Suicide prevention: reflections on progress over the past decade.

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.

The long-term changing patterns of suicide mortality in China from 1987 to 2020: continuing urban-rural disparity.

BACKGROUND: Over the past three decades, China has experienced significant changes in urban-rural, gender, and age-specific suicide mortality patterns. This study aimed to investigate the long-term trends in suicide mortality in China from 1987 to 2020. METHODS: Suicide mortality data were obtained from China's National Health Commission. Joinpoint regression analysis was used to examine changes in trends and age-period-cohort modeling to estimate age, period, and cohort effects on suicide mortality from 1987 to 2020. Net drift, local drift, longitudinal age curves, and period relative risks were also calculated. RESULTS: Crude and age-standardized suicide mortality in China showed continuing downward trends from 1987 to 2020, with a more pronounced decrease in rural areas (net drift = -7.07%, p<0.01) compared to urban areas (net drift = -3.41%, p<0.01). The decline curve of urban areas could be divided into three substages. Period and cohort effects were more prominent in rural areas. Suicide risk was highest among individuals aged 20-24 and gradually increased after age 60. Females, particularly those of childbearing age, had higher suicide risk than males, with a reversal observed after age 50. This gender reversal showed distinct patterns in urban and rural areas, with a widening gap in urban areas and a relatively stable gap in rural areas. CONCLUSIONS: Suicide mortality in China has consistently declined over the past three decades. However, disparities in age, gender, and urban-rural settings persist, with new patterns emerging. Targeted suicide prevention programs are urgently needed for high-risk groups, including females of childbearing age and the elderly, and to address the slower decrease and reversing urban-rural gender trends.

Emerging Trends of Self-Harm Using Sodium Nitrite in an Online Suicide Community: Observational Study Using Natural Language Processing Analysis.

Background: There is growing concern around the use of sodium nitrite (SN) as an emerging means of suicide, particularly among younger people. Given the limited information on the topic from traditional public health surveillance sources, we studied posts made to an online suicide discussion forum, "Sanctioned Suicide," which is a primary source of information on the use and procurement of SN. Objective: This study aims to determine the trends in SN purchase and use, as obtained via data mining from subscriber posts on the forum. We also aim to determine the substances and topics commonly co-occurring with SN, as well as the geographical distribution of users and sources of SN. Methods: We collected all publicly available from the site's inception in March 2018 to October 2022. Using data-driven methods, including natural language processing and machine learning, we analyzed the trends in SN mentions over time, including the locations of SN consumers and the sources from which SN is procured. We developed a transformer-based source and location classifier to determine the geographical distribution of the sources of SN. Results: Posts pertaining to SN show a rise in popularity, and there were statistically significant correlations between real-life use of SN and suicidal intent when compared to data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (⍴=0.727; P<.001) and the National Poison Data System (⍴=0.866; P=.001). We observed frequent co-mentions of antiemetics, benzodiazepines, and acid regulators with SN. Our proposed machine learning-based source and location classifier can detect potential sources of SN with an accuracy of 72.92% and showed consumption in the United States and elsewhere. Conclusions: Vital information about SN and other emerging mechanisms of suicide can be obtained from online forums.

Trends in cancer-related suicide in the United States: a population-based epidemiology study spanning 40 years of data.

Large cohort studies examining trends in cancer-related suicide are lacking. We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database, encompassing a total of 4,870,410 patients diagnosed with cancer from 1975 to 2017 in the United States. Joinpoint regression was used to estimate the annual percent change (APC) and average annual percentage change (AAPC) of age-adjusted rates of suicide. In the past 40 years, we revealed a gradual increase in cancer-related suicide rates from 1975 to 1989, followed by a gradual decrease from 1989 to 2013, and a marked decrease from 2013 to 2017. These trends suggested the potential impact of advancements in psychosocial care for patients with cancer in contributing to the observed decrease in suicide rates.

Road vehicle collision suicide in Australia: Trends, collision types, and individual characteristics.

