Public health measures related to the transmissibility of suicide.

Transmission is an important concept in suicide prevention. It can occur when exposure to another person's death by suicide (or to suicide-related information more generally) draws attention to suicide or highlights specific suicide methods. In this paper, the fourth in a Series on a public health approach to suicide prevention, we contend that the transmissibility of suicide must be considered when determining optimal ways to address it. We draw on five examples of how transmission might occur and be prevented. The first two examples relate to transmission initiated by representations of suicide in traditional and new media. The third concerns transmission that leads to suicide clusters, and the fourth considers a specific setting in which transmission occurs, namely secondary schools. Finally, we discuss how suicide risk might be countered by the transmission of suicide prevention messages in media campaigns.

Association Between Prosuicide Website Searches Through Google and Suicide Death in the United States From 2010 to 2021: Lagged Time-Series Analysis.

BACKGROUND:  The rate of suicide death has been increasing, making understanding risk factors of growing importance. While exposure to explicit suicide-related media, such as description of means in news reports or sensationalized fictional portrayal, is known to increase population suicide rates, it is not known whether prosuicide website forums, which often promote or facilitate information about fatal suicide means, are related to change in suicide deaths overall or by specific means. OBJECTIVE:  This study aimed to estimate the association of the frequency of Google searches of known prosuicide web forums and content with death by suicide over time in the United States, by age, sex, and means of death. METHODS:  National monthly Google search data for names of common prosuicide websites between January 2010 and December 2021 were extracted from Google Health Trends API (application programming interface). Suicide deaths were identified using the CDC (Centers for Disease Control and Prevention) National Vital Statistics System (NVSS), and 3 primary means of death were identified (poisoning, suffocation, and firearm). Distributed lag nonlinear models (DLNMs) were then used to estimate the lagged association between the number of Google searches on suicide mortality, stratified by age, sex, and means, and adjusted for month. Sensitivity analyses, including using autoregressive integrated moving average (ARIMA) modeling approaches, were also conducted. RESULTS:  Months in the United States in which search rates for prosuicide websites increased had more documented deaths by intentional poisoning and suffocation among both adolescents and adults. For example, the risk of poisoning suicide among youth and young adults (age 10-24 years) was 1.79 (95% CI 1.06-3.03) times higher in months with 22 searches per 10 million as compared to 0 searches. The risk of poisoning suicide among adults aged 25-64 was 1.10 (95% CI 1.03-1.16) times higher 1 month after searches reached 9 per 10 million compared with 0 searches. We also observed that increased search rates were associated with fewer youth suicide deaths by firearms with a 3-month time lag for adolescents. These models were robust to sensitivity tests. CONCLUSIONS:  Although more analysis is needed, the findings are suggestive of an association between increased prosuicide website access and increased suicide deaths, specifically deaths by poisoning and suffocation. These findings emphasize the need to further investigate sites containing potentially dangerous information and their associations with deaths by suicide, as they may affect vulnerable individuals.

Quantifying suicide contagion at population scale.

The spread of suicidal behavior among individuals is often described as a contagion; however, rigorous modeling of suicide as a dynamic, contagious process is minimal. Here, we develop and validate a model-inference system depicting suicide ideation and death and use it to quantify the contagion processes in the US associated with two prominent celebrity suicide events: Robin Williams during 2014 and Kate Spade and Anthony Bourdain, which occurred 3 days apart during 2018. We show that both events produced large transient increases of suicide contagion contact rates, i.e., the spread of suicidal thought and behavior, and a period of elevated suicidal ideation in the general population. Our modeling approach provides a framework for quantifying suicidal contagion and better understanding, preventing, and containing its spread.

Evaluating the Experience of Teen-to-Teen Crisis Line Volunteers: A Pilot Study.

