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

Subscribe to receive the research roundup straight to your inbox!

🇨🇦 Barry, R. et al. (2022). Rurality as a risk factor for attempted suicide and death by suicide in Ontario, Canada. Canadian Journal of Psychiatry, 67(9).

This study examines rurality as a risk factor for attempted suicide and suicidal death. Data were captured from Ontario hospital and emergency department visits in the years 2007- 2017.

Abstract – This study aims to examine rural and urban differences in attempted suicide and death by suicide in Ontario, Canada. Method: This is a population-based nested case-control study. Data were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario between 2007 and 2017. All adults living in Ontario who attempted suicide or died by suicide are included in the study, and controls were matched by sex and age. Suicides were captured using vital statistics. Suicide attempts were determined using emergency department service codes. Results: Rurality is a risk factor for attempted suicide and death by suicide. Rural males are more likely to die by suicide compared with urban males (adjusted odds ratio(AOR) = 1.70, 95% confidence interval (CI), 1.49 to 1.95), and the odds of death by suicide increase with increasing levels of rurality. Rural males and females have an increased risk of attempted suicide compared with their urban counterparts (males: AOR = 1.37, 95% CI, 1.24 to 1.50) (females: AOR = 1.26, 95% CI,  1.14 to 1.39), with a pattern of increasing risk of suicide attempts with increasing rurality. Rural females are not at increased risk of suicide compared with urban females (AOR = 1.08, 95% CI, 0.80 to 1.45). Sensitivity analyses corroborated the results. Conclusions: Rural males are almost two times more likely to die by suicide compared with urban males, and both rural males and females have an elevated risk of suicide attempts compared with urban residents. Future research should examine potential mediators of the relationship between rurality and suicide.

Chang, C.J. et al. (2022). Greater minority stress is associated with lower intentions to disclose suicidal thoughts among LGBTQ+ youth. Archives of Suicide Research,26(2), 626-640.

LGBTQ+ youth aged 12-24 were surveyed to determine associations between level of minority stress and disclosure of suicidal ideation.

Abstract – Objective: The current study examined suicide-related disclosure intentions in LGBTQ + youth, and the associations between reporting of lifetime experiences of minority stress and intentions to disclose suicidal thoughts. Method: A sample of 592 LGBTQ + youth ages 12–24 (22.3% cisgender men, 33.1% cisgender women, 44.6% gender diverse, 75.3% white) who contacted an LGBTQ-specific crisis service, completed a survey. Results: Youth reported highest intentions to disclose future suicidal ideation to LGBTQ-specific crisis services, a mental health professional, and someone they know who also identifies as LGBTQ. They reported lowest suicide-related disclosure intentions to family, spiritual counselors, and emergency room personnel. Greater lifetime minority stress was significantly associated with lower suicide-related disclosure intentions. When specific domains of minority stress were examined separately, five domains were significantly associated with lower suicide-related disclosure intentions: identity management, family rejection, homonegative communication, negative expectancies, and internalized homonegativity. However, only internalized homonegativity remained significant when they were examined simultaneously. In addition, greater lifetime minority stress was significantly associated with lower suicide-related disclosure intentions to some groups (e.g., family, friends), but not others (e.g., others who have thought about or attempted suicide, others who identify as LGBT). Conclusions: Minority stress may play an important role in LGBTQ + youth’s suicide-related disclosure intentions. As such, reducing minority stress and its effects may be an important target to promote disclosure of suicidal thoughts and access to treatment among LGBTQ + youth.

Ferguson, M. et al. (2022). The effectiveness of the safety planning intervention for adults experiencing suicide-related distress: A systematic review. Archives of Suicide Research, 26(3), 1022-1045.

26 studies of the safety planning intervention were examined for effectiveness among adults experiencing suicide-related distress.

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.

🇨🇦 Fuller-Thomson, E. et al. (2022). The dark side of ADHD: Factors associated with suicide attempts among those with ADHD in a national representative Canadian sample. Archives of Suicide Research,26 (3), 1122-1140.

Data from the Canadian Community Health Survey were used to correlate suicide attempt factors with those associated with attention deficit hyperactivity disorder (ADHD).

Abstract – Aim: This study investigated the prevalence and odds of suicide attempts among adults with attention deficit hyperactivity disorder (ADHD) compared to those without and identified factors associated with suicide attempts among adults with ADHD. Methods: Secondary analysis of the nationally representative Canadian Community Health Survey–Mental Health (CCHS-MH) (n = 21,744 adults, of whom 529 had ADHD). Respondents were asked whether they received an ADHD diagnosis from a health care professional. Lifetime suicide attempt was based on self-report. Results: Adults with ADHD were much more likely to have attempted suicide than those without (14.0% vs. 2.7%). One in four women with ADHD have attempted suicide. Sixty percent of the association between ADHD and attempted suicide was attenuated when lifetime history of depression and anxiety disorders were taken into account. Female gender, lower education attainment, substance abuse, lifetime history of depression, and childhood exposure to chronic parental domestic violence were found to be independent correlates of lifetime suicide attempts among those with ADHD. Conclusion: These findings can inform targeted screening and outreach to the most vulnerable adults with ADHD.

