Best practice for integrating digital interventions into clinical care for young people at risk of suicide: a Delphi study.

BACKGROUND: Digital tools have the capacity to complement and enhance clinical care for young people at risk of suicide. Despite the rapid rise of digital tools, their rate of integration into clinical practice remains low. The poor uptake of digital tools may be in part due to the lack of best-practice guidelines for clinicians and services to safely apply them with this population. METHODS: A Delphi study was conducted to produce a set of best-practice guidelines for clinicians and services on integrating digital tools into clinical care for young people at risk of suicide. First, a questionnaire was developed incorporating action items derived from peer-reviewed and grey literature, and stakeholder interviews with 17 participants. Next, two independent expert panels comprising professionals (academics and clinical staff; n = 20) and young people with lived experience of using digital technology for support with suicidal thoughts and behaviours (n = 29) rated items across two consensus rounds. Items reaching consensus (rated as "essential" or "important" by at least 80% of panel members) at the end of round two were collated into a set of guidelines. RESULTS: Out of 326 individual items rated by the panels, 188 (57.7%) reached consensus for inclusion in the guidelines. The endorsed items provide guidance on important topics when working with young people, including when and for whom digital tools should be used, how to select a digital tool and identify potentially harmful content, and identifying and managing suicide risk conveyed via digital tools. Several items directed at services (rather than individual clinicians) were also endorsed. CONCLUSIONS: This study offers world-first evidence-informed guidelines for clinicians and services to integrate digital tools into clinical care for young people at risk of suicide. Implementation of the guidelines is an important next step and will hopefully lead to improved uptake of potentially helpful digital tools in clinical practice.

Can #chatsafe support parents and carers beyond Australia? A qualitative study.

BACKGROUND: Rates of self-harm and suicide are rising for young people globally and many implicate social media in this problem. To address this concern and to increase the confidence of adults to communicate safely about suicide and social media with young people, the #chatsafe Guide for Parents and Carers was developed in Australia. With significant uptake of the resource among Australian adults, the aim of the current study was to update and contextualise the #chatsafe Guide for Parents and Carers for audiences in 15 countries globally. To improve the relevance of this resource for parents and carers in these countries, the present study sought to understand the concerns held by parents, carers and suicide prevention professionals around the world about these topics and to explore the extent to which a resource such as #chatsafe would be helpful within their communities. METHODS: Seven focus groups were conducted via Zoom with parents, carers and suicide prevention professionals (n = 40) from 15 countries. Transcribed data were coded and thematically analysed using both inductive and deductive processes. RESULTS: Six themes are reported: (1) Two scary 'S' words; (2) Country and culture impact who talks (or is silent) about self-harm and suicide; (3) The need for a protective social ecosystem; (4) #chatsafe is a tool that can help parents, carers and young people worldwide; (5) #chatsafe should consider local context and end users to improve its relevance for parents and carers worldwide; and (6) A range of marketing and dissemination strategies are needed to reach adults with #chatsafe information. Findings of this study informed the update and contextualisation of the #chatsafe Guide for Parents and Carers for adult audiences in 15 countries. CONCLUSIONS: The findings from this study underscore a universal need for psychoeducation initiatives that provide adults with the skills and knowledge to support the mental health of young people, both online and offline, and that resources like #chastafe can play an important role in providing reliable information about these topics to adults across a range of cultures and contexts.

Development of best practice guidelines for clinical and community service providers to prevent suicide in LGBTQA+ young people: A Delphi expert consensus study.

