Journal articles on the topic 'Suicide Prevention and Crisis Service'

In 1989 a crisis occurred in a West Country seaside town. Its psychiatric services had been regarded as a vanguard of community care, having been fully established some three years previously when the in-patient facilities which had been based in a mental hospital some 15 miles away were closed. The framework of the new-style service consisted of five mental health centres scattered throughout the residential area and a 60-bed in-patient unit, based in the grounds of the local district general hospital.

Background: Suicide is the deliberate killing of oneself. Although it is preventable, suicide accounts for over 800,000 global deaths annually. There is the need to scale-up prevention strategies, and one of these strategies is the provision of suicide telephone helplines. Objectives: To describe the pattern of calls received by a suicide telephone helpline and the types of intervention provided in a Nigerian facility. Methods: This was a descriptive study of the first 100 completed calls received on a 24-hour suicide telephone helpline service by trained responders. Results: All the calls emanated from 14 states of the federation, with the majority (83.0%) from the Southern parts of the country. The reasons for the telephone calls varied from crisis situations (47.0%) to telephone number-verification (27.0%), mental health information (20.0%), and others (6.0%). The mean age of the crisis -situation callers was 25.8 years, with a slight female preponderance (53.2%); most were single in marital status (68.1%) and unemployed (70.2%). A majority (72.3%) of the callers had an underlying mental condition, 68.1% had suicidal ideation while 12.8% had previously attempted suicide. All the crisis callers were offered interventions ranging from phone counselling to linkage to the nearest mental health services. Conclusion: A majority of the crisis callers were offered mental health services, raising the possibility that the availability of telephone helplines may play a role in suicide prevention in Nigeria.

The Public Health Agency of Canada is funding a new Canada Suicide Prevention Service (CSPS), timely both in recognition of the need for a public health approach to suicide prevention, and also in the context of the COVID-19 pandemic, which is causing concern about the potential for increases in suicide. This editorial reviews priorities for suicide prevention in Canada, in relation to the evidence for crisis line services, and current international best practices in the implementation of crisis lines; in particular, the CSPS recognizes the importance of being guided by existing evidence as well as the opportunity to contribute to evidence, to lead innovation in suicide prevention, and to involve communities and people with lived experience in suicide prevention efforts.

Despite the improved understanding of the determinants of suicide over recent decades, the mean suicide rate within the United Kingdom (UK) has remained at 10 per 100,000 per annum, with about 28% accessing mental health services in the 12 months prior to death. In this paper, we outlined a novel systems-level approach to tackling this problem through objectively differentiating the level of severity for each suicide risk presentation and providing fast-track pathways to care for all, including life-threatening cases. An additional operational challenge addressed within the proposed model was the saturation of local crisis mental health services with approximately 150 suicidality referrals per month, including non-mental health cases. This paper discussed a service improvement initiative undertaken within a National Health Service (NHS) secondary care mental health provider’s open-access 24/7 crisis and home treatment service. An organisation-wide bespoke “suicide risk triage” system utilising the Collaborative Assessment and Management of Suicidality (CAMS) was implemented across all services. The preliminary impacts on suicidality, suicide rates and service user outcomes were described.

Background: Suicide is the leading cause of death among young people in Australia. Media campaigns have the potential to reach a broad audience, change attitudes and behaviours, and, ultimately, help prevent suicide. Little is known about the type of content or format suicide prevention media message should take to help prevent suicide among young people. Objective: the objective of this study was to involve young people aged 18 to 24 years in developing three suicide prevention public service announcement (PSAs) targeting young people at risk of suicide appropriate for testing in a randomised controlled trial (RCT). Method: fifteen young people attended at least one of four workshops in Melbourne, Australia. The workshops focused on exploring the appropriateness of three key suicide prevention media PSAs: “Talk to someone”, “Find what works for you”, and “Life can get better”. Young people also provided input into message content, format, and design. Results: participants perceived that all three suicide prevention PSAs were useful and helpful. Participants were concerned that the PSAs may not be suitable for nonwestern cultural groups, could trivialise psychological suffering, and that the actions they promoted could seem distant or unattainable to young people at risk. The featuring of young people, especially young people with hopeful narratives of how they overcame a suicidal crisis, was considered to be an important characteristic of suicide prevention PSAs targeting young people. Conclusions: Developing suicide prevention PSAs with young people is rare but essential to better understand young people’s needs and improve the quality of suicide prevention media PSAs. Further research is needed to evaluate the impact of suicide prevention PSAs developed by young people, for young people.

Abstract. Background: One of the critical measures in suicide prevention is promoting public awareness of crisis hotline numbers so that individuals can more readily seek help in a time of crisis. Although public service advertisements (PSA) may be effective in raising the rates of both awareness and use of a suicide hotline, few investigations have been performed regarding their effectiveness in South Korea, where the suicide rate is the highest among OECD countries. Aims: The goal of this study was to evaluate the effectiveness of a television PSA campaign. Method: We analyzed a database of crisis phone calls compiled by the Korean Ministry of Health and Welfare to track changes in call volume to a crisis hotline that was promoted in a TV campaign. We compared daily call counts for three periods of equal length: before, during, and after the campaign. Results: The number of crisis calls during the campaign was about 1.6 times greater than the number before or after the campaign. Relative to the number of suicide-related calls in the previous year, the number of calls during the campaign period surged, displaying a noticeable increase. Conclusion: The findings confirmed that this campaign had a positive impact on call volume to the suicide hotline.

Abstract. Background: Lesbian, gay, bisexual, and transgender (LGBT) youth are more than twice as likely to attempt suicide than their peers. Although LGBT-specific crisis services have been developed, little is known about the need for these services beyond that of general lifeline services. Aims: The present study sought to (a) describe the primary reasons for calling a specialized provider as opposed to another and (b) examine sociodemographic differences in the primary reason by race, ethnicity, gender, age, and sexual orientation. Method: Data from 657 youth who sought crisis services from an LGBT-specific national service provider in the United States were assessed. Logistic regression models assessed demographic differences. Thematic analysis of open-ended responses regarding reasons for choosing this LGBT-specific crisis service provider followed a consensus model. Results: Most respondents indicated they either would not have contacted another helpline (26%) or were not sure (48%). Nearly half (42%) indicated they called specifically because of LGBT-affirming counselors, a reason more commonly reported by gender minority (transgender and gender nonbinary) and queer or pansexual youth than cisgender, gay, or lesbian youth. Conclusion: LGBT-specific crisis services appear to play an important role in suicide prevention. Further research is needed to understand the use of culturally tailored suicide prevention approaches.

