Suicide prevention in Hong Kong: pushing boundaries while building bridges.

Hong Kong is a natural laboratory for studying suicides-small geographic footprint, bustling economic activity, rapidly changing socio-demographic transitions, and cultural crossroads. Its qualities also intensify the challenges posed when seeking to prevent them. In this viewpoint, we showed the research and practices of suicide prevention efforts made by the Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP), which provide the theoretical underpinning of suicide prevention and empirical evidence. CSRP adopted a multi-level public health approach (universal, selective and indicated), and has collaboratively designed, implemented, and evaluated numerous programs that have demonstrated effectiveness in suicide prevention and mental well-being promotion. The center serves as a hub and a catalyst for creating, identifying, deploying, and evaluating suicide prevention initiatives, which have the potential to reduce regional suicides rates when taken to scale and sustained.

Quality of asynchronous webchats vs in-person consultations for postpartum depression in China: a cross-sectional, mixed methods study using standardized patients.

Background: Prompt professional care for postpartum depression (PPD) is difficult to obtain in China. Though online consultations improve accessibility and reduce stigma, the quality of services compared to in-person consultations is unclear. Methods: Five trained, undisclosed "standardized patients" (SPs) made "asynchronous webchats" visits and in-person visits with psychiatrists. Visits were made to 85 psychiatrists who were based in 69 hospitals in ten provincial capital cities. The care between online and in-person consultations with the same psychiatrist was compared, including diagnosis, guideline adherence, and patient-centeredness. False discovery rate (FDR) was used to adjust p values. Third visits using asynchronous webchats were made to psychiatrists who offered discrepant diagnoses. Thematic content analysis was used for the discrepancies. Findings: The proportion of diagnostic accuracy was lower for online than in-person visits (76.5% [65/85] vs 91.8% [78/85]; pFDR = 0.0066), as were the proportions of completing questions involving clinical history (16.6% vs 42.7%; pFDR < 0.0001), and management decisions (16.2% vs 27.5%; pFDR < 0.0001) consistent with recommended guidelines. Patient-centeredness was lower online than in-person (pFDR < 0.0001). Fifteen of 16 psychiatrists completed third visits, most of them considered lack of nonverbal information online as a key barrier. Interpretation: Online consultations using asynchronous webchats were inferior to in-person consultations, with respect to diagnostic accuracy, adherence to recommended clinical guidelines, and patient-centeredness. To fully realise the potential benefits of online consultations and to prevent safety issues, there is an urgent need for major improvement in the quality and oversight of these consultations. Funding: China Medical Board, National Natural Science Foundation of China, and Swiss Agency for Development and Cooperation Global Cooperation Department.

Prevalence of and optimal screening tool for postpartum depression in a community-based population in China.

BACKGROUND: Postpartum depression (PPD) is an important public health problem worldwide. China is planning to launch PPD screening in community settings, but there are questions on the community prevalence of PPD and validated screening tools. METHODS: We sought to recruit all eligible new mothers during postnatal home visits in two districts of Changsha, China, and after informed consent, screened them for PPD using three self-administered questionnaires-the Edinburgh Postpartum Depression Scale (EPDS), the Patient Health Questionnaire (PHQ-9), and Whooley Questions for Depression Screening. Video structured diagnostic interviews were performed online according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) by qualified specialists who were blinded to screening results. Optimal screening was determined based on the acceptability of scales and diagnostic accuracy metrics including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Out of 3004 eligible women, 2730 (90.9 %) completed the screening questionnaires. Among those screened, the video structured diagnostic interview was administered to 1862 (68.2 %) and 62 (3.3 %) were diagnosed with a current depressive condition. The optimal screening approach involved combining Whooley Questions (at least one "yes") with EPDS (cutoff >10) in series, with sensitivity of 0.76 (95 % CI 0.63 to 0.85), specificity of 0.93 (0.92 to 0.94), PPV of 0.28 (0.21 to 0.36) and NPV of 0.99 (0.98 to 1.00). LIMITATIONS: Due to the regional sample and exclusion of mothers with telephone contact rather than home visits, our findings may not be fully generalizable to the entire population. CONCLUSIONS: The prevalence of PPD among women in this sample was substantially lower than those reported in previous studies in China, the majority of which used screen positivity in measuring prevalence. Combining Whooley Questions with EPDS in series is the most optimal screening approach in this population, though this would still result in a high number of false positives at current prevalence.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