BACKGROUND: Suicide by road vehicle collision in Australia is under-explored with mixed findings. We aimed to address this research gap by examining time trends, different types of vehicle collision, and individual characteristics related to vehicle-collision suicide. METHOD: We retrospectively analyzed deaths by suicide between 1st January 2001 and 31st December 2017 in Australia, using coronial records from the National Coronial Information System. The travel mode used and collision counterpart were retrieved from records of death by vehicle-collision suicide using all available information. We conducted negative binomial regression analysis to examine annual changes in suicide rate by vehicle collision on a public road (N = 640) and other methods of suicide (N = 41,890), and logistic regression analysis to examine individual characteristics associated with the likelihood of dying by suicide via road vehicle collision. RESULTS: Overall, the national suicide rate involving road vehicle collision significantly increased, while the rate by other methods significantly decreased. Drivers accounted for 61% of suicide events by vehicle collision, of which 72% were single-vehicle collisions (commonly involving a tree). For multiple-vehicle collision suicide events, 82% involved collision with a truck. Pedestrians accounted for more than one-third of suicide events, of which 58% involved collision with a truck and 23% involved collision with a car/van. Individuals who were male (odds ratio 1.15; 95% CI 0.88-1.50), aged <25 years old (odds ratio 5.27; 95% CI 3.05-9.10), non-Indigenous (odds ratio 3.36; 95% CI 1.71-6.62), and born overseas (odds ratio 1.40; 95% CI 1.10-1.79) were more likely to die by vehicle-collision suicide than by other methods of suicide. CONCLUSIONS: This study provides a better understanding of road vehicle collision suicide in Australia and informs future research directions on topic. Our findings can be used to inform suicide prevention initiatives to reduce vehicle-collision suicide deaths.

[Epidemic characteristics and trend analysis of major injuries deaths among children and adolescents in Jiangsu Province from 2012 to 2021].

Objective: To understand the situation and epidemic characteristics of injury deaths among children aged 5 to 24 years in Jiangsu Province from 2012 to 2021 and the trend of annual changes. Methods: The main injury mortality data of children and adolescents was collected, and the crude and standardized mortality rates of road traffic accidents, drowning, suicide, and accidental falls among children and adolescents over a decade and the annual average percentage of change (AAPC) were calculated. The main injury mortality characteristics and trends of children and adolescents of different age groups and genders were analyzed. Results: The total number of injury deaths among 5 to 24 adolescents in Jiangsu Province was 16 052, with a standardized mortality rate of 9.58/100 000. There was no significant trend in the overall standardized mortality rate of injuries (AAPC=-3.450%, P=0.055). The standardized mortality rate of road traffic injuries among children and adolescents showed a decreasing trend over the past decade, with statistical significance (AAPC=-9.406%, P<0.001). The standardized suicide mortality rate showed an upward trend over the past decade, with statistical significance (AAPC=9.000%, P=0.001). The overall injury mortality rate showed an upward trend with age. Suicide rates in males and females were on the rise and both have statistical significance (AAPC=9.420% and AAPC=9.607%, both P<0.05). The standardized mortality rates of female traffic accidents, drowning, and male traffic accidents showed a decreasing trend and were statistically significant (AAPC for female traffic accidents=-7.364%, AAPC for female drowning=-5.352%, and AAPC for male traffic accidents=-10.242%, all P<0.05). The standardized mortality rate of urban and rural traffic accidents showed a decreasing trend and was statistically significant(AAPC=-7.899% and AAPC=-9.421%, both P<0.001). The standardized suicide mortality rate showed an upward trend and statistical significance (AAPC=11.009% and AAPC=7.528%, both P<0.05). Conclusions: The overall injury situation of children and adolescents in Jiangsu Province improved in the past decade from 2012 to 2021, but the suicide mortality rate was on the rise. It is necessary to focus on the mental health issues of this age group and to strengthen the prevention and control of suicide among children and adolescents, in Jiangsu.

Suicide mortality in Spain during the COVID-19 pandemic: Longitudinal analysis of sociodemographic factors.

The COVID-19 pandemic has compromised public health response across the globe. Several countries reported increasing number of suicides during the pandemic. This study aimed to analyze the suicide mortality series in Spain (2000-2021), with a particular interest in depicting longitudinal trends during the COVID-19 pandemic. Moreover, it intended to identify sociodemographic groups with a higher increase in suicide victims during the pandemic. To do so, suicide cases from the National death index data were used. Weighted annual mortality rate was compared between pre-pandemic and pandemic years. Poisson time series models were used to analyze the trend in suicide mortality, considering sociodemographic variables (sex, age, migration status, marital status, and urbanicity). As a result, weighted mortality rate for 2020 was 8.92 (CI95 = [8.29, 9.57]) and 9.21 for 2021 (CI95 = [8.56, 9.88]). Annual mortality from the pandemic years was significantly higher than mortality from the prepandemic ones (p < .01). Poisson regression revealed a significant increase of cases during the pandemic months, RR = 1.05 (CI95 = [1.02, 1.08]); being significant for both sexes, and migration groups (RR > 1.02, across series). A significantly increased number of suicides was also observed for mid-age adults, large urban areas, and single people (RR > 1.05, across series). To sum up, our study supports an increasing number of suicide victims in Spain during the pandemic. We show that the COVID-19 influence on suicide risk factors (e.g., lack of social support networks) plays a critical role in the increasing trend of specific sociodemographic groups.

