You feel it was written about you: client acceptability of a group intervention for repeat suicide attempts.

BACKGROUND: Repeat attempts increase risk of death by suicide. The Psychosocial/psychoeducational Intervention for People with recurrent Suicide Attempts (PISA)/Skills for Safer Living (SfSL) is a group intervention targeting repeat attempts. AIMS: To evaluate the acceptability of PISA/SfSL to clients and identify key model components influencing this. METHODS: This exploratory mixed-methods study involved adults who completed PISA/SfSL (N = 16). Participants completed semi-structured interviews and a satisfaction questionnaire post-intervention, and self-report outcome measures of population specific challenges pre and post-intervention and at 6-month follow-up. RESULTS: Qualitative themes illuminate three interrelated response processes; connection with each other and the model, taking control of life, and gaining a sense of value. Quantitative outcome measures indicated positive trends in suicidality, hopelessness, alexithymia, and problem-solving. High satisfaction levels indicated its quality, relevancy, applicability and helpfulness. Key components influencing responses were PISA/SfSL's; psychosocial group format and processes, psychoeducational and skill development content, and ethos. Results suggest PISA/SfSL was acceptable to those with repeat suicide attempts. CONCLUSIONS: The study highlights the usefulness of group work and the importance of consistency with guidelines in suicide intervention. It supports the view that recovery in suicidality and engagement in treatment are complex processes. It adds to previous research demonstrating acceptability among facilitators.

Meaning-Centered Men's Groups: Initial Findings of an Intervention to Enhance Resiliency and Reduce Suicide Risk in Men Facing Retirement.

Objectives: To assess the preliminary effectiveness of Meaning-Centered Men's Groups (MCMG), a 12-session existentially-oriented, community-based, psychological group intervention designed to enhance psychological resiliency and prevent the onset or exacerbation of suicide ideation among men who are concerned about or struggling with the transition to retirement.Methods: We recruited 30 men (n= 10 per group), 55 years and older (M= 63.7, SD= 4.1) from community settings to participate in a course of MCMG to be delivered in a community center. Participants completed eligibility, pre-, mid-, and post-group assessments of suicide ideation and psychological risk and resiliency factors.Results: Participants experienced significant increases in attitudinal sources of meaning in life, psychological well-being, life satisfaction, retirement satisfaction, and general health, and decreases in depression, hopelessness, loneliness, and suicide ideation.Conclusions: Preliminary findings suggest that MCMG is a novel men's mental health intervention that may help to enhance psychological well-being and potentially reduce the severity or prevent the onset of symptoms of depression, hopelessness, and suicide ideation.Clinical Implications: Upstream psychological interventions may serve an important role in mental health promotion and suicide prevention with potentially vulnerable individuals facing challenging life transitions.

"We Went Out to Explore, But Gained Nothing But Illness": Immigration Expectations, Reality, Risk and Resilience in Chinese-Canadian Women with a History of Suicide-Related Behaviour.

Suicide is a complex and tragic outcome driven by biological, psychological, social and cultural factors. Women of Chinese descent and women who have immigrated to other countries have higher rates of suicidal ideation and behaviour, and immigration-related stress may contribute. To understand the experiences of immigration and their relationship with distress and suicide-related behaviour in Chinese women who have immigrated to Canada. 10 semi-structured qualitative interviews with Chinese women who have immigrated to Toronto, Canada and have a history of suicide-related behaviour were completed and analyzed using a constructivist grounded theory methodology. Immigration-related and acculturation stress stemmed from unmet expectations and harsh realities. These repeated experiences resulted in hopelessness, helplessness, and alienation, which are risk factors for suicide and suicide-related behaviour. However, immigration-related support can also increase hope, self-efficacy and connectedness to foster recovery and resilience. This is the first qualitative study focusing on immigration experiences and its relationship to suicide-related behaviour in Chinese immigrant women. Knowledge of immigration and acculturation stressors can a) help identify and support women at risk for suicide and b) form a target for social intervention for all immigrant women, regardless of suicide risk.

Psychotherapy for Borderline Personality Disorder: Progress and Remaining Challenges.

PURPOSE: The main purpose of this review was to critically evaluate the literature on psychotherapies for borderline personality disorder (BPD) published over the past 5 years to identify the progress with remaining challenges and to determine priority areas for future research. METHOD: A systematic review of the literature over the last 5 years was undertaken. RESULTS: The review yielded 184 relevant abstracts, and after applying inclusion criteria, 16 articles were fully reviewed based on the articles' implications for future research and/or clinical practice. CONCLUSION: Our review indicated that patients with various severities benefited from psychotherapy; more intensive therapies were not significantly superior to less intensive therapies; enhancing emotion regulation processes and fostering more coherent self-identity were important mechanisms of change; therapies had been extended to patients with BPD and posttraumatic stress disorder; and more research was needed to be directed at functional outcomes.