🇨🇦 Cuperfain, A.B. et al. (2022). A qualitative analysis of suicide notes to understand suicidality in older adults. The American Journal of Geriatric Psychiatry.

This is a qualitative study of older adults who have died by suicide between 2003 and 2009. The content of their suicide notes, obtained from the Office of Chief Coroner for Ontario, are analyzed.

Abstract – Objective: Suicide is a complex multifactorial process influenced by a variety of biological, psychological, and social stressors. Many older adults face a characteristic set of challenges that predispose them to suicidal ideation, suicide-related behavior, and death by suicide. This study explored the subjective experience of suicidality through the analysis of suicide notes from older adults.
Design: Qualitative study analyzing written suicide notes. Setting: Written notes for suicide deaths in Toronto, Canada, between 2003 and 2009 were obtained from the Office of the Chief Coroner for Ontario. Participants: The analysis comprised 29 suicide notes (mean words per note: 221; range: 6–1095) written by individuals 65 years and older (mean ± SD age: 76.2 ± 8.3). Measurements: We employed a constructivist grounded theory framework for the analysis, conducted through line-by-line open coding, axial coding, and theorizing of data to establish themes. Results: Suicide notes elucidated the writers’ conception of suicide and their emotional responses to stressors. Expressed narratives contributing to suicide centered on burdensomeness or guilt, experiences of mental illness, loneliness or isolation, and poor physical health or disability. Terms related to pain, poor sleep, apology, and inability to go on were recurrent. Conclusions: Suicide notes enrich our understanding of the thoughts and emotions of those at highest risk of suicide, and they inform potential interventions for reducing suicide risk in older adults.

Phalp, L. et al. (2022). An exploration of the relationship between adverse events on the farm and suicidal ideation in farmers. International Journal of Social Psychiatry, 68(8), 1682– 1688.

A study of the relationship between adverse farming events and farmer suicidal ideation was undertaken between July 2018 and February 2019. A questionnaire was disseminated among adult farmers.

Abstract – Background: The risk of suicide for agricultural workers in parts of the United Kingdom (UK) is almost twice the national average. Existing literature has suggested that adverse farming events, where failure is  determined by uncontrollable and unpredictable forces, may be to blame. Yet, the impact of such events on farmer suicidality has not been explicitly explored. Aims: The present paper therefore aimed to investigate the relationship between adverse farming events and suicidal ideation in farmers. Methods: A cross-sectional questionnaire battery was disseminated between July 2018 and February 2019, and completed by 170 adult farmers. Results: Over a 12-month period, 88.8% reported that they had experienced an adverse farming event and 32.9% said that they had experienced suicidal thoughts. Correlational analysis revealed a relationship between these variables. Conclusions: The high prevalence of suicidal ideation within farmers demonstrates a critical need for intervention. Likewise, the prevalence of adverse farming events suggests that interventions need to be appropriately tailored, with greater understanding about the impact of such events on the mental wellbeing of farmers.

Polanco-Roman, L. et al. (2022). Racial/ethnic discrimination and suicide-related risk in a treatment-seeking group of ethnoracially minoritized adolescents. Clinical Child Psychology and Psychiatry.

In this study, The Youth Risk Behavior Surveillance survey is used to measure suicide and suicidal behaviours among ethno-racially minoritized youth in the United States.

Abstract – Introduction and aims: Despite growing evidence demonstrating the negative mental health effects of racism-related experiences, racial/ethnic discrimination is seldom examined in youth suicide risk. The present study tested the association between racial/ethnic discrimination and well-supported correlates of suicide-related risk including emotion reactivity and dysregulation, and severity of psychiatric symptoms in a sample of ethnoracially minoritized adolescents receiving outpatient psychiatric services. Methods: Participants were adolescents (N = 46; 80.4% female; 65.2% Latinx) who ranged in age from 13-20 years old (M=15.42; SD=1.83) recruited from a child outpatient psychiatry clinic in a low-resourced community in Northeast US. Youth completed a clinical interview and a battery of surveys. Results: Findings from separate linear regression models show that increases in frequency of racial/ethnic discrimination were associated with increases in severity of suicidal ideation (SI), independent of emotion reactivity and dysregulation, and symptoms of PTSD and depression. Discriminatory experiences involving personal insults, witnessing family being discriminated, and school-based contexts were uniquely associated with SI. Discussion and conclusion: Preliminary findings support the association between racial/ethnic discrimination and increased severity of suicide-related risk in ethnoracially minoritized adolescents. Accounting for racial/ethnic discrimination may improve the cultural responsiveness of youth suicide prevention strategies within outpatient psychiatric care.

