Suicidal behaviours and associated factors among medical students in Bangladesh: a protocol for systematic review and meta-analysis (2000-2024).

INTRODUCTION: Suicidal behaviour is common among medical students, and the prevalence rates might vary across various regions. Even though various systematic reviews have been conducted to assess suicidal behaviours among medical students in general, no review has ever assessed or carried out a sub-analysis to show the burden of suicidal behaviours among Bangladeshi medical students. METHODS AND ANALYSIS: The research team will search the PubMed (Medline), Scopus, PsycINFO and Google Scholar databases for papers published between January 2000 and May 2024 using truncated and phrase-searched keywords and relevant subject headings. Cross-sectional studies, case series, case reports and cohort studies published in English will be included in the review. Review papers, commentaries, preprints, meeting abstracts, protocols and letters will be excluded. Two reviewers will screen the retrieved papers independently. Disagreements between two reviewers will be resolved by a third reviewer. Exposure will be different factors that initiate suicidal behaviours among medical students. The prevalence of suicidal behaviours (suicidal ideation, suicide plans and suicide attempts) in addition to the factors responsible, and types of suicide method will be extracted. Narrative synthesis and meta-analysis will be conducted and the findings will be summarised. For enhanced visualisation of the included studies, forest plots will be constructed. Heterogeneity among the studies will be assessed and sensitivity analysis will be conducted based on study quality. Included studies will be critically appraised using Joanna Briggs's Institutional critical appraisal tools developed for different study designs. ETHICS AND DISSEMINATION: The study will synthesise evidence extracted from published studies. As the review does not involve the collection of primary data, ethical approval will not be required. Findings will be disseminated orally (eg, conferences, webinars) and in writing (ie, journal paper). PROSPERO REGISTRATION NUMBER: CDR 42023493595.

Debate: How the business model of social media fuels the need for greater moderation.

The current business model of social media companies is to keep users engaged and on screen, so that data can be obtained from them, and targeted advertisements sold. To maintain user engagement, recommender systems (algorithms) promote content, which can be extreme, and includes mental health content. Extreme mental health content, such as self-harm images, can be pushed to any user and then more and more extreme content can be pushed to them. The normalisation, amplification or glamorisation of harmful content can have negative impacts upon the user, who may struggle to express what is happening online to anyone. In contrast with the views of Zhang et al. (Child and Adolescent Mental Health, 2024, 29, 104), without greater, timely moderation of harmful content, the promotion of self-harm, suicide and eating disorders will continue on social media, with potentially devastating consequences.

Suicide, suicide attempts and self-harm in Moroccan prisons.

PURPOSE: High rates of suicide and self-harm are reported in prisons in Western countries, while fewer studies exist from a non-Western context. This study aims to identify rates of suicide, non-fatal suicide attempts and self-harm in Moroccan prisons and to better understand the context, methods, tools, predictors and profile of persons engaged in the acts. DESIGN/METHODOLOGY/APPROACH: The authors report findings from a mixed-methods study carried out before an intervention project. The study consists of a systematic literature review, an analysis of suicide case files, a quantitative survey on suicide attempts and self-harm, as well as interviews and focus group discussions. The authors calculate suicide, suicide attempt and self-harm rates and present descriptive data on the incidents. The authors use regression models to explore the association between the number of incidents per individual and selected predictors, adjusting for clustering by institution. FINDINGS: Over a four-year period, 29 detained persons in Morocco died by suicide (average annual suicide rate 8.7 per 100,000). Most were men under the age of 30. Hanging accounted for all but one case. In one year, 230 suicide attempts were reported. Over a three-months period, 110 self-harm cases were reported from 18 institutions, cutting being the most common method. Self-harm was significantly more prevalent among persons with a life sentence or repeated incarcerations. RESEARCH LIMITATIONS/IMPLICATIONS: To make the study manageable as part of an intervention project, the authors collected data on suicides and suicide attempts from all prisons, while data on self-harm were collected from fewer prisons and over a shorter time period. The authors did not collect comparable information from detained persons who did not die by suicide, attempt suicide or self-harm. This prevented comparative analyses. Further, it is possible that self-harm cases were not reported if they did not result in serious physical injury. Data were collected by prison staff; thus, the voice of incarcerated persons is absent. PRACTICAL IMPLICATIONS: This study provided a solid basis for designing an intervention project including the development of a national prison policy and guidelines on suicides, suicide attempts and self-harm and a country-wide training program for prison staff. It also led to a better surveillance system, allowing for trend analysis and better-informed policymaking. The qualitative results helped create an understanding of how staff may trivialize self-harm. This was integrated into the training package for staff, resulting in the creation of prison staff trainers who became the strongest advocates against the notion that self-harm was best ignored. ORIGINALITY/VALUE: To the best of the authors' knowledge, this is the first published data on suicide and self-harm in Moroccan prisons. It underscores the necessity for the intervention project and gives valuable insights into suicide and self-harm in a non-Western prison context. Further research is needed to assess whether the findings are typical of the region.

