Utility of Single Items within the Suicidal Behaviors Questionnaire-Revised (SBQ-R): A Bayesian Network Approach and Relative Importance Analysis.

The Suicidal Behaviors Questionnaire-Revised (SBQ-R) comprises four content-specific items widely used to assess the history of suicide-related thoughts, plans or attempts, frequency of suicidal ideation, communication of intent to die by suicide and self-reported likelihood of a suicide attempt. Each item focuses on a specific parameter of the suicide-related thoughts and behaviors construct. Past research has primarily focused on the total score. This study used Bayesian network modeling and relative importance analyses on SBQ-R data from 1160 U.S. and 1141 Chinese undergraduate students. The Bayesian network analysis results showed that Item 1 is suitable for identifying other parameters of the suicide-related thoughts and behaviors construct. The results of the relative importance analysis further highlighted the relevancy of each SBQ-R item score when examining evidence for suicide-related thoughts and behaviors. These findings provided empirical support for using the SBQ-R item scores to understand the performances of different suicide-related behavior parameters. Further, they demonstrated the potential value of examining individual item-level responses to offer clinically meaningful insights. To conclude, the SBQ-R allows for the evaluation of each critical suicide-related thought and behavior parameter and the overall suicide risk.

Tracking and Profiling Repeated Users Over Time in Text-Based Counseling: Longitudinal Observational Study With Hierarchical Clustering.

BACKGROUND: Due to their accessibility and anonymity, web-based counseling services are expanding at an unprecedented rate. One of the most prominent challenges such services face is repeated users, who represent a small fraction of total users but consume significant resources by continually returning to the system and reiterating the same narrative and issues. A deeper understanding of repeated users and tailoring interventions may help improve service efficiency and effectiveness. Previous studies on repeated users were mainly on telephone counseling, and the classification of repeated users tended to be arbitrary and failed to capture the heterogeneity in this group of users. OBJECTIVE: In this study, we aimed to develop a systematic method to profile repeated users and to understand what drives their use of the service. By doing so, we aimed to provide insight and practical implications that can inform the provision of service catering to different types of users and improve service effectiveness. METHODS: We extracted session data from 29,400 users from a free 24/7 web-based counseling service from 2018 to 2021. To systematically investigate the heterogeneity of repeated users, hierarchical clustering was used to classify the users based on 3 indicators of service use behaviors, including the duration of their user journey, use frequency, and intensity. We then compared the psychological profile of the identified subgroups including their suicide risks and primary concerns to gain insights into the factors driving their patterns of service use. RESULTS: Three clusters of repeated users with clear psychological profiles were detected: episodic, intermittent, and persistent-intensive users. Generally, compared with one-time users, repeated users showed higher suicide risks and more complicated backgrounds, including more severe presenting issues such as suicide or self-harm, bullying, and addictive behaviors. Higher frequency and intensity of service use were also associated with elevated suicide risk levels and a higher proportion of users citing mental disorders as their primary concerns. CONCLUSIONS: This study presents a systematic method of identifying and classifying repeated users in web-based counseling services. The proposed bottom-up clustering method identified 3 subgroups of repeated users with distinct service behaviors and psychological profiles. The findings can facilitate frontline personnel in delivering more efficient interventions and the proposed method can also be meaningful to a wider range of services in improving service provision, resource allocation, and service effectiveness.

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

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

Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis.

Importance: Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies. Objective: To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts. Design, Setting, and Participants: This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023. Exposures: Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods. Main Outcomes and Measures: Disclosure of recent intent, suicide note presence, and known psychotropic usage. Results: Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged ≥71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%]). Conclusions and Relevance: This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Efficacy of ChatGPT in Cantonese Sentiment Analysis: Comparative Study.