🇨🇦 Chartrand, H. et al. (2022). A longitudinal study of correlates, discharge disposition, and rate of re-presentation to emergency services of adults who engage in non-suicidal self-injury. Archives of Suicide Research, 26(3), 1141-1158.

The distinctions between non-suicidal self-injury (NSSI) and suicide attempts (SA) are examined using data culled from adult psychiatric services emergency departments in Winnipeg. In total, there were 4772 ER presentations used from 2009-2012.

Abstract – Objective: In DSM-5, non-suicidal self-injury (NSSI) and suicide attempts (SA) are classified as distinct disorders in the section of conditions for further study. However, some have questioned the validity of distinguishing NSSI from SA. The objective of this study was to longitudinally examine the correlates, discharge disposition, and rate of re-presentation to emergency services of adults who engaged in NSSI and compare them to (a) adults who engage in SA and (b) adults with no self-harm or suicidal ideation (SI). Method: Data came from 4,772 presentations to adult psychiatric services in the emergency departments of tertiary care hospitals in Winnipeg, Canada between January 2009 and June 2012. Chart reviews were conducted for all presentations with NSSI (n = 158), and a sample of those with SA (n = 172) and no SH or SI (n = 173). Results: Among the adults who returned to emergency services, those who originally presented with SA re-presented significantly sooner than those who presented with NSSI. (χ2(1) = 7.457, p = 0.006). Those who originally presented with NSSI that returned to hospital did not return with repeat NSSI, but instead the majority re-presented with suicidal thoughts and SA. Further, those who re-presented with NSSI and SA were less likely to be hospitalized or to receive a referral to mental health services, and more likely to be discharged to usual care at time of initial presentation. Conclusions: Overall, these findings indicate a trajectory of escalation of self-harm behavior for certain people who engage in NSSI, especially those who re-present to emergency services.

Niederkrotenthaler, T. et al. (2022). Association of 7 million+ tweets featuring suicide-related content with daily calls to the Suicide Prevention Lifeline and with suicides, United States, 2016–2018. Australian & New Zealand Journal of Psychiatry.

The authors sought to see an association between suicide-related tweets with calls to the Suicide Prevention Lifeline and suicide deaths in the 2016-2018 time period.

Abstract – Objective: The aim of this study was to assess associations of various content areas of Twitter posts with help-seeking from the US National Suicide Prevention Lifeline (Lifeline) and with suicides. Methods: We retrieved 7,150,610 suicide-related tweets geolocated to the United States and posted between 1 January 2016 and 31 December 2018. Using a specially devised machine-learning approach, we categorized posts into content about prevention, suicide awareness, personal suicidal ideation without coping, personal coping and recovery, suicide cases and other. We then applied seasonal autoregressive integrated moving average analyses to assess associations of tweet categories with daily calls to the US National Suicide Prevention Lifeline (Lifeline) and suicides on the same day. We hypothesized that coping-related and prevention-related tweets are associated with greater help-seeking and potentially fewer suicides. Results: The percentage of posts per category was 15.4% (standard deviation: 7.6%) for awareness, 13.8% (standard deviation: 9.4%) for prevention, 12.3% (standard deviation: 9.1%) for suicide cases, 2.4% (standard deviation: 2.1%) for suicidal ideation without coping and 0.8% (standard deviation: 1.7%) for coping posts. Tweets about prevention were positively associated with Lifeline calls (B = 1.94, SE = 0.73, p = 0.008) and negatively associated with suicides (B = −0.11, standard error = 0.05, p = 0.038). Total number of tweets were negatively associated with calls (B = −0.01, standard error  = 0.0003, p = 0.007) and positively associated with suicide, (B = 6.4 × 10−5, standard error  = 2.6 × 10−5, p = 0.015). Conclusion: This is the first large-scale study to suggest that daily volume of specific suicide-prevention-related social media content on Twitter corresponds to higher daily levels of help-seeking behaviour and lower daily number of suicide deaths.

🇨🇦 Flannigan, K. et al. (2022). Fetal alcohol spectrum disorder and suicidality: What does the literature tell us? Journal of Mental Health Research in Intellectual Disabilities, 15(3), 217-252.

There is not a huge amount of research among individuals with fetal alcohol spectrum disorder (FASD) and suicidal behaviours. However, this a Canadian scoping review of 28 articles, found in both the academic and grey literature, that do address this issue.

