Emergency department care experience of suicidal patients: A qualitative analysis of patients' perspectives.

INTRODUCTION: Individuals experiencing suicidal ideation or behavior frequently seek assistance at the emergency department (ED), yet the care they receive does not consistently align with their needs. This study explores the ED care experience of suicidal patients from their own perspective and offers recommendations to improve ED care for this population. METHOD: This qualitative study uses a descriptive interpretative design. Semi-structured interviews were conducted with 7 individuals who sought care in an ED due to suicidal ideation or behavior. Transcripts were analyzed using thematic analysis. FINDINGS: Participants' experiences were marked by an unsuited physical environment described as uncomfortable, noisy, and depressing. The organization of care was perceived as inadequate as patients complained about limited front-line access to mental health expertise, long waiting times, overworked staff, and inequities between patients with physical injuries and those with mental health concerns. Participants reported feelings of being trapped, left on their own and mistreated during their ED stay. Most found their care experience unhelpful or distressing, leaving them reluctant to reconsult. Specific recommendations based on patients' testimonials and literature are provided to enhance the ED care experience of suicidal patients. CONCLUSION: This study highlights several areas for improvement of the ED care experience of suicidal patients. Changes in current practices are needed to offer suicidal patients the satisfying care experience they deserve.

Validation of a French questionnaire assessing knowledge of suicide.

OBJECTIVES: The objective of this study was to develop and validate the Knowledge of Suicide Scale (KSS), elaborated to assess adherence to myths about suicide. METHODS: The KSS is a self-questionnaire including 22 statements relating to myths about suicide for which the respondent is asked to rate his degree of adherence on a scale ranging from 0 ("strongly disagree") to 10 ("completely agree"). Using the script concordance test scoring method, the respondents' scores were compared with those of experts to obtain, for each item, a score between 0 (maximum deviation with the experts) and 1 (minimum deviation with the experts). One thousand and thirty-five individuals (222 psychiatric interns, 332 medical interns in the first semester excluding psychiatry and 481 journalism students) were included. RESULTS: According to the exploratory factor analysis, the KSS is a two-dimensional scale: the first subscale includes 15 items and the second seven items. The tool showed excellent face validity, correct convergent and divergent validities (multi-method multi-feature analyzes), and good internal consistency (Cronbach's alpha coefficient between 0.66 and 0.83 for scales and subscales). The KSS is moderately and negatively correlated with the Stigma of Suicide Scale (r=-0.3). It significantly discriminates groups with different expected levels of knowledge regarding suicide (P<0.001). CONCLUSIONS: The KSS demonstrated good psychometric properties to measure adherence to myths about suicide. This tool could be useful in assessing the effectiveness of suicide prevention literacy improvement programs.

Social isolation and suicide risk: Literature review and perspectives.

BACKGROUND: Suicide is a major public health problem and a cause of premature mortality. With a view to prevention, a great deal of research has been devoted to the determinants of suicide, focusing mostly on individual risk factors, particularly depression. In addition to causes intrinsic to the individual, the social environment has also been widely studied, particularly social isolation. This paper examines the social dimension of suicide etiology through a review of the literature on the relationship between suicide and social isolation. METHODS: Medline searches via PubMed and PsycINFO were conducted. The keywords were "suicid*" AND "isolation." RESULTS: Of the 2,684 articles initially retrieved, 46 were included in the review. CONCLUSIONS: Supported by proven theoretical foundations, mainly those developed by E. Durkheim and T. Joiner, a large majority of the articles included endorse the idea of a causal relationship between social isolation and suicide, and conversely, a protective effect of social support against suicide. Moreover, the association between suicide and social isolation is subject to variations related to age, gender, psychopathology, and specific circumstances. The social etiology of suicide has implications for intervention and future research.

Comparing Childhood Characteristics of Adopted and Non-adopted Individuals Deceased by Suicide.

Objective: Across the globe more than 35,000 children a year are adopted by non-relatives, and some studies suggest that adopted individuals may be more vulnerable to developing mental disorders. To map the differences in suicide risk factors in adopted and non-adopted individuals, this study will compare the development of mental disorders as well as life events occurring before the age of 18 for both adopted and non-adopted individuals deceased by suicide. Methods: This study included 13 adopted and 26 non-adopted individuals deceased by suicide as well as 26 non-adopted living control individuals. Cases were taken from a data bank created over the last decade by researchers of [our institution] comprising a mixture of 700 suicide cases and living control individuals aged from 14 to 84. Adopted and non-adopted individuals deceased by suicide; adopted individuals deceased by suicide and non-adopted living control individuals were each compared on Axis I and II disorders, early life events, and burdens of adversity. Results: Results show significant differences, with a higher rate of Attention Deficit Hyperactivity Disorder, mental health comorbidity and Cluster C personality disorders among adopted individuals. Furthermore, adopted individuals have higher adversity scores prior to the age of 15. Conclusion: This study underlines the fact that adoptive families need to be supported throughout adoption. Health care professionals need specialized training on this matter, and the psychological challenges adopted individuals face need to be treated at the earliest juncture.

Suicide in French Polynesia: a retrospective analysis based on medicolegal documents and interview with family.