Exploring fidelity of enactment in a cluster randomised controlled trial testing the effectiveness of 'gatekeeper' training for pesticide vendors in reducing self-poisoning in rural Sri Lanka: protocol for a multimethod qualitative study.

INTRODUCTION: Pesticide self-poisoning causes severe health and socioeconomic hardship in low- and middle-income countries, including Sri Lanka. A stepped-wedge cluster randomised controlled trial (cRCT) has been designed to test whether 'gatekeeper' training for pesticide vendors reduces pesticide self-poisoning in rural Sri Lanka (Vendor cRCT). Ensuring intervention fidelity in RCTs is essential for consistently replicating interventions, accurately assessing their impact and improving outcomes. Thus, the overarching goal of this proposed study is to explore to what extent the pesticide vendors use the 'gatekeeper' strategies. METHODS AND ANALYSIS: A multimethod qualitative research design is being used to explore the pesticide-selling behaviours of vendors after the 'gatekeeper' training. A subsample of the Vendor cRCT Study population is being recruited using a stratified purposive sampling method in all six intervention districts in Sri Lanka to ensure that the sample is representative of the pesticide vendors in the study area. Participant diaries, observations and focus group discussions are being adopted to collect data. Data triangulation will be performed and data will be analysed thematically. ETHICS AND DISSEMINATION: The study was approved by the Ethics and Research Committee, Faculty of Medicine and Allied Sciences, at the Rajarata University of Sri Lanka (ERC/2023/09). All participants will provide informed consent. Findings will be disseminated in scientific peer-reviewed journals and conference presentations.

Intravenous ketamine for emergency department treatment of suicidal ideation in a paediatric population: protocol for a double-blind, randomised, placebo-controlled, parallel-arm pilot trial (KSI study).

INTRODUCTION: Suicidal ideation (SI) is a common and severe cause of morbidity in adolescents. Patients frequently present to the emergency department (ED) for care, yet there is no acute therapeutic intervention for SI. A single dose of intravenous ketamine has demonstrated efficacy in rapidly reducing SI in adults; however, ketamine has not been studied in paediatrics. We aim to determine the feasibility of a trial of a single intravenous ketamine dose to reduce SI for patients in the paediatric ED. METHODS AND ANALYSIS: This will be a single-centre, double-blind, randomised, placebo-controlled, parallel-arm pilot trial of intravenous ketamine for ED treatment of SI in a paediatric population. INTERVENTION: one intravenous dose of 0.5 mg/kg of ketamine (max 50 mg), over 40 min. Placebo: one intravenous dose of 0.5 mL/kg (max 50 mL) of normal saline, over 40 min. Participants will be randomised in a 1:1 ratio. SI severity will be measured at baseline, 40 min, 80 min, 120 min, 24 hours and 7 days. We aim to recruit 20 participants. The primary feasibility outcome is the proportion of eligible patients who complete the study protocol. We will pilot three SI severity tools and explore the efficacy, safety and tolerability of the intervention. ETHICS AND DISSEMINATION: This study will be conducted according to Canadian Biomedical Research Tutorial, international standards of Good Clinical Practice and the Health Canada, Food and Drug Act, Part C, Division 5. The study documents have been approved by the CHEO Research Institute Research Ethics Board (CHEO REB (23/02E)). Participants must provide free and informed consent to participate. If incapable due to age, assenting participants with parental/legal guardian consent may participate. On completion, we will endeavour to present results at international conferences, and publish the results in a peer-reviewed journal. Participants will receive a results letter. TRIAL REGISTRATION NUMBER: NCT05468840.

