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

Hanson, L., et al. (2020). Work related sexual harassment and risk of suicide and suicide attempts: Prospective cohort study. BMJ. DOI: http//
Workplace sexual harassment has an impact on workplace stress and increased depression and anxiety. This Swedish study examines the effects work related sexual harassment has on suicide attempts and suicidal deaths.

Abstract – Objective: To analyze the relation between exposure to workplace sexual harassment and suicide, as well as suicide attempts. Design: Prospective cohort study. Setting: Sweden. Participants: 86,451 men and women of working age in paid work across different occupations responded to a self-report questionnaire including exposure to work related sexual harassment between 1995 and 2013. The analytical sample included 85,205 people with valid data on sexual harassment, follow-up time, and age. Main outcome measures suicide and suicide attempts ascertained from administrative registers (mean follow-up time 13 years). Results: Among the people included in the respective analyses of suicide and suicide attempts, 125 (0.1%) died from suicide and 816 (1%) had a suicide attempt during follow-up (rate 0.1 and 0.8 cases per 1000 person years). Overall, 11 of 4095 participants exposed to workplace sexual harassment and 114 of 81,110 unexposed participants committed suicide, and 61/4043 exposed and 755/80513 unexposed participants had a record of suicide attempt. In Cox regression analyses adjusted for a range of sociodemographic characteristics, workplace sexual harassment was associated with an excess risk of both suicide (hazard ratio 2.82, 95% confidence interval 1.49 to 5.34) and suicide attempts (1.59, 1.21 to 2.08), and risk estimates remained significantly increased after adjustment for baseline health and certain work characteristics. No obvious differences between men and women were found. Conclusions: The results support the hypothesis that workplace sexual harassment is prospectively associated with suicidal behaviour. This suggests that suicide prevention considering the social work environment may be useful. More research is, however, needed to determine causality, risk factors for workplace sexual harassment, and explanations for an association between work related sexual harassment and suicidal behaviour.

Wasserman, D. (2020). Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World Psychiatry, 19, 294-306.
Leading European suicidologist Danuta Wasserman and team advocate long-term universal-selective-indicated suicide prevention strategies, as the effects of the COVID-19 pandemic will linger long after the pandemic has passed. Once the “crisis” phase and a temporary positive societal response during this period have passed, then the economic and mental health fallout may  become apparent and there will be a need for sustained and robust strategies.

Abstract – Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates decrease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and protective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals.  Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which contexts.

Koenig, J., et al. (2020). High-frequency ecological momentary assessment of emotional and interpersonal states preceding and following self-injury in female adolescents. European Child & Adolescent Psychiatry. Published online 29 August 2020.
Female adolescents are among the most represented demographic considering Non-Suicidal Self-Injury (NSSI). This study looks at the assessment taken of female patients before and after their self-injury to help shed light on this phenomenon.

Abstract – Non-suicidal self-injury (NSSI) is a considerable health problem among adolescents. Affect regulation by means of self-injury may promote the maintenance of NSSI. However, existing findings have limited ecological validity. The present study aimed to assess emotional and interpersonal states preceding and following incidents of NSSI in female adolescents. Adolescents with NSSI-disorder completed ecological momentary assessments of affective and interpersonal states on an hourly basis for multiple days. Multilevel mixed-effect regression analyses were conducted to assess antecedences and consequences of acts of self-injury. Data from n = 73 female adolescents covering a total of 52 acts of self-injury were available for analyses. The urge to self-injure on the between subject-level and negative affect on the within-level were best predictors of self-injury. Surprisingly, self-injury increased negative affect and decreased feelings of attachment (mother only) in the following hour. In line with findings in adults, results illustrate the important association between negative affect and self-injury in female adolescents. However, the occurrence of NSSI itself was related to concurrent increases in negative affect, and even prospectively predicted a consecutive increase in negative affect. Therefore, improvements of negative affect following (or during) self-injury, as previously reported, are at best short-lived (< 1 h).