OBJECTIVE: The aim of this study was to develop best practice guidelines for preventing suicide and reducing suicidal thoughts and behaviours in LGBTQA+ young people (lesbian, gay, bisexual, trans, queer/questioning, asexual, and those of other diverse sexualities and genders) within clinical and community service settings in Australia. METHODS: We conducted a Delphi expert consensus study. A systematic literature search and interviews with key informants informed an initial 270-item questionnaire. Two expert panels completed the questionnaire, delivered over two rounds: (1) Australian professionals with expertise in LGBTQA+ mental health/suicide prevention and (2) Australian LGBTQA+ young people aged 14-25 with lived experience of suicidal thoughts and/or behaviours. Items endorsed as 'essential' or 'important' by >80% of both expert panels were included in the guidelines. RESULTS: A total of 115 people participated in the Delphi process; n = 52 professionals completed Round 1, and n = 42 completed Round 2; n = 63 LGBTQA+ young people completed Round 1, and n = 50 completed Round 2. A total of 290 items were included in the guidelines and grouped into: (1) general principles for creating an affirming and inclusive environment for LGBTQA+ young people; (2) assessing suicide risk and working with suicidal LGBTQA+ young people; (3) considerations for specific LGBTQA+ populations; and (4) advocating for LGBTQA+ young people. CONCLUSION: These guidelines are the first of their kind in Australia. They provide practical support to service providers regardless of prior training in LGBTQ+ identities or mental health, with the aim of reducing suicidal thoughts and behaviours, and preventing suicide, in LGBTQA+ young people.

Initial validation of the Multidimensional Adolescent Functioning Scale (MAFS) in Spanish-speaking students from Chilean secondary schools.

INTRODUCTION: Psychosocial functioning is closely associated with psychopathology and wellbeing in different populations, particularly adolescents. Despite its relevance, measures assessing psychosocial functioning in healthy adolescents are scant as most focus on adults or clinical populations. We evaluated the psychometric properties of the Multidimensional Adolescent Functioning Scale (MAFS), a self-report questionnaire created to assess three dimensions of psychosocial functioning ('general functioning', 'family-related functioning', and 'peer-related functioning') in adolescents from the general population. METHODS: After translation and cultural adaptation, we administered the Spanish MAFS to 619 adolescents aged 14 to 19. We assessed the factor structure, internal consistency, and associations with depressive symptoms, suicidal ideation, cognitive-behavioral skills, cognitive reappraisal (CR), and expressive suppression (ES). We additionally tested for measurement invariance based on biological sex. RESULTS: The original three-factor structure showed the best fit. Internal consistency was good for the total scale (ω = 0.874; α = 0.869; GLB = 0.939, rM=0.216) and for all subscales (ω = 0.806-0.839; α = 0.769 to 0.812; GLB = 0.861-0.873). Correlations between all three MAFS subscales were significant, ranging between 0.291 and 0.554. All MAFS subscales correlated positively and significantly with cognitive-behavioral skills and adaptive regulatory strategies and negatively with depressive symptoms and suicidal ideation. CONCLUSION: The Spanish MAFS translation is a valid and reliable self-report measure to assess three domains of psychosocial functioning in adolescents aged 14-19 from the general population.

Interventions for youth suicide and suicide-related behaviour: An update to a systematic review.

OBJECTIVE: To update our 2018 review with the latest evidence from randomised controlled trials (RCTs) on the effectiveness of interventions to prevent youth suicide and suicide-related behaviour. METHOD: In keeping with our 2018 review, Embase, PsycInfo, and Medline were searched using relevant key words. Included trials were RCTs evaluating the impact of an intervention or approach designed to prevent or reduce youth suicide and suicide-related behaviour. Key data were extracted, and results synthesised narratively. RESULTS: Thirty RCTs were included across clinical (n = 13), educational (n = 8), and community settings (n = 9). No trials were conducted in workplace or primary care settings, or with indigenous populations, and few trials involved partnerships with young people. There were some concerns or a high risk of bias for most trials. CONCLUSION: While a relatively large number of RCTs have been published in recent years, knowledge gaps remain. Further high-quality RCTs are needed, including those focussing on vulnerable population groups. Meaningful consumer involvement and a stronger emphasis on implementation are also recommended.

Suicide by young Australians, 2006-2015: a cross-sectional analysis of national coronial data.

