Factors influencing mental health service delivery during public health emergencies: a scoping review protocol.

Background: Unforeseeable public health emergencies (PHEs) profoundly impact psychological well-being and disrupt mental health care provision in affected regions. To enhance preparedness for future emergencies, it is crucial to understand the effectiveness of mental health services, their underlying mechanisms, the populations they are tailored to, and their appropriateness across distinct emergencies. The aim of this scoping review will be to explore how mental health services have responded to PHEs, focusing on their effectiveness as well as barriers and facilitators to implementation. Methods: Following the five-stage Arksey-O'Malley guidance, as updated further by Westphaln and colleagues, this mixed-methods scoping review will search academic and grey literature. Publications related to mental health interventions and supports delivered during PHEs will be considered for inclusion. The interventions and supports are operationally defined as any adaptations to mental health service provision at the international, national, regional or community level as a consequence of PHEs. The "Four Ss" framework will be utilised to provide structure for the evidence synthesis and inform categorisation of interventions and supports delivered during PHEs. Any research methodology will be considered for inclusion. Two reviewers will independently screen titles, abstracts, and full texts of publications against eligibility criteria. The gathered data will be depicted in accordance with the Four Ss" framework through the utilisation of descriptive/analytical statistics and supplemented by narrative exploration of findings. Conclusions: Considering the diverse research methodologies and the varied applicability of services in different contexts of PHEs, this review will offer insights into the type, effectiveness, and implementation barriers and facilitators of mental health interventions and supports delivered during PHEs. By employing the "Four Ss" framework, the review will guide decision-making bodies in identifying effective and practical aspects of mental health system operations during emergencies.

Validation of the Malay version of the Patient Health Questionnaire-4 (PHQ-4) among Malaysian undergraduates.

The study's objective is to validate the Malay version of the Patient Health Questionnaire-4 (PHQ-4) among Malaysian undergraduates. A cross-sectional survey was distributed at three universities in Malaysia (N = 500; mean age = 21.66 ± 1.57). The internal consistency of the Malay PHQ-4 was acceptable (α = .78, 95 % CI [.74, .81]), while the test-retest reliability was good (ICC = .77, 95 % CI [.34, .91], p < .001). The one-factor structure showed the best fit in confirmatory factor analysis and was similar across sexes. The Malay PHQ-4 has acceptable psychometric properties and can be used for pre-clinical screening purposes among Malaysian undergraduate students.

Implementation of Complex Suicide Prevention Interventions: Insights into Barriers, Facilitators and Lessons Learned.

INTRODUCTION: Effective suicide prevention interventions are infrequently translated into practice and policy. One way to bridge this gap is to understand the influence of theoretical determinants on intervention delivery, adoption, and sustainment and lessons learned. This study aimed to examine barriers, facilitators and lessons learned from implementing complex suicide prevention interventions across the world. METHODS AND MATERIALS: This study was a secondary analysis of a systematic review of complex suicide prevention interventions, following updated PRISMA guidelines. English published records and grey literature between 1990 and 2022 were searched on PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL. Related reports were organized into clusters. Data was extracted from clusters of reports on interventions and were mapped using the updated Consolidated Framework for Implementation Research. RESULTS: The most frequently-reported barriers were reported within the intervention setting and were related to the perceived appropriateness of interventions within settings; shared norms, beliefs; and maintaining formal and informal networks and connections. The most frequently reported facilitators concerned individuals' motivation, capability/capacity, and felt need. Lessons learned focused on the importance of tailoring the intervention, responding to contextual needs and the importance of community engagement throughout the process. CONCLUSION: This study emphasizes the importance of documenting and analyzing important influences on implementation. The complex interplay between the contextual determinants and implementation is discussed. These findings contribute to a better understanding of barriers and facilitators salient for implementation of complex suicide prevention interventions.

Online versus in-person gatekeeper suicide prevention training: comparison in a community sample.

BACKGROUND: Suicide prevention gatekeeper Training (GKT) is a frequently used suicide prevention intervention, however, there is still limited information about its long-term impact and effectiveness of online delivery. AIMS: The current study aimed to test the effectiveness of online GKT compared to in-person GKT in improving participant training outcomes. METHODS: A non-randomised comparison of pre-, post- and six-month follow-up data was conducted. In total 545 people participated in GKT, 317 in SafeTALK in-person sessions and 228 in online "Start" GKT by LivingWorks. Main outcome measures included: perceived knowledge; perceived preparedness; gatekeeper efficacy; and gatekeeper reluctance to intervene. RESULTS: Linear mixed model analysis demonstrated a significant effect for time for both modes of delivery for all four outcome measures. Post-hoc testing revealed that significant improvement in all outcomes were maintained above baseline at six-months following online and in-person training. CONCLUSIONS: Online training performed as good, or better than in-person GKT, on measured outcomes demonstrating utility and effectiveness of the modality for use in suicide prevention training practices. Findings additionally indicate that online training may reach participants that in-person programs do not. This study provides evidence that Online GKT has significant utility in addressing a crucial need for online alternatives to evidence-based suicide prevention training.