BACKGROUND: Sentiment analysis is a significant yet difficult task in natural language processing. The linguistic peculiarities of Cantonese, including its high similarity with Standard Chinese, its grammatical and lexical uniqueness, and its colloquialism and multilingualism, make it different from other languages and pose additional challenges to sentiment analysis. Recent advances in models such as ChatGPT offer potential viable solutions. OBJECTIVE: This study investigated the efficacy of GPT-3.5 and GPT-4 in Cantonese sentiment analysis in the context of web-based counseling and compared their performance with other mainstream methods, including lexicon-based methods and machine learning approaches. METHODS: We analyzed transcripts from a web-based, text-based counseling service in Hong Kong, including a total of 131 individual counseling sessions and 6169 messages between counselors and help-seekers. First, a codebook was developed for human annotation. A simple prompt ("Is the sentiment of this Cantonese text positive, neutral, or negative? Respond with the sentiment label only.") was then given to GPT-3.5 and GPT-4 to label each message's sentiment. GPT-3.5 and GPT-4's performance was compared with a lexicon-based method and 3 state-of-the-art models, including linear regression, support vector machines, and long short-term memory neural networks. RESULTS: Our findings revealed ChatGPT's remarkable accuracy in sentiment classification, with GPT-3.5 and GPT-4, respectively, achieving 92.1% (5682/6169) and 95.3% (5880/6169) accuracy in identifying positive, neutral, and negative sentiment, thereby outperforming the traditional lexicon-based method, which had an accuracy of 37.2% (2295/6169), and the 3 machine learning models, which had accuracies ranging from 66% (4072/6169) to 70.9% (4374/6169). CONCLUSIONS: Among many text analysis techniques, ChatGPT demonstrates superior accuracy and emerges as a promising tool for Cantonese sentiment analysis. This study also highlights ChatGPT's applicability in real-world scenarios, such as monitoring the quality of text-based counseling services and detecting message-level sentiments in vivo. The insights derived from this study pave the way for further exploration into the capabilities of ChatGPT in the context of underresourced languages and specialized domains like psychotherapy and natural language processing.

Psychosocial and financial well-being mediated the effects of COVID-19 distress on suicidality: a serial mediation model among Hong Kong young adults.

PURPOSE: The COVID-19 pandemic has brought significant distress on not only the physical health but also mental health of individuals. The present study investigated the direct and indirect effects from COVID-19 distress to suicidality via psychosocial and financial well-being among young people. METHODS: This cross-sectional survey recruited 1472 Hong Kong young people via random sampling in 2021. The respondents completed a phone survey on COVID-19 distress, the four-item Patient Health Questionnaire and items on social well-being, financial well-being, and suicidality. Structural equation modeling (SEM) was conducted to examine the direct and indirect effects of COVID-19 distress on suicidality via psychosocial and financial well-being. RESULTS: The direct effect of COVID-19 distress on suicidality was not significant (ß = 0.022, 95% CI - 0.097-0.156). The total indirect effect from COVID-19 distress to suicidality was significant and positive (αßγ = 0.150, 95% CI = 0.085-0.245) and accounted for 87% of the total effect (B = 0.172, 95% CI = 0.043-0.341). There were significant specific indirect effects via social well-being and psychological distress, and financial well-being and psychological distress. CONCLUSION: The present findings support different pathways from COVID-19 distress to suicidality via functioning in different domains among young people in Hong Kong. Measures are needed to ameliorate the impact on their social and financial well-being to reduce their psychological distress and suicidality.

Spatial-temporal analysis of suicide clusters for suicide prevention in Hong Kong: a territory-wide study using 2014-2018 Hong Kong Coroner's Court reports.

Background: This study aimed to (i) identify high-risk suicide-methods clusters, based on location of residence and suicide incidence; and (ii) compare the characteristics of cases and spatial units inside and outside clusters. Methods: Suicide data of 4672 cases was obtained from the Coroner's Court reports in Hong Kong (2014-2018). Monthly aggregated suicide numbers based on location of residence, and suicide incidence, were obtained in small tertiary planning units (STPUs). Community-level characteristics and population of STPUs were retrieved from 2016 Census. Retrospective space-time analyses were performed to identify locations with elevated suicide rates over specific time periods, i.e., spatial-temporal clusters. Clusters were evaluated for overall suicide (any method), as well as jumping, hanging, and charcoal burning methods, in location of residence and suicide incidence. Bi-variate analysis was performed to compare the characteristics of cases, and spatial units, inside and outside the clusters. Findings: Suicide clusters involving jumping and charcoal burning were identified, but no hanging clusters were found. The within-cluster distribution of types of housing was different from that of outside. For most of the overall suicide and suicide by jumping clusters, spatial units within the clusters were more socially disadvantaged compared to those outside. Interpretation: Clusters varied by suicide methods, location of residence and location of incidence. The findings highlighted the need for consistent and concerted support from different stakeholders within suicide clusters, to ensure appropriate design, implementation and sustainability of effective suicide prevention programs. Funding: General Research Fund (37000320) and seed fund from the University of Hong Kong (104006710).

