This is a summary of the latest significant Canadian (🇨🇦) and international suicide research we collected in the past month:

Lee, W. et al. (2021). Exploring the mediating role of methamphetamine use in the relationship between adverse childhood experiences and attempted suicide. Addictive Behaviors. DOI: 10.1016/j.addbeh.2021.107060
A study from Taiwan exploring methamphetamine use and attempted suicide among those who have had adverse childhood experiences.

Abstract – Objective: Methamphetamine (METH) use and adverse childhood experiences (ACEs) has been associated with an increased risk of suicidal behaviour. However, whether METH use underlies the risk of suicide attributable to ACEs is unknown and warrants investigation to inform preventive interventions. In this study, we examined the mediating role of METH use in the relationship between attempted suicide and ACEs. Method: METH users recruited from a mandatory detoxification center (n = 346) and healthy controls (n = 342) both completed a survey related to 9 types of ACE, which was based the Family Health Questionnaire. A lifetime history of attempted suicide was obtained using the Chinese version of the Composite International Diagnostic Interview. We conducted a bootstrapped mediation analysis to examine the mediating effect of METH use on the association between ACEs and attempted suicide. Results: Female gender, METH use, and having multiple (≥3) ACEs were associated with an increased risk of attempted suicide. A dose–response relationship between the number of ACEs and suicide rate was observed among individuals with METH use. METH use significantly mediated the association between ACEs and attempted suicide in those with multiple (2 and 3 ACEs respectively with proportion mediated 0.16 and 0.42) and specific types of ACEs (physical abuse, witnessing maternal battering, household substance abuse, sexual abuse, and parental separation with proportion mediated 0.25, 0.35, 0.38, 0.48, 0.47 respectively). Conclusion: Our study is the first to demonstrate that METH use partially mediates the association between ACEs and attempted suicide. Addressing METH use in people with ACEs could reduce their suicide risk.

Wilson, M. et al. (2021). Adherence to guideline creation recommendations for suicide prevention in the emergency department: A systematic review. The American Journal of Emergency Medicine. DOI: 10.1016/j.ajem.2021.07.042
This systematic review looks at adherence to clinical practice guidelines for suicide prevention in emergency departments. The authors ask whether these guidelines need further development.

Abstract – Objectives: Suicide rates are rising in the United States. As emergency department (ED) providers often have limited training in management of suicidal patients and minimal access to mental health experts, clinical practice guidelines (CPGs) may improve care for these patients. However, clinical practice guidelines that do not adhere to quality standards for development may be harmful both to patients, if they promote practices based on flawed evidence, and to ED providers, if used in malpractice claims. In 2011, the Institute of Medicine created standards to determine the trustworthiness of CPGs. This review assessed the adherence of suicide prevention CPGs, intended for the ED, to these standards. Secondary objectives were to assess the association of adherence both with first author/organization specialty (ED vs non-ED) and with inclusion of recommendations on substance use, a potent risk factor for suicide. Methods: This is a systematic review of available suicide-prevention CPGs for the ED in both peer-reviewed and gray literature. This review followed the PRISMA standards for reporting systematic reviews. Results: Of 22 included CPGs, the 7 ED-sponsored CPGs had higher adherence to quality standards (3.1 vs 2.4) and included the highest-rated CPG (ICAR(Larkin et al., 2005 [2])E) identified by this review. Regardless of specialty, nearly all CPGs included some mention of identifying or managing substance use. Conclusions: Most suicide prevention CPGs intended for the ED are written by non-ED first authors or organizations and have low adherence to quality standards. Future CPGs should be developed with more scientific rigor, include a multidisciplinary writing group, and be created by authors working in the practice environment to which the CPG applies.

Gould, M. et al. (2021). National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters’ perceptions of effectiveness. Suicide and Life-Threatening Behavior. DOI: 10.1111/sltb.12795
Most surveys of crisis line service users have involved those engaged in telephone conversations. This study explores the modality of chat platforms (an under-researched area) and the experiences of its users.

Abstract – Objective: As part of the National Suicide Prevention Lifeline’s crisis response system, the Lifeline Crisis Chat Network (LCC) answers chats from hundreds of thousands of at-risk individuals yearly. The study’s objective was to assess the effectiveness of these online crisis interventions. Method: Data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys completed by LCC chatters from October 2017–June 2018 were analyzed. The relationship of several effectiveness measures with chatter demographics, pre-chat distress, suicidal ideation, and chatters’ perceptions of engagement with their counselors was examined using a series of logistic regression analyses. Results: Chatters were significantly and substantially less distressed at the end of the chat intervention than at the beginning. By the end of the chat, two-thirds of suicidal chatters reported that the chat had been helpful, while just under half reported being less suicidal. Conclusions: Our study offers empirical evidence for the Lifeline’s online crisis chat services’ effectiveness, but also highlights areas for improvement. This is of critical import in light of the recent designation of 988 as the nationwide number for the Lifeline beginning in 2022, which will increase the Lifeline’s prominence in providing suicide prevention and mental health crisis interventions in the United States.