Pesticides and passion: a qualitative psychological autopsy study of suicide in Guyana.

Background: The suicide rate in Guyana has consistently ranked in the top ten globally, yet there is only limited literature related to the context in which these suicides occur. This study aims to better understand the psychosocial circumstances and characteristics of suicides in Guyana. Methods: This case series study utilised a qualitative psychological autopsy method. One to three informants per deceased person (N = 31) were interviewed regarding the lives of 20 Guyanese who died by suicide (14 M, 6 F, aged 10-74 years). Interpretative Phenomenological Analysis was utilised for the data. Findings: Four superordinate themes were identified: Interpersonal Conflict, Trauma, Health, and Unknown Reasons. Interpersonal conflict included subordinate themes of Domestic Abuse, Marital Separation, and Financial Disputes. Health included subordinate themes of Physical Health and Mental Health. Pesticide poisoning was the method used by Guyanese people whose suicide was triggered primarily by interpersonal conflict. Interpretation: The findings illustrate the complexities of suicide in Guyana and the importance of adopting a biopsychosocial perspective to suicide prevention. Suicide prevention should include mental health and suicide literacy training of medical professionals. It is recommended that the importation of highly toxic pesticides be restricted, and that less toxic substitutes be promoted. Convenience sampling, recall bias, and limited informants are limitations of this study. Future research should focus on suicidal behaviour using larger sample sizes. Funding: This research was supported by an Australian Government Research Training Program Scholarship through Griffith University Australia.

Effectiveness of suicide prevention gatekeeper training: 12-month follow-up of SafeTALK training to community members.

OBJECTIVE: Long-term assessments of gatekeeper training (GKT) with multiple follow-ups are rare. Therefore, the aim of the current analysis is to examine 12-month follow-up outcomes of SafeTALK training in addition to the earlier analysis of pre-, post-, and 6-month follow-up. METHOD: Two hundred and sixty two community volunteers participated in half-day (4-h) gatekeeper training sessions. Before, after, and 6- and 12-month follow-up surveys were used to assess participants' knowledge, efficacy, and reluctance to intervene. Linear mixed effects regression was used in statistical analysis. RESULTS: Fifty six participants (21.4%) completed the 12-month follow-up, representing an attrition rate of 78.6% from pre-test. Linear mixed model analysis revealed a significant, consistent effect for time for knowledge, efficacy, and reluctance. Post-hoc testing revealed significant differences between scores at pre-test and 12-month follow-up for GK knowledge and efficacy; however, no significant difference was seen between these time points for reluctance to intervene. No significant change was measured between the 6 and 12 months for any outcomes. GK knowledge and efficacy remained significantly above pre-test scores. CONCLUSION: The evaluation of the GKT demonstrated the long-term effectiveness of community-based suicide prevention training programs to improve and maintain GK knowledge and efficacy.

Validation of the Malay version of the Life Events Checklist for DSM-5 among Malaysian undergraduates.

This cross-sectional study aimed to validate the Life Events Checklist for DSM-5 (LEC-5) among Malaysian undergraduates (N = 500; mean age = 21.66 ± 1.57), of which 90.4% had ever experienced a lifetime traumatic event. Cronbach's alpha of .87 (95% CI [.86, .89]) and McDonald's omega of .89 (95% CI [.89, .93]) indicated good reliability. Confirmatory factor analysis based on a six-factor structure showed the best fit. The measurement invariance showed that the six-factor structure was similar across sexes. Therefore, the Malay LEC-5 is a valid and reliable instrument to screen for traumatic events among Malaysian undergraduates.

Lived experience perspectives guiding improvements to the Systematic Tailored Assessment for Responding to Suicidality protocol.