IntroductionThe use of new technologies is beginning to be embraced by volunteers and professionals, from crisis lines, suicide prevention centers, mental health centers, researchers and politicians.ObjectivesNew technologies have entered the field of suicide prevention with high expectations for the future, despite a relatively slow start. Internet, smartphones, apps, social networks and self-help computer programs have a strong potential to achieve, sustain and help people at risk of suicide, their families, teachers, health professionals and for the survivors.AimsTo provide comprehensive overview on the role of new technologies in suicide prevention.MethodsGiven the relatively early and underdeveloped state of this area of inquiry, the author viewed his task as gathering and critically appraising the available research relevant to the topic, with the aim of formulating a hypothesis to be tested with further research.ResultsNew cheaper services will soon be available to effectively reach and assist the most vulnerable people and prevent suicides. The potential to help vulnerable people who do not use conventional mental health services and people in regions with inadequate psychiatric facilities represents an attractive target with favourable perspectives for suicide prevention Smartphone, apps, websites, avatar coach, and virtual suicidal subjects are important for both delivering help as well as to educate mental health professionals as in the case of role playing.ConclusionsShadows and lights are emerging through the use of new technologies. If more people can be reached there are however concern for improper use of social network and pro-suicide websites.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Background: Helplines are a significant phenomenon in the mixed economy of health and social care. Given the often anonymous and fleeting nature of caller contact, it is difficult to obtain data about their impact and how users perceive their value. This paper reports findings from an online survey of callers contacting Samaritans emotional support services. Aims: To explore the (self-reported) characteristics of callers using a national suicide prevention helpline and their reasons given for contacting the service, and to present the users’ evaluations of the service they received. Methods: Online survey of a self-selected sample of callers. Results: 1,309 responses were received between May 2008 and May 2009. There were high incidences of expressed suicidality and mental health issues. Regular and ongoing use of the service was common. Respondents used the service for complex and varied reasons and often as part of a network of support. Conclusions: Respondents reported high levels of satisfaction with the service and perceived contact to be helpful. Although Samaritans aims to provide a crisis service, many callers do not access this in isolation or as a last resort, instead contacting the organization selectively and often in tandem with other types of support.

The medical model continues to dominate research and shape policy and service responses to suicide. In this work we challenge the assumption that the medical model always provides the most effective and appropriate care for persons who are suicidal. In particular, we point to service user perspectives of health services which show that interventions are often experienced as discriminatory, culturally inappropriate, and incongruent with the needs and values of persons who are suicidal. We then examine “humanistic” approaches to care that have been proposed as a corrective to an overly medical model. We argue that the focus on improving interpersonal relations set out in humanistic approaches does not mitigate the prevailing risk management culture in contemporary suicide prevention and may impede the provision of more effective care. Finally, we draw attention to the tradition of non-medical approaches to supporting persons who are suicidal. Using Maytree (a U.K. crisis support service) as a case study, we outline some of the key features of alternative service models that we consider central to the design of more culturally appropriate and effective interventions. We conclude by making three key recommendations for improving services to persons who are suicidal.

Abstract. Background: Crisis support services have historically been offered by phone-based suicide prevention hotlines, but are increasingly becoming available through alternative modalities, including Internet chat and text messaging. Aims: To better understand differences in the use of phone and chat/text services. Method: We conducted semistructured interviews with call responders at the Veterans Crisis Line who utilize multimodal methods to respond to veterans in crisis. Results: Responders indicated that veterans may access the chat/text service primarily for reasons that included a desire for anonymity and possible inability to use the phone. Responders were divided on whether callers and chatters presented with different issues or risk of suicide; however, they suggested that veterans frequently use chat/text to make their first contact with mental health services. Limitations: We spoke with call responders, not the veterans themselves. Additionally, as this is qualitative research, applicability to other settings may be limited. Conclusion: While new platforms offer promise, participants also indicated that chat services can supplement phone lines, but not replace them.

Workplaces are critical in suicide prevention because work-related factors can be associated with suicide, and because workplaces can be effective suicide prevention sites. Understanding the circumstances associated with work-related suicides can advance worksite prevention efforts. Data from the United States Centers for Disease Control and Prevention, National Violent Death Reporting System from 2013 to 2017 were used to examine characteristics and circumstances associated with work compared with non-work suicides. Work-related suicides included those indicated as work-related on the death certificate or in which the death investigation mentioned a work problem or work crisis. Of the 84,389 suicides, 12.1% had some relation to the decedent’s work. Males, those aged 21–54, and with at least a college education, were most likely to have work-related suicides. The circumstances most strongly associated with work-related suicide were financial problems (Odds Ratio (OR) = 4.7; 95% Confidence Interval (CI) = 4.5–5.0), prior depressed mood (OR = 2.4; 95% CI = 2.3–2.5), and eviction/loss of home (OR = 1.6; 95% CI = 1.4–1.7). Suicides among healthcare practitioners and management occupations had the highest odds of being work-related. Workplace wellness programs can consider incorporating services, such as financial planning and mental health services, as potentially up-stream approaches to prevent work-related suicide.

Abstract. Background: Postvention services aim to support people bereaved by suicide and reduce the adverse impacts associated with suicide bereavement. StandBy Support After Suicide is a community-based suicide bereavement service that provides support and a coordinated response for people bereaved by suicide. Aims: We aimed to evaluate the effectiveness of the StandBy service in reducing suicidality, grief reactions associated with suicide bereavement, and social isolation among clients. Method: A retrospective cross-sectional design using an online survey was used to compare StandBy clients with people bereaved by suicide who did not access the StandBy service. Results: Among people whose most recent loss to suicide was within the past 12 months, people supported by StandBy were significantly less likely to be at risk of suicidality, experience a loss of social support, and experience social loneliness compared with people bereaved by suicide who had not accessed the StandBy service. Limitations: Owing to the use of a cross-sectional design, it was not possible to determine changes over time. Conclusion: Postvention in the form of a community-based crisis intervention, at the time of or close to a suicide, is effective in reducing adverse outcomes associated with suicide bereavement, and an important aspect of suicide prevention.

