Geographic Variation, Economic Activity, and Labor Market Characteristics in Trajectories of Suicide in the United States, 2008-2020.

Suicide rates in the United States have increased over the past 15 years, with substantial geographic variation in these increases; yet there have been few attempts to cluster counties by the magnitude of suicide rate changes according to intercept and slope or to identify the economic precursors of increases. We used vital statistics data and growth mixture models to identify clusters of counties by their magnitude of suicide growth from 2008 to 2020 and examined associations with county economic and labor indices. Our models identified 5 clusters, each differentiated by intercept and slope magnitude, with the highest-rate cluster (4% of counties) being observed mainly in sparsely populated areas in the West and Alaska, starting the time series at 25.4 suicides per 100,000 population, and exhibiting the steepest increase in slope (0.69/100,000/year). There was no cluster for which the suicide rate was stable or declining. Counties in the highest-rate cluster were more likely to have agricultural and service economies and less likely to have urban professional economies. Given the increased burden of suicide, with no clusters of counties improving over time, additional policy and prevention efforts are needed, particularly targeted at rural areas in the West.

Hindcasts and forecasts of suicide mortality in US: A modeling study.

Deaths by suicide, as well as suicidal ideations, plans and attempts, have been increasing in the US for the past two decades. Deployment of effective interventions would require timely, geographically well-resolved estimates of suicide activity. In this study, we evaluated the feasibility of a two-step process for predicting suicide mortality: a) generation of hindcasts, mortality estimates for past months for which observational data would not have been available if forecasts were generated in real-time; and b) generation of forecasts with observational data augmented with hindcasts. Calls to crisis hotline services and online queries to the Google search engine for suicide-related terms were used as proxy data sources to generate hindcasts. The primary hindcast model (auto) is an Autoregressive Integrated Moving average model (ARIMA), trained on suicide mortality rates alone. Three regression models augment hindcast estimates from auto with call rates (calls), GHT search rates (ght) and both datasets together (calls_ght). The 4 forecast models used are ARIMA models trained with corresponding hindcast estimates. All models were evaluated against a baseline random walk with drift model. Rolling monthly 6-month ahead forecasts for all 50 states between 2012 and 2020 were generated. Quantile score (QS) was used to assess the quality of the forecast distributions. Median QS for auto was better than baseline (0.114 vs. 0.21. Median QS of augmented models were lower than auto, but not significantly different from each other (Wilcoxon signed-rank test, p > .05). Forecasts from augmented models were also better calibrated. Together, these results provide evidence that proxy data can address delays in release of suicide mortality data and improve forecast quality. An operational forecast system of state-level suicide risk may be feasible with sustained engagement between modelers and public health departments to appraise data sources and methods as well as to continuously evaluate forecast accuracy.

Evaluating the Experience of Teen-to-Teen Crisis Line Volunteers: A Pilot Study.

Teen-to-teen (t2t) crisis lines are a special type of crisis service where youth volunteers help their peers. Although prior research has examined the experience of adult crisis line responders, no research has examined the experience of adolescents who do this work. In collaboration with two of the largest t2t lines in the U.S., this pilot study is the first examination of t2t crisis line work. Volunteers (ages 14-20) reported: their primary motivation for joining the crisis lines was to help others and give back to the community; responding to a range of peers' problems on the t2t crisis line, including high-risk suicide contacts; and a range of ways the crisis line work impacted their lives. Findings provide preliminary information about the experience of adolescents engaging in t2t crisis line work. Additional research is needed in larger and more diverse samples to understand the impact of crisis line work for youth.

Associations of suicide-related media reporting characteristics with help-seeking and suicide in Oregon and Washington.