The differential impacts of social deprivation and social fragmentation on suicides: A lesson from Hong Kong.

INTRODUCTION: Little research has conducted to examine the association between social deprivation and social fragmentation, overall and method-specific suicide risk, and how these associations may change over time. This study investigated the association between social deprivation and social fragmentation with overall and method-specific suicide in Hong Kong from 1999 to 2018. METHODS: Suicide death data of each small tertiary planning unit (STPU) was obtained from the Census and Statistics Department of Hong Kong. Socio-economic characteristics in STPU level were obtained from Census and Bi-census. Exploratory principal component analysis was used to construct the social deprivation (SDI) and social fragmentation indices (SFI) based on the socio-economic characteristics. Bayesian hierarchical modelling was conducted to explore the association between SDI and SFI with overall and method-specific suicide over time, controlling for population density and male-to-female ratio. RESULTS: Higher risk of suicide was generally observed around Kowloon Peninsula and some parts in the Northern, Northwestern and Southwestern areas depending on methods. The effect of SDI and SFI on suicide risk varied by years and methods. In 2014-2018, for every 10% increase in SDI, the suicide risk for overall, jumping, hanging, and charcoal burning elevated by 22% (95%Crl = 10%-37%), 26% (95%Crl = 12%-41%), 31% (95%Crl = 14%-51%), and 21% (95%Crl = 4%-42%) respectively. CONCLUSION: Spatial variations and effects of SDI and SFI on overall and method-specific suicide risks varied by different periods. SDI was observed to be a stronger factor in the recent years. Situations should be monitored, and interventions should be implemented and adjusted accordingly to the changes.

Intergenerational social mobility and suicide risk by firearm and other means in US males.

Firearms are the leading method of suicide in US men, and socioeconomic status (SES) is associated with suicide risk. In this 40-year mortality follow-up of a national cohort of US men, we examined if improved SES relative to one's family of origin, upward intergenerational social mobility (ISM), is associated with lowered risk for firearm suicide and suicide by other means in US men. Family of origin SES was assessed as part of Project Talent, a broad survey of US high school students in 1960. 42,766 men in the cohort completed follow-up surveys at age 29, assessing attained SES via education, occupation, and income. ISM was measured by change between harmonized SES composites. Mortality follow-up was conducted through age 70. Adjusting for baseline SES and race/ethnicity, a 1 standard deviation increase in SES was associated with a 31% reduction in firearm suicide risk later in the life course (HR [95% CI] = 0·69 [0·54, 0·88], P = 0·003), and a smaller, non-significant reduction in suicide by other means (HR [95% CI] = 0·80 [0·60, 1·07], P = 0·136). Traits associated with both suicide and SES attainment (cognitive ability, calm, impulsivity) only modestly attenuated this association. Upward ISM was more strongly associated with reduced firearm suicide risk in males with parents of low SES. The association between upward ISM and reduced firearm suicide mortality risk prevailed over ensuing decades. Policies improving social mobility in US males, particularly those of lower SES, may function as de-facto firearm suicide prevention strategies.

Effectiveness of a community-based peer support service among persons suffering severe mental illness in China.

