Sociodemographic and psychosocial risk factors of railway suicide a mixed-methods study combining data of all suicide decedents in the Netherlands with data from a psychosocial autopsy study.

BACKGROUND: Railway suicide has profound implications for the victims and their family, and affects train drivers, railway personnel, emergency services and witnesses. To inform a multilevel prevention strategy, more knowledge is required about psychosocial and precipitating risk factors of railway suicide. METHODS: Data from Statistics Netherlands of all suicides between 2017 and 2021 (n = 9.241) of whom 986 died by railway suicide and interview data from a psychosocial autopsy of railway suicide decedents (n = 39) were integrated. We performed logistic regression analyses to identify sociodemographic predictors of railway suicide compared to other methods of suicide. The Constant Comparative Method was subsequently employed on interview data from the psychosocial autopsy to identify patterns in psychosocial risk factors for railway suicide. RESULTS: The strongest predictors of railway suicide compared to other suicide methods were young age (< 30 years old), native Dutch, a high educational level, living in a multi-person household (especially living with parents or in an institution), living in a rural area and a high annual household income of > 150.000 euros. Several subgroups emerged in the psychosocial autopsy interviews, which specifically reflect populations at risk of railway suicide. These subgroups were [1] young adult males with autism spectrum disorder who strived for more autonomy and an independent life, [2] young adult females with persistent suicidal thoughts and behaviours, [3] middle-aged males with a persistent mood disorder who lived with family and who faced stressors proximal to the suicide in personal and professional settings, [4] male out-of-the-blue suicides and [5] persons with psychotic symptoms and a rapid deterioration. CONCLUSIONS: based on our findings we propose and discuss several recommendations to prevent railway suicide. We must continue to invest in a safe railway environment by training personnel and installing barriers. Additionally, we should adopt prevention strategies that align the needs of subgroups at increased risk, including young females who have attempted other methods of suicide and young males with autism spectrum disorder. Future research should determine the cost-effectiveness and feasibility of low-maintenance, automated interventions near crossings and psychiatric facilities.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis.

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Identifying populations at ultra-high risk of suicide using a novel machine learning method.

BACKGROUND: Targeted interventions for suicide prevention rely on adequate identification of groups at elevated risk. Several risk factors for suicide are known, but little is known about the interactions between risk factors. Interactions between risk factors may aid in detecting more specific sub-populations at higher risk. METHODS: Here, we use a novel machine learning heuristic to detect sub-populations at ultra high-risk for suicide based on interacting risk factors. The data-driven and hypothesis-free model is applied to investigate data covering the entire population of the Netherlands. FINDINGS: We found three sub-populations with extremely high suicide rates (i.e. >50 suicides per 100,000 person years, compared to 12/100,000 in the general population), namely: (1) people on unfit for work benefits that were never married, (2) males on unfit for work benefits, and (3) those aged 55-69 who live alone, were never married and have a relatively low household income. Additionally, we found two sub-populations where the rate was higher than expected based on individual risk factors alone: widowed males, and people aged 25-39 with a low level of education. INTERPRETATION: Our model is effective at finding ultra-high risk groups which can be targeted using sub-population level interventions. Additionally, it is effective at identifying high-risk groups that would not be considered risk groups based on conventional risk factor analysis.

"I Don't Feel at Home in This World" Sexual and Gender Minority Emerging Adults' Self-Perceived Links Between Their Suicidal Thoughts and Sexual Orientation or Gender Identity.

