Suicide prevention in Hong Kong: pushing boundaries while building bridges.

Hong Kong is a natural laboratory for studying suicides-small geographic footprint, bustling economic activity, rapidly changing socio-demographic transitions, and cultural crossroads. Its qualities also intensify the challenges posed when seeking to prevent them. In this viewpoint, we showed the research and practices of suicide prevention efforts made by the Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP), which provide the theoretical underpinning of suicide prevention and empirical evidence. CSRP adopted a multi-level public health approach (universal, selective and indicated), and has collaboratively designed, implemented, and evaluated numerous programs that have demonstrated effectiveness in suicide prevention and mental well-being promotion. The center serves as a hub and a catalyst for creating, identifying, deploying, and evaluating suicide prevention initiatives, which have the potential to reduce regional suicides rates when taken to scale and sustained.

The Impacts of Intimate Partner Violence on Postpartum Depression: An Updated Meta-Analysis.

The associations between intimate partner violence (IPV) and postpartum depression (PPD) have been well established in previous reviews. However, none has explored potential differences between IPV subtypes or exposure times, which could help healthcare providers recognize the adverse impacts of various IPV subtypes and conduct comprehensive IPV screening. This study aimed to estimate the impacts of overall IPV and its subtypes (physical, psychological, and sexual) on PPD using an updated meta-analysis and to examine the potential role of IPV exposure time and regional income levels. Four English databases (Medline, PsycINFO, PubMed, and Web of Science) and two Chinese databases (China National Knowledge Infrastructure [CNKI] and Wanfang Database) were systematically searched. We included 76 studies with 388,966 samples. Random-effects models were used to pool the odds ratios (ORs) across studies. Overall, IPV and its subtypes had statistically significant impacts on PPD (overall: OR = 2.50, physical: OR = 2.31, psychological: OR = 2.22, sexual: OR = 1.75). A higher impact of IPV on PPD was observed in middle- and low-income regions (OR = 3.01) than in high-income regions (OR = 1.92). IPV during pregnancy (OR = 2.73) had a greater impact on PPD than lifetime IPV (OR = 2.24). This study provides updated evidence for the significant impact of IPV and its subtypes and exposure time on PPD. Women at risk of exposure to physical IPV, especially during pregnancy, are in urgent need of support to reduce the risk of PPD.

Effects of Community-Based Caring Contact in Reducing Thwarted Belongingness Among Postdischarge Young Adults With Self-Harm: Randomized Controlled Trial.

BACKGROUND: For patients with self-harm behaviors, the urge to hurt themselves persists after hospital discharge, leading to costly readmissions and even death. Hence, postdischarge intervention programs that reduce self-harm behavior among patients should be part of a cogent community mental health care policy. OBJECTIVE: We aimed to determine whether a combination of a self-help mobile app and volunteer support could complement treatment as usual (TAU) to reduce the risk of suicide among these patients. METHODS: We conducted a pragmatic randomized controlled trial on discharged patients aged between 18 and 45 years with self-harm episodes/suicide attempts, all of whom were recruited from 4 hospital emergency departments in Hong Kong. Participants were randomly assigned to one of three groups: (1) mobile app + TAU ("apps"), (2) mobile app + volunteer support + TAU ("volunteers"), or (3) TAU only as the control group ("TAU"). They were asked to submit a mobile app-based questionnaire during 4 measurement time points at monthly intervals. RESULTS: A total of 40 participants were recruited. Blending volunteer care with a preprogrammed mobile app was found to be effective in improving service compliance. Drawing upon the interpersonal-psychological theory of suicide, our findings suggested that a reduction in perceived burdensomeness and thwarted belongingness through community-based caring contact are linked to improvement in hopelessness, albeit a transient one, and suicide risk. CONCLUSIONS: A combination of volunteer care with a self-help mobile app as a strategy for strengthening the continuity of care can be cautiously implemented for discharged patients at risk of self-harm during the transition from the hospital to a community setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT03081078; https://clinicaltrials.gov/study/NCT03081078.

Quality of life of services users in psychotropic drug treatment and rehabilitation services: a qualitative study from service user and provider perspectives.

