The 988 suicide hotline-Lifeline or letdown? A pre-post policy analysis.

Suicide has emerged as an urgent threat in recent years as COVID-19 impaired the health and economic wellbeing of millions of Americans. According to the Centers for Disease Control and Prevention, the impact of COVID-19 and the ongoing opioid epidemic has "taken a mental, emotional, physical, and economic toll on individuals, families, and communities," increasing the need for innovative solutions to prevent suicide on a national scale. The National Suicide Hotline Designation Act of 2020 established 988 as the universal telephone number for suicide prevention and represents a key federal intervention to address this crisis. However, research on 9-8-8's effectiveness is limited, given the Act's recent enactment and implementation at the federal and state levels. This policy analysis investigates how and to what extent the mental health crisis system in Georgia has improved since the implementation of the 2020 Act as well as the implications of state law on population-level mental health outcomes. Georgia is used as a nationally representative case study for two reasons: (1) Georgia had a robust statewide suicide hotline prior to 2020, providing solid infrastructure on which federal expansion of a suicide hotline number could be built, and (2) the conflicting characteristics of Georgia's mental health system represent several different pockets of the U.S., allowing this analysis to apply to a broad range of states and locales. The paper draws on takeaways from Georgia to propose state and national policy recommendations for equitable interventions to prevent and respond to this form of violence.

The Spatio-Temporal Distribution of Suicide-related Emergency Calls in a European City: Age and Gender Patterns, and Neighborhood Influences.

Objective: The aim of this study was to conduct a comprehensive spatio-temporal analysis of suicide-related emergency calls in the city of Valencia (Spain) over a six-year period. To this end we first examined age and gender patterns and, second, the influence of neighborhood characteristics on general and gender-specific spatio-temporal patterns of suicide-related emergency calls. Method: Geocoded data on suicide-related emergency calls between 2017 and 2022 (N = 10,030) were collected from the 112 emergency service in Valencia. Data were aggregated at the census block group level, used as a proxy for neighborhoods, and trimesters were considered as the temporal unit. Two set of analyses were performed: (1) demographic (age and gender) and temporal descriptive analyses and (2) general and gender-specific Bayesian spatio-temporal autoregressive models. Results: Descriptive analyses revealed a higher incidence of suicide-related emergency calls among females and an increase in calls among the 18-23 age group from 2020 onwards. The general spatio-temporal model showed higher levels of suicide-related emergency calls in neighborhoods characterized by lower education levels and population density, and higher residential mobility, aging population, and immigrant concentration. Relevant gender differences were also observed. A seasonal effect was noted, with a peak in calls during spring for females and summer for males. Conclusions: These findings highlight the need for comprehensive mental health targeted interventions and preventive strategies that account for gender-specific disparities, age-related vulnerabilities, and the specific characteristics of neighborhoods.

Specific effects of cumulative childhood trauma on suicidality among youths.

BACKGROUND: Suicidality was very high among individuals who suffered from childhood trauma. The distribution of cumulative childhood trauma among youths remains unclear, as well as the specific effects of cumulative childhood trauma on suicidality. This study attempted to explore the distribution of cumulative childhood trauma and examine the specific effects of cumulative childhood trauma on suicidality. METHODS: A cross-sectional design was employed in this study, with 117,769 college students recruited from 63 universities in Jilin Province, China. All variables were measured by corresponding self-report questionnaires. The Venn diagram was used to represent the distribution of single and cumulative childhood trauma. ANOVA and chi-square tests were conducted to identify the high-risk suicide groups. Multiple linear regression analysis was performed to examine risk factors for suicidality for overlapping subtypes. RESULTS: 27,671 (23.5%) participants reported suffering from childhood trauma, of which 49.5% were male (Mage = 19.59, SD = 1.76). The "physical neglect" group accounted for the largest proportion (31.5%). Suicidality was the highest in the "overlap of childhood neglect, emotional abuse, and physical abuse" group (2.0%). Depression, obsessive-compulsive disorder, and post-traumatic stress disorder were common risk factors for suicidality. LIMITATIONS: This study was limited by cross-sectional studies and self-report bias. CONCLUSIONS: The childhood trauma subtype group with the largest proportion was not necessarily the highest suicidality. Both the largest group and the highest-risk suicide group require special attention to their respective risk factors.