Patterns of Social Determinants of Health and Child Mental Health, Cognition, and Physical Health.

Importance: Social determinants of health (SDOH) influence child health. However, most previous studies have used individual, small-set, or cherry-picked SDOH variables without examining unbiased computed SDOH patterns from high-dimensional SDOH factors to investigate associations with child mental health, cognition, and physical health. Objective: To identify SDOH patterns and estimate their associations with children's mental, cognitive, and physical developmental outcomes. Design, Setting, and Participants: This population-based cohort study included children aged 9 to 10 years at baseline and their caregivers enrolled in the Adolescent Brain Cognitive Development (ABCD) Study between 2016 and 2021. The ABCD Study includes 21 sites across 17 states. Exposures: Eighty-four neighborhood-level, geocoded variables spanning 7 domains of SDOH, including bias, education, physical and health infrastructure, natural environment, socioeconomic status, social context, and crime and drugs, were studied. Hierarchical agglomerative clustering was used to identify SDOH patterns. Main Outcomes and Measures: Associations of SDOH and child mental health (internalizing and externalizing behaviors) and suicidal behaviors, cognitive function (performance, reading skills), and physical health (body mass index, exercise, sleep disorder) were estimated using mixed-effects linear and logistic regression models. Results: Among 10 504 children (baseline median [SD] age, 9.9 [0.6] years; 5510 boys [52.5%] and 4994 girls [47.5%]; 229 Asian [2.2%], 1468 Black [14.0%], 2128 Hispanic [20.3%], 5565 White [53.0%], and 1108 multiracial [10.5%]), 4 SDOH patterns were identified: pattern 1, affluence (4078 children [38.8%]); pattern 2, high-stigma environment (2661 children [25.3%]); pattern 3, high socioeconomic deprivation (2653 children [25.3%]); and pattern 4, high crime and drug sales, low education, and high population density (1112 children [10.6%]). The SDOH patterns were distinctly associated with child health outcomes. Children exposed to socioeconomic deprivation (SDOH pattern 3) showed the worst health profiles, manifesting more internalizing (ß = 0.75; 95% CI, 0.14-1.37) and externalizing (ß = 1.43; 95% CI, 0.83-2.02) mental health problems, lower cognitive performance, and adverse physical health. Conclusions: This study shows that an unbiased quantitative analysis of multidimensional SDOH can permit the determination of how SDOH patterns are associated with child developmental outcomes. Children exposed to socioeconomic deprivation showed the worst outcomes relative to other SDOH categories. These findings suggest the need to determine whether improvement in socioeconomic conditions can enhance child developmental outcomes.

Gender differences in the relationships between meaning in life, mental health status and digital media use during Covid-19.

BACKGROUND: The COVID-19 pandemic has had a significant impact on individuals' social lives, mental health status, and meaning in life (MIL). Globally, the use of different types of digital media has become a proxy for pre-COVID social lives for many people. This study investigated gender differences in the relationship between use of digital media, mental health status and MIL, during COVID-19 in Hong Kong. METHODS: This cross-sectional study surveyed 1,488 young people recruited via city-wide random sampling in 2021. Respondents completed a phone survey on digital media use, Patient Health Questionnaire (PHQ-2), Generalized Anxiety Disorder (GAD-2), COVID-19 impact, meaning in life, and demographics. Gender differences in MIL were tested with an independent sample t-test. Gender-specific multiple linear regression models tested associations between MIL and explanatory variables of age, educational level, history of diagnosis, digital media use, and mental health status. RESULTS: There was a significant gender difference in MIL (males (M = 12.90, SD = 4.12); females (M = 13.45, SD = 3.96); t (1485) = -2.656, p = .008). For males, all variables significantly associated to MIL (F (9, 759) = 15.731, p < .000, R2 = .157). However, for females, while the overall model for MIL was significant (F (9, 709) = 12.105, p < .001, R2 = .133), the only significant associated variable was mental health status. CONCLUSION: Females had significantly better MIL under COVID-19 than males. Digital media use contributed to MIL in males but not females, and there were gender-specific associated factors of MIL.

Risk and protective factors related to changes in mental health among adolescents since COVID-19 in Hong Kong: a cross-sectional study.

