Changes in Media Reporting Quality and Suicides Following National Media Engagement on Responsible Reporting of Suicide in Canada: Changements de la Qualité des reportages dans les médias sur les suicides suite à l'engagement des médias nationaux à la déclaration responsable du suicide au Canada.

OBJECTIVE: Responsible media reporting is an accepted strategy for preventing suicide. In 2015, suicide prevention experts launched a media engagement initiative aimed at improving suicide-related reporting in Canada; its impact on media reporting quality and suicide deaths is unknown. METHOD: This pre-post observational study examined changes in reporting characteristics in a random sample of suicide-related articles from major publications in the Greater Toronto Area (GTA) media market. Articles (n = 900) included 450 from the 6-year periods prior to and after the initiative began. We also examined changes in suicide counts in the GTA between these epochs. We used chi-square tests to analyse changes in reporting characteristics and time-series analyses to identify changes in suicide counts. Secondary outcomes focused on guidelines developed by media professionals in Canada and how they may have influenced media reporting quality as well as on the overarching narrative of media articles during the most recent years of available data. RESULTS: Across-the-board improvement was observed in suicide-related reporting with substantial reductions in many elements of putatively harmful content and substantial increases in all aspects of putatively protective content. However, overarching article narratives remained potentially harmful with 55.2% of articles telling the story of someone's death and 20.8% presenting an other negative message. Only 3.6% of articles told a story of survival. After controlling for potential confounders, a nonsignificant numeric decrease in suicide counts was identified after initiative implementation (ω = -5.41, SE = 3.43, t = 1.58, p = 0.12). CONCLUSIONS: We found evidence that a strategy to engage media in Canada changed the content of reporting, but there was only a nonsignificant trend towards fewer suicides. A more fundamental change in media narratives to focus on survival rather than death appears warranted.

Experiences of suicide survivors of sharing their stories about suicidality and overcoming a crisis in media and public talks: a qualitative study.

BACKGROUND: Media stories of hope and recovery from suicidal ideation have been found to have a positive impact on the audience, but little is known about how individuals who share their own experiences perceive the effects of their storytelling. This study aimed to assess qualitatively, through focus groups, how individuals who shared their personal story of hope and recovery in the media and public talks experienced the process, and which aspects they perceived as important in sharing their coping story. METHODS: Three focus groups were conducted with a total of n = 12 individuals. These included n = 5 participants with experience of suicidal ideation or a suicide attempt, n = 4 individuals who had been bereaved through suicide, and n = 3 participants who experienced both. Participants were recruited from the American organisation "Suicide Survivors United". Thematic analysis was used to assess the participants' perception and experiences of sharing their story. RESULTS: Participants shared that the intention to help others was the main motivation to share their story of hope and recovery. Participants noted many positive effects of their storytelling on themselves and also received positive feedback from the audience, such as improved help-seeking attitudes. The participants offered recommendations for those who want to share their story of hope and recovery, including careful personal preparation and media training before going public. They also discussed media recommendations for talking about suicide in the media. CONCLUSIONS: Sharing a personal story of hope and recovery may have a beneficial impact on the storytellers. Storytelling requires a careful preparation and training before going public and support and guidance is crucial in all stages of the storytelling, particularly to help unexperienced storytellers in going public and using their personal narratives to help prevent suicide.

The Role of the Narrative in Educative Suicide Awareness Materials: A Randomized Controlled Trial.

