Suicide-related Outcomes Research Articles

Virtual Mental Health Care and Suicide-Related Events

The rising suicide rates in the US emphasize the need for effective prevention. While telehealth has transformed access to mental health care, the impact of telehealth on suicide outcomes is unknown. To evaluate the association of virtual mental health services with individual-level suicide-related events (SREs). This retrospective cohort study using broadband access as an instrumental variable assessed a national sample of Veterans Health Administration patients who received mental health care between March 1, 2020, and December 31, 2021. Participants were recently separated (ie, discharged or released from active duty) veterans who completed their active duty service between March 1, 2019, and December 31, 2020, and who received at least 2 outpatient or inpatient diagnoses related to major depressive disorder, substance use disorder, or posttraumatic stress disorder within the year before their most recent separation date. Data were analyzed May 1 to October 31, 2023. Percentage of a patient's total mental health visits that were conducted virtually by psychiatrists, psychologists, or social workers within a calendar month. Binary measure indicating whether the patient had experienced an SRE (defined as a nonfatal suicide attempt, intentional self-harm, or suicide death) in a specific month and year as evaluated an instrumental variable probit model. The sample included 66 387 data points from 16 236 unique recently separated veterans. Among these entries, 44 766 were for male veterans (67.4%), the mean (SD) age across the sample was 32.9 (8.9) years, and the sample was representative of the US veteran population. There were 929 SREs (1.4%). Virtual mental health visits comprised a mean (SD) of 44.6% (46.1%) of all mental health visits. In instrumental variable probit analyses accounting for factors simultaneously associated with use of virtual mental health care and SRE risk, a 1% increase in the probability of virtual mental health visits was associated with a 2.5% decrease in SREs. Findings from this cohort study using a retrospective quasi-experimental design found that an increase in virtual mental health visits relative to total visits was associated with a statistically significant decrease in SREs, suggesting that providing virtual mental health services may reduce suicide-related outcomes.

Risk of suicide in patients with atrial fibrillation receiving different oral anticoagulants: a nationwide analysis using target trial emulation framework

BackgroundThe suicide risk in patients with atrial fibrillation receiving novel oral anticoagulants or warfarin has not been evaluated in real-world practice. Moreover, reducing vitamin K levels may increase the suicide risk, underscoring the importance of selecting appropriate oral anticoagulants to prevent unintended outcomes. Therefore, we aimed to evaluate the association between different types of oral anticoagulants and the risk of attempted and completed suicide among patients with atrial fibrillation.MethodsThis nationwide study retrieved data from Taiwan's National Health Insurance Research Database from 2012 to 2020. This study included patients with atrial fibrillation aged 20 years and older who newly received oral anticoagulant treatment, and who had no contraindications for NOACs and no history of suicide-related events. The main outcomes were suicide-related outcomes, including attempted suicide and completed suicide. This study employed the target trial emulation framework to improve the causal inference for the observed association. ResultsA total of 103,768 (71.74%) patients taking NOACs and 40,877 (28.26%) patients taking warfarin were included in this study. Compared to those receiving warfarin, patients receiving NOACs were associated with a lower risk of suicide-related outcomes (HR, 0.82; 95% CIs, 0.69–0.96).ConclusionsThe findings of this cohort study suggested that patients receiving NOACs were associated with a lower risk of suicidal attempts but similar risk of complete suicide, compared to those receiving warfarin. Considering the risk of suicide, NOACs could be the preferred anticoagulants for patients with atrial fibrillation.

Identifying latent classes of suicidal ambivalence: Associations with suicide risk correlates and outcomes.

Research has largely conceptualized suicidal ambivalence as the difference between one's wish to live and wish to die without fully considering other suicide ideation (SI) experiences included on measures like the Beck Scale for Suicide Ideation (BSS). We utilized BSS items to identify SI latent classes and examined relevant correlates and outcomes. We collected self-report data from two samples of US adults who: (1) self-identified as LGBTQ+ (N = 349; cross-sectional) and (2) self-reported past-week SI (BSS score ≥ 11; N = 133; 3 timepoints). Latent class analyses supported three-class (Sample 1) and four-class solutions (Sample 2), which included ambivalent classes. In Sample 1, sexual orientation, gender, depression, anxiety, SI, and suicide-specific rumination were concurrently associated with class membership. In Sample 2, depression, SI, suicide-specific rumination, and physical/psychological distance from suicide methods were concurrently associated with class membership. In Sample 2, at both follow-ups, suicide plans/preparations and Acute Suicidal Affective Disturbance symptom frequencies were provided by class membership, and suicidal intent significantly differed by class membership. SI classes differed by sample and evidenced nuances in SI and suicidal ambivalence. Risk factors and suicide-related outcomes also differed by class membership. Implications and limitations are discussed.