<p>Previous suicide attempt is the most important predictor of death by suicide. Thus preventive interventions after attempting to suicide is essential to prevent reattempts. This paper attempts to determine whether phone preventive interventions or other vehicles (postal cards, email and case management) are effective in reattempt prevention and health promotion after discharge by providing an overview of studies on suicide reattempts. The research investigated in this review conducted from 1995 to 2014. A total of 26 cases related to the aim of this research were derived from 36 English articles with the aforementioned keywords Research shows that providing comprehensive aids, social support, and follow-up after discharge can significantly prevent suicide reattempts. Several studies showed that follow-up support (phone calls, crisis cards, mails, postal cards.) after discharge can significantly decrease the risk of suicide. More randomized controlled trials (RCT) are required to determine what factors of follow-up are more effective than other methods.</p>

Introduction:Although suicide rates are decreasing in most European countries, suicide is still a major health concern. Despite of the fact, that the vast majority of suicidal patients contacted with health care services before the suicidal act, the doctor-patient meeting is a necessary, but sometimes not sufficient way enough to prevent suicide. Most patients, who commit or attempt suicide, are not regarded as being at high immediate risk at their final contact with health care services.Aims and methods:Based on reviewing the relevant literature and on our previous studies we developed a brief, practical, clinical guideline, which may aid general practitioners and primary care professionals to assess suicide risk and also to manage these patients.Results:We introduce a model for an integrated, regional suicide prevention strategy, which includes recognition, risk assessment and also intervention. The main steps of our model are to recognize warning signs, explore crisis situation and/or psychopathologic symptoms, assess protective and risk factors, estimate suicide risk, plan intervention strategies, and finally manage suicidal patients through the different levels of intervention.Conclusion:In the management of suicidal behaviour the complex stress-diathesis model has to be adjusted by considering biological markers (mental disorders, personality traits) and psycho-social factors (crisis, negative life events, interpersonal conflicts). Only after the assessment of these factors primary care professionals, as ‘gatekeepers’ can manage suicidal patients effectively by using adequate psychopharmacotherapeutic and psychotherapeutic facilities in the recognition, treatment and prevention of suicidal behaviour.

Introduction:Although suicide rates are decreasing in most European countries, suicide is still a major health concern. Despite of the fact, that the vast majority of suicidal patients contacted with health care services before the suicidal act, the doctor-patient meeting is a necessary, but sometimes not sufficient way enough to prevent suicide. Most patients, who commit or attempt suicide, are not regarded as being at high immediate risk at their final contact with health care services.Aims and methods:Based on reviewing the relevant literature and on our previous studies we developed a brief, practical, clinical guideline, which may aid general practitioners and primary care professionals to assess suicide risk and also to manage these patients.Results:We introduce a model for an integrated, regional suicide prevention strategy, which includes recognition, risk assessment and also intervention. The main steps of our model are to recognize warning signs, explore crisis situation and/or psychopathologic symptoms, assess protective and risk factors, estimate suicide risk, plan intervention strategies, and finally manage suicidal patients through the different levels of intervention.Conclusion:In the management of suicidal behaviour the complex stress-diathesis model has to be adjusted by considering biological markers (mental disorders, personality traits) and psycho-social factors (crisis, negative life events, interpersonal conflicts). Only after the assessment of these factors primary care professionals, as ‘gatekeepers’ can manage suicidal patients effectively by using adequate psychopharmacotherapeutic and psychotherapeutic facilities in the recognition, treatment and prevention of suicidal behaviour.

IntroductionFor individuals presenting to the emergency department (ED) for a suicide attempt, the period after discharge from hospital is marked by heightened vulnerability for further suicide attempts. Effective care following a suicidal crisis has the potential to significantly decrease this risk. The current study aims to examine the impact of the LifeSpan multilevel suicide prevention model on experiences of care following a suicidal crisis. Perspectives from healthcare consumers (individuals who have presented to the ED following a suicidal crisis), carers, and health professionals will be explored. The LifeSpan model is currently being evaluated as a high-fidelity trial in four geographically defined regions in New South Wales, Australia.Methods and analysisThis study will use a mixed methods prospective cohort design. Quantitative data collection includes a structured survey, administered to healthcare consumers from LifeSpan sites and control sites. Two cohorts of healthcare consumers will be recruited 12 months apart with baseline assessment occurring within 18 months of the ED presentation, and follow-up 12 months after the initial assessment. Survey participants will be recruited online and through participating EDs, mental health organisations and aftercare services. Qualitative interview data from healthcare consumers, carers who have accompanied a loved one to the ED following a suicidal crisis and health professionals who provide care to people at risk of suicide will be collected concurrently with the recruitment of the first cohort of survey participants. Purposive and convenience sampling techniques will be used for recruitment of interview participants. The primary outcome for this study will be healthcare consumers’ experiences of service provided at the ED. Analysis will be undertaken of the change over time within LifeSpan sites, as well as between LifeSpan sites and control sites, using mixed effects repeated measures models as principal means of data analysis.Ethics and disseminationThis research has been approved by the Hunter New England Human Research Ethics Committee (HREC/17/HNE/144). Results will be disseminated via conferences and peer-reviewed journals.Trial registration numberACTRN12617000457347.

Suicide is a huge public health problem, which needs more attention. One doctor commits suicide in the U.S. every day -- the highest suicide rate of any profession. According to the American Foundation for Suicide Prevention, physicians are at a higher risk than the general population for suicide. Methods: A Brief Communication that focus on the starkest sign of the crisis gripping medicine: the number of physicians who commit suicide every year. Include: discovery or development of new information’s, novelty in modeling scientific, elucidation of mechanisms editorials and channels of information. Results: The medical profession has proven to have one of the highest risks of death by suicide among professions. About 15-30% of students and residents screen positive for depression. Studies also show that 1 in 16 trainees report suicidal ideation. The researchers also suggest that psychiatry help is still a taboo among doctors. Limitations: As Short Communications are expected to have higher than average impact on the field rather than report on incremental research, they will receive prioritized and rapid publication. Conclusion: Strategies to reduce preventable deaths should include preventive and treatment service. We should all strive to help usher in a new era of medical culture that promotes sustainable medical careers. Excessive pressures and expectations at work, may entail to a loss of meaning of work and of self for physicians. Key-words: Suicide; Doctors; Medicine; Mental Health

The Swedish National Program to Develop Suicide Prevention was created through collaboration between the National Board of Health and Welfare, the National Institute of Public Health, and the Centre for Suicide Research and Prevention. These institutions aim to provide joint support for the development of suicide prevention in Sweden by, for example, encouraging educational and development project. The program was signed for the National Council for Suicide Prevention by Agneta Dreber, Director-General, National Institute of Public Health; Danuta Wasserman, Professor of Psychiatry and Suicidology, Head, National Centre for Suicide Research and Prevention; and Claes Örtendahl, Director-General, National Board of Health and Welfare. This article, edited by Jan Beskow, Professor of Psychiatry at the Centre for Suicide Research and Prevention, is an abridged version submitted to Crisis at the request of the Editors.

