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

Chen, Y-Y., et al. (2021). Caregiving as suicide prevention : An ecological 20-country study of the association between men’s family carework, unemployment, and suicide. Social Psychiatry and Psychiatric Epidemiology. DOI:10.1007/s00127-021-02095-9
This study aims to discover if there is a link between family carework, unemployment, and suicide among men and if family care engagement is a protective factor against suicide.

Abstract – Purpose: Suicide rates are generally higher in men than in women. Men’s higher suicide mortality is often attributed to public-life adversities, such as unemployment. Building on the theory that men’s suicide vulnerability is also related to their private-life behaviors, particularly men’s low engagement in family carework, this ecological study explored the association between men’s family carework, unemployment, and suicide. Methods: Family-carework data for twenty Organization for Economic Co-operation and Development (OECD) countries were obtained from the OECD Family Database. Sex-specific age-standardized suicide rates came from the Global Burden of Disease dataset. The association between men’s engagement in family carework and suicide rates by sex was estimated, with OECD’s unemployment-benefits index and United-Nations’ Human Development-Index (HDI) evaluated as controls. The moderation of men’s carework on the unemployment-suicide relationship was also assessed. Results: Overall and sex-specific suicide rates were lower in countries where men reported more family carework. In these countries, higher unemployment rates were not associated with higher male suicide rates. In countries where men reported less family carework, higher unemployment was associated with higher male suicide rates, independent of country’s HDI. Unemployment benefits were not associated with suicide rates. Men’s family carework moderated the association between unemployment and suicide rates. Conclusion: This study’s findings that higher levels of men’s family carework were associated with lower suicide mortality, especially among men and under high-unemployment conditions, point to the suicide-protective potential of men’s family carework. They are consistent with evidence that where gender equality is greater, men’s and women’s well-being, health, and longevity are greater.

Onie, S., et al. (2021). The use of closed-circuit television and video in suicide prevention: Narrative review and future directions. JMIR Mental Health, 8(5), e27663. DOI:10.2196/27663
CCTV and video are promising areas for the identification of suicidal behaviours preceding a suicide attempt and may offer opportunities for intervention.

Abstract – Background: Suicide is a recognized public health issue, with approximately 800,000 people dying by suicide each year. Among the different technologies used in suicide research, closed-circuit television (CCTV) and video have been used for a wide array of applications, including assessing crisis behaviors at metro stations, and using computer vision to identify a suicide attempt in progress. However, there has been no review of suicide research and interventions using CCTV and video. Objective: The objective of this study was to review the literature to understand how CCTV and video data have been used in understanding and preventing suicide. Furthermore, to more fully capture progress in the field, we report on an ongoing study to respond to an identified gap in the narrative review, by using a computer vision–based system to identify behaviors prior to a suicide attempt. Methods: We conducted a search using the keywords “suicide,” “cctv,” and “video” on PubMed, Inspec, and Web of Science. We included any studies which used CCTV or video footage to understand or prevent suicide. If a study fell into our area of interest, we included it regardless of the quality as our goal was to understand the scope of how CCTV and video had been used rather than quantify any specific effect size, but we noted the shortcomings in their design and analyses when discussing the studies. Results: The review found that CCTV and video have primarily been used in 3 ways: (1) to identify risk factors for suicide (eg, inferring depression from facial expressions), (2) understanding suicide after an attempt (eg, forensic applications), and (3) as part of an intervention (eg, using computer vision and automated systems to identify if a suicide attempt is in progress). Furthermore, work in progress demonstrates how we can identify behaviors prior to an attempt at a hotspot, an important gap identified by papers in the literature. Conclusions: Thus far, CCTV and video have been used in a wide array of applications, most notably in designing automated detection systems, with the field heading toward an automated detection system for early intervention. Despite many challenges, we show promising progress in developing an automated detection system for preattempt behaviors, which may allow for early intervention.