Background: Community-based peer support service is widely and effectively deployed for persons suffering severe mental illness (SMI) in countries with well-developed outpatient mental health systems. The objective of this study is to evaluate the effectiveness of a 1-year peer service project among persons with SMI implemented in China. Methods: A total of 101 consumers (service recipients) and 66 family caregivers were recruited at baseline from communities located in Beijing and Chengdu. Severity of psychiatric symptoms, personal and social functioning, self-esteem, life satisfaction, and medication adherence were evaluated among consumers. Self-esteem, life satisfaction, anxiety, and depressive symptoms were assessed among family caregivers. Participants were reevaluated at 1 year with the same measures. Changes in outcomes from baseline to 1-year follow-up were examined using paired sample t tests or Stuart-Maxwell tests. Results: Consumers' psychiatric symptoms were decreased at 1 year (p < 0.001). Their personal and social functioning (p = 0.003) and life satisfaction (p < 0.001) were increased. There were no improvements in self-esteem (p = 0.108) and medication adherence (ps ≥ 0.827) among consumers. For caregivers, no increases were presented in outcomes at the 1-year assessment (ps ≥ 0.164). Conclusions: The findings suggest that peer support services could be sustainably implemented across China, with positive impacts on the psychiatric symptoms, social functioning, and life satisfaction of participants suffering SMI.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Measurement of primary care providers' suicide prevention skills following didactic education.

OBJECTIVE: Almost half of individuals who die by suicide have had contact with primary care (PC) services within 1 month of their death. PC providers must be able to assess and manage patients' suicidal ideation, intent, and behaviors. When didactic training is provided to providers, it is assumed that their requisite skills are well developed. The current study assessed observed skills following high-quality online didactics. METHOD: Medical residents and nurse practitioner (NP) trainees (n = 127) participated in online didactic training as part of their education program, followed by a standardized patient interaction conducted to assess demonstrated suicide prevention skills (i.e., assessment of risk factors, protective factors, suicidal ideation and behavior, safety planning). RESULTS: Participants demonstrated only about 50% of the possible total skills in most domains and were least competent in assessing potential risk for suicide. Regression analyses showed that residents were rated significantly higher than NPs on observed skills. Personal experience with suicide was not associated with any observed skills. Baseline knowledge scores were positively associated with some skills while elapsed days since completion of didactics were negatively associated with skills. CONCLUSIONS: Didactics were insufficient for building suicide-specific assessment skills among physicians and nurses in advanced training.

"Whose Fault Is It?" How Rural Chinese Women Explain Intimate Partner Violence: A Qualitative Study.

Women are often the victims of intimate partner violence (IPV). Though China has established its first statute against domestic violence, the service developments for victims fall behind. It is important to assess community members' perceptions of what causes IPV to create interventions to prevent and address IPV. This study completed the Short Explanatory Model Interview (SEMI) among a subset sample from a large epidemiology study in rural Sichuan China. The social ecological model was applied to analyze qualitative interviews. Among 339 participants, the average age was 46.01 ± 12.42 years old. There were 31.86% of them had been educated, 14.75% of them had migrant worker partners, and 49.26% of them had experienced violence from their partners in the last year. There were 252 participants attributed IPV to individual factors, and they primarily discussed the social characteristics, behaviors, personalities or even health problems of the husband or the wife in the vignette. Under this theme, there were 86 participants blaming the victim for being anxious, social disconnectedness or lazy; and there were 166 participants blaming to the perpetrator being abusive, irresponsibility, lack of understanding, and cheating. There were 44 women believed the cause was relational, in which there were 41 participants attributed the problem to the broken relationship between the couple and three participants attributed to the lack of support. There were 28 participants believed the cause was communal and societal, such as being poor, family problems, fate, and believed IPV was a common scene. There were 15 participants could not identify the cause of IPV. These participants usually provided very brief responses and barely had insight on violent behaviors or confidence in discussing the cause. Our findings offer a direction for understanding the rural Chinese women's beliefs about the etiology of IPV to better develop interventions which must consider raising a public awareness campaign about the risk factors of IPV and focus on reducing self-blame among victims.