Abstract. This paper evaluates the contribution to suicide prevention made by an innovative project, Maytree, a respite center for the suicidal. Maytree offers a distinctive brief period of sanctuary for four nights for suicidal people; within this limited time it aims to provide opportunities through talking, reflecting, and relaxing for reducing the intense feelings that lead to suicidal behavior. The focus of this paper is on evaluating the first 3 years of Maytree's operation, exploring how Maytree works, and its effects on the people who stay there as “guests.” This shows that Maytree reaches people who are at significant risk of suicide. Guests report both short term relief and longer term benefits. These changes are understood, through applying crisis intervention theory, as being generated by the opportunities for change in the Maytree approach. Thus, there is the potential for a benign cycle to be established. Maytree's model is different from that of mainstream, statutory services; we conclude that Maytree complements these services and also challenges the values and frameworks of statutory provision in the field of suicide prevention.

Abstract. Until now, suicide prevention efforts have been limited in developing countries, although there are pockets of excellent achievement. Various universal, selective, and indicated interventions have been implemented, many of which target a different pattern of risk factors to those in developed countries. In the absence of sufficient mental health services, developing countries rely heavily on nongovernment organizations (NGOs) to provide crisis interventions for suicidal individuals, as well as proactive interventions aimed at raising community awareness and building resilience. Often these NGOs work within a social and public health framework, collaborating with others to provide nested suicide prevention programs that are responsive to local community needs. There is a clear need to develop appropriate, relevant and effective national suicide prevention plans in developing countries, since, to date, only Sri Lanka has done so. These plans should focus on a range of priority areas, specify the actions necessary to achieve positive change in these priority areas, consider the range of collaborators required to implement these actions, and structure their efforts at national, regional, and local levels. The plans should also promote the collection of accurate data on completed and attempted suicide, and should foster evaluation efforts.

ABSTRACT Introduction Suicide is a significant problem in the U.S. military, with rates surpassing the U.S. general population as of 2008. Although there have been significant advances regarding suicide risk factors among U.S. military service members and veterans, there is little research about risk factors associated with suicide that could be potentially identified in theater. One salient study group consists of service members who receive a psychiatric aeromedical evacuation out of theater. The primary aims of this study were as follows: (1) determine the incidence of suicide-related aeromedical evacuation in deployed service members, (2) identify demographic and military characteristics associated with suicide-related aeromedical evacuation, and (3) evaluate the relationship between suicide-related aeromedical evacuation from a deployed setting and military separation. Materials and Methods This was an archival analysis of U.S. Transportation Command Regulating and Command and Control Evacuation System and Defense Manpower Data Center electronic records of U.S. military service members (N = 7023) who were deployed to Iraq or Afghanistan and received a psychiatric aeromedical evacuation out of theater between 2001 and 2013. χ2 tests of independence and standardized residuals were used to identify cells with observed frequencies and proportions, respectively, that significantly differed from what would be expected by chance. In addition, odds ratios were calculated to provide context about the nature of any significant relationships. Results For every 1000 psychiatric aeromedical evacuations that occurred between 2001 and 2013, 34.4 were suicide related. Gender, ethnicity, branch of service, occupation classification, and deployment theater were associated with suicide-related aeromedical evacuation (odds ratios ranged from 1.37 to 3.02). Overall, 53% of all service members who received an aeromedical evacuation for any psychiatric condition had been separated from the military for a variety of reasons (both voluntary and involuntary) upon record review in 2015. Suicide-related aeromedical evacuation was associated with a 37% increased risk of military separation compared to evacuation for another psychiatric condition (P &lt; 0.02). Conclusions Findings provide novel information on risk factors associated with suicide-related aeromedical evacuation as well as military separation following a suicide-related aeromedical evacuation. In many cases, the psychiatric aeromedical evacuation of a service member for suicidal ideations and their subsequent separation from active duty is in the best interest of the individual and the military. However, the evacuation and eventual military separation can be costly for the military and the service member. Consequently, the military should focus on indicated prevention interventions for individuals who show sufficient early signs of crisis and functional problems so that specialized interventions can be used in theater to prevent evacuation. Indicated prevention interventions should start with leaders’ awareness and mitigation of risk and, when feasible, evidence-based interventions for suicide risk provided by behavioral health (eg, brief cognitive behavioral therapy for suicide). Future research should evaluate the feasibility, safety, and efficacy of delivering suicide-related interventions in theater.

Due to the continuing high suicide rates among young men, there is a need to understand help-seeking behaviour and engagement with tailored suicide prevention interventions. The aim of this study was to compare help-seeking among younger and older men who attended a therapeutic centre for men in a suicidal crisis. In this case series study, data were collected from 546 men who were referred into a community-based therapeutic service in North West England. Of the 546 men, 337 (52%) received therapy; 161 (48%) were aged between 18 and 30 years (mean age 24 years, SD = 3.4). Analyses included baseline differences, symptom trajectories for the CORE-34 Clinical Outcome Measure (CORE-OM), and engagement with the therapy. For the CORE-OM, there was a clinically significant reduction in mean scores between assessment and discharge (p < 0.001) for both younger and older men. At initial assessment, younger men were less affected by entrapment (46% vs. 62%; p = 0.02), defeat (33% vs. 52%; p = 0.01), not engaging in new goals (38% vs. 47%; p = 0.02), and positive attitudes towards suicide (14% vs. 18%; p = 0.001) than older men. At discharge assessment, older men were significantly more likely to have an absence of positive future thinking (15% vs. 8%; p = 0.03), have less social support (45% vs. 33%; p = 0.02), and feelings of entrapment (17% vs. 14%; p = 0.02) than younger men. Future research needs to assess the long-term effects of help-seeking using a brief psychological intervention for young men in order to understand whether the effects of the therapy are sustainable over a period of time following discharge from the service.