OBJECTIVE: To assess the demographic, social, and clinical characteristics of young Australians who die by suicide. DESIGN: Retrospective analysis of National Coronial Information System (NCIS) data. SETTING, PARTICIPANTS: People aged 10-24 years who died by suicide in Australia during 2006-2015. MAIN OUTCOME MEASURES: Demographic, social, and clinical characteristics of young people who died by suicide; circumstances of death recorded in the NCIS. RESULTS: 3365 young people died of suicide during 2006-2015 (including 2473 boys and men, 73.5%); 1292 people (38.4%) lived in areas of greater socio-economic disadvantage. Free text reports were included in the NCIS for 3027 people (90%), of whom 1237 (40.9%) had diagnosed mental health disorders and 475 (15.7%) had possible mental health disorders. Alcohol consumption near the time of death was detected in 1015 of 3027 cases (33.5%); histories of self-harm were recorded in 940 cases (31.1%) and of illicit substance misuse in 852 (28.1%). Adverse life events included history of abuse or neglect (223, 7.4%), suicide of relatives, friends, or acquaintances (202, 6.7%), and financial difficulties (174, 5.8%). CONCLUSIONS: Three-quarters of the young people who died by suicide were boys or young men, and 57% had diagnosed or possible mental health disorders, suggesting that the mental health and wellbeing of young Australians should be a key target for youth suicide prevention. To reduce the number of youth suicides, it is imperative that prevention strategies target the mental health and psychosocial stressors that lead to suicidal crises in young people.

The Mitigating Toxic Stress study design: approaches to developmental evaluation of pediatric health care innovations addressing social determinants of health and toxic stress.

BACKGROUND: Health care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress. Because infants' experiences are inextricably tied to their caregivers, an important target for mitigating "toxic" stress exposure in early childhood is through reducing parents' experiences of chronic stress in addition to protecting children from direct experiences of harm such as physical or sexual abuse. Conducting screening to identify when children are exposed to early life adversity is a first step; connecting families to needed support services is an essential component to addressing identified challenges. This paper presents the methodology of a three-year study of health care systems innovations designed to engage and support parents of infants to prevent and mitigate children's toxic stress exposures. METHODS: Key study features included: 1) multi-component study in five U.S. communities and nine pediatric health care clinics and the families they serve, 2) a developmental evaluation approach to describe how innovations are experienced over time at three levels-community systems, pediatric providers, and families, and 3) rapid cycle feedback conducted with communities, clinics and families to co-interpret data and findings. Data sources included: 1) focus groups and interviews with community stakeholders, clinic staff, and families, 2) electronic health record and Medicaid services data extracted to assess health care quality, utilization, and financial impact, and 3) clinic-recruitment of 908 parents of infants in a longitudinal survey. RESULTS: The sample is briefly characterized based on responses to the enrollment phase of the parent survey. CONCLUSIONS: We discuss the study design elements' contribution to generating evidence needed by innovators, communities, and clinics to modify and sustain investments in these innovations to prevent or mitigate the effects of exposure to toxic stress on young children.

Ethical concerns in suicide research: thematic analysis of the views of human research ethics committees in Australia.

BACKGROUND: Suicide research aims to contribute to a better understanding of suicidal behaviour and its prevention. However, there are many ethical challenges in this research field, for example, regarding consent and potential risks to participants. While studies to-date have focused on the perspective of the researchers, this study aimed to investigate the views and experiences of members of Human Research Ethics Committees (HRECs) in dealing with suicide-related study applications. METHODS: This qualitative study entailed a thematic analysis using an inductive approach. We conducted semi-structured interviews with a purposive sample (N = 15) of HREC Chairs or their delegates from Australian research-intensive universities. The interview guide included questions regarding the ethical concerns and challenges in suicide-related research raised by HREC members, how they dealt with those challenges and what advice they could give to researchers. RESULTS: The analysis identified four main themes: (1) HREC members' experiences of reviewing suicide-related study applications, (2) HREC members' perceptions of suicide, suicide research, and study participants, (3) Complexity in HREC members' decision-making processes, and (4) HREC members' relationships with researchers. CONCLUSIONS: Reliance on ethical guidelines and dialogue with researchers are crucial in the assessment of suicide-related study applications. Both researchers and HREC members may benefit from guidance and resources on how to conduct ethically sound suicide-related studies. Developing working relationships will be likely to help HRECs to facilitate high quality, ethical suicide-related research and researchers to conduct such research.

Correction: Moderated Online Social Therapy for Young People With Active Suicidal Ideation: Qualitative Study.

[This corrects the article DOI: 10.2196/24260.].

Moderated Online Social Therapy for Young People With Active Suicidal Ideation: Qualitative Study.

