Terapia de Aceptación y Compromiso en conducta suicida: una revisión sistemática / Acceptance and Commitment Therapy on suicidal behavior: a systematic review

El suicidio se ha convertido en un problema social y de salud pública a nivel mundial. En este sentido, la Terapia de Aceptación y Compromiso (ACT) podría ser eficaz en su abordaje, existiendo evidencia sobre la relación entre algunos de sus componentes y la conducta suicida. Así, el presente estudio tuvo por objetivo realizar una revisión sistemática sobre la eficacia de ACT en conducta suicida. Para ello se siguió el protocolo PRISMA, empleando las siguientes bases de datos: PsycInfo, PubMed, Scopus y PsicoDoc. Inicialmente se obtuvieron 108 publicaciones potencialmente relevantes, de las cuales, finalmente, 13 fueron incluidas en la revisión. La calidad de los estudios se analizó a través de un instrumento de evaluación de riesgo de sesgos. Como resultados, a nivel general se observaron disminuciones estadísticamente significativas en ideación suicida (IS) y factores de riesgo de suicidio. Además, algunos estudios señalaron relaciones estadísticamente significativas entre un aumento de flexibilidad psicológica y la disminución de IS. Si bien los datos apuntaron a una posible eficacia de ACT en la reducción de IS, es necesario llevar a cabo mayor número de estudios experimentales que contemplen la complejidad de la conducta suicida y exploren los procesos de cambio implicados.(AU)

Suicide has emerged as a pressing global issue affecting both so-ciety and public health.In this context, Acceptance and Commitment Therapy (ACT) could prove effective in its approach, supported by evi-dence of the relationship between certain components of ACT and suicidal behavior. Thus, the present study aims to conduct a systematic review on the efficacy of ACT in suicidal behavior. For this, the PRISMA protocol was followed, using thefollowing databases: PsycInfo, PubMed, Scopus and PsicoDoc. Initially, 108 potentially relevant publicationswereobtained,13ofwhichwerefinallyincludedinthereview.Weanalyzedstudy qualityus-ingariskofbiasassessmentinstrument.Asaresult,statisticallysignificantdecreases in suicidal ideation (SI) and suicide risk factors were observed. In addition, some studies indicated statistically significant relationships be-tween increased psychological flexibility and decreasedSI.WhilethedatasuggestedthepotentialeffectivenessofACTinreducingsuicidal ideation (SI), more experimental studies are needed to consider the complexity of suicidal behavior and explore the processes of changeinvolved.(AU)

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

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

Machine learning approach for the development of a crucial tool in suicide prevention: The Suicide Crisis Inventory-2 (SCI-2) Short Form.

The Suicide Crisis Syndrome (SCS) describes a suicidal mental state marked by entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal that has predictive capacity for near-term suicidal behavior. The Suicide Crisis Inventory-2 (SCI-2), a reliable clinical tool that assesses SCS, lacks a short form for use in clinical settings which we sought to address with statistical analysis. To address this need, a community sample of 10,357 participants responded to an anonymous survey after which predictive performance for suicidal ideation (SI) and SI with preparatory behavior (SI-P) was measured using logistic regression, random forest, and gradient boosting algorithms. Four-fold cross-validation was used to split the dataset in 1,000 iterations. We compared rankings to the SCI-Short Form to inform the short form of the SCI-2. Logistic regression performed best in every analysis. The SI results were used to build the SCI-2-Short Form (SCI-2-SF) utilizing the two top ranking items from each SCS criterion. SHAP analysis of the SCI-2 resulted in meaningful rankings of its items. The SCI-2-SF, derived from these rankings, will be tested for predictive validity and utility in future studies.

Share of Adult Suicides After Recent Jail Release.

Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study.

Background: Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety. Objective: We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9. Methods: This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion. Results: Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002). Conclusions: Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

"There's room to do more": a mixed-methods study of the Temporary Assistance for Needy Families (TANF) diversion program and intimate partner violence in Georgia.

Introduction: Intimate partner violence (IPV) is a risk factor for homicides and suicides. As poverty is both a predictor and a consequence of IPV, interventions that alleviate poverty-related stressors could mitigate IPV-related harms. Temporary Assistance for Needy Families (TANF), a monthly cash assistance program, is one such potential intervention. In the state of Georgia, the TANF diversion program, which provides a non-recurrent lump-sum payment to deter individuals from monthly TANF benefits, is an understudied component of TANF that may influence the effectiveness of state TANF programs in supporting IPV survivors. Aim: This study quantifies and qualifies the role of Georgia's TANF diversion program in shaping IPV-related mortality. Methods: This study relies on a mixed-methods sequential explanatory design. Using data from the Georgia Violent Death Reporting System (GA-VDRS), an interrupted time series analysis was conducted to estimate the effect of TANF diversion on IPV-related homicides and suicides. Semi-structured interviews were then administered with TANF policy experts and advocates, welfare caseworkers, and benefit recipients (n = 20) to contextualize the quantitative findings. Results: The interrupted time series analysis revealed three fewer IPV-related deaths per month after implementing TANF diversion, compared to pre-diversion forecasts (coefficient = -3.003, 95%CI [-5.474, -0.532]). However, the qualitative interviews illustrated three themes regarding TANF diversion: (1) it is a "band-aid" solution to the access barriers associated with TANF, (2) it provides short-term relief to recipients making hard choices, and (3) its limitations reveal avenues for policy change. Discussion: While diversion has the potential to reduce deaths from IPV, it may be an insufficient means of mitigating the poverty-related contributors to IPV harms. Its limitations unveil the need for improved programs to better support IPV survivors.

