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

Special Research

The following two articles do not address suicide or suicidal behaviours directly, but they do examine psychological adversities encountered as a result of epidemic outbreaks (this is timely research considering our current COVID-19 situation). The first paper is a literature review of quarantines and the psychological effects of those quarantined. The second looks at a more specific population—health care workers in China—and their mental health outcomes during the recent Covid-19 epidemic in Wuhan, China.

Brooks, S.K., et al. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 395: 912–20. S0140-6736(20)30460-8

Abstract: The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.

Lai, J., et al. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Psychiatry.

Abstract: Importance – Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed. Objective – To assess the magnitude of mental health outcomes and associated factors among health care workers treating patients exposed to COVID-19 in China. Design, setting and participants – This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements from 1257 health care workers in 34 hospitals from January 29, 2020, to February 3, 2020, in China. Health care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 were eligible. Main outcomes and measures – The degree of symptoms of depression, anxiety, insomnia, and distress was assessed by the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised, respectively. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes. Results – A total of 1257 of 1830 contacted individuals completed the survey, with a participation rate of 68.7%. A total of 813 (64.7%) were aged 26 to 40 years, and 964 (76.7%) were women. Of all participants, 764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%) worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care workers. A considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe degrees of all measurements of mental health symptoms than other health care workers (eg, median [IQR] Patient Health Questionnaire scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [interquartile range {IQR}] Generalized Anxiety Disorder scale scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] Insomnia Severity Index scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] Impact of Event Scale–Revised scores among those In Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001). Multivariable logistic regression analysis showed participants from outside Hubei province were associated with lower risk of experiencing symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008). Frontline health care workers engaged in direct diagnosis, treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms of depression (OR, 1.52; 95%CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95%CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95%CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95%CI, 1.25-2.04; P < .001). Conclusions and Relevance – In this survey of heath care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China, participants reported experiencing psychological burden, especially nurses, women, those in Wuhan, and frontline health care workers directly engaged in the diagnosis, treatment, and care for patients with COVID-19.

(🇨🇦) Perret, J. (2020). Prevalence of mental health outcomes among Canadian veterinarians. Journal of the American Veterinary Medical Association, 256(3), 365-375.
There is much evidence that the mental health of veterinarians is poorer than that of the general population. However, evidence among Canadian veterinarians has been less plentiful. This welcome Canadian study corroborates the mental health outcomes found in American and international research.

Abstract: Objective – To estimate the prevalence of perceived stress, burnout, depression, anxiety, compassion fatigue, compassion satisfaction, resilience, and suicidal ideation among Canadian veterinarians and compare results with those for other populations. Sample – 1,403 veterinarians across Canada. Procedures – The study represented a cross-sectional online survey. The questionnaire incorporated validated psychometric instruments to measure perceived stress, burnout, depression, anxiety, compassion fatigue, and resilience as well as questions regarding suicidal ideation. Means and relative proportions in categories of severity were compared between genders as well as with normative data for the general population and results for veterinarians in the United Kingdom. Results – Approximately 10% of Canadian veterinarians (n = 1,403) completed the survey. Relative to the general population, survey participants had significantly higher mean scores for subscales of burnout and compassion fatigue, anxiety, and depression and significantly lower mean resilience. Relative to males, females had significantly higher mean scores for perceived stress, emotional exhaustion, burnout, secondary traumatic stress, anxiety, and depression and significantly lower mean resilience. Participants also had higher mean scores for anxiety and depression relative to results for United Kingdom veterinarians. The 12-month prevalence of suicidal ideation for participants was 26.2%, which was substantially higher than the estimated prevalence for the general international population (2.1% to 10.0%). Conclusions and Clinical Relevance – Results suggested that the mental health of Canadian veterinarians was poor, compared with the mental health of the general population. These results should serve as a call to action for tools and educational programs directed at supporting veterinarian mental wellness in Canada, with special attention paid to the disparate needs of the genders.

