Research Roundup – October 2023
This is a summary of the latest significant Canadian (
) and international suicide research we collected in the past month.
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Cusimano, M.D. et al. (2023). An interrupted time series evaluation of the effect of cannabis legalization on intentional self-harm in two Canadian provinces: Ontario and Alberta. Health Promotion and Chronic Disease Prevention in Canada. 43(9), 403-408. https://doi.org/10.24095/hpcdp.43.9.02
This is a study to determine whether the legalization of cannabis has had an effect on self-harming behaviours in Canada. Alberta and Ontario ER visits and hospitalizations for self-harm were analyzed from 2010 to 2020.
Abstract – Introduction: Despite the association between cannabis use and higher prevalence of suicidal ideation and attempt, the effect of cannabis legalization and regulation in Canada on intentional self-harm has not been determined. Methods: We used an interrupted time series of population-based rates of emergency department (ED) visits and hospitalizations for intentional self-harm per 100 000 in Ontario and Alberta from January/April 2010 to February 2020. Aggregate monthly counts of ED visits and hospitalizations for intentional self-harm (ICD-10 codes X60-X84, R45.8) were obtained from the National Ambulatory Care Reporting System and Discharge Abstract Database, respectively. Results: The legalization and regulation of cannabis in Canada was not significantly associated with a change in rates of ED visits for intentional self-harm in Ontario (level = 0.58, 95% CI: -1.14 to 2.31; trend = -0.17, 95% CI: -0.35 to 0.01) or Alberta (level = -0.06, 95% CI: -2.25 to 2.12; trend = -0.07, 95% CI: -0.27 to 0.13). Hospitalizations for intentional self-harm also remained unchanged in Ontario (level = -0.14, 95% CI: -0.48 to 0.20; trend = 0.01, 95% CI: -0.03 to 0.04) and Alberta (level = -0.41, 95% CI: -1.03 to 0.21; trend = -0.03, 95% CI: -0.08 to 0.03). Conclusion: Legalization and regulation of cannabis in Canada has not increased rates of ED visits or hospitalizations for intentional self-harm in Ontario and Alberta. Individual-level analyses that account for demographic characteristics and include other provinces and territories are needed.
Mitchell, R.H.B. et al. (2023). Self-harm among youth during the first 28 months of the COVID-19 pandemic in Ontario, Canada: A population-based study. Canadian Medical Association Journal. 195, E1210-20. https://doi.org/10.1503/cmaj.230127
The rates of self-harming behaviours among youth during the COVID-19 pandemic is the focus of this study. The authors aim to gauge whether ER visitations and hospitalizations increased.
Abstract – Background: Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use. Methods: We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10–17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10–13 yr and 14–17 yr), sex and mental health service use (new and continuing). Results: In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19–1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46–2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10–13 years and those aged 14–17 years, as well as for both those new to the mental health system and those already engaged in care. Interpretation: Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population.
Liu, L. et al. (2023). Suicidality and protective factors among sexual and gender minority youth and adults in Canada: A cross‑sectional, population‑based study. BMC Public Health. https://doi.org/10.1186/s12889-023-16285-4
Data were culled from the Canadian Community Health Surveys from 2015, 2016 and 2019 to estimate the prevalence of suicidal behaviours and protective factors among youth and adult sexual minority populations. Estimates in the changes in the prevalence of suicidal ideation and protective factors were also made in the fall of 2020 and compared with the same period in the pre-pandemic. Ultimately, these data were compared to youth and adults in the heterosexual population.
Abstract – Background: Sexual and gender minority populations experience elevated risks for suicidality. This study aimed to assess prevalence and disparities in non-fatal suicidality and potential protective factors related to social support and health care access among sexual and gender minority youth and adults and their heterosexual and cisgender counterparts in Canada. The second objective was to examine changes in the prevalence of suicidal ideation and protective factors during the COVID-19 pandemic. Methods: Pooled data from the 2015, 2016 and 2019 Canadian Community Health Surveys were used to estimate pre-pandemic prevalence of suicidal ideation, plans and attempts, and protective factors. The study also estimated changes in the prevalence of recent suicidal ideation and protective factors in fall 2020, compared with the same period pre-pandemic. Results: The prevalence of suicidality was higher among the sexual minority populations compared with the heterosexual population, and the prevalence was highest among the bisexual population, regardless of sex or age group. The pre-pandemic prevalence of recent suicidal ideation was 14.0% for the bisexual population, 5.2% for the gay/lesbian population, and 2.4% for the heterosexual population. The prevalence of lifetime suicide attempts was 16.6%, 8.6%, and 2.8% respectively. More than 40% of sexual minority populations aged 15–44 years had lifetime suicidal ideation; 64.3% and 36.5% of the gender minority population had lifetime suicidal ideation and suicide attempts. Sexual and gender minority populations had a lower prevalence of protective factors related to social support and health care access. The prevalence of recent suicidal ideation among sexual and gender minority populations increased in fall 2020, and they tended to experience longer wait times for immediate care needed. Conclusions: Sexual and gender minority populations had a higher prevalence of suicidality and less social support and health care access compared to the heterosexual and cisgender populations. The pandemic was associated with increased suicidal ideation and limited access to care for these groups. Public health interventions that target modifiable protective factors may help decrease suicidality and reduce health disparities.