OBJECTIVES: To examine whether sexual and gender minority (SGM) emerging adults perceived their SGM status was linked to suicidal ideation, and to explore if their responses fell within tenets of the minority stress framework. METHOD: Open text (survey) responses of Dutch and Flemish SGM emerging adults (n = 187) were thematically analysed using the constant comparative comparison method for qualitative analysis. RESULTS: We identified 8 themes in our qualitative analysis. Two themes fell within the scope of the minority stress framework that has received little attention: (1) concerns about relationships and family planning and (2) feeling different (internal stressor). Two additional themes emerged largely beyond the scope of existing minority stress framework studies on suicidality: (3) SGM-related questioning; (4) negativity in LGBT communities. Four established minority stress framework themes emerged: (5) gender identity stress; (6) victimization; (7) coming-out stress; (8) psychological difficulties linked to SGM status. CONCLUSION: Suicide prevention needs to focus on supporting SGM emerging adults who worry about feeling "different", or who have concerns over their romantic and family life, on reducing gender minority stress, as well as on caring for those who are victimized due to their sexual or gender identity.

Forecasting call and chat volumes at online helplines for mental health.

BACKGROUND: Each year, many help seekers in need contact health helplines for mental support. It is crucial that they receive support immediately, and that waiting times are minimal. In order to minimize delay, helplines must have adequate staffing levels, especially during peak hours. This has raised the need for means to predict the call and chat volumes ahead of time accurately. Motivated by this, in this paper, we analyze real-life data to develop models for accurately forecasting call volumes, for both phone and chat conversations for online mental health support. METHODS: This research was conducted on real call and chat data (adequately anonymized) provided by 113 Suicide Prevention (Over ons | 113 Zelfmoordpreventie) (throughout referred to as '113'), the online helpline for suicide prevention in the Netherlands. Chat and phone call data were analyzed to better understand the important factors that influence the call arrival process. These factors were then used as input to several Machine Learning (ML) models to forecast the number of call and chat arrivals. Next to that, senior counselors of the helpline completed a web-based questionnaire after each shift to assess their perception of the workload. RESULTS: This study has led to several remarkable and key insights. First, the most important factors that determine the call volumes for the helpline are the trend, and weekly and daily cyclic patterns (cycles), while monthly and yearly cycles were found to be non-significant predictors for the number of phone and chat conversations. Second, media events that were included in this study only have limited-and only short-term-impact on the call volumes. Third, so-called (S)ARIMA models are shown to lead to the most accurate prediction in the case of short-term forecasting, while simple linear models work best for long-term forecasting. Fourth, questionnaires filled in by senior counselors show that the experienced workload is mainly correlated to the number of chat conversations compared to phone calls. CONCLUSION: (S)ARIMA models can best be used to forecast the number of daily chats and phone calls with a MAPE of less than 10 in short-term forecasting. These models perform better than other models showing that the number of arrivals depends on historical data. These forecasts can be used as support for planning the number of counselors needed. Furthermore, the questionnaire data show that the workload experienced by senior counselors is more dependent on the number of chat arrivals and less on the number of available agents, showing the value of insight into the arrival process of conversations.

The self-perceived needs of adolescents with suicidal behaviour: a scoping review.

Suicidal behaviour in adolescents is a major public health problem. Much research on this issue has focused on epidemiology and risk factors for suicidal behaviour, paying less attention to the self-perceived needs of adolescents. However, to increase engagement in suicide prevention, it is important to include the views of adolescents. A scoping review was performed to identify the available empirical study findings, of any study design, related to the self-perceived needs of adolescents with suicidal behaviour. The literature databases Medline, Embase, Psycinfo, CINAHL, ERIC, Scopus, and Web of Science were searched. Twenty-nine studies from 14 predominantly Anglo countries were included in the scoping review. The review showed that girls were overrepresented and that studies predominantly used qualitative approaches. The identified needs of adolescents with suicidal behaviour can broadly be grouped into needs related to the following areas: the importance of connecting with other people; adolescents' self-help strategies and personal growth after self-harm; mental healthcare; school or study programs; and needs related to society in relation to taboo on suicidal behaviour. Prevention of suicidal behaviour in adolescents will need to focus on development and strengthening of interventions fitting the needs of adolescents in these areas.

Detecting changes in help seeker conversations on a suicide prevention helpline during the COVID- 19 pandemic: in-depth analysis using encoder representations from transformers.