BACKGROUND: Web-based interventions are a promising approach to support youth at risk of suicide, and those incorporating peer-to-peer social networking may have the added potential to target interpersonal states of perceived burdensomeness and thwarted belongingness. Owing to feasibility and safety concerns, including fear of contagion, this had not been tested until recently. In 2018, we conducted a pilot evaluation to test the feasibility, safety, and acceptability of a Moderated Online Social Therapy intervention, called Affinity, with a sample of young people with active suicidal ideation. OBJECTIVE: The aim of this study is to report qualitative data collected from study participants regarding their experience of the web-based social network and the consequent safety features. METHODS: Affinity is a closed website incorporating 3 key components: therapeutic content delivered via comics, peer-to-peer social networking, and moderation by peers and clinicians. Semistructured interviews were conducted with 17 young people who participated in the pilot study after 8 weeks of exposure to the intervention. Interview data from 2 young people who did not use Affinity were excluded from the analysis. The interviews were analyzed using thematic analysis, with the frequency of responses characterized using the consensual qualitative research method. The results are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. RESULTS: A total of 4 overarching themes were identified: a safe and supportive environment, the importance of mutual experiences, difficulty engaging and connecting, and the pros and cons of banning discussions about suicide. Interestingly, although Affinity was perceived to be safe and free of judgment, concerns about negative evaluation and triggering others were significant barriers to posting on the social network. Participants generally supported the banning of conversations about suicide, although for some this was perceived to reinforce stigma or was associated with frustration and distress. CONCLUSIONS: The results not only support the safety and potential therapeutic benefit of the social networking aspect of Affinity but also highlight several implementation challenges. There is a need to carefully balance the need for stringent safety and design features while ensuring that the potential for therapeutic benefit is maximized.

Association of suicidal behavior with exposure to suicide and suicide attempt: A systematic review and multilevel meta-analysis.

BACKGROUND: Exposure to suicidal behavior may be associated with increased risk of suicide, suicide attempt, and suicidal ideation and is a significant public health problem. However, evidence to date has not reliably distinguished between exposure to suicide versus suicide attempt, nor whether the risk differs across suicide-related outcomes, which have markedly different public health implications. Our aim therefore was to quantitatively assess the independent risk associated with exposure to suicide and suicide attempt on suicide, suicide attempt, and suicidal ideation outcomes and to identify moderators of this risk using multilevel meta-analysis. METHODS AND FINDINGS: We systematically searched MEDLINE, Embase, PsycINFO, CINAHL, ASSIA, Sociological Abstracts, IBSS, and Social Services Abstracts from inception to 19 November 2019. Eligible studies included comparative data on prior exposure to suicide, suicide attempt, or suicidal behavior (composite measure-suicide or suicide attempt) and the outcomes of suicide, suicide attempt, and suicidal ideation in relatives, friends, and acquaintances. Dichotomous events or odds ratios (ORs) of suicide, suicide attempt, and suicidal ideation were analyzed using multilevel meta-analyses to accommodate the non-independence of effect sizes. We assessed study quality using the National Heart, Lung, and Blood Institute quality assessment tool for observational studies. Thirty-four independent studies that presented 71 effect sizes (exposure to suicide: k = 42, from 22 independent studies; exposure to suicide attempt: k = 19, from 13 independent studies; exposure to suicidal behavior (composite): k = 10, from 5 independent studies) encompassing 13,923,029 individuals were eligible. Exposure to suicide was associated with increased odds of suicide (11 studies, N = 13,464,582; OR = 3.23, 95% CI = 2.32 to 4.51, P < 0.001) and suicide attempt (10 studies, N = 121,836; OR = 2.91, 95% CI = 2.01 to 4.23, P < 0.001). However, no evidence of an association was observed for suicidal ideation outcomes (2 studies, N = 43,354; OR = 1.85, 95% CI = 0.97 to 3.51, P = 0.06). Exposure to suicide attempt was associated with increased odds of suicide attempt (10 studies, N = 341,793; OR = 3.53, 95% CI = 2.63 to 4.73, P < 0.001), but not suicide death (3 studies, N = 723; OR = 1.64, 95% CI = 0.90 to 2.98, P = 0.11). By contrast, exposure to suicidal behavior (composite) was associated with increased odds of suicide (4 studies, N = 1,479; OR = 3.83, 95% CI = 2.38 to 6.17, P < 0.001) but not suicide attempt (1 study, N = 666; OR = 1.10, 95% CI = 0.69 to 1.76, P = 0.90), a finding that was inconsistent with the separate analyses of exposure to suicide and suicide attempt. Key limitations of this study include fair study quality and the possibility of unmeasured confounders influencing the findings. The review has been prospectively registered with PROSPERO (CRD42018104629). CONCLUSIONS: The findings of this systematic review and meta-analysis indicate that prior exposure to suicide and prior exposure to suicide attempt in the general population are associated with increased odds of subsequent suicidal behavior, but these exposures do not incur uniform risk across the full range of suicide-related outcomes. Therefore, future studies should refrain from combining these exposures into single composite measures of exposure to suicidal behavior. Finally, future studies should consider designing interventions that target suicide-related outcomes in those exposed to suicide and that include efforts to mitigate the adverse effects of exposure to suicide attempt on subsequent suicide attempt outcomes.