There has been a debate about the suitability of different narratives in educative suicide prevention materials. Whereas some suicide prevention experts recommend raising awareness of suicide by highlighting its prevalence, others argue that this approach may normalize suicide and advocate focusing on help resources instead. Unfortunately, empirical evidence regarding this question is lacking. This randomized controlled trial aimed to test the impact of educative news articles that conveyed different narratives of suicide prevention. One article focused on the prevalence of suicide, one article highlighted professional help resources, and one article emphasized on how everyone can help to prevent suicide. We randomized n = 334 participants to read either one of these three articles or an article unrelated to suicide. Data on suicidal ideation, stigmatizing attitudes toward suicidal individuals, attitudes toward suicide prevention, and help-seeking intentions were collected with questionnaires, and implicit measures were used to assess participants' mental accessibility of concepts related to suicide and suicide prevention. Participants exposed to the article highlighting the high prevalence of suicide tended to show a higher accessibility of potentially detrimental cognitive concepts related to suicide. In contrast, the accessibility of the concept of "helping" and that "suicide is preventable" was higher in participants' memory when exposed to materials focusing on help. It seems that the impact of educative suicide awareness materials on readers' access to suicide- and suicide-prevention-related concepts in memory varied depending on the narrative featured in the article.

Effects of the mental health promotion seminar 'Coping with stress' in the undergraduate medical curriculum of the Medical University of Vienna.

BACKGROUND: High prevalence rates of distress and burnout in medical students are well-documented in mental health literature. Different types of interventions have been developed in the past in order to reduce stress in medical undergraduate students and promote better coping skills. There is, however, a paucity of studies that have tested the effectiveness of these interventions. This study aimed to examine the effect of different versions of the seminar 'Coping with stress', which was implemented in the first year of the undergraduate curriculum of the Medical University of Vienna in the summer semester of 2018, on students' mental health. METHODS: Invitations to participate in the study were sent via email to six cohorts of students from the Medical University of Vienna. Two cohorts participated in the onsite version of the seminar 'Coping with stress', whereas two cohorts participated in the online version of the seminar, and two cohorts received no intervention (control group). Data on burnout risk, life satisfaction, stress, and knowledge about available help resources were collected via online questionnaires from n = 137 students before and after the curriculum module that contained the seminar. RESULTS: Medical students who participated in the onsite seminar reported a reduction of some aspects of burnout, a decrease in stress, and an increase in knowledge about available help resources. No such effect was seen in the control group. Participants of the online seminar experienced a similar increase in knowledge about available help resources, but no changes in other outcomes. CONCLUSIONS: The findings support the notion that the onsite seminar of 'Coping with stress' had a positive impact on medical students' mental health and is a useful addition to the medical curriculum by promoting mental health literacy. TRIAL REGISTRATION: This research has been registered in the German Clinical Trial Registry with the registration number DRKS00018981 and the registration date 14/11/2019.

Caring Contacts to Reduce Psychiatric Morbidity Following Hospitalization During the COVID-19 Pandemic: A Pilot Randomized Controlled Trial.

OBJECTIVES: Caring Contacts are an emerging intervention that aims to reduce distress and suicide risk after acute psychiatric care. This trial aimed to determine whether, during a pandemic, there was any evidence that the mental health benefits and reduction in suicidal ideation (SI) associated with delivering Caring Contacts to recently discharged psychiatric patients were greater than a control communication. The secondary objective was to identify whether the predicted benefits were greater among people living alone or those diagnosed with depression. METHOD: A single-site pilot randomized clinical trial (n = 100), with patients recruited from the adult Inpatient Psychiatry Unit at Sunnybrook Health Sciences Centre, Toronto, Canada between August 2020 and May 2021. Participants were randomized (1:1) to the Caring Contact or control group. Participants received three Caring Contact or control communications via email or mail (on days 4, 21, and 56 post-discharge). Mental health symptoms were assessed using the self-report Hopkins Symptom Checklist-25 (HSCL-25) scores at discharge (baseline) and when participants received each communication. Analysis of variance was used for the primary comparisons and exploratory analyses for subgroups. RESULTS: Both groups experienced a significant worsening of mental health symptoms at all time points post-discharge relative to baseline. There were no significant differences between groups at any time point, however, on day 4 there was a 24.2% and 72.6% attenuated worsening in the Caring Contact group compared to the control group for total symptom severity and SI, respectively. There was no significant interaction effect for the depression subgroup or those living alone. CONCLUSIONS: While this pilot study was not powered to identify significant differences between groups, results are indicative of feasibility and acceptability of the intervention and provide some indication that Caring Contacts may have benefited patients in the days following discharge, supporting the need for larger-scale trials. The study was registered with clinicaltrials.gov (study ID NCT04456062).