Purpose – Telephone crisis services are increasingly subject to a requirement to “prove their worth” as a suicide prevention strategy. The purpose of this paper is to: first, provide a detailed overview of the evidence on the impact of telephone crisis services on suicidal users; second, determine the limitations of the outcome measures used in this evidence; and third, suggest directions for future research. Design/methodology/approach – MEDLINE via Pubmed (from 1966), PsycINFO APA (from 1967) and ProQuest Dissertation and Theses (all to 4 June 2015) were searched. Papers were systematically extracted by title then abstract according to predefined inclusion and exclusion criteria. Findings – In total, 18 articles met inclusion criteria representing a range of outcome measures: changes during calls, reutilization of service, compliance with advice, caller satisfaction and counsellor satisfaction. The majority of studies showed beneficial impact on an immediate and intermediate degree of suicidal urgency, depressive mental states as well as positive feedback from users and counsellors. Research limitations/implications – A major limitation pertains to differences in the use of the term “suicidal”. Other limitations include the lack of long-term follow-up and of controlled research designs. Future research should include a focus on long-term follow-up designs, involving strict data protection. Furthermore, more qualitative research is needed in order to capture the essential nature of the intervention. Originality/value – This paper attempts to broaden the study and the concept of “effectiveness” as hitherto used in the literature about telephone crisis services and offers suggestions for future research.

In this article the author introduces the Hotline for Mental Health in Shanghai. According to the experience gained over the past 2 years, most of the 8214 callers were having difficulties in interpersonal relationships, often in relation to lovers and partners. Love affairs were the main reason for telephone consultation among the unmarried callers (51%), while marital disputes and family problems were the most common reason for married callers (57%). Some people who suffered from mental disorders made calls asking for help in management or social support. These calls included rehabilitation of psychoses (3.5%), sleep disturbance (3.2%), and suicidal ideation (2.2%). The author suggests that such a hotline service can be a simple and practicable crisis intervention approach for suicide prevention in Shanghai.

Objectives: This study aimed to assess the association of the quality scores of hotline psychological intervention and the reduction of subsequent suicidal acts among high suicidal risk callers. Methods: High-risk callers at a national crisis hotline service in China were recruited and prospectively followed for up to 3 months after receiving a hotline psychological intervention. The quality of the intervention was evaluated by supervisors who listened to the tape-recorded calls using the Counseling Skills Rating Scale for Psychological Support Hotlines, which assessed three counseling domains: process, attitude and communication skill. The primary outcome was the occurrence of suicidal acts during the follow-up period. Secondary outcomes were before versus after changes during the intake intervention call in hopefulness, psychological stress and suicide intention reported by the callers. Results: Over the 3-month follow-up, 45 of 778 high-risk callers reported 61 suicide attempts, and 3 other callers died by suicide. Subsequent suicidal act was significantly more common in callers classified as being at higher risk during the intake call. Higher scores on the quality of suicidality assessing of the Counseling Skills Rating Scale for Psychological Support Hotlines were associated with reduced risk of suicidal acts during follow-up (hazard ratio = 0.38, 95% confidence interval = [0.18, 0.85]). Higher scores on the communication skill domain were associated with increases in hopefulness (β = 0.09) after the intervention, and higher scores on the counseling process domain (β = −0.12) and higher suicidal risk scores (β = −0.12) were associated with decreased suicide intention after intervention. Conclusion: Several characteristics of a hotline intervention for suicide prevention were associated with decreased risk of suicidal acts during follow-up. Intervention skill training for hotline operators should emphasize these specific counseling skills.

This paper presents trends and characteristics for 32,094 suicidal presentations to two Emergency Departments (EDs) in a large health service in Australia across a 10-year period (2009–2018). Prevalence of annual suicidal presentations and for selected groups of consumers (by sex, age groups, and ethnicity) was determined from a machine learning diagnostic algorithm developed for this purpose and a Bayesian estimation approach. A linear increase in the number of suicidal presentations over 10 years was observed, which was 2.8-times higher than the increase noted in all ED presentations and 6.1-times higher than the increase in the population size. Females had higher presentation rates than males, particularly among younger age groups. The highest rates of presentations were by persons aged 15–24. Overseas-born persons had around half the rates of suicidal presentations than Australian-born persons, and Indigenous persons had 2.9-times higher rates than non-Indigenous persons. Of all presenters, 70.6% presented once, but 5.7% had five or more presentations. Seasonal distribution of presentations showed a peak at the end of spring and a decline in winter months. These findings can inform the allocation of health resources and guide the development of suicide prevention strategies for people presenting to hospitals in suicidal crisis.

Most police Mental Health Act (Section 136) detentions in England and Wales relate to suicide prevention. Despite attempts to reduce detention rates, numbers have risen almost continually. Although Section 136 has been subject to much academic and public policy scrutiny, the topic of individuals being detained on multiple occasions remains under-researched and thus poorly understood. A mixed methods study combined six in-depth interviews with people who had experienced numerous suicidal crises and police intervention, with detailed police and mental health records. A national police survey provided wider context. Consultants with lived experience of complex mental health problems jointly analysed interviews. Repeated detention is a nationally recognised issue. In South East England, it almost exclusively relates to suicide or self-harm and accounts for a third of all detentions. Females are detained with the highest frequencies. The qualitative accounts revealed complex histories of unresolved trauma that had catastrophically damaged interviewee’s relational foundations, rendering them disenfranchised from services and consigned to relying on police intervention in repeated suicidal crises. A model is proposed that offers a way to conceptualise the phenomenon of repeated detention, highlighting that long-term solutions to sustain change are imperative, as reactive-only responses can perpetuate crisis cycles.