Ethical issues and practical barriers in internet-based suicide prevention research: a review and investigator survey.

BACKGROUND: People who are at elevated risk of suicide stand to benefit from internet-based interventions; however, research in this area is likely impacted by a range of ethical and practical challenges. The aim of this study was to examine the ethical issues and practical barriers associated with clinical studies of internet-based interventions for suicide prevention. METHOD: This was a mixed-methods study involving two phases. First, a systematic search was conducted to identify studies evaluating internet-based interventions for people at risk of suicide, and information pertaining to safety protocols and exclusion criteria was extracted. Second, investigators on the included studies were invited to complete an online survey comprising open-ended and forced-choice responses. Quantitative and qualitative methods were used to analyse the data. RESULTS: The literature search identified 18 eligible studies, of which three excluded participants based on severity of suicide risk. Half of the 15 suicide researchers who participated in the survey had experienced problems obtaining ethics approval, and none had encountered adverse events attributed to their intervention. Survey respondents noted the difficulty of managing risk in online environments and the limitations associated with implementing safety protocols, although some also reported increased confidence resulting from the ethical review process. Respondents recommended researchers pursue a collaborative relationship with their research ethics committees. CONCLUSION: There is a balance to be achieved between the need to minimise the risk of adverse events whilst also ensuring interventions are being validated on populations who may be most likely to use and benefit from them (i.e., those who prefer anonymity). Further research is required to obtain the views of research ethics committees and research participants on these issues. Dialogue between researchers and ethics committees is necessary to address the need to ensure safety while also advancing the timely development of effective interventions in this critical area.

Effectiveness of interventions for people bereaved through suicide: a systematic review of controlled studies of grief, psychosocial and suicide-related outcomes.

BACKGROUND: Suicide bereavement is a risk factor for adverse outcomes related to grief, social functioning, mental health and suicidal behaviour. Consequently, suicide bereavement support (i.e., postvention) has been identified as an important suicide prevention strategy. However, little is known about its effectiveness. To redress this gap, this review aimed to assess the evidence of effectiveness of interventions for people bereaved by suicide, and appraise the quality of the research in this field. METHODS: We conducted a systematic review according to PRISMA guidelines. Searches of peer-reviewed literature in Medline, PsycINFO, Embase and EBM Reviews identified 12 papers reporting on 11 relevant studies conducted between 1984 and 2018. RESULTS: Across studies, there was a wide variety of intervention modalities, study populations, control groups, and grief, psychosocial and suicide-related outcome measures. Overall, the quality of studies was weak. While there was some evidence of the effectiveness of interventions for uncomplicated grief, evidence of the effectiveness of complicated grief interventions was lacking. Based on this scant evidence, interventions which seem to show promise include supportive, therapeutic and educational approaches, involve the social environment of the bereaved, and comprise a series of sessions led by trained facilitators. CONCLUSIONS: There is a clear need for additional methodologically sound studies in this area. Specifically, selection procedures, sample sizes, randomization, and the use of appropriate measures are crucial. As people bereaved by suicide are at-risk of adverse grief, mental ill-health and suicidal behaviour, further research across the life-span is essential to prevent grief and mental health ramifications.