Stack, S. & Rockett, I. (2021). Social distancing predicts suicide rates: Analysis of the 1918 flu pandemic in 43 large cities, research note. Suicide and Life-Threatening Behavior. DOI: 10.1111/sltb.12729
The authors measure the impact of social distancing measures (school closings, public gathering bans, quarantine of ill persons) on the suicide rates of 43 American cities during the 1918 Flu Pandemic.

Abstract – Social distancing (e.g., school and business closings) has been emphasized in current sociopolitical efforts in controlling COVID‐19. Such policies are assumed to increase suicide risk through lowering social integration. While two studies have linked the presence of a pandemic to suicide rates, no study has assessed the degree of social distancing on suicide rates during a pandemic. The present study fills this gap with data on the extent of social distancing during the Spanish flu epidemic in 43 large cities. The results find that increasing social distancing increases suicide rates independent of the influenza mortality rate.

🇨🇦 Lariviere, N., ET AL. (2021). Addressing suicide in entry-to-practice occupational therapy programs: A Canadian picture. Journal of Occupational Therapy Education, 5(3), 10.
Occupational Therapy students across Canada were questioned on whether they had received suicide prevention training practices in their university curricula and to offer their impressions on that training.

Abstract – The purpose of this study was to discover how competencies related to suicide prevention are currently taught to student occupational therapists in Canadian universities. A cross-sectional descriptive design was used to survey the 14 Canadian university occupational therapy programs. 12/14 programs responded. All endorsed the use of a range of pedagogical approaches, but there was little similarity from one university to another. Learning activities mainly related to mitigating imminent suicide risk (intervention) and illustrated a lack of attention to the continuum of suicidal behavior (prevention, intervention, and postvention). All universities showed a clear willingness to improve their approach, but there is no current gold standard to strive for. Future initiatives can support research in this regard to ensure student occupational therapists are better prepared to address the full continuum of prevention, intervention, and postvention with explicit attention to an occupational perspective.

de Jonge-Heesen, K., et al. (2020). How to cope with perfectionism? Perfectionism as a risk factor for suicidality and the role of cognitive coping in adolescents. Journal of Rational-Emotive & Cognitive-Behavior Therapy. DOI: 10.1007/s10942-020-00368-x
Research had found associations between suicidality and the personality trait know as perfectionism. This study looks at perfectionism and suicidality in a sample of Dutch secondary school students between the ages of 12 and 15.

Abstract – Suicide among adolescents is a significant health concern. Gaining more knowledge about markers that contribute to or protect against suicide is crucial. Perfectionism is found to be a personality trait that is strongly predictive for suicidality; it can be divided into personal standards perfectionism (PS) and concerns about mistakes and doubts perfectionism (CMD). This study investigated the association between PS, CMD, and suicidality in a sample of 273 Dutch secondary school students aged between 12 and 15 years old (M=13.54, SD=0.58, 55.8% males). We also examined whether adaptive, or maladaptive cognitive coping strategies influenced these associations. We hypothesized that students high in PS or CMD would experience an increased suicidality. Moreover, we expected that adaptive coping strategies would act as buffer between the association of perfectionism and suicidality, and that maladaptive coping strategies would strengthen this association. For analyses, we used a regression model with latent variables. The results showed that higher scores in perfectionism (PS and CMD) were related to an increase in suicidality. High levels of maladaptive coping in combination with high levels of perfectionism were associated with an increase in suicidality. Although adaptive coping was related to a decrease in suicidality, adaptive coping in interaction with PS and with CMD was not a predictor of suicidality. The results are relevant for prevention, and intervention programs. This paper makes recommendations for clinical practice and further research in order to prevent suicidality in adolescents.

Scarth, B. et al. (2021). Strategies to stay alive: Adaptive toolboxes for living well with suicidal behavior. International Journal of Environmental Research and Public Health. DOI: 10.3390/ijerph18158013
This qualitative study looks at strategies of manageability utilized by those who experience chronic suicidality or repeated suicide attempts. 17 American respondents with lived experience of suicidal behaviours were questioned.