Insufficient Sleep is Associated With Increasing Trends in Adolescent Suicidal Behaviors.

PURPOSE: Youth suicide has been increasing and became a public health concern worldwide. Identifying insufficient sleep as the potential risk factor is critical to reducing suicide risk and increasing trends. This study aimed to determine whether insufficient sleep is associated with increasing trends in suicidal behaviors and disparities by sex, age, and race/ethnicity among school adolescents. METHODS: The present study used biennial data from the US nationally representative Youth Risk Behavior Survey from 2007 to 2019. Joinpoint regression models were used to estimate biennial percent changes (BPCs) and average BPCs (ABPCs) of suicidal behaviors by sleep duration. Logistic regression models were used to examine the association between insufficient sleep and suicidal behaviors. RESULTS: Of 73,356 adolescent students included (mean [standard deviation] age, 16.11 [1.23] years), 50.03% were female. Suicidal ideation and suicide plan among insufficient sleep group increased from 2007 to 2019 (BPC = 2.88% [95% confidence interval {CI}: 1.65%, 4.13%]; BPC = 3.42% [95% CI: 2.09%, 4.77%]), but were nonsignificant among sufficient sleep group. Trends in suicidal ideation (ABPC = 3.03% [95% CI: 1.35%, 4.73%]) and suicide plan (ABPC = 4.03% [95% CI: 2.47%, 5.62%]) among female adolescents with insufficient sleep increased, but nonsignificant among male adolescents with insufficient sleep. Suicidal ideation (ABPC = 1.73% [95% CI: 0.51%, 2.97%]) and suicide plan (ABPC = 2.31% [95% CI: 0.70%, 3.95%]) increased among younger adolescents only with insufficient sleep, whereas suicide trends by sleep duration were similar among older adolescents. Suicide plan among insufficient sleep group increased across the four racial groups, with BPC highest for the White (BPC = 3.48% [95% CI: 1.31%, 5.69%]), and lowest for the Hispanic/Latino (BPC = 1.18% [95% CI: 0.15%, 2.23%]), but were nonsignificant among sufficient sleep group except for the White (BPC = 2.83% [95% CI: 0.62%, 5.09%]). DISCUSSION: Insufficient sleep was disproportionately associated with increasing trends in suicidal behaviors among female, younger, and non-White adolescent students. Ensuring sufficient sleep can potentially reduce suicide among school adolescents.

Characteristics of and Variation in Suicide Mortality Related to Retirement During the Great Recession: Perspectives From the National Violent Death Reporting System.

BACKGROUND AND OBJECTIVES: Suicide rates typically increase during recessions. However, few studies have explored how recessions affect risk among older adults nearing retirement. This study used a large suicide mortality registry to characterize and quantify suicide related to retirement during the Great Recession (GR). RESEARCH DESIGN AND METHODS: Data come from the National Violent Death Reporting System (NVDRS, 2004-2017; N = 53,298 suicide deaths age ≥50). We analyzed the text narratives (i.e., descriptions of the most salient circumstances to each suicide) of these decedents using natural language processing (NLP) to identify cases that were "retirement-related" (RR, e.g., anticipating, being unable to, or recently retiring). We used time-series analysis to quantify variation in RR over the GR, and compared these trends to retirees (i.e., decedents whose occupation was "retired") and all decedents aged ≥50. We used content and network analysis to characterize themes represented in the narratives. RESULTS: There were 878 RR cases (1.6% of suicides aged ≥50) identified by the NLP model; only 52% of these cases were among retirees. RR cases were younger (62 vs 75 years) and more educated (41.5% vs 24.5% college degree) than retirees. The rate of RR suicide was positively associated with indicators of the GR (e.g., short-term unemployment R2 = 0.70, p = .024), but economic indicators were not correlated with the suicide rate among retirees or older adults in general. Economic issues were more central to the narratives of RR cases during the GR compared to other periods. DISCUSSION AND IMPLICATIONS: Recessions shape suicide risk related to retirement transitions.

Temporal Trend in Suicide Mortality for Chinese Adolescents, 2008 to 2021.

This study aims to evaluate the temporal trend in suicide mortality for Chinese adolescents aged 10 to 19 years from 2008 to 2021.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019.