BACKGROUND: Preventatives measures to combat the spread of COVID- 19 have introduced social isolation, loneliness and financial stress. This study aims to identify whether the COVID-19 pandemic is related to changes in suicide-related problems for help seekers on a suicide prevention helpline. METHODS: A retrospective cohort study was conducted using chat data from a suicide prevention helpline in the Netherlands. The natural language processing method BERTopic was used to detect common topics in messages from December 1, 2019 until June 1, 2020 (N = 8589). Relative topic occurrence was compared before and during the lock down starting on March 23, 2020. The observed changes in topic usage were likewise analyzed for male and female, younger and older help seekers and help seekers living alone. RESULTS: The topic of the COVID-19 pandemic saw an 808% increase in relative occurrence after the lockdown. Furthermore, the results show that help seeker increased mention of thanking the counsellor (+ 15%), and male and young help seekers were grateful for the conversation (+ 45% and + 32% respectively). Coping methods such as watching TV (- 21%) or listening to music (- 15%) saw a decreased mention. Plans for suicide (- 9%) and plans for suicide at a specific location (- 15%) also saw a decreased mention. However, plans for suicide were mentioned more frequently by help seekers over 30 years old (+ 11%) or who live alone and (+ 52%). Furthermore, male help seekers talked about contact with emergency care (+ 43%) and panic and anxiety (+ 24%) more often. Negative emotions (+ 22%) and lack of self-confidence (+ 15%) were mentioned more often by help seekers under 30, and help seekers over 30 saw an increased mention of substance abuse (+ 9%). CONCLUSION: While mentions of distraction, social interaction and plans for suicide decreased, expressions of gratefulness for the helpline increased, highlighting the importance of contact to help seekers during the lockdown. Help seekers under 30, male or who live alone, showed changes that negatively related to suicidality and should be monitored closely.

Guidelines improve patient outcomes in specialised mental health care: A systematic review and meta-analysis.

OBJECTIVE: The uptake of evidence-based guideline recommendations appears to be challenging. In the midst of the discussion on how to overcome these barriers, the question of whether the use of guidelines leads to improved patient outcomes threatens to be overlooked. This study examined the effectiveness of evidence-based guidelines for all psychiatric disorders on patient health outcomes in specialist mental health care. All types of evidence-based guidelines, such as psychological and medication-focused guidelines, were eligible for inclusion. Provider performance was measured as a secondary outcome. Time to remission when treated with the guidelines was also examined. METHOD: Six databases were searched until 10 August 2020. Studies were selected, and data were extracted independently according to the PRISMA guidelines. Random effects meta-analyses were used to pool estimates across studies. Risk of bias was assessed according to the Cochrane Effective Practice and Organization of Care Review Group criteria. PROSPERO: CRD42020171311. RESULTS: The meta-analysis included 18 studies (N = 5380). Guidelines showed a positive significant effect size on the severity of psychopathological symptoms at the patient level when compared to treatment-as-usual (TAU) (d = 0.29, 95%-CI = (0.19, 0.40), p < 0.001). Removal of a potential outlier gave globally the same results with Cohen's d = 0.26. Time to remission was shorter in the guideline treatment compared with TAU (HR = 1.54, 95%-CI = (1.29, 1.84), p = 0.001, n = 3). CONCLUSIONS: Patients cared for with guideline-adherent treatments improve to a greater degree and more quickly than patients treated with TAU. Knowledge on the mechanisms of change during guideline-adherent treatment needs to be developed further such that we can provide the best possible treatment to patients in routine care.

Identifying socio-demographic risk factors for suicide using data on an individual level.