Comorbid Depression and Other Predictors of PTSD Severity in Urban Public Transit Employees.

The purpose of the study was to determine whether post traumatic stress disorder (PTSD) with Major Depressive Disorder (MDD) among urban public transit employees who were exposed to a workplace traumatic event is associated with greater PTSD severity over the 6-month follow-up period compared to PTSD without MDD, and also to identify predictors of PTSD severity among these employees. Information about Axis-I diagnosis and PTSD severity were collected from the SCID-I and the Modified PTSD Symptom Scale (MPSS) respectively. PTSD without MDD (N = 29) and PTSD with MDD (N = 37) groups were not significantly different in terms of PTSD severity. The severity of depression (p = 0.01), female (p = 0.01), non-Caucasian (p = 0.01), perceived high workplace related stress (p = 0.02), and history of lifetime trauma (p = 0.01) were significantly associated with greater PTSD severity after controlling other variables. This study highlights the importance of modifiable variables for reducing PTSD severity after a workplace traumatic event in transit employees.

Indo-Canadian Collaboration for Suicide Prevention: Training Needs Assessment for Healthcare Professionals in India.

The main purpose of the study was to conduct a comprehensive needs assessment of primary healthcare professionals in order to develop a training program aimed at enhancing competencies in suicide risk assessment and management. A total of 144 primary healthcare professionals (physicians = 46; primary care workers = 98) completed the needs assessment questionnaire. The majority of healthcare professionals rated their level of comfort and competence in assessing, treating, and referring suicidal patients as medium or high. However, their knowledge about suicide, risk factors for suicide, asking about suicidal behaviour, and helping a suicidal patient was rated low or medium. Overall, the scarcity of qualified healthcare professionals and the existing gaps in core competencies for suicide risk assessment and management was identified. Development of innovative and effective competencies-based suicide specific training for primary care providers in India is urgently required.

Randomised pilot study comparing a coach to SMARTPhone reminders to aid the management of heart failure (HF) patients: humans or machines.

Ambulatory management of congestive heart failure (HF) continues to be a challenging clinical problem. Recent studies have focused on the role of HF clinics, nurse practitioners and disease management programmes to reduce HF readmissions. This pilot study is a pragmatic factorial study comparing a coach intervention, a SMARTPHONE REMINDER system intervention and BOTH interventions combined to Treatment as USUAL (TAU). We determined that both modalities were acceptable to patients prior to randomisation. Fifty-four patients were randomised to the four groups. The COACH group had no readmissions for HF 6 months after enrolment compared with 18% for the SMARTPHONE REMINDER Group, 8% for the BOTH intervention group and 13% for TAU. Medium-to-high medication adherence was maintained in all four groups although sodium consumption was lower at 3 months for the COACH and combined (BOTH) groups. This pilot study suggests a beneficial effect on rehospitalisation with the use of support measures including coaches and telephone reminders that needs confirmation in a larger trial.

The relationship between personality disorders and Axis I psychopathology: deconstructing comorbidity.

The purpose of this review is (a) to study and systematically review the recent literature examining the co-occurrence and relationships between Axis I psychiatric disorders and Axis II personality disorders, specifically the six originally proposed for the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, and (b) to consider the clinical utility of the current Axis I and Axis II approach in the DSM-IV-TR and apply findings to state a position on the issue of collapsing together Axis I and Axis II. Community surveys or prospective cohort studies were reviewed as a priority. Our review indicates that the associations between clinical disorders and personality disorders clearly varied within each disorder and across the six personality disorders. Our understanding has advanced, particularly related to the clinical utility of comorbidity, and there may be sufficient evidence to support moving borderline personality disorder to Axis I. However, it seems premature to conclude that comorbidity is best conceptualized by having all disorders in a single category or by deleting disorders so that comorbidity is reduced. Our review suggests some priorities for future research into comorbidity, such as including personality disorders in future multivariate comorbidity models.

An exploratory study of the relationship between changes in emotion and cognitive processes and treatment outcome in borderline personality disorder.

