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

🇨🇦 Ansloos, J. & Cooper, A. (2023). Is suicide a water justice issue? Investigating long-term drinking water advisories and suicide in First Nations in Canada. International Journal of Environmental Research and Public Health. 20, 4045.  

The authors investigate a potential relationship between Indigenous communities with long-term drinking water advisories and suicide. Data were used from 2011 to 2016.

Abstract – First Nations experience disproportionate rates of suicide when compared to the general population. Various risk factors are identified to increase understanding of the prevalence of suicide among First Nations, but environmental dimensions of suicide are understudied. This study asks whether water insecurity, as reflected by long-term drinking water advisories (LT-DWA), has any bearing on the distribution of suicide in First Nations across Canada, and specifically in Ontario. To assess this, we established the proportion of First Nations with LT-DWAs in Canada and in Ontario that have had suicides occur between 2011 and 2016 through a review of media archives. This proportion was compared to census data on the proportion of First Nations with suicides in Canada and in Ontario between 2011 and 2016, and statistical significance of difference was determined through chi-square goodness of fit test. Overall, the findings were mixed. Nationally, there was no significant difference of proportion of First Nations with LT-DWAs with combined (confirmed and probable) reported suicides occurring when compared to census proportions; however, at the provincial level, findings had significant differences. The authors conclude that water insecurity in First Nations, as indicated by the presence of a LT-DWA in First Nations across may be an important environmental dimension of suicide, contributing to enhanced risk for suicide in First Nations.

🇨🇦 Barry, R. et al. (2023). Help-seeking behavior among adults who attempted or died by suicide in Ontario, Canada. Suicide and Life-Threatening Behavior. 53(1), 54-63.

Data were culled from administrative databases capturing hospital, emergency department (ED), and general practitioner visits across Ontario from 2007 to 2017. The researchers aimed to measure help-seeking behaviours among those living in rural areas prior to suicide or attempted suicide.

Abstract – Introduction: This study aims to determine the relationship between rurality and help-seeking behavior prior to a suicide or suicide attempt. Methods: Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital, emergency department (ED), and general practitioner (GP) visits across Ontario. Rurality was defined using the Rurality Index of Ontario scores. Help-seeking was based on accessing health services 1 year prior to the event. Results: Among those who died by suicide (N = 9848), those living in rural areas were less likely to seek help from a psychiatrist (rural males: AOR = 0.42, 95% CI = 0.31–0.57; rural females: AOR = 0.46, 95% CI = 0.29–0.97) compared with those living in urban areas. We found a similar association among those who attempted suicide (N = 82,480) (rural males: AOR = 0.49, 95% CI = 0.43–0.56; rural females: AOR = 0.51, 95% CI = 0.46–0.57). Rural males and females were more likely to seek care from an ED for mental health reasons compared with urban males and females. Conclusions: Among people who died by suicide, those living in rural areas are generally less likely to access psychiatrists and GPs and more likely to access EDs, suggesting that people living in rural areas may have less access to care than their urban counterparts.

Jansen, K.J. et al. (2023). Culturally adapting caring contacts for suicide prevention in four Alaska Native and American Indian communities. Archives of Suicide Research. 27(1), 89-106.

Caring contacts is a suicide prevention intervention that has shown efficacy in the reduction of suicidal behaviours. This is a community-based research study of both community members and health system stakeholders in Alaskan Indigenous communities. They were convened in focus groups and interviews to adapt the caring contacts intervention for use with diverse Indigenous groups.

Abstract – Aim: Despite substantial tribal, state, and federal effort, American Indian and Alaska Native (AI/AN) suicide rates have changed little in the last 30 years, prompting attention to new and innovative approaches to this persistent health disparity. Suicide prevention interventions with demonstrated success in other populations may be useful in AI/AN communities. Caring Contacts is a suicide prevention intervention that has been adapted and shown to reduce suicide ideation, attempts, and deaths in other populations. Methods: We used a community-based participatory research approach to gather qualitative data from community members, healthcare providers, and leaders in four AI/AN communities. These data were analyzed thematically and used to adapt Caring Contacts for use in a subsequent clinical trial with AI/AN people at high risk for suicide. Results: A total of 189 community members and other health system stakeholders in four tribal communities participated in focus groups and interviews. Caring Contacts was perceived in all communities to be acceptable. Feedback for intervention adaptations focused on the themes of trial eligibility criteria; instruments; message frequency, timing, and content; and cultural considerations. Conclusion: Overall, AI/AN study participants in four diverse AI/AN communities endorsed the use of Caring Contacts for suicide prevention in their communities. Intervention adaptations for use in these communities centered primarily on message frequency and timing as well as expanding access to Caring Contacts. The results of this study may be applicable to other populations that experience suicide-related health disparities.