MATES in Construction (MATES) is a multimodal, peer-led, workplace suicide prevention and early intervention program developed to reduce the risk of suicide among construction industry workers through active facilitation of appropriate support. The MATES case management model provides an example of a nonclinical service for meeting the needs of individuals in the construction industry who, while at elevated risk of mental health problems and suicidality, are traditionally less likely to seek help. The aim of this research was to conduct an evaluation of the MATES case management database to quantify service demand, and to examine the demographic, occupational profile, presenting issues, referral pathways, and perceived benefit of case management among individuals who used this service. The research reports on routinely collected data from the Queensland MATES case management database, which contains records on 3759 individuals collected over the period 2010–2018, and findings from a small and opportunistic exit survey undertaken with 14 clients in 2019. Overall, findings suggest that the demand for case management through MATES has increased significantly and that clients felt that their needs and concerns were appropriately addressed. The most common presenting issues were relationship, work, and family problems, suicide, and mental health concerns. Findings confirm that causes of distress extend beyond the realm of mental disorder and span a range of psychosocial issues. Significantly, it offers an approach that may divert individuals in crisis away from presenting to over-run emergency departments, and towards services that are more equipped to meet their individual needs.

Greenbelt CARES Youth Services Bureau (CARES) is the human services arm of the city of Greenbelt, Maryland, offering direct services to children and their families living in or near this suburb of Washington. CARES has operated for eighteen years, providing formal and informal counseling, crisis intervention, suicide prevention, substance abuse education and prevention, information, referral services, a job bank, a tutoring program, a general equivalency diploma preparatory course, a family clinic, school discussion groups, and training of school personnel. Two-thirds of the services are supplied by qualified volunteers who receive continuous training, technical support, and feedback from a group of peers and mentors.

SummaryAims – Specialist interventions in community psychiatry for severe mental illness are expanding and their place needs to be re-examined. Methods – Recent literature is reviewed to evaluate the advantages and disadvantages of specialist teams. Results – Good community mental health services reduce drop out from care, prevent suicide and unnatural deaths, and reduce admission to hospital. Most of these features have been also demonstrated by assertive community outreach and crisis resolution teams when good community services are not available. In well established community services assertive community teams do not reduce admission but both practitioners and patients prefer this service to other approaches and it leads to better engagement. Crisis resolution teams appear to be more successful than assertive community teams in preventing admission to hospital, although head- to-head comparisons have not yet been made. All specialist teams have the potential of fragmenting services and thereby reducing continuity of care. Conclusions – The assets of improved engagement and greater satisfaction with assertive, crisis resolution and home treatment teams are clear from recent evidence, but to improve integration of services they are probably best incorporated into community mental health services rather than standing alone.Declaration of Interest: The author has been the sole consultant in two assertive outreach teams since 1994 and might there- fore be expected to be in favour of this genre of service. He has received grants for evaluation of different services models from the Department of Health (UK) and the Medical Research Council (UK).

AbstractBackground:Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events.Methods:Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8–12 meetings with a therapist that focused on “crisis intervention” techniques.Results:212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program’s population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts.Conclusions:The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

Purpose – The purpose of this paper is to discuss five domains impacted by the transformation of correctional mental health care in the USA: public health, public safety, legal obligations, fiscal responsibility and ethical standards, as well as critical issues such as administrative segregation, suicide prevention and reentry planning. Design/methodology/approach – In the last four decades, the USA has seen a sizable growth in its criminal justice system and corrections population. It has also seen reductions in civil and community-based mental health care. Persons with mental disabilities have come to represent a highly disproportional segment of the corrections population. The paper discusses the implications and underlying causes of these developments as well as recent responses to them. Findings – This set of circumstances is starting to change the mission of correctional health services from crisis intervention and suicide prevention to include preparation for the inmate's almost inevitable return to the community. Originality/value – Such changes have led to further developments in correctional mental health care, in particular, policy designed to treat mental illness, reduce its destructive outcomes such as suicide, and facilitate successful reentry into the community in attempts to reduce recidivism and improve clinical outcomes. Mental health care professionals working within corrections have likewise faced ethical challenges in effectuating treatment.

Evidence indicates that stigma impedes an individual’s chance of seeking professional help for a mental health crisis. Commonly reported aggregate-level results for stigma-reduction efforts obfuscate how much stigma reduction is needed to incur a practically meaningful change within an individual, defined here as an attitudinal shift and openness towards seeking mental health for oneself and/or support for others. When basing conclusions and recommendations about stigma-reducing interventions on aggregate scales, it is unclear how much stigma reduction is needed to incur meaningful change within an individual. We explored the impact of reductions in stigma of help-seeking scores in response to an online suicide prevention video among young adults in the United States, using online surveys to collect qualitative and quantitative data. We compared mean changes in the stigma scores from pre- to post-test (video exposure) of 371 young U.S. adults using standard t-tests and individual level analysis. A separate thematic analysis of free-text responses was also conducted from a smaller, randomly-selected subgroup, capturing individuals’ attitudes towards help-seeking for mental health problems. Great attention was given to participants to ensure that they were in a campus setting where counseling services were available. Four main themes emerged: (1) small changes in stigma scores were associated with individual reports of meaningful reductions in their attitudes towards professional counseling; (2) increased empathy towards victims of suicide and other mental health problems sometimes indicated increased empathy for victims of suicide and decreased openness in professional help; (3) empathy towards victims sometimes took the form of increased scores and grief or sadness, possibly thwarting the potential for help-seeking; and (4) self-reports of decreased stigma were not always associated with increased openness towards help-seeking. Results also indicated that small stigma score charges, not meeting statistical significance, were often associated with increased openness towards seeking help. These findings, discovered using mixed-methods, contribute to the body of literature regarding stigma towards suicide and help-seeking by demonstrating deficits in the aggregate-only analysis of stigma-reducing interventions specifically aimed at suicide prevention. Such individuation in stigma experiences indicates that public education on how to reduce the stigma of help-seeking for suicide prevention needs to consider individual-level analyses for improving target populations. Recommendations for future research include additional studies prior to releasing suicide prevention videos to public forums where they may be seen by individuals without access to help.