Intended And Unintended Outcomes After FDA Pediatric Antidepressant Warnings: A Systematic Review.

Since 2003, the Food and Drug Administration (FDA) has warned that antidepressants may be associated with suicidal thoughts and behaviors among youth. An FDA advisory in 2003 and a black-box warning in 2005 focused on children and adolescents younger than age eighteen. The FDA expanded the black-box warning in 2007 to include young adults. Both warnings were intended to increase physician monitoring of suicidal thoughts and behaviors. Our systematic review identified thirty-four studies of depression and suicide-related outcomes after these warnings; eleven of these studies met research design criteria established to reduce biases. The eleven studies examined monitoring for suicidal thoughts and behaviors, physician visits for depression, depression diagnoses, psychotherapy visits, antidepressant treatment and use, and psychotropic drug poisonings (a proxy for suicide attempts) and suicide deaths. We assessed possible spillover to adults not targeted by the warnings. The one study that measured intended physician monitoring of suicidal thoughts and behaviors did not find evidence of an increase. Multiple studies found significant unintended reductions in mental health care after the warnings. After these reductions, there were marked increases in psychotropic drug poisonings and suicide deaths. These findings support reevaluation of risks and benefits of the FDA's black-box antidepressant warnings.

How I think about how I feel: Personal beliefs about emotion prospectively predict suicide-related outcomes and depression symptoms

One transdiagnostic process that may be critical to depression and suicidal ideation is beliefs about the nature of one's own emotions, both concurrently and longitudinally. In a sample of community adults (n = 143), we assessed personal emotion beliefs about the degree to which one's own emotions are malleable, unique, and last a long time. There were significant associations between stronger views that one's own emotions were fixed, unique to you, and had a longer duration and higher clinical symptom severity, including higher levels of current suicidal ideation, and less adaptive emotion regulation. Mediation analyses using longitudinal data clarified that the differential engagement in emotion regulation, specifically rumination, represented the link tying specific personal emotion beliefs to clinical symptoms and that, in certain cases, the opposite pathway is also significant – differences in clinical symptoms mediated the relationship between specific personal emotion beliefs and emotion regulation (rumination) longitudinally. Additionally, personal emotion beliefs varied based on depression status, as determined using a semi-structured clinical interview. For example, individuals meeting current criteria for Major Depressive Disorder (MDD) held stronger views that their emotions were unique to them compared to individuals with remitted MDD or no history of MDD. The current study's findings highlight the important role of specific personal emotion beliefs in clinical symptoms concurrently and longitudinally and mechanisms in these relationships. These results could guide future research on interventions to promote more adaptive beliefs about emotion to improve clinical outcomes.

Implementation of caring contacts using patient feedback to reduce suicide-related outcomes following psychiatric hospitalization.

Suicide risk is substantially elevated following discharge from a psychiatric hospitalization. Caring Contacts (CCs) are brief communications delivered post-discharge that can help to improve mental health outcomes. This three-phase, mixed-method quality-improvement study revised an existing CC intervention using iterative patient and community feedback. Inpatients (n = 2) and community members (n = 13) participated in focus groups to improve existing CC messages (phases 1 and 2). We piloted these messages among individuals with a suicide-related concern following discharge from an inpatient psychiatric hospitalization (n = 27), sending CCs on days 2 and 7 post-discharge (phase 3). Phase 3 participants completed mental health symptom measures at baseline and day 7, and provided feedback on these messages. Phase 1 and 2 focus group participants indicated preferences for shorter, more visually appealing messages that featured personalized, recovery-focused content. Phase 3 participants demonstrated reductions in depressive symptoms at day-7 post-discharge (-6.4% mean score on Hopkins-Symptom-Checklist, -9.0% mean score on Entrapment-Scale). Most participants agreed that CC messages helped them feel more connected to the hospital and encouraged help-seeking behavior post-discharge. This study supports the use of an iterative process, including patient feedback, to improve CC messages and provides further pilot evidence that CC can have beneficial effects.