BACKGROUND: Most research has suggested that children and adolescents had poorer mental health than pre-COVID-19 pandemic status. There have been few investigations into factors associated with pre-peri pandemic differences in young people's mental health status. Our study aimed to investigate the association between sociodemographic factors, attitudes, and daily life experiences and these differences. METHODS: We used self-reported cross-sectional data from the Youth Sexuality Survey (YSS) by the Family Planning Association of Hong Kong, collected from secondary school students aged 10-16 between the fourth and fifth waves of the pandemic. The study outcome was pre-peri pandemic differences in mental health (better, unchanged, or poorer). Associations between the study outcome with age, sex, satisfaction with academic performance, school life, relationship with classmates and family life, and average sleeping and exercising time in the past month, were assessed through multinomial logistic regression, controlling for depressive/anxiety symptoms and change in physical health status since the pandemic. RESULTS: There were 6,665 respondents. Compared with pre-pandemic, approximately 30% reported poorer mental health, whilst 20% reported better mental health. Females (OR = 1.355, 95% CI = 1.159-1.585) and those dissatisfied with their academic performance (OR = 1.468, 95% CI = 1.233-1.748) were significantly more likely to report poorer mental health with reference to unchanged status, while those satisfied with family life had improved mental health with reference to unchanged (OR = 1.261, 95% CI = 1.006-1.579) and poorer status (OR = 1.369, 95% CI = 1.085-1.728). CONCLUSION: Policy and community strategies that promote good family relationships are thus essential for young people's mental health during societal challenges such as the COVID-19 pandemic.

Shifts in patterns of help-seeking during the COVID-19 pandemic: The case of Hong Kong's younger generation.

RATIONALE: Help-seeking can convert an individual's bonding social capital into social support, which has been shown to buffer the impact of psychological distress. The younger generation (individuals aged 15-35 years) have been the least likely to actively seek help despite facing a rising burden of mental health problems. COVID-19 pandemic restrictions may have altered their help-seeking behaviors, but the extent of such shift remains little understood, particularly in Asian contexts. OBJECTIVE: To understand how the younger generation's patterns of help-seeking (activation of different combinations of support sources) have shifted in pandemic times, who have experienced the shift, and what explanatory factors are involved. METHODS: Data were obtained from two waves (2019, 2020) of online survey responses by 438 community-dwelling younger generation people in Hong Kong, recruited through the authors' affiliated institutions and territory-wide community outreach organizations. Latent class analysis was conducted on participants' self-reported help-seeking behaviors in each survey wave. Constituents' characteristics in each latent class were examined, and between-wave changes in individuals' class membership were identified. Logistic regressions identified explanatory factors that significantly explained the changes. RESULTS: Three consistent patterns of help-seeking were identified in both survey waves. A major shift was observed for individuals with poorer mental health histories who faced moderate distress. They relied on their family, friends, and partner pre-pandemic, but no longer activated these supports during the pandemic. Posting status updates on social media, along with various communication habits and sociodemographic factors that differed by age group, were associated with this shift. CONCLUSIONS: Shifts in the younger generation's patterns of help-seeking may be an early warning signal to invest additional resources in facilitating help-seeking among the younger generation. Findings also serve as a reminder that public health restrictions may have inadvertent mental health implications that should be considered in future scenarios.

Item Response Theory and Differential Item Functioning Analyses With the Suicidal Behaviors Questionnaire-Revised in US and Chinese Samples.

Background: Despite the widespread use of the Suicidal Behaviors Questionnaire-Revised (SBQ-R) and advances in item response theory (IRT) modeling, item-level analysis with the SBQ-R has been minimal. Aims: This study extended IRT modeling strategies to examine the response parameters and potential differential item functioning (DIF) of the individual SBQ-R items in samples of US (N = 320) and Chinese (N = 298) undergraduate students. Method: Responses to the items were calibrated using the unidimensional graded response IRT model. Goodness-of-fit, item parameters, and DIF were evaluated. Results: The unidimensional graded response IRT model provided a good fit to the sample data. Results showed that the SBQ-R items had various item discrimination parameters and item severity parameters. Also, each SBQ-R item functioned similarly between the US and Chinese respondents. In particular, Item 1 (history of attempts) demonstrated high discrimination and severity of suicide-related thoughts and behaviors (STBs). Limitations: The use of cross-sectional data from convenience samples of undergraduate students could be considered a major limitation. Conclusion: The findings from the IRT analysis provided empirical support that each SBQ-R item taps into STBs and that scores for Item 1 can be used for screening purposes.

