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

Mason, A., et al. (2021). A content analysis of Reddit users’ perspectives on reasons for not following through with a suicide attempt. Cyberpsychology, Behavior, and Social Networks. DOI:10.1089/cyber.2020.0521.
A content analysis of Reddit users whose posts express suicidal thoughts as well as potential protective factors and reasons for living that may prevent an escalation to suicide.

Abstract – Despite a growing understanding of the triggers for suicidal thoughts and behavior, little is known about the mechanisms that prevent people from killing themselves. The goal of the present study was to use publicly available Reddit data to better understand the reasons that people give for not following through with a potentially lethal suicide attempt. Threads containing key terms (e.g., “kill yourself”) within the subreddit /r/AskReddit were collected and all top posts from these threads were thematically coded. Across the posts collected, 11 different themes were identified: friends and family, curiosity and optimism about the future, spite, purpose, transience, hobbies, animals/pets, fear of survival, fear of pain, death and/or the afterlife, apathy/laziness, and intervention. Some additional themes were captured in an “other” category, and a twelfth theme, use of pharmaceutical drugs, was identified, but not discussed. These findings provide a broad overview about the proximal protective factors that directly stopped people from making a suicide attempt. They also illustrate the potential for Reddit as platform through which to better understand factors that may help to identify and support those in suicidal crisis. Such insight may help to inform intervention and prevention strategies for suicide and those in suicidal crisis.

Edmonds, W., et al. (2021). Adolescent athletes and suicide: A model for treatment and prevention. Aggression and Violent Behavior. DOI:10.1016/j.avb.2021.101580
A subgroup of the United States adolescent population, the adolescent athlete, is observed for its unique characteristics and factors in relation to suicide. There are both positive and protective factors which will set them apart from the greater general adolescent population.

Abstract – When examining suicide in the US adolescent population, subgroups are typically lost in the shuffle. We believe that subgroups are bound by unique characteristics and these distinguishing factors should be taken into clinical consideration. With that in mind, we provide the case that athletes be deemed a specific population and superfluous information regarding athletes should be thoughtfully integrated into treatment and prevention models when dealing with depression and suicidal behavior. This manuscript will be particularly useful for clinicians who have little or no experience working with athletes. We cover theoretical constructs often utilized when examining athletes such as perfectionism, fear of failure and social cognitive theory. We also introduce potential risk factors unique to the athletic domain and offer models for treatment such as the traditional cognitive behavioral therapy, the transtheoretical model of change, motivational interviewing, mindfulness therapy and psychophysiological approaches. The goal of this manuscript is not to explain a link between athletes and suicide- rather, our goal is to help clinicians who work with athletes or plan to work with adolescent athletes to build an expansive view of the unique culture related to the sporting domain. The coverage of risk factors and theoretical models are not meant to be comprehensive or exhaustive and the treatment suggestions are not intended to replace traditionally accepted approaches to suicidality, rather to serve as an adjunct to a clinical approach when working specifically with adolescent athletes.

Hill, R., et al. (2021). Suicide ideation and attempts in a pediatric emergency department before and during COVID-19. Pediatrics, 147(3). DOI:10.1542/peds.2020-029280
A comparison of the rates of ideation and attempts for youth aged 11-21 in a pediatric emergency department in Texas. The figures compared are between those in 2019 and March through July 2020, the initial months of the COVID-19 Pandemic.

Abstract – Objectives: Recent studies have identified elevated rates of mental health concerns during the COVID-19 pandemic. This study sought to evaluate whether youth reported greater frequency of suicide-related behaviors during the 2020 COVID-19 pandemic, as compared with data from 2019. We hypothesized that rates of suicide-related behaviors would be elevated between the months of March and July 2020, as compared with 2019, corresponding to the onset of the COVID-19 pandemic. Method: Routine suicide risk screening was completed with youth ages 11-21 in a pediatric Emergency Department. Electronic health records data for suicide risk screens completed between January-July 2019 and January-July 2020 were evaluated. A total of 9,092 completed screens were examined (mean age 14.72 years, 47.7% Hispanic/Latinx, 26.7% non-Hispanic White, 18.7% non-Hispanic Black). Results: Analyses compared rates of positive suicide risk screens for January-July 2020 with corresponding rates from January-July 2019. Results indicated a significantly higher rate of suicide ideation in March and July 2020 and higher rates of suicide attempts in February, March, April, and July 2020, as compared with the same months in 2019. Demographic characteristics (sex, race/ethnicity) were not associated with increased rates of suicide-related behaviors during this period. Conclusions: Results indicated that rates of suicide ideation and attempts were higher during some months of 2020, as compared with 2019, but were not universally higher across this period. Months with significantly higher rates of suicide-related behaviors appear to correspond to times when COVID-related stressors and community responses were heightened, indicating that youth experienced elevated distress during these periods.