"There's room to do more": a mixed-methods study of the Temporary Assistance for Needy Families (TANF) diversion program and intimate partner violence in Georgia.

Introduction: Intimate partner violence (IPV) is a risk factor for homicides and suicides. As poverty is both a predictor and a consequence of IPV, interventions that alleviate poverty-related stressors could mitigate IPV-related harms. Temporary Assistance for Needy Families (TANF), a monthly cash assistance program, is one such potential intervention. In the state of Georgia, the TANF diversion program, which provides a non-recurrent lump-sum payment to deter individuals from monthly TANF benefits, is an understudied component of TANF that may influence the effectiveness of state TANF programs in supporting IPV survivors. Aim: This study quantifies and qualifies the role of Georgia's TANF diversion program in shaping IPV-related mortality. Methods: This study relies on a mixed-methods sequential explanatory design. Using data from the Georgia Violent Death Reporting System (GA-VDRS), an interrupted time series analysis was conducted to estimate the effect of TANF diversion on IPV-related homicides and suicides. Semi-structured interviews were then administered with TANF policy experts and advocates, welfare caseworkers, and benefit recipients (n = 20) to contextualize the quantitative findings. Results: The interrupted time series analysis revealed three fewer IPV-related deaths per month after implementing TANF diversion, compared to pre-diversion forecasts (coefficient = -3.003, 95%CI [-5.474, -0.532]). However, the qualitative interviews illustrated three themes regarding TANF diversion: (1) it is a "band-aid" solution to the access barriers associated with TANF, (2) it provides short-term relief to recipients making hard choices, and (3) its limitations reveal avenues for policy change. Discussion: While diversion has the potential to reduce deaths from IPV, it may be an insufficient means of mitigating the poverty-related contributors to IPV harms. Its limitations unveil the need for improved programs to better support IPV survivors.

The long-term changing patterns of suicide mortality in China from 1987 to 2020: continuing urban-rural disparity.

BACKGROUND: Over the past three decades, China has experienced significant changes in urban-rural, gender, and age-specific suicide mortality patterns. This study aimed to investigate the long-term trends in suicide mortality in China from 1987 to 2020. METHODS: Suicide mortality data were obtained from China's National Health Commission. Joinpoint regression analysis was used to examine changes in trends and age-period-cohort modeling to estimate age, period, and cohort effects on suicide mortality from 1987 to 2020. Net drift, local drift, longitudinal age curves, and period relative risks were also calculated. RESULTS: Crude and age-standardized suicide mortality in China showed continuing downward trends from 1987 to 2020, with a more pronounced decrease in rural areas (net drift = -7.07%, p<0.01) compared to urban areas (net drift = -3.41%, p<0.01). The decline curve of urban areas could be divided into three substages. Period and cohort effects were more prominent in rural areas. Suicide risk was highest among individuals aged 20-24 and gradually increased after age 60. Females, particularly those of childbearing age, had higher suicide risk than males, with a reversal observed after age 50. This gender reversal showed distinct patterns in urban and rural areas, with a widening gap in urban areas and a relatively stable gap in rural areas. CONCLUSIONS: Suicide mortality in China has consistently declined over the past three decades. However, disparities in age, gender, and urban-rural settings persist, with new patterns emerging. Targeted suicide prevention programs are urgently needed for high-risk groups, including females of childbearing age and the elderly, and to address the slower decrease and reversing urban-rural gender trends.

Suicide prevention: reflections on progress over the past decade.

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.

Epidemiological characteristics and behaviors of online broadcast suicidality in China: implications for targeted prevention strategies.