Sequential multiple assignment randomised trial of a brief contact intervention for suicide risk management among discharged psychiatric patients: an implementation study protocol.

INTRODUCTION: The postdischarge suicide risk among psychiatric patients is significantly higher than it is among patients with other diseases and general population. The brief contact interventions (BCIs) are recommended to decrease suicide risk in areas with limited mental health service resources like China. This study aims to develop a postdischarge suicide intervention strategy based on BCIs and evaluate its implementability under the implementation outcome framework. METHODS AND ANALYSIS: This study will invite psychiatric patients and family members, clinical and community mental health service providers as the community team to develop a postdischarge suicide intervention strategy. The study will recruit 312 patients with psychotic symptoms and 312 patients with major depressive disorder discharged from Shenzhen Kangning Hospital (SKH) in a Sequential Multiple Assignment Randomised Trial. Participants will be initially randomised into two intervention groups to receive BCIs monthly and weekly, and they will be rerandomised into three intervention groups to receive BCIs monthly, biweekly and weekly at 3 months after discharge according to the change of their suicide risk. Follow-ups are scheduled at 1, 3, 6 and 12 months after discharge. With the intention-to-treat approach, generalised estimating equation and survival analysis will be applied. This study will also collect qualitative and quantitative information on implementation and service outcomes from the community team. ETHICS/DISSEMINATION: This study has received ethical approval from the Ethics Committee Review Board of SKH. All participants will provide written informed consent prior to enrolment. The findings of the study will be disseminated through peer-reviewed scientific journals, conference presentations. A project report will be submitted to the National Natural Science Foundation of China as the concluding report of this funded project, and to the mental health authorities in the Shenzhen to refine and apply evidence-based and pragmatic interventions into health systems for postdischarge suicide prevention. TRIAL REGISTRATION NUMBER: NCT04907669.

The Colorado National Collaborative: A public health approach to suicide prevention.

OBJECTIVE: Suicide rates in the United States have risen dramatically during the 21st century despite national, state and local level commitments to prevention, improvements in the development and delivery of evidence-informed prevention approaches, and advances in epidemiological capacity to identify areas for targeted intervention. Complex problems require comprehensive solutions. In Colorado, that solution is a comprehensive, integrated public health collaboration that aligns diverse community and programmatic efforts across the prevention continuum. The Colorado National Collaborative (CNC) is pursuing a real-world test of the public health approach to suicide prevention by helping community coalitions deliver a package of evidence-informed activities in geographically defined community systems. METHODS: The CNC began by identifying six diverse Colorado counties with high suicide rates or number of deaths. Working closely with community, state, and national partners, CNC identified existing community-level risk and protective factors, programs, and policies. This process provided insight on the overlay between existing efforts and identified burden centers and drivers. RESULTS: The CNC team identified six components for strategic implementation: (1) connectedness, (2) economic stability and supports, (3) education and awareness, (4) access to suicide safer care, (5) lethal means safety, and (6) postvention. Evaluation is being conducted through a collaborative, participatory, and empowerment approach that incorporates stakeholders as leaders in all aspects of the process. CONCLUSION: The CNC includes data-driven identification of populations at risk of suicide, community identification of protective factors, and true collaboration between prevention experts at the national, state, and local level in implementing a comprehensive approach to prevention. Lessons learned are discussed.

Experiences and perceptions of perinatal depression among new immigrant Chinese parents: a qualitative study.