Quality of life (QoL) is a widely recognized and valuable social outcome measure in drug treatment and rehabilitation services, but the discrepancies in QoL perceptions between service users and providers remain under-explored. In this study, semi-structured interviews were conducted with service users (n = 22) and providers (n = 29) to capture their perceptions of QoL and explore the similarities and discrepancies between their views. A thematic analysis and contrast exploration revealed a shared understanding of QoL that extends beyond health to six dimensions and prioritizes empowerment and connection. However, divergent views emerged regarding the priorities of material conditions, emotional well-being, and physical health. Findings underscore the importance of using shared decision-making as a strategy to effectively address these discrepancies and promote a more patient-centered approach in treatment and rehabilitation services.

Students' interaction anxiety and social phobia in interprofessional education in Hong Kong: mapping a new research direction.

BACKGROUND: Interprofessional education (IPE) has been promoted as a breakthrough in healthcare because of the impact when professionals work as a team. However, despite its inception dating back to the 1960s, its science has taken a long time to advance. There is a need to theorize IPE to cultivate creative insights for a nuanced understanding of IPE. This study aims to propose a research agenda on social interaction by understanding the measurement scales used and guiding researchers to contribute to the discussion of social processes in IPE. METHOD: This quantitative research was undertaken in a cross-institutional IPE involving 925 healthcare students (Medicine, Nursing, Social Work, Chinese Medicine, Pharmacy, Speech Language Pathology, Clinical Psychology, Food and Nutritional Science and Physiotherapy) from two institutions in Hong Kong. Participants completed the Social Interaction Anxiety Scale (SIAS-6) and Social Phobia Scale (SPS-6). We applied a construct validation approach: within-network and between-network validation. We performed confirmatory factors analysis, t-test, analysis of variance and regression analysis. RESULTS: CFA results indicated that current data fit the a priori model providing support to within-network validity [RMSEA=.08, NFI=.959, CFI=.965, IFI=.965, TLI=.955]. The criteria for acceptable fit were met. The scales were invariant between genders, across year levels and disciplines. Results indicated that social interaction anxiety and social phobia negatively predicted behavioural engagement (F = 25.093, p<.001, R2=.065) and positively predicted behavioural disaffection (F = 22.169, p<.001, R2=.057) to IPE, suggesting between-network validity. CONCLUSIONS: Our data provided support for the validity of the scales when used among healthcare students in Hong Kong. SIAS-6 and SPS-6 have sound psychometric properties based on students' data in Hong Kong. We identified quantitative, qualitative and mixed methods research designs to guide researchers in getting involved in the discussion of students' social interactions in IPE.Key MessagesThe Social Anxiety Scale (SIAS-6) and Social Phobia Scale (SPS-6) scales have sound psychometric properties based on the large-scale healthcare students' data in IPE in Hong Kong.Social interaction anxiety and social phobia negatively predicted students' behavioural engagement with IPE and positively predicted behavioural disaffection. The scales are invariant in terms of gender, year level and discipline.Quantitative, qualitative and mixed methods studies are proposed to aid researchers to contribute in healthcare education literature using the SIAS-6 and SPS-6.

The Opportunities and Challenges of the First Three Years of Open Up, an Online Text-Based Counselling Service for Youth and Young Adults.

We present the opportunities and challenges of Open Up, a free, 24/7 online text-based counselling service to support youth in Hong Kong. The number of youths served more than doubled within the first three years since its inception in 2018 in response to increasing youth suicidality and mental health needs. Good practice models are being developed in order to sustain and further scale up the service. We discuss the structure of the operation, usage pattern and its effectiveness, the use of AI to improve users experience, and the role of volunteer in the operation. We also present the challenges in further enhancing the operation, calling for more research, especially on the identification of the optimal number of users that can be concurrently served by a counsellor, the effective approach to respond to a small percentage of repeated users who has taken up a disproportional volume of service, and the way to optimize the use of big data analytics and AI technology to enhance the service. These advancements will benefit not only Open Up but also similar services across the globe.

Detecting suicide risk using knowledge-aware natural language processing and counseling service data.

RATIONALE: Detecting users at risk of suicide in text-based counseling services is essential to ensure that at-risk individuals are flagged and prioritized. OBJECTIVE: The objective of this study is to develop a domain knowledge-aware risk assessment (KARA) model to improve our ability of suicide detection in online counseling systems. METHODS: We obtained the largest known de-identified dataset from an emotional support system established in Hong Kong, comprising 5682 Cantonese conversations between help-seekers and counselors. Of those, 682 conversations disclosed crisis intentions of suicide. We constructed a suicide-knowledge graph, representing suicide-related domain knowledge as a computer-processible graph. Such knowledge graph was embedded into a deep learning model to improve its ability to identify help-seekers in crisis. As the baseline, a standard NLP model was applied to the same task. 80% of the study samples were randomly sampled to train model parameters. The remaining 20% were used for model validation. Evaluation metrics including precision, recall, and c-statistic were reported. RESULTS: Both KARA and the baseline achieved high precision (0.984 and 0.951, shown in Table 2) and high recall (0.942 and 0.947) towards non-crisis cases. For crisis cases, however, KARA model achieved a much higher recall than the baseline (0.870 vs 0.791). The c-statistics of KARA and the baseline were 0.815 and 0.760, respectively. CONCLUSION: KARA significantly outperformed standard NLP models, demonstrating good translational value and clinical relevance.