BACKGROUND: Suicide is a complex issue. Due to the relative rarity of the event, studies into risk factors are regularly limited by sample size or biased samples. The aims of the study were to find risk factors for suicide that are robust to intercorrelation, and which were based on a large and unbiased sample. METHODS: Using a training set of 5854 suicides and 596,416 control cases, we fit a logistic regression model and then evaluate the performance on a test set of 1425 suicides and 594,893 control cases. The data used was micro-data of Statistics Netherlands (CBS) with data on each inhabitant of the Netherlands. RESULTS: Taking the effect of possible correlating risk factors into account, those with a higher risk for suicide are men, middle-aged people, people with low income, those living alone, the unemployed, and those with mental or physical health problems. People with a lower risk are the highly educated, those with a non-western immigration background, and those living with a partner. CONCLUSION: We confirmed previously known risk factors such as male gender, middle-age, and low income and found that they are risk factors that are robust to intercorrelation. We found that debt and urbanicity were mostly insignificant and found that the regional differences found in raw frequencies are mostly explained away after correction of correlating risk factors, indicating that these differences were primarily caused due to the differences in the demographic makeup of the regions. We found an AUC of 0.77, which is high for a model predicting suicide death and comparable to the performance of deep learning models but with the benefit of remaining explainable.

The effect of local Suicide Prevention Action Networks (SUPRANET) on stigma, taboo and attitudes towards professional help-seeking: an exposure-response analysis.

PURPOSE: In 2017, the European Alliance against Depression (EAAD) programme was introduced in the Netherlands through the creation of six local Suicide Prevention Action Networks (SUPRANET Community). This programme consists of interventions on four levels: (1) a public awareness campaign, (2) training local gatekeepers, (3) targeting high-risk persons in the community and (4) training of primary care professionals. This study aims to gain insight into the effectiveness of the SUPRANET programme on attitudinal changes in the general public by studying the exposure-response relationship. METHODS: A repeated cross-sectional design, using general population surveys to measure key variables over time. The surveys were conducted in the six intervention regions (N = 2586) and in the Netherlands as a whole as a control region (N = 4187) and include questions on socio-demographic variables, brand awareness of the Dutch helpline, perceived taboo on suicide, attitudes towards depression and help-seeking. To examine the exposure-response relationship, regions were differentiated into 3 groups: low, medium and high exposure of the SUPRANET programme. RESULTS: The results revealed that respondents in the intervention regions considered professional help to be more valuable and were more likely to be familiar with the Dutch helpline than respondents in the control region. In the exposure-response analyses, the grading of effects was too small to reach statistical significance. CONCLUSION: Our study provides the first evidence for the effectiveness of the SUPRANET Community programme on creating attitudinal change in the general public.

Content-Based Recommender Support System for Counselors in a Suicide Prevention Chat Helpline: Design and Evaluation Study.

BACKGROUND: The working environment of a suicide prevention helpline requires high emotional and cognitive awareness from chat counselors. A shared opinion among counselors is that as a chat conversation becomes more difficult, it takes more effort and a longer amount of time to compose a response, which, in turn, can lead to writer's block. OBJECTIVE: This study evaluates and then designs supportive technology to determine if a support system that provides inspiration can help counselors resolve writer's block when they encounter difficult situations in chats with help-seekers. METHODS: A content-based recommender system with sentence embedding was used to search a chat corpus for similar chat situations. The system showed a counselor the most similar parts of former chat conversations so that the counselor would be able to use approaches previously taken by their colleagues as inspiration. In a within-subject experiment, counselors' chat replies when confronted with a difficult situation were analyzed to determine if experts could see a noticeable difference in chat replies that were obtained in 3 conditions: (1) with the help of the support system, (2) with written advice from a senior counselor, or (3) when receiving no help. In addition, the system's utility and usability were measured, and the validity of the algorithm was examined. RESULTS: A total of 24 counselors used a prototype of the support system; the results showed that, by reading chat replies, experts were able to significantly predict if counselors had received help from the support system or from a senior counselor (P=.004). Counselors scored the information they received from a senior counselor (M=1.46, SD 1.91) as significantly more helpful than the information received from the support system or when no help was given at all (M=-0.21, SD 2.26). Finally, compared with randomly selected former chat conversations, counselors rated the ones identified by the content-based recommendation system as significantly more similar to their current chats (ß=.30, P<.001). CONCLUSIONS: Support given to counselors influenced how they responded in difficult conversations. However, the higher utility scores given for the advice from senior counselors seem to indicate that specific actionable instructions are preferred. We expect that these findings will be beneficial for developing a system that can use similar chat situations to generate advice in a descriptive style, hence helping counselors through writer's block.

