Recognizing and coping with suicidal thoughts: A mixed-methods investigation of digital safety plan content.

OBJECTIVES: Suicide safety plans are a personalized means of documenting how a person at risk of suicide recognizes and intends to cope with emerging suicidal thoughts. This study aimed to understand how users of digital suicide safety plans describe their warning signs, methods of coping and any relationships between these that may emerge. METHODS: A sample comprising 150 users of the Australian suicide safety planning smartphone app Beyond Now consented to share the content of their safety plans. Reflexive thematic analysis was used to identify themes in overall plan content. Most participants identified as women (61%), had a history of at least one suicide attempt (61%) and completed their plans by themselves (84%). RESULTS: Three major themes emerged: (1) interpersonal challenges and complexity; (2) matching coping strategies to warning signs; and (3) helpful and harmful digital technology use. Most plans appeared to demonstrate high self-awareness of warning signs and available supports. CONCLUSIONS: Safety plan content provides a window into the thought process underlying the recognition of suicidal thoughts and the attempts to manage them. An opportunity exists for practitioners and support persons to use this content when collaboratively supporting a safety plan user to improve their coping strategies and support networks.

The association between home learning during COVID-19 lockdowns and subsequent school attendance among children with neurodevelopmental conditions.

BACKGROUND: Children with neurodevelopmental conditions have high levels of school absence. During the COVID-19 pandemic, schools closed for many students. The relationship between home learning during school closures and subsequent school attendance requires attention to better understand the impact of pandemic education policy decisions on this population. This study aims to investigate the association between home learning, hybrid learning and school learning during school closures (in January-March 2021) with subsequent school attendance (in May 2021) in children with neurodevelopmental conditions. METHODS: An online survey was completed by 809 parents/carers of 5- to 15-year-old autistic children and/or children with intellectual disability. Regression models examined the association of learning location during school closures with subsequent school absence (i.e., total days missed, persistent absence and school refusal). RESULTS: Children who were learning from home during school closures later missed 4.6 days of a possible 19. Children in hybrid and school learning missed 2.4 and 1.6 school days, respectively. The rates of school absence and persistent absence were significantly higher in the home learning group even after adjusting for confounders. Learning location was not associated with subsequent school refusal. CONCLUSIONS: Policies for school closures and learning from home during public health emergencies may exacerbate school attendance problems in this group of vulnerable children.

Evaluating the Effect of Parent-Child Interactive Groups in a School-Based Parent Training Program: Parenting Behavior, Parenting Stress and Sense of Competence.

The Exploring Together program is a group-based parent training program that comprises separate parent, child, and teacher components, and a combined parent-child interactive component. A cluster-randomized trial design was used to compare the Exploring Together program with (Exploring Together; ET) and without (Exploring Together-Adapted; ET-Adapted) the parent-child interactive component. One hundred and thirty-six parents and their children (aged 5-10 years) with externalizing and/or internalizing problems participated in the trial, recruited from primary schools. There was a significant reduction in negative parenting behavior across both treatment groups (ET and ET-Adapted) but no significant improvement in positive parenting behaviors. Parenting self-efficacy improved significantly across both treatment groups however there was no significant change in parenting satisfaction or parenting stress. There was no consistent evidence of superiority of one version of the Exploring Together program over the other. Further investigation regarding treatment dosage and mastery of parenting skills associated with the program is warranted.

Associations Between Anxiety and Home Learning Difficulties in Children and Adolescents with ADHD During the COVID-19 Pandemic.

The COVID-19 pandemic has markedly impacted functioning for children and adolescents including those with attention-deficit/hyperactivity disorder (ADHD). We explored home learning difficulties (HLD) during COVID-19 restrictions in Australian children (aged 5-17) with ADHD, aiming to: (1) describe home learning experiences, and (2) examine associations between child anxiety (i.e., concurrent anxiety symptoms and pre-existing anxiety disorder status) and HLD. Baseline data from the longitudinal ADHD COVID-19 Survey were used (n = 122). Parents reported on school factors and HLD; pre-existing anxiety and co-occurring difficulties; anxiety, ADHD, and oppositional symptoms; demographics; and medications. Parents retrospectively reported more children often looked forward to school pre-pandemic, than during the pandemic. Anxiety symptoms, but not pre-existing anxiety disorder status, were associated with HLD after accounting for covariates. ADHD inattention symptoms were also associated with HLD. Results support recommendations to continue pre-pandemic supports to assist with ADHD symptoms during home learning, and strategies/supports for families are discussed.