Teen-to-teen (t2t) crisis lines are a special type of crisis service where youth volunteers help their peers. Although prior research has examined the experience of adult crisis line responders, no research has examined the experience of adolescents who do this work. In collaboration with two of the largest t2t lines in the U.S., this pilot study is the first examination of t2t crisis line work. Volunteers (ages 14-20) reported: their primary motivation for joining the crisis lines was to help others and give back to the community; responding to a range of peers' problems on the t2t crisis line, including high-risk suicide contacts; and a range of ways the crisis line work impacted their lives. Findings provide preliminary information about the experience of adolescents engaging in t2t crisis line work. Additional research is needed in larger and more diverse samples to understand the impact of crisis line work for youth.

"Breaking the Silence" Suicide Prevention Media Campaign in Oregon, April 7-14, 2019.

Background: Between April 7 and 14, 2019, the "Breaking the Silence" media engagement campaign was launched in Oregon. Aims: We aimed to assess the consistency of media content related to the campaign with media guidelines and the quantitative footprint on Twitter (now X) over time. Method: Media items related to the campaign were analyzed regarding focus and consistency with media guidelines for suicide reporting and compared with other suicide-related reports published in the same time frame, as well as with reporting in Washington, the control region. Tweets related to the campaign were retrieved to assess the social media footprint. Results: There were n = 104 media items in the campaign month, mainly in the campaign week. Items typically used a narrative featuring suicide advocacy or policy/prevention programs. As compared to other items with a similar focus, they scored better on several protective characteristics listed in media recommendations. Stories of coping with adversity, however, were scarce. The social media footprint on Twitter was small. Limitations: Inability to make causal claims about campaign impact. Conclusion: Media items from the Breaking the Silence campaign appeared mainly consistent with media guidelines, but some aspects, such as stories of recovery, were under-represented.

"Breaking the silence" suicide Prevention media campaign in Oregon: Evaluation of impact on help-seeking and suicide mortality.

INTRODUCTION: Research has established that suicide-related media can impact suicide rates both positively and negatively, supporting efforts to engage the media in the service of suicide prevention. The goal of the current study is to evaluate the impact of a suicide prevention media campaign implemented April 7-14, 2019 in Oregon. METHODS: Several indices of help-seeking behavior and suicide risk were employed: suicide-related Google Health API searches, National Suicide Prevention Lifeline (Lifeline) (currently known as the 988 Suicide and Crisis Lifeline) call volume, and state suicide mortality data from April 7, 2016-May 6, 2019. Eight states with similar 2016-2018 average suicide rates were compared with Oregon. Bayesian structural time-series modeling in R was used to test intervention effects. RESULTS: During the 30 days following the start of the campaign, there was a significant increase in Lifeline calls from Oregon area codes (2488 observed vs. 2283 expected calls, p = 0.03). There were no significant changes in suicide mortality or suicide-related Google searches in Oregon. CONCLUSIONS: The campaign appeared to increase help-seeking behavior in the form of Lifeline calls, without any indication of an iatrogenic suicide contagion effect. However, the campaign's potential to reduce suicide mortality was unmet.

Geographic Variation, Economic Activity, and Labor Market Characteristics in Trajectories of Suicide in the United States, 2008-2020.

Suicide rates in the United States have increased over the past 15 years, with substantial geographic variation in these increases; yet there have been few attempts to cluster counties by the magnitude of suicide rate changes according to intercept and slope or to identify the economic precursors of increases. We used vital statistics data and growth mixture models to identify clusters of counties by their magnitude of suicide growth from 2008 to 2020 and examined associations with county economic and labor indices. Our models identified 5 clusters, each differentiated by intercept and slope magnitude, with the highest-rate cluster (4% of counties) being observed mainly in sparsely populated areas in the West and Alaska, starting the time series at 25.4 suicides per 100,000 population, and exhibiting the steepest increase in slope (0.69/100,000/year). There was no cluster for which the suicide rate was stable or declining. Counties in the highest-rate cluster were more likely to have agricultural and service economies and less likely to have urban professional economies. Given the increased burden of suicide, with no clusters of counties improving over time, additional policy and prevention efforts are needed, particularly targeted at rural areas in the West.

Ethnoracial Disparities in Rates of Non-Natural Causes of Death After the 2020 COVID-19 Outbreak in New York State.