Objectives: Suicide is a global health concern, exacerbated by stigma around mental illnesses. Online platforms like Twitter and Sina Weibo have seen a rise in "online broadcast suicide," where individuals share suicidal thoughts and actions. However, there is limited understanding of the epidemiological characteristics, particularly in China. This study aims to analyze the demographics and behaviors of individuals engaging in online broadcast suicide in China to inform targeted prevention strategies. Methods: A total of 525 incidents were identified through systematic retrieval of relevant news reports from online sources. Subsequently, a content analysis was performed on these reports to extract detailed information on the characteristics of each individual incident. Results: Among the incidents analyzed, the male-to-female ratio was 1:1.6, with an average age of 23.1 ± 5.9 years. Approximately 71.9% took place in Southern China. Unemployment was reported in 15.0% of incidents. Relationship breakup (62.3%) was cited as the leading cause of suicide. Wrist cutting (58.2%) emerged as the predominant suicide method, and home (36.2%) was the most common location for these tragic events. Instant messaging apps were the primary platforms (54.7%) for conveying suicidal thoughts and actions. Additionally, among the 525 incidents examined, 12.0% disclosed having a mental disorder, and 7.6% had a history of prior suicide attempts. Significant variations were observed across age, gender, region, and occupation categories. Conclusion: This study emphasizes the importance of developing suicide prevention programs for internet users. Besides, interventions should be customized to meet the specific needs of various populations.

Time-varying living arrangements and suicide death in the general population sample: 14-year causal survival analysis via pooled logistic regression.

AIMS: While past research suggested that living arrangements are associated with suicide death, no study has examined the impact of sustained living arrangements and the change in living arrangements. Also, previous survival analysis studies only reported a single hazard ratio (HR), whereas the actual HR may change over time. We aimed to address these limitations using causal inference approaches. METHODS: Multi-point data from a general Japanese population sample were used. Participants reported their living arrangements twice within a 5-year time interval. After that, suicide death, non-suicide death and all-cause mortality were evaluated over 14 years. We used inverse probability weighted pooled logistic regression and cumulative incidence curve, evaluating the association of time-varying living arrangements with suicide death. We also studied non-suicide death and all-cause mortality to contextualize the association. Missing data for covariates were handled using random forest imputation. RESULTS: A total of 86,749 participants were analysed, with a mean age (standard deviation) of 51.7 (7.90) at baseline. Of these, 306 died by suicide during the 14-year follow-up. Persistently living alone was associated with an increased risk of suicide death (risk difference [RD]: 1.1%, 95% confidence interval [CI]: 0.3-2.5%; risk ratio [RR]: 4.00, 95% CI: 1.83-7.41), non-suicide death (RD: 7.8%, 95% CI: 5.2-10.5%; RR: 1.56, 95% CI: 1.38-1.74) and all-cause mortality (RD: 8.7%, 95% CI: 6.2-11.3%; RR: 1.60, 95% CI: 1.42-1.79) at the end of the follow-up. The cumulative incidence curve showed that these associations were consistent throughout the follow-up. Across all types of mortality, the increased risk was smaller for those who started to live with someone and those who transitioned to living alone. The results remained robust in sensitivity analyses. CONCLUSIONS: Individuals who persistently live alone have an increased risk of suicide death as well as non-suicide death and all-cause mortality, whereas this impact is weaker for those who change their living arrangements.

Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis.

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Risk factors and their association network for young adults' suicidality: a cross-sectional study.

BACKGROUND: Understanding the intricate influences of risk factors contributing to suicide among young individuals remains a challenge. The current study employed interpretable machine learning and network analysis to unravel critical suicide-associated factors in Chinese university students. METHODS: A total of 68,071 students were recruited between Sep 2016 and Sep 2020 in China. Students reported their lifetime experiences with suicidal thoughts and behaviors, categorized as suicide ideation (SI), suicide plan (SP), and suicide attempt (SA). We assessed 36 suicide-associated factors including psychopathology, family environment, life events, and stigma. Local interpretations were provided using Shapley additive explanation (SHAP) interaction values, while a mixed graphical model facilitated a global understanding of their interplay. RESULTS: Local explanations based on SHAP interaction values suggested that psychoticism and depression severity emerged as pivotal factors for SI, while paranoid ideation strongly correlated with SP and SA. In addition, childhood neglect significantly predicted SA. Regarding the mixed graphical model, a hierarchical structure emerged, suggesting that family factors preceded proximal psychopathological factors, with abuse and neglect retaining unique effects. Centrality indices derived from the network highlighted the importance of subjective socioeconomic status and education in connecting various risk factors. CONCLUSIONS: The proximity of psychopathological factors to suicidality underscores their significance. The global structures of the network suggested that co-occurring factors influence suicidal behavior in a hierarchical manner. Therefore, prospective prevention strategies should take into account the hierarchical structure and unique trajectories of factors.