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

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

A machine learning approach to detect potentially harmful and protective suicide-related content in broadcast media.

Suicide-related media content has preventive or harmful effects depending on the specific content. Proactive media screening for suicide prevention is hampered by the scarcity of machine learning approaches to detect specific characteristics in news reports. This study applied machine learning to label large quantities of broadcast (TV and radio) media data according to media recommendations reporting suicide. We manually labeled 2519 English transcripts from 44 broadcast sources in Oregon and Washington, USA, published between April 2019 and March 2020. We conducted a content analysis of media reports regarding content characteristics. We trained a benchmark of machine learning models including a majority classifier, approaches based on word frequency (TF-IDF with a linear SVM) and a deep learning model (BERT). We applied these models to a selection of more simple (e.g., focus on a suicide death), and subsequently to putatively more complex tasks (e.g., determining the main focus of a text from 14 categories). Tf-idf with SVM and BERT were clearly better than the naive majority classifier for all characteristics. In a test dataset not used during model training, F1-scores (i.e., the harmonic mean of precision and recall) ranged from 0.90 for celebrity suicide down to 0.58 for the identification of the main focus of the media item. Model performance depended strongly on the number of training samples available, and much less on assumed difficulty of the classification task. This study demonstrates that machine learning models can achieve very satisfactory results for classifying suicide-related broadcast media content, including multi-class characteristics, as long as enough training samples are available. The developed models enable future large-scale screening and investigations of broadcast media.

The 988 suicide hotline-Lifeline or letdown? A pre-post policy analysis.

Suicide has emerged as an urgent threat in recent years as COVID-19 impaired the health and economic wellbeing of millions of Americans. According to the Centers for Disease Control and Prevention, the impact of COVID-19 and the ongoing opioid epidemic has "taken a mental, emotional, physical, and economic toll on individuals, families, and communities," increasing the need for innovative solutions to prevent suicide on a national scale. The National Suicide Hotline Designation Act of 2020 established 988 as the universal telephone number for suicide prevention and represents a key federal intervention to address this crisis. However, research on 9-8-8's effectiveness is limited, given the Act's recent enactment and implementation at the federal and state levels. This policy analysis investigates how and to what extent the mental health crisis system in Georgia has improved since the implementation of the 2020 Act as well as the implications of state law on population-level mental health outcomes. Georgia is used as a nationally representative case study for two reasons: (1) Georgia had a robust statewide suicide hotline prior to 2020, providing solid infrastructure on which federal expansion of a suicide hotline number could be built, and (2) the conflicting characteristics of Georgia's mental health system represent several different pockets of the U.S., allowing this analysis to apply to a broad range of states and locales. The paper draws on takeaways from Georgia to propose state and national policy recommendations for equitable interventions to prevent and respond to this form of violence.

Workplace interventions to prevent suicide: A scoping review.

OBJECTIVES: To map organisational interventions for workplace suicide prevention, identifying the effects, mechanisms, moderators, implementation and economic costs, and how interventions are evaluated. BACKGROUND: Suicide is a devastating event that can have a profound and lasting impact on the individuals and families affected, with the highest rates found among adults of work age. Employers have a legal and ethical responsibility to provide a safe working environment for their employees, which includes addressing the issue of suicide and promoting mental health and well-being. METHODS: A realist perspective was taken, to identify within organisational suicide prevention interventions, what works, for whom and in what circumstances. Published and unpublished studies in six databases were searched. To extract and map data on the interventions the Effect, Mechanism, Moderator, Implementation, Economic (EMMIE) framework was used. Mechanisms were deductively analysed against Bronfenbrenner's socio-ecological model. RESULTS: From 3187 records screened, 46 papers describing 36 interventions within the military, healthcare, the construction industry, emergency services, office workers, veterinary surgeons, the energy sector and higher education. Most mechanisms were aimed at the individual's immediate environment, with the most common being education or training on recognising signs of stress, suicidality or mental illness in oneself. Studies examined the effectiveness of interventions in terms of suicide rates, suicidality or symptoms of mental illness, and changes in perceptions, attitudes or beliefs, with most reporting positive results. Few studies reported economic costs but those that did suggested that the interventions are cost-effective. CONCLUSIONS: It seems likely that organisational suicide prevention programmes can have a positive impact on attitudes and beliefs towards suicide as well reducing the risk of suicide. Education, to support individuals to recognise the signs and symptoms of stress, mental ill health and suicidality in both themselves and others, is likely to be an effective starting point for successful interventions.