Molitor, D. et al. (2023). Air pollution and suicide in rural and urban America: Evidence from wildfire smoke. PNAS. https://doi.org/10.1073/pnas.2221621120
This is a timely piece examining air pollution from wildfire smoke and its relationship with suicide in both rural and urban America.
Abstract – Air pollution poses well-established risks to physical health, but little is known about its effects on mental health. We study the relationship between wildfire smoke exposure and suicide risk in the United States in 2007 to 2019 using data on all deaths by suicide and satellite-based measures of wildfire smoke and ambient fine particulate matter (PM2.5) concentrations. We identify the causal effects of wildfire smoke pollution on suicide by relating year-over-year fluctuations in county-level monthly smoke exposure to fluctuations in suicide rates and compare the effects across local areas and demographic groups that differ considerably in their baseline suicide risk. In rural counties, an additional day of smoke increases monthly mean PM2.5 by 0.41 μg/m3 and suicide deaths by 0.11 per million residents, such that a 1-μg/m3 (13%) increase in monthly wildfire-derived fine particulate matter leads to 0.27 additional suicide deaths per million residents (a 2.0% increase). These effects are concentrated among demographic groups with both high baseline suicide risk and high exposure to outdoor air: men, working-age adults, non-Hispanic Whites, and adults with no college education. By contrast, we find no evidence that smoke pollution increases suicide risk among any urban demographic group. This study provides large-scale evidence that air pollution elevates the risk of suicide, disproportionately so among rural populations.
Kenneally, L. et al. (2023). Pilot randomized controlled trial of a brief strategy to prevent suicide after discharge from residential addiction treatment. Journal of Substance Use and Addiction Treatment. https://doi.org/10.1016/j.josat.2023.209156
This is a pilot trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC). Veterans who were patients at the residential recovery centre SUD (substance use disorder) 28-day program and were deemed at risk for suicide participated.
Abstract – Introduction: Veterans are at greater risk for suicide and veterans with substance use disorder (SUD) have an even greater risk. Little research has looked into brief interventions to prevent suicide in this population in residential substance use treatment programs. Method: We conducted a pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients participating in the Residential Recovery Center (RRC) SUD 28-day program and deemed at risk for suicide. We measured changes in symptoms at 1-, 3-, and 6-months. We looked at social connectedness, suicidal ideation, hopelessness, thwarted belongingness, perceived burdensomeness, and treatment engagement. Results: The study enrolled twenty patients. One participant withdrew immediately after baseline. We found that adherence to VA BIC components was high, as 100 % of patients (N = 10) completed 70 % or more of the VA BIC visits. Furthermore, 80 % of intervention group patients (N = 8) completed all VA BIC components. During the six-month follow-up, suicidal ideation improved in patients assigned to VA BIC, while it worsened in the standard care arm. Similarly, patients assigned to VA BIC reported a reduction in perceived burdensomeness over the six-month follow-up period while it worsened in the standard care arm. Additionally, VA BIC may modestly improve treatment engagement in the first month post discharge. Conclusion: We were able to recruit and enroll patients from a residential SUD treatment program into a clinical trial of the VA BIC intervention. Our preliminary results suggest that VA BIC may be useful in reducing suicidal ideation and perceived burdensomeness in patients who are discharged from residential SUD treatment programs and increasing treatment engagement. Future trials of VA BIC should determine whether VA BIC can reduce the risk of suicide in patients who are discharged from residential SUD treatment programs.
Hunter, S. et al. (2023). The association between social fragmentation and deaths attributable to alcohol, drug use, and suicide: Longitudinal evidence from a population-based sample of Canadian adults. Preventive Medicine. https://doi.org/10.1016/j.ypmed.2023.107688
Deaths of despair, those attributed to alcohol use, drug use or suicide, were examined in relation to social fragmentation (defined as low integration at the community level). Data from the Canadian Vital Statistics Database and Canadian Census Health and Environment Cohorts were used.