Additional Value of Peer Informants in Psychological Autopsy Studies of Youth Suicides.

In this study, we examined the feasibility and added value of including peer informants in a psychological autopsy study of youth suicides. Peer semi-structured interview data from 16 cases were analyzed qualitatively and compared to parent data. Results show that peers added information to parents' narratives in general and particularly on social relationships, bullying, school experiences, social media, and family relations. Peers also provided additional information on the presence of certain issues (such as social media contagion) as well as on the emotional impact from certain adverse events that seemed to have functioned as precipitating factors. We conclude that including peers in psychological autopsy studies of youth suicides is feasible and of added value but that more research is desirable. The results initially can be used in the design of psychological autopsies so that the maximum amount of information about each suicide will be learned.

Prioritizing suicide prevention guideline recommendations in specialist mental healthcare: a Delphi study.

BACKGROUND: The Delphi technique is a proven and reliable method to create common definitions and to achieve convergence of opinion. This study aimed to prioritize suicide prevention guideline recommendations and to develop a set of quality indicators (QIs) for suicide prevention in specialist mental healthcare. METHODS: This study selected 12 key recommendations from the guideline to modify them into QIs. After feedback from two face-to-face workgroup sessions, 11 recommendations were rephrased and selected to serve as QIs. Next, a Delphi study with the 11 QIs was performed to achieve convergence of opinion among a panel of 90 participants (23 suicide experts, 23 members of patients' advisory boards or experts with experiences in suicidal behavior and 44 mental healthcare professionals). The participants scored the 11 QIs on two selection criteria: relevance (it affects the number of suicides in the institution) and action orientation (institutions or professionals themselves can influence it) using a 5-point Likert scale. Also, data analysts working in mental healthcare institutions (MHIs) rated each QI on feasibility (is it feasible to monitor and extract from existing systems). Consensus was defined as 70% agreement with priority scores of four or five. RESULTS: Out of the 11 recommendations, participants prioritized five recommendations as relevant and action-oriented in optimizing the quality of care for suicide prevention: 1) screening for suicidal thoughts and behavior, 2) safety plan, 3) early follow-up on discharge, 4) continuity of care and 5) involving family or significant others. Only one of the 11 recommendations early follow-up on discharge reached consensus on all three selection criteria (relevance, action orientation, and feasibility). CONCLUSIONS: The prioritization of relevant and action-oriented suicide prevention guideline recommendations is an important step towards the improvement of quality of care in specialist mental healthcare.

Suicide prevention gatekeeper training in the Netherlands improves gatekeepers' knowledge of suicide prevention and their confidence to discuss suicidality, an observational study.

BACKGROUND: The gatekeeper training is designed to help identify suicidal individuals, respond to suicidal ideation and refer to help. The internationally widely used training shows promising results. This is the first study presenting its effectiveness in the Netherlands and the first study investigating the effect in different employment sectors. METHODS: In an observational study, 113 Suicide Prevention - the Dutch suicide prevention expertise centre and lifeline - trained 526 professionals as gatekeepers. Changes in gatekeepers' identifying and referral behaviour, knowledge of suicide prevention and skills-confidence were studied, using a pre-post (6 weeks after training) self-report questionnaire. Outcomes were analyzed with General Linear Model (GLM) repeated measures with four employment sectors (healthcare-, educational-, socioeconomic and other sectors) as a between-subjects factor. RESULTS: Pre-post self-reports of 174 respondents showed no change in the identification of suicidal people, referrals to the general practitioner (GP) or lifeline 113, but significant improvement in professionals' knowledge and confidence (p < .001). Results did not differ between employment sectors. CONCLUSIONS: The gatekeeper training significantly increases suicide prevention knowledge and skills confidence in abilities to address suicidality. Healthcare, education, socioeconomic and other professionals (e.g. security, justice, transport, church workers) benefit similarly from the training. Increasing the number of gatekeeper training programs in all sectors is recommended.