🇨🇦 Lesage, A. et al. (2023). Implementing a suicide audit in Montreal: Taking suicide review further to make concrete recommendations for suicide prevention. Archives of Suicide Research. 27(1), 29-42.

A retrospective analysis of 39 suicides in Montreal in 2016 was undertaken using the psychological autopsy approach. The aim was to use this audit to generate recommendations for the improvement of suicide prevention practices.

Abstract – Objective: A suicide audit was pilot implemented in order to generate recommendations on how to improve suicide prevention. Methods: Thirty-nine consecutive suicides that occurred in Montreal, Canada from January to October 2016 were audited. A retrospective analysis of their life trajectory and service utilization was conducted using the psychological autopsy method, which included interviewing suicide-bereaved survivors and examining health and social services records and the coroner’s investigation file. A psychosocial and service utilization profile was drawn for each decedent. A multidisciplinary panel reviewed each case summary to identify gaps in terms of individual intervention, provincial public health and social services, and regional programs. Results: Five main suicide prevention recommendations were made to prevent similar suicides: (1) deploy mobile crisis intervention teams (short-term, high-intensity, home-based treatment) in hospital emergency departments; (2) train primary and specialized mental health care professionals to screen for and manage substance use disorders; and (3) implement public awareness campaigns to encourage help seeking for depression and substance use disorders; (4) access for all, regardless of age, to an effective psychosis treatment program; and (5) provide universal access to a general practitioner, especially for men. Conclusions: The suicide audit procedure was implemented effectively, and targeted recommendations were generated to prevent similar suicides. However, resistance from medical and hospital quality boards arose during the process, though these could be allayed if regional and provincial authorities actively endorsed the multidisciplinary and multi stakeholders suicide audit process.

🇨🇦 Libon, J. et al. (2023). Youth perspectives on barriers and opportunities for the development of a peer support model to promote mental health and prevent suicide. Western Journal of Nursing Research, 45(3), 208-214.

This is a qualitative study involving 11 youth who participated in 3 co-design workshops. Their responses helped inform the development of a peer support model for mental health promotion and suicide prevention. The target audience for the model is youth in small communities in western Canada.

Abstract – Suicide prevention is a public health priority. The purpose of this study was to elicit and document the perspectives of youth (ages 15–24) on the development of a peer support model for mental health promotion and suicide prevention for youth in small communities in western Canada. A qualitative descriptive approach informed by a socioecological framework was used to conduct the study. Eleven youth participated in a series of three co-design workshops. Data collection was conducted remotely using Zoom. Data were analyzed using thematic analysis. The following three themes are identified: (a) contextual factors for youth; (b) community spaces and social media; and (c) apps and integrated care. These themes elucidated challenges faced by the youth, strategies for reducing barriers for youth who need support, and opportunities for enhancing youth mental health through responsive community-identified services. Overall, youth were supportive of the potential use of peer support to augment services in their communities.

🇨🇦 Madigan, S. et al. (2023). Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: A systematic review and meta-analysis. The Lancet.

A review of 42 studies from January 2020 to December 2022 looking at emergency department visits by children and adolescents for suicidal behaviours during the COVID-19 pandemic.