Introduction: COVID-19 was associated with increases in non-natural cause mortality in the U.S., including deaths due to drug overdose, homicide, and motor vehicle crashes. Initial reports indicated higher rates of non-natural mortality among ethnoracial minority groups. This report aims to clarify these disparities by documenting trends in non-natural mortality across ethnoracial groups during the 2020 COVID-19 surge in New York State. Methods: We report monthly trends in non-natural cause mortality (overall and stratified by ethnoracial status) in New York State from January 2019 through December 2020, which included the COVID-19 onset in March 2020. Results: Total mean monthly unintentional overdose rates per 100,000 increased from 17.45 (before surge: January 2019-February 2020) to 23.19 (after surge: March 2020-December 2020) (mean difference=5.73, 95% CI=3.82, 7.65; p<0.001). Mean monthly homicide death rates increased from 2.34 before surge to 3.55 after surge (mean difference=1.20, 95% CI=0.60, 1.81; p<0.001), with the increase seen primarily in the non-Latinx Black population. Although increasing unintentional overdose death rates before surge equally affected non-Latinx White, Latinx, and non-Latinx Black persons, they remained high for non-Latinx Black persons but dropped for the other 2 groups after the pandemic onset. None of the ethnoracial subgroups showed significant increases in suicide or motor vehicle crash death rates. Conclusions: Non-Latinx Black persons showed disproportionately high and sustained increased rates of unintentional overdose and homicide death rates after the 2020 COVID-19 surge in New York State. Fatality review and death scene investigation research is needed to better understand these disparities.

Trends in Crisis Hotline Call Rates and Suicide Mortality in the United States.

OBJECTIVE: Utilization of the 988 Suicide and Crisis Lifeline (Lifeline; formerly called the National Suicide Prevention Lifeline) was analyzed in relation to suicide deaths in U.S. states between 2007 and 2020 to identify states with potential unmet need for mental health crisis hotline services. METHODS: Annual state call rates were calculated from calls routed to the Lifeline during the 2007-2020 period (N=13.6 million). Annual state suicide mortality rates (standardized) were calculated from suicide deaths reported to the National Vital Statistics System (2007-2020 cumulative deaths=588,122). Call rate ratio (CRR) and mortality rate ratio (MRR) were estimated by state and year. RESULTS: Sixteen U.S. states demonstrated a consistently high MRR and a low CRR, suggesting high suicide burden and relatively low Lifeline use. Heterogeneity in state CRRs decreased over time. CONCLUSIONS: Prioritizing states with a high MRR and a low CRR for messaging and outreach regarding the availability of the Lifeline can ensure more equitable, need-based access to this critical resource.

Hindcasts and forecasts of suicide mortality in US: A modeling study.

Deaths by suicide, as well as suicidal ideations, plans and attempts, have been increasing in the US for the past two decades. Deployment of effective interventions would require timely, geographically well-resolved estimates of suicide activity. In this study, we evaluated the feasibility of a two-step process for predicting suicide mortality: a) generation of hindcasts, mortality estimates for past months for which observational data would not have been available if forecasts were generated in real-time; and b) generation of forecasts with observational data augmented with hindcasts. Calls to crisis hotline services and online queries to the Google search engine for suicide-related terms were used as proxy data sources to generate hindcasts. The primary hindcast model (auto) is an Autoregressive Integrated Moving average model (ARIMA), trained on suicide mortality rates alone. Three regression models augment hindcast estimates from auto with call rates (calls), GHT search rates (ght) and both datasets together (calls_ght). The 4 forecast models used are ARIMA models trained with corresponding hindcast estimates. All models were evaluated against a baseline random walk with drift model. Rolling monthly 6-month ahead forecasts for all 50 states between 2012 and 2020 were generated. Quantile score (QS) was used to assess the quality of the forecast distributions. Median QS for auto was better than baseline (0.114 vs. 0.21. Median QS of augmented models were lower than auto, but not significantly different from each other (Wilcoxon signed-rank test, p > .05). Forecasts from augmented models were also better calibrated. Together, these results provide evidence that proxy data can address delays in release of suicide mortality data and improve forecast quality. An operational forecast system of state-level suicide risk may be feasible with sustained engagement between modelers and public health departments to appraise data sources and methods as well as to continuously evaluate forecast accuracy.