Is the narrative the message? The relationship between suicide-related narratives in media reports and subsequent suicides.

OBJECTIVES: When journalists report on the details of a suicide, the way that they contextualize the meaning of the event (i.e. the 'narrative') can have significant consequences for readers. The 'Werther' and 'Papageno' narrative effects refer to increases and decreases in suicides across populations following media reports on suicidal acts or mastery of crises, respectively. The goal of this study was to investigate the impact of these different narrative constructs on subsequent suicides. METHODS: This study examined the change in suicide counts over time in Toronto, Canada. It used latent difference score analysis, examining suicide-related print media reports in the Toronto media market (2011-2014). Articles (N = 6367) were coded as having a potentially harmful narrative if they described suicide in a celebrity or described a suicide death in a non-celebrity and included the suicide method. Articles were coded as having potentially protective narratives if they included at least one element of protective content (e.g. alternatives to suicide) without including any information about suicidal behaviour (i.e. suicide attempts or death). RESULTS: Latent difference score longitudinal multigroup analyses identified a dose-response relationship in which the trajectory of suicides following harmful 'Werther' narrative reports increased over time, while protective 'Papageno' narrative reports declined. The latent difference score model demonstrated significant goodness of fit and parameter estimates, with each group demonstrating different trajectories of change in reported suicides over time: (χ2[6], N = 6367) = 13.16; χ2/df = 2.19; Akaike information criterion = 97.16, comparative fit index = 0.96, root mean square error of approximation = 0.03. CONCLUSION: Our findings support the notion that the 'narrative' matters when reporting on suicide. Specifically, 'Werther' narratives of suicides in celebrities and suicides in non-celebrities where the methods were described were associated with more subsequent suicides while 'Papageno' narratives of survival and crisis mastery without depictions of suicidal behaviours were associated with fewer subsequent suicides. These results may inform efforts to prevent imitation suicides.

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

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

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

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

Period effects in the risk of labour market marginalization among refugees in Sweden: a register-based cohort study.

BACKGROUND: Changes in Swedish national insurance policies over time and/or migration-related health inequalities may influence the risk for labour market marginalization (LMM) in refugees as compared to the Swedish-born host population. This study aimed to investigate potential period effects in the association between refugee status and the risk of LMM and explore any differences by country of birth, age and duration of residence. METHODS: Using national registers, three cohorts including all Swedish residents during 1999, 2004 and 2009 were followed for 4 years (cohort 2000, 2005 and 2010). Cox regression models were used to examine associations between refugee status and LMM defined as long-term unemployment (>180 days annually) and disability pension. The analyses were adjusted for socio-demographic factors, morbidities and labour market-related factors. Stratified analyses were run for age, country of birth and duration of residence. RESULTS: Across the cohorts, hazard ratios (HRs) were higher for long-term unemployment [2000: HR = 1.98; 95% confidence interval (CI): 1.96-2.01; 2005: HR = 2.30; 95% CI: 2.27-2.33; 2010: HR = 2.78; 95% CI: 2.75-2.81] for refugees compared to Swedish-born but not for disability pension. HRs for long-term unemployment were highest among refugees aged 25-34 and 35-44 years, from Somalia, Afghanistan and Iraq and refugees with a shorter duration of residence. CONCLUSIONS: The risk of long-term unemployment appears to have increased for refugees over time. Particularly some refugee subgroups experienced more difficulties. These findings highlight ongoing disparities for refugees and implicate on a broader scale that changes in policies such as stricter regulations in the insurance or healthcare system might adversely affect them.

Effects of suicide prevention videos developed by and targeting adolescents: a randomized controlled trial.