Importance: Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking. Objectives: To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals. Design, Setting, and Participants: Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age. Exposures: Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types. Main Outcomes and Measures: Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals. Results: Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations. Conclusions and Relevance: Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

Analysis of suicide statistics and trends between 2011 and 2021 among Korean women.

PURPOSE: This study aims to analyze the number of suicide deaths in women, trends in suicide mortality, characteristics of suicide by age, and outcomes of suicide means over the past decade (2011- 2021) in South Korea. METHODS: Using cause of death data from Statistics Korea, an in-depth analysis of Korean women's suicide trends was conducted for the period of 2011-2021. RESULTS: In 2021, women's suicide death in Korea was 4,159, a rate of 16.2 per 100,000 population. The rate increased by 1.4% from the previous year. Since 2011, women's suicide rate has been on a steady downward trend, but since 2018, it has been on the rise again. Suicide rates among women in their 20s and 30s have increased, especially since the coronavirus disease 2019 pandemic, and suicide rates among women over 70 years remain high. As compared to 2011, pesticide poisoning and hanging among the means of suicide have decreased significantly, while drug and carbon monoxide continue to increase. CONCLUSION: Suicide rates for Korean women in their 20s and 30s have increased significantly in recent years, and those for women over 70 years remain high. Therefore, it is necessary to investigate the causes and establish national policies for targeted management of these age groups, which contributes significantly to the rising suicide rate among Korean women.

Discussion of the features of suicide trends in 1994-1995 and 2019-2020: The need for different contents in suicide prevention measures for both periods in Japan from the viewpoint of the present.

Japan is a country that is prone to natural disasters. This study compared the characteristics of suicide trends before and after the Great Hanshin-Awaji Earthquake, and during the current COVID-19 pandemic 25 years later. In the present study, we examined the annual number of suicides, the number of suicides by age group, and the reason for suicide during the period associated with the earthquake (1994-1995) and the period associated with the pandemic (2019-2020). This study used statistical analyses to compare the two periods. Our findings suggest that research needs to be conducted from the perspective of legal medicine and social medicine to devise current and future measures to prevent suicides. During the first period, suicides increased in 1995 compared to 1994. Suicide due to economic and life problems increased significantly. During the second period, suicides increased in 2020 compared to 2019. Suicides by males decreased significantly and those by females increased significantly; suicides by individuals aged 19 or under and by those aged 20-29 increased significantly, while suicides by individuals aged 60-69 decreased significantly; and suicides due to "other problems" increased significantly, while suicides due to economic and life problems decreased significantly. Ongoing studies of detailed trends in suicides due to the effects of COVID-19 need to be conducted in the future, and it is important to determine suicide risk due to the effects of COVID-19. Legal medicine and social medicine are fields that conduct such studies and that can offer science-based responses to these trends.

Introduction to the PLOS ONE collection on 'Understanding and preventing suicide: Towards novel and inclusive approaches'.

More than 700,000 people lose their lives to suicide each year and evidence suggests that the current COVID-19 pandemic is leading to increases in risk factors for suicide and suicide-related behaviour, in particular among young people. It is widely documented that some sectors of the population are over-represented in the suicide statistics. It is also well established that the pathways that lead someone to a suicidal crisis are complex and differ across regions and sectors of the population; as such a multi-faceted approach to prevention is required. Many of us would also argue that novel approaches, that combine broad population-based strategies with individual interventions, and approaches that capitalise on new technologies and methodologies are also required. For these reasons, when bringing together this collection, we deliberately sought studies that focused upon those groups who are over-represented in the suicide statistics yet under-represented in research. We also called for studies that reported on novel approaches to suicide prevention and for studies that reflected the voices of people with lived experience of suicide, also often unheard in research efforts.

Changes in Suicide Rates - United States, 2019 and 2020.