Siry, B.J., et al., (2021). Lethal means counseling for suicide prevention: Views of emergency department clinicians. General Hospital Psychiatry, 71, 95-101. DOI:10.1016/j.genhosppsych.2021.04.011
Means safety is a best practice in suicide prevention. This study looks at “Lock to Live”, a means safety initiative, and its perception among patients and clinicians.

Abstract – Objective: Lethal means safety – counseling and guidance about reducing access to home firearms and medications – is recommended for emergency department patients at risk of suicide. Decision aids are tools that can facilitate potentially difficult decisions by incorporating personal preferences and values. The present study evaluates clinician perceptions about the implementation and utility of “Lock to Live,” a lethal means safety decision aid. Method: One-on-one qualitative interviews were conducted with clinicians (n = 15) at three large emergency departments. Interviewees were asked to evaluate the “Lock to Live” decision tool and its potential implementation and utilization in the emergency department. Interviews were recorded and transcribed. Data were coded via thematic analysis; two coders developed a shared codebook iteratively with high interrater reliability. Results: Perspectives on the tool fell into three domains: (1) patients (use with patients and families), (2) clinicians, and (3) emergency department system. Interviewees noted that the tool had numerous potential benefits but that its uptake and effectiveness would depend on clinicians’ perceptions on its utility, time constraints, and integration into workflow. Addressable concerns related to relationship to other resources, fit within emergency department workflow, and clarification about which emergency department clinician types should use the tool. Conclusions: “Lock to Live” represents a promising new tool for use in suicide prevention as an aid to lethal means counseling. This qualitative study provides insights into the importance of considering the clinical environment when designing and implementing interventions.

Sampasa-Kanyinga, H., et al. (2021). Nonmedical use of prescription opioids, psychological distress, and suicidality among adolescents. Social Psychiatry and Psychiatric Epidemiology. 56, 783–791. DOI:10.1007/s00127-020-01958-x
🇨🇦 This Canadian study looks at the potential links between the use of nonmedical prescription opioids and psychological distress and suicidality among adolescents. The study culled survey data from a province-wide (Ontario) representative sample of 5582 adolescents in grades 7 through 12.

Abstract – Purpose: The present study examined associations between nonmedical use of prescription opioids and serious psychological distress, suicidal ideation, and suicide attempts, and tested whether age and sex moderate these relationships. Methods: Data on 5582 adolescents were obtained from a representative province-wide survey of students in grades 7 through 12 (mean age: 15.3 years) across Ontario, Canada. Nonmedical use of prescribed opioids in the last 12 months was categorized in “no use”, “infrequent use (1–2 times)”, and “regular use (3 times or more)”. Logistic regression analysis was adjusted for age, sex, ethnicity, subjective socioeconomic status, and other substance use (i.e., tobacco cigarette, alcohol, cannabis). Results: Overall, regular nonmedical use of prescription opioids was strongly associated with greater odds of serious psychological distress (OR: 3.47; 95% CI 1.42–8.45), suicidal ideation (OR: 2.73; 95% CI 1.84–4.05), and suicide attempts (OR: 3.21; 95% CI 1.40–7.37). However, infrequent nonmedical use of prescription opioids was associated with greater odds of serious psychological distress (OR: 1.79; 95% CI 1.08–2.98) and suicidal ideation (OR: 1.63; 95% CI 1.20–2.21), but not suicide attempts (OR: 1.84; 95% CI 0.76–4.45). Age-stratified analyses showed that both infrequent (OR: 1.61; 95% CI 1.01–2.58) and regular (OR: 3.40; 95% CI 2.11–5.46) nonmedical use of prescription opioids was strongly associated with greater odds of suicidal ideation among 15- to 20-year-olds, but not 11- to 14-year-olds. Conclusion: These findings suggest that nonmedical use of prescription opioids is strongly associated with mental health problems among adolescents. Future research using a longitudinal design is needed to confirm age differences and temporality.