Abstract – Background: Social fragmentation has been theorized and empirically associated with suicide in prior research. However, less is known about whether social fragmentation is associated with deaths attributed to alcohol use or drug use. This research examined the association between social fragmentation and risk for deaths attributable to alcohol use, drug use, and suicide (collectively known as deaths of despair) among Canadian adults. Methods: A weighted sample representing 15,324,645 Canadians within 288 census divisions between 2006 and 2019 was used. Mortality data from the Canadian Vital Statistics Database (alcoholic liver disease, drug use, and suicide) was linked with census division socioeconomic data from the 2006 Canadian census using the Canadian Census Health and Environment Cohorts. Social fragmentation at the census division was created based on the Congdon Index. Cox-proportional hazard regression with survey weights and the sandwich estimator were used to account for clustering of individuals (level-1) nested within census divisions (level-2).+ Results: After adjusting for individual and census division confounders, social fragmentation was positively associated with all-cause mortality (HR = 1.04; 95% CI: 1.02, 1.07), suicide (HR = 1.09; 95%CI: 1.01, 1.18), drug overdose related mortality (HR = 1.13; 95%CI: 1.03, 1.24), and deaths of despair (HR = 1.10; 95% CI: 1.04, 1.16), and not significantly associated with alcohol related liver disease (HR = 1.06; 95% CI: 0.91, 1.23). Conclusion: Social fragmentation is associated with an increased hazard of deaths of despair among Canadian adults. Efforts to improve social cohesion in areas that are highly socially fragmented need to be evaluated.
Montiel, C. & Mishara, B.L. (2023). A qualitative study of factors involved in the helping behaviors of suicide prevention gatekeepers. Death Studies. https://doi.org/10.1080/07481187.2023.2246018
The Quebec gatekeeper program is a training for community members to adequately identify individuals at-risk for suicide and refer them to resources for help. Participants trained in this program were studied to explore their capacity to engage in the identification and support of people at risk of suicide.
Abstract – This study explores the factors involved in the capacity of newly trained suicide prevention gatekeepers to engage in the identification and support of people at risk of suicide. In-depth telephone interviews were conducted with 18 gatekeepers from various settings who had participated in a larger quantitative study of the impact of gatekeeper training. Conventional content analysis was performed on the data collected. Participants said that gatekeeper training provided key information and legitimized their role. Previous experience with suicidal friends and family members motivated their involvement and helped them to engage with at-risk individuals. Support available from the setting, including attitudes toward suicide, resources for referrals and promotion of the gatekeeper activities, were instrumental in gatekeepers’ ability to fulfill their role. Gatekeeper programs may benefit from adopting a comprehensive approach to gatekeeper helping behaviors by attending to their contextual influences, and the effects of gatekeepers’ personal experiences.
Inostroza, C. et al. (2023). Peer-support groups for suicide loss survivors: A systematic review. Social Work with Groups. https://doi.org/10.1080/01609513.2023.2249053
A systematic review of peer-support group programs for those who have lost someone to suicide was undertaken. 12 quantitative and 2 qualitative studies were selected to examine the effectiveness of these groups among suicide loss survivors.
Abstract – Despite the increase in research on suicide bereavement, the effectiveness of peer-support group programs in promoting the grief process and mental health of suicide loss survivors remains unclear. The goal of our study was to determine the effectiveness of peer-support group programs for suicide loss survivors. A systematic review (PROSPERO ID: CRD42022307591) of articles published from January 2000 to December 2021 was applied in the databases PubMed, Web of Science, Scopus, and SciELO. Articles written in English, Spanish, or Portuguese with full text availability were included in this review to perform a narrative synthesis of the results and a bias analysis. 12 qualitative and two quantitative studies, were selected. No evidence of efficacy in reducing suicidal behavior was found. Qualitative studies highlighted that these types of groups provide social support, enabling individuals to cope with grief and mitigating psychological discomfort. In conclusion, from evidence-based medicine, results on peer-support groups for suicide loss survivors has a low level of certainty and an insufficient grade of recommendation. Nevertheless, qualitative studies indicate the potential benefits of these programs. The prevailing use of qualitative methodologies accounts for a participatory and subjective epistemology, typical of community programs such as peer-support programs. Finally, both quantitative and qualitative perspectives are necessary for the integration and validation of mutual support groups for suicide survivors in public mental health services.
Mirick, R.G. & Berkowitz, L. (2023). After a suicide death in a high school: Exploring students’ perspectives. Journal of Social Work in End-of-Life & Palliative Care. https://doi.org/10.1080/15524256.2023.2256481
A qualitative study of the experiences of high school students surrounding grief and loss following a suicidal death at school.