News Media Framing of Suicide Circumstances and Gender: Mixed Methods Analysis.

BACKGROUND: Suicide is a leading cause of death worldwide. Journalistic reporting guidelines were created to curb the impact of unsafe reporting; however, how suicide is framed in news reports may differ by important characteristics such as the circumstances and the decedent's gender. OBJECTIVE: This study aimed to examine the degree to which news media reports of suicides are framed using stigmatized or glorified language and differences in such framing by gender and circumstance of suicide. METHODS: We analyzed 200 news articles regarding suicides and applied the validated Stigma of Suicide Scale to identify stigmatized and glorified language. We assessed linguistic similarity with 2 widely used metrics, cosine similarity and mutual information scores, using a machine learning-based large language model. RESULTS: News reports of male suicides were framed more similarly to stigmatizing (P<.001) and glorifying (P=.005) language than reports of female suicides. Considering the circumstances of suicide, mutual information scores indicated that differences in the use of stigmatizing or glorifying language by gender were most pronounced for articles attributing legal (0.155), relationship (0.268), or mental health problems (0.251) as the cause. CONCLUSIONS: Linguistic differences, by gender, in stigmatizing or glorifying language when reporting suicide may exacerbate suicide disparities.

The correlation between cumulative burden of mental disorders and self-harm, shame, and insight in young female patients with schizophrenia.

This study delves into the correlation between the cumulative burden of mental disorders and self-harm, shame, and insight in young female patients with schizophrenia. A prospective randomized controlled study was used to recruit 62 female schizophrenia patients who met the recruitment conditions from January 2022 to December 2023. The participants were randomly divided into an experimental group (31 cases) and a control group (31 cases) using a computer-based random number distribution method. The experimental group underwent an 8-week Mindfulness-Based Cognitive Therapy (MBCT) intervention, while the control group received conventional treatment. Data was collected using the Modified EI-SHS scale, the Link's Stigma Scale (LSS), the Five-factor Mindfulness Scale (FFMQ), and the Self-awareness and Therapeutic Attitude Questionnaire (ITAQ) before and after the intervention. One-way ANOVA and repeated measure ANOVA were used to compare and analyze the two groups of data. The experimental group exhibited a significant reduction in EI-SHS and LSS scores (100.26 ± 11.48 vs. 88.35 ± 10.09, 112.81 ± 12.30 vs. 100.50 ± 13.52, p < 0.01), coupled with significant increase in FFMQ and ITAQ scores (113.77 ± 12.25 vs. 128.31 ± 14.09, 14.03 ± 4.18 vs. 17.30 ± 2.96, p < 0.01). A positive correlation was found between overall stigma scores and mood disorder scores (r = 0.379, P < 0.011). Correlation analysis revealed a negative correlation between mindfulness (self-awareness) and stigma (r = -0.128, P = 0.025). MBCT effectively reduced stigma in young women with schizophrenia and improved coping tendencies, cognitive status, and attitudes toward mental illness, ultimately reducing the cumulative burden of mental disorders and self-harm in these patients. Increased levels of mindfulness correspond to improved cognitive status and a more positive attitude toward treatment for mental illness. It is of great value to promote MBCT in female patients with schizophrenia.

Variation in completeness of coding external cause of injuries under ICD-10-CM.

INTRODUCTION: Information about causes of injury is key for injury prevention efforts. Historically, cause-of-injury coding in clinical practice has been incomplete due to the need for extra diagnosis codes in the International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) coding. The transition to ICD-10-CM and increased use of clinical support software for diagnosis coding is expected to improve completeness of cause-of-injury coding. This paper assesses the recording of external cause-of-injury codes specifically for those diagnoses where an additional code is still required. METHODS: We used electronic health record and claims data from 10 health systems from October 2015 to December 2021 to identify all inpatient and emergency encounters with a primary diagnosis of injury. The proportion of encounters that also included a valid external cause-of-injury code is presented. RESULTS: Most health systems had high rates of cause-of-injury coding: over 85% in emergency departments and over 75% in inpatient encounters with primary injury diagnoses. However, several sites had lower rates in both settings. State mandates were associated with consistently high external cause recording. CONCLUSIONS: Completeness of cause-of-injury coding improved since the adoption of ICD-10-CM coding and increased slightly over the study period at most sites. However, significant variation remained, and completeness of cause-of-injury coding in any diagnosis data used for injury prevention planning should be empirically determined.