Rural-to-urban migration, discrimination experience, and health in China: Evidence from propensity score analysis.

This research examines how rural-to-urban migration influences health through discrimination experience in China after considering migration selection bias. We conducted propensity score matching (PSM) to obtain a matched group of rural residents and rural-to-urban migrants with a similar probability of migrating from rural to urban areas using data from the 2014 China Family Panel Studies (CFPS). Regression and mediation analyses were performed after PSM. The results of regression analysis after PSM indicated that rural-to-urban migrants reported more discrimination experience than rural residents, and those of mediation analysis revealed discrimination experience to exert negative indirect effects on the associations between rural-to-urban migration and three measures of health: self-reported health, psychological distress, and physical discomfort. Sensitivity analysis using different calipers yielded similar results. Relevant policies and practices are required to respond to the unfair treatment and discrimination experienced by this migrant population.

A Community-Based Response to a Suicide Cluster.

Background: A 45-month community-based suicide prevention program was launched in response to the emergence of a suicide cluster in 2010 in Hong Kong. Aims: This study aimed to evaluate the effectiveness of the program, document the implementation and outcomes of the project, and identify factors that contribute to the outcomes. Method: The program was delivered following the five key components of the public health approach: (a) community consensus building; (b) surveillance and monitoring; (c) development of coordinated action strategies; (d) interventions development and implementation at the universal, selective, and indicated levels; and (d) program evaluation. Results: A significant decreasing trend of suicide was found in the study site during the intervention period, whereas no changes were found in the three control sites. Spatial analysis also showed that the suicide cluster subsided after the intervention. Three impacts and one challenge of the program were identified from the qualitative feedback of the program stakeholders. Limitations: More investigations should be made to assess the sustainability of this community-based suicide prevention effort in the long run. Conclusion: A community-based suicide prevention program was successfully implemented to address the suicide cluster. A reduction in the suicide rate was observed after the intervention.

A Digital Game and School-Based Intervention for Students in Hong Kong: Quasi-Experimental Design.

BACKGROUND: In Hong Kong, with an increasing number of children experiencing mental health issues, there is a need to not only develop innovative interventions but also develop comprehensive prevention interventions so as to reduce their anxiety symptoms and enhance their emotional management and interpersonal relationships. OBJECTIVE: The aim of this study was to determine the effectiveness of The Adventures of DoReMiFa, an integration model of the cognitive-behavioral approach and positive psychology by using digital game-based and school-based mental health enhancement intervention to magnify the social and emotional health and well-being of the school children in Hong Kong aged 9 to 11 years. METHODS: A quasi-experimental design method was used to evaluate this digital game and school-based intervention. The Adventures of DoReMiFa was piloted in 4 primary schools where students were allocated to either an intervention or a control group. The participants were assessed at pre- and postintervention with a 6-month follow-up measuring their mental health knowledge, levels of anxiety symptoms, positive and negative thinking, perspective-taking, and self-esteem. RESULTS: A total of 459 primary school students from 4 primary schools participated in the study. The response rate on the questionnaires answered on the Web was up to 85.1% (391/459). Compared with the control group, the intervention group was found to have significant association with improved mental health knowledge at the time immediately after the intervention (beta=.46; P=.01) and in the 6-month postintervention period (beta=.66; P<.001); for perspective-taking, the intervention group had exhibited a significant improvement 6 months after the completion of the universal program (beta=1.50; P=.03). The intervention, however, was found not to be effective in reducing the rates of anxiety symptoms and negative thinking among the participating students. CONCLUSIONS: The Adventures of DoReMiFa, an integration of a digital game-based and school-based mental health enhancement intervention, was shown to be effective in elevating the knowledge of mental health and promoting perspective-taking in the primary school students of Hong Kong. Although there was insufficient evidence to support a reduction in symptoms of anxiety and negative automatic thoughts, the overall results were still encouraging in that a preventive effect was found, indicating that the program has the potential to enhance the mental well-being of schoolchildren. It also suggests that knowledge enhancement may not necessarily lead to behavior change, and more focused effort may be needed to achieve the translation. The implications and limitations of this study and suggestions for future research were also discussed.