OBJECTIVE: Specific content characteristics of suicide media reporting might differentially impact suicides in the population, but studies have not considered the overarching theme of the respective media stories and other relevant outcomes besides suicide, such as help-seeking behaviours. METHODS: We obtained 5652 media reports related to suicide from 6 print, 44 broadcast and 251 online sources in Oregon and Washington states, published between April 2019 and March 2020. We conducted a content analysis of stories regarding their overarching focus and specific content characteristics based on media recommendations for suicide reporting. We applied logistic regression analyses to assess how focus and content characteristics were associated with subsequent calls to the US National Suicide Prevention Lifeline (Lifeline) and suicides in these two states in the week after publication compared to a control time period. RESULTS: Compared to a focus on suicide death, a focus on suicidal ideation, suicide prevention, healing stories, community suicide crises/suicide clusters and homicide suicide was associated with more calls. As compared to a focus on suicide death, stories on suicide prevention and stories on community suicide crises/suicide clusters were also associated with no increase in suicides. Regarding specific content characteristics, there were associations that were largely consistent with previous work in the area, for example, an association of celebrity suicide reporting with increases in suicide. CONCLUSION: The overall focus of a media story may influence help-seeking and suicides, and several story characteristics appear to be related to both outcomes. More research is needed to investigate possible causal effects and pathways.

Association of 7 million+ tweets featuring suicide-related content with daily calls to the Suicide Prevention Lifeline and with suicides, United States, 2016-2018.

OBJECTIVE: The aim of this study was to assess associations of various content areas of Twitter posts with help-seeking from the US National Suicide Prevention Lifeline (Lifeline) and with suicides. METHODS: We retrieved 7,150,610 suicide-related tweets geolocated to the United States and posted between 1 January 2016 and 31 December 2018. Using a specially devised machine-learning approach, we categorized posts into content about prevention, suicide awareness, personal suicidal ideation without coping, personal coping and recovery, suicide cases and other. We then applied seasonal autoregressive integrated moving average analyses to assess associations of tweet categories with daily calls to the US National Suicide Prevention Lifeline (Lifeline) and suicides on the same day. We hypothesized that coping-related and prevention-related tweets are associated with greater help-seeking and potentially fewer suicides. RESULTS: The percentage of posts per category was 15.4% (standard deviation: 7.6%) for awareness, 13.8% (standard deviation: 9.4%) for prevention, 12.3% (standard deviation: 9.1%) for suicide cases, 2.4% (standard deviation: 2.1%) for suicidal ideation without coping and 0.8% (standard deviation: 1.7%) for coping posts. Tweets about prevention were positively associated with Lifeline calls (B = 1.94, SE = 0.73, p = 0.008) and negatively associated with suicides (B = -0.11, standard error = 0.05, p = 0.038). Total number of tweets were negatively associated with calls (B = -0.01, standard error = 0.0003, p = 0.007) and positively associated with suicide, (B = 6.4 × 10-5, standard error = 2.6 × 10-5, p = 0.015). CONCLUSION: This is the first large-scale study to suggest that daily volume of specific suicide-prevention-related social media content on Twitter corresponds to higher daily levels of help-seeking behaviour and lower daily number of suicide deaths. PREREGISTRATION: As Predicted, #66922, 26 May 2021.

Age, period, and cohort effects on suicide death in the United States from 1999 to 2018: moderation by sex, race, and firearm involvement.

The role of sex, race, and suicide method on recent increases in suicide mortality in the United States remains unclear. Estimating the age, period, and cohort effects underlying suicide mortality trends can provide important insights for the causal hypothesis generating process. We generated updated age-period-cohort effect estimates of recent suicide mortality rates in the US, examining the putative roles of sex, race, and method for suicide, using data from all death certificates in the US between 1999 and 2018. After designating deaths as attributable to suicide according to ICD-10 underlying cause of death codes X60-X84, Y87.0, and U03, we (i) used hexagonal grids to describe rates of suicide by age, period, and cohort visually and (ii) modeled sex-, race-, and suicide method-specific age, period, and cohort effects. We found that, while suicide mortality increased in the US between 1999 and 2018 across age, sex, race, and suicide method, there was substantial heterogeneity in age and cohort effects by method, sex, and race, with a first peak of suicide risk in youth, a second peak in older ages-specific to male firearm suicide, and increased rates among younger cohorts of non-White individuals. Our findings should prompt discussion regarding age-specific clinical firearm safety interventions, drivers of minoritized populations' adverse early-life experiences, and racial differences in access to and quality of mental healthcare.