Women of Turkish descent in Germany show higher rates of suicidal behavior compared to their host populations and men of Turkish descent. This indicates a demand for a better understanding of suicidality in this group. Nine focus groups ( N = 61) were conducted to assess explanatory models including patterns of distress, perceived causes, course/consequences of and reactions towards a suicidal crisis, help-seeking behavior, and potential intervention and prevention strategies. All participants were of Turkish descent living in Berlin, Germany. The focus groups included two with professionals such as psychiatrists or psychotherapists, two with Community Mothers, three with women from the community (ages: 18 -34, 35 -49, 50+), and of three suicide attempters (ages: 18 -33, 38 -66). Data were analyzed using the methodology of thematic analysis. Results show that suicide-related behaviors, attitudes, and help-seeking behavior have gender and culture-specific characteristics. Two central themes were identified: the impact of family and community and the impact of German society. Participants stated that they believe that family and community pressures as well as discrimination and lack of acceptance cause social isolation. Fear of stigmatization and dishonoring themselves or their family, as well as shame and self-stigma decrease the likelihood of reaching out for help. Recommended strategies are community and family interventions, promotion of integration and social inclusion, awareness campaigns to destigmatize suicidality and the use of mental health services, empowerment of women, as well as the improvement of cultural sensitivity and competency of services.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. 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Background Chronic pain is a significant risk factor for suicidal ideation (SI) and suicidal behavior (SB), including a 20%-40% prevalence rate of SI, a prevalence between 5% and 14% of suicide attempts, and a doubled risk of death by suicide in patients with chronic pain compared to controls. In most studies, associations between chronic pain and suicidality are robust, even after adjusting for the effect of sociodemographics and psychiatric comorbidity, and particularly for depressive conditions. A number of specific conditions that can modulate suicidality risk in patients with chronic pain have been investigated, but there is a need for their more specific characterization. Numerous recent studies have shown that demoralization and meaning in life (MiL) constructs affect suicidality as risk and protective factors, respectively. These constructs have been mainly investigated in patients with somatic illness and in community-dwelling individuals who may present with SI or SB independently of a psychiatric diagnosis of depression. However, a paucity of studies investigated them in suicidal patients affected by chronic pain. Objective The primary objective of this project is to investigate the relationship between demoralization and MiL on SI risk in patients with chronic pain. The secondary objectives are (1) to test whether demoralization can occur independently of depression in patients with chronic pain and SI, (2) to examine whether the expected association between demoralization and SI may be explained by a sole dimension of demoralization: hopelessness, (3) to examine whether the presence of MiL, but not the search for MiL, is associated with less SI, and (4) to explore whether previously described MiL profiles (ie, high presence-high search, high presence-low search, moderate presence-moderate search, low presence-low search, and low presence-high search) emerge in our cohort. Methods This project is a single-center, observational, case-control study—the Demoralization and Meaning in Life (DEMiL) study—conducted by the Division of Clinical Pharmacology and Toxicology, the Multidisciplinary Pain Centre, and the Service of Liaison Psychiatry and Crisis Intervention at the Geneva University Hospitals. Self- and hetero-administered questionnaires were conducted among patients and controls, matched by age and gender. The Ethics Committee of the Canton of Geneva approved the scientific utilization of collected data (project No. 2017-02138; decision dated January 25, 2018). Data have been analyzed with SPSS, version 23.0, software (IBM Corp). Results From March 1, 2018, to November 30, 2019, 70 patients and 70 controls were enrolled. Statistical analyses are still in progress and are expected to be finalized in November 2020. To date, we did not observe any unfavorable event for which a causal relationship with the collection of health-related personal data could be ruled out. Results of this study are expected to form the basis for possible prevention and psychotherapeutic interventions oriented toward demoralization and MiL constructs for suicidal patients with chronic pain. Conclusions The interest in exploring demoralization and MiL in chronic pain patients with SI arises from the common clinical observation that experiencing chronic pain often requires a revision of one’s life goals and expectations. Hence, the impact of chronic pain is not limited to patients’ biopsychosocial functioning, but it affects the existential domain as well. The major clinical implications in suicidal patients with chronic pain consist in trying to (1) delineate a more precise and individualized suicide risk profile, (2) improve detection and prevention strategies by investigating SI also in individuals who do not present with a clinically diagnosed depression, and (3) enhance the panel of interventions by broadening supportive or psychotherapeutic actions, taking into consideration the existential condition of a person who suffers and strives to deal with his or her suffering. International Registered Report Identifier (IRRID) DERR1-10.2196/24882

Objective: This paper describes a small qualitative research study conducted in the area of suicide. Family and close friends of 15 young people who lived in Sydney, New South Wales, prior to their suicide, between 1990 and 1995, were interviewed to elicit their perceptions of the healthcare support given to the suicidees prior to their death. Method: Content analysis of in-depth interview transcripts identifying common themes in the description of the participants' experiences and impressions was carried out. A recurring theme was their call for more proactive management and support programs for people at risk of suicide, as well as education and support for close family and friends. Result: Participants claimed that they believed there were inadequate supports in place, that information and education were uncoordinated and sparse, and that healthcare workers were not effective in preventing suicide attempts because they lacked adequate diagnostic and management skills and displayed poor attitudes towards suicidees. Conclusion: Experiences of care received and suggestions for improving them by people closely associated with suicide, provide healthcare staff with important information about the types of information, education and support that those at risk of suicide and their loved ones require at a time of crisis.