Robins, J.E., et al. (2021). Alcohol dependence and heavy episodic drinking are associated with different levels of risk of death or repeat emergency service attendance after a suicide attempt. Drug and Alcohol Dependence, 224, 108725.
Alcohol use can be a risk factor for suicide. However, Alcohol Use Disorder (AUD) is a broad spectrum and the differences of designation within the disorder are rarely taken into account when applied to suicide. This study examines whether there is a difference among those categorized as alcohol dependent, those who experience heavy episodic drinking, or those who are low risk drinkers and their risk of death and repeat emergency rook visitation.

Abstract – Background: Alcohol use is a multidimensional risk factor for suicidal behaviour. However, suicide prevention strategies often take ‘one-size-fits-all’ approaches to alcohol use, reflecting an evidence base built on unidimensional measures. Latent Class Analysis can use a range of measures to differentiate distinct patterns of alcohol using behaviour and their associated risks. Methods: We analysed Electronic Health Record data from 650 suicidal adults detained for up to 36 h using police powers (Section 136 of the Mental Health Act 1983, amended 2007) to facilitate psychiatric assessment at a Health-Based Place of Safety, a dedicated emergency psychiatric care centre in London, UK. We conducted a Latent Class Analysis of alcohol using behaviours at first detention, and used multivariable logistic regression to estimate the association of each identified latent class with subsequent death or recontact with emergency psychiatric care over a median follow-up of 490 days, adjusting for sex, age and past-year psychiatric diagnosis. Results: Three classes of alcohol use were identified: low risk drinkers, heavy episodic drinkers and dependent drinkers. The dependent drinking class had twice the odds of death or recontact with emergency psychiatric care as the low risk drinking class (OR 2.32, 95 %CI 1.62–3.32, p < 0.001). Conversely, the heavy episodic drinking class was associated with lower odds of death or recontact than the low risk drinking class (OR 0.66, 95 %CI 0.53−0.81, p < 0.001). Conclusions: The risk of adverse outcomes after a suicide attempt are not uniform for different alcohol use classes. Clinical assessment and suicide prevention efforts should be tailored accordingly.

Harris, B.R. (2021). Suicide as a hidden contributor to the opioid crisis and the role that primary care and emergency medicine play in addressing it. Preventative Medicine. 148, 106572. DOI:10.1016/j.ypmed.2021.106572
A commentary by Brett Harris of the University of Albany School of Public Health. He notes the concurrent rise in both opioid overdoses and suicide and the role that primary care and emergency departments can play in addressing both phenomena.

Abstract – Deaths from overdose have risen dramatically over the past decade, driven mainly by opioids. In response, the Centers for Disease Control and Prevention released guidance on safe prescribing, safe storage of medications, Medication-Assisted Treatment (MAT), and the use of Naloxone to reverse an overdose. Even with this guidance, overdose deaths continue to rise. Suicide prevention is a strategy that may help address this problem. Suicide rose 32.4% between 1999 and 2019, from 10.5 to 13.9 per 100,000. Closely linked to overdose, the suicide rate among those with opioid use disorder is 87 per 100,000 population, six times that of the general US population. With multiple shared individual-level risk factors, strict standards for case ascertainment, and high potential for misclassification of opioid suicides, the distinction between overdose and suicide is often unclear, and the number of suicides is likely underestimated. The Surgeon General recently released a call to action for a public health approach to suicide prevention. Primary care and emergency departments have a major role to play. This commentary describes suicide as a hidden contributor to the opioid crisis; the rationale for integration of suicide prevention in primary care and emergency departments; and screening, education, brief intervention, and follow up and monitoring techniques that these settings can employ. Done effectively, this strategy has the potential to save countless lives.