Background and aims: Suicide risk assessment protocols have traditionally been developed by clinical or research experts in suicidology, with little formal involvement of those with a lived experience of suicide. This study broadly aimed to seek lived experience perspectives of the Systematic Tailored Assessment for Responding to Suicidality (STARS) protocol A further aim was to elicit lived experience suggestions for wording and language used in the existing items within sections of the STARS protocol (STARS-p). Method: Participants were 33 adults (Female = 64%) with a lived experience of suicide, who attended a virtual research workshop at the National Lived Experience of Suicide Summit (2021). After being educated about STARS-p, participants provided their overall perceptions of STARS-p as well as suggestions for rewording and language use across the sections of STARS-p. Their responses were gathered using a virtual online platform for live electronic data collection. A three-phase process of qualitative content analysis was used, engaging both inductive and deductive approaches to explore study aims one and two, respectively. The Consolidated Criteria for Reporting Qualitative Research was followed to enhance quality of reporting. Results: Qualitative content analysis of participants' views of the STARS-p reflected three main categories, namely, STARS philosophy; What STARS aspires to; and Continuity of care and meeting needs. Responses characterized participants' perceptions of the core purpose of STARS-p and ways for refining or adapting it to suit diverse needs and settings. Based on deductive content analysis, suggested modifications to wording of items and additional items to extend sections were identified. Conclusion: The study yielded novel perspectives from those with a lived experience of suicide, which will inform improvements to the next edition of STARS-p. The STARS training (required for licensed use of the protocol) will be updated accordingly, in line with these results.

Active involvement of people with lived experience of suicide in suicide research: a Delphi consensus study.

BACKGROUND: The importance and value of involvement of people with lived experience of suicide has been recognized in suicide research and prevention. Nonetheless, clear guidance on research collaboration and co-production is lacking. This study aimed to address this gap by developing a set of guidelines on active involvement of people with lived experience of suicide in suicide studies., i.e., conducting research with or by people with lived experience, rather than to, about or for them. METHODS: The Delphi method was used to determine statements on best practice for the active involvement of people with lived experience of suicide in suicide research. Statements were compiled through a systematic search of the scientific and grey literature, and reviewing qualitative data from a recent related study conducted by the authors. Two expert panels: people with lived experience of suicide (n = 44) and suicide researchers (n = 29) rated statements over three rounds of an online survey. Statements endorsed by at least 80% of panellists of each panel were included in the guidelines. RESULTS: Panellists endorsed 96 out of 126 statements in 17 sections covering the full research cycle from deciding on the research question and securing funding, to conducting research and disseminating and implementing outcomes. Overall, there was a substantial level of agreement between the two panels regarding support from research institutions, collaboration and co-production, communication and shared decision making, conducting research, self-care, acknowledgment, and dissemination and implementation. However, panels also disagreed on specific statements regarding representativeness and diversity, managing expectations, time and budgeting, training, and self-disclosure. CONCLUSIONS: This study identified consensus recommendations on active involvement of people with lived experience of suicide in suicide research, including co-production. Support from research institutions and funders, and training on co-production for researchers and people with lived experience, are needed for successful implementation and uptake of the guidelines.

Utilisation and application of implementation science in complex suicide prevention interventions: A systematic review.

OBJECTIVES: Little is known about how complex, multilevel, and multicomponent suicide prevention interventions work in real life settings. Understanding the methods used to systematically adopt, deliver, and sustain these interventions could ensure that they have the best chance of unfolding their full effect. This systematic review aimed to examine the application and extent of utilisation of implementation science in understanding and evaluating complex suicide prevention interventions. METHODS: The review adhered to updated PRISMA guidelines and was prospectively registered with PROSPERO (CRD42021247950). PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL were searched. All English-language records (1990-2022) with suicide and/or self-harm as the primary aims or targets of intervention were eligible. A forward citation search and a reference search further bolstered the search strategy. Interventions were considered complex if they consisted of three or more components and were implemented across two or more levels of socio-ecology or levels of prevention. RESULTS: One hundred thirty-nine records describing 19 complex interventions were identified. In 13 interventions, use of implementation science approaches, primarily process evaluations, was explicitly stated. However, extent of utilisation of implementation science approaches was found to be inconsistent and incomprehensive. LIMITATIONS: The inclusion criteria, along with a narrow definition of complex interventions may have limited our findings. CONCLUSION: Understanding the implementation of complex interventions is crucial for unlocking key questions about theory-practice knowledge translation. Inconsistent reporting and inadequate understanding of implementation processes can lead to loss of critical, experiential knowledge related to what works to prevent suicide in real world settings.

Informing and Sustaining Participation of Lived Experience in the Suicide Prevention Workforce.