Suicide-Related Outcomes Among Adults in Custody: An Umbrella Review of Systematic Literature Reviews

We conducted a comprehensive umbrella review including all published meta-analyses and systematic reviews on suicide-related outcomes among adults in custody. Eligible studies were searched for in major scientific databases following the PRISMA method up to February 2023. The quality of each study was assessed using the AMSTAR-2 protocol. Twenty studies were included, consisting of 11 meta-analyses and nine systematic reviews. Factors associated with suicide outcomes among individuals in custody were categorized into five domains: clinical status, historical, custodial, criminological, and prevention. However, all systematic studies reported considerable heterogeneity (I2 > 50%–85%). Most systematic literature reviews and/or meta-analyses showed moderate quality based on AMSTAR-2. This umbrella review highlights individual factors (in the clinical status and historical domain), contextual factors (in the custodial and criminological domains), and protective factors (in the prevention domain) to provide a clearer understanding of the prison-related domains involved in the development and maintenance of suicide-related outcomes.

Examining the predictive utility of suicidal ideation characteristics in relation to real-time monitoring of suicidal ideation and suicide attempts at follow-up.

Several characteristics of suicidal ideation, including frequency, duration, perceived controllability, and intensity, have been identified. The present study examined whether these characteristics of baseline suicidal ideation uniquely predicted (1) the severity, variability, and frequency of suicidal ideation assessed through real-time monitoring; and (2) suicide attempts at 3-week and 6-month follow-up among recently discharged psychiatric inpatients. A sample of 249 adults (Mage = 40.43, 55.1% female, 91.4% White) completed a baseline assessment of their suicidal ideation characteristics during psychiatric hospitalization, five daily ecological momentary assessments (EMA) for 21 days following discharge, and follow-up assessments of suicide-related outcomes at 3-week and 6-month follow-up. Perceived controllability of suicidal thoughts was uniquely associated with the variability of EMA-assessed suicidal ideation and the presence of suicide attempts at 3-week, but not 6-month follow-up. No other characteristic of baseline suicidal ideation was uniquely associated with EMA-assessed suicidal ideation or the presence of suicide attempts at follow-up. Given links between the perceived controllability of suicidal ideation and (1) momentary variability of suicidal ideation and (2) suicide attempts over the subsequent 3 weeks, perceived controllability of suicidal thinking may be a useful marker of short-term risk that may be malleable to clinical intervention.

Place-Based Differences in the Association Between Greenspace and Suicide-Related Outcomes Among Young People

PurposeThis study investigated place-based differences in the association between greenspace and suicide-related outcomes (SROs) among young people, guided by the following two objectives: (1) Contextualize place-based differences in the association between greenspace and SRO prevalence among young people at the community level in five different urbanities (urban, suburban, micropolitan, small towns, and rural/isolated communities) and (2) identify which greenspace metrics (quantity, quality, or accessibility) are most protective for SROs at the community level. MethodsPublicly available greenspace datasets were used to derive greenspace quantity, quality, and accessibility metrics. SRO emergency department visits for young people were identified from 2016–2019 in North Carolina, USA. Generalized linear models investigated the association between greenspace metrics and community-level drivers of SRO prevalence. Shapely additive explanations confirmed the most important greenspace variables in accurately predicting community-level SRO prevalence. ResultsThe prevalence of SROs was highest in communities with the least amount of public greenspace; this association was most pronounced in suburban communities, with SROs 27% higher in suburban communities with low quantities of greenspace (PRRUrban: 1.11, confidence interval [CI]: 1.08–1.13; PRRSuburban: 1.27, CI: 1.10–1.46; PRRSmallTowns: 1.21, CI: 1.05–1.39), and in communities with the worst greenspace accessibility (i.e., furthest distance to nearest greenspace) (PRRUrban: 1.07, CI: 1.04–1.10; PRRRural&Isolated: 1.95, CI: 1.54–2.49). DiscussionOur analysis provides place-based, community-specific findings to guide targeted greenspace interventions aimed at addressing the rising prevalence of SROs among young people. Our findings suggest that greenspace quantity interventions may be most effective in urban, suburban, and small-town communities, and greenspace accessibility interventions may be most useful in urban and rural/isolated communities.