Suicide and the agent-host-environment triad: leveraging surveillance sources to inform prevention.

Suicide in the US has increased in the last decade, across virtually every age and demographic group. Parallel increases have occurred in non-fatal self-harm as well. Research on suicide across the world has consistently demonstrated that suicide shares many properties with a communicable disease, including person-to-person transmission and point-source outbreaks. This essay illustrates the communicable nature of suicide through analogy to basic infectious disease principles, including evidence for transmission and vulnerability through the agent-host-environment triad. We describe how mathematical modeling, a suite of epidemiological methods, which the COVID-19 pandemic has brought into renewed focus, can and should be applied to suicide in order to understand the dynamics of transmission and to forecast emerging risk areas. We describe how new and innovative sources of data, including social media and search engine data, can be used to augment traditional suicide surveillance, as well as the opportunities and challenges for modeling suicide as a communicable disease process in an effort to guide clinical and public health suicide prevention efforts.

Peer-adult network structure and suicide attempts in 38 high schools: implications for network-informed suicide prevention.

BACKGROUND: Strengthening social integration could prevent suicidal behavior. However, minimal research has examined social integration through relationship network structure. To address this important gap, we tested whether structural characteristics of school networks predict school rates of ideation and attempts. METHODS: In 38 US high schools, 10,291 students nominated close friends and trusted adults to construct social networks. We used mixed-effects logistic regression models to test individual student networks and likelihood of suicidal ideation (SI) and suicide attempts (SA); and linear regression models to estimate associations between school network characteristics and school rates of SI, SA, and SA among all with ideation. RESULTS: Lower peer network integration and cohesion increased likelihood of SI and SA across individual and school-level models. Two factors increased SA: student isolation from adults and suicidal students' popularity and clustering. A multivariable model identified higher SA in schools where youth-adult relationships were concentrated in fewer students (B = 4.95 [1.46, 8.44]) and suicidal students had higher relative popularity versus nonsuicidal peers (B = 0.93 [0.10, 1.77]). Schools had lower SA rates when more students named the same trusted adults named by friends and many students named the same trusted adults. When adjusting for depression, violence victimization and bullying, estimates for adult network characteristics were substantially unchanged whereas some peer effects decreased. CONCLUSIONS: Schoolwide peer and youth-adult relationship patterns influence SA rates beyond individual student connections. Network characteristics associated with suicide attempts map onto three theory-informed domains: social integration versus thwarted relational needs, group cohesion, and suicidal students' social influence. Network interventions addressing these processes, such as maximizing youth-adult connections schoolwide and heightening influence of youth with healthy coping, could create more protective schools. Longitudinal and intervention studies are needed to determine how schools differentiate in network structure and clarify reciprocal dynamics between network characteristics and suicidal behavior.

Spatiotemporal clustering of suicides in the US from 1999 to 2016: a spatial epidemiological approach.