The Most Effective Interventions for Classification Model Development to Predict Chat Outcomes Based on the Conversation Content in Online Suicide Prevention Chats: Machine Learning Approach.

BACKGROUND: For the provision of optimal care in a suicide prevention helpline, it is important to know what contributes to positive or negative effects on help seekers. Helplines can often be contacted through text-based chat services, which produce large amounts of text data for use in large-scale analysis. OBJECTIVE: We trained a machine learning classification model to predict chat outcomes based on the content of the chat conversations in suicide helplines and identified the counsellor utterances that had the most impact on its outputs. METHODS: From August 2021 until January 2023, help seekers (N=6903) scored themselves on factors known to be associated with suicidality (eg, hopelessness, feeling entrapped, will to live) before and after a chat conversation with the suicide prevention helpline in the Netherlands (113 Suicide Prevention). Machine learning text analysis was used to predict help seeker scores on these factors. Using 2 approaches for interpreting machine learning models, we identified text messages from helpers in a chat that contributed the most to the prediction of the model. RESULTS: According to the machine learning model, helpers' positive affirmations and expressing involvement contributed to improved scores of the help seekers. Use of macros and ending the chat prematurely due to the help seeker being in an unsafe situation had negative effects on help seekers. CONCLUSIONS: This study reveals insights for improving helpline chats, emphasizing the value of an evocative style with questions, positive affirmations, and practical advice. It also underscores the potential of machine learning in helpline chat analysis.

Breaking Down Barriers to a Suicide Prevention Helpline: Web-Based Randomized Controlled Trial.

Background: Every month, around 3800 people complete an anonymous self-test for suicidal thoughts on the website of the Dutch suicide prevention helpline. Although 70% score high on the severity of suicidal thoughts, <10% navigate to the web page about contacting the helpline. Objective: This study aimed to test the effectiveness of a brief barrier reduction intervention (BRI) in motivating people with severe suicidal thoughts to contact the suicide prevention helpline, specifically in high-risk groups such as men and middle-aged people. Methods: We conducted a fully automated, web-based, randomized controlled trial. Respondents with severe suicidal thoughts and little motivation to contact the helpline were randomly allocated either to a brief BRI, in which they received a short, tailored message based on their self-reported barrier to the helpline (n=610), or a general advisory text (care as usual as the control group: n=612). Effectiveness was evaluated using both behavioral and attitudinal measurements. The primary outcome measure was the use of a direct link to contact the helpline after completing the intervention or control condition. Secondary outcomes were the self-reported likelihood of contacting the helpline and satisfaction with the received self-test. Results: In total, 2124 website visitors completed the Suicidal Ideation Attributes Scale and the demographic questions in the entry screening questionnaire. Among them, 1222 were randomized into the intervention or control group. Eventually, 772 respondents completed the randomized controlled trial (intervention group: n=369; control group: n=403). The most selected barrier in both groups was "I don't think that my problems are serious enough." At the end of the trial, 33.1% (n=122) of the respondents in the intervention group used the direct link to the helpline. This was not significantly different from the respondents in the control group (144/403, 35.7%; odds ratio 0.87, 95% CI 0.64-1.18, P=.38). However, the respondents who received the BRI did score higher on their self-reported likelihood of contacting the helpline at a later point in time (B=0.22, 95% CI 0.12-0.32, P≤.001) and on satisfaction with the self-test (B=0.27, 95% CI 0.01-0.53, P=.04). For male and middle-aged respondents specifically, the results were comparable to that of the whole group. Conclusions: This trial was the first time the helpline was able to connect with high-risk website visitors who were hesitant to contact the helpline. Although the BRI could not ensure that those respondents immediately used the direct link to the helpline at the end of the trial, it is encouraging that respondents indicated that they were more likely to contact the helpline at a later point in time. In addition, this low-cost intervention provided greater insight into the perceived barriers to service. Follow-up research should be focused on identifying the added value of other components (eg, video or photo material) in the BRI and increasing its effectiveness, especially for men and middle-aged people.

