Distanciamento Social em Pandemias: O Risco e a Prevenção do Suicídio Frente aos Impactos Psicossociais da COVID-19

A national focus on suicide has sparked innovative research and a growing knowledge base. This is critical work that informs policy and clinical care, and this special issue on suicide in women is particularly timely. Rates of suicide among women are on the rise and are markedly higher among some subgroups of women. In 2017, women veterans were 2.2 times more likely to die by suicide than civilian women; the age-adjusted rates were 16.8/100,000 for women veterans compared with 7.6/100,000 for nonveteran women.1 The reasons for these disparities are multifactorial and effective strategies to reduce disparities—and suicide rates more generally—are critically needed. Here we illustrate some of the ways the Office of Mental Health and Suicide Prevention (OMHSP) of the Department of Veterans Affairs (VA) is applying research findings to develop new resources and initiatives to support women veterans' well-being and mental health, and to mitigate their suicide risk. One notable clinical resource is the VA Reproductive Mental Health Consultation Program, recently launched by the Women's Mental Health (WMH) Section of OMHSP. Reproductive cycle stages can influence suicide risk in women. Women with premenstrual dysphoric disorder (PMDD) have a greater likelihood of having suicidal thoughts, plans, and attempts,2 and women who attempt suicide have a greater likelihood of experiencing PMDD.3 Suicidal ideation is more frequently endorsed by women who are in the transition to menopause (perimenopause) as compared to premenopausal and postmenopausal women, and as compared to men.4 Pregnancy is a major cause of discontinuing antidepressants,5 which can increase suicide risk in vulnerable women. Accurately diagnosing and effectively treating mental health challenges during these reproductive cycle stages is an essential part of suicide prevention efforts. To this end, VA offers a Reproductive Mental Health Consultation Program available to all VA clinicians. Subject matter experts respond to questions about reproductive mental health concerns with evidence-based replies tailored to individual circumstances, allowing for direct translation of research findings into clinical applicability. New provider training resources have been developed to broadly disseminate clinically relevant research findings. The Suicide Prevention Program in VA's OMHSP has developed the From Science to Practice series of brief evidence summaries. Each focuses on specific suicide risk and protective factors and includes a concise review of relevant research in the general population and, when available, specific to veterans. Evidence-informed actions and resources providers can use to support their patients are also included. In addition to informing suicide prevention efforts within the VA, these products are available to community providers and include community-based resources. Of particular relevance to suicide prevention in women veterans, the series includes evidence summaries of associations between suicide risks and women's mental and sexual health, reproductive health and the experience of military sexual trauma. Evidence about suicide prevention and risks in women has also been integrated into the core curriculum of VA's annual WMH Mini-Residency. The WMH Mini-Residency, led by the WMH Section of OMHSP, provides in-depth training within a specific area of focus (women's mental health), concentrated within several days of expert-led didactics and highly interactive small-group sessions. For example, suicide risk is increased in the context of several traumas more common in women, such as intimate partner violence6 and sexual trauma7,8 and, among women veterans, military sexual trauma.9–11 It is also associated with a variety of mental health diagnoses,12 as well as sleep disorders,13 physical conditions such as chronic pain14 and multimorbidity.13 To enhance clinicians' understanding of these links, relevant material about suicide risk is incorporated into every topic taught during this intensive training, which is attended by mental health clinicians from every VA medical center nationally. For instance, training content on bipolar disorder includes factors associated with suicide that differ by sex15 and content on women's perinatal mental health notes that intimate partner violence during the perinatal period increases risk for suicide.16 Content on nonsuicidal self-injury (NSSI) addresses the distinction between NSSI and self-directed violence with suicidal intent, and the complex links between NSSI, onset of suicidal ideation, and initiation of suicidal behaviors.17,18 The WMH Mini-Residency is essential training for VA's WMH Champions, who serve as local points of contact for women's mental health at all VA medical centers. Following their participation in the WMH Mini-Residency, WMH Champions complete a 6-month action plan to advance gender-sensitive women's mental health services at their local VA facilities. Some action plans directly focus on strengthening suicide prevention efforts for women veterans by, for example, organizing community outreach events and sharing information about women veterans' suicide risks and prevention strategies, or partnering with VA Suicide Prevention Coordinators to teach clinical staff about gender-tailored safety planning strategies. Others indirectly strengthen suicide prevention efforts, for instance by implementing gender-tailored intake and assessment procedures and developing new clinical resources that address suicide risks in women veterans, such as problems with distress tolerance and emotion regulation. In addition to integrating material about suicide risk across topics covered in the WMH Mini-Residency, the WMH Section of OMHSP developed a case-based interactive workshop to enhance clinicians' knowledge and skills regarding women-specific suicide prevention. Through stepwise case discussions, multidisciplinary clinicians learn how PMDD, pregnancy, the postpartum period, and perimenopause can affect women's suicide risk, how to assess mental health and suicide risk across female reproductive cycle stages, and how to adapt mental health treatment during reproductive cycle stages. This foundational workshop provides screening, assessment and tracking tools, and relevant resources. Use of composite case examples and guided discussion model evidence-informed clinical decision making and mirror processes used by VA's Reproductive Mental Health Consultation Program to apply research findings to inform clinical decision making. A final example of how the growing evidence base continues to inform VA suicide prevention efforts is the development and dissemination of lethal means safety strategies, specifically around gun storage and medication disposal. Self-inflicted firearm injury and poisoning are the leading causes of suicide death in women veterans, accounting for 43.2% and 28.7% of suicide deaths in women veterans, respectively.1 All VA health care facilities provide veteran patients with gun safety locks, free of charge, and VA's MedSAFE Program offers prepaid envelopes that can be used to return unused medications for safe disposal. A new training resource, in development by VA's Suicide Prevention Program in OMHSP, is designed to educate VA women's health providers about ways to tailor lethal means safety counseling to address gender-related risks, motivating factors, and obstacles. For instance, framing safe gun storage and medication disposal as child safety practices may resonate strongly with mothers and encourage uptake of these methods. Another example is the importance of addressing feelings of vulnerability and fear as potential barriers to safe storage of firearms for women who have experienced interpersonal assault and report feeling safer with a loaded weapon close by. These gender-sensitive suicide prevention efforts are the product of close collaborative ties between VA policymakers, clinical leaders, and the very talented research community whose work potentiates important innovations for real world impact. Significant strides have already been made and greater advances are on the horizon.