Online social work engagement and empowerment for young internet users: A quasi-experiment.

BACKGROUND: The increasing penetration of Internet use among young people poses challenges for youth service engagement through bricks-and-mortar youth centers owing to the decline in the number of walk-ins. This study was to identify the psychosocial and behavioral outcome changes effected through online engagement and empowerment interventions offered to at-risk youths by three local social work youth service providers. METHODS: A quasi-experimental design was adopted to compare the effects of online engagement and empowerment on 182 young service users with 191 age- and gender-matched controlled participants over nine months. RESULTS: Significant improvement in emotional distress and social withdrawal behaviors were found in the intervention group. LIMITATIONS: Non-randomized study, nonequivalent comparison group DISCUSSION: Whether online social work services can substitute offline services should be further examined in randomized controlled trials. Online social work intervention identifies its acceptability among young people and professional feedback holds promise for providing a complimentary route of alleviating emotional distress and social withdrawal in at-risk youths.

Evidence-Based Suicide Prevention: Collective Impact of Engagement with Community Stakeholders.

Purpose: In response to the rising suicide trend in Hong Kong, the Centre for Suicide Research and Prevention ("CSRP") was established in 2002, with the aim to capitalize on the collective impact of research-support practices to prevent suicides.Method: The CSRP has since become an international knowledge hub that applies a public health approach and innovative strategies to address suicide-related problems at multiple levels.Results: The CSRP actively engages in research, teaching, and knowledge exchange with community stakeholders. These effort are associated with Hong Kong's more than 30% reduction in suicide rates between 2003 and 2016.Discussion: The rationale for and examples of the CSRP's practices in face of the suicide prevention challenges lay ahead were also discussed.Conclusion: The outcomes of these practices, which hold great potential for suicide prevention worldwide, have contributed to important academic debates in the field of suicidology.

Intergenerational support, satisfaction with parent-child relationship and elderly parents' life satisfaction in Hong Kong.

OBJECTIVES: This study examines in what exchange patterns that three types of intergenerational support are associated with elderly parents' life satisfaction, and whether elderly parents' evaluation on parent-child relationship plays a mediation role on those associations. METHOD: Data were drawn from Hong Kong Panel Survey for Poverty Alleviation. Respondents aged 65 and over were included ( N=504). Three types of support, namely, daily-living, financial, and emotional support were examined in four patterns-the over-benefited , under-benefited , reciprocal and no flow of exchange. A multivariable linear regression was applied to investigate the association between pattern of intergenerational exchange and life satisfaction, and mediation analysis was employed to examine the mediating role of satisfaction with parent-child relationship on their associations. RESULTS: Elderly parents were less satisfied with their lives when they had no flow of exchange in daily-living support, and more satisfied when they were under-benefited in financial support, and over-benefited or reciprocal in emotional support. Elderly parents' satisfaction with parent-child relationship mediated the association between exchange of emotional support and life satisfaction; but not the association between daily-living or financial support and life satisfaction. CONCLUSION: Different types of intergenerational support are associated with elderly parents' life satisfaction in different patterns.

Suicide rates in China, 2004-2014: comparing data from two sample-based mortality surveillance systems.

BACKGROUND: The decreasing suicide rate in China has been regarded as a major contributor to the decline of global suicide rate in the past decade. However, previous estimations on China's suicide rates might not be accurate, since often they were based on the data from the Ministry of Health's Vital Registration ("MOH-VR") System, which is biased towards the better-off population. This study aims to compare suicide data extracted from the MOH-VR System with a more representative mortality surveillance system, namely the Center for Disease Control and Prevention's Disease Surveillance Points ("CDC-DSP") System, and update China's national and subnational suicide rates in the period of 2004-2014. METHODS: The CDC-DSP data are obtained from the National Cause-of-Death Surveillance Dataset (2004-2014) and the MOH-VR data are from the Chinese Health Statistics Yearbooks (2005-2012) and the China Health and Family Planning Statistics Yearbooks (2013-2015). First, a negative binomial regression model was used to test the associations between the source of data (CDC-DSP/MOH-VR) and suicide rates in 2004-2014. Joinpoint regression analyses and Kitagawa's decomposition method are then applied to analyze the trends of the crude suicide rates. RESULTS: Both systems indicated China's suicide rates decreased over the study period. However, before the two systems merged in 2013, the CDC-DSP System reported significantly higher national suicide rates (IRR = 1.18, 95% Confidence Interval [CI]: 1.13-1.24) and rural suicide rates (IRR = 1.29, 95% CI: 1.21-1.38) than the MOH-VR System. The CDC-DSP System also showed significant reversing points in 2011 (95% CI: 2006-2012) and 2006 (95% CI: 2006-2008) on the rural and urban suicide trends. Moreover, the suicide rates in the east and central urban regions were reversed in 2011 and 2008. CONCLUSIONS: The biased MOH-VR System underestimated China's national and rural suicide rates. Although not widely appreciated in the field of suicide research, the CDC-DSP System provides more accurate estimations on China's suicide rates and is recommended for future studies to monitor the reversing trends of suicide rates in China's more developed areas.