The evolution of charcoal-burning suicide: A systematic scoping review.

INTRODUCTION: Suicide by charcoal burning has accounted for more than 100,000 deaths. It has become an increasingly common suicide method in Hong Kong since first reported in 1998, and it has spread into South Korea, Taiwan, Japan and other countries. This systematic scoping review aimed to explore current evidence on trends, risk factors, impact of media and prevention strategies for this suicide method, and to identify research gaps. METHODS: A search for articles published from January 1998 to June 2021 was conducted through electronic databases (MEDLINE, EMBASE, SCOPUS and PsycINFO) with the keywords (suicide*) AND (charcoal). Articles describing prevalence, trends, characteristics, risk factors and prevention strategies of charcoal burning suicide deaths were included. Non-peer-reviewed articles, non-English articles, commentaries/editorials/letters, poster abstracts, reviews, meta-analyses and studies that documented only charcoal burning suicide attempters/survivors were excluded. RESULTS: Eighty-eight studies were identified, most from East Asia. Charcoal burning suicide rates in Hong Kong, Taiwan and Japan has passed the peak, while continuing to increase in South Korea. Risk factors are changing and not static. Media appears to play an important role in triggering and spreading information. Restricting access to charcoal, and raising public awareness have been effective in the short term in preventing charcoal burning suicide, but there is little information on their long-term effectiveness or sustainability. DISCUSSION: More research is required to update the development and dynamic changes of charcoal burning suicide and the contributing factors. The evidence from this review may assist in detecting and intervening early for future novel suicide methods.

Youths' attitudes toward open discussion of suicide, preferred contexts, and the impact of Internet use: An exploratory sequential mixed-methods study in Hong Kong.

BACKGROUND: Although the necessity and benefits of having the open and public discussion about suicide have been recognized, youths' opinions regarding such discussion remain unknown. AIMS: To explore youths' attitudes toward open suicide discussion, particularly concerning their preference of discussion contexts and impacts of Internet use. METHOD: This exploratory sequential mixed-methods study targeted Hong Kong youths aged 15 to 19. A total of six focus groups and 12 individual interviews were held (N = 40). Topics included adolescents' views of open suicide discussion, concerns, perceived benefits, and preferred contexts. The questionnaire survey (N = 1,676) was conducted subsequently to investigate the prevalence of youths' perspectives on public discussion of suicide and relationships with discussion contexts, use of social media platforms, and motivations of online expression. RESULTS: Qualitative findings revealed three types of attitudes toward open suicide discussion: reluctance, support, and indifference. Major barriers included cultural norms, topic sensitivity, privacy concerns, contagion effect, fear of embarrassment, and unpleasant experiences in school programs. Results of quantitative analyses showed that reluctance was the dominant attitude among adolescents, and taboo was the top concern. Variations in youths' attitudes were related to gender, school academic banding, and suicide-related experiences. Notably, adolescents who had been exposed to suicide messages in contexts of peer networks and online platforms were more likely to endorse open suicide discussion. In addition, an increased likelihood of engaging in public suicide discussion was associated with the use of Instagram, WhatsApp, and Snapchat, and the motive of 'expressing emotions and opinions' online. CONCLUSIONS: Our results indicated a prevalent rejection among adolescents toward open suicide discussion, suggesting the issue of stigma, the need for tailored programs, the value of appropriate contexts, and the impact of Internet use. These findings may facilitate the development of school-based suicide prevention initiatives and the efficacy of online services for suicide-related communication.

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

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

The Use of Close Friends on Instagram, Help-Seeking Willingness, and Suicidality Among Hong Kong Youth: Exploratory Sequential Mixed Methods Study.