Kia, H., et al. (2021). Peer support as a protective factor against suicide in trans populations: A scoping review. Social Science and Medicine, 279. DOI:10.1016/j.socscimed.2021.114026
Research indicates that there is an elevated risk of suicide among the transgender population. This scoping review contains 34 studies which are analyzed for evidence of peer support as a protective factor against suicide for trans persons.

Abstract – Rationale: There is a growing body of research involving transgender (trans) individuals that foregrounds elevated rates of suicidality in trans populations. Although peer support is increasingly studied as a protective factor against suicide among trans persons, the scholarship in this area continues to be limited and has yet to be synthesized and appraised. Objective: In this paper, we address this existing gap in the literature by presenting the results of a scoping review of the literature examining the significance and function of peer support in mitigating suicide risk in trans populations. Academic Psychiatry, 45, 252-256. Methods: This scoping review is based on an analysis of 34 studies that were included following the execution of a methodical search and selection process. Drawing on scoping review methodology, along with PRISMA-P guidelines, we selected peer-reviewed empirical works, published between 2000 and 2020, which examined relationships between providing, seeking, and/or receiving peer support and suicide risk in trans populations. Results: Our findings, which are conceptualized using the minority stress model as a guiding theoretical framework, reveal that while the literature generally substantiates the protective significance of peer support for trans persons, a small body of work also uncovers novel and unanticipated sources of peer support, including social support offered by trans peers online, which are infrequently and inconsistently examined in this body of scholarship. Conclusions: Using our appraisal of the literature, we outline the need for future research to further elucidate the significance and function of peer support in protecting against suicide among trans persons. In particular, we discuss the need for exploratory inquiry to inform a conceptualization and operationalization of peer support that more fully and consistently accounts for how such support (including online and community-based support) is sought, received, and experienced among trans persons in the context of suicide.

Mishara, B. & Fortin, L. (2021). Long-term effects of a comprehensive police suicide prevention program. Crisis. DOI:10.1027/0227-5910/a000774.
🇨🇦 A follow-up to a 2012 study on a police suicide prevention program in Montreal. The authors found a decrease in suicides in 2012, 12 years after implementation of the program. The present study aimed to ascertain if this trend has continued.

Abstract – Mishara and Martin (2012) reported decreases in suicides 12 years after implementation of a police suicide prevention program. Aims: We aimed to determine whether suicide decreases were sustained 10 years later. Method: We examined coroners’ investigations of police deaths from 2009 through 2018. Results: From 2009 to 2018, Montreal suicide rates increased but this was not significantly different from the previous 12 years and the rate for other Quebec police remained significantly higher than Montreal (p < .006). The 22-year Montreal postprogram rate was significantly lower than the preprogram rate (p < .002), and the 22-year rate for other police during the same years was not significantly different from earlier. Limitations: Uncontrolled factors may have influenced the rates, including the 11% increase in women in the Montreal police. The observed mean aging of the Montreal police personnel would have been expected to bias toward finding increases in suicides. However, the maintenance of decreases in suicide rates was observed. Conclusion: The decrease in suicides observed 12 years after the program was sustained for another 10 years, and appears related to the program. Rates for comparable police remained higher. A continuing comprehensive suicide prevention program tailored to the context may reduce suicides for extended time periods.

Ferguson, M., et al. (2021). The effectiveness of the safety planning intervention for adults experiencing suicide-related distress: A systematic review. Archives of Suicide. DOI:10.1080/13811118.2021.1915217
A systematic review of 26 studies examining the effectiveness of Stanley and Brown’s Safety Planning Intervention (SPI) in the mitigation of suicide-related thoughts and behaviours.