Variations in healthcare utilization for mental health problems prior to suicide by socioeconomic status: a Norwegian register-based population study.

BACKGROUND: Suicide poses a major public health challenge, claiming around 650 lives annually in Norway. There is limited understanding of mental healthcare utilization patterns preceding suicide, particularly relating to socioeconomic status (SES). This study analyzes mental health service use among Norwegian citizens aged 20-64 from 2009 to 2021, emphasizing disparities related to SES. METHODS: This is a population-wide registry-based study. We include mental health consultations with both primary and specialist healthcare services, and investigate patterns of service use regarding educational attainment, employment status and income and compare this to the population in general. All suicides in the period (N = 4731) are included in the study. The aim is to investigate potential discrepancies in service use the year and month preceding suicide, seeking to enhance targeted preventive interventions. RESULTS: Our results show significant variations in healthcare use for mental health problems the last year preceding suicide, according to the components of SES, for both men and women. Those with higher education utilize the mental healthcare services prior to suicide to a higher degree than men and women with high school education or less, whereas employed men and men with high income level have significantly lower mental healthcare usage prior to suicide both the last year and month compared to the non-employed men and men with low-income level. Employed women also had a lower mental healthcare usage, whereas the results regarding income are not significant for women. CONCLUSION: Mental healthcare use prior to suicide varies across the SES components. Notably, the SES groups exhibit heterogeneity, with gendered patterns. Targeted interventions for low consultation rates among employed men, and men with high income and lower education are needed, while women, and men in at-risk groups, such as the non-employed and those with low income, demonstrate higher mental healthcare utilization, warranting comprehensive suicide prevention measures.

Disease burden of mental disorders among children and adolescents considering both co-morbidities and suicide in Northeastern China.

BACKGROUND: Few studies have assessed the burden of mental disorders among children and adolescents considering the impact of co-morbidities and suicide on disability adjusted life years (DALYs). METHODS: This was a multicenter cross-sectional study. Our survey data in Liaoning Province (LN) were used to estimate the burden of six mental disorders, supplemented with data from other investigative studies conducted in China to assess four other disorders. DALYs were derived from the sum of years lived with a disability (YLDs) adjusted for co-morbidities, and the years of life lost (YLLs) adjusted for suicide. The changes in DALYs, YLDs, and YLLs were compared with and without adjustment for co-morbidities and suicide. RESULTS: The DALYs rate of mental disorders among children and adolescents in LN decreased from 1579.6/105 to 1391.4/105, after adjusting for both co-morbidities and suicide (-11.9%). The DALYs rate for major depression, anxiety disorder, and conduct disorder (-80.8/105, -75.0/105 and -30.2/105, respectively) were the top three contributors to the DALYs reduction (-188.2/105). The YLDs decreased from 72724.8 to 62478.5 after co-morbidity adjustment (-17.8%), mainly due to the reduction by major depression (-35.3%) and attention deficit/hyperactivity disorder [ADHD] (-34.2%). The YLLs increased from 130 to 1697.8 after adjusting for suicides (+ 56.9% of all suicide YLLs), mainly due to the contribution of major depression (+ 32.4%) and anxiety disorder (+ 10.4%). Compared to GBD 2010, the estimated DALY rate for mental disorders in LN was to be about 80%, with the proportion of DALYs and DALY rates explained by major depressive disorder accounted for only approximately one-third (14.6% vs. 41.9% and 202.6 vs. 759.9, respectively). But the proportion and absolute level of DALY rates explained by anxiety disorders were approximately 2-fold higher (39.7% vs. 19.6% and 552.2 vs. 323.3, respectively). CONCLUSIONS: The DALYs of mental disorders among Chinese children and adolescents were approximately 80% of the global level, with anxiety disorders imposing about 2 times the global level. Co-morbidity and suicide must be adjusted when calculating DALYs.

