Non-fatal self-harm and suicide following postpartum psychiatric emergency department visits: A population-based retrospective cohort study.

In a population-based cohort of postpartum individuals in Ontario, Canada, this study aimed to determine the risk of non-fatal self-harm and suicide within one year of an initial postpartum psychiatric emergency department (ED) visit (2008-2020), and the key associated factors. Of 16,475 postpartum individuals with psychiatric ED visits, 714 (4.3 %) had non-fatal self-harm within one year, and 23 (0.15 %) died by suicide. Risk was substantially higher for those with self-harm at the initial presentation. Further efforts to connect individuals with postpartum psychiatric ED visits with needed inpatient care and outpatient follow-up are required to reduce non-fatal self-harm and suicide risk.

Prototyping the implementation of a suicide prevention protocol in primary care settings using PDSA cycles: a mixed method study.

Introduction: In Canada, approximately 4,500 individuals die by suicide annually. Approximately 45% of suicide decedents had contact with their primary care provider within the month prior to their death. Current versus never smokers have an 81% increased risk of death by suicide. Those who smoke have additional risks for suicide such as depression, chronic pain, alcohol, and other substance use. They are more likely to experience adverse social determinants of health. Taken together, this suggests that smoking cessation programs in primary care could be facilitators of suicide prevention, but this has not been studied. Study objectives: The objectives of the study are to understand barriers/facilitators to implementing a suicide prevention protocol within a smoking cessation program (STOP program), which is deployed by an academic mental health and addiction treatment hospital in primary care clinics and to develop and test implementation strategies to facilitate the uptake of suicide screening and assessment in primary care clinics across Ontario. Methods: The study employed a three-phase sequential mixed-method design. Phase 1: Conducted interviews guided by the Consolidated Framework for Implementation Research exploring barriers to implementing a suicide prevention protocol. Phase 2: Performed consensus discussions to map barriers to implementation strategies using the Expert Recommendations for Implementing Change tool and rank barriers by relevance. Phase 3: Evaluated the feasibility and acceptability of implementation strategies using Plan Do Study Act cycles. Results: Eleven healthcare providers and four research assistants identified lack of training and the need of better educational materials as implementation barriers. Participants endorsed and tested the top three ranked implementation strategies, namely, a webinar, adding a preamble before depression survey questions, and an infographic. After participating in the webinar and reviewing the educational materials, all participants endorsed the three strategies as acceptable/very acceptable and feasible/very feasible. Conclusion: Although there are barriers to implementing a suicide prevention protocol within primary care, it is possible to overcome them with strategies deemed both acceptable and feasible. These results offer promising practice solutions to implement a suicide prevention protocol in smoking cessation programs delivered in primary care settings. Future efforts should track implementation of these strategies and measure outcomes, including provider confidence, self-efficacy, and knowledge, and patient outcomes.

Risk of Repeat Psychiatric Emergency Department Visits in the Postpartum Period: A Population-Based Retrospective Cohort Study.

STUDY OBJECTIVE: Approximately 1 in 100 postpartum individuals visit an emergency department (ED) for a psychiatric reason. Repeat visits can signify problems with the quality of care received during or after the initial visit; this study aimed to understand risk for repeat postpartum psychiatric ED visits. METHODS: This population-based cohort study used Ontario, Canada health administrative data available through ICES (formerly the Institute for Clinical Evaluative Sciences) to identify all individuals discharged from postpartum psychiatric ED visits (2008 to 2021) and measured the proportion with one or more repeat psychiatric ED visit within 30 days. Using modified Poisson regression, we calculated the association between one or more repeat visits and sociodemographic, medical, obstetric, infant, continuity of care, past service use, and index ED visit characteristics both overall and stratified by psychiatric diagnosis. RESULTS: Of 14,100 individuals, 11.7% had one or more repeat psychiatric ED visits within 30 days. Repeat visit risk was highest for those with schizophrenia-spectrum disorders (28.2%, adjusted risk ratio 2.41; 95% confidence interval 1.88 to 3.08, versus 9.5% anxiety referent). Low (versus no) psychiatric care continuity, prior psychiatric ED visits and admissions, and initial visits within 90 days postpartum were also associated with increased risk, whereas intentional self-injury was associated with reduced risk. In diagnosis-stratified analyses, the factors most consistently associated with repeat ED visits were past psychiatric ED visits and admissions, and initial visits within 90 days postpartum. CONCLUSIONS: Over 1 in 10 postpartum psychiatric ED visits are followed by a repeat visit within 30 days. Targeted approaches are needed across clinical populations to reduce repeat ED visits in this population with young infants.