Abstract – Introduction: Limited research has been conducted on suicidality among individuals with FASD. The purpose of this scoping review was to understand (1) how suicidality has been measured; (2) what proportion of individuals experience suicidality across the lifespan; and (3) what contextual factors are associated with suicidality. Method: We conducted a scoping review of the literature on FASD and suicidality. Twenty-eight articles and gray literature sources were included. Results: We identified an elevated risk of suicidal ideation, attempts, and death among individuals with FASD. Most studies were Canadian, published within the last 10 years, and focused on adolescents and adults in clinical settings. Only six studies were specifically designed to examine suicidality in FASD. Conclusion: This review provides a foundational understanding of suicidality in FASD with important implications for research, policy, and practice. Rates of suicidality across the lifespan are high, underscoring the need for evidence-based approaches to screening, prevention, and treatment.

🇨🇦 Sood, M. et al. (2022). Suicide and self-harm among physicians in Ontario, Canada. Canadian Journal of Psychiatry, 67(10).  

Registration data from the College of Physicians and Surgeons of Ontario were used to gauge the risk of suicide and self-harm among physicians as compared to the general population.

Abstract – Background: Studies of occupation-associated suicide suggest physicians may be at a higher risk of suicide compared to nonphysicians. We set out to assess the risk of suicide and self-harm among physicians and compare it to nonphysicians. Methods: We conducted a population-based, retrospective cohort study using registration data from the College of Physicians and Surgeons of Ontario from 1990 to 2016 with a follow-up to 2017, linked to Ontario health administrative databases. Using age- and sex-standardized rates and inverse probability-weighted, cause-specific hazards regression models, we compared rates of suicide, self-harm, and a composite of either event among all newly registered physicians to nonphysician controls. Results: Among 35,989 physicians and 6,585,197 nonphysicians, unadjusted suicide events (0.07% vs. 0.11%) and rates (9.44 vs. 11.55 per 100,000 person-years) were similar. Weighted analyses found a hazard ratio of 1.05 (95% confidence interval: 0.69 to 1.60). Self-harm requiring health care was lower among physicians (0.22% vs. 0.46%; hazard ratio: 0.65, 95% confidence interval: 0.52 to 0.82), as was the composite of suicide or self-harm (hazard ratio: 0.70, 95% confidence interval: 0.57 to 0.86). The composite of suicide or self-harm was associated with a history of a mood or anxiety disorder (odds ratio: 2.84, 95% confidence interval: 1.17 to 6.87), an outpatient mental health visit in the past year (odds ratio: 3.08, 95% confidence interval: 1.34 to 7.10) and psychiatry visit in the preceding year (odds ratio: 3.87, 95% confidence interval: 1.67 to 8.95). Interpretation: Physicians in Ontario are at a similar risk of suicide deaths and a lower risk of self-harm requiring health care relative to nonphysicians. Risk factors associated with suicide or self-harm may help inform prevention programs.

🇨🇦 Varin, M. et al. (2022). Increased alcohol use, heavy episodic drinking, and suicide ideation during the COVID-19 pandemic in Canada. Canadian Journal of Public Health.

This is a study of the Canadian general population during the COVID-19 pandemic. The Survey on COVID-19 and Mental Health 2020 is used to measure levels of alcohol intake and suicidal ideation during this period.

Abstract – Objective: Alcohol use is a known risk factor for suicidality, yet this relationship has not been explored during the pandemic in Canada. As a growing body of evidence demonstrates the negative impact of COVID-19 on alcohol consumption and associated harms in Canada, there is a need to examine this more closely. Methods: Using the Survey on COVID-19 and Mental Health 2020, we compared the prevalence of suicide ideation among: (1) individuals who reported an increase in alcohol consumption vs those who reported a decrease/no change, and (2) individuals who reported past month heavy episodic drinking vs those who did not. We compared overall unadjusted odds ratios and across a number of sociodemographic and mental health variables. All estimates were weighted to ensure they were nationally representative. Results: The prevalence and likelihood of suicide ideation were significantly higher among people who reported increased alcohol consumption during the pandemic (4.9% vs 2.0%; OR = 2.6, 95% CI: 1.8, 3.7) and people who reported past month heavy episodic drinking (3.4% vs 2.1%; OR = 1.7, 95% CI: 1.2, 2.3). Males and middle-aged and older-aged individuals had the highest odds ratios for increased alcohol consumption and past month heavy episodic drinking with suicide ideation. Conclusion: In the Canadian general population during the COVID-19 pandemic, there were significant associations between suicide ideation and increased alcohol use as well as past month heavy episodic drinking across specific sociodemographic subgroups. Future research could explore these associations while adjusting for social determinants of health such as income security, employment, education, social support, stress, and mental health.