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.

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

Reductions in Postdischarge Suicide After Deinstitutionalization and Decentralization: A Nationwide Register Study in Finland

Suicide Prevention in an International Context.

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

Background:Public health measures that prevent the spread of COVID-19, such as social distancing, may increase the risk for suicide among American Indians due to decreased social connectedness that is crucial to wellbeing. Telehealth represents a potential solution, but barriers to effective suicide prevention may exist.Materials and Methods:In collaboration with Tribal and Urban Indian Health Center providers, this study measured suicide prevention practices during COVID-19. A 44-item Likert-type, web-based survey was distributed to Montana-based professionals who directly provide suicide prevention services to American Indians at risk for suicide. Descriptive statistics were calculated for survey items, and Mann–Whitney U tests examined the differences in telehealth use, training, skills among Montana geographic areas, and barriers between providers and their clients/patients.Results:Among the 80 respondents, two-thirds agreed or strongly agreed that American Indians experienced greater social disconnection since the COVID-19 pandemic began. Almost 98% agreed that telehealth was needed, and 93% were willing to use telehealth for suicide prevention services. Among current users, 75% agreed telehealth was effective for suicide prevention. Over one-third of respondents reported using telehealth for the first time during COVID-19 pandemic, and 30% use telehealth at least “usually” since the COVID-19 pandemic began, up from 6.3%. Compared with their own experiences, providers perceive their American Indian client/patients as experiencing greater barriers to telehealth.Discussion:Telehealth was increasingly utilized for suicide prevention during the COVID-19 pandemic. Opportunities to improve telehealth access should be explored, including investments in telehealth technologies for American Indians at risk for suicide.