Engagement of vulnerable youths using internet platforms.

AIM: The aim of this study was to explore the online distress and help-seeking behavior of youths in Hong Kong. METHODS: A cross-sectional telephone-based survey was conducted among 1,010 young people in Hong Kong. Logistic regression analysis was then performed to identify the factors associated with those who reported expressing emotional distress online and the differences in help-seeking behavior among four groups of youths: (1) the non-distressed (reference) group; (2) "Did not seek help" group; (3) "Seek informal help" group; and (4) "Seek formal help" group. RESULTS: The seeking of help and expression of distress online were found to be associated with a higher lifetime prevalence of suicidal ideation. The "Seek formal help" and "Did not seek help" groups had a similar risk profile, including a higher prevalence of suicidal ideation, non-suicidal self-injury, unsafe sex, and being bullied. The "Seek informal help" group was more likely to express distress online, which indicates that this population of youths may be accessible to professional identification. Approximately 20% of the distressed youths surveyed had not sought help despite expressing their distress online. IMPLICATION: The study's results indicate that helping professionals have opportunities to develop strategic engagement methods that make use of social media to help distressed youths.

A Public Health Approach in Responding to the Spread of Helium Suicide in Hong Kong.

BACKGROUND: The use of the helium suicide method has been increasing in popularity in Hong Kong since 2012. We have learned a valuable lesson in curbing the spread of charcoal burning (CB) suicide in the past 15 years and hope to prevent the helium suicide method from taking off in the community. AIMS: To document what actions have been taken to contain the spread of the helium suicide method and review the preliminary impact of these actions. METHOD: We adopted a public health approach by engaging stakeholders from multiple sectors, including the police force, the fire services department, coroners, pathologists, mass media, and online media outlets. RESULTS: A monitoring system was established by compiling data extracted from news reports, coroners' reports, and police investigations. Risk and protective factors were identified. Intervention strategies were developed to strengthen protective factors and minimize risk factors. This novel suicide method has not spread as rapidly as the CB suicide method. The preliminary outcomes suggest our actions to be effective. LIMITATIONS: The count of helium suicides in 2015 might be low. The impacts of the interventions are only estimated and require additional empirical verifications. CONCLUSION: The public health approach of engaging multiple partners in the early phase of a potential epidemic can be a good guide to meeting the challenges posed by any new suicide methods that emerge in the future.

Decomposing change in China's suicide rate, 1990-2010: ageing and urbanisation.

OBJECTIVE: The study empirically quantifies the contributions of age composition and urbanisation to changes in the suicide rate in China over the periods 1990-2000 and 2000-2010. METHODS: A decompositional method was used to quantify the absolute and relative contributions of the age structure; the age-specific proportion of the urban population and the suicide rate of each age-specific, gender-specific and urban/rural cohort to the overall suicide rates in the two 10-year intervals. RESULTS: In the period between 1990 and 2000, a significant decline in the suicide rate among younger age groups (especially young rural women) was identified as the main driving force of the downward trend in the overall suicide rate. In 2000-2010, the rate of decline in suicide was predominantly explained by the drop in the suicide rate among all age groups in rural areas, with the exception of those aged over 80. The positive impact of urbanisation on the decline of the suicide rate has gradually diminished relative to the earlier period. CONCLUSION: As the positive impact of urbanisation on suicide rates is diminishing, further urbanisation and rapid change in society may induce stress and adjustment problems that are not conducive to the promotion of well-being. Furthermore, as China is facing the prospects of slower economic growth and a rapidly ageing population, suicides among older adults may also be elevated, particularly among those in rural areas with insufficient healthcare and social support. In order to maintain the decreasing trend of suicide in China, it is important for the Chinese government to pay more attention to the mental well-being of the population and to mitigate the stress of urban life and to provide timely support to older adults especially in rural areas.