Machine Learning-Based Prediction of Suicidal Thinking in Adolescents by Derivation and Validation in 3 Independent Worldwide Cohorts: Algorithm Development and Validation Study.

BACKGROUND: Suicide is the second-leading cause of death among adolescents and is associated with clusters of suicides. Despite numerous studies on this preventable cause of death, the focus has primarily been on single nations and traditional statistical methods. OBJECTIVE: This study aims to develop a predictive model for adolescent suicidal thinking using multinational data sets and machine learning (ML). METHODS: We used data from the Korea Youth Risk Behavior Web-based Survey with 566,875 adolescents aged between 13 and 18 years and conducted external validation using the Youth Risk Behavior Survey with 103,874 adolescents and Norway's University National General Survey with 19,574 adolescents. Several tree-based ML models were developed, and feature importance and Shapley additive explanations values were analyzed to identify risk factors for adolescent suicidal thinking. RESULTS: When trained on the Korea Youth Risk Behavior Web-based Survey data from South Korea with a 95% CI, the XGBoost model reported an area under the receiver operating characteristic (AUROC) curve of 90.06% (95% CI 89.97-90.16), displaying superior performance compared to other models. For external validation using the Youth Risk Behavior Survey data from the United States and the University National General Survey from Norway, the XGBoost model achieved AUROCs of 83.09% and 81.27%, respectively. Across all data sets, XGBoost consistently outperformed the other models with the highest AUROC score, and was selected as the optimal model. In terms of predictors of suicidal thinking, feelings of sadness and despair were the most influential, accounting for 57.4% of the impact, followed by stress status at 19.8%. This was followed by age (5.7%), household income (4%), academic achievement (3.4%), sex (2.1%), and others, which contributed less than 2% each. CONCLUSIONS: This study used ML by integrating diverse data sets from 3 countries to address adolescent suicide. The findings highlight the important role of emotional health indicators in predicting suicidal thinking among adolescents. Specifically, sadness and despair were identified as the most significant predictors, followed by stressful conditions and age. These findings emphasize the critical need for early diagnosis and prevention of mental health issues during adolescence.

Share of Adult Suicides After Recent Jail Release.

Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

Parental Legal System Involvement, Positive Childhood Experiences, and Suicide Risk.

OBJECTIVES: To examine whether adverse parental legal system involvement (incarceration, arrest) was associated with suicide risk, accounting for other adverse childhood experiences, and whether there was a moderating relationship between positive childhood experiences (PCEs) and parental legal system involvement in suicide risk. METHODS: This cross-sectional study used 2-year follow-up data from the Adolescent Brain Cognitive Development Study when children were age 11 to 12 years. Outcomes were lifetime suicidal ideation, attempts, and nonsuicidal self-injury (NSSI). Exposures were parent incarceration or arrest. We used generalized linear models to estimate the relative risk of suicide outcomes from adverse parent legal involvement and whether there was an interaction between parent legal system involvement and PCE count, controlling for adverse childhood experiences and demographic factors. RESULTS: Among our sample (n = 10 532;), 687 children (6.5%) reported parent incarceration and 1265 (12.0%) reported parent arrest. Suicidal ideation was the most frequent risk outcome (n = 490; 4.7%). Children whose parents had been incarcerated had a relative risk of suicidal ideation of 1.74 (95% CI: 1.32-2.31). Children whose parents had been arrested had a relative risk of suicidal ideation of 1.89 (95% CI: 1.53-2.37) and a relative risk of suicide attempt of 2.69 (95% CI: 1.7-4.25). Parental incarceration/arrest were not associated with NSSI. PCEs were associated with reduced relative risk of suicidal ideation and NSSI, though there was no significant interaction between PCEs and adverse parent legal system involvement exposures. CONCLUSIONS: Parental legal system involvement may negatively affect child mental health. Strengthening PCEs in childhood may mitigate suicide-related risks.