General practitioners training about suicide prevention and risk: A systematic review of literature

BackgroundThe COVID‐19 pandemic has spurred the implementation of several public safety measures to contain virus spread, most notably socially distancing policies. Prior research has linked similar public safety measures (i.e., quarantine) with suicide risk, in addition to supporting the role of social connection in suicidal thoughts and behaviors; consequently, there is a need to better understand the relationship between widespread social distancing policies and suicide risk. The current study aimed to examine the prospective association between COVID‐19‐related social distancing practices and suicidal ideation.MethodsParticipants (N = 472) completed measures of suicidal ideation and impacts of social distancing practices at baseline and two weeks later.ResultsAfter controlling for general psychosocial distress (i.e., depression, social connectedness), cross‐lagged regression models identified prospective, bidirectional relationships between perceived impacts of social distancing on one's mental health and both passive and active suicidal ideation. The impact of social distancing on work/social routine was not associated with suicidal ideation.ConclusionsOverall, findings suggest the importance of an individual's perception regarding the effect of social distancing on their mental health, rather than the disruption to work or social routine, in suicide risk. Findings highlight potential targets for suicide risk prevention and intervention.

Since February 2020, as U.S. public health efforts have focused on containing the spread of COVID-19, gun sales in the country have skyrocketed, physical distancing necessary to curb transmission h...

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Background Patients with substance use disorders are at high risk for suicidal ideas and behaviors. Prevention of suicide among these patients should be a public health priority. Objective The objective of this study was to investigate the prevalence and correlates of suicidal ideas and suicide risk among patients with substance use disorders. Methods This study included 100 patients with substance use disorders who sought treatment at Zagazig University hospital, Egypt. All participants were interviewed using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text-Revised and rated by Beck Suicide Scale. Drug-related problems were assessed using the Arabic version of Addiction Severity Index. Urine screen for drugs was done for all patients participated in the study. Results Twenty-seven percent of the patients with substance use disorders had suicidal ideas, 22% had suicide risk, and 9% had history of suicidal attempts. Females were 5 times more likely to have suicide risk than males. Unemployed patients were three times more likely to have suicide risk than employed or skilled workers. There was an association between suicide risk and heroin use and alcohol dependence and patients with positive family history of suicide. . Conclusions Suicidal ideas and suicide risk were common among patients with substance use disorders. Female gender, unemployment, heroin use, and alcohol dependence and positive family history of suicide were predictors of suicide ideation and risk in patients with substance use disorders.

BackgroundRates of suicide remain elevated among U.S. Veterans and have increased disproportionately among Asian American and Pacific Islander (AAPI) Veterans. Knowledge is limited regarding suicide prevention considerations for clinicians working with AAPI Veterans, yet culturally responsive strategies tend to be most effective. To address this gap, we sought to elucidate subject matter experts’ perspectives regarding suicide prevention considerations for AAPI Veterans.MethodsQualitative interviews were conducted with 14 key informants (e.g., clinicians, researchers) in 2023 to understand their experiences with, and recommendations for, preventing suicide among AAPI Veterans in the Continental U.S. Interview transcripts were analyzed through thematic analysis, with an inductive approach.ResultsKey informants discussed the heterogeneity of the AAPI population and emphasized the need to balance cultural sensitivity and cultural humility in suicide prevention with AAPI Veterans. Fear of bringing shame and dishonor upon one’s family was described as a factor which may prevent AAPI Veterans from disclosing mental health concerns and suicide risk and which may prevent them from accessing healthcare services for mental health and suicidality. Suicide risk among AAPI Veterans was viewed as being shaped by shame and the centrality of the family-collective, with family conferring both protection against and risk for suicide. Cultural norms and beliefs regarding suicide were considered pertinent to suicide among AAPI Veterans and included beliefs about perseverance in coping with distress to permittance of suicide in specific circumstances. Somatic idioms were described as a means by which AAPI Veterans may communicate distress and suicidality, with key informants discussing how this may impact treatment and outreach.ConclusionKey informant interviews provided crucial insights into cultural factors salient to conceptualizing and addressing AAPI Veterans’ risk for suicide. These findings can be utilized to inform tailored suicide prevention for this population, with emphasis on addressing mental health stigma, considering somatic idioms of distress, and considering the role of family in suicide risk and prevention.