Can sports participation be a protective factor against suicide-related outcomes in adolescents: a systematic review.

Suicide-related outcomes among adolescents have become a serious public health problem worldwide. Emerging evidence suggests that sports participation may interact with suicide-related outcomes. The objective of this systematic review is to systematically review and summarize the association between sports participation and suicide-related outcomes among adolescents. A systematic review according to PRISMA Statement (International Platform of Registered Systematic Review and Meta-Analysis Protocols registration: INPLASY202330072) https://inplasy.com/inplasy-2023-3-0072/. The literature search was conducted in three electronic databases: Web of Science, PubMed, and EBSCOhost. A total of 16 studies (12 cross-sectional studies, 4 prospective studies) met the inclusion criteria were evaluated. Strong consistent evidence was found for the negative association between suicidal ideation, suicide attempts, and sports participation among adolescents. There was insufficient evidence to support consistency in the association between sports participation and suicide plans, and no evidence regarding gender differences between sports participation and these suicide-related outcomes. Furthermore, there was heterogeneity in the measures of sports participation and suicide-related outcomes across the included studies. Evidence suggests that more sports participations are associated with lower suicidal ideation and suicide attempts in adolescents. However, the directionality of the observed associations should be examined based on more high-quality longitudinal studies in the future.

The “Vicious Circle of addictive Social Media Use and Mental Health” Model

Social media use (SMU) is a significant part of many people's everyday life. Research around the globe describes an increase of addictive SMU tendencies since the COVID-19 outbreak. The present work combines available findings in the “Vicious Circle of addictive Social Media Use and Mental Health” model to explain how social media (SM) activity can contribute to the development of addictive tendencies, which consequences they have for mental health, and how to prevent them. Following the model, the interplay between the risk factors negative experiences caused by daily hassles and by unexpected global and traumatic events, SMU (dimension “quality”), and SM flow can directly contribute to addictive SMU through the “vicious circle”. Time spent on SMU (dimension “quantity”), symptoms of depression and anxiety, and the personality trait narcissism contribute to the circle as moderators. Symptoms of stress, insomnia, and suicide-related outcomes are described as potential consequences of addictive SMU. Based on longitudinal intervention studies, a conscious reduction of SMU time and an increase of physical activity, as well as positive mental health and mindfulness are identified as protective factors that reduce the risk of addictive tendencies. The model contributes to a better understanding of addictive SMU. Implications of the model for future research and praxis, specifically for mental health programs and therapeutic treatment are discussed.

A Scoping Review of Suicide Prevention Interventions for Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Individuals

A Scoping Review of Suicide Prevention Interventions for Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Individuals

Harmonizing federal interagency traumatic brain injury research data to examine depression and suicide-related outcomes.

This proof-of-concept study was conducted to establish the feasibility of compiling Federal Interagency Traumatic Brain Injury Research (FITBIR) data pertaining to depression and suicide risk, with the secondary goal of improving understanding regarding these outcomes. FITBIR is a national repository of participant-level traumatic brain injury (TBI) data designed to address methodological limitations (e.g., small sample size, heterogeneity of injuries). FITBIR studies with TBI severity and measures related to depression and suicidal ideation were identified. Data were harmonized across relevant studies and grouped to identify "probable depression" and suicidal ideation, resulting in a large, combined sample. Rates of probable depression and suicidal ideation were described across the available studies, considering the influence of demographic and/or injury-related factors on outcomes. Cross-sectional studies meeting criteria included four studies with depression outcomes and two with suicidal ideation outcomes. Two studies reported data appropriate for comparative analyses on depression. Combined results suggested that approximately 71% of participants were categorized as having probable depression. Participants with a history of mild TBI had 2.54 greater odds of probable depression (95% confidence interval [1.93, 3.34]) than those without a history of TBI. Methods, harmonization code, and meta-databases related to TBI, probable depression, and suicidal ideation are now publicly available on the FITBIR website. Even with limited data, harmonization of FITBIR studies can serve as the basis for ongoing TBI and mental health research. Analyses will be more robust in the future as more studies with relevant outcome data are added to the FITBIR database. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Positive mental health accounts for the relationship between insomnia symptoms and suicide-related outcomes