(🇨🇦) Ligier, et al. (2020). Are school difficulties an early sign for mental disorder diagnosis and suicide prevention? A comparative study of individuals who died by suicide and control groupChild and Adolescent Psychiatry and Mental Health.
A Canadian study examining school difficulties and their possible association with mental illness and suicide.

Abstract: Background – Suicide is the third leading cause of death worldwide among youth aged 10- to 19, and mental disorders are often associated in the etiology of suicidal behavior. Mental disorders are often under-diagnosed and undertreated in young people, a situation likely to increase the severity of the disorder and suicide risk. Presence of school difficulties may, in some cases, be a consequence of mental disorder, and theses difficulties are observable. Therefore, early detection and early intervention of school difficulties may alleviate the development of mental disorders and suicide vulnerability. The aim of this study is to understand the link between school difficulties and suicide risk. Methods – We used the data bank gathered by the McGill Group on Suicide Studies over the past two decades through interviews with the relatives of individuals who died by suicide and with individuals from the community as a control group. We included data on common sociodemographic characteristics, life events and mental health characteristics identified before age 18, among individuals who died before the age of 35 or were interviewed before the age of 35. We identified 200 individuals who died by suicide and 97 living controls. We compared groups according to gender and characteristics. Results – Within the total sample, 74% were male, 13% had met with academic failure, 18% had engaged in inappropriate behavior at school, and 18% presented combined school difficulties. Combined school difficulties (academic failure and inappropriate behavior) for both sexes and academic failure alone for males were associated with higher suicide risk before the age of 35. School difficulties generally began in early childhood and were linked to mental disorders/difficulties and substance abuse before age 18. Conclusions – This study underlines the importance for parents, teachers, and educators to identify children with school difficulties—academic failure and behavioral difficulties at school—as early as possible in order to be able to propose adapted interventions. Early identification and proper diagnosis may prevent chronicity of some disorders, accumulation of adverse events, and even suicide.

Hoffberg, et al. (2020). The effectiveness of crisis line services: A systematic review.Frontiers in Public Health.
Crisis lines are an essential component of suicide prevention efforts. There are studies on the effectiveness of crisis lines. However, more nuanced and robust research that studies beyond “measured proximal outcomes” is needed. Moreover, studies of crisis chat are few and “no studies have been conducted to evaluate the effectiveness of text-related services”.

Abstract: Background – Crisis lines are a standard component of a public health approach to suicide prevention. Clinical aims include reducing individuals’ crisis states, psychological distress, and risk of suicide. Efforts may also include enhancing access and facilitating connections to behavioral health care. This review examines models of crisis line services for demonstrated effectiveness. Methods – Literature searches of Medline, EMBASE, PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were conducted from January 1, 1990, to May 7, 2018. Experts were contacted, and references were mined for additional studies. Eligible studies provided health- or utilization-related effectiveness outcome(s). Results were graded according to the Oxford Centre for Evidence-Based Medicine and evaluated for risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. Results – Thirty-three studies yielded effectiveness outcomes. In most cases findings regarding crisis calls vs. other modalities were presented. Evaluation approaches included user- and helper-reported data, silent monitoring, and analyses of administrative records. About half of studies reported immediate proximal outcomes (during the crisis service), and the remaining reported distal outcomes (up to four years post-contact). Most studies were rated at Oxford level four evidence and 80% were assessed at high risk of bias. Conclusions – High quality evidence demonstrating crisis line effectiveness is lacking. Moreover, most approaches to demonstrating impact only measured proximal outcomes. Research should focus on innovative strategies to assess proximal and distal outcomes, with a specific focus on behavioral health treatment engagement and future self-directed violence.

(🇨🇦) Ranahan and White (2020). Creating suicide-safer communities in British Columbia: A focused ethnography.Journal of Ethnographic & Qualitative Research, 14, 42-58,
A significant study of a province-wide gatekeeper training program undertaken in British Columbia by CMHA in 2015-2018.