Holm, A., et al. (2021). Suicide prevention strategies for older persons: An integrative review of empirical and theoretical papers. Nursing Open. DOI:10.1002/nop2.789.
Suicide prevention strategies for older adults are scarce. This review looks at circumstances specific to older adults and proposes the most useful suicide prevention strategies for this population.

Abstract – Aim: To synthesize suicide prevention strategies for older adults. The review question was Which suicide prevention strategies are useful for older adults? Design: Integrative review. Data sources: Academic Search Premier, CINAHL, Ovid PsycINFO and PubMed were searched for articles published between January 2009 and December 2019. Review methods: An integrative review of quantitative, qualitative and theoretical papers with a qualitative thematic analysis. Results: Key aspects of the included studies contributed to the formulation of four themes: (1) Recognizing older adults’ physical and/or mental health problems and referring them for help and treatment, (2) Designing an educational program, (3) Communication and dialogue about warning signs and (4) Social support and awareness of causing significant others emotional pain. The findings indicate an urgent need to identify effective suicide prevention strategies for older adults.

🇨🇦 Shahram, S., et al. (2021). Promoting “Zest for Life”: A Systematic Literature Review of Resiliency Factors to Prevent Youth Suicide. Journal of Research on Adolescence, 31(1), 4-24. DOI:10.1111/jora.12588
A review focusing on resiliency factors, both internal (positive self‐appraisal, zest for life, personal traits, and coping skills) and external (social support system and inclusive environments), and their relationship with suicidality. 37 studies were included.

Abstract – Suicide is a leading cause of death among youth globally. In this critical interpretive synthesis, we examined literature on resiliency factors and suicidality. Systematic searches identified 474 articles, 37 of which were included. Results revealed internal (positive self‐appraisal, zest for life, personal traits, and coping skills) and external factors (social support system and inclusive environments) contribute to resilience among youth, with age, sex and gender, and Indigenous identity as important intersecting considerations. Findings validated fostering resilience as primary suicide prevention among youth, with little explanation for how these factors may work to protect youth from suicidality. Continued research in this area requires a focus on how to promote resilience at the community and systems levels.

🇨🇦 Liu, L., et al. (2021). Changes over time in means of suicide in Canada: An analysis of mortality data from 1981 to 2018. CMAJ, 193(10), E331-338. DOI:10.1503/cmaj.202378
The rates of suicide involving suffocation, poisoning, and firearms as means of suicide have changed throughout the decades. This analysis looks at the Canadian mortality data from 1981 to 2018 to identify these changes.

Abstract – Background: Ongoing surveillance of the means of suicide is necessary for effective prevention. We examined how mortality rates owing to different means of suicide changed in Canada from 1981 to 2018. Methods: We obtained data from 1981 to 2018 on suicide deaths of individuals aged 10 years and older, from the Canadian Vital Statistics Death Database. We used joinpoint regression analysis to examine changes over time in the suicide mortality rate for the 3 most common means of suicide. Results: The age-standardized suicide mortality rate declined in earlier decades for both sexes but did not significantly change in recent decades for either sex. The age-standardized rate of suicide by suffocation increased from 1993 for females (2.1% per year) and from 1996 for males (0.4% per year). The age-standardized rate of suicide by poisoning decreased for females (2.2% per year) and males (2.1% per year) from 1981 to 2018. The age-standardized rate of suicide by firearm decreased from 1981 to 2008 (7.4% per year) but did not significantly change thereafter for females; for males, it decreased 2.1% per year from 1981 to 1993 and 5.7% per year from 1993 to 2007 but did not significantly change thereafter. Interpretation: For both sexes, the rate of suicide by poisoning is decreasing, the rate of suicide by suffocation is increasing, and the rate of suicide by firearm has not significantly changed in the last decade. Given the high proportion of suicide deaths by suffocation, its increasing rate and the difficulty of restricting the means of suffocation, other approaches to suicide prevention are needed.