Suicide prevention videos featuring young people's personal narratives of hope and recovery are increasingly used in suicide prevention, but research on their effects is scarce. A double-blind randomized controlled trial was conducted to test the effects of a suicide prevention video featuring an adolescent mastering his suicidal ideation by getting help on 14 to 19-year-olds. N = 299 adolescents were randomly allocated to watch the intervention video (n = 148) or a control video unrelated to mental health (n = 151). Questionnaire data were collected before (T1) and immediately after exposure (T2), and 4 weeks later (T3). Data were analyzed with a repeated-measures ANCOVA. The primary outcome was suicidal ideation, assessed with the Reasons for Living Inventory for Adolescents. Secondary outcomes were help-seeking intentions, attitudes towards suicide, stigmatization of suicidality, and mood. There was an immediate beneficial effect of the intervention on suicidal ideation (T2 mean change from baseline within intervention group MChange = - 0.16 [95% CI - 0.20 to - 0.12], mean difference compared to control group MDiff = - 0.09 [95% CI - 0.15 to - 0.03], ηp2 = 0.03), which was not maintained at T3. Participants reported significantly higher help-seeking intentions, which was maintained at 4-week follow-up. They also reported a sustained reduction of favorable attitudes to suicide. Effects on suicidal ideation were mediated by identification with the featured protagonist. Adolescents appear to benefit from suicide prevention narratives featuring personal stories from peers on coping with suicidal ideation and help-seeking.Trial registration DRKS00017405; 24/09/19; retrospectively registered.

Youth voices and experiences regarding a school-based cognitive behavioral therapy skills intervention: lessons for future engagement and adaptation.

BACKGROUND: The Cognitive Behavioral Therapy Skills Intervention (or CBTSI) aims to build mental health literacy and knowledge, allowing youth to build resilience and improve mental health broadly. In Ontario, Canada, youth voice is scant and European studies have largely reported on youth factors supporting stigma reduction, help-seeking intentions and overall satisfaction with a given intervention. Process evaluations and implementation that underpin what youth require to embrace mental health literacy interventions, particularly those that embed key learning principles in the everyday curriculum, have not been broached. The goal of this study is to understand both barriers and facilitators to engagement with the CBTSI (an intervention novel in itself because of the combined mental health plus cognitive behavior therapy (CBT) skills principles embedded in literacy) and the resources and structures that students report requiring, to fully engage with such an intervention. METHODS: Student focus groups were conducted utilizing qualitative interviews that were analyzed thematically. Analysis was informed using principles of pragmatism and analyzed inductively using thematic analysis (Braun and Clarke, Qual Res Psychol 3:77-101, 2006), first looking at the whole and then coding for themes, within an interpretivist framework. Youth were in middle school (grade 7 and 8) in Toronto, Canada who had received the CBTSI. Face to face interview guides with iterative questioning were conducted in February of 2020, and these interviews were audio-recorded and professionally transcribed. Teachers randomly chose a subset of youth whose parents consented to the research to ensure ethno-racial similarity to classroom demographics. RESULTS: There were eight groups with sixty students who participated. Students were 12 to 14 years of age. Major themes were identified: maximizing the opportunities for involvement and self-determination created an atmosphere where confidence and self-compassion could flourish, signalling to the students that they understood and were able to deploy the strategies they were taught; students expressed that the intervention needs to be adapted to enhance personal dignity, respecting both individual wishes and goals in light of the variability in student reported mental health. A model explains the structures and adaptations required to maximize learning based on youth feedback. INTERPRETATION: Mental health literacy incorporating CBT is a promising population-based health promotion intervention. Future adaptations and implementation decisions regarding the CBTSI need to address the wishes and experiences of these youth. Youth voice in this study explored factors that prevent and promote the uptake of the key lessons within the context of existing variability in student mental health that is often found within the context of a regular classroom. The results should be used to adapt the CBTSI as it is disseminated more broadly.