Are young female suicides increasing? A comparison of sex-specific rates and characteristics of youth suicides in Australia over 2004-2014.

BACKGROUND: Australian mortality statistics suggest that young female suicides have increased since 2004 in comparison to young males, a pattern documented across other Western high-income countries. This may indicate a need for more targeted and multifaceted youth suicide prevention efforts. However, sex-based time trends are yet to be tested empirically within a comprehensive Australian sample. The aim of this study was to examine changes over time in sex-based rates and characteristics of all suicides among young people in Australia (2004-2014). METHODS: National Coronial Information System and Australian Bureau of Statistics data provided annual suicide counts and rates for 10-24-year-olds in Australia (2004-2014), stratified by sex, age group, Indigenous status and methods. Negative binomial regressions estimated time trends in population-stratified rates, and multinomial logistic regressions estimated time trends by major suicide methods (i.e., hanging, drug poisoning). RESULTS: Between 2004 and 2014, 3709 young Australians aged 10-24 years died by suicide. Whilst, overall, youth suicide rates did not increase significantly in Australia between 2004 and 2014, there was a significant increase in suicide rates for females (incident rate ratio [IRR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), but not males. Rates were consistently higher among Aboriginal/Torres Strait Islander youth, males, and in older (20-24-years) as compared to younger (15-19 years) age groups. Overall, the odds of using hanging as a method of suicide increased over time among both males and females, whilst the odds of using drug-poisoning did not change over this period. CONCLUSIONS: We showed that suicide rates among young females, but not young males, increased over the study period. Patterns were observed in the use of major suicide methods with hanging the most frequently used method among both sexes and more likely among younger and Aboriginal/Torres Strait Islander groups. Findings highlight the need to broaden current conceptualizations of youth suicide to one increasingly involving young females, and strengthen the case for a multifaceted prevention approach that capitalize on young females' greater help-seeking propensity.

Suicide Prevention Media Campaigns: A Systematic Literature Review.

Suicide prevention media campaigns are gaining traction as a means of combatting suicide. The current review set out to synthesize information about the effectiveness of these campaigns. We searched four electronic databases for studies that provided evidence on the effectiveness of media campaigns. We focused on studies that described an evaluation of the effectiveness of an entire campaign or a public service announcement explicitly aimed at suicide prevention. We identified 20 studies of varying quality. Studies that looked at whether campaign exposure leads to improved knowledge and awareness of suicide found support for this. Most studies that considered whether campaign materials can achieve improvements in attitudes toward suicide also found this to be the case, although there were some exceptions. Some studies found that media campaigns could boost help-seeking, whereas others suggested that they made no difference or only had an impact when particular sources of help or particular types of help-seeking were considered. Relatively few studies had sufficient statistical power to examine whether media campaigns had an impact on the ultimate behavioral outcome of suicides, but those that did demonstrated significant reductions. Our review indicates that media campaigns should be considered in the suite of interventions that might be used to prevent suicide. Evidence for their effectiveness is still amassing, but there are strong suggestions that they can achieve positive results in terms of certain suicide-related outcomes. Care should be taken to ensure that campaign developers get the messaging of campaigns right, and further work is needed to determine which messages work and which ones do not, and how effective messages should be disseminated. There is an onus on those developing and delivering campaigns to evaluate them carefully and to share the findings with others. There is a need for evaluations that employ rigorous designs assessing the most pertinent outcomes. These evaluations should explore the nature of given campaigns in detail - in particular the messaging contained within them - in order to tease out which messages work well and which do not. They should also take into account the reach of the campaign, in order to determine whether it would be reasonable to expect that they might have their desired effect.

Population attributable risk of factors associated with the repetition of self-harm behaviour in young people presenting to clinical services: a systematic review and meta-analysis.