Westers, N.J. (2020). 25 years of suicide research and prevention: How much has changed? Clinical Child Psychology and Psychiatry, 25(4), 729–733.
A commentary by Nicholas Westers who looks at the suicide research and prevention landscape over the last quarter century.  Westers sees improvements in some areas, including public health interventions, restricting access to lethal means and the increased inclusion of lived experience individuals in the suicide prevention conversation.

Abstract – Twenty five years ago the 1995 World Health Report noted that suicide was the second leading cause of death for young people in most countries (second only to accidents), with rates rising more quickly than those of any other age group (World Health Organization, 1995). It was on this backdrop that the first issue of Clinical Child Psychology and Psychiatry (CCPP) was released. It included an appropriately timed paper aiming to increase treatment adherence and follow-up among adolescents presenting to the emergency room for a suicide attempt (Rotheram-Borus, Piacentini, Miller et al., 1996). To this end, the authors developed an intervention program for multidisciplinary staff in the emergency room with later publications showing promising results (Rotheram-Borus, Piacentini, Van Rossem et al., 1996; Rotheram-Borus et al., 2000). Other brief interventions offered in emergency rooms have since been developed, such as the Family Intervention for Suicide Prevention (Asarnow et al., 2009), Therapeutic Assessment (Ougrin et al., 2011), and the Safety Planning Intervention (Stanley et al., 2018).

🇨🇦 Bertrand, L., et al. (2020). Suicidal ideation and insomnia in bipolar disorders. The Canadian Journal of Psychiatry, 65(11), 802-810.
This Canadian study tries to determine if there is a relationship between ideation and insomnia in patients experiencing bipolar disorders. They monitored a cohort of 76 outpatients ranging in age from 18 to 65 over 10 consecutive days.

Abstract – Objective: Bipolar disorder (BD) confers elevated suicide risk and associates with misaligned circadian rhythm. Real-time monitoring of objectively measured sleep is a novel approach to detect and prevent suicidal behavior. The study aimed at understanding associations between subjective insomnia and actigraphy data with severity of suicidal ideation in BDs. Methods: This prospective cohort study comprised 76 outpatients with a BD aged 18 to 65 inclusively. Main measures included 10 consecutive days of wrist actigraphy; the Athens Insomnia Scale (AIS); the Montgomery–Åsberg Depression Rating Scale (MADRS); the Quick Inventory of Depressive Symptoms-16, self-rating (QIDS-SR-16); and the Columbia Suicide Severity Rating Scale. Diagnoses, medications, and suicide attempts were obtained from chart review. Results: Suicidal ideation correlated moderately with subjective insomnia (AIS with QIDS-SR-16 item 12 ρ =0.26, P = 0.03; MADRS item 10 ρ = 0.33, P = 0.003). Graphical sleep patterns showed that suicidal patients were enriched among the most fragmented sleep patterns, and this was confirmed by correlations of suicidal ideation with actigraphy data at 2 visits. Patients with lifetime suicide attempts (n = 8) had more varied objective sleep (a higher standard deviation of center of daily inactivity [0.64 vs. 0.26, P = 0.01], consolidation of daily inactivity [0.18 vs. 0.10, P = <0.001], sleep offset [3.02 hours vs. 1.90 hours, P = <0.001], and total sleep [105 vs. 69 minutes, P = 0.02], and a lower consolidation of daily inactivity [0.65 vs. 0.79, P = 0.03]). Conclusions: Subjective insomnia, a nonstigmatized symptom, can complement suicidality screens. Longer follow-ups and larger samples are warranted to understand whether real-time sleep monitoring predicts suicidal ideation in patient subgroups or individually.

Granek, L. & Nakash, O. (2020). Prevalence and risk factors for suicidality in cancer patients and oncology healthcare professionals strategies in identifying suicide risk in cancer patients. Current Opinion in Supportive and Palliative Care, 14(3), 239-246. DOI: 10.1097/SPC.0000000000000503
Cancer patients are more at risk for suicidal behaviours than the general population. This study recommends suicide prevention training for oncology health care professionals to screen potential suicide risk among their patients.