Abstract: Suicide prevention gatekeeper training is designed in order to enhance participants’ recognition of persons in distress, enhance skills in responding, and referrals to help. In response to rising suicide rates in British Columbia, Canada, two standardized gatekeeper training programs were implemented by the Canadian Mental Health Association between 2015-2018. In order to explore their implementation within the dynamic and diverse contexts through the province, we conducted a focused ethnography informed by a relational constructionist framework of analysis. Our exploration over three phases of data collection, which included interviews, document analysis, and field observations, identified the network of interactions that both enabled and constrained various relationships, decisions, and opportunities for learning. Through the results of the present study, we indicated that the coordinators of the programs pivoted away from initial goals of training (i.e., number of individuals trained) towards community readiness, thereby generating pathways to helping, selling, and constructing responsibility to help as well as negotiating communities of place. These findings of the present study are discussed in relation to future large-scale suicide prevention efforts.

Ross, V. (2020). A suicide prevention initiative at a jumping site: A mixed-methods evaluation.EClinicalMedicine.
Means restriction is a best practice in suicide prevention. Reducing access to suicide “hot spots” is one effective example of means restriction. This study uses qualitative and quantitative methods to evaluate such measures taken at an iconic Australian suicide jumping site.

Abstract: Background – Gap Park in Sydney, Australia has historically been recognised as a suicide jumping site. In 2010–2011 the Gap Park Masterplan initiative implemented a series of suicide prevention measures. This study applied a mixed-methods design to evaluate the effectiveness of the Masterplan in reducing suicides. Methods – Data from the Australian National Coronial Information System (NCIS) was examined to compare suicides at Gap Park before and after the Masterplan was implemented. This was complemented with qualitative data from interviews with police officers who respond to suicidal behaviours at Gap Park. Findings – Joinpoint analysis of NCIS data showed a non-significant upward trend in jumping suicides during the study period. A significant upward trend in suicides was seen for females before the implementation of the Masterplan (2000–2010), followed by a significant downward trend from the implementation period onwards (2010–2016) for females: however, a non-significant upward trend for males was observed. Qualitative analysis of police interviews identified six key themes: romanticism and attraction at hotspots, profiles and behavioural patterns of suicidal individuals, responding to a person in a suicidal crisis, repeat attempts, means restriction, and personal impacts on police officers. Interpretation – The mixed-method study provided important insights, suggesting the Gap Park Masterplan has contributed to a reduction in female, but not in male jumping suicides. Further qualitative information from police officers suggested that the safety barriers were not difficult to climb, and may be more of a visual or psychological barrier. However, the effectiveness of CCTV and alarms in the detection and location of suicide attempters was highlighted.

DeVille, D., et al. (2020). Prevalence and family-related factors associated with suicidal ideation, suicide attempts, and self-injury in children aged 9 to 10 years.JAMA Network Open, 3(2) e1920956.
Suicidal and self-harming behaviours of pre-adolescent children is an area very under-researched. This American study looks at the association between family environment and suicidal behaviours and self-harm among children.