Relevance. Russia has high mortality rates in general and among the working-age population, with dominating effects of external causes.Intention– To study rates and structures of the medical-statistical indicators of mortality due to diseases and the effects of external causes in the employees of the State Fire Service of the EMERCOM of Russia over 20 years from 1996 to 2015.Methods.Annual population under study averaged (108.8 ± 6.2) thousand people, or about 80% of all the employees of the State Fire Service of Russia who had special military ranks. Operating staff comprised 53.4%, other employees – 46.6%. Mortality rates were calculated per 100 thousand employees of the State Fire Service of Russia. Data on the mortality of working-age men in Russia was obtained on the website of the Federal Statistics Service of Russia (Rosstat) [http://www.gks.ru/]. The unification of accounting and analysis of indicators was achieved using the International Statistical Classification of Diseases and Related Health Problems, the 10th revision (ICD-10). Results and Discussion. Mortality rate among employees of the State Fire Service of the EMERCOM of Russia in 1996–2015 was (116.9 ± 5.7) deaths per 100 thousand employees per year vs 11 times higher mortality rate among the working-age male population of Russia: (1063.9 ± 33.7) deaths per 100 thousand men (p < 0.001). The mean age of the deceased employees of the State Fire Service of Russia was (44.5 ± 0.3) years, with overall mean age (36.9 ± 1.6) years (p < 0.001). The leading causes of death among employees of the State Fire Service of Russia (from more to less significant) were injuries and other effects of external causes (ICD-10 chapter XIX), diseases of the circulatory system (chapter IX) and neoplasms (II), diseases of the digestive system (XI) and diseases of the respiratory system (X). Mortality rates from these causes per 100 thousand employees per year amounted to (63.3 ± 33.7), (32.6 ± 2.7), (7.1 ± 0.6), (5.3 ± 1.0) and (5.0 ± 0.9) deaths; in cause-of-death structure – 54.2, 27.9, 6.0, 4.5 and 4.3%, respectively. The mortality rate from suicide among working-age Russian men was 6.4 times higher than that of firefighters – (66.0 ± 4.1) and (10.3 ± 1.1) deaths per 100 thousand men, respectively. However, in the overall cause-of-death structure, this cause accounted for a larger share in employ ees of the Russian State Fire Service (6.2 vs 8.8%). Statistically significant difference (p < 0.05) was found when comparing occupational fatalities among the operating personnel of the State Fire Service of Russia and working population in Russia: (14.9 ±1.4) deaths per 100 thousand employees per year vs (11.6 ± 0.7) deaths per 100 thousand workers per year. Mortality rates of firefighters were calculated in the Federal districts and regions of Russia. For a number of causes of death in firefighters, there is a significant contribution of occupational factors, which require further research.Conclusion.There is a low alertness for identifying neoplasms and crisis conditions in firefighters. Focusing on the leading diseases, behavioral disorders, prevention of injuries, poisoning and other effects of external causes will improve health and reduce mortality of employees of the State Fire Service of Russia.Authors declare the absence of existing and potential conflicts of interest concerning the article publication.

Background Digital phenotyping and machine learning are currently being used to augment or even replace traditional analytic procedures in many domains, including health care. Given the heavy reliance on smartphones and mobile devices around the world, this readily available source of data is an important and highly underutilized source that has the potential to improve mental health risk prediction and prevention and advance mental health globally. Objective This study aimed to apply machine learning in an acute mental health setting for suicide risk prediction. This study uses a nascent approach, adding to existing knowledge by using data collected through a smartphone in place of clinical data, which have typically been collected from health care records. Methods We created a smartphone app called Strength Within Me, which was linked to Fitbit, Apple Health kit, and Facebook, to collect salient clinical information such as sleep behavior and mood, step frequency and count, and engagement patterns with the phone from a cohort of inpatients with acute mental health (n=66). In addition, clinical research interviews were used to assess mood, sleep, and suicide risk. Multiple machine learning algorithms were tested to determine the best fit. Results K-nearest neighbors (KNN; k=2) with uniform weighting and the Euclidean distance metric emerged as the most promising algorithm, with 68% mean accuracy (averaged over 10,000 simulations of splitting the training and testing data via 10-fold cross-validation) and an average area under the curve of 0.65. We applied a combined 5×2 F test to test the model performance of KNN against the baseline classifier that guesses training majority, random forest, support vector machine and logistic regression, and achieved F statistics of 10.7 (P=.009) and 17.6 (P=.003) for training majority and random forest, respectively, rejecting the null of performance being the same. Therefore, we have taken the first steps in prototyping a system that could continuously and accurately assess the risk of suicide via mobile devices. Conclusions Predicting for suicidality is an underaddressed area of research to which this paper makes a useful contribution. This is part of the first generation of studies to suggest that it is feasible to utilize smartphone-generated user input and passive sensor data to generate a risk algorithm among inpatients at suicide risk. The model reveals fair concordance between phone-derived and research-generated clinical data, and with iterative development, it has the potential for accurate discriminant risk prediction. However, although full automation and independence of clinical judgment or input would be a worthy development for those individuals who are less likely to access specialist mental health services, and for providing a timely response in a crisis situation, the ethical and legal implications of such advances in the field of psychiatry need to be acknowledged.

Physician burnout is a national crisis with medicine among occupations with higher suicide risk, at 1.8 times the national average. Few pathology departments address this issue, and even fewer residency programs offer formal resiliency training. We implemented a high-stress environment resiliency strategy and an Accreditation Council for Graduate Medical Education-compliant curriculum to our residency program. Its purpose was to apply initiatives employed in the finance industry, then to measure their effectiveness. Utilizing methods from financial companies such as Goldman Sachs, we adopted the following initiatives in our residency program: (1) approach burnout as a dilemma requiring a tridimensional strategy: providing wellness training for the individual, programmatic group strategies, and an institutional wellness plan; (2) formalize a wellness curriculum, implementing wellness talks focused on stress prevention, management, and treatment; (3) offer free sessions with resilience coaches, psychological help, Employee Assistance Program, and chaplain services; (4) modify our mentorship program, pairing first-year residents with senior residents; (5) implement mindfulness practices; (6) provide easy access to volunteer opportunities and networking; (7) offer fitness center discounts. Effectiveness was measured through 2 surveys of 13 residents representing day 0 (before wellness initiatives were implemented) and at 1 year. Results indicate a significant improvement in utilization of wellness tools. This study demonstrates that wellness and resilience can be taught. Our ultimate goals are to increase wellness among pathology residents, to prepare them for a high-stress environment before entering the workforce, and to prepare them to incorporate the tools they have learned into their new workplaces.

Background: Determining optimal methods for preventing suicide continues to be an elusive goal. Aims: The study examines benefits and possible untoward effects of public service announcements (PSAs) for young adults. Methods: Young adult participants (N = 279) were randomly assigned to one of three conditions: (a) a billboard simulation, (b) a 30-s TV ad simulation, and (c) a no-information condition. Results: Largely replicating a study previously conducted with adolescents, the results provided some evidence of the benefit of the simulated TV ad (e. g., increased knowledge, perceived as useful), but it also provided some evidence of untoward effects for the billboard (e. g., viewers were less likely to endorse help-seeking strategies, normative beliefs were altered for high-risk participants). Conclusions: These results are preliminary but nevertheless highlight the need for carefully researching existing messages prior to market diffusion, so that the well-intended efforts of preventionists can meet their desired goals.