Abstract – Background: There is a lack of consensus about the effect of the COVID-19 pandemic on the mental health of children and adolescents. We aimed to compare rates of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation during the pandemic with those before the pandemic. Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO for studies published between Jan 1, 2020, and Dec 19, 2022. Studies published in English with data on paediatric (ie, those aged <19 years) emergency department visits before and during the COVID-19 pandemic were included. Case studies and qualitative analyses were excluded. Changes in attempted suicide, self-harm, suicidal ideation, and other mental-illness indicators (e.g., anxiety, depression, and psychosis) were expressed as ratios of the rates of emergency department visits during the pandemic compared with those before the pandemic, and we analysed these with a random-effects meta-analysis. This study was registered with PROSPERO, CRD42022341897. Findings: 10 360 non-duplicate records were retrieved, which yielded 42 relevant studies (with 130 sample-estimates) representing 11·1 million emergency department visits for all indications of children and adolescents across 18 countries. The mean age of the samples of children and adolescents across studies was 11·7 years (SD 3·1, range 5·5–16·3), and there were on average 57·6% girls and 43·4% boys as a proportion of emergency department visits for any health reasons (ie, physical and mental). Only one study had data related to race or ethnicity. There was good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08–1·37), modest evidence of an increase in emergency department visits for suicidal ideation (1·08, 0·93–1·25), and good evidence for only a slight change in self-harm (0·96, 0·89–1·04). Rates of emergency department visits for other mental-illness indications showed very good evidence of a decline (0·81, 0·74–0·89), and paediatric visits for all health indications showed strong evidence of a reduction (0·68, 0·62–0·75). When rates for attempted suicide and suicidal ideation were combined as a single measure, there was good evidence of an increase in emergency department visits among girls (1·39, 1·04–1·88) and only modest evidence of an increase among boys (1·06, 0·92–1·24). Self-harm among older children (mean age 16·3 years, range 13·0–16·3) showed good evidence of an increase (1·18, 1·00–1·39), but among younger children (mean age 9·0 years, range 5·5–12·0) there was modest evidence of a decrease (0·85, 0·70–1·05). Interpretation: The integration of mental health support within community health and the education system—including promotion, prevention, early intervention, and treatment—is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents.

Marshall, P. et al. (2023). Caring for a friend or family member who has experienced suicidal behaviour: A systematic review and qualitative synthesis. Psychology and Psychotherapy Theory Research and Practice.

This is a review of 19 studies documenting the experiences and perspectives of individuals who have cared for friends and family with suicidal behaviours.

Abstract – Purpose: Friends and family members can be important sources of support for people who are or have been suicidal. This review aimed to synthesise qualitative evidence regarding carers’ perspectives of supporting someone who has experienced suicidal behaviour. Methods: Five electronic databases (Web of Science, CINAHL, PsychINFO, MEDLINE, and SocINDEX) were searched from inception to May 2022. Eligible qualitative studies were published in English and investigated the caring experiences of friends or family members of people who had experienced suicidal behaviour, defined as any form of suicidal ideation and/or attempts. Studies focused on non-suicidal self-injury or suicide bereavement were excluded. Data from 19 eligible studies were analysed using thematic synthesis. Results: Initial carer reactions to suicidal behaviour included profound anxiety and intensive monitoring for signs of increased suicide risk amongst those they supported. Carers also reported significant challenges with understanding how to provide effective interpersonal support following suicidal crises. Professional support was perceived to be most effective when provided in a timely, interpersonally sensitive and safety-focused manner. However, several studies detailed carers’ difficulties accessing appropriate support and challenges managing their own distress. Conclusions: Carers face significant challenges with knowing how to respond to suicidal behaviour, where to find appropriate help, and how to manage their own distress. Future research should seek to investigate the effectiveness of easily accessible methods of information provision and support tailored for carers of people who have experienced suicidal behaviour.

Peltier, B. et al. (2023). A longitudinal study of suicidality in a homeless population sample. Archives of Suicide Research. 27(1), 1-12.

This study looks at suicidal behaviours in a homeless population in St. Louis, Missouri. A baseline sample of 400 adults were initially assessed and re-interviewed at both I- year and 2- year intervals.