Identifying post-traumatic stress disorder in women of refugee background at a public antenatal clinic.

The aim of this study was to investigate symptomatology and diagnoses of PTSD and subthreshold PTSD and the screening properties of the Harvard Trauma Questionnaire (HTQ) within a sample of Dari-speaking women of refugee background receiving antenatal care. This cross-sectional study administered the HTQ to 52 Dari-speaking women at a public pregnancy clinic. The trauma module from the Structured Clinical Interview (SCID-5) was administered. Interview material was presented to an expert panel, blinded to the HTQ screening results, in order to achieve consensus diagnoses of PTSD using Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) criteria. Three women (5.8%) met DSM-5 criteria for PTSD. Eleven women (21.15%) met criteria for subthreshold PTSD, defined as meeting two or three of the DSM-5 criteria domains. A comparison of HTQ cut-off scores was conducted and a score of ≥ 2.25 on the HTQ demonstrated excellent sensitivity 1.00 (95% CI 0.29-1.00) and specificity 0.76 (95% CI 0.61-0.87) in detecting PTSD; however, a wide confidence interval for sensitivity was found. A cut-off score of ≥ 2 provided the best balance of sensitivity 1.00 (95% CI 0.72-1.00) and specificity 0.80 (95% CI 0.65-0.91) when assessing for subthreshold PTSD. Screening for perinatal PTSD for women of refugee background is recommended, in order to identify those at risk of DSM diagnosis and also those women experiencing distressing PTSD symptomatology.

Short-term outcomes of the Therapist-assisted Online Parenting Strategies intervention for parents of adolescents treated for anxiety and/or depression: A single-arm double-baseline trial.

OBJECTIVE: This study aimed to evaluate whether the Therapist-assisted Online Parenting Strategies programme increased parenting behaviours known to be supportive of adolescents experiencing anxiety and/or depression. Secondary parenting outcomes of parental self-efficacy, parental accommodation, carer burden, parent-adolescent attachment, family functioning and parent distress were also examined, along with adolescent outcomes of anxiety and depression symptoms, suicidal ideation and sleep. METHOD: Seventy-one parents (94.4% females) and their adolescents (73.2% females) aged 12-18 years (Mean = 15.02, SD = 1.56) being treated for depression and/or anxiety in Australia were recruited into a single-arm double-baseline open-label trial. Parents received Therapist-assisted Online Parenting Strategies, which comprised up to nine web-based modules each supplemented with coaching sessions via videoconferencing. Outcomes were analysed using latent growth curve modelling to determine if changes to outcomes at post-intervention (4 month post-second baseline) exceeded changes between two baselines measured 1 month apart. RESULTS: Sixty-five parents (91.6%) completed at least one module of the online parenting intervention and on average received nine coaching sessions (SD = 2). Parenting behaviours targeted by Therapist-assisted Online Parenting Strategies improved at post-intervention (Cohen's d = 1.16, 95% confidence interval [0.78, 1.51]). Parent-reported parental self-efficacy and parent-adolescent attachment increased (Cohen's d = 1.44 [1.05, 1.82] and 0.39 [0.05, 0.74], respectively), while impairments to family functioning and parent distress decreased (Cohen's d = -0.51 [-0.86, -0.16] and -0.84 [-1.23, -0.44], respectively). Changes to adolescent anxiety, depression and sleep were not significant. CONCLUSION: The Therapist-assisted Online Parenting Strategies intervention improved self-reported parenting behaviours, parental self-efficacy, parent levels of distress, parent-adolescent attachment, and family functioning in parents with adolescents being treated for anxiety and/or depression. However, significant changes in adolescent mental health and sleep outcomes at post-intervention were not observed. The usefulness of a therapist-supported online parenting programme in addressing a service gap for parents seeking professional help is indicated. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number (ACTRN) 12618000290291, prospectively registered on 26 February 2018; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368031.

