new measure offers a new, albeit preliminary, means by which to examine self-harm reasoning in a non-inpatient sample. There have been some attempts to establish the psychometric properties of Ed Shneidman's Psychological Pain Assessment Scale (PPAS), but problems have arisen regarding internal consistency, factor structures, and concurrent validity. The stimuli for the PPAS are pictures and the assessment is based on narrative responses. In this preliminary investigation, Maurizio Pompili, et al., administered the Shneidman Psychological Pain Assessment Scale (PPAS) to 88 psychiatric patients. They found that both current and worst-ever psychache were significantly higher in those patients judged by a psychiatrist, on the basis of a structured clinical review, to be at risk of suicide. However, current and worst-ever psychache were not associated with having attempted suicide in the past. Thus, for the present sample of psychiatric patients, the PPAS appears to be more sensitive to current suicidality, then to past suicidality. This study raises some questions about the central aspect of the pictorial format of the PPAS and raises concerns about establishing concurrent validity for this instrument. Although this investigation identifies some of the limits of the PPAS, it does suggest some areas for future study. Inasmuch as rates are reported as low, there has been limited study of suicide in Islamic countries. Birol Demirel, et al. conducted the first study of suicide notes in Turkey, an Islamic country. Using a classification method of analysis, 49 suicide notes (a rate of 34.5%) were studied. The results show that note writers do not differ greatly from other suicides. A further analyses of younger (<40) and older (>40) suicide note writers revealed few significant differences. Their results, together with the results of classification studies in different countries, suggest that caution is in order in transposing findings from one country to other countries.

A National Suicide Prevention Strategy for Canadians--From Research to Policy and Practice.