Abstract – Objective: Little research has been conducted on the timing of the onset and course of suicidality relative to the timing of the onset and temporal status of homelessness. Therefore, this longitudinal study investigated suicidal ideation and plans and suicide attempts in a homeless population in relation to housing attainment, psychiatric disorders, and substance use/disorders. Method: Prospective longitudinal follow-up data were collected from a representative sample of literally homeless adults in St. Louis (N = 255) using the Diagnostic Interview Schedule/Homeless Supplement, the Composite International Diagnostic Interview-Substance Abuse Module, and urine drug screens. Associations among suicidal symptom variables, housing status, psychiatric/substance use disorders, and substance use were examined at baseline and longitudinally. Results: Lifetime prevalence of suicidal ideation/plan and suicide attempts in this homeless population were much higher than in the general population. Onset of suicidal symptoms had typically preceded onset of homelessness. Few individuals experienced suicidal ideation/plans or attempted suicide during this study, and even fewer experienced new suicidal symptoms after baseline. Securing stable housing during the study follow-up was associated with lower rates of suicidal ideation/plans. Conclusions: This study’s findings contradict assumptions that the high prevalence of suicidal symptoms in homeless populations can be explained by the difficulties and miseries of homelessness. Psychiatric illness, substance abuse, and psychosocial factors associated with homelessness may be direct contributors to suicidal symptoms and thus represent strategic intervention targets.

🇨🇦 Richard-Devantoy, S. et al. (2023). Association between childhood cognitive skills & adult suicidal behavior: A systematic review and meta-analysis. Journal of Affective Disorders. 325, 158-168.

This is a systematic review of 23 studies looking at the association between childhood cognitive skills and subsequent adult suicidal behaviours.

Abstract – Background: It is unclear whether cognitive skill deficits during childhood carry risk for suicide attempt or mortality later in adulthood at the population level. We conducted a systematic review and meta-analysis of population-based studies examining the association between childhood cognitive skills and adult suicidal behavior, namely attempt and mortality. Method: We systematically searched databases for articles then extracted study characteristics and estimates on the association between childhood cognitive skills (ie, IQ or school performance at age ≤ 18 years) and later suicide attempt and mortality. Random-effect meta-analysis was used to quantify this association across all studies with available data. Results: Twenty-three studies met the inclusion criteria and suggest an association between lower childhood cognitive skills and increased risk of suicidal behavior. Meta-analysis of the adjusted estimates from 11 studies (N = 2,830,191) found the association to be small but statistically significant. Heterogeneity was significant but moderate, and results were unlikely to be influenced by publication bias. In subgroup analyses, associations were significant only for males. No difference in effect size was found between suicide attempt and suicide mortality. Limitations: Cognitive skills were measured with different cognitive subtests. Heterogeneity in the age of cognitive skills assessment. Meta-regression and subgroup analyses were based on a relatively low number of studies. Conclusions: Individuals with lower cognitive skills in childhood have a greater risk of suicidal behavior in adulthood, especially males. Although the association was small, interventions improving cognitive skills may yield large effects on suicide prevention at the population level if the association is causal.

🇨🇦 Schwartz, C. et al. (2023). Suicide prevention: Reaching young people at risk. Children’s Mental Health Research Quarterly. 17(1), 1–19.

This is an edition of the Children’s Health Policy Centre’s (Simon Fraser University) journal Quarterly. The entire issue is devoted to the topic of suicide prevention and children at risk of suicide. Sections include: recognizing risk; reaching those most in need; implications for practice and policy.

Abstract – Background: Suicide is one of the leading causes of death for youth in Canada. Consequently, understanding what leads to suicidality is essential in informing efforts to reduce this problem. We therefore set out to identify interventions designed to reduce suicide in young people identified as being at risk. Methods: We used systematic review methods to identify randomized controlled trials (RCTs) evaluating targeted prevention interventions for young people. After applying our rigorous inclusion criteria, we accepted eight RCTs evaluating seven interventions. Results: Attachment-Based Family Therapy, Multisystemic Therapy and Resourceful Adolescent Parent Program were the interventions that showed benefits for reducing suicidal behaviours, including attempts and/or ideation, in young people at final follow-up assessments. Conclusions: There are effective ways to reduce the risk of suicide among young people – including offering comprehensive interventions and ensuring youth have access to adequate mental health services and supports.

Suleiman, K. & El-Gabalawy, O., Zia, B. & Awaad, R. (2023). Suicide responses in American Muslim communities: A community case study. Journal of Muslim Mental Health.

This study looks at two cases of suicide in American Muslim communities and their respective responses to them.