Emergency department visits for self-harm in adolescents after release of the Netflix series '13 Reasons Why'.

OBJECTIVE: To determine whether the release of the first season of the Netflix series '13 Reasons Why' was associated with changes in emergency department presentations for self-harm. METHODS: Healthcare utilization databases were used to identify emergency department and outpatient presentations according to age and sex for residents of Ontario, Canada. Data from 2007 to 2018 were used in autoregressive integrated moving average models for time series forecasting with a pre-specified hypothesis that rates of emergency department presentations for self-harm would increase in the 3-month period following the release of 13 Reasons Why (1 April 2017 to 30 June 2017). Chi-square and t tests were used to identify demographic and health service use differences between those presenting to emergency department with self-harm during this epoch compared to a control period (1 April 2016 to 30 June 2016). RESULTS: There was a significant estimated excess of 75 self-harm-related emergency department visits (+6.4%) in the 3 months after 13 Reasons Why above what was predicted by the autoregressive integrated moving average model (standard error = 32.4; p = 0.02); adolescents aged 10-19 years had 60 excess visits (standard error = 30.7; p = 0.048), whereas adults demonstrated no significant change. Sex-stratified analyses demonstrated that these findings were largely driven by significant increases in females. There were no differences in demographic or health service use characteristics between those who presented to emergency department with self-harm in April to June 2017 vs April to June 2016. CONCLUSIONS: This study demonstrated a significant increase in self-harm emergency department visits associated with the release of 13 Reasons Why. It adds to previously published mortality, survey and helpline data collectively demonstrating negative mental health outcomes associated with 13 Reasons Why.

Detecting Potentially Harmful and Protective Suicide-Related Content on Twitter: Machine Learning Approach.

BACKGROUND: Research has repeatedly shown that exposure to suicide-related news media content is associated with suicide rates, with some content characteristics likely having harmful and others potentially protective effects. Although good evidence exists for a few selected characteristics, systematic and large-scale investigations are lacking. Moreover, the growing importance of social media, particularly among young adults, calls for studies on the effects of the content posted on these platforms. OBJECTIVE: This study applies natural language processing and machine learning methods to classify large quantities of social media data according to characteristics identified as potentially harmful or beneficial in media effects research on suicide and prevention. METHODS: We manually labeled 3202 English tweets using a novel annotation scheme that classifies suicide-related tweets into 12 categories. Based on these categories, we trained a benchmark of machine learning models for a multiclass and a binary classification task. As models, we included a majority classifier, an approach based on word frequency (term frequency-inverse document frequency with a linear support vector machine) and 2 state-of-the-art deep learning models (Bidirectional Encoder Representations from Transformers [BERT] and XLNet). The first task classified posts into 6 main content categories, which are particularly relevant for suicide prevention based on previous evidence. These included personal stories of either suicidal ideation and attempts or coping and recovery, calls for action intending to spread either problem awareness or prevention-related information, reporting of suicide cases, and other tweets irrelevant to these 5 categories. The second classification task was binary and separated posts in the 11 categories referring to actual suicide from posts in the off-topic category, which use suicide-related terms in another meaning or context. RESULTS: In both tasks, the performance of the 2 deep learning models was very similar and better than that of the majority or the word frequency classifier. BERT and XLNet reached accuracy scores above 73% on average across the 6 main categories in the test set and F1-scores between 0.69 and 0.85 for all but the suicidal ideation and attempts category (F1=0.55). In the binary classification task, they correctly labeled around 88% of the tweets as about suicide versus off-topic, with BERT achieving F1-scores of 0.93 and 0.74, respectively. These classification performances were similar to human performance in most cases and were comparable with state-of-the-art models on similar tasks. CONCLUSIONS: The achieved performance scores highlight machine learning as a useful tool for media effects research on suicide. The clear advantage of BERT and XLNet suggests that there is crucial information about meaning in the context of words beyond mere word frequencies in tweets about suicide. By making data labeling more efficient, this work has enabled large-scale investigations on harmful and protective associations of social media content with suicide rates and help-seeking behavior.