PURPOSE: This study aims to describe and characterize the spatial and temporal clustering patterns of suicide in the ten states with the greatest suicide burden in the United States from 1999 to 2016. METHODS: All suicide deaths from January 1, 1999 to December 31, 2016 in the United States were identified using data from the Wide-ranging Online Data for Epidemiologic Research (WONDER) dataset. The ten states with the highest age-adjusted suicide rates were Montana, Alaska, Wyoming, New Mexico, Nevada, Utah, Idaho, Colorado, Arizona, and Oklahoma. A spatiotemporal scan statistic using a discrete Poisson model was employed to retrospectively detect spatiotemporal suicide clusters. RESULTS: From 1999 to 2016, a total of 649,843 suicides were recorded in the United States. Nineteen statistically significant spatiotemporal suicide mortality clusters were identified in the states with the greatest suicide rates, and 13.53% of the suicide cases within these states clustered spatiotemporally. The risk ratio of the clusters ranged from 1.45 to 3.64 (p < 0.001). All states had at least one cluster, with three clusters spanning multiple states, and four clusters were found in Arizona. While there was no clear secular trend in the average size of suicide clusters, the number of clusters increased from 1999 to 2016. CONCLUSIONS: Hot spots for suicidal behavior in the United States warrant public health intervention and continued surveillance. As suicide rates in the US continue to increase annually, public health efforts could be maximized by focusing on regions with substantial clustering.

Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line.

Data sharing between technology companies and academic health researchers has multiple health care, scientific, social, and business benefits. Many companies remain wary about such sharing because of unaddressed concerns about ethics, data security, logistics, and public relations. Without guidance on these issues, few companies are willing to take on the potential work and risks involved in noncommercial data sharing, and the scientific and societal potential of their data goes unrealized. In this paper, we describe the 18-month long pilot of a data-sharing program led by Crisis Text Line (CTL), a not-for-profit technology company that provides a free 24/7 text line for people in crisis. The primary goal of the data-sharing pilot was to design, develop, and implement a rigorous framework of principles and protocols for the safe and ethical sharing of user data. CTL used a stakeholder-based policy process to develop a feasible and ethical data-sharing program. The process comprised forming a data ethics committee; identifying policy challenges and solutions; announcing the program and generating interest; and revising the policy and launching the program. Once the pilot was complete, CTL examined how well the program ran and compared it with other potential program models before putting in place the program that was most suitable for its organizational needs. By drawing on CTL's experiences, we have created a 3-step set of guidelines for other organizations that wish to develop their own data-sharing program with academic researchers. The guidelines explain how to (1) determine the value and suitability of the data and organization for creating a data-sharing program; (2) decide on an appropriate data sharing and collaboration model; and (3) develop protocols and technical solutions for safe and ethical data sharing and the best organizational structure for implementing the program. An internal evaluation determined that the pilot satisfied CTL's goals of sharing scientific data and protecting client confidentiality. The policy development process also yielded key principles and protocols regarding the ethical challenges involved in data sharing that can be applied by other organizations. Finally, CTL's internal review of the pilot program developed a number of alternative models for sharing data that will suit a range of organizations with different priorities and capabilities. In implementing and studying this pilot program, CTL aimed both to optimize its own future data-sharing programs and to inform similar decisions made by others. Open data programs are both important and feasible to establish. With careful planning and appropriate resources, data sharing between big data companies and academic researchers can advance their shared mission to benefit society and improve lives.

"Breaking the silence" suicide Prevention media campaign in Oregon: Evaluation of impact on help-seeking and suicide mortality.

INTRODUCTION: Research has established that suicide-related media can impact suicide rates both positively and negatively, supporting efforts to engage the media in the service of suicide prevention. The goal of the current study is to evaluate the impact of a suicide prevention media campaign implemented April 7-14, 2019 in Oregon. METHODS: Several indices of help-seeking behavior and suicide risk were employed: suicide-related Google Health API searches, National Suicide Prevention Lifeline (Lifeline) (currently known as the 988 Suicide and Crisis Lifeline) call volume, and state suicide mortality data from April 7, 2016-May 6, 2019. Eight states with similar 2016-2018 average suicide rates were compared with Oregon. Bayesian structural time-series modeling in R was used to test intervention effects. RESULTS: During the 30 days following the start of the campaign, there was a significant increase in Lifeline calls from Oregon area codes (2488 observed vs. 2283 expected calls, p = 0.03). There were no significant changes in suicide mortality or suicide-related Google searches in Oregon. CONCLUSIONS: The campaign appeared to increase help-seeking behavior in the form of Lifeline calls, without any indication of an iatrogenic suicide contagion effect. However, the campaign's potential to reduce suicide mortality was unmet.