The repetition of hospital-treated self-harm by young people is common. However, little work has summarised the modifiable factors associated with this. A thorough understanding of those factors most strongly associated with repetition could guide the development of relevant clinical interventions. We systematically reviewed four databases (EMBASE, Medline, PubMed and PsycINFO) until 15 April 2016 to identify all observational studies of factors for the repetition of self-harm or suicide reattempts (together referred to as 'self-harm behaviour') in young people. We quantified the magnitude of association with odds ratios (OR) and 95% confidence intervals (CIs) and calculated the population attributable risk (PAR) and population preventable fraction (PPF) for modifiable factors to provide an indication of the potential impact in reducing subsequent self-harm behaviour in this population. Seventeen studies were included comprising 10,726 participants. Borderline personality disorder (OR 3.47, 95% CI 1.84-6.53; PAR 42.4%), any personality disorder (OR 2.54, 95% CI 1.71-3.78; PAR 16.3%), and any mood disorder (OR 2.16, 95% CI 1.09-4.29; PAR 42.2%) are important modifiable risk factors. Severity of hopelessness (OR 2.95, 95% CI 1.74-5.01), suicidal ideation (OR 2.01, 95% CI 1.43-2.81), and previous sexual abuse (OR 1.52, 95% CI 1.02-2.28; PAR 12.8%) are also associated with repetition of self-harm. We recommend that clinical services should focus on identifying key modifiable risk factors at the individual patient level, whilst the reduction of exposure to child and adolescent sexual abuse would also be a useful goal for public health interventions.

Commentary: Adolescent self-harm prevention and intervention in secondary schools: a survey of staff in England and Wales - a reflection on Evans et al. (2019).

Self-harm (SH) continues to be a worldwide concern among adolescents and there is a great need for programming aimed at reducing SH in adolescents. Evans and colleagues discuss the opinions of school staff from a representative sample of secondary schools across England and Wales regarding their school's current prevention and intervention practices in responding to self-harm and how this should be addressed in future practice. The most salient points include the high prevalence of SH internationally, the existing barriers to SH prevention and intervention and possible solutions to these barriers. There is clearly an urgent need for high quality, evidence-based interventions that can be embedded in school settings, and have the capacity to overcome both the individual and structural barriers to supporting these vulnerable young people.

Depression and suicide among medical practitioners in Australia.

This review will provide an overview of the prevalence of, and risk factors for, depression and suicide in medical practitioners. It will also discuss the barriers to accessing appropriate care and potential interventions for this population.

Suicide prevention in educational settings: a review.

OBJECTIVES: Youth suicide rates are unacceptably high. Schools have long been accepted as an appropriate setting for suicide prevention activities. This review aims to synthesise the evidence for all types of suicide prevention interventions across educational settings. METHODS: The review draws on two previous reviews conducted by the authors. In order to be included, studies had to test a specific suicide prevention intervention in an educational setting, have a suicide-related outcome and target young people. RESULTS: A totally of 21 studies were included: 17 were conducted in school settings and four in universities. Seven of the school-based studies (41%) and one of the university studies (25%) were randomised controlled trials. Overall, the trials conducted in schools reported positive effects, as did four of the non- randomised controlled trials. Two of the university-based studies reported positive effects. Both universal and indicated interventions showed positive results; no iatrogenic effects were reported. CONCLUSIONS: School-based studies can have a positive impact on suicide-related behaviour and, overall, do not appear to cause harm. Study quality is variable, and the number of studies conducted in school settings far exceed those conducted in universities. These gaps need to be addressed by future research.

Improving patient care after a suicide attempt.

OBJECTIVES: Improving the care that patients receive after a suicide attempt will reduce the risk of a subsequent suicide attempt. We described how care for these patients can be improved and identified the available guidelines. METHODS: We reviewed the literature on crisis and aftercare, psychosocial assessment, risk assessment, brief contact interventions, and brief interventions. RESULTS: People who have made a suicide attempt are at increased risk of suicide, and the period immediately after discharge from hospital is particularly risky. Patients require an empathic response at their first point of contact, comprehensive psychosocial assessment, effective discharge planning, rapid and assertive follow-up, and coordinated care in the subsequent months. CONCLUSIONS: Empathic and effective care that begins in the emergency department and extends through to community care is imperative. Enough is known about the risks of inadequate care and the key ingredients of effective care to proceed with changes to Australia's healthcare response to a suicide attempt.