Suicide was among the 10 leading causes of death in the United States in 2020 among persons aged 10-64 years, and the second leading cause of death among children and adolescents aged 10-14 and adults aged 25-34 years (1). During 1999-2020, nearly 840,000 lives were lost to suicide in the United States. During that period, the overall suicide rate peaked in 2018 and declined in 2019 and 2020 (1). Despite the recent decline in the suicide rate, factors such as social isolation, economic decline, family stressors, new or worsening mental health symptoms, and disruptions to work and school associated with the COVID-19 pandemic have raised concerns about suicide risk in the United States. During 2020, a total of 12.2 million U.S. adults reported serious thoughts of suicide and 1.2 million attempted suicide (2). To understand how changes in suicide death rates might have varied among subpopulations, CDC analyzed counts and age-adjusted suicide rates during 2019 and 2020 by demographic characteristics, mechanism of injury, county urbanization level, and state. From 2019 to 2020, the suicide rate declined by 3% overall, including 8% among females and 2% among males. Significant declines occurred in seven states but remained stable in the other states and the District of Columbia. Despite two consecutive years of declines, the overall suicide rate remains 30% higher compared with that in 2000 (1). A comprehensive approach to suicide prevention that uses data driven decision-making and implements prevention strategies with the best available evidence, especially among disproportionately affected populations (3), is critical to realizing further declines in suicide and reaching the national goal of reducing the suicide rate by 20% by 2025 (4).

Perceptions towards charcoal-burning suicide and the surge of this lethal method in Taiwan.

OBJECTIVE: Whether sociocultural perceptions of charcoal-burning suicide have influenced its rapid increase in prevalence is unclear. We aimed to explore perceptions of Taiwan's general population regarding charcoal-burning suicide, their personal belief in life after death, and related feelings of thoughts associated with those who attempt charcoal-burning suicide. METHODS: An online web-based survey, focussing on sociocultural attitudes towards death, as well as perceptions towards charcoal-burning suicide, and those who attempt charcoal-burning suicide, was conducted from 14 January to 14 June 2016. RESULTS: In total, 1343 adults completed the online survey (mean age of 33.46; 66.6% women). Notably, 90.3% of participants considered charcoal burning to be an easily accessible suicide method. Multivariable analyses revealed that among the examined factors, the perceived 'painlessness' of charcoal-burning suicide was associated with an over seven-fold increased risk of choosing charcoal-burning suicide (OR = 7.394; p < 0.001; 95% CI: 2.614-20.912). CONCLUSION: As reflected in this study, charcoal-burning suicide is perceived as easily accessible and painless. The perceived 'painlessness' may be the factor that distinguishes the choice of charcoal-burning suicide from that of other suicide methods. Future efforts to target these perceptions regarding charcoal-burning suicide may be warranted in both media reporting and suicide prevention programmes.

Reasons for Suicide During the COVID-19 Pandemic in Japan.

Importance: Although the suicide rate in Japan increased during the COVID-19 pandemic, the reasons for suicide have yet to be comprehensively investigated. Objective: To assess which reasons for suicide had rates that exceeded the expected number of suicide deaths for that reason during the COVID-19 pandemic. Design, Setting, and Participants: This national, population-based cross-sectional study of data on suicides gathered by the Ministry of Health, Labor, and Welfare from January 2020 to May 2021 used a times-series analysis on the numbers of reason-identified suicides. Data of decedents were recorded by the National Police Agency and compiled by the Ministry of Health, Labor, and Welfare. Exposure: For category analysis, we compared data from January 2020 to May 2021 with data from December 2014 to June 2020. For subcategory analysis, data from January 2020 to May 2021 were compared with data from January 2019 to June 2020. Main Outcomes and Measures: The main outcome was the monthly excess suicide rate, ie, the difference between the observed number of monthly suicide deaths and the upper bound of the 1-sided 95% CI for the expected number of suicide deaths in that month. Reasons for suicide were categorized into family, health, economy, work, relationships, school, and others, which were further divided into 52 subcategories. A quasi-Poisson regression model was used to estimate the expected number of monthly suicides. Individual regression models were used for each of the 7 categories, 52 subcategories, men, women, and both genders. Results: From the 29 938 suicides (9984 [33.3%] women; 1093 [3.7%] aged <20 years; 3147 [10.5%] aged >80 years), there were 21 027 reason-identified suicides (7415 [35.3%] women). For both genders, all categories indicated monthly excess suicide rates, except for school in men. October 2020 had the highest excess suicide rates for all cases (observed, 1577; upper bound of 95% CI for expected number of suicides, 1254; 25.8% greater). In men, the highest monthly excess suicide rate was 24.3% for the other category in August 2020 (observed, 87; upper bound of 95% CI for expected number, 70); in women, it was 85.7% for school in August 2020 (observed, 26; upper bound of 95% CI for expected number, 14). Conclusions and Relevance: In this study, observed suicides corresponding to all 7 categories of reasons exceeded the monthly estimates (based on data from before or during the COVID-19 pandemic), except for school-related reasons in men. This study can be used as a basis for developing intervention programs for suicide prevention.

Mental Health Services Under Strain in Rural America.

Improvements are needed to address high rates of suicide.