Suicide-related Twitter Content in Response to a National Mental Health Awareness Campaign and the Association between the Campaign and Suicide Rates in Ontario.

OBJECTIVE: Mental health awareness (MHA) campaigns have been shown to be successful in improving mental health literacy, decreasing stigma, and generating public discussion. However, there is a dearth of evidence regarding the effects of these campaigns on behavioral outcomes such as suicides. Therefore, the objective of this article is to characterize the association between the event and suicide in Canada's most populous province and the content of suicide-related tweets referencing a Canadian MHA campaign (Bell Let's Talk Day [BLTD]). METHODS: Suicide counts during the week of BTLD were compared to a control window (2011 to 2016) to test for associations between the BLTD event and suicide. Suicide tweets geolocated to Ontario, posted in 2016 with the BLTD hashtag were coded for specific putatively harmful and protective content. RESULTS: There was no associated change in suicide counts. Tweets (n = 3,763) mainly included content related to general comments about suicide death (68%) and suicide being a problem (42.8%) with little putatively helpful content such as stories of resilience (0.6%) and messages of hope (2.2%). CONCLUSIONS: In Ontario, this national mental health media campaign was associated with a high volume of suicide-related tweets but not necessarily including content expected to diminish suicide rates. Campaigns like BLTD should strongly consider greater attention to suicide-related messaging that promotes help-seeking and resilience. This may help to further decrease stigmatization, and potentially, reduce suicide rates.

Suicide mortality in the United States following the suicides of Kate Spade and Anthony Bourdain.

OBJECTIVE: The suicides of Kate Spade and Anthony Bourdain, two major American icons, in a span of days in June 2018 represent a unique and tragic natural experiment to characterize associations with actual suicides in the aftermath of celebrity suicides. The aim of this study was to identify changes in suicide counts after their deaths. METHODS: Suicide data were obtained from the United States' Centers for Disease Control and Prevention's public-use mortality file. A time-series analysis was performed, examining monthly suicide data by age group (⩽19, 20-44, 45-64 and ⩾65 years), for both men and women, for all suicide methods and for hanging versus non-hanging methods, from January 1999 to December 2018. Seasonal autoregressive integrated moving-average models were fitted to the pre-June 2018 period, estimating suicides in subsequent months and identifying deviations from expected values. The volume of Twitter posts about Kate Spade and Anthony Bourdain was used as a proxy of societal attention. RESULTS: Tweets about the celebrities were mainly concentrated in June 2018 and faded quickly in July. Total suicides exceeded the 95% confidence interval for June and approximated the upper limit of the 95% confidence interval in July. Over this 2-month span, there were 418 (95% confidence interval = [184, 652]) more suicides than expected, including 275 (95% confidence interval = [79, 471]) excess suicides in men and 182 (95% confidence interval = [93, 271]) in women. These equate to 4.8%, 4.1% and 9.1% increases above expected counts. There were 392 (95% confidence interval = [271, 514]) excess suicides by hanging, a 14.5% increase, with no significant increase in all other methods combined. CONCLUSION AND RELEVANCE: These findings demonstrate that mortality following celebrity suicides can occur at a similar magnitude to that observed for other public health emergencies. They underscore the urgency for interventions to mitigate imitation effects after celebrity suicide reporting.

The association between Twitter content and suicide.