Experiences of Sexual and Reproductive Health Care Access for Women and Nonbinary People With Early Psychosis: Towards an Integrated Perspective of Service Users and Clinicians.

OBJECTIVE: Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis. METHOD: We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care. RESULTS: Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access. CONCLUSIONS: SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs.

Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project.

BACKGROUND: Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization. OBJECTIVE: The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians' perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2). METHODS: We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1. RESULTS: This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway. CONCLUSIONS: Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians' behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50643.

"It feels terrible that people are making decisions for me": Reflections and experiences of individuals with psychiatric disability who have substitute decision makers for treatment.

OBJECTIVE: In Canada and elsewhere, making treatment decisions for a person with serious mental illness (SMI) who was found incapable for treatment decisions via a substitute decision maker (SDM) is the norm. This practice is often called into question from a rights-based perspective. The literature on the views of affected individuals is limited. We explore the experiences of adults with SMI who have had SDMs to gain more in-depth understanding. METHOD: We conducted semistructured interviews with 11 consumers of psychiatric services who have had experiences with SDM (range 1-12 years) at an urban hospital in Toronto, Canada. RESULTS: Thematic analysis showed five main themes and related subthemes, including: (1) strong dissatisfaction with and rejection of the SDM's role and purpose; (2) pervasive sense of stigma associated with having a SDM; (3) ongoing struggles to gain autonomy; (4) mixed changes in relationship with and views about SDM; and (5) views on how to improve SDM process. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Our study highlights substantial dissatisfaction with the current SDM system and approaches among adults with SMI who have had SDMs. Issues of stigma and struggles to regain autonomy are prevalent. We discuss the personal, clinical, and social-legal contexts in which they occur, particularly in light of the United Nations' Convention on the Rights of Persons with Disabilities that calls for replacing SDMs with supported decision making. Rights-based approaches to care carry substantial practice implications and call for thoughtful change management. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sexual health experiences of women and non-binary people with early psychosis: qualitative study.

BACKGROUND: Women and gender-diverse people with early psychosis are at risk for suboptimal sexual health outcomes, yet little research has explored their sexual health experiences. AIMS: This study explored sexual health experiences and related priorities among women and gender-diverse people with early psychosis, to identify opportunities for improvements in sexual health and well-being. METHOD: Semi-structured individual qualitative interviews explored how patient participants (n = 19, aged 18-31 years, cisgender and transgender women and non-binary individuals) receiving clinical care from early psychosis programmes in Ontario, Canada, experienced their sexual health, including sexual function and behaviour. Thematic analysis was conducted, with triangulation from interviews/focus groups with clinicians (n = 36) who provide sexual and mental healthcare for this population. RESULTS: Three key themes were identified based on patient interviews: theme 1 was the impact of psychotic illness and its treatments on sexual function and activity, including variable changes in sex drive, attitudes and behaviours during acute psychosis, vulnerability to trauma and medications; theme 2 related to intimacy and sexual relationships in the context of psychosis, with bidirectional effects between relationships and mental health; and theme 3 comprised autonomy, identity and intersectional considerations, including gender, sexuality, culture and religion, which interplay with psychosis and sexual health. Clinicians raised each of these priority areas, but emphasised risk prevention relative to patients' more holistic view of their sexual health and well-being. CONCLUSIONS: Women and non-binary people with early psychosis have wide-ranging sexual health priorities, affecting many facets of their lives. Clinical care should incorporate this knowledge to optimise sexual health and well-being in this population.

Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada.