Abstract – By the time they leave high school, 17% of adolescents will have experienced the suicide death of a friend, peer, or classmate. While some will be unaffected or experience a brief period of distress following the death, for others the death will cause significant disruption and distress, even increasing their risk of suicidal thoughts and behaviors. It is essential for social workers to be able to support at-risk adolescents after this type of loss. To do this, it is critical to understand the ways that adolescents experience the death, grieve, and recover from the loss. This qualitative study explored adolescents’ experiences with grief and loss following an adolescent suicide death in the United States. Thematic analysis of semi-structured interviews with young adults (N = 13) who had been exposed to the suicide death of a peer, classmate, or friend while in high school examined themes about their processing of the death, yielding four themes about sense-making and making meaning about the death. Implications for social workers, schools, and suicide postvention researchers are identified and discussed.
Mergler, D. et al. (2023). The contribution across three generations of mercury exposure to attempted suicide among children and youth in Grassy Narrow First Nation, Canada: An integrational analysis. Environmental Health Perspective, 131(7). https://doi.org/10.1289/EHP11301
The people of Grassy Narrows First Nation in Ontario, Canada experienced mercury contamination in their river systems in the 1970s. This study is to determine whether this environmental catastrophe has had an effect on the frequency of attempted suicide among children and youth of Grassy Narrows across three subsequent generations.
Abstract – BACKGROUND: For 60 y, the people of Asubpeeschoseewagong Anishinabek (Grassy Narrows First Nation) have endured the effects of massive mercury (Hg) contamination of their river system, central to their traditions, culture, livelihood, and diet. In the years following the Hg discharge into the English–Wabigoon River system by a chloralkali plant in the early 1970s, there was a dramatic increase in youth suicides. Several authors attributed this increase solely to social disruption caused by the disaster. OBJECTIVE: This research examined the possible contribution of Hg exposure across three generations on attempted suicides among today’s children (5–11 y old) and youth (12–17 y old), using a matrilineal intergenerational paradigm. METHODS: Information from the 2016–2017 Grassy Narrows Community Health Assessment (GN-CHA) survey was merged with Hg biomonitoring data from government surveillance programs (1970–1997). Data from 162 children/youth (5–17 years of age), whose mothers (n= 80) had provided information on themselves, their parents, and children, were retained for analyses. Direct and indirect indicators of Hg exposure included a) grandfather had worked as a fishing guide, and b) mother’s measured and estimated umbilical cord blood and childhood hair Hg and her fish consumption during pregnancy with this child. Structural equation modeling (SEM) was used to examine significant links from grandparents (G0) to mothers’ exposure and mental health (G1) and children/youth (G2) risk for attempted suicide. RESULTS: Mothers’ (G1) median age was 33 y, 86.3% of grandmothers (G0) had lived in Grassy Narrows territory during their pregnancy, and 52.5% of grandfathers (G0) had worked as fishing guides. Sixty percent of children (G2) were <12 years of age Mothers reported that among teenagers (G2: 12–17 years of age), 41.2% of girls and 10.7% of boys had ever attempted suicide. The SEM suggested two pathways that significantly linked grandparents (G0) to children’s (G2) attempted suicides: a) through mothers’ (G1) prenatal and childhood Hg exposure and psychological distress, and b) through maternal fish consumption during pregnancy (G1/G2), which is an important contributor to children’s emotional state and behavior. DISCUSSION: Despite minimal individual information on G0 and G1 past life experiences, the findings support the hypothesis that Hg exposure over three generations contributes to the mental health of today’s children and youth. The prevalence of Grassy Narrows youth ever having attempted suicide is three times that of other First Nations in Canada.
Arendt, F. et al. (2023). ChatGPT, artificial intelligence, and suicide prevention: A call for targeted and concentrated research effort. Crisis. https://doi.org/10.1027/0227-5910/a000915
This commentary makes the assertion that more robust research is needed to address ChatGPT and AI within the scope of suicide prevention.
Abstract – There is an ever-increasing speed in digital transformation, including health communication and healthcare. ChatGPT is one of the most recent milestones in this regard, having been introduced to the public by OpenAI in November 2022. Although ChatGPT is still under development, it is likely that we will face a widespread rollout of such tools during the next few years. ChatGPT is one of the latest innovations that will make accessibility of health information even easier and low-threshold. As a so-called large language model, ChatGPT has been trained with machine learning approaches on a vast amount of text-based content available online, enabling it to perform various natural language processing tasks. The features of ChatGPT are similar to Internet search engines such as Google, but, over and above that, users also have the opportunity to interact with it. If users ask any question, ChatGPT will reply, which can potentially start a conversation between the users and ChatGPT. Users can freely decide on their topic, and on the length and language of the conversation, and ChatGPT is available to them 24/7. Although the applied large language model has its limitations, such as its inability to generate new thoughts – any content has to be already freely available online – it appears that a point has now been reached in human history at which artificial intelligence can make substantial contributions to the healthcare process. It is reasonable to expect that the performance of artificial intelligence-based tools will further increase in the near future.
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