A Web-Based Training Program for School Staff to Respond to Self-Harm: Design and Development of the Supportive Response to Self-Harm Program.

BACKGROUND: Self-harm is common among adolescents and is a major public health concern. School staff may be the first adults to notice a young person's self-harm and are well placed to provide support or signpost students to help. However, school staff often report that they do not feel equipped or confident to support students. Despite the need, there is a lack of evidence-based training about self-harm for school staff. A web-based training program would provide schools with a flexible and cost-effective method of increasing staff knowledge, skills, and confidence in how to respond to students who self-harm. OBJECTIVE: The main objective of this study was to coproduce an evidence-based training program for school staff to improve their skills and confidence in responding to students who self-harm (Supportive Response to Self-Harm [SORTS]). This paper describes the design and development process of an initial prototype coproduced with stakeholders to ensure that the intervention meets their requirements. METHODS: Using a user-centered design and person-based approach, the SORTS prototype was informed by (1) a review of research literature, existing guidelines, and policies; (2) coproduction discussions with the technical provider and subject matter experts (mental health, education, and self-harm); (3) findings from focus groups with young people; and (4) coproduction workshops with school staff. Thematic analysis using the framework method was applied. RESULTS: Coproduction sessions with experts and the technical provider enabled us to produce a draft of the training content, a wireframe, and example high-fidelity user interface designs. Analysis of focus groups and workshops generated four key themes: (1) need for a training program; (2) acceptability, practicality, and implementation; (3) design, content, and navigation; and (4) adaptations and improvements. The findings showed that there is a clear need for a web-based training program about self-harm in schools, and the proposed program content and design were useful, practical, and acceptable. Consultations with stakeholders informed the iterative development of the prototype. CONCLUSIONS: SORTS is a web-based training program for school staff to appropriately respond to students who self-harm that is based on research evidence and developed in collaboration with stakeholders. The SORTS program will equip school staff with the skills and strategies to respond in a supportive way to students who self-harm and encourage schools to adopt a whole-school approach to self-harm. Further research is needed to complete the intervention development based on the feedback from this study and evaluate the program's effectiveness. If found to be effective, the SORTS program could be implemented in schools and other youth organizations.

Suicide Ideation and Self-Harm Behaviors in First-Year Dormitory Students at a Public Midwestern University: A Pilot Study.

Purpose: Currently, 1 in 5 college students struggle with suicidal ideation while 7% to 44% engage in nonsuicidal self-injury. Illinois has one of the highest teenage and college student suicide rates in the United States. This pilot study assessed suicide ideation and self-harm behaviors at a public Illinois university. This is the first study to use 5 standardized psychological instruments to investigate these 2 crises in freshmen college students who are all required to reside in dormitories. The main hypothesis was to determine if the independent effects of freshmen students' depression, Five-Factor Model, and Reasons for Living affected the dependent variables, self-harm behaviors and suicide ideation. Methods: Forty first-year college dormitory students completed the Beck Depression Inventory-II, Scale of Suicidal Ideation, Five-Factor Model, Inventory of Statements About Self-Injury, and Reasons for Living Scale in person. Results: Participants were 18 to 19 years old, predominantly female (65%), and non-White (62%). Forty percent reported self-harm behaviors and 19% reported suicidal ideation. The top reasons for contemplated suicide attempts included the inability to solve problems (33%) and attention/revenge (28%). Students experienced high levels of anxiety (55%), self-consciousness (43%), and depression (18%). Depression was associated with suicide ideation (ß = 0.05, P = .006), while neuroticism and openness were associated with self-harm behaviors (aOR = 3.36, P = .02, aOR = 0.48, P = .047, respectively). Ninety-five percent reported "responsibility to family" as a Reason for Living. Conclusions: Preliminary evidence necessitates an examination of self-harm and suicide ideation among all freshmen, investigating both risk and protective factors. In the future, a prevention intervention should be implemented campus-wide (and eventually nationwide) for all first-year dormitory students to enhance their mental well-being.