Importance: Reasons for elevated suicide risks among autistic people are unclear, with insufficient population-based research on sex-specific patterns to inform tailored prevention and intervention. Objectives: To examine sex-stratified rates of self-harm events and suicide death among autistic individuals compared with nonautistic individuals, as well as the associated sociodemographic and clinical risk factors. Design, Setting, and Participants: This population-based matched-cohort study using linked health administrative databases in Ontario, Canada included all individuals with physician-recorded autism diagnoses from April 1, 1988, to March 31, 2018, each matched on age and sex to 4 nonautistic individuals from the general population. Self-harm events resulting in emergency health care from April 1, 2005, to December 31, 2020, were examined for one cohort, and death by suicide and other causes from April 1, 1993, to December 31, 2018, were examined for another cohort. Statistical analyses were conducted between October 2021 and June 2023. Exposure: Physician-recorded autism diagnoses from 1988 to 2018 from health administrative databases. Main Outcomes and Measures: Autistic and nonautistic individuals who were sex stratified a priori were compared using Andersen-Gill recurrent event models on self-harm events, and cause-specific competing risk models on death by suicide or other causes. Neighborhood-level income and rurality indices, and individual-level broad diagnostic categories of intellectual disabilities, mood and anxiety disorders, schizophrenia spectrum disorders, substance use disorders, and personality disorders were covariates. Results: For self-harm events (cohort, 379 630 individuals; median age at maximum follow-up, 20 years [IQR, 15-28 years]; median age of first autism diagnosis claim for autistic individuals, 9 years [IQR, 4-15 years]; 19 800 autistic females, 56 126 autistic males 79 200 nonautistic females, and 224 504 nonautistic males), among both sexes, autism diagnoses had independent associations with self-harm events (females: relative rate, 1.83; 95% CI, 1.61-2.08; males: relative rate, 1.47; 95% CI, 1.28-1.69) after accounting for income, rurality, intellectual disabilities, and psychiatric diagnoses. For suicide death (cohort, 334 690 individuals; median age at maximum follow-up, 19 years [IQR, 14-27 years]; median age of first autism diagnosis claim for autistic individuals, 10 years [IQR, 5-16 years]; 17 982 autistic females, 48 956 autistic males, 71 928 nonautistic females, 195 824 nonautistic males), there was a significantly higher crude hazard ratio among autistic females (1.98; 95% CI, 1.11-3.56) and a nonsignificantly higher crude hazard ratio among autistic males (1.34; 95% CI, 0.99-1.82); the increased risks were associated with psychiatric diagnoses. Conclusions and Relevance: This cohort study suggests that autistic individuals experienced increased risks of self-harm events and suicide death. Psychiatric diagnoses were significantly associated with the increased risks among both sexes, especially for suicide death, and in partially sex-unique ways. Autism-tailored and autism-informed clinical and social support to reduce suicide risks should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses.

A trauma-informed approach to suicide prevention for the COVID-19 pandemic.

During the COVID-19 pandemic, researchers have questioned how the devastation of the pandemic might impact suicide rates. While initial evidence on suicide rates during the early stages of the pandemic is mixed, there are signs we should still remain vigilant. One way of conceptualizing the long-term effects of the pandemic is as a source of multiple traumatic events: the collective trauma of widespread illness and death and social upheaval, individual traumas from the virus itself (e.g., serious illness and disability, traumatic grief, vicarious trauma), traumas from the social and economic consequences (e.g., domestic violence, unemployment), and its intersections with pre-pandemic traumas and oppression. Given trauma is a well-established risk factor for suicide, this carries significant implications for suicide prevention in the wake of the pandemic. Yet access to trauma-informed care, education, and research remains limited. The pandemic presents a unique opportunity to address these gaps and implement a trauma-informed approach to suicide prevention. Building on existing frameworks, we describe how effective suicide prevention for the pandemic must incorporate trauma-informed and trauma-specific services, strategies, and policies; capacity building; collaborative research; and knowledge exchange. Attending to the traumatic effects of the pandemic may reduce the long-term impact on suicide rates.

"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors.

OBJECTIVES: Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018. RESULTS: After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies). CONCLUSIONS: The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Pan-Canadian study of psychiatric care (PCPC): protocol for a mixed-methods study.

INTRODUCTION: The Canadian population has poor and inequitable access to psychiatric care despite a steady per-capita supply of psychiatrists in most provinces. There is some quantitative evidence that practice style and characteristics vary substantially among psychiatrists. However, how this compares across jurisdictions and implications for workforce planning require further study. A qualitative exploration of psychiatrists' preferences for practice style and the practice choices that result is also lacking. The goal of this study is to inform psychiatrist workforce planning to improve access to psychiatric care by: (1) developing and evaluating comparable indicators of supply of psychiatric care across provinces, (2) analysing variations and changes in the characteristics of the psychiatrist workforce, including demographics and practice style and (3) studying psychiatrist practice choices and intentions, and the factors that lead to these choices. METHODS AND ANALYSIS: A cross-provincial mixed-methods study will be conducted in the Canadian provinces of British Columbia, Manitoba, Ontario and Nova Scotia. We will analyse linked-health administrative data within three of the four provinces to develop comparable indicators of supply and characterise psychiatric services at the regional level within provinces. We will use latent profile analysis to estimate the probability that a psychiatrist is in a particular practice style and map the geographical distribution of psychiatrist practices overlayed with measures of need for psychiatric care. We will also conduct in-depth, semistructured qualitative interviews with psychiatrists in each province to explore their preferences and practice choices and to inform workforce planning. ETHICS AND DISSEMINATION: This study was approved by Ontario Tech University Research Ethics Board (16637 and 16795) and institutions affiliated with the study team. We built a team comprising experienced researchers, psychiatrists, medical educators and policymakers in mental health services and workforce planning to disseminate knowledge that will support effective human resource policies to improve access to psychiatric care in Canada.