"Breaking the Silence" Suicide Prevention Media Campaign in Oregon, April 7-14, 2019.

Background: Between April 7 and 14, 2019, the "Breaking the Silence" media engagement campaign was launched in Oregon. Aims: We aimed to assess the consistency of media content related to the campaign with media guidelines and the quantitative footprint on Twitter (now X) over time. Method: Media items related to the campaign were analyzed regarding focus and consistency with media guidelines for suicide reporting and compared with other suicide-related reports published in the same time frame, as well as with reporting in Washington, the control region. Tweets related to the campaign were retrieved to assess the social media footprint. Results: There were n = 104 media items in the campaign month, mainly in the campaign week. Items typically used a narrative featuring suicide advocacy or policy/prevention programs. As compared to other items with a similar focus, they scored better on several protective characteristics listed in media recommendations. Stories of coping with adversity, however, were scarce. The social media footprint on Twitter was small. Limitations: Inability to make causal claims about campaign impact. Conclusion: Media items from the Breaking the Silence campaign appeared mainly consistent with media guidelines, but some aspects, such as stories of recovery, were under-represented.

Gatekeeper training for suicide prevention in First Nations community members: a randomized controlled trial.

BACKGROUND: Gatekeeper training aims to train people to recognize and identify those who are at risk for suicide and assist them in getting care. Applied Suicide Intervention Skills Training (ASIST), a form of gatekeeper training, has been implemented around the world without a controlled evaluation. We hypothesized that participants in 2 days of ASIST gatekeeper training would have increased knowledge and preparedness to help people with suicidal ideation in comparison to participants who received a 2-day Resilience Retreat that did not focus on suicide awareness and intervention skills (control condition). METHODS: First Nations on reserve people in Northwestern Manitoba, aged 16 years and older, were recruited and randomized to two arms of the study. Self-reported measures were collected at three time points-immediately pre-, immediately post-, and 6 months post intervention. The primary outcome was the Suicide Intervention Response Inventory, a validated scale that assesses the capacity for individuals to intervene with suicidal behavior. Secondary outcomes included self-reported preparedness measures and gatekeeper behaviors. RESULTS: In comparison with the Resilience Retreat (n = 24), ASIST training (n = 31) was not associated with a significant impact on all outcomes of the study based on intention-to-treat analysis. There was a trend toward an increase in suicidal ideation among those who participated in the ASIST in comparison to those who were in the Resilience Retreat. CONCLUSIONS: The lack of efficacy of ASIST in a First Nations on-reserve sample is concerning in the context of widespread policies in Canada on the use of gatekeeper training in suicide prevention.

Emotion regulation difficulties, youth-adult relationships, and suicide attempts among high school students in underserved communities.

To develop and refine interventions to prevent youth suicide, knowledge is needed about specific processes that reduce risk at a population level. Using a cross-sectional design, the present study tested hypotheses regarding associations between self-reported suicide attempts, emotion regulation difficulties, and positive youth-adult relationships among 7,978 high-school students (48.6% male, 49.9% female) in 30 high schools from predominantly rural, low-income communities. 683 students (8.6%) reported a past-year suicide attempt. Emotion regulation difficulties and a lack of trusted adults at home and school were associated with increased risk for making a past-year suicide attempt, above and beyond the effects of depressive symptoms and demographic factors. The association between emotion regulation difficulties and suicide attempts was modestly lower among students who perceived themselves as having higher levels of trusted adults in the family, consistent with a protective effect. Having a trusted adult in the community (outside of school and family) was associated with fewer suicide attempts in models that controlled only for demographic covariates, but not when taking symptoms of depression into account. These findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. Reaching these targets in a broad population of adolescents will require new delivery systems and "option rich" (OR) intervention designs.

Trends in Crisis Hotline Call Rates and Suicide Mortality in the United States.