Epidemiological analysis of fatal and non-fatal firearm injuries occurring in gun establishments in the United States, 2015-2022.

BACKGROUND: Firearm-related injury represents a significant public health problem in the USA. Firearm purchasing has risen nationwide and there has been increased efforts to deploy injury prevention initiatives within gun establishments. However, firearm-related risks and harms that may occur inside these high-exposure settings are not well characterized. METHODS: This secondary analysis leveraged Gun Violence Archive data to quantify firearm injury prevalence rates within different types of gun establishments from 1 January 2015 to 31 December 2022. Data were restricted to incidents that occurred in gun ranges, gun shops, and public and private ranges. The following incident characteristics were available in the individual-level data: date, location, injury count, fatality count, victim demographics (age, sex), shooting intent (suicide/self-inflicted, assault/homicide, unintentional, undetermined) and establishment type. RESULTS: Over 7 years, 445 non-fatal and 183 fatal shooting events occurred across 576 unique establishments. Non-fatal, unintentional injuries predominated in stand-alone firing ranges whereas fatal, self-inflicted injuries concentrated in retail shops with accompanying firing ranges. Firearm-related assaults were prevalent among stand-alone retail shops. CONCLUSION: Overall, this secondary analysis underscores that the prevalence of firearm injury in gun establishments across the USA is low, and these settings should continue to be studied as important contexts for intervention. Interweaving public health interventions into gun establishments presents an opportunity to potentially reduce associated harms to consumers interacting within these environments.

Cyberbullying Perpetration and Victimization as Risk Factors for Self-Harm: Results From a Longitudinal Cohort Study of 13-14-Year-Olds in England.

PURPOSE: Cyberbullying is a crucial issue that affects adolescent mental health, with evidence to suggest that adolescents who are victims of cyberbullying are at higher risk for self-harm. However, longitudinal evidence is lacking, meaning the direction of effects cannot be established. This study investigated longitudinal associations between levels of cyberbullying involvement (bully, victim, or both), frequency, and self-harm a year later in an adolescent sample. METHODS: Data were collected from Year 9 students (13-14-year-olds; N = 1,195) enrolled in 19 schools in Southwest England using an online questionnaire with a 1-year follow-up period (October 2019-October 2020). Multivariable logistic regression analysis was conducted to test for associations between different levels of cyberbullying involvement at baseline and the likelihood of self-harm a year later, adjusting for key covariates. A secondary regression analysis also explored the associations between the frequency of cyberbullying involvement at baseline and subsequent self-harm. RESULTS: Compared to those with no cyberbullying involvement, individuals who were both victims and perpetrators (adjusted odds ratio = 2.94, 95% confidence interval: 1.99-4.34) as well as victims only (adjusted odds ratio = 2.81, 95% confidence interval: 1.95-4.04) showed an increased risk of subsequent self-harm. In terms of frequency, associations were found between frequent and occasional cyberbullying and self-harm for both victims and perpetrators; however, associations for the perpetrator group attenuated to the null following adjustment for covariates. DISCUSSION: Our findings highlight cyberbullying in early adolescence as a risk factor for subsequent self-harm. Cyberbullying prevention should be a priority for school mental health interventions, with consideration that most perpetrators of cyberbullying may also be victims.

Clinical effectiveness and safety of adding a self-harm prevention app (BlueIce) to specialist mental health care for adolescents who repeatedly self-harm: A single blind randomised controlled trial (the BASH study).

No randomised controlled trials have evaluated whether the addition of a smartphone app to usual child and adolescent mental health care (CAMHS) can reduce self-harm in adolescents (<18 years) with repeated self-harm. We enrolled 170 participants aged 12-17, receiving CAMHS treatment who had self-harmed ≥2 in the past 12 months. Participants were randomised via an independent web-based system (1:1, minimised for gender, age, self-harm frequency, and depression severity) to treatment as usual (TAU) or treatment as usual plus BlueIce (TAU+BI). BlueIce is a self-harm prevention app that includes techniques from CBT and DBT that was co-designed with adolescents who self-harm. The primary outcome was change from baseline to 12-weeks on the self-harm scale of the Risk Taking and Self-Harm Inventory for Adolescents (RTSHIA), analysed by intention to treat (ITT). Emergency department attendances or admissions for self-harm were assessed over 6-months via a review of clinical records. Both groups improved but there were no statistically significant between group differences at 12 weeks or 6 months on the self-harm scale of the RTSHIA. There were fewer emergency department attendances and admissions in those who received the app, a finding that approached statistical significance. BlueIce can be helpful in some important aspects by contributing to fewer emergency department admissions and attendances. TRIAL REGISTRATION: Trial registration number ISRCTN10541045.