Edwards, T., et al. (2021). Suicide prevention: The role of families and carers. Asia-Pacific Psychiatry. e12453. DOI: 10.1111/appy.12453
This article presents recommendations to encourage family involvement in suicide risk assessment.

Abstract – Families and carers can play an important role in helping prevent suicide. Unfortunately, silence and secrecy within the family environment have sometimes prevented family members from intervening to potentially change the course of suicide intent. This article describes a family-oriented assessment process that can facilitate family-involvement in care. Suicide risk assessment requires a skilled interview with the individual patient to determine accurately suicidal intent. However, family members provide a vital source of collateral information for assessing risk and the relational support needed to diminish risk. Strength-based strategies for intervening with patients and family members to help prevent suicide are described.

🇨🇦 Cote, D., et al. (2021). Suicide-related Twitter content in response to a national mental health awareness campaign and the association between the campaign and suicide rates in Ontario. The Canadian Journal of Psychiatry. DOI:10.1177/0706743720982428
An analysis of suicide-related tweets responding to the Bell Let’s Talk campaign was conducted to gauge if there is relationship between this mental health campaign and suicide rates.

Abstract – Objective: Mental health awareness (MHA) campaigns have been shown to be successful in improving mental health literacy, decreasing stigma, and generating public discussion. However, there is a dearth of evidence regarding the effects of these campaigns on behavioral outcomes such as suicides.  Therefore, the objective of this article is to characterize the association between the event and suicide in Canada’s most populous province and the content of suicide-related tweets referencing a Canadian MHA campaign (Bell Let’s Talk Day [BLTD]). Methods: Suicide counts during the week of BTLD were compared to a control window (2011 to 2016) to test for associations between the BLTD event and suicide. Suicide tweets geolocated to Ontario, posted in 2016 with the BLTD hashtag were coded for specific putatively harmful and protective content. Results: There was no associated change in suicide counts. Tweets (n ¼ 3,763) mainly included content related to general comments about suicide death (68%) and suicide being a problem (42.8%) with little putatively helpful content such as stories of resilience (0.6%) and messages of hope (2.2%). Conclusions: In Ontario, this national mental health media campaign was associated with a high volume of suicide-related tweets but not necessarily including content expected to diminish suicide rates. Campaigns like BLTD should strongly consider greater attention to suicide-related messaging that promotes help-seeking and resilience. This may help to further decrease stigmatization, and potentially, reduce suicide rates.

Bowersox, N., et al. (2021).Peer-based interventions targeting suicide prevention: A scoping review. American Journal of Community Psychology. DOI:10.1002/ajcp.12510
Peer supports and peer-based interventions for those at risk of suicide are gaining increasing attention in suicide prevention. This review looks at papers studying a range of services delivered by peers, including gatekeeper training, crisis support, relapse prevention and others.

Abstract – Peers of individuals at risk for suicide may be able to play important roles in suicide prevention. The aim of the current study is to conduct a scoping review to characterize the breadth of peer-delivered suicide prevention services and their outcomes to inform future service delivery and research. Articles were selected based on search terms related to peers, suicide, or crisis. After reviews of identified abstracts (N = 2681), selected full-text articles (N = 286), and additional references (N = 62), a total of 84 articles were retained for the final review sample. Types of suicide prevention services delivered by peers included being a gatekeeper, on-demand crisis support, crisis support in acute care settings, and crisis or relapse prevention. Peer relationships employed in suicide prevention services included fellow laypersons; members of the same sociodemographic subgroup (e.g., racial minority), workplace, or institution (e.g., university, correctional facility); and the shared experience of having a mental condition. The majority of published studies were program descriptions or uncontrolled trials, with only three of 84 articles qualifying as randomized controlled trials. Despite a lack of methodological rigor in identified studies, peer support interventions for suicide prevention have been implemented utilizing a diverse range of peer provider types and functions. New and existing peer-delivered suicide prevention services should incorporate more rigorous evaluation methods regarding acceptability and effectiveness.