Parent and child mental health trajectories April 2020 to May 2021: Strict lockdown versus no lockdown in Australia.

OBJECTIVE: To control a second-wave COVID-19 outbreak, the state of Victoria in Australia experienced one of the world's first long and strict lockdowns over July-October 2020, while the rest of Australia experienced 'COVID-normal' with minimal restrictions. We (1) investigate trajectories of parent/child mental health outcomes in Victoria vs non-Victoria and (2) identify baseline demographic, individual and COVID-19-related factors associated with mental health trajectories. METHODS: Online community sample of 2004 Australian parents with rapid repeated assessment over 14 time-points over April 2020 to May 2021. Measures assessed parent mental health (Depression, Anxiety and Stress Scales-21), child depression symptoms (13-item Short Mood and Feelings Questionnaire) and child anxiety symptoms (four items from Brief Spence Children's Anxiety Scale). RESULTS: Mental health trajectories shadowed COVID-19 infection rates. Victorians reported a peak in mental health symptoms at the time of the second-wave lockdown compared to other states. Key baseline predictors, including parent and child loneliness (standardized regression coefficient [ß] = 0.09-0.46), parent/child diagnoses (ß = 0.07-0.21), couple conflict (ß = 0.07-0.18) and COVID-19 stressors, such as worry/concern about COVID-19, illness and loss of job (ß = 0.12-0.15), predicted elevated trajectories. Effects of predictors on parent and child mental health trajectories are illustrated in an online interactive app for readers (https://lingtax.shinyapps.io/CPAS_trend/). CONCLUSION: Our findings provide evidence of worse trajectories of parent and child mental health symptoms at a time coinciding with a second COVID-19 outbreak involving strict lockdown in Victoria, compared to non-locked states in Australia. We identified several baseline factors that may be useful in detecting high-risk families who are likely to require additional support early on in future lockdowns.

Psychological interventions for depression in children and young people with an intellectual disability and/or autism: systematic review.

BACKGROUND: Children and young people with intellectual disability and/or Autism Spectrum Disorder (autism) experience higher rates of mental health problems, including depression, than their typically developing peers. Although international guidelines suggest psychological therapies as first-line intervention for children and young people, there is limited evidence for psychological therapy for depression in children and young people with intellectual disability and/or autism. AIMS: To evaluate the current evidence base for psychological interventions for depression in children and young people with intellectual disability and/or autism, and examine the experiences of children and young people with intellectual disability and/or autism, their families and therapists, in receiving and delivering psychological treatment for depression. METHOD: Databases were searched up to 30 April 2020 using pre-defined search terms and criteria. Articles were independently screened and assessed for risk of bias. Data were synthesised and reported in a narrative review format. RESULTS: A total of 10 studies met the inclusion criteria. Four identified studies were clinical case reports and six were quasi-experimental or experimental studies. All studies were assessed as being of moderate or high risk of bias. Participants with intellectual disability were included in four studies. There was limited data on the experiences of young people, their families or therapists in receiving or delivering psychological treatment for depression. CONCLUSIONS: Well-designed, randomised controlled trials are critical to develop an evidence base for psychological treatment for young people with intellectual disability and/or autism with depression. Future research should evaluate the treatment experiences of young people, their families and therapists.

Perceived Invalidation in Adolescent Borderline Personality Disorder: An Investigation of Parallel Reports of Caregiver Responses to Negative Emotions.

Childhood experiences of emotional invalidation are commonly reported by adults with borderline personality disorder (BPD). This study aimed to compare perceptions of emotional invalidation between adolescents with and adolescents without BPD, and their primary caregivers. Participants were 51 adolescents subdivided into a clinical group of 26 adolescents with BPD and a community-control group of 25 adolescents, each with their primary caregivers. To examine perceptions of invalidation, adolescents and caregivers completed parallel reports assessing caregiver responses to adolescents' negative emotions. Adolescents with BPD reported more punitive and less supportive responses to their negative emotions than their caregivers. In the control group, by contrast, differences between caregiver and adolescent reports were due to caregivers rating themselves more harshly than did adolescents. Findings demonstrated that adolescents with BPD perceived their caregivers to be relatively less supportive and more invalidating than did adolescents without BPD. Results highlight the importance of adolescents' subjective experiences of caregiving to enduring borderline psychopathology.