BACKGROUND: Currently, there is no comprehensive study focused on identifying what is needed to support ongoing participation within the suicide prevention lived experience workforce (LEW). It is unclear what specific factors may impede or support ongoing participation in the LEW. The aim of this study was to explore the experiences of suicide prevention LEW in terms of its sustainability. METHOD: A qualitative interview method was utilised, with a purposive sample of participants who had engaged in the LEW for at least 12 months. The sample comprised 13 individuals (nine females, four males) who engaged in multiple LEW roles, with over half (54%) working in the LEW for more than 5 years. Data were analysed using thematic analysis. RESULTS: Five main themes were identified: support, passion, personal impact, training, and work diversity. Each theme offers perspectives about the challenges participants face within the suicide prevention LEW. CONCLUSION: Challenges faced are both similar to those found in the broader MH sector and unique to suicide prevention. Findings suggest that managing expectations of the LEW is important and can inform the creation of guidelines for a supported and sustainable suicide prevention LEW.

Evaluating the Effectiveness of Components of National Suicide Prevention Strategies.

Background: National suicide prevention strategies support development of suicide prevention activities and their evaluation. Aims: To describe components included in national suicide prevention strategies and analyze the potential contribution of individual components to reduce suicide rates. Method: We conducted a narrative review and statistical analysis of national suicide prevention strategies. The narrative review was based on a framework of 12 components and included 29 countries (14 lower middle-income countries [LMICs] and 15 high-income countries [HICs]) with a national suicide prevention strategy. The statistical analyses covered suicide mortality data for 24 countries with a national strategy (9 LMICs and 15 HICs). Results: The number of components adopted in national strategies ranged from 4 to 11, and training and education were included in 96.5% of strategies. Estimated period effects for total suicide rates in individual countries ranged from a significant decrease in the yearly suicide rate (RR = 0.80; 95% CI 0.69-0.93) to a significant increase (RR = 1.12; 95% CI 1.05-1.19). There were no changes in suicide mortality associated with individual components of national strategies. Limitations: The limitations of existing suicide mortality data apply to our study. Conclusion: Further detailed evaluations will help identify the specific contribution of individual components to the impact national strategies. Until then, countries should be encouraged to implement and evaluate comprehensive national suicide prevention strategies.

Why Do We Agree to Disagree? Agreement and Reasons for Disagreement in Judgements of Intentional Self-Harm from Coroners and a Suicide Register in Queensland, Australia, from 2001 to 2015.

Suicides are likely to be underreported. In Australia, the National Coronial Information System (NCIS) provides information about suicide deaths reported to coroners. The NCIS represents the findings on the intent of the deceased as determined by coroners. We used the Queensland Suicide Register (QSR) to assess the direction, magnitude, and predictors of any differences in the reporting of suicide in Queensland. Therefore, we conducted a consecutive case series study to assess agreement and variation between linked data from the NCIS and QSR determinations of suicide for all suicide deaths (N = 9520) in the QSR from 2001 to 2015 recorded from routinely collected coronial data. The rate of concordance between the QSR and NCIS for cases of intentional self-harm was 92.7%. There was disagreement between the findings in the data, since 6.3% (n = 597) were considered as intentional self-harm in the QSR but not in the NCIS, and, less commonly, 0.9% (n = 87) were considered intentional self-harm in the NCIS but not in the QSR. Overall, the QSR reported 510 more suicides than the NCIS in 15 years. These findings indicate that using suicide mortality data from suicide registers may not underreport suicide as often.

Coping Styles Utilized during Suicide and Sudden Death Bereavement in the First Six Months.

Individuals bereaved by suicide experience substantial emotional distress and are at risk for poorer mental health, substance use concerns, and suicidal behaviors. This study aimed to explore whether those bereaved by suicide reported different coping styles compared to those bereaved by sudden death in the first six months. It also aimed to determine whether a previous mental health diagnosis (PMHD) and experiencing stigma and/or shame impacted the utilization of adaptive and maladaptive coping. The sample was constituted by individuals bereaved by suicide (n = 142) compared to those bereaved by sudden death (n = 63), six months after loss. The study included immediate family members who were 18 years or older and understood the English language. After controlling for demographics there were no significant differences in coping styles between bereavement types. Regardless of bereavement type, having a PMHD was associated with increased avoidant and problem-focused coping, and stigma and shame were each associated with increased avoidant coping. Women were also more likely to report using adaptive coping. Findings demonstrate no difference by bereavement type and have implications for the tailoring of grief/postvention supports that are sensitive to perceived stigma/shame to better facilitate utilization of adaptive emotion-focused coping, particularly for men and those with pre-existing mental health problems.

Suicide among transport industry workers: A systematic review and meta-analysis.