Abstract – The safety planning intervention (SPI) is gaining momentum in suicide prevention practice and research. This systematic review sought to determine the effectiveness of the SPI for adults experiencing suicide-related distress. Systematic searches of international, peer-reviewed literature were conducted in six databases (Cochrane Trials, Embase, Emcare, Medline, PsycINFO and Web of Science), including terms for safety planning, suicide, and suicide-related outcomes. A total of 565 results were included for screening. Result screening (title/abstract and full-text), data extraction and critical appraisal were conducted in duplicate. Twenty-six studies met the inclusion criteria. Studies were primarily quantitative (n = 20), largely with general adult or veteran samples; a small number of studies explored the perspectives of staff and significant others. Half of the studies included the SPI as a standalone intervention, while the other half examined the SPI in combination with other interventions. Most interventions were delivered in-person, with a hard-copy safety plan created, while a smaller number explored internet-based interventions. Primary measures included: suicidality (ideation, behavior, deaths; 10 studies), suicide-related outcomes (depression, hopelessness; 5 studies) and treatment outcomes (hospitalizations, treatment engagement; 7 studies). The evidence supports improvements in each of these domains, with complementary findings from the remaining quantitative and qualitative studies suggesting that the SPI is a feasible and acceptable intervention. While positive, these findings are limited by the heterogeneity of interventions and study designs, making the specific impact of the SPI difficult to both determine and generalize. Conversely, this also points to the flexibility of the SPI.

Ferguson, M., et al. (2021). Staff perspectives of safety planning as a suicide prevention intervention for people of refugee and asylum-seeker background: A qualitative investigation. Crisis: The Journal of Crisis Intervention and Suicide Prevention. DOI:10.1027/0227-5910/a000781
An examination of safety planning as an appropriate intervention for those experiencing suicidal thoughts or behaviours and have a refugee or asylum-seeker background.

Abstract – Background: Safety planning involves the co-development of a personalized list of coping strategies to prevent a suicide crisis. Aims: We explored the perspectives of workers regarding safety planning as a suicide prevention strategy for people of refugee background and those seeking asylum in Australia. Method: Participants attended suicide prevention training, specific to refugees and asylum seekers, at which safety planning was a key component. Semistructured, posttraining interviews (n = 12) were analyzed thematically. Results: Four key themes were identified: safety planning as a co-created, personalized activity for the client; therapeutic benefits of developing a safety plan; barriers to engaging in safety planning; strategies to enhance safety planning engagement. Limitations: First-hand refugee and asylum-seeker experiences were not included. Conclusion: As a relatively low-cost, flexible intervention, safety planning may be valuable and effective for these groups.

Gusmao, R., et al. (2021). Suicide time-series structural change analysis in Portugal (1913-2018): Impact of register bias on suicide trends. Journal of Affective Disorders. DOI:10.1016/j.jad.2021.04.048
An analysis of suicide and other causes of death in Portugal over a hundred-year time span.

Abstract – Background: Suicide is a potentially preventable cause of death. Epidemiology might help to identify death determinants and to monitor prevention strategies. Few studies address secular trends in suicide deaths, and even fewer describe trend-changes in relation to data collection/registration bias. Moreover, suicide is admittedly underreported. It is crucial to validate results in the context of other external causes of death trends, such as unintentional and undetermined intent deaths. We aimed to explore trends in suicide and other external causes of death in Portugal from the inception of registries until 2018, considering breaks in series. Methods: We collected data from all available official primary sources. We calculated cause-specific age-standardized death rates (SDR) by sex for ages equal or higher than 15 years with reference to the European Standard Population. We considered suicide (S), undetermined intent deaths (UnD), accidents (Accs), and all causes of death (ttMty). A time-series structural analysis was executed. Results: Suicide and other external causes of death rates were consistently higher in males than females. A global decline of deaths by suicide, undetermined intention and unintentional is observable. Breakpoints in years 1930, 1954, 1982, 2000-2001 were associated with major changes in deaths registration procedures or methodology. Conclusions: The epidemiology of suicide in Portugal has changed over 106 years. However, adjusted data and consideration of bias reduce trends fluctuation. Trend changes are akin to specific changes in methodology of death registry. Suicide surveillance will improve with more reliable and stable procedures.

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