This exploratory study examined specific emotion processes and cognitive problem-solving processes in individuals with borderline personality disorder (BPD), and assessed the relationship of these changes to treatment outcome. Emotion and cognitive problem-solving processes were assessed using the Toronto Alexithymia Scale, the Linguistic Inquiry Word Count, the Derogatis Affect Balance Scale, and the Problem Solving Inventory. Participants who showed greater improvements in affect balance, problem solving, and the ability to identify and describe emotions showed greater improvements on treatment outcome, with affect balance remaining statistically significant under the most conservative conditions. The results provide preliminary evidence to support the theory that specific improvements in emotion and cognitive processes are associated with positive treatment outcomes (symptom distress, interpersonal functioning) in BPD. The implications for treatment are discussed.

"I thought that I had to be alive to repay my parents": Filial piety as a risk and protective factor for suicidal behavior in a qualitative study of Chinese women.

Filial piety involves the Confucian view that children always have a duty to be obedient and to provide care for their parents. Filial piety has been described as both a risk and a protective factor in depression and suicide. This qualitative study aimed to explore the role of filial piety in the suicidal behavior of Chinese women. Qualitative interviews were conducted with Chinese women with a history of suicidal behavior living in the Beijing area (n = 29). Filial piety data were extracted and analyzed in accordance with constructivist grounded theory. The women described five specific family and filial piety factors and how they influenced their ability to fulfill family role obligations, which was described as a nexus connecting these factors to depression, suicidal behavior, and recovery. The five factors were: 1) rigidity of parental filial expectations, 2) perception of family relationships as positive/supportive or negative/harsh, 3) whether filial piety is of high or low personal value in the woman's life, 4) any experiences of rebellion leading to punitive consequences, and 5) how much filial piety she receives from her children. These factors could inform suicide risk assessments in this population. They can be harnessed as part of recovery and protect against future suicidal behavior.

Lessons from a Canada-China cross-national qualitative suicide research collaboration.

A cross-national qualitative suicide study was conducted by Tsinghua University and the University of Toronto with two samples of Chinese women in Beijing and Toronto. The aim of this article is to reflect on lessons learned from this collaborative study. A literature review guided the analysis. A focus group was conducted with members of both research teams. A semi-structured interview guide was developed to explore the researchers' experiences of participating in the cross-national study. Focus group transcript data and observations from authors informed the analysis, situated in the existing literature on cross-national qualitative health research and guided by Baistow's cross-national research frame. Our study highlights how cross-national research involves conceptual and practical challenges that require negotiation. Such research also holds many opportunities, including (1) using a different cultural lens to understand differences and clarify similarities cross-culturally; (2) co-constructing knowledge through collaboration; (3) deconstructing one's own assumptions; and (4) engaging in an inspiring and empowering experience in collaboration.

Last Words: Are There Differences in Psychosocial and Clinical Antecedents Among Suicide Decedents Who Leave E-Notes, Paper Notes, or No Note?

OBJECTIVE: Only a minority of suicide decedents leave a suicide note. Typically, the notes are handwritten on paper; however, electronic suicide notes have been reported with increasing frequency. This emerging phenomenon remains generally under-researched. The aim of this study was to compare the psychosocial and clinical antecedents of suicide decedents who left E-notes with those who left paper notes or no notes. METHOD: The study was embedded in the Southwestern Ontario Suicide Study (SOSS). The SOSS was a three-year case series of consecutive deaths by suicide that occurred in the region between 2012 and 2014. Data on psychosocial and clinical antecedents were collected with a modified version of the Manchester questionnaire used in the UK. RESULTS: Of the 476 suicides files reviewed, 45.8% contained a suicide note. A total of 383 separate suicide notes were left: 74.3% were paper notes and 25.7% were E-notes. The results of the multivariate regression analyses indicate that the likelihood of leaving a suicide note was negatively associated with a history of admissions to a mental health unit, while the likelihood of leaving an E-note was negatively associated with age, positively associated with presence of a mental disorder, and negatively associated with history of hospital admissions. CONCLUSIONS: Future studies with larger samples need to consider the timing of the text messages, and appraise whether there was the intent of seeking help or rescue in the text messages.

Experiences of substance-using suicidal males who present frequently to the emergency department.