Abstract – This community case study describes the experiences of two neighboring Muslim communities in the United States, following respective incidents of suicide. Case summaries are first presented to contextualize the community response to the suicides. Subsequently, the discussion highlights relevant cultural and religious factors that impacted the responses of mosque leadership, mental health professionals, and the communities at large. Concerns related to the deceased’s afterlife, community connectedness, privacy, shame, and communication barriers were prominent in each case and shaped the courses of response. The COVID-19 pandemic and divergent responses to external support played significant roles in creating disparate outcomes in these communities. The discussion emphasizes the need for dissemination of evidence-based, religiously grounded, and culturally competent curricula for implementing mental health awareness programming and long-term suicide prevention efforts. Insights about cultural and religious factors influencing community responses were derived from the described cases in this paper and informed the development of a comprehensive suicide prevention, intervention, and postvention manual and training program tailored for Muslim communities.

Torok, M. et al. (2023). A spatial analysis of suicide displacement as at high-risk cliff-based location following installation of a means restriction initiative. Prevention Science.

While research on means restriction interventions on bridges is relatively extensive, studies on means restrictions at high-risk cliff-based locations are sparse. This study looks at suicide displacement at one such location in Australia, following the installation of a means reduction initiative.

Abstract—Means restriction interventions are recognised as highly effective for the deterrence of suicide attempts by jumping. While such interventions can lead to significant reductions in suicide, it is unclear whether these reductions represent a displacement effect, whereby individuals are instead choosing to attempt suicide at other nearby locations which offer the same means. The potential displacement of suicides as an unintended consequence of means restriction has been relatively unexplored to date. The only studies exploring displacement effects have focused on bridges, which are relatively easily contained sites; no studies have yet explored displacement effects at cliff-based high risk suicide locations (hotspots). Using Australian coronial data for the period of 2006–2019, we undertook joinpoint and kernel density analysis of suicides by jumping at a well-known cliff-based hotspot in Sydney, Australia, to determine whether there was evidence of displacement to local and broader surrounding cliffs following the installation of a multi-component harm minimization intervention (the Gap Park Masterplan). While slight decreases were noted in the immediate area subject to the structural intervention in the post-implementation period, alongside slight increases in the surrounding cliffs, there was no evidence for statistically significant changes. While kernel density analyses did not identify the emergence of any new hotspot locations in the post-implementation period, three existing hotspot sites of concern were found in our total area of interest, with greater than expected growth in the density of one of the hotspots. While we found no persuasive evidence of displacement, ongoing monitoring of the cliff-based location where the structural interventions were implemented is needed to ensure the ongoing safety of the area.

🇨🇦 Villeneuve, P.J. et al. (2023). Daily changes in ambient air pollution concentrations and temperature and suicide mortality in Canada: Findings from a national time-stratified case-crossover study. Environmental Research. 223, 115477.

Suicidal death data from the Canadian Vital Statistics Death Database (CVSD) were used to analyze any relationship between elevated levels of air pollution and suicide.

Abstract— Introduction: Worldwide, approximately 1900 people die by suicide daily. Daily elevations in air pollution and temperature have previously been linked to a higher risk of death from suicide. To date, there have been relatively few studies of air pollution and suicide, particularly at a national level. National analyses play an important role in shaping health policy to mitigate against adverse health outcomes. Methods: We used a time-stratified case-crossover study design to investigate the influence of short-term (i.e., day to day) interquartile range (IQR) increases in air pollutants (nitrogen dioxide [NO2], ozone [O3], and fine particulate matter [PM2.5]) and temperature on suicide mortality in Canada between 2002 and 2015. For air pollution models, odds ratios (ORs) derived from conditional logistic regression models were adjusted for average daily temperature, and holidays. For temperature models, ORs were adjusted for holidays. Stratified analyses were undertaken by suicide type (non-violent and violent), sex, age, and season. Results: Analyses are based on 50,800 suicide deaths. Overall, temperature effects were stronger than those for air pollution. A same day IQR increase in temperature (9.6 °C) was associated with a 10.1% increase (95% confidence interval (CI): 9.0%–11.2%) of death from suicide. For 3-day average increase of O3 (IQR = 14.1 ppb), PM2.5 (IQR = 5.6 μg/m3) and NO2 (IQR = 9.7 ppb) the corresponding risks were 4.7% (95% CI: 3.9, 5.6), 3.4% (95% CI: 3.0, 3.8), and 2.0% (95% CI: 1.1, 2.8), respectively. All pollutants showed stronger associations with suicide during the warmer season (April–September). Stratified analyses revealed stronger associations for both temperature and air pollution in women. Conclusions: Daily increases in air pollution and temperature were found to increase the risk of death from suicide. Females, particularly during warmer season, were most vulnerable to these exposures. Policy decisions related to air pollution and climate change should consider effects on mental health.