BACKGROUND: Social networking sites (SNSs) have gained popularity in recent years for help seeking and self-distress expression among adolescents. Although online suicidal expression is believed to have major benefits, various concerns have also been raised, particularly around privacy issues. Understanding youths' help-seeking behavior on SNSs is critical for effective suicide prevention; however, most research neglects the impacts of the private SNS context. OBJECTIVE: This study aims to examine youths' private SNS use via the new Instagram feature, Close Friends, and its association with both online and offline help-seeking willingness as well as youths' suicidality. METHODS: This study employed an exploratory sequential mixed methods approach with a combination of explorative qualitative interviews and a systematic quantitative survey, targeting youth aged 15-19 years in Hong Kong. The motivations for utilizing Close Friends and concerns regarding online expression were addressed in the focus group and individual interviews (n=40). A cross-sectional survey (n=1676) was conducted subsequently with eligible secondary school students to examine the prevalence of Close Friends usage, their online and offline help-seeking willingness, and suicide-related experiences. RESULTS: A total of 3 primary motives for using Close Friends were identified during interviews, including (1) interaction and help seeking, (2) release of negative emotions, and (3) ventilation and self-expression. Most participants also highlighted the privacy concerns associated with public online communication and the importance of contacting close friends for emotional support. Survey results showed that use of Close Friends was quite prevalent among adolescents (1163/1646, 70.66%), with around 46% (754/1646, 45.81%) of respondents being frequent users. Differences by gender and school academic banding were also revealed. Regarding help-seeking intentions, youths were generally positive about seeking help from peers and friends offline (1010/1266, 79.78%) yet negative about seeking assistance from online friends or professionals with whom they had not yet developed a real-world connection (173/1266, 13.67%). Most notably, frequencies of Close Friends usage were differentially associated with online and offline help-seeking willingness and youths' suicidality. Compared with nonusers, those who had ever used the feature were more likely to seek offline support (adjusted odds ratios [AORs] 1.82-2.36), whereas heavy use of Close Friends was associated with increased odds of online help-seeking willingness (AOR 1.76, 95% CI 1.06-2.93) and a higher risk of suicidality (AOR 1.53, 95% CI 1.01-2.31). CONCLUSIONS: The popularity of Close Friends reflects the increasing need for private online expression among youth. This study demonstrates the importance of Close Friends for self-expression and private conversation and inadequacy of peer support for suicidal adolescents. Further research is needed to identify the causal relationship between Close Friends usage and help-seeking willingness to guide the advancement of suicide prevention strategies. Researchers and social media platforms may cooperate to co-design a risk monitoring system tailored to the private SNS context, assisting professionals in identifying youth at risk of suicide.

Motivations for Online Expression, Willingness of Online Help-Seeking, and the Risk of Suicide Among Hong Kong Youths: A Mixed-Methods Study.

Despite widespread interest in social media use, little is known about the heterogeneity of underlying motivations for online engagement among at-risk adolescents. This study adopted a mixed-methods approach to evaluate the motives of online expression among Hong Kong youths aged 15-19, as well as their relationships to online help-seeking willingness and suicide risks. In total, 6 focus groups and 12 individual interviews were conducted (N = 40) to elicit information regarding online expression purposes and to construct questionnaire items. The cross-sectional survey (N = 1,676) was undertaken subsequently to determine the prevalence of motives, and their correlations with online help-seeking willingness and suicide risks. Qualitative interviews revealed two key themes: major motivations for online expression, and features of online expression and help-seeking among suicidal youths. Quantitative analyses demonstrated the prevalence of each online expression purpose, with most reporting on "emotional expression" and "life sharing and documentation," but variations identified by gender, school academic banding, and suicide-related experience. Notably, an ordinal logistic regression model revealed that motives of "emotional expression" and "image building" were associated with increased suicide risks, while the purpose of "life sharing" was associated with decreased suicide risks. Those who expressed online for "self-expression" and "friend making" showed a stronger willingness for online help-seeking. These findings provide a more holistic overview of the purposes of online expression, which suggested the likelihood of mental health issues and the need for support. Such insight may facilitate the development of more effective suicide prevention strategies and online intervention services.

The Suicidal Behaviors Questionnaire-Revised (SBQ-R) and its Chinese version (C-SBQ-R): Further validity testing using the culture, comprehension, and translation bias procedure.