BACKGROUND: Immigrant status, acculturation level, race and ethnicity have been found to contribute to the utilization of mental health services in the perinatal period. This study explored perinatal experiences and perceptions among Chinese immigrant mothers and their spouses, as well as the possible barriers and facilitators that affect their health care utilization. METHODS: We recruited 13 women ages 18-35 years born in mainland China, living in Rochester, New York, and residing less than 5 years in the United States. Participants primary language was Mandarin Chinese and all had given birth to at least one live infant within the past 7 years. Participants' age was at least 18 years old at the time of delivery. Five spouses also participated. We divided women in two focus groups and held one focus group for men, with data collection including demographic questionnaires and semi-structured focus group questions conducted in December 2014. Data were analyzed following thematic analysis. RESULTS: Four themes emerged: experiences of perinatal depression; perceptions of perinatal depression; general preventive and coping strategies; and attitudes toward the supportive use social media applications (apps) and text messaging during the perinatal period. Participants had limited knowledge of perinatal depression and had difficulty distinguishing between normal perinatal mood fluctuations and more severe symptoms of depression. They discussed immigrant-related stress, conflicts with parents/in-laws while "doing the month", the perceived gap between the ideal of "perfect moms" and reality, and challenges with parenting as the causes of perinatal depression. Women approved of screening for the condition but were conservative about follow-up interventions. As for the management of perinatal depression, participants preferred to deal with the problem within the family before seeking external help, due to potential stigma as well as Chinese traditional culture. They were receptive to obtaining pertinent health information from anonymous social media apps, preferring these to personal text messages. CONCLUSION: The recent immigrant Chinese parents to the United States in the study had limited knowledge of perinatal depression and did not make full use of mental health services for support due to language and cultural barriers. Screening for perinatal depression is only the first step. Future research should explore what interventions may serve as an acceptable approach to overcoming these gaps.

Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis.

BACKGROUND: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION: Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

Brief Video-Based Suicide Prevention Training for Primary Care.

BACKGROUND AND OBJECTIVES: One-third of individuals who die by suicide had primary care contact in the preceding month. Primary care trainees need engaging and effective suicide prevention training that can be delivered within tight time and resource constraints. However, training is currently scarce and its effectiveness unknown. The objective of this study was to assess learner engagement, learning, self-efficacy, and perceived ability to transfer training to practice from brief video-based modules centered around visual concept mapping of suicide prevention practices. METHODS: We assigned 127 primary care trainees 21 brief instructional videos to watch. We analyzed engagement by monitoring the proportion of learners who began each video and the proportion of the video watched. We assessed knowledge and self-efficacy pre- and posttraining. Learners provided feedback on satisfaction with modules and ability to transfer training to practice. RESULTS: Engagement was high, with most learners watching most of each video (mean=83.2%). Increase in knowledge was large (t(131 df)=19.91, P<.001). Confidence in ability to manage suicide risk rose significantly (t(131 df)=16.31, P<.001). Perception of ability to transfer training to practice was moderate. Satisfaction with modules was high. Feedback asked for patient scenarios and practical skills examples. CONCLUSIONS: This training successfully engaged primary health care trainees in suicide prevention education. Training transfer will be improved by adding skill demonstrations, a suicide attempt survivor perspective, and a memorable framework to assist implementation of knowledge. A new iteration incorporating these improvements is under evaluation. Variants for other health care settings are under development.

Chinese Women's Acceptance and Uptake of Referral after Screening for Perinatal Depression.

China recently issued a national plan on perinatal depression (PND) screening. Previous studies elsewhere suggested that uptake of referral after screening for PND is suboptimal, but little is known in China. In this cohort study including 1126 women in Hunan, we identified women at a high risk of PND using the Edinburgh Postpartum Depression Scale (EPDS) over multiple time points. We texted them and offered free consultations with a psychiatrist/psychologist. Among 248 screen-positive women, only three expressed interest and one attended the appointment. We surveyed the women about their reasons for declining referrals and preferred means of care. Of the 161 respondents, 128 (79.5%) indicated that they could cope with the condition without professional assistance and 142 (88.2%) chose their families as the preferred source of help. Only 15 (9.3%) chose professionals as their first option. Implementing a referral policy for screen-positive women would mean approximately one-third of women who gave birth in China would be eligible. Our result argues against referring all screen-positive women for professional services at this time. Interventions should instead build upon the tradition of family support in a more engaged response. These considerations are relevant for the implementation of national screening for PND in China.