The prevalence, course, and risk factors of suicidal ideation and suicide attempts among students in vocational education.

BACKGROUND: Worldwide, suicide is one of the leading causes of death among adolescents and young adults. Given that suicide in this age group is common within vocational students, this study aims to provide insights into the prevalence, course, and risk factors of suicidal ideation (SI) and suicide attempts (SA) among students in vocational education over the past 10 years. METHODS: This study has a repeated cross-sectional design, utilizing data from 2013 to 2023 provided by the 'Testjeleefstijl' foundation in the Netherlands ('Test Your Lifestyle'). In total, 101,182 students in vocational education completed a web-based standardized questionnaire. Univariate logistic regression was used to test the predictive value of risk factors separately (anxiety and depression, gender, age and school year) on SI and SA. In addition, a machine learning model (Berkelmans et al., 2023) ​was used for high-risk identification of combined risk factors (multivariate models). RESULTS: Within vocational students, 12-month SI and SA prevalence increased from respectively 17.7% and 2.3% in schoolyear 2013-2014 to 23% and 3.2% in 2022-2023. Although female gender significantly predicted SI and SA in the univariate analyses, the multivariate models revealed that female gender decreased the likelihood of both SI (OR 0.9) and SA (OR 0.7). A high risk for anxiety and depression was the strongest predictor in the multivariate models for SI (OR 42.8) and SA (OR 19.0). CONCLUSION: Over the past decade, the prevalence of SI and SA increased in students in vocational education, with the risk of anxiety and depression being the strongest contributing factor. While females had a higher prevalence of anxiety and depression, the results suggest these conditions tend to lead to SI and SA more quickly among male students. Early intervention in suicide prevention is crucial, highlighting the need to identify and address anxiety and depression. Vocational education schools have a critical role in this, emphasizing early screening and intervention, with specific attention to gender-specific factors.

Reducing suicides in mental healthcare: results from a 4-year follow-up implementation study in the Netherlands (SUPRANET).

Objective: In 2016, the SUicide PRevention Action NETwork (SUPRANET) was launched. The SUPRANET intervention aims at better implementing the suicide prevention guideline. An implementation study was developed to evaluate the impact of SUPRANET over time on three outcomes: 1) suicides, 2) registration of suicide attempts, and 3) professionals' knowledge and adherence to the guideline. Methods: This study included 13 institutions, and used an uncontrolled longitudinal prospective design, collecting biannual data on a 2-level structure (institutional and team level). Suicides and suicide attempts were extracted from data systems. Professionals' knowledge and adherence were measured using a self-report questionnaire. A three-step interrupted time series analysis (ITSA) was performed for the first two outcomes. Step 1 assessed whether institutions executed the SUPRANET intervention as intended. Step 2 examined if institutions complied with the four guideline recommendations. Based on steps 1 and 2, institutions were classified as below or above average and after that, included as moderators in step 3 to examine the effect of SUPRANET over time compared to the baseline. The third outcome was analyzed with a longitudinal multilevel regression analysis, and tested for moderation. Results: After institutions were labeled based on their efforts and investments made (below average vs above average), we found no statistically significant difference in suicides (standardized mortality ratio) between the two groups relative to the baseline. Institutions labeled as above average did register significantly more suicide attempts directly after the start of the intervention (78.8 per 100,000 patients, p<0.001, 95%CI=(51.3 per 100,000, 106.4 per 100,000)), and as the study progressed, they continued to report a significantly greater improvement in the number of registered attempts compared with institutions assigned as below average (8.7 per 100,000 patients per half year, p=0.004, 95%CI=(3.3 per 100,000, 14.1 per 100,000)). Professionals working at institutions that invested more in the SUPRANET activities adhered significantly better to the guideline over time (b=1.39, 95%CI=(0.12,2.65), p=0.032). Conclusion: Institutions labeled as above average registered significantly more suicide attempts and also better adhered to the guideline compared with institutions that had performed less well. Although no convincing intervention effect on suicides was found within the study period, we do think that this network is potentially able to reduce suicides. Continuous investments and fully implementing as many guideline recommendations as possible are essential to achieve the biggest drop in suicides.

Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis.

Importance: Suicidal ideation and suicide attempts are debilitating mental health problems that are often treated with indirect psychotherapy (ie, psychotherapy that focuses on other mental health problems, such as depression or personality disorders). The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts. Objective: To investigate the effect sizes of direct and indirect psychotherapy on suicidal ideation and the incidence of suicide attempts. Data Sources: PubMed, Embase, PsycInfo, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up until April 1, 2023. Study Selection: Randomized clinical trials of psychotherapy for any mental health problem, delivered in any setting, compared with any control group, and reporting suicidal ideation or suicide attempts were included. Studies measuring suicidal ideation with 1 item were excluded. Data Extraction and Synthesis: PRISMA guidelines were followed. Summary data were extracted by 2 independent researchers and pooled using 3-level meta-analyses. Main Outcomes and Measures: Hedges g was pooled for suicidal ideation and relative risk (RR) was pooled for suicide attempts. Results: Of 15 006 studies identified, 147 comprising 193 comparisons and 11 001 participants were included. Direct and indirect psychotherapy conditions were associated with reduced suicidal ideation (direct: g, -0.39; 95% CI, -0.53 to -0.24; I2, 83.2; indirect: g, -0.30; 95% CI, -0.42 to -0.18; I2, 52.2). Direct and indirect psychotherapy conditions were also associated with reduced suicide attempts (direct: RR, 0.72; 95% CI, 0.62 to 0.84; I2, 40.5; indirect: RR, 0.68; 95% CI, 0.48 to 0.95; I2, 0). Sensitivity analyses largely confirmed these results. Conclusions and Relevance: Direct and indirect interventions had similar effect sizes for reducing suicidal ideation and suicide attempts. Suicide prevention strategies could make greater use of indirect treatments to provide effective interventions for people who would not likely seek treatment for suicidal ideation or self-harm.

The forever decision: a qualitative study among survivors of a suicide attempt.

Background: Suicide attempts have a profound emotional impact on both individuals and society as a whole. This qualitative study delves into three key aspects: 1) the progression through the suicidal process, 2) the influential factors facilitating the transition from ideation to attempt using the volitional moderators within the integrated motivational-volitional (IMV) model, and 3) preventive strategies impeding this transition from ideation to attempt. Methods: Between October 1, 2022 and March 7, 2023 we interviewed 27 adults (23 women, four men, mean age 33 years) who attempted suicide within the past 12 months. Participants were recruited through social media and in collaboration with several mental health institutions in the Netherlands. The participants were initially screened and interviewed based on the Pathway to Suicidal Actions Interview. Analysis was performed employing the constant comparative method. Findings: Despite the heterogeneity of the suicidal process, suicidal thoughts predominately emerged during adolescence (Mdn = 15, M = 17.8). In most participants, planning and preparatory actions occurred long before the attempt, with a median of six years prior to the attempt for the selection of the method. All volitional moderators were observed, although pain sensitivity in particular varied among participants. Access to lethal means and planning emerged as important moderators in the suicidal process. Asking the survivors what could have helped to prevent their attempts, most participants mentioned that they felt their suicidality was not taken seriously enough. Interpretation: We discussed the significance of planning in the suicidal process, challenges in conceptualizing planning and impulsivity, and individual differences in pain sensitivity. Based on the findings, we underscore the critical need for restricting access to means, giving greater consideration to preparatory actions within the suicidal process, and fostering open dialogues about suicidality. Funding: This research was funded by ProRail, the Dutch rail infrastructure manager in line with their work on mental health.