County-level estimates of suicide mortality in the USA: a modelling study.

BACKGROUND: Suicide is one of the leading causes of death in the USA and population risk prediction models can inform decisions on the type, location, and timing of public health interventions. We aimed to develop a prediction model to estimate county-level suicide risk in the USA using population characteristics. METHODS: We obtained data on all deaths by suicide reported to the National Vital Statistics System between Jan 1, 2005, and Dec 31, 2019, and age, sex, race, and county of residence of the decedents were extracted to calculate baseline risk. We also obtained county-level annual measures of socioeconomic predictors of suicide risk (unemployment, weekly wage, poverty prevalence, median household income, and population density) and state-level prevalence of major depressive disorder and firearm ownership from US public sources. We applied conditional autoregressive models, which account for spatiotemporal autocorrelation in response and predictors, to estimate county-level suicide risk. FINDINGS: Estimates derived from conditional autoregressive models were more accurate than from models not adjusted for spatiotemporal autocorrelation. Inclusion of suicide risk and protective covariates further reduced errors. Suicide risk was estimated to increase with each SD increase in firearm ownership (2·8% [95% credible interval (CrI) 1·8 to 3·9]), prevalence of major depressive episode (1·0% [0·4 to 1·5]), and unemployment rate (2·8% [1·9 to 3·8]). Conversely, risk was estimated to decrease by 4·3% (-5·1 to -3·2) for each SD increase in median household income and by 4·3% (-5·8 to -2·5) for each SD increase in population density. An increase in the heterogeneity in county-specific suicide risk was also observed during the study period. INTERPRETATION: Area-level characteristics and the conditional autoregressive models can estimate population-level suicide risk. Availability of near real-time situational data are necessary for the translation of these models into a surveillance setting. Monitoring changes in population-level risk of suicide could help public health agencies select and deploy targeted interventions quickly. FUNDING: US National Institute of Mental Health.

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.

Perceived Impact of COVID-19 Among Callers to the National Suicide Prevention Lifeline.

Background: Research indicates that the COVID-19 pandemic caused increases in psychological distress and suicidal ideation. Aims: To describe the ways suicidal callers to the National Suicide Prevention Lifeline (Lifeline) perceived COVID-19 to have impacted them and assess whether these callers perceived COVID-19-related stress as contributing to their suicidal thoughts. Method: Telephone interviews were conducted with 412 suicidal callers to 12 Lifeline centers. Logistic regression analyses were used to examine the associations between demographic factors and individual COVID-19 stressors and to determine whether callers who endorsed COVID-19-related stress as contributing to their suicidal thoughts differed from those who did not regarding demographics, current suicide risk, history of suicidality, Lifeline use, or individual COVID-19 stressors. Results: Over half of callers reported that COVID-19-related stress contributed to their suicidal ideation (CRSSI). Callers who endorsed CRSSI had higher odds than those who did not of mentioning financial difficulties when asked how COVID-19 impacted them. The two groups of callers did not differ on the other factors examined. Limitations: Interviewed callers may not be representative of all Lifeline callers. Conclusion: Despite the subjective burden of COVID-19-related stress on suicidal Lifeline callers, this was not associated with new suicidality or heightened suicide risk.

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.

Temporal Trends in Suicide Methods Among Adolescents in the US.

This cross-sectional study evaluates the temporal trends in suicide methods among US adolescents, with variation by sex and race.

Suicide numbers during the first 9-15 months of the COVID-19 pandemic compared with pre-existing trends: An interrupted time series analysis in 33 countries.