Abstract: Importance – Although suicide is a leading cause of death for children in the United States, and the rate of suicide in childhood has steadily increased, little is known about suicidal ideation and behaviors in children. Objective To assess the overall prevalence of suicidal ideation, suicide attempts, and nonsuicidal self-injury, as well as family-related factors associated with suicidality and self-injury among preadolescent children. Design, Setting, and Participants – Cross-sectional study using retrospective analysis of the baseline sample from the Adolescent Brain Cognitive Development (ABCD) study. This multicenter investigation used an epidemiologically informed school-based recruitment strategy, with consideration of the demographic composition of the 21 ABCD sites and the United States as a whole. The sample included children aged 9 to 10 years and their caregivers. Main Outcomes and Measures – Lifetime suicidal ideation, suicide attempts, and nonsuicidal self-injury as reported by children and their caregivers in a computerized version of the Kiddie Schedule for Affective Disorders and Schizophrenia. Results – A total of 11 814 children aged 9 to 10 years (47.8% girls; 52.0% white) and their caregivers were included. After poststratification sociodemographic weighting, the approximate prevalence rates were 6.4% (95% CI, 5.7%-7.3%) for lifetime history of passive suicidal ideation; 4.4% (95% CI, 3.9%-5.0%) for nonspecific active suicidal ideation; 2.4% (95% CI, 2.1%-2.7%) for active ideation with method, intent, or plan; 1.3% (95% CI, 1.0%-1.6%) for suicide attempts; and 9.1% (95% CI, 8.1-10.3) for nonsuicidal self-injury. After covarying by sex, family history, internalizing and externalizing problems, and relevant psychosocial variables, high family conflict was significantly associated with suicidal ideation (odds ratio [OR], 1.12; 95% CI, 1.07-1.16) and nonsuicidal self-injury (OR, 1.09; 95% CI, 1.05-1.14), and low parental monitoring was significantly associated with ideation (OR, 0.97; 95% CI, 0.95-0.98), attempts (OR, 0.91; 95% CI, 0.86-0.97), and nonsuicidal self-injury (OR, 0.95; 95% CI, 0.93-0.98); these findings were consistent after internal replication. Most of children’s reports of suicidality and self-injury were either unknown or not reported by their caregivers. Conclusions and Relevance – This study demonstrates the association of family factors, including high family conflict and low parental monitoring, with suicidality and self-injury in children. Future research and ongoing prevention and intervention efforts may benefit from the examination of family factors.

Duarte, D., et al. (2020). Male and female physician suicidality: A systematic review and meta-analysis.JAMA Psychiatry.
The rate of physician suicide is known to be higher than most professions. This review looks at studies of male and female physician suicide since 1980.

Abstract: Objective – To evaluate male and female physician suicide risks compared with the general population from 1980 to date and test whether there is a reduction of SMR in cohorts after 1980 compared with before 1980 via a meta-analysis, modeling studies, and a systematic review emphasizing physician suicide risk factors. Data Sources – This study uses studies retrieved from PubMed, Scielo, PsycINFO, and Lilacs for human studies published by October 3, 2019, using the search term “(((suicide) OR (self-harm) OR (suicidality)) AND ((physicians) OR (doctors))).” Databases were also searched from countries listed in articles selected for review. Data were also extracted from an existing article by other authors to facilitate comparisons of the pre-1980 suicide rate with the post-1980 changes. Study Selection – Original articles assessing male and/or female physician suicide were included; for the meta-analysis, only cohorts from 1980 to the present were included. Data Extraction and Synthesis – The preregistered systematic review and meta-analysis followed Cochrane, PRISMA, and MOOSE guidelines. Data were extracted into standardized tables per a prespecified structured checklist, and quality scores were added. Heterogeneity was tested via Q test, I2, and τ2. For pooled effect estimates, we used random-effects models. The Begg and Egger tests, sensitivity analyses, and meta-regression were performed. Proportional mortality ratios were presented when SMR data could not be extracted. Main Outcomes and Measures – Suicide SMRs for male and female physicians from 1980 to the present and changes over time (before and after 1980). Results – Of 7877 search results, 32 articles were included in the systematic review and 9 articles and data sets in the meta-analysis. Meta-analysis showed a significantly higher suicide SMR in female physicians compared with women in general (1.46 [95% CI, 1.02-1.91]) and a significantly lower suicide SMR in male physicians compared with men in general (0.67 [95% CI, 0.55-0.79]). Male and female physician SMRs significantly decreased after 1980 vs before 1980 (male physicians: SMR, −0.84 [95% CI, −1.26 to −0.42]; P < .001; female physicians: SMR, −1.96 [95% CI, −3.09 to −0.84]; P = .002). No evidence of publication bias was found. Conclusions and Relevance In this study, suicide SMR was found to be high in female physicians and low in male physicians since 1980 but also to have decreased over time in both groups. Physician suicides are multifactorial, and further research into these factors is critical.

(🇨🇦) Di Nota, P., et al. (2020). Mental disorders, suicidal ideation, plans and attempts among Canadian police.Occupational Medicine.
First responders are an at-risk group for trauma, metal health disorders, and suicidal behaviours. This study looks at the prevalence of these phenomena among sworn and civilian members of Canadian police and the relationship between these disorders and suicide among them.