OBJECTIVE: Utilization of the 988 Suicide and Crisis Lifeline (Lifeline; formerly called the National Suicide Prevention Lifeline) was analyzed in relation to suicide deaths in U.S. states between 2007 and 2020 to identify states with potential unmet need for mental health crisis hotline services. METHODS: Annual state call rates were calculated from calls routed to the Lifeline during the 2007-2020 period (N=13.6 million). Annual state suicide mortality rates (standardized) were calculated from suicide deaths reported to the National Vital Statistics System (2007-2020 cumulative deaths=588,122). Call rate ratio (CRR) and mortality rate ratio (MRR) were estimated by state and year. RESULTS: Sixteen U.S. states demonstrated a consistently high MRR and a low CRR, suggesting high suicide burden and relatively low Lifeline use. Heterogeneity in state CRRs decreased over time. CONCLUSIONS: Prioritizing states with a high MRR and a low CRR for messaging and outreach regarding the availability of the Lifeline can ensure more equitable, need-based access to this critical resource.

County-level estimates of suicide mortality in the USA: a modelling study.

BACKGROUND: Suicide is one of the leading causes of death in the USA and population risk prediction models can inform decisions on the type, location, and timing of public health interventions. We aimed to develop a prediction model to estimate county-level suicide risk in the USA using population characteristics. METHODS: We obtained data on all deaths by suicide reported to the National Vital Statistics System between Jan 1, 2005, and Dec 31, 2019, and age, sex, race, and county of residence of the decedents were extracted to calculate baseline risk. We also obtained county-level annual measures of socioeconomic predictors of suicide risk (unemployment, weekly wage, poverty prevalence, median household income, and population density) and state-level prevalence of major depressive disorder and firearm ownership from US public sources. We applied conditional autoregressive models, which account for spatiotemporal autocorrelation in response and predictors, to estimate county-level suicide risk. FINDINGS: Estimates derived from conditional autoregressive models were more accurate than from models not adjusted for spatiotemporal autocorrelation. Inclusion of suicide risk and protective covariates further reduced errors. Suicide risk was estimated to increase with each SD increase in firearm ownership (2·8% [95% credible interval (CrI) 1·8 to 3·9]), prevalence of major depressive episode (1·0% [0·4 to 1·5]), and unemployment rate (2·8% [1·9 to 3·8]). Conversely, risk was estimated to decrease by 4·3% (-5·1 to -3·2) for each SD increase in median household income and by 4·3% (-5·8 to -2·5) for each SD increase in population density. An increase in the heterogeneity in county-specific suicide risk was also observed during the study period. INTERPRETATION: Area-level characteristics and the conditional autoregressive models can estimate population-level suicide risk. Availability of near real-time situational data are necessary for the translation of these models into a surveillance setting. Monitoring changes in population-level risk of suicide could help public health agencies select and deploy targeted interventions quickly. FUNDING: US National Institute of Mental Health.

Perceived Impact of COVID-19 Among Callers to the National Suicide Prevention Lifeline.

Background: Research indicates that the COVID-19 pandemic caused increases in psychological distress and suicidal ideation. Aims: To describe the ways suicidal callers to the National Suicide Prevention Lifeline (Lifeline) perceived COVID-19 to have impacted them and assess whether these callers perceived COVID-19-related stress as contributing to their suicidal thoughts. Method: Telephone interviews were conducted with 412 suicidal callers to 12 Lifeline centers. Logistic regression analyses were used to examine the associations between demographic factors and individual COVID-19 stressors and to determine whether callers who endorsed COVID-19-related stress as contributing to their suicidal thoughts differed from those who did not regarding demographics, current suicide risk, history of suicidality, Lifeline use, or individual COVID-19 stressors. Results: Over half of callers reported that COVID-19-related stress contributed to their suicidal ideation (CRSSI). Callers who endorsed CRSSI had higher odds than those who did not of mentioning financial difficulties when asked how COVID-19 impacted them. The two groups of callers did not differ on the other factors examined. Limitations: Interviewed callers may not be representative of all Lifeline callers. Conclusion: Despite the subjective burden of COVID-19-related stress on suicidal Lifeline callers, this was not associated with new suicidality or heightened suicide risk.