OBJECTIVE: A growing body of research has established that specific elements of suicide-related news reporting can be associated with increased or decreased subsequent suicide rates. This has not been systematically investigated for social media. The aim of this study was to identify associations between specific social media content and suicide deaths. METHODS: Suicide-related tweets (n = 787) geolocated to Toronto, Canada and originating from the highest level influencers over a 1-year period (July 2015 to June 2016) were coded for general, putatively harmful and putatively protective content. Multivariable logistic regression was used to examine whether tweet characteristics were associated with increases or decreases in suicide deaths in Toronto in the 7 days after posting, compared with a 7-day control window. RESULTS: Elements independently associated with increased subsequent suicide counts were tweets about the suicide of a local newspaper reporter (OR = 5.27, 95% CI = [1.27, 21.99]), 'other' social causes of suicide (e.g. cultural, relational, legal problems; OR = 2.39, 95% CI = [1.17, 4.86]), advocacy efforts (OR = 2.34, 95% CI = [1.48, 3.70]) and suicide death (OR = 1.52, 95% CI = [1.07, 2.15]). Elements most strongly independently associated with decreased subsequent suicides were tweets about murder suicides (OR = 0.02, 95% CI = [0.002, 0.17]) and suicide in first responders (OR = 0.17, 95% CI = [0.05, 0.52]). CONCLUSIONS: These findings largely comport with the theory of suicide contagion and associations observed with traditional news media. They specifically suggest that tweets describing suicide deaths and/or sensationalized news stories may be harmful while those that present suicide as undesirable, tragic and/or preventable may be helpful. These results suggest that social media is both an important exposure and potential avenue for intervention.

Initiation of antidepressant use among refugee and Swedish-born youth after diagnosis of a common mental disorder: findings from the REMAIN study.

PURPOSE: The objective of this study was to compare the initiation and type of antidepressant use between refugees and matched Swedish-born youth after a diagnosis of a common mental disorder (CMD) and assess sociodemographic and clinical factors associated with the initiation. METHODS: The study cohort included youth aged 16-25 years, with an incident diagnosis of CMD based on specialized health care registers in Sweden 2006-2016, without prior antidepressant use during 1 year. One Swedish-born person was matched for each identified refugee youth (N = 3936 in both groups). Initiation of antidepressant use and factors associated with the initiation, were investigated with logistic regression yielding Odds ratios, OR, and 95% Confidence Intervals, CI. RESULTS: Refugees were less likely to initiate antidepressant use compared with Swedish-born (40.5% vs. 59.6%, adjusted OR 0.43, 95% CI 0.39-0.48). Selective serotonin reuptake inhibitors (SSRIs) were less frequently initiated for refugees than Swedish-born (71.2% vs. 81.3% of initiations, p < 0.0001). Sertraline was the most commonly initiated antidepressant both for refugees (34.3%) and Swedish-born individuals (40.3%). Among refugees, factors associated with increased odds of antidepressant initiation were previous use of anxiolytics or hypnotics, previous sickness absence of < 90 days, cancer and older age (OR range 1.07-2.72), and less than 5 years duration of residency in Sweden was associated with decreased odds (OR 0.76, 95% CI 0.63-0.92). CONCLUSION: Young refugees with a CMD seem to initiate antidepressants in general and those most effective considerably less often than their Swedish-born counterparts.

The Impact of Educative News Articles about Suicide Prevention: A Randomized Controlled Trial.

Media stories featuring stories of personal experiences of coping with suicidal ideation have been shown to decrease suicide risk, but it is unclear whether more impersonal awareness materials have similar effects. This study aimed to test the impact of impersonal educative news articles featuring interviews with suicide prevention experts. Because the impact of news articles may be determined by the articles' pull quotes and headlines, we also aimed to compare the impact of two versions of the same suicide prevention news article. One version featured headlines and pull quotes highlighting the message that suicide is preventable, whereas the other version focused on the message that suicide is prevalent. In a web-based randomized controlled trial, n = 425 participants either read a news article featuring a prevention expert with one of the above versions of the same text or an article unrelated to suicide. Data on suicidal ideation, stigmatizing attitudes toward suicidal individuals, policy attitudes toward suicide prevention, help-seeking intentions, and assumptions on the prevalence of suicide-related behavior were measured with questionnaires. The assumed prevalence of suicide in the population was greater in both intervention groups than in the control group, but the articles did not have an impact on other outcomes, and there were no differences for variations in headlines and pull quotes. Impersonal suicide prevention articles appear safe to use and do not have an impact on suicide risk factors in general population samples.