BackgroundSuicide risk screening in healthcare settings plays a significant role in suicide prevention. Healthcare staff who are poorly informed about self-harm and suicide risk are less likely to identify and subsequently screen at-risk individuals. This mixed-method systematic review aimed to appraise and synthesise evidence from studies that explored and promoted healthcare staff's knowledge and awareness of suicide and self-harm risk in healthcare settings. MethodsElectronic databases (CINAHL, MEDLINE, APA PsycInfo, APA PsycARTICLES, Psychology and behavioural Science Collection, ERIC, and SocINDEX), the Cochrane Library, and various grey literature databases were searched for relevant studies. The level of evidence and methodological quality of the included studies were assessed. ResultsEighteen empirical studies were included. Levels of knowledge about suicide and self-harm risk varied significantly across the reviewed studies. Face-to-face group training and educational programmes, digital or online educational programmes, and an educational poster campaign were amongst the strategies used to promote awareness of suicide and self-harm risk, with the majority marginally succeeding in doing so. LimitationsThe reviewed studies were heterogeneous in terms of design, interventions, and outcome measures which made it difficult to make comparisons. The overall level of scientific evidence was classified as being relatively low. The lack of blinding and lack of a control group were amongst the limitations for experimental studies. ConclusionsLong-term, routine face-to-face group training programmes should be established to educate healthcare staff about suicide risk across all professions and in specific patient groups.

BackgroundSuicide rates have increased substantially among Asian American, Native Hawaiian, and Pacific Islander Veterans. However, little is known about the context of suicide risk or how best to tailor care for this population, especially as it relates specifically to Asian American Veterans, for whom extant research has been limited. We explored Asian American Veterans’ lived experiences with suicidal thoughts and behaviors, their perspectives regarding suicide risk and prevention, and the broader context in which these occurred.MethodsQualitative interviews were conducted in 2022–2023 with 20 Asian American Veterans with histories of suicidal ideation and/or suicide attempt(s). Interviews explored participants’ identities and values (i.e., for context), as well as their beliefs, experiences and perspectives regarding suicide prevention (e.g., how suicide is discussed among Asian American Veterans, factors that might cause Asian American Veterans to experience suicidal ideation, and how suicide prevention initiatives can be tailored to address the needs of Asian American Veterans). Interview transcripts were analyzed through inductive thematic content analysis.ResultsWe identified four themes relevant to Asian American Veterans’ experiences with suicidal thoughts and behaviors, perspectives on suicide risk and prevention, and the context in which these occurred. First, participants spoke to the “model minority” stereotype and pressure to convey self-discipline and perfectionism and to acculturate to American or Western values, which were also shaped by their own or familial immigration experiences. Second, participants reflected upon their minoritized status within the U.S. military, which often mirrored the sense of “otherness” experienced outside of their military service. While participants described positive overall experiences in the military, they also described experiencing racism during their military service. Third, mental health stigma was salient, shaped by cultural beliefs and perceived as consistent with military culture, deterring disclosure and help-seeking and posing an obstacle for suicide prevention. Lastly, destigmatizing mental healthcare and increasing the visibility of Asian American Veterans seeking mental health services were considered paramount to suicide prevention.ConclusionConsiderations for preventing suicide among Asian American Veterans include addressing the sociocultural factors that shape mental health, suicide risk, and healthcare use. In particular, findings suggest the importance of addressing stereotypes about Asian Americans (e.g., model minority myth), preventing behaviors that contribute to a sense of “otherness,” and increasing the visibility of Asian American Veterans in outreach and messaging to promote help-seeking.