Abstract – Suicidal behavior constitutes a major global problem. Qualitative research utilizing the first-hand experiences of those who have survived attempts to take their own lives can offer much in the way of understanding how to live well despite ongoing suicidal behavior. Given that suicidal intentions and behaviors occur within the person’s subjective construal, the solutions to living—and preferably living well—despite such inclinations must also be subjective and adaptive. The aim of this study was therefore to understand how individuals live with different aspects of their suicidal behavior and their use of effective strategies to protect themselves from future attempts. Thematic analysis of semi-structured, qualitative interviews with 17 participants with lived experience of suicidal behavior from the USA yielded two main themes: (i) the ‘dynamic relationship with suicidal behavior: living with, and through’, and (ii) ‘the toolbox’. Each of these themes had four subthemes. Participants in this study offered important insights into what helped them not just survive ongoing suicidal behavior, but how they created unique toolboxes to continue living, and to live well. These toolboxes contained personalized solutions to dealing with recurring threats to their subjective wellbeing and included diverse solutions from spirituality, pets, peer-support, participating in the arts, through to traditional therapeutic supports. Some participants also discussed the importance of broader social policy and societal changes that help them live. The findings highlight crucial implications for suicide prevention efforts, especially in terms of encouraging collaborations with the lived experience community and furthering a strengths-based approach to mitigating suicidal behaviors. We encourage the clinical community to work in partnership with service-users to enable them to generate effective solutions to living—and living well—through suicidal behavior.

🇨🇦 Fernandes, J., et al. (2021). What are Canadian emergency physicians’ attitudes and self-perceived competence toward patients who present with suicidal ideation? Canadian Journal of Emergency Medicine. (2021). Published online 1 July 2021. DOI: 10.1007/s43678-021-00157-0
A survey of Canadian emergency room physicians was conducted to gauge their attitudes toward and their self-perceived abilities to treat patients with suicidal ideation.

Abstract – Introduction: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) attitudes toward and understanding of individuals with suicidal ideation. Methods: We developed a web-based survey on suicide knowledge, which was pilot tested by two EPs and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. The Understanding of Suicidal Patients (USP) Scale is an 11-point questionnaire to assess healthcare providers’ attitudes toward individuals with suicidal ideation. Other questions pertaining to suicidal ideation, self-perceptions on ability to treat suicidal patients, and personal experiences with suicide were asked in Likert format. Results: One hundred eighty-eight Canadian EPs responded to the survey (15% response rate), with a median age of 49 (IQR 39—55), academic practice reported by 55% of respondents, and 65% of respondents identified as male. The mean USP score was 21.8 (95% CI 21.1–22.5), which indicates a generally positive attitude and willingness to provide care for suicidal patients. Only 17% of respondents had participated in specific training for treatment of suicidal patients in the last five years, while the majority of respondents estimate treating 5–15 patients with suicidal ideation a month. Sixty four percent of respondents indicated they had the skills to screen patients for suicidal ideation, but less than one-third felt they could create a personalized safety plan for patients. Conclusions: Respondents have a generally positive attitude toward treating individuals with suicidal ideation. Respondents scored highly on the USP scale that measured willingness to provide care for and empathize with suicidal patients. Respondents felt they had the skills to adequately screen patients for suicidal ideation. Key gaps in knowledge were identified suggesting improved residency and ongoing medical education opportunities are needed to better improve care for this vulnerable population.

Ruch, D.A., et al. (2021). Characteristics and precipitating circumstances of suicide among children aged 5 to 11 years in the United States, 2013-2017. JAMA Network Open, 4(7), e2115683. DOI: 10.1001/jamanetworkopen.2021.15683
Suicide among children is an under-researched area of suicide prevention. This study uses data of children aged 5 to 11 culled from the National Violent Death Reporting System (NVDRS) to determine commonalities of child suicide.

Abstract – Importance: Suicide is the eighth leading cause of death among children aged 5 to 11 years, with rates increasing during the past decade. A better understanding of factors associated with childhood suicide can inform developmentally appropriate prevention strategies. Objective: To examine characteristics and precipitating circumstances of childhood suicide. Design, Setting, and Participants: This qualitative study examined restricted-use data from the National Violent Death Reporting System (NVDRS) regarding child suicide decedents aged 5 to 11 years in the US from 2013 to 2017. The NVDRS is a state-based surveillance system that collects data on suicide and violent deaths in 50 states, with restricted-use data available from 37 states. Details and context related to suicide deaths were identified through a content analysis of case narratives from coroner or medical examiner and law enforcement reports associated with each incident. Exposures: Characteristics and precipitating circumstances associated with suicide cited in the coroner, medical examiner, and law enforcement case narratives. Main Outcomes and Measures: Suicide incidence and risk factors for suicide including mental health, prior suicidal behavior, trauma, and peer, school, or family-related problems. Results: Analyses included 134 child decedents (101 [75.4%] males; 79 [59.0%] White individuals; 109 [81.3%] non-Hispanic individuals; mean [SD] age, 10.6 [0.8] years). Most suicides occurred in the child’s home (95.5% [n = 128]), and more specifically in the child’s bedroom. Suicide by hanging or suffocation (78.4% [n = 105]) was the most frequent method, followed by firearms (18.7% [n = 25]). Details on gun access were noted in 88.0% (n = 22) of suicides by firearm, and in every case, the child obtained a firearm stored unsafely in the home. Findings revealed childhood suicide was associated with numerous risk factors accumulated over time, and suggest a progression toward suicidal behavior, especially for youth with a history of psychopathology and suicidal behavior. An argument between the child and a family member and/or disciplinary action was often a precipitating circumstance of the suicide. Conclusions and Relevance: This qualitative study found that childhood suicide was associated with multiple risk factors and commonly preceded by a negative precipitating event. Potential prevention strategies include improvements in suicide risk assessment, family relations, and lethal means restriction, particularly safe firearm storage. Future research examining the myriad aspects of childhood suicide, including racial/ethnic and sex differences, is needed.