Clinicians', patients' and carers' perspectives on borderline personality disorder in Pakistan: A mixed methods study protocol.

Borderline Personality Disorder (BPD) is a condition characterised by significant social and occupational impairment and high rates of suicide. In high income countries, mental health professionals carry negative attitudes towards patients with BPD, find it difficult to work with patients with BPD, and even avoid seeing these patients. Negative attitudes and stigma can cause patients to fear mistreatment by health care providers and create additional barriers to care. Patients' self-stigma and illness understanding BPD also affects treatment engagement and outcomes; better knowledge about mental illness predicts intentions to seek care. The perspectives of mental health clinicians and patients on BPD have not been researched in the Pakistani setting and likely differ from other settings due to economic, cultural, and health care system differences. Our study aims to understand the attitudes of mental health clinicians towards patients with BPD in Pakistan using a self-report survey. We also aim to explore explanatory models of illness in individuals with BPD and their family members/carers using a Short Explanatory Model Interview (SEMI). The results of this study are important as we know attitudes and illness understanding greatly impact care. Results of this study will help guide BPD-specific training for mental health clinicians who care for patients with BPD and help inform approaches to interventions for patients with BPD in Pakistan.

Predictive care: a protocol for a computational ethnographic approach to building fair models of inpatient violence in emergency psychiatry.

INTRODUCTION: Managing violence or aggression is an ongoing challenge in emergency psychiatry. Many patients identified as being at risk do not go on to become violent or aggressive. Efforts to automate the assessment of risk involve training machine learning (ML) models on data from electronic health records (EHRs) to predict these behaviours. However, no studies to date have examined which patient groups may be over-represented in false positive predictions, despite evidence of social and clinical biases that may lead to higher perceptions of risk in patients defined by intersecting features (eg, race, gender). Because risk assessment can impact psychiatric care (eg, via coercive measures, such as restraints), it is unclear which patients might be underserved or harmed by the application of ML. METHODS AND ANALYSIS: We pilot a computational ethnography to study how the integration of ML into risk assessment might impact acute psychiatric care, with a focus on how EHR data is compiled and used to predict a risk of violence or aggression. Our objectives include: (1) evaluating an ML model trained on psychiatric EHRs to predict violent or aggressive incidents for intersectional bias; and (2) completing participant observation and qualitative interviews in an emergency psychiatric setting to explore how social, clinical and structural biases are encoded in the training data. Our overall aim is to study the impact of ML applications in acute psychiatry on marginalised and underserved patient groups. ETHICS AND DISSEMINATION: The project was approved by the research ethics board at The Centre for Addiction and Mental Health (053/2021). Study findings will be presented in peer-reviewed journals, conferences and shared with service users and providers.

Risk of hospital admission after discharge from postpartum psychiatric emergency department visits: A focus on the social determinants of health.

OBJECTIVE: Of those with postpartum psychiatric emergency department (ED) visits, a minority of receive hospital admission at their initial visit. Among those discharged, we aimed to determine subsequent risk of psychiatric admission, and understand how social determinants of health (SDOH) - individually and collectively - impact this risk. METHOD: From all postpartum individuals discharged from psychiatric ED visits in Ontario, Canada (2008-2020)(n = 13,130), we generated adjusted relative risks (aRR) for psychiatric inpatient admission within 365 days post-ED visit by four SDOH (age, neighbourhood income, community size, immigration) and other clinical factors. Using latent class analysis (LCA) to identify subgroups based on clustering of SDOH, we then compared adjusted risk across subgroups. RESULTS: Psychiatric admission occurred for 9.5% (n = 1242) within 365 days. Across SDOH, risk was lower among adolescents (vs. ≥35 years aRR 0.80, 95%CI 0.65-0.97) and immigrants (<5 years in Canada vs. Canadian-born/long-term residents 0.70, 0.51-0.96; ≥5 years in Canada 0.79, 0.65-0.95). Among four identified subgroups, compared to the "older/urban/high-income" subgroup (11.1% admission), the "urban/immigrant/low-income" (7.6%; 0.68, 0.55-0.82) and "young/rural/low-income" subgroups (9.7%; 0.78, 0.63-0.96), but not the "semi-urban/middle-income" subgroup (9.5%; 0.86, 0.73-1.01), were at lower admission risk. CONCLUSIONS: Future research is needed to explore reasons for SDOH-based differences in admission risk, and inform equitable postpartum services.