Insomnia symptoms have been shown to be associated with suicide ideation/behavior. However, the underlying mechanism is unclear and studies on protective factors that might mitigate the association between sleep-related problems and suicide ideation/behavior are largely missing. On this background the aim of the current study was to investigate, whether positive mental health (PMH) accounts for the association between insomnia symptoms and suicidal ideation/behavior. A total of 913 participants (72.2% women; age: M(SD) = 25.91 (7.08)) completed measures on insomnia symptoms, PMH and suicide ideation/behavior via an online survey. The results reveal a significant association between insomnia symptoms and PMH. Both variables were significantly linked to lifetime suicide ideation/behavior and 12-month suicide ideation. Moreover, the association between insomnia symptoms and suicide-related outcomes was significantly mitigated by PMH. The current findings complement previous studies on the association between insomnia symptoms and suicide ideation/behavior. Furthermore, they demonstrate that PMH can mitigate the risk of suicide-related outcomes. Therapeutic intervention targeting insomnia symptoms and fostering PMH might be useful in the prevention of suicide ideation/behavior.

Self-harm presentations to hospital trauma centre emergency departments during the first year of the COVID-19 pandemic

The COVID-19 pandemic raised concerns regarding increased suicide-related behaviours. We compared characteristics and counts of Emergency Department (ED) presentations for self-harm, an important suicide-related outcome, during versus prior to the pandemic's first year. We included patients presenting with self-harm to the ED of two trauma centres in Toronto, Canada. Time series models compared intra-pandemic (March 2020-February 2021) presentation counts to predictions from pre-pandemic data. The self-harm proportion of ED presentations was compared between the intra-pandemic period and preceding three years. A retrospective chart review of eligible patients seen from March 2019-February 2021 compared pre- vs. intra-pandemic patient and injury characteristics. While monthly intra-pandemic self-harm counts were largely within expected ranges, the self-harm proportion of total presentations increased. Being widowed (OR=9.46; 95 %CI=1.10–81.08), employment/financial stressors (OR=1.65, 95 %CI=1.06–2.58), job loss (OR=3.83; 95 %CI=1.36–10.76), and chest-stabbing self-harm (OR=2.50; 95 %CI=1.16–5.39) were associated with intra-pandemic presentations. Intra-pandemic self-harm was also associated with Intensive Care Unit (ICU) admission (OR=2.18, 95 %CI=1.41–3.38). In summary, while the number of self-harm presentations to these trauma centres did not increase during the early pandemic, their proportion was increased. The association of intra-pandemic self-harm with variables indicating medically severe injury, economic stressors, and being widowed may inform future suicide and self-harm prevention strategies.

Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review.

Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps. This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps. Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies. Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use.

Characteristics of suicide prevention programs implemented for young people in rural areas: A systematic review of the literature

BackgroundFor young living in rural areas around the world, suicide is a leading cause of death, stressing the need to understand characteristics of programs aiming to impact suicide and related behaviours. AimA systematic literature review aimed to synthesise the evidence and explore characteristics of programs seeking to impact suicidal behaviours (rates, attempts, ideation) for young people in rural areas. MethodData sources: Electronic databases EMBASE, Medline, PsycINFO and Scopus. Study eligibility criteria, participants, and interventions: Studies measuring suicide-related outcomes (rates, attempts, ideation) for youth (people aged 12–25 years) in rural areas worldwide, published 1 January 2000 to 6 June 2023. Study appraisal and synthesis: Data were thematically analysed, exploring intervention characteristics. Mixed Methods Appraisal Tool assessed study quality. ResultsEleven (11) studies met the selection criteria. Studies impacting suicides and attempts were often multiple strategies, multi-layered, combining universal, selective, and indicated programs, implemented across systems and settings, including public-health psychoeducation, referral mechanisms, crisis lines, postvention, peer support, outreach, means restriction, mindfulness, and gatekeeper training. Psychoeducation and mindfulness contributed to decreased suicidal ideation. Community-level partners were central to efforts, including working groups, networks, Indigenous people, people with lived experience, volunteers, and peers. ConclusionsVaried programs have capacity to reduce suicide rates and related behaviours among young people in rural areas, with communities and schools as crucial settings. Programs implemented across levels show promise at reducing the number of young people who end their lives by suicide or attempt to do so, demonstrating a need for program evaluations and continued, long-term outcome monitoring.