Place-Based Differences in the Association Between Greenspace and Suicide-Related Outcomes Among Young People.

PURPOSE: This study investigated place-based differences in the association between greenspace and suicide-related outcomes (SROs) among young people, guided by the following two objectives: (1) Contextualize place-based differences in the association between greenspace and SRO prevalence among young people at the community level in five different urbanities (urban, suburban, micropolitan, small towns, and rural/isolated communities) and (2) identify which greenspace metrics (quantity, quality, or accessibility) are most protective for SROs at the community level. METHODS: Publicly available greenspace datasets were used to derive greenspace quantity, quality, and accessibility metrics. SRO emergency department visits for young people were identified from 2016-2019 in North Carolina, USA. Generalized linear models investigated the association between greenspace metrics and community-level drivers of SRO prevalence. Shapely additive explanations confirmed the most important greenspace variables in accurately predicting community-level SRO prevalence. RESULTS: The prevalence of SROs was highest in communities with the least amount of public greenspace; this association was most pronounced in suburban communities, with SROs 27% higher in suburban communities with low quantities of greenspace (PRRUrban: 1.11, confidence interval [CI]: 1.08-1.13; PRRSuburban: 1.27, CI: 1.10-1.46; PRRSmallTowns: 1.21, CI: 1.05-1.39), and in communities with the worst greenspace accessibility (i.e., furthest distance to nearest greenspace) (PRRUrban: 1.07, CI: 1.04-1.10; PRRRural&Isolated: 1.95, CI: 1.54-2.49). DISCUSSION: Our analysis provides place-based, community-specific findings to guide targeted greenspace interventions aimed at addressing the rising prevalence of SROs among young people. Our findings suggest that greenspace quantity interventions may be most effective in urban, suburban, and small-town communities, and greenspace accessibility interventions may be most useful in urban and rural/isolated communities.

Effects of Patient-Initiated Brief Admissions on Psychiatric Care Consumption in Borderline Personality Disorder: ARegister-Based Study.

Previous studies have reported that patients with borderline personality disorder (BPD) often have negative experiences in psychiatric inpatient care. To address this issue, a novel intervention known as patient-initiated brief admission (PIBA) has been developed. PIBA offers a constructive approach to crisis management in situations of heightened anxiety, as well as during instances of self-harm and suicidal ideation. The intervention allows patients to directly contact the psychiatric ward to initiate a brief admission lasting 1-3 days. This easily accessible care option during a crisis has the potential to prevent harm to the patient and reduce the need for prolonged hospital stays. The aim of the present study is to investigate the effects of PIBA on psychiatric care consumption among patients diagnosed with BPD. This retrospective register-based study includes data from both inpatient and outpatient care registries for patients diagnosed with BPD. Data were extracted from the National Board of Health and Welfare in Sweden. The study period encompasses 2013-2020, with the PIBA intervention occurring between 2016 and 2019. The sample included 107 patients in the PIBA group and 5659 matched controls. Data were analysed using a difference-in-differences (DiD) approach through ordinary least squares (OLS) regression and ordinal logistic regression. Throughout the 3-year follow-up, both groups exhibited a reduction in the number of days of utilisation of psychiatric inpatient care services. The DiD analysis indicated an additional decrease of 1.5 days at the 6-month mark for the PIBA group (ß = -1.436, SE = 1.531), expanding to 3 days fewer at the 12-month follow-up (ß = -3.590, SE = 3.546), although not statistically significant. For outpatient care, the PIBA group displayed an increase in the number of visits, averaging to half a visit more every 6 months (ß = 0.503, SE = 0.263) compared with the controls. Statistically significant differences were observed for two out of six measurements at the 12-month (ß = 0.960, SE = 0.456) and 18-month follow-up period (ß = 0.436, SE = 0.219). The PIBA group had a statistically significant lower odds of experiencing extended lengths of inpatient care days after the index date than the controls (OR 0.56, 95% CI: 0.44-0.72). In conclusion, PIBA was associated with a significant reduction in the length of individual hospital stays, but not in the overall number of inpatient care days. PIBA may be linked to a shift from longer inpatient care utilisation to outpatient care utilisation. These findings suggest that PIBA may reduce the risk of prolonged hospitalisations for patients who have access to the intervention. Future research should explore the impact of PIBA on healthcare costs and cost-effectiveness, both in relation to health care for the individual and cost-effectiveness in relation to recovery and health.