Suicide and Self-Harm Among Immigrant Youth to Ontario, Canada From Muslim Majority Countries: A Population-Based Study.

OBJECTIVE: To examine the association between Muslim religious affiliation and suicide and self-harm presentations among first- and second-generation immigrant youth. METHODS: We performed a population-based cohort study involving individuals aged 12 to 24 years, living in Ontario, who immigrated to Canada between 1 January 2003 and 31 May 2017 (first generation) and those born to immigrant mothers (second generation). Health administrative and demographic data were used to analyze suicide and self-harm presentations. Sex-stratified logistic regression models generated odds ratios (OR) for suicide and negative binomial regression models generated rate ratios (aRR) for self-harm presentations, adjusting for refugee status and time since migration. RESULTS: Of 1,070,248 immigrant youth (50.1% female), there were 129,919 (23.8%) females and 129,446 (24.2%) males from Muslim-majority countries. Males from Muslim-majority countries had lower suicide rates (3.8/100,000 person years [PY]) compared to males from Muslim-minority countries (5.9/100,000 PY) (OR: 0.62, 95% CI, 0.42-0.92). Rates of suicide between female Muslim-majority and Muslim-minority groups were not different (Muslim-majority 1.8/100,000 PY; Muslim-minority 2.2/100,000 PY) (OR: 0.82, 95% CI, 0.46-1.47). Males from Muslim-majority countries had lower rates of self-harm presentations than males from Muslim-minority (<10%) countries (Muslim majority: 12.2/10,000 PY, Muslim-minority: 14.1/10,000 PY) (aRR: 0.82, 95% CI, 0.75, 0.90). Among female immigrants, rates of self-harm presentations were not different among Muslim-majority (30.1/10,000 PY) compared to Muslim-minority (<10%) (32.9/10,000 PY) (aRR: 0.93, 95% CI, 0.87-1.00) countries. For females, older age at immigration conferred a lower risk of self-harm presentations. CONCLUSION: Being a male from a Muslim-majority country may confer protection from suicide and self-harm presentations but the same was not observed for females. Approaches to understanding the observed sex-based differences are warranted.

Information and communication technology-based interventions for suicide prevention implemented in clinical settings: a scoping review.

BACKGROUND: A large number of information and communication technology (ICT) based interventions exist for suicide prevention. However, not much is known about which of these ICTs are implemented in clinical settings and their implementation characteristics. In response, this scoping review aimed to systematically explore the breadth of evidence on ICT-based interventions for suicide prevention implemented in clinical settings and then to identify and characterize implementation barriers and facilitators, as well as evaluation outcomes, and measures. METHODS: We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was applied to the following six databases between August 17-20, 2021: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Library, Information Science and Technology Abstracts. We also supplemented our search with Google searches and hand-searching reference lists of relevant reviews. To be included in this review, studies must include ICT-based interventions for any spectrum of suicide-related thoughts and behaviours including non-suicidal self-injury. Additionally, these ICTs must be implemented in clinical settings, such as emergency department and in-patient units. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to prepare this full report. RESULTS: This review included a total of 75 citations, describing 70 studies and 66 ICT-based interventions for suicide prevention implemented in clinical settings. The majority of ICTs were computerized interventions and/or applications (n = 55). These ICTs were commonly used as indicated strategies (n = 49) targeting patients who were actively presenting with suicide risk. The three most common suicide prevention intervention categories identified were post-discharge follow-up (n = 27), screening and/or assessment (n = 22), and safety planning (n = 20). A paucity of reported information was identified related to implementation strategies, barriers and facilitators. The most reported implementation strategies included training, education, and collaborative initiatives. Barriers and facilitators of implementation included the need for resource supports, knowledge, skills, motivation as well as engagement with clinicians with research teams. Studies included outcomes at patient, clinician, and health system levels, and implementation outcomes included acceptability, feasibility, fidelity, and penetration. CONCLUSION: This review presents several trends of the ICT-based interventions for suicide prevention implemented in clinical settings and identifies a need for future research to strengthen the evidence base for improving implementation. More effort is required to better understand and support the implementation and sustainability of ICTs in clinical settings. The findings can also serve as a future resource for researchers seeking to evaluate the impact and implementation of ICTs.

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness.

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.