Shame and Non-suicidal Self-injury: Conceptualization and Preliminary Test of a Novel Developmental Model among Emerging Adults.

Non-suicidal self-injury (NSSI) is particularly prevalent during adolescence and emerging adulthood. The salience of shame during these developmental periods suggests that shame may be inherently linked to NSSI, and at least partially explain the high rates of NSSI observed among youth. In this article, a theoretical developmental model relating shame and NSSI is proposed, and results from a preliminary test of a sub-set of cross-sectional relationships in this model is presented. In the model tested, it was hypothesized that adverse caregiving experiences in prior development (i.e., childhood to late adolescence) like parental invalidation and child maltreatment, established predictors of NSSI, would be linked to proximal episodes of NSSI (i.e., past year) through current shame-proneness (i.e., experiencing shame in a trait-like manner) and internalizing shame-coping (i.e., responding to shame through attacking one's self and withdrawing). It was also hypothesized that some key proximal predictors of NSSI during youth development, such as low body esteem, increased loneliness and heightened psychological distress, would be linked to proximal NSSI via shame-proneness and internalizing shame-coping. Using structural equation modelling, it was observed that data, obtained via self-reports completed by 573 emerging adults (age in years: M = 20.7, SD= 2.20, 69.1% female, NSSI history: n = 220, where most recent NSSI episode was within a year of study participation) recruited throughout Australia between June 2013 and June 2014, fit the hypothesized model well. Tests of indirect effects indicated that current shame-proneness and internalizing shame-coping significantly linked perceived parental invalidation and prior experiences of child maltreatment to proximal NSSI, though this relationship was, unexpectedly, an inverse one in relation to child maltreatment. Current shame-proneness was also linked to proximal NSSI via internalizing shame-coping, current loneliness, and current psychological distress, but not through current body esteem. Finally, proximal self-evaluations of body esteem, loneliness and increased psychological distress were linked to recent NSSI through internalizing shame-coping. The theory and findings presented in this article contribute to a deeper developmental understanding of NSSI among youth, highlight crucial pathways between adverse caregiving experiences and NSSI, and illuminate important shame-based mechanisms that potentially warrant clinical attention for at-risk individuals. Future research directions and clinical recommendations are discussed.

An investigation of the mentalization-based model of borderline pathology in adolescents.

OBJECTIVE: According to mentalization-based theory, transgenerational transmission of mentalization from caregiver to offspring is implicated in the pathogenesis of borderline personality disorder (BPD). Recent research has demonstrated an association between hypermentalizing (excessive, inaccurate mental state reasoning) and BPD, indicating the particular relevance of this form of mentalizing dysfunction to the transgenerational mentalization-based model. As yet, no study has empirically assessed a transgenerational mentalization-based model of BPD. The current study sought firstly to test the mentalization-based model, and additionally, to determine the form of mentalizing dysfunction in caregivers (e.g., hypo- or hypermentalizing) most relevant to a hypermentalizing model of BPD. METHOD: Participants were a mixed sample of adolescents with BPD and a sample of non-clinical adolescents, and their respective primary caregivers (n = 102; 51 dyads). Using an ecologically valid measure of mentalization, mediational analyses were conducted to examine the relationships between caregiver mentalizing, adolescent mentalizing, and adolescent borderline features. RESULTS: Findings demonstrated that adolescent mentalization mediated the effect of caregiver mentalization on adolescent borderline personality pathology. Furthermore, results indicated that hypomentalizing in caregivers was related to adolescent borderline personality pathology via an effect on adolescent hypermentalizing. CONCLUSIONS: Results provide empirical support for the mentalization-based model of BPD, and suggest the indirect influence of caregiver mentalization on adolescent borderline psychopathology. Results further indicate the relevance of caregiver hypomentalizing to a hypermentalizing model of BPD.

The Cranky Thermometers: Visual analogue scales measuring irritability in youth.