Abstract – Purpose of review: The aim of this study was to summarize the literature on prevalence and risk factors for suicidality in cancer patients and to document the research on oncology healthcare professionals’ strategies in identifying this risk. Recent findings: Cancer patients exhibit increased risk of suicidality compared with the general population. Various risk factors have been identified including sociodemographic factors such as poverty, being male and elderly as well as disease-related attributes such as cancer type and stage. The literature on how healthcare professionals identify suicide risk is sparse. Ten articles were found that focused on two main themes. These included information on systematic strategies in identifying suicide risk and factors that affect healthcare professionals’ ability to identify risk in their patients. Summary: Although there is an immense amount of literature documenting the problem of suicidality among patients, the research on how healthcare professionals identify and respond to these indications in patients is nearly nonexistent. Cancer centres should implement standardized and systematic screening of cancer patients for suicidality and research on this patient population should collect and report these data. Ongoing training and education for healthcare professionals who work in the oncology setting on how to identify and respond to suicide risk among cancer patients is urgently needed.

Kammer, J., et al. (2020). Most individuals are seen in outpatient medical settings prior to intentional self-harm and suicide attempts treated in a hospital setting. Journal of Behavioral Health Services & Research. 1-13.
This study corroborates other research which states that the majority of those who self-harm or attempt suicide had seen a health care provider within 30 days of their episode and almost all had seen someone in the previous year. This reiterates the need for improved suicide prevention training among primary care providers.

Abstract – The objective of this quantitative retrospective study is to understand healthcare patterns prior to self-harm, which may inform prevention efforts and identify intervention sites. Medicaid claims within 30, 60, 90, and 365 days prior to hospital-treated self-harm between 11/1/2015 and 11/1/2016 in New York State (N = 7492) were examined. Numbers and proportions were calculated for all service types. Participants were predominately 15–34, female, and White. Most (97%) had prior-year services, 94% outpatient care (73% behavioral health, 90% medical), 69% emergency department (37% behavioral health, 59% medical), and 42% inpatient services (34% behavioral health, 20% medical). About 86% received services within 90 days and 80% within 60 days. Utilization was high within 30 days prior, with 69% having one or more services. Medical services were more common than behavioral health (94% versus 79% in prior year); outpatient (94%) was more common than emergency (69%) and inpatient (42%) care. Given that most patients received health services within 30 days and almost all saw providers within the year prior, the findings indicate that improved prevention efforts within the healthcare system can reduce the incidence of self-harm.

🇨🇦 Asikhari, A. (2020). Mental disorders and subsequent suicide events in a representative sample. Journal of Affective Disorders, 277, 456-462.
A Canadian study analyzing data from the Canadian Community Health Survey 2002 in comparison to the Death Database 2000-2011 and the Hospitalization Database 1999/2000-2012/2013 for a cohort figure of 27,000. The authors wanted to see if there were associations between Major Depressive Episodes (MDE, bipolar disorders (BPD), anxiety disorders(AD), substance dependence and subsequent suicide events (deaths or hospitalizations for suicide attempts).

Abstract – Objective: This study examined the patterns of association between mental disorders and subsequent suicide in a community sample representative of the Canadian household population. Methods: This retrospective cohort study used data from the Canadian Community Health Survey 2002 linked to the Death Database 2000-2011 and the Hospitalization Database 1999/2000-2012/2013) (n=27,000). Mental disorders (past year major depressive episodes (MDE), bipolar disorders (BPD), anxiety disorders (AD), and substance dependence (SD)) and subsequent suicide events (deaths or hospitalizations for suicide attempts) were identified. Competing risk regression models were used to analyze the time-to-event data, adjusting for age, sex, marital status, and educational attainment. Results: Past year mental disorders were diagnosed in 11.38% of the cohort and 0.41% had suicide events. An increased hazard of suicide events associated with MDE, SD and AD weakened over-time, but this was not observed for BPD. For example, the HR of suicide events for MDE was 6.02 (95% confidence interval (CI)=2.65, 13.68) in the first 4 years, whereas it was 2.03 (95% CI=0.91, 4.53) after 4 years. Whereas the HRs of suicide events for BPD were 16.95 (95% CI=6.88, 41.75) and 15.81 (95% CI=5.89, 42.45) before and after 4 years.