OBJECTIVE: This qualitative study investigated the repeated use of the emergency department (ED) by men with a history of suicidal behaviour and substance abuse to understand the needs and barriers to care for this high-risk group. Identification of common themes from interviews with patients and health care workers can serve as a basis for improved ED-based interventions. METHODS: Using semistructured interviews, patients, ED staff and family physicians were asked about needs of the aformentioned group. Twenty-five patients were interviewed and completed questionnaires regarding their substance use, aggression, parasuicidal behaviour, alexithymia and childhood trauma. In addition, 27 staff members were interviewed. Interviews were tape-recorded, transcribed and qualitatively analyzed using an iterative coding process. RESULTS: Of the 25 patients, 23 (96%) had a mood or anxiety disorder and 18 (75%) had borderline personality disorder. One-half of the patients scored high and another quarter scored moderate on alexithymia testing. The ED was viewed as a last resort despite seeking help. Frustration was felt by both patients and staff regarding difficult communication, especially during an acute crisis. CONCLUSION: The ED plays an important role in the provision of care for men with recurrent suicidal behaviour and substance abuse. Some of the diagnoses and problems faced by these patients are beyond the purview of the ED; however, staff can identify mutual goals for crisis interventions, allow for frequent communication and seek to de-escalate situations through the validation of the stress patients are experiencing.

The Feasibility and Clinical Utility of Conducting a Confidential Inquiry Into Suicide in Southwestern Ontario.

BACKGROUND AND AIMS: Given the effectiveness of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI) in the UK, the present study evaluated this approach in Southwestern Ontario. A systematic confidential examination of suicides in Ontario was developed to guide quality improvement of services and suicide prevention. METHOD: A 3-year case series of consecutive suicides in Southwestern Ontario identified by the Office of the Chief Coroner was compiled. Clinicians who provided care to suicide decedents completed an online confidential suicide questionnaire offered through a secured portal. RESULTS: A total of 476 suicide cases were analyzed. In all, 270 invitations to clinicians were sent, 237 (87.8%) responded to the invitation and 187 (69.3%) completed the online questionnaire. The majority of the suicide decedents (54.6%, n = 260), were between the ages of 40 and 64 (x = 47.2, SD = 17.1), White (91.4%, n = 416), single (34.2%, n = 439), and male (74.4%, n = 476). Of the 86 cases of self-poisoning, prescription medications were used in 66.3%. Almost two thirds of decedents visited the clinician in the month prior to their death. LIMITATIONS: The results of the survey were drawn from suicides in Southwestern Ontario and generalizing these findings should be done with caution. CONCLUSION: This study highlights (a) the value of the clinicians' survey to identify gaps in clinical services and (b) the necessity of improvements in suicide risk assessment/management and restriction of prescription medications.

Confidential Survey Into Southwestern Ontario Suicide: Implication for Primary Care Practice.

OBJECTIVE: To describe sociodemographic and clinical characteristics of suicide decedents and to explore the pattern of clinical and suicide risk assessment in primary care settings. METHODS: A 3-year case series of consecutive suicides (January 1, 2012, to December 31, 2014) in Southwestern Ontario, Canada, identified by the Office of the Chief Coroner of Ontario and Ontario Forensic Pathology Service (OCC/OFPS) was conducted. Clinicians who provided care to suicide decedents completed a confidential suicide questionnaire offered online through a secured portal or by hardcopy. RESULTS: A total of 476 suicide cases were analyzed using data extracted from the OCC/OFPS files or provided by clinicians who had completed the survey. Hanging (42.8%) was the most common method of suicide, followed by self-poisoning (17.9%). More than half of the decedents (51.8%) used psychotropic medications, and 29.4% used opiates to self-poison. Typically, these self-poisonings involved prescribed medications (70.6%). Over two-thirds (67.4%) of suicide decedents had consulted their primary care physician prior to their deaths, and 63.6% had been seen by a physician within 28 days of their death. Suicide risk assessments were reportedly conducted in 87.1% of these visits. Of those who were assessed, the immediate risk of suicide was deemed to be absent in 39.8%, low in 50.0%, moderate in 8.3%, and high in only 1.9%. CONCLUSION: The findings from this confidential survey may be important for the formulation of recommendations that could improve suicide prevention in primary care practice.

Affective instability and suicidal ideation and behavior in patients with borderline personality disorder.

This study employed an Experience Sampling Methodology (ESM) to test whether various elements of affective instability can predict future suicide ideation in patients with borderline personality disorder (BPD) and a history of recurrent suicidal behavior. Eighty-two individuals with BPD and a history of recurrent suicidal behavior were followed prospectively for one month during which time they recorded their current mood states, 6 times daily over three weeks. Accounting for a set of robust suicide risk factors in multiple regression analyses, only negative mood intensity was significantly related to intensity of self-reported suicide ideation and to number of suicidal behaviors over the past year. Other elements of affective instability examined (e.g., mood amplitude, dyscontrol, and reactivity) were not associated with future suicide ideation or with recent suicidal behavior. Affective instability in patients with BPD is highly variable from one individual to another and is characterized by high levels of intense negative mood. These negative mood states, versus other aspects of mood variability, seem to be more closely tied to the occurrence of suicidal ideation and behavior.

Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts.

OBJECTIVE: This qualitative study aimed to capture the experience of living in the ambivalent space between life and death for adults with recurrent suicide attempts (RSA). It sought to expand upon an earlier study that explored the processes involved in transitioning away from RSA among adults, which revealed that occupying this ambivalent space is a crucial part of this process. DESIGN: Interpretive phenomenological analysis (IPA) was used. This methodology was designed to explore the lived experiences and meaning making and enabled interpretation of the multidimensional subjective experiences of RSA participants. METHODS: In-depth semi-structured interviews were conducted with eight adult women with a history of RSA who had participated in a therapeutic intervention at the research site (Skills for Safer Living: A Psychosocial/Psychoeducational Intervention for People with Recurrent Suicide Attempts [SfSL/PISA]). The six stages of IPA were followed to analyse the interview data. RESULTS: Analysis revealed the superordinate theme, 'surviving moment to moment', which refers to a precarious state of making decisions about one's life and destiny on a moment-to-moment basis without clear commitment to either life or death. Two subordinate themes were identified: 'deciding not to die in the moment' when the participants were more invested in dying than living and 'deciding to live in the moment' when they were more invested in living than dying. CONCLUSION: The study illuminated the complex process of making decisions about ones' destiny on a moment-to-moment basis. It revealed the torment experienced when occupying this state, while paradoxically, also revealing how indecision about life and death provided a lifeline opportunity for those with RSA. Clinicians who recognize the subtle distinctions associated with this in-between state can tailor their interventions accordingly. PRACTITIONER POINTS: Surviving moment to moment is characterized by a state of emotional flux and uncertainty about one's destiny, where the person has not fully committed to either life or death. Within this state, there are two interlinked subprocesses, whereby the person is leaning more towards death or life. A critical feature in working with this client group is to recognize their ambiguity and the fragility and temporality of their decisions about their destiny. The practitioner has an opportunity to be a catalyst in the momentum towards life by demonstrating understanding of this survival struggle and tailoring intervention to fit with the nuanced processes within this state.

Facilitators and barriers to doing workplace mental health research: Case study of acute psychological trauma in a public transit system.

The Acute Psychological Trauma (APT) Study was a collaboration between an acute care hospital, a specialized multidisciplinary program designed to meet the mental health needs of injured workers, and a large urban public transit system. The overall purpose was to evaluate a Best Practices Intervention (BPI) for employees affected by acute psychological trauma compared to a Treatment as Usual (TAU) group. The specific purpose is to discuss facilitators and barriers that were recognized in implementing and carrying out mental health research in a workplace setting. Over the course of the APT study, a joint implementation committee was responsible for day-to-day study operations and made regular observations on the facilitators and barriers that arose throughout the study. The facilitators to this study included the longstanding relationships among the partners, increased recognition for the need of mental health research in the workplace, and the existence of a community advisory committee. The significant barriers to doing this study of mental health research in the workplace included differences in organizational culture, inconsistent union support, co-interventions, and stigma. Researchers and funding agencies need to be flexible and provide additional resources in order to overcome the barriers that can exist doing workplace mental health research.

Best practice intervention for post-traumatic stress disorder among transit workers.

BACKGROUND: Transportation industry workers are at high risk for exposure to traumatic incidents in the workplace. A considerable number of those exposed to such incidents will develop post-traumatic stress disorder (PTSD) symptoms, which leads to high rates of absenteeism and are costly to the public transit corporation and workplace safety compensation insurance. OBJECTIVE: To determine whether the newly implemented Best Practice Intervention (BPI) provides superior outcomeswhen compared with Treatment-as-Usual (TAU) interventions in improving workers' rates of return to work (RTW), decreasing duration of time lost from work and overall reduction in severity of PTSD symptoms 6 months after exposure. METHODS: A sequential mixed methods approach was used with qualitative analysis followed by a pre-post intervention design. Sixty-two participants were recruited to the (TAU) phase of the study and 79 to the (BPI) phase. RESULTS: Significant differences were observed between the TAU and BPI groups in number of lost work days (TAU: 20 days vs. BPI: 52 days, p = 0.02). PTSD symptoms decreased with time (MPPS score: 51.3 vs. 24.35; p < 0.001). One-fifth of the participants (21 %) did not return to work by the end of the 6 months follow-up period. CONCLUSIONS: The study demonstrated the value of workplace interventions in improving awareness of psychological symptoms after exposure to a traumatic incident and the value of screening for PTSD symptoms.