Abstract: Background – Recent investigations have demonstrated a significant prevalence of mental health disorders, including post-traumatic stress disorder (PTSD), and suicidal ideation, plans and attempts among Canadian public safety personnel, including police officers. What remains unknown is the relationship between mental disorders and suicide among sworn police officers, and the prevalence of both among civilian police workers. Aims – To examine the relationship between suicidal ideation, plans and attempts and positive mental health screens for depression, anxiety, panic disorder, alcohol abuse and PTSD among Canadian sworn and civilian police employees. Methods – Participants completed an online survey that included self-report screening tools for depression, anxiety, panic disorder, alcohol abuse and PTSD. Respondents were also asked if they ever contemplated, planned or attempted suicide. Between-group (Royal Canadian Mounted Police [RCMP], provincial/municipal police and civilians) differences on mental health screening tools were calculated using Kruskal–Wallis analyses. The relationship between mental disorders and suicidal ideation, plans and attempts was evaluated with a series of logistic regressions. Results – There were 4236 civilian and sworn officer participants in the study. RCMP officers reported more suicidal ideation than other police and scored highest on measures of PTSD, depression, anxiety, stress and panic disorder, which were significantly associated with suicidal ideation and plans but not attempts. Relative to provincial and municipal police, civilians reported more suicide attempts and scored higher on measures of anxiety. Conclusions – The results identify a strong relationship between mental health disorders and increased risk for suicidal ideation, plans and attempts among sworn and civilian Canadian police employees.

(🇨🇦) Affleck, W., et al. (2020). Suicide amongst the Inuit of Nunavut: An exploration of life trajectories.International Journal of Environmental Research and Public Health, 17(6),1812.
The Inuit in Nunavut and elsewhere in northern Canada consistently have some of the highest suicide rates in the world. This Canadian paper looks at the complex nature of Indigenous suicide which needs to be viewed in a larger social and economic context, than solely at the level of the individual, to be fully understood.

Abstract: This article reports results of the life trajectories from 92 Inuit who died by suicide, matched for age and gender with 92 living-controls. A proxy-based procedure and semi-structured interviews with informants were conducted to obtain trajectories of developmental events occurring over the life course for suicide and community-matched controls. Results from this research indicate two different trajectories that differentiate the control-group from the suicide-group throughout the life course. Even though the number of suicide attempts are similar between both groups, the suicide-group had a more important burden of adversity, which seemed to create a cascading effect, leading to suicide.

(🇨🇦) Sanderson, M. et al. (2020). Predicting death by suicide following an emergency department visit for parasuicide with administrative health care system data and machine learning.EBioMedicine
A Canadian study looking at the promising role artificial intelligence may have on the prediction of future suicidality. In this case, data from Alberta emergency visits for self-harming behaviours are examined.

Abstract: Background – Suicide is a leading cause of death worldwide and results in a large number of person years of life lost. There is an opportunity to evaluate whether administrative health care system data and machine learning can quantify suicide risk in a clinical setting. Methods – The objective was to compare the performance of prediction models that quantify the risk of death by suicide within 90 days of an ED visit for parasuicide with predictors available in administrative health care system data. The modeling dataset was assembled from 5 administrative health care data systems. The data systems contained nearly all of the physician visits, ambulatory care visits, inpatient hospitalizations, and community pharmacy dispenses, of nearly the entire 4.07 million persons in Alberta, Canada. 101 predictors were selected, and these were assembled for each of the 8 quarters (2 years) prior to the quarter of death, resulting in 808 predictors in total for each person. Prediction model performance was validated with 10-fold cross-validation. Findings – The optimal gradient boosted trees prediction model achieved promising discrimination (AUC: 0.88) and calibration that could lead to clinical applications. The 5 most important predictors in the optimal gradient boosted trees model each came from a different administrative health care data system. Interpretation – The combination of predictors from multiple administrative data systems and the combination of personal and ecologic predictors resulted in promising prediction performance. Further research is needed to develop prediction models optimized for implementation in clinical settings.

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