Background: Predicted increases in suicide were not generally observed in the early months of the COVID-19 pandemic. However, the picture may be changing and patterns might vary across demographic groups. We aimed to provide a timely, granular picture of the pandemic's impact on suicides globally. Methods: We identified suicide data from official public-sector sources for countries/areas-within-countries, searching websites and academic literature and contacting data custodians and authors as necessary. We sent our first data request on 22nd June 2021 and stopped collecting data on 31st October 2021. We used interrupted time series (ITS) analyses to model the association between the pandemic's emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed and expected numbers of suicides in the pandemic's first nine and first 10-15 months and used meta-regression to explore sources of variation. Findings: We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income; 25 with whole-country data, 12 with data for area(s)-within-the-country, four with both). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis; more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries' COVID-19 mortality rate, stringency of public health response, economic support level, or presence of a national suicide prevention strategy. Nor were they explained by countries' income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well. Interpretation: Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these countries/areas-within-countries are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue. Funding: None.

Help-seeker expectations and outcomes of a crisis support service: Comparison of suicide-related and non-suicide-related contacts to lifeline Australia.

Lifeline Australia aims to prevent suicide and support community members in personal crisis via the provision of free anonymous telephone, online chat and text message services. This study aimed to identify the expectations and outcomes of Lifeline help-seekers, including whether there are differences between suicide-related and non-suicide-related contacts. Help-seekers (N = 553) who had previously contacted Lifeline via telephone, online chat, or text message crisis services were recruited via social media and a link provided after Lifeline service use, who completed an online survey about their awareness, expectations and outcomes of Lifeline's services. The responses from help-seekers who self-reported suicide-related and non-suicide-related reasons for contact were compared. Participants were highly aware of Lifeline's services, particularly the phone service. The main expectations of all help-seekers were to feel heard and listened to, feel less upset and feel understood. There were 59.5% of the sample that reported suicidality as a reason for contact. Suicide-related contacts endorsed more reasons for contact than non-suicide-related contacts. Expectations of suicide-related help-seekers were greater, but they were less likely to report that their expectations were met. The high expectations and complexity of suicide-related contacts reveal the challenges in meeting the needs of this high-priority group, particularly within the context of the multiple demands on crisis support services.

Individuals who text crisis text line: Key characteristics and opportunities for suicide prevention.

OBJECTIVE: Text-based crisis services are increasingly prominent, with inclusion in the national 988 crisis number launching in 2022. Yet little is known about who uses them. This study seeks to understand the population served by Crisis Text Line (CTL), the largest crisis text service in the United States. METHODS: Secondary data analysis was conducted on de-identified Crisis Counselor reports, texter post-conversation survey responses, and anonymized text conversation data from 85,877 texters who contacted CTL during a 12-month period. We examined Crisis Counselor's ratings of suicide ideation severity, texters' reports of race, gender, sexual orientation, recent mental health symptoms, and additional sources of help, and logs of frequency of contact. RESULTS: 76% of texters were under 25. 79% were female. 48% identified as other than heterosexual/straight. 64% had only one conversation. 79% were above the clinical cutoff for depression and 80% for anxiety, while 23% had thoughts of suicide. 23% received help from a doctor or therapist, and 28% received help only from CTL. CONCLUSIONS: CTL reaches a highly distressed, young, mostly female population, including typically underserved minorities and a substantial percentage of individuals who do not receive help elsewhere. These findings support the decision to include texting in the forthcoming national 988 implementation.

Crisis text-line interventions: Evaluation of texters' perceptions of effectiveness.

OBJECTIVE: Crisis Text Line (CTL), the largest provider of text-based crisis intervention services in the U.S., has answered nearly 7 million conversations since its inception in 2013. The study's objective was to assess texter's perceptions of the effectiveness of CTL crisis interventions. METHOD: Survey data completed by 85,877 texters linked to volunteer crisis counselor (CC) reports from October 12, 2017, to October 11, 2018 were analyzed. The relationship of several effectiveness measures with texters' demographic and psychosocial characteristics, frequency of CTL usage, and texters' perceptions of engagement with their CCs was examined using a series of logistic regression analyses. RESULTS: By the end of the text-based conversation, nearly 90% of suicidal texters reported that the conversation was helpful, and nearly half reported being less suicidal. CONCLUSIONS: Our study offers evidence for CTL's perceived effectiveness. These findings are of critical importance in light of the launch of a nationwide three-digit number (988) for suicide prevention and mental health crisis supports in the U.S., which will include texting.