Wardle, H. et al. (2023). Changes in severity of problem gambling and subsequent suicide attempts: A longitudinal survey of young adults in Great Britain, 2018–20. The Lancet Public Health.

The Emerging Adults Gambling Survey is a longitudinal survey of people aged 16-24 who were interviewed between June 2019-August 2019 and July-October 2020. The authors used these data to determine changes in severity of gambling and attempted suicide.

Abstract— Background: Cross-sectional studies identify problem gambling as a risk factor for suicidality. Using an online longitudinal survey, we aimed to examine the association between changes in severity of gambling behaviour and attempted suicide. Methods: The Emerging Adults Gambling Survey is a longitudinal survey of people in England, Scotland, and Wales, aged 16–24 years interviewed online between June 25 and Aug 16, 2019 (wave 1) and 1 year later between July 13 and Oct 8, 2020 (wave 2). The Problem Gambling Severity Index (PGSI) was administered at both waves. Multivariable logistic regression models examined wave 1 PGSI score and between-wave change in PGSI score as risk factors for suicide attempts at wave 2, unadjusted and with adjustment for wellbeing, anxiousness, impulsivity, perceived loneliness, and suicide attempts wave 1. Findings: 3549 participants were interviewed in wave 1 and 2094 were interviewed in wave 2, of whom 1941 were included in this analysis (749 [39%] men; 1192 women [61%]). Prevalence of attempted suicide did not change between waves (wave 1: 3·7% [95% CI 2·9–4·8], n=75; wave 2: 3·3% [2·5–4·3], n=65). 78·9% (95% CI 76·7–80·9, n=1575) of participants had stable PGSI scores between the two waves, 13·7% (11·9–15·6, n=233) of participants had a decrease in PGSI score by 1 or more, and 7·5% (6·2–8·9, n=133) had an increase in PGSI score by 1 or more. An increase in PGSI scores over time was associated with suicide attempt at wave 2, even with adjustment for baseline PGSI score and other factors (adjusted odds ratio 2·74 [95% CI 1·20–6·27]). Wave 1 PGSI score alone was not associated with suicide attempt at wave 2 in fully adjusted models. Interpretation: Repeated routine screening for changes in gambling harm could be embedded in health, social care, and public service settings to allow effective identification and suicide prevention activities among young adults.

Zabelski, S. et al. (2023). Crisis lines: Current status and recommendations for research and policy. Psychiatric Services.

This is a paper with policy and research recommendations for crisis lines, with a particular focus on the ongoing transition to a 3-digit (988) number in the United States.

Abstract— Objective: The 988 telephone number was established by the National Suicide Hotline Designation Act of 2020 and implemented in July 2022 as a more accessible way to reach the National Suicide Prevention Lifeline. Current financial and training resources, however, are insufficient to ensure effective implementation. Methods: To better understand the state of the literature on crisis support lines in light of the 988 transition, the authors summarized research on suicidal and nonsuicidal outcomes of callers, research on other types of crisis support services, and the benefits of text- and chat-based crisis lines. Results: Overall, existing evidence for the effectiveness of crisis lines has been weak and has primarily focused on short-term improvements in user distress and on user satisfaction. In addition, research on crisis lines specifically targeted to marginalized populations (e.g., sexual minority groups) and on text- or chat-based crisis lines is lacking. Conclusions: The policy-focused recommendations derived from this review include the need for additional research on crisis lines, design and evaluation of culturally tailored training for volunteers and staff, and ethical oversight of private data collected from crisis services. Scaling up state-level planning and comprehensive crisis systems is necessary to successfully implement 988 and to fill current training and research gaps.

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