Feasibility and acceptability of autism adapted safety plans: an external pilot randomised controlled trial.

Background: Autistic people are a high-risk group for self-harm and suicide. There are no evidence-based suicide prevention interventions developed specifically for autistic people. We undertook a pilot feasibility randomised controlled trial of autism adapted safety plans (AASP) to reduce self-harm and suicide for autistic people. Methods: This study took place in the United Kingdom and followed a randomised, two-arm, controlled design. Autistic adults (n = 53, mean age = 39, gender = 49% female, 29% not male or female) were recruited via third sector organisations and self-referral between 11.8.21 and 19.10.22. Participants were randomised without stratification to usual care with or without AASP. The AASP was completed by the autistic adults together with someone trained to support them. Research staff who completed follow-up assessments were blind to participant allocation. Primary outcomes were feasibility and acceptability. Participants were assessed at baseline, 1 and 6 months. Primary data were analysed under the intention to treat principle. Study protocol is published. The trial is closed to new participants. This study is registered with the ISRCTN registry, ISRCTN70594445. Findings: 53 participants consented, 49 were randomised to either AASP with usual care (n = 25) or usual care (n = 24). 68% of participants in the AASP arm were satisfied with the AASP and 41% rated it as useable. Feedback on the AASP and research methods were positive with suggested adaptations to some outcome measures. Retention and completion of outcomes measures in both arms was excellent, as was fidelity of delivery of the AASP. Interpretation: Study progression criteria were met, suggesting that the parameters of a future definitive trial of clinical and cost effectiveness of AASP to reduce self-harm and suicide in autistic adults are achievable, with minor recommended adaptions to outcome measures and AASP. Future research should explore the use of AASP in routine clinical practice. Funding: This study is funded by the NIHR [Public Health Research Programme (NIHR129196)].

Association of screen-based activities and risk of self-harm and suicidal behaviors among young people: A systematic review and meta-analysis of longitudinal studies.

Emerging evidence suggests that screen-based activities are associated with self-harm and suicidal behaviors. This study aimed to examine these associations among young people through a meta-analysis. We systematically searched EBSCO pshyARTICLES, MEDLINE (via PubMed), EMBASE, and Web of Science from their inception to April 1, 2022, and updated on May 1, 2024. Longitudinal studies reporting the association between various screen-based activities and subsequent self-harm and suicidal behaviors in young people aged 10 to 24 were included. Nineteen longitudinal studies were included in the qualitative synthesis, and 13 studies comprising 43,489 young people were included in the meta-analysis, revealing that total screen use is significantly associated with the risks of self-harm and suicidal behaviors. Cyberbullying victimization was also related to these adverse outcomes. Subgroup analyses indicated that social media use and problematic screen use are significant risk factors for self-harm and suicidal behaviors. Study quality was appraised using the Newcastle-Ottawa Scale, and potential publication bias was deemed unlikely to affect the results significantly. These findings suggest that screen-based activities should be considered in the management and intervention strategies for self-harm and suicidal behaviors in young people.

The iceberg model of suicidal ideation and behaviour in Danish adolescents: integration of national registry and self-reported data within a national birth cohort.