A Pilot Study on the Efficacy of Volunteer Mentorship for Young Adults With Self-Harm Behaviors Using a Quasi-Experimental Design.

BACKGROUND: Studies have shown that postdischarge care for self-harm patients is effective in reducing repeated suicidal behaviors. Little is known about whether volunteer support can help reduce self-harm repetition and improve psychosocial well-being. AIM: This study investigated the efficacy of volunteer support in preventing repetition of self-harm. METHOD: This study used a quasi-experimental design by assigning self-harm patients admitted to the emergency departments to an intervention group with volunteer support and treatment as usual (TAU) for 9 months and to a control group of TAU. Outcome measures include repetition of self-harm, suicidal ideation, hopelessness, and level of depressive and anxiety symptoms. RESULTS: A total of 74 cases were recruited (38 participants; 36 controls). There were no significant differences in age, gender, and clinical condition between the two groups at the baseline. The intervention group showed significant improvements in hopelessness and depressive symptoms. However, the number of cases of suicide ideation and of repetition of self-harm episodes was similar for both groups at the postintervention period. CONCLUSION: Postdischarge care provided by volunteers showed significant improvement in hopelessness and depression. Volunteers have been commonly involved in suicide prevention services. Further research using rigorous methods is recommended for improving service quality in the long term.

The Effectiveness and Sustainability of a Universal School-Based Programme for Preventing Depression in Chinese Adolescents: A Follow-Up Study Using Quasi-Experimental Design.

BACKGROUND: A pilot study about the effectiveness of a universal school-based programme, "The Little Prince is Depressed", for preventing depression in Chinese adolescents in Hong Kong was conducted and reported previously. This study used a larger sample to examine the effectiveness and sustainability of the programme. METHODS: This study used quasi-experimental design. Twelve schools enrolled in "The Little Prince is Depressed" programme either as an intervention or a control condition. The intervention schools carried out the 12-session programme in two phases: the professional-led first phase and the teacher-led second phase. All participants were required to complete a questionnaire at three time points measuring their (1) depressive, anxiety, and stress levels; (2) knowledge of mental health; (3) attitudes towards mental illness; (4) perceived social support; and (5) help-seeking behaviours. RESULTS: A total of 3,391 students participated in the study. The level of depressive symptoms did not reduce significantly at post-intervention; however, a delayed effect was observed at follow-up assessment for the participants of the teacher-led group in reducing anxiety and stress levels. Also, the knowledge of mental health and attitudes towards mental illness of the intervention-group participants significantly improved at post-test, and the outcomes were maintained at 4 to 5 months after the intervention in both the professional-led and the teacher-led conditions (p<.05). A preference among schoolchildren for whom to seek help from was identified. CONCLUSIONS: The universal depression prevention programme was effective in enhancing knowledge of mental health and promoting a more positive attitude towards mental illness among adolescents in Hong Kong. In particular, the teacher-led group showed better outcomes than the professional-led group in reducing students' anxiety and stress at follow-up period. The programme can achieve sustainability in schools if teachers are provided with adequate support.

Health and psychosocial service use among suicides without psychiatric illness.

Although mental illness is a major suicide risk factor, some cases of suicide list no symptoms of mental disorder at the time of death. Studying suicides without psychiatric illness has important implications for social work because this group's service needs seem to have been overlooked. The authors of this article conducted a psychological autopsy study of 150 people who committed suicide and 150 age- and gender-matched living controls. Suicides without psychiatric illness showed similar detectable psychopathology as the suicide and living control groups with nonpsychotic psychiatric disorders. Though suicides without psychiatric disorders showed fewer warning signs that could be noticed by their informants, they experienced more negative life events than living controls. The suicide cases without psychiatric illness also seemed to be less protected by enabling factors (such as social support and employment) than living controls with and without psychiatric disorders. Furthermore, they had lower use of services than the control and deceased-with-diagnosis groups. With fewer at-risk signs and poorer enabling resources, they were undetected or unengaged by the existing physical, psychiatric, and psychosocial services. This group should be of concern to social workers, who may develop community-based health education programs and preventive services to meet this vulnerable population's psychosocial needs.