Gleason, L.L., et al. (2021). Under the surface: The role of covert cues in peer suicide risk referrals. School Mental Health. DOI: 10.1007/s12310-021-09459-1
This study looks at a specific suicide prevention training (SOS-Signs of Suicide) aimed at high school students. The objective was to determine whether this training “influences referral intentions for overt and covert suicide cues” of peers who may be at risk for suicide.

Abstract – Suicidal thoughts and behaviors are highly prevalent among adolescents, and peers are often the first, and sometimes only, people to know about youth suicidality. Since many adolescents do not directly disclose suicidal thoughts, school-based suicide prevention programs aim to train youth to recognize warning signs of suicide in their peers that serve as “cues” to refer at-risk peers to an appropriate adult. However, peer-presented cues vary widely in presentation, and adolescents are more likely to recognize overt (i.e., obvious or explicit) as opposed to covert (i.e., hidden or implied) cues. The type of cue exhibited may, in turn, affect whether adolescents make a referral to an adult. The current study examined whether training suicide prevention influences referral intentions for overt and covert suicide cues. Participants included 244 high school students (54% female; Mage = 16.21) in the Southeastern United States who received suicide prevention training (SOS; signs of suicide) as part of their health curriculum. Prior to training, students endorsed higher referral intentions for peers exhibiting overt compared to covert cues. Training was associated with increased intentions to refer peers across cue type, but referral intentions for covert cues improved significantly from pre to post-training while those for overt cues remained high and stable. Findings suggest that suicide prevention training might differentially improve students’ ability to detect and respond appropriately to less obvious indicators of suicide risk. These findings may inform the adaptation and development of future, more nuanced school-based suicide prevention programming.

🇨🇦 Suresh, R., et al. (2021). Program evaluation of a student-led peer support service at a Canadian university. International Journal of Mental Health Systems, 15(54). DOI: 10.1186/s13033-021-00479-7
Students and peer support volunteers at a Canadian university were surveyed about their mental well-being, experiences with previous mental health services, and their experiences with the Peer Support Centre (PSC).

Abstract – Background: University students often experience numerous financial, social and emotional stressors that can affect their mental health. The Peer Support Centre (PSC) is a pilot project that was established to provide peer support to students in these stressful conditions. We wanted to investigate whether peer support is a viable form of support that would benefit university students. The objective of this study is to determine whether the organization was indeed providing a beneficial service to students and if it was fulfilling the needs of the students that visited the service. Methods: After a support session, students and peer support providers completed an anonymous questionnaire regarding their self-reported mental wellbeing using the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) metrics, and Outcome Rating Scale (ORS). They were also asked about their experience with previous professional mental health services as well as their experience at the PSC. With the data collected from 1043 students and 797 volunteers from September 2016–March 2020, a program evaluation was conducted for quality improvement purposes. Results: The PSC is used by students of different sexes, genders, and ethnicities. Students reported having a low ORS score, moderate anxiety as per the GAD-7 and moderate depression according to the PHQ-9. They find it easy to use and rely on it as an alternative form of support when they approach barriers that prevent them from accessing professional services. Lastly, the peer support providers feel very validated in their role and overall quite prepared and helpful when helping their fellow peers. Conclusions: The establishment of a student service that provides peer support would be beneficial to the members of a university/college campus.

🇨🇦 Bergmans, Y. (2021). Providing virtual suicide prevention groups for people experiencing suicidality: Pivoting service delivery during the COVID-19 pandemic. International Social Work. Published online 4 August 2021. DOI: 10.1177/0020872821996781
This paper examines how Skills for Safer Living, a 20-week face-to-face group intervention for people with recurrent suicide attempts, transitioned to virtual groups because of the COVID-19 pandemic.

Abstract – Skills for Safer Living is a 20-week group intervention for people with recurrent suicide attempts. This article details how it pivoted from in-person to virtual groups due to the COVID-19 pandemic. Concerns of privacy, client safety, and how to deliver the program virtually are explored, along with lessons learned.

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