Ethnoracial Disparities in Rates of Non-Natural Causes of Death After the 2020 COVID-19 Outbreak in New York State.

Introduction: COVID-19 was associated with increases in non-natural cause mortality in the U.S., including deaths due to drug overdose, homicide, and motor vehicle crashes. Initial reports indicated higher rates of non-natural mortality among ethnoracial minority groups. This report aims to clarify these disparities by documenting trends in non-natural mortality across ethnoracial groups during the 2020 COVID-19 surge in New York State. Methods: We report monthly trends in non-natural cause mortality (overall and stratified by ethnoracial status) in New York State from January 2019 through December 2020, which included the COVID-19 onset in March 2020. Results: Total mean monthly unintentional overdose rates per 100,000 increased from 17.45 (before surge: January 2019-February 2020) to 23.19 (after surge: March 2020-December 2020) (mean difference=5.73, 95% CI=3.82, 7.65; p<0.001). Mean monthly homicide death rates increased from 2.34 before surge to 3.55 after surge (mean difference=1.20, 95% CI=0.60, 1.81; p<0.001), with the increase seen primarily in the non-Latinx Black population. Although increasing unintentional overdose death rates before surge equally affected non-Latinx White, Latinx, and non-Latinx Black persons, they remained high for non-Latinx Black persons but dropped for the other 2 groups after the pandemic onset. None of the ethnoracial subgroups showed significant increases in suicide or motor vehicle crash death rates. Conclusions: Non-Latinx Black persons showed disproportionately high and sustained increased rates of unintentional overdose and homicide death rates after the 2020 COVID-19 surge in New York State. Fatality review and death scene investigation research is needed to better understand these disparities.

Crisis text-line interventions: Evaluation of texters' perceptions of effectiveness.

OBJECTIVE: Crisis Text Line (CTL), the largest provider of text-based crisis intervention services in the U.S., has answered nearly 7 million conversations since its inception in 2013. The study's objective was to assess texter's perceptions of the effectiveness of CTL crisis interventions. METHOD: Survey data completed by 85,877 texters linked to volunteer crisis counselor (CC) reports from October 12, 2017, to October 11, 2018 were analyzed. The relationship of several effectiveness measures with texters' demographic and psychosocial characteristics, frequency of CTL usage, and texters' perceptions of engagement with their CCs was examined using a series of logistic regression analyses. RESULTS: By the end of the text-based conversation, nearly 90% of suicidal texters reported that the conversation was helpful, and nearly half reported being less suicidal. CONCLUSIONS: Our study offers evidence for CTL's perceived effectiveness. These findings are of critical importance in light of the launch of a nationwide three-digit number (988) for suicide prevention and mental health crisis supports in the U.S., which will include texting.

Treatment of Patients Presenting With Suicidal Behavior in North American Pediatric Emergency Departments.

OBJECTIVE: This study sought to identify current practices for the treatment of patients presenting with suicidal ideation or a recent suicide attempt in pediatric emergency departments (EDs) in North America. METHODS: From October 10, 2018, to January 19, 2020, the authors conducted a cross-sectional online survey on current practices of pediatric emergency medicine chiefs practicing in the United States and Canada. RESULTS: Forty-six (34%) of 136 chiefs of pediatric emergency medicine responded to the survey. The three most frequent improvements chiefs reported they would like to see in the care of young patients with suicidal ideation or suicide attempt were easier access to mental health personnel for evaluations, having mental health personnel take primary responsibility for patient evaluation and treatment, and better access to mental health personnel for dispositional planning. CONCLUSIONS: The findings highlight the need for better mental health care in pediatric EDs to serve patients at increased risk for suicide.