This study assessed the psychometric properties of two visual analogue scales of irritability, known as the Cranky Thermometers (CT), in both an Australian community secondary-school sample (N = 164) and a sample of adolescents with a depressive disorder (N = 127). The first scale Cranky Now measures current irritability, and the second, Cranky Two Weeks, measures peak irritability within the last two weeks. CT scores were significantly higher in adolescents with major depressive disorder than in the school sample and showed improvement following treatment for depression. Positive associations were found between CT and irritability scores as determined by Kiddie Schedule for Affective Disorders and Schizophrenia (not irritable, sub-threshold, threshold irritability) and Affective Reactivity Index scores. Results suggest that the CTs are rapidly administered, have promising psychometric properties and demonstrate utility in measuring irritability in clinical and community settings.

Systematic Review and Meta-analysis of Parent Group Interventions for Primary School Children Aged 4-12 Years with Externalizing and/or Internalizing Problems.

This systematic review and meta-analysis evaluates the efficacy of parent training group interventions to treat child externalizing and/or internalizing problems. A search identified 21 randomized controlled trials of parent group interventions aimed at ameliorating child externalizing and/or internalizing problems in children aged 4-12 years. Random effects meta-analyses yielded significant pooled treatment effect size (g) estimates for child externalizing (g = -0.38) and internalizing problems (g = -0.18). Child anxiety symptoms or internalizing problems evident in children with externalizing behavior problems did not change significantly following intervention. Study quality was a statistically significant moderator of treatment response for child externalizing problems, however hours of planned parent group treatment and treatment recipient were not. Findings support the use of parent group interventions as an effective treatment for reducing externalizing problems in children aged 4-12 years. Whilst statistically significant, programs had a limited impact on internalizing symptoms, indicating a need for further investigation.

Should we recommend exercise to adolescents with depressive symptoms? A meta-analysis.

There is growing interest in the potential role of exercise in the reduction of depressive symptoms. The aim of this meta-analysis was to examine whether exercise reduces depressive symptoms amongst depressed adolescents. The following databases were searched on 30 January 2015: MEDLINE, PsychINFO, SPORTDiscuss and PUBMED. Studies were included if they examined exercise interventions amongst adolescents with clinical levels of depressive symptoms, were published in peer-reviewed journals in the English language and contained a control/comparison group. Of 6631 retrieved studies, eight studies were included in the meta-analysis. Meta-analysis was conducted using a random effects model due to the high level of heterogeneity identified amongst studies ( I 2 = 65.1, P < .005). The analysis revealed a moderate reduction in depressive symptoms post-intervention (Hedge's g = -0.61, P = .007). This analysis provides preliminary evidence that exercise is effective in reducing symptoms of depression among adolescents with clinical levels of depressive symptoms. The present meta-analysis, however, is limited by the generally low quality of included studies, high level of between-study heterogeneity and restriction of inclusion criteria to published studies. Further high-quality trials with depressed adolescents are needed to determine the efficacy of exercise in the reduction of depressive symptoms and the exercise parameters associated with the antidepressant effects of exercise.

Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial.

This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11-16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.

Familial separations, coping styles, and PTSD symptomatology in resettled refugee youth.

Youth from refugee backgrounds have been found to experience high rates of posttraumatic stress disorder (PTSD), even after years of resettlement. The present study sought to investigate how familial separations and coping styles act as correlates of PTSD symptoms in resettled refugee youth (N = 50). Participants (Mage = 16.63; range: 12-21) completed self-report questionnaires assessing PTSD symptoms and their use of coping styles, and engaged in a semi-structured interview designed by the authors to investigate their resettlement and adaptational experiences in Australia. Youth who were separated from immediate family members demonstrated significantly more PTSD symptoms than their counterparts, and there was a relationship between avoidant coping and PTSD, although this diminished once the confound between scales was controlled for. This study found evidence for the integrity of the family unit as a correlate of PTSD in refugee youth, but no evidence of a relationship between coping style and family separations.

Day program for young people with anorexia nervosa.