The Suicidal Behaviors Questionnaire-Revised (SBQ-R), a 4-item instrument for assessing and screening suicide-related thoughts and behaviors, has been translated into several different languages. In this study, we examined the psychometric properties of the SBQ-R and a new Chinese version of the instrument (C-SBQ-R) for college student samples. We used the culture, comprehension, and translation bias (CCT) procedure to examine the responses of independent Chinese college student samples who completed the C-SBQ-R (N1 = 298) and the SBQ-R (N2 = 292) and a U.S. college student sample (N3 = 320) who completed the SBQ-R. We found that the samples' C-SBQ-R and SBQ-R scale scores showed acceptable internal consistency reliability estimates, factor structures, and concurrent validity estimates. Measurement invariance was established across groups differing in (a) language but not culture, (b) culture but not language, and (c) both language and culture. Receiver operating characteristic curve analysis results showed that the cutoff score of 7 was similar for both the C-SBQ-R and the SBQ-R in screening for suicide-related thoughts and behaviors. Our findings provided empirical support that the psychometric properties of the C-SBQ-R and the SBQ-R are similar; both could be used to assess the suicide-related thoughts and behaviors constructs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association of Social Determinants of Health and Vaccinations With Child Mental Health During the COVID-19 Pandemic in the US.

Importance: The COVID-19 pandemic disproportionately affected mental health in socioeconomically disadvantaged children in the US. However, little is known about the relationship of preexisting and time-varying social determinants of health (SDoH) at individual and structural levels, vaccination eligibility/rates, and the racial and ethnic differences to trajectories of child mental health during the COVID-19 pandemic. Objective: To estimate the association of trajectories of child mental health to multilevel SDoH and vaccination eligibility/rates. Design, Setting, and Participants: This prospective longitudinal cohort study, conducted from May 16, 2020, to March 2, 2021, integrated structural-level, pandemic-related data with the Adolescent Brain Cognitive Development (ABCD) cohort data (release 4.0). The ABCD study recruited 11 878 children (baseline) and conducted 6 COVID-19 rapid response surveys across 21 US sites (in 17 states) from May 16, 2020, to March 2, 2021. Exposures: Preexisting individual (eg, household income) and structural (area deprivation) SDoH and time-varying individual (eg, food insecurity, unemployment) and structural (eg, social distancing, vaccination eligibility/rates) SDoH. Main Outcomes and Measures: Perceived Stress Scale, the National Institutes of Health-Toolbox emotion measures, and COVID-19-related worry. Results: The longitudinal sample included 8493 children (mean [SD] age, 9.93 [0.63] years; 5011 girls [47.89%]; 245 Asian [2.34%], 1213 Black [11.59%], 2029 Hispanic [19.39%], 5851 White [55.93%], and 1124 children of other/multiracial ethnicity [10.74%]). Trajectories of stress, sadness, and COVID-19-related worry decreased after adult vaccination rollout. Compared with younger children, boys, White children, or those living with married parents, those who reported greater perceived stress included older children aged 12 to 15 years (ß = 0.26; 95% CI, 0.12-0.41; P < .001); girls (ß = 0.75; 95% CI, 0.61-0.89; P < .001); Hispanic children (ß = 0.24; 95% CI, 0.01-0.47; P = .04); children living with separated parents (ß = 0.50; 95% CI, 0.03-0.96; P = .04); children experiencing disrupted medical health care access (ß = 0.19; 95% CI, 0.01-0.36; P = .04); children living in economically deprived neighborhoods (ß = 0.28; 95% CI, 0.05-0.51; P = .02); children living in areas with more full-time working-class adults who were unable to social distance (ß = 1.35; 95% CI, 0.13-2.67; P = .04); and children living in states with fewer fully vaccinated adults (ß = 0.59; 95% CI, 0.16-1.02; P = .007). COVID-19 pandemic-related worry was higher among Asian children (ß = 0.22; 95% CI, 0.08-0.37; P = .003), Black children (ß = 0.33; 95% CI, 0.22-0.43; P < .001), children of other/multiracial ethnicity (ß = 0.17; 95% CI, 0.09-0.25; P < .001), and children with disrupted medical health care (ß = 0.15; 95% CI, 0.09-0.21) and disrupted mental health treatment (ß = 0.11; 95% CI, 0.06-0.16). Inability to afford food was associated with increased sadness (ß = 1.50; 95% CI, 0.06-2.93; P = .04). States with later vaccination eligibility dates for all adults were associated with greater COVID-19-related worry (ß = 0.16; 95% CI, 0.01-0.31; P = .03) and decreased positive affect (ß = -1.78; 95% CI, -3.39 to -0.18; P = .03) among children. Conclusions and Relevance: Results of this study suggest a disproportionately adverse association of the COVID-19 pandemic with child mental health among racial and ethnic minority groups, which may be improved by addressing modifiable individual (food insecurity, unemployment, health services, parental supervision) and structural (area deprivation, job protection, vaccination) SDoH.