Building stronger bonds: The impact of family support and communication on suicidal behaviors among Black men who have sex with men.

It has been well documented that men who identify with a sexual orientation other than heterosexual are at a greater risk for suicide-related outcomes. What is less known are the protective factors that can reduce such negative outcomes and contribute to their resilience. This study used data collected between December 1, 2021, and January 2022 to understand how family factors contribute to or prevent depression symptoms and suicide outcomes among young Black men who have sex with men (BMSM) ages 18 to 29 (N = 400). A path analysis was conducted to explore the direct and indirect effects of suicide attempts. Surprisingly, there were nuanced findings that showed having a family member or friend die by suicide was indirectly associated with suicide planning and suicide attempts. It was also unexpectedly noted that there was a positive relationship between higher rates of depressive symptoms and higher levels of support from family members. The population focused on in this study is understudied and has unique needs. Identifying familial support may not automatically reduce the thoughts and plans of young BMSM, which is an example of why their intersecting marginalized identities must be considered when conducting further research, creating interventions, and providing therapeutic services.

Mental health of Canadian youth: A systematic review and meta-analysis of studies examining changes in depression, anxiety, and suicide-related outcomes during the COVID-19 pandemic.

This systematic review and meta-analysis aims to describe Canadian youth mental health during the COVID-19 pandemic, focusing on changes in anxiety and depressive symptoms and suicidality. We searched four databases up to February 2023 for longitudinal or repeated cross-sectional studies reporting on changes in depressive and anxiety symptoms, suicidality, or related services utilization among young people under 25 years old residing in Canada during the COVID-19 pandemic. Random-effects meta-analyses were performed for studies comparing depressive and anxiety symptoms from before to during the first, second, and third COVID-19 waves (up to June 2021), and between COVID-19 waves. Other studies were described narratively. Risk of bias was assessed using an adapted Joanna Briggs Institute Checklist. Of the 7916 records screened, 35 articles met inclusion criteria for this review. Included studies were highly heterogeneous in design, population, and type of change investigated, and many had a high risk of bias. The meta-analyses found that depressive symptoms worsened minimally from pre-pandemic to wave 1 but returned to pre-pandemic levels by wave 2. Anxiety symptoms were broadly comparable from pre-pandemic to waves 1 and 2 but worsened from waves 1 to 3 and from pre-pandemic to wave 1 for girls. The narrative review included several studies that provided inconclusive evidence of increases in services utilization. The current evidence is limited and highly heterogeneous, making it insufficient to draw definitive conclusions regarding the short- to medium-term impact of the pandemic on youth mental health in Canada. Obtaining better mental health surveillance among Canadian youth is imperative.

Are autistic females at greater risk of suicide? A call for clarity to advance suicide prevention for the whole community.

Understanding suicide risk is critical for supporting prevention. A growing body of evidence shows autistic people are at greater risk for multiple suicide-related outcomes than non-autistic people. This commentary is in response to an observed pattern of miscommunication in scientific and community spaces about autistic females having higher risk of suicide. However, it is not always clear who they are being compared with in these statements. To address this confusion, we summarize the current population-based evidence on autistic suicide risk, highlighting findings related to sex similarities and differences, which actually indicates comparable rates of suicide death among autistic males and females, and mixed findings related to sex differences in risk of other suicidal behaviors. We call for greater clarity in suicide risk communication moving forward focused on outcomes, measurement, sampling methods, and comparison groups to reflect accurate conclusions about existing evidence. Further research is needed about the full range of suicide-related outcomes for autistic people, including a greater understanding of sex differences as well as potential gender differences to include transgender and nonbinary autistic people. However, studies of sex and gender differences should not overshadow the compelling need for efforts to understand and address the elevated risk of suicidal thoughts, behaviors, and death among autistic people across sex and gender boundaries.