Hospital records are used to identify suicide attempts in many countries but not all individuals present to hospital after a suicide attempt i.e., suggesting a 'hidden number'. Our aim was to present the prevalence of suicide ideation, plans, attempts, and suicides among Danish adolescents, including attempts not resulting in hospital contact. The study population consisted of participants in the Danish National Birth Cohort participating in an 18-year follow-up, with individual-level linkage to national register data. Prevalence was estimated with a variable with mutually exclusive categories ranging from no suicidality to self-reported suicide ideation, -plans, -attempt and hospital-recorded suicide attempt and stratified on sex and parental income. The 'hidden number' was estimated as the ratio between suicide attempts with and without hospital contact. Among 47 858 participants, all aged 18-years, 36% girls and 28% boys reported suicide ideation at least once in their life. In addition, 6% girls and 3% boys had either reported or been recorded with a suicide attempt. For every attempt recorded in the hospital setting, two girls (ratio, 1:2) and six boys (ratio, 1:6) reported having attempted suicide without hospital contact. The prevalence of any suicide attempt was 8% and 3% in the lowest and highest income group, respectively. Before age 18, 0·011% girls and 0·016% boys had died by suicide. In conclusion, suicidal ideation and behaviour are common in adolescents and there is a substantial 'hidden number' of adolescents with suicide attempt. These results emphasize the need for early age suicide preventive interventions in community-settings e.g., school environments.

Work-related suicide: Evolving understandings of etiology & intervention.

Previously published analyses of suicide case investigations suggest that work or working conditions contribute to 10%-13% of suicide deaths. Yet, the way in which work may increase suicide risk is an underdeveloped area of epidemiologic research. In this Commentary, we propose a definition of work-related suicide from an occupational health and safety perspective, and review the case investigation-based and epidemiologic evidence on work-related causes of suicide. We identified six broad categories of potential work-related causes of suicide, which are: (1) workplace chemical, physical, and psychosocial exposures; (2) exposure to trauma on the job; (3) access to means of suicide through work; (4) exposure to high-stigma work environments; (5) exposure to normative environments promoting extreme orientation to work; and (6) adverse experiences arising from work-related injury or illness. We summarise current evidence in a schema of potential work-related causes that can also be applied in workplace risk assessment and suicide case investigations. There are numerous implications of these findings for policy and practice. Various principle- and evidence-based workplace intervention strategies for suicide prevention exist, some of which have been shown to improve suicide-prevention literacy, reduce stigma, enhance helping behaviours, and in some instances maybe even reduce suicide rates. Prevailing practice in workplace suicide prevention, however, overly emphasises individual- and illness-directed interventions, with little attention directed to addressing the working conditions that may increase suicide risk. We conclude that a stronger emphasis on improving working conditions will be required for workplace suicide prevention to reach its full preventive potential.

Acceptability, use and safety of the BlueIce self-harm prevention app: qualitative findings from the Beating Adolescent Self-Harm (BASH) randomised controlled trial.

BACKGROUND: Little is known about the social validity of self-harm prevention apps for young adolescents with severe mental health problems who repeatedly self-harm. OBJECTIVE: We assessed the acceptability, use and safety of BlueIce, a self-harm prevention app for young adolescents who self-harm. METHODS: Mixed methods study involving a content analysis of postuse interviews. Participants were a clinical group of 60 UK adolescents aged 12-17 with repeated self-harm, randomised to receive BlueIce. FINDINGS: BlueIce was used by 57/60 (95%) respondents with 47/57 (82%) using BlueIce when thinking about self-harm. 17/47 (36%) who were thinking about self-harm used it on more than six occasions with 36/47 (77%) reporting that BlueIce prevented at least one episode of self-harm. 33/47 (70%) reported occasions when they used the app but still went on to self-harm. Reasons why the app was not used or not helpful included feeling too distressed, a negative mindset, prior decision to self-harm or forgetting. BlueIce was rated 4.09 (SD=0.75) out of 5 stars, with high mean ratings out of 10 for ease of use (8.70, SD=1.37) and good for acceptability (7.68, SD=2.05) and helpfulness (6.77, SD=1.72). No respondent identified BlueIce as triggering any episode of self-harm. CONCLUSION: These findings are consistent with previous evaluations and highlight the acceptability, use and safety of BlueIce. Self-reports indicate that BlueIce prevented some episodes of self-harm. CLINICAL IMPLICATIONS: Our results highlight the acceptability of the BlueIce self-harm app for young adolescents who repeatedly self-harm.