Effects of suicide awareness materials on individuals with recent suicidal ideation or attempt: online randomised controlled trial.

BACKGROUND: Awareness materials featuring ways of coping with suicidal ideation can reduce suicidal ideation, the so-called Papageno effect. All of the previous experimental studies on this subject have been conducted with individuals not at risk of suicide. AIMS: To assess effects of suicide awareness materials in a sample of individuals with recent suicidal ideation. Trial registration: German Clinical Trial Registry ID number DRKS00013613. METHOD: Adults (n = 266) with recent self-reported suicidal ideation or attempt were randomised to read an educative article featuring a lay individual with personal experience of suicidality (n = 86), a similar article featuring a mental health expert (n = 90), or an unrelated article (n = 90) in a double-blind online randomised controlled trial. Questionnaire data were collected before (T1) and immediately after exposure (T2) as well as 1 week later (study end-point, T3) and analysed with linear mixed models. The primary outcome was suicide risk as assessed using the Survival and Coping Beliefs subscale of the Reasons for Living Inventory (RFLI); secondary outcomes were suicide-prevention knowledge and mood. RESULTS: There was an immediate beneficial effect on suicide risk in the intervention group exposed to the message delivered by the individual with personal experience (group 1) as compared with the control group that was maintained until the study end-point (study end-point: RFLI score mean difference from baseline within group 1 MD = -0.36 (95% CI -0.66 to -0.06), mean difference compared with control group MD = -0.71 (95% CI -1.27 to -0.14); d = -0.18). The effect was particularly pronounced for individuals with recent suicide attempt (RFLI score at T3, compared with control group: MD = -1.55 (95% CI -2.52 to -0.57); d = -0.23). Participants in this group also showed increased prevention-related knowledge compared with the control group. CONCLUSIONS: Individuals with a recent suicide attempt appear to benefit from a printed narrative of positive coping with suicidal ideation. The intervention materials do not increase short-term suicide risk.

Belief in suicide prevention myths and its effect on helping: a nationally representative survey of Australian adults.

BACKGROUND: Debunking suicide myths, such as 'asking someone about suicide could make them start thinking about it' is a common strategy in suicide prevention education. However, there has been little research investigating the relationship between suicide myths and helping behavior toward people at risk of suicide. We aimed to identify sociodemographic characteristics associated with belief in eight common suicide myths and the associations between beliefs in these myths and helping intentions and behaviors toward a family member or friend in severe distress or at risk of suicide. METHODS: We conducted a random digit dial (mobile and landline) survey of 3002 Australian adults. We asked respondents about their beliefs in suicide myths, intentions to help a person in severe distress or at risk of suicide presented in a vignette, and helping actions taken toward such a person in the last 12 months. We weighted this data to be representative of the Australian population. Regression analyses were undertaken to determine associations between sociodemographic and exposure characteristics and beliefs in suicide myths, and between beliefs in myths and helping intentions and behaviors. RESULTS: Being male, speaking a language other than English at home and being over 60 years were associated with the strongest beliefs in suicide myths. The strongest and most consistent associations were found between belief in the myth 'asking someone about suicide could make them start thinking about it', risk assessment intentions and behaviours and intentions to undertaken actions not recommended for suicide prevention. CONCLUSIONS: Identifying those sociodemographic groups most likely to believe in suicide myths allows targeted intervention for suicide prevention education 'debunking' suicide myths. By isolating those myths that are most commonly believed, and their specific effects on helping intentions and behaviors, suicide prevention educators can target these specific myths to have the most effect on helping behavior. Our findings suggest that targeting the myth 'asking someone about suicide could make them start thinking about it' may have the greatest effects on helping behavior, and that men, those aged over 60 years and those speaking a language other than English at home could most benefit from myth 'debunking'.