Kuffel, R., et al. (2021). PTSD, risk of suicide, and unintended death by overdose in mid-to late-life. American Journal of Geriatric Psychiatry, 29(4), 59-60. DOI:10.1016/j.jagp.2021.01.051
This study compared veterans with diagnosed PTSD and veterans with no PTSD with risk of attempted suicide and suicide by drug overdose.

Abstract – Although posttraumatic stress disorder (PTSD) may increase risk of suicide in mid- to late-life, findings have been controversial, in large part, because studies have not accounted for comorbid disorders. Moreover, little is known about association between mid- to late-life PTSD and apparent accidental death by overdose, which could be due to suicidal intent. Thus, we conducted a comprehensive study to examine PTSD and risk of death by suicide, suicide attempt, and unintended death by overdose among veterans in mid- to late-life. Methods: This nationwide cohort study included all veterans ≥50 years (N=1,038,980) seen in the Veterans Health Administration starting 2012-2013 (baseline) and followed through December 31, 2017. Veterans with a PTSD diagnosis were propensity-matched 1:1 with patients without PTSD. They were matched on age, gender, race/ethnicity, income, education, homelessness, service connection, Charlson comorbidity index, and neuropsychiatric disorders. Dates of suicide attempt and cause-specific mortality at follow up were defined using the National Suicide Prevention Applications Network and the Mortality Data Repository, respectively. PTSD was identified by two or more ICD-9 codes in electronic medical records at baseline. PTSD and risk of suicide-related outcomes were assessed using multivariable models. Fine-Gray proportional hazards regression was used to examine time to outcome event at follow up. Models were next adjusted in steps, with the final adjustment accounting for sociodemographics, Charlson comorbidity index, and neuropsychiatric diagnoses. Other outcomes examined using similar methods included death by drug overdose (i.e., antiepileptics/sedative-hypnotics, narcotics, and unspecified/other cause-specific drug categories) for suicide, unintentional, and undetermined death. Results: Of 1,038,980 patients in our study, 519,490 had PTSD. The mean participant age was 63.56, 59,542 (5.73%) were women, and 765,572 (73.68%) were non-Hispanic White. Although firearms were by far the leading method of suicide death for those with and without PTSD, there was no significant between-group difference related to firearms. However, veterans with PTSD were significantly more likely to die by suicide by drug overdose compared with those without a PTSD diagnosis. As shown in Table 1, after adjusting for sociodemographics, Charlson comorbidities, and neuropsychiatric diagnoses, the hazard ratio for risk of suicide in veterans with PTSD was 1.57 (95% CI, 1.51, 1.63) for any suicide attempt; 1.09 (95% CI, 1.01, 1.19) for death by suicide; 1.43 (95% CI, 1.32, 1.56) for drug overdose death overall; 1.53 (95% CI, 1.21, 1.94) for suicide death by drug overdose. Further analyses explored type of drug involved in overdose and demonstrated that veterans with PTSD had hazard ratios of 1.44 (95% CI, 1.26, 1.65) for narcotics and 1.48 (1.31-1.68) for other /unspecified drugs (Figure 1). We also found that having PTSD increased unintentional death, suicide death, and undetermined intent for narcotics by 1.4 to 2.4 times, and for other/unspecified drugs by 1.4 to 1.8 times. Conclusions: The findings suggest that veterans with PTSD aged ≥50 years in VA healthcare, have persistently elevated risk for suicide attempts and suicide death, particularly by drug overdose. This current work may inform clinical practice targeting late-life suicide prevention efforts by promoting improved prescribing and drug-monitoring. Future medication recommendations to treat PTSD may need to consider less risky drugs than narcotics, as well as emphasize inquiring about potential illicit drug use and access, for older adults. More research is needed to elucidate the relationship of PTSD to increased risk of mid- to late-life death by suicide and unintended drug overdose, exploring what other and unspecific drugs do and do not exacerbate this risk.

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