OBJECTIVES: Working in high-stress and male-dominated occupations is associated with an elevated risk of suicide. The current study sought to conduct the first systematic literature review and meta-analysis aimed at determining suicide risk across the diverse, high pressure and male-dominated transport industry (commercial aviation, merchant seafaring, transit/driving) as compared to the general/employed population. METHODS: Searches of PubMed/Medline, Scopus and PsycINFO databases were conducted without date restriction until March 2021. Studies were included if they were written in English, were peer reviewed, and presented primary observational research data. Studies referring exclusively to suicidal ideation, suicide attempts, self-harm, and/or accidents were excluded. RESULTS: Following deletion of duplicates and non-English titles, a total of 4201 titles/abstracts were screened and 92 full-texts were read against inclusion/exclusion criteria. The final included sample consisted of 23 articles (16 used for meta-analysis). Results from the meta-analysis indicated that transport workers had a significantly elevated risk for suicide as compared to the general/employed population. Results were consistent across sensitivity analyses, and there was some variation across subgroup analyses. CONCLUSIONS: Overall, we found transport workers had a significantly higher risk for suicide than the general/employed population, and this appeared to be driven by the association for those working in merchant seafaring/maritime occupations. The findings are discussed in relation to an identified need for the development, implementation, and evaluation of tailored workplace suicide prevention strategies for transport industry workers.

Long-Term Use and Application of Systematic Tailored Assessment for Responding to Suicidality (STARS) Protocol Following Original Training.

BACKGROUND: Understanding the use of Systematic Tailored Assessment for Responding to Suicidality protocol (STARS-p) in practice by trained mental health practitioners over the longer- term is critical to informing further developments. The study aim was to examine practitioners' experiences of STARS-p and factors associated with its use in practice over a 12-24-month period after training. METHOD: Practitioners who undertook the STARS-p training completed an online survey 12-24 months post training. The survey focused on the frequency of use of STARS-p (in full and each section) as well as perceptions about STARS-p applied in practice. Analyses included correlations, logistic regression and content analysis. RESULTS: 67 participants (81% female, Mage = 43.2, SD = 10.3) were included in the analyses. A total of 80.6% of participants had used the entire STARS-p at some time-point in their practice and less than half (44.7%) frequently used the entire STARS-p (all components in one administration). Parts A, B and C were used frequently in suicide risk assessment (SRA) by 84%, 71% and 82% of participants, respectively. Use of the entire protocol and different sections was most related to male gender, perceived ease of administration and confidence in the use of the protocol. Qualitative results revealed three main themes. CONCLUSIONS: STARS-p as a whole or its parts, is frequently used. Advantages of, and barriers to, using STARS-p in practice can inform further developments of STARS-p and STARS training.

Consumer Perspectives on the Use of Artificial Intelligence Technology and Automation in Crisis Support Services: Mixed Methods Study.

BACKGROUND: Emerging technologies, such as artificial intelligence (AI), have the potential to enhance service responsiveness and quality, improve reach to underserved groups, and help address the lack of workforce capacity in health and mental health care. However, little research has been conducted on the acceptability of AI, particularly in mental health and crisis support, and how this may inform the development of responsible and responsive innovation in the area. OBJECTIVE: This study aims to explore the level of support for the use of technology and automation, such as AI, in Lifeline's crisis support services in Australia; the likelihood of service use if technology and automation were implemented; the impact of demographic characteristics on the level of support and likelihood of service use; and reasons for not using Lifeline's crisis support services if technology and automation were implemented in the future. METHODS: A mixed methods study involving a computer-assisted telephone interview and a web-based survey was undertaken from 2019 to 2020 to explore expectations and anticipated outcomes of Lifeline's crisis support services in a nationally representative community sample (n=1300) and a Lifeline help-seeker sample (n=553). Participants were aged between 18 and 93 years. Quantitative descriptive analysis, binary logistic regression models, and qualitative thematic analysis were conducted to address the research objectives. RESULTS: One-third of the community and help-seeker participants did not support the collection of information about service users through technology and automation (ie, via AI), and approximately half of the participants reported that they would be less likely to use the service if automation was introduced. Significant demographic differences were observed between the community and help-seeker samples. Of the demographics, only older age predicted being less likely to endorse technology and automation to tailor Lifeline's crisis support service and use such services (odds ratio 1.48-1.66, 99% CI 1.03-2.38; P<.001 to P=.005). The most common reason for reluctance, reported by both samples, was that respondents wanted to speak to a real person, assuming that human counselors would be replaced by automated robots or machine services. CONCLUSIONS: Although Lifeline plans to always have a real person providing crisis support, help-seekers automatically fear this will not be the case if new technology and automation such as AI are introduced. Consequently, incorporating innovative use of technology to improve help-seeker outcomes in such services will require careful messaging and assurance that the human connection will continue.