OBJECTIVES: This study examined changes in body mass index (BMI), anorectic cognitions, and psychological distress following day program treatment. METHODS: Participants were 42 female patients from the Monash Health Butterfly eating disorder day program, with anorexia nervosa (AN) restricting type (n = 35) or AN binge-eating/purging type (n = 7), ranging from 12 to 24 years. RESULTS: Participants' BMI increased significantly over time. Higher motivation at intake predicted a greater increase in BMI over time, compared to those with lower motivation at intake. There were also significant reductions in drive for thinness, body dissatisfaction, anxiety, and depression scores, and improved motivation following two, four and six months of treatment. CONCLUSIONS: These findings provide further evidence that day programs can assist in weight restoration and improvements in psychological aspects of AN in adolescents and young adults.

Feasibility and validity of ecological momentary assessment in adolescents with high-functioning autism and Asperger's disorder.

Ecological Momentary Assessment (EMA) may increase accuracy of data compared with retrospective questionnaires by assessing behaviours as they occur, hence decreasing recall biases and increasing ecological validity. This study examined the feasibility and concurrent validity of an EMA tool for adolescents with High-Functioning Autism Spectrum Disorders (HFASD). Thirty-one adolescents with HFASD completed a mobile phone EMA application that assessed stressors and coping for two weeks. Parents and adolescents also completed retrospective measures of the adolescent's coping/stressors. Moderate compliance with the EMA tool was achieved and some concurrent validity was established with the retrospective measure of coping. Concordance was found between the types of stressors reported by parents and adolescents but not the quantity. The results suggest adolescents with HFASD are capable of reporting on their stressors and coping via EMA. EMA has the potential to be a valuable research tool in this population.

Safety plan use and suicide-related coping in a sample of Australian online help-seekers.

BACKGROUND: Suicide safety plans can improve suicide-related coping skills and reduce suicidal thoughts and behaviours (STBs). However, little is known about their use and impact outside of treatment settings, where most suicidal crises will occur. The current study explored the prevalence of safety plan use among an online sample of help-seekers with lifetime STBs, and whether STBs and suicide-related coping differed between those with and without safety plans. An exploratory aim was to investigate barriers to safety plan use. METHOD: Participants (N = 1251) completed an online, anonymous survey at a mental health support website (Beyond Blue). The survey measured lifetime STBs, past-month suicidal ideation, suicide-related coping, help-seeking intentions and behaviour. RESULTS: Despite high levels of past-month suicidal ideation and past-year help-seeking, most participants (89.5 %) did not have a safety plan, and most of those were not familiar with the concept (70.5 %). Participants with safety plans reported a higher rate of past suicide attempts, but higher suicide-related coping and help-seeking behaviour. Among participants without safety plans, negative attitudes toward safety planning were positively associated with suicidal ideation and negatively associated with suicide-related coping. LIMITATIONS: Participants were primarily female, English-speaking visitors to a mental health support website. Cross-sectional design precludes conclusions being drawn about safety planning effectiveness over time. CONCLUSION: This study highlights the low prevalence of safety plan use among online help-seekers with lifetime STBs and the need to better promote safety planning as an intervention with autonomous benefits, including crisis preparedness and improved suicide-related coping skills.

Perceived Usefulness of Self-Guided Versus Collaborative Suicide Safety Plans in Online Help-Seekers.

Background: Suicide safety plans were originally devised to be paper-based and clinician-guided, but digital self-guided plans are now common. Aim: This study explored whether plan format (paper vs. digital), assistance (self-authored vs. collaboration), and suicide attempt history were associated with differences in suicidal ideation, suicide-related coping, and perceived usefulness. Method: An online sample of safety plan users (N = 131) completed a survey assessing suicidal ideation, suicide-related coping, and perceived usefulness of their plan. t tests compared outcomes by plan format, collaboration, and suicide attempt history. Pearson correlations explored associations between reasons for plan use, suicidal ideation, and suicide-related coping. Results: Suicidal ideation was significantly higher, and perceived usefulness significantly lower in participants with a past suicide attempt (vs. none) and in those who had collaborated to make their safety plan (vs. self-authored). Collaborators were largely health professionals. No significant differences were found between plan formats. Suicide-related coping was associated with higher perceived usefulness overall. Limitations: Our study design was cross-sectional, utilizing a largely young, female, English-speaking, online help-seeking sample. Conclusions: For clients with prior suicide attempts and higher levels of suicidal ideation, meaningful collaboration may be needed to find safety plan coping strategies that are perceived as useful.