The Spatio-Temporal Distribution of Suicide-related Emergency Calls in a European City: Age and Gender Patterns, and Neighborhood Influences.

Objective: The aim of this study was to conduct a comprehensive spatio-temporal analysis of suicide-related emergency calls in the city of Valencia (Spain) over a six-year period. To this end we first examined age and gender patterns and, second, the influence of neighborhood characteristics on general and gender-specific spatio-temporal patterns of suicide-related emergency calls. Method: Geocoded data on suicide-related emergency calls between 2017 and 2022 (N = 10,030) were collected from the 112 emergency service in Valencia. Data were aggregated at the census block group level, used as a proxy for neighborhoods, and trimesters were considered as the temporal unit. Two set of analyses were performed: (1) demographic (age and gender) and temporal descriptive analyses and (2) general and gender-specific Bayesian spatio-temporal autoregressive models. Results: Descriptive analyses revealed a higher incidence of suicide-related emergency calls among females and an increase in calls among the 18-23 age group from 2020 onwards. The general spatio-temporal model showed higher levels of suicide-related emergency calls in neighborhoods characterized by lower education levels and population density, and higher residential mobility, aging population, and immigrant concentration. Relevant gender differences were also observed. A seasonal effect was noted, with a peak in calls during spring for females and summer for males. Conclusions: These findings highlight the need for comprehensive mental health targeted interventions and preventive strategies that account for gender-specific disparities, age-related vulnerabilities, and the specific characteristics of neighborhoods.

Psychological maltreatment, meaning-centered coping, psychological flexibility, and suicide cognitions: A moderated mediation model.

BACKGROUND: Mental health problems are currently diversifying, increasing the possibility of suicide. Exposure to psychological maltreatment is one of the factors that increases suicidal cognitions. In addition, psychological flexibility and meaning-centered approaches may be effective in coping with suicidal cognitions. OBJECTIVE: A hypothesized model was tested to examine the relationships among psychological maltreatment, suicidal cognitions, psychological flexibility, and meaning-centered coping. METHOD: Data were collected from a sample of 652 participants. Mediation and moderation analyses were conducted to examine the mediating and moderating role of psychological flexibility and meaning-centered coping in the relationship between childhood psychological maltreatment and suicide cognitions among Turkish adults. RESULTS: The results of the study indicated significant negative and positive relationships between psychological maltreatment, suicide cognitions, psychological flexibility, and meaning-centered coping. The findings suggest that psychological flexibility and meaning-centered coping have a serial mediating effect on the relationship between psychological maltreatment and suicide cognitions. Furthermore, according to the study results, psychological flexibility plays a moderating role both between psychological maltreatment and suicidal cognitions and between meaning-centered coping and suicidal cognitions. CONCLUSIONS: The study suggests that psychological maltreatment can be considered as a risk factor and meaning-centered coping and psychological flexibility as protective factors in suicide prevention studies.

Depressive symptoms and neuroticism mediate the association between traumatic events and suicidality - A latent class mediation analysis of UK Biobank Database.

BACKGROUND: Mental disorders that follow traumatic experience may increase risk of suicidality, but a comprehensive approach to understand how these mental disorders mediate the association between psychological traumatic experience and suicidality should be elucidated. In this study, we attempted to provide comprehensive evidence on how depressive symptoms and neuroticism can mediate the association between psychological traumatic experiences and suicidal behaviours including suicidal ideation, suicidal planning, and suicide attempts. METHODS: We analyzed 111,931 participants from UK Biobank who had completed mental health web-based questionnaire from 2016 to 2017. "Self-harm and suicidal behaviour and ideation (SSBI) score" was calculated by the response from suicidal behaviours and self-harm questionnaires. Conducting multivariate linear regression, depressive symptoms, anxiety symptoms, and neuroticism were selected as potential mediators. We constructed a latent class mediation model estimated direct effect of psychological traumatic events on suicidality and indirect effect of psychological traumatic events mediated by depressive symptoms and neuroticism. RESULTS: Psychological traumatic events were positively associated with suicidal behaviours. Depressive symptoms and neuroticism significantly mediated the effect of psychological traumatic events on suicidality. Anxiety symptoms did not mediate the association between psychological traumatic events and suicidality. CONCLUSION: Psychological traumatic events, irrespective of life stage of occurrence, are associated with suicidality. The association between psychological traumatic events and suicidality can be partially explained by depressive symptoms and neuroticism of those who were exposed to psychological trauma.