Bradley, N. (2020). Suicide and dentistry: An unwanted link. British Dental Journal in Practice, 33(10), 20–21.
A commentary from a dentist who has lived experience with suicide. He cites British Dentistry Association research conducted between 1995 and 2011 that showed members of the profession have high levels of stress and burnout in the United Kingdom. The same research showed that 17.6% of dentists admitted to seriously attempting suicide and 77 dentists took their own lives.

AbstractWe have all heard the narrative that dentistry is stressful and we as a group of professionals are at high risk of suicide. There are other occupations who are at higher risk, such as low-skilled male labourers who are three times more at risk than the average male, but the risk of suicide among female health professionals is 24% higher than the female national average. Research by the BDA shows that dentistry is associated with high levels of stress and burnout, with 17.6% of dentists surveyed admitting to have seriously considered committing suicide4 and between 1995 and 2011, 77 dentists died as a result of taking their own lives.

Edwards, T., et al. (2020). Social media responses to online suicide-related news articles. Crisis.
An Australian study of social media adherence to Mindframe’s (Australia’s counterpart to Canada’s Mindset guidelines) responsible suicide reporting guidelines:

Abstract – Background: Responsible media reporting of suicide is important to prevent contagion effects. Online media reporting is increasingly becoming the primary source of news information for many people. Aims: This study aimed to assess compliance with responsible media reporting guidelines, and whether social media responses were associated with compliance. Method: A random sample of Australian digital news articles over a 9-month period were coded for compliance to Mindframe suicide reporting guidelines. Social media responses (number of shares and number of comments) were collected via Facebook. Results: From the sample of 275 articles, articles were compliant with a median of seven of the nine recommendations. Articles compliant with more than seven recommendations were shared more frequently (median: 93 vs. 38 shares, p = .017) but no difference was observed in the number of comments (median: 0 vs. 0, p = .340). Limitations: Other factors associated with individual events and articles are also likely to contribute to the response on social media. Although no difference in the number of comments was observed, the nature of these comments may differ. Conclusion: Improved understanding of how to maximize dissemination of positive messages may help minimize contagion effects.

Watling, D., et al. (2020). Developing an intervention for suicide prevention: A rapid review of lived experience involvement. Archives of Suicide Research. DOI: 10.1080/13811118.2020.1833799
A timely review of a vastly under-represented segment of those involved in suicide prevention—persons with lived experience. The authors look at 11 studies culled from the last ten years.

Abstract – Objective: While suicide prevention interventions should be informed by lived experience, there are no reviews examining involvement of lived experience (LE) thus far. This rapid review aimed to synthesize available studies using LE of suicidality to guide the development of suicide prevention interventions. Method: A rapid review following PRISMA guidelines was conducted. Key electronic databases were searched for the literature for the last 10 years (2010 until June 2019) to identify studies that have incorporated the lived experience of people of suicide to develop a suicide prevention intervention. Key features of the LE intervention development process were synthesized and discussed. Results: A final 11 studies from 13 papers were selected for synthesis. Most studies employed focus groups (73%). Research questions focused on participant preferences, experiences, and recommendations for suicide prevention interventions. Considering the qualitative nature, majority of studies used thematic analyses to study participant responses and generate intervention components based on identified themes. Translation from research findings into a physical intervention was described in limited detail across all studies. The rapid review was limited to the literature about development of interventions using LE of suicide published in English in last 10 years. Conclusions: With an increased focus on person-centered care and LE insuicide prevention, such valuable expertise should be integrated into intervention development. This review provides insight into the process to ensure responses to suicidal persons are well aligned with the needs of those they serve.

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