OBJECTIVE: To analyse the epidemiological data on suicide in French Polynesia (FP). METHODS: Data on suicides were collected from the Public Health Direction, Judicial Police Investigations Court of Justice records, the Centre d'Opérations et de Renseignements de la Gendarmerie, patient records for those hospitalized in psychiatry and from psychological autopsies. RESULTS: The dataset consisted of 316 suicide cases in FP over 25 years (1992-2016). In FP, suicide was more frequent in men (sex ratio 3.2:1), young people (mean age, 34.4 years) and individuals with previously diagnosed psychiatric disorders (100 of 316; 31.6%) The most common method of suicide was hanging (276 of 316; 87.3%). A history of previous suicide attempts was found in 25 of 56 (44.6%) of suicide cases, when documented. The most common potential triggering factors for suicide were emotional problems. The suicide rates have remained stable during 1992-2016 (mean 10.6/100 000 inhabitants per year), with periods of economic crises increasing suicide rates. CONCLUSIONS: These results provide valuable information to enable the effective targeting of suicide prevention strategies toward those at high risk. Economic crises had larger impacts in the French overseas territories than mainland France. Given the unprecedented economic impact of the Covid-19 pandemic in FP, there is an urgent need to implement suicide epidemiological surveillance and prevention programmes.

Adversity Over the Life Course: A Comparison Between Women and Men Who Died by Suicide.

Purpose: This study sets out to compare the presence of life events across different domains throughout the life course which may contribute to the burden of adversity experienced differently among men and women who died by suicide. Method: In a sample of 303 individuals (213 men and 90 women), data was derived from extensive clinical interviews conducted with informants. Models allowed the identification of patterns of life trajectories. Results: Overall, the burden of adversity was similar across the life course except for the 5-9, 25-29, and 30-34 age ranges, where a significant difference appeared between genders [t-test = 2.13 (p < 0.05), 2.16 (p < 0.05) and 3.08 (p < 0.005), respectively] that seems to disadvantage women. The early adversities of violence and neglect, between 0 and 19 years old, are important for both groups. During the life course, women were more exposed to interpersonal adverse events such as being victims of negligence and violence, relational difficulties or abuse from their spouse, as well as tension with their own children. Men encountered more academic difficulties, legal entanglements and financial difficulties, and were more than three times more likely to develop an alcohol/drug abuse problem than women. Conclusions: The data suggests some gender differences in exposure to longstanding and severe life problems contributing to suicide vulnerability. For women, the continuing burden emerges from chronic interpersonal adversities, whereas, for men, the adverse events are to a larger degree socially exposed, compounded with alcohol misuse. The adversities, especially those of a public or social nature, may be witnessed by others, which should favor the detection of vulnerability over the life course, and psychosocial or mental health services should be offered and provided earlier during the life course. Yet more men die by suicide than women. Resiliency and protective factors may benefit women to a greater degree. Future research should tackle the challenge of investigating these important elements. Meanwhile, from a public health perspective, access to psychosocial and mental health services and social acceptability of seeking services should be part of an ongoing effort in all institutional structures as a way of decreasing downstream mental health problems and vulnerability to suicide.

Everyday ethics of suicide care: Survey of mental health care providers' perspectives and support needs.

Suicide occurs in people of all ages and backgrounds, which negatively affects families, communities, and the health care providers (HCPs) who care for them. The objective of this study was to better understand HCPs' perspectives of everyday ethical issues related to caring for suicidal patients, and their perceived needs for training and/or support to address these issues. We conducted a mixed methods survey among HCPs working in mental health in Québec, Canada. Survey questions addressed their perspectives and experiences of everyday ethical challenges they encounter in their practice with people who are suicidal, and their perceived needs for training and/or support therein. 477 HCPs completed the survey. Most participants mentioned encountering ethical issues when caring for people who are suicidal. The challenges HCPs encounter in their practice with people who are suicidal are numerous, including issues related to maintaining privacy, confidentiality, freedom and the therapeutic relationship. The lack of time, resources and professional support to address these issues was emphasized. Most HCPs reported that the training or education they have received does not allow them to address everyday ethical issues related to suicide care. In sum, there is a clear reported need for better training and support for HCPs who are offering care to people who are suicidal in relation to everyday ethical issues they encounter. Implications for practice include providing greater access to training, including access to specialists in ethics to address specific issues. This additional support could alleviate morally distressing situations for HCPs.

Suicides in Nunavik: a life course study.

This study reports results of a life course study conducted with Inuit in Nunavik to obtain information on the life adversities and cumulative burden of adversity for three groups: those who died by suicide, those who attempted suicide, and those who experienced suicidal ideation but never attempted. The study involved different levels of collaboration between health authorities, front-line health workers and the research team. Results indicate that substance misuse and relational difficulties are most associated with the burden of adversity for those people who died by suicide, while bullying is most associated with the burden of adversity for those people who have made suicide attempts and those who have never made a suicide attempt. Specifically targeting parent-child relations, substance misuse, and bullying may be an important upstream strategy for reducing future suicidality in Nunavik.

The Role of Adolescence in Development Paths Toward Suicide: Specificities and Shaping of Adversity Trajectories.

Purpose: Adolescence is a key period of transitions in the psychological, cognitive, neurobiological and relational domains, which is associated to high susceptibility to adverse life experiences. However, the way adolescent development alters life paths toward suicide remains unclear. Thereby, we aimed at testing whether and how adolescence interfered with the adversity trajectories of individuals who died by suicide. Methods: In a sample of 303 individuals who died by suicide, longitudinal Burden of Adversity ratings were derived from extensive psychological autopsies and life trajectory narrative interviews conducted with informants. Piecewise Joint Latent Class Models allowed the identification of patterns of adversity trajectories and tested the introduction of breakpoints in life-paths. Classes inferred from the optimal model were compared in terms of socio-demographics, psychopathology, and rate of different adverse life events. Results: The most accurate model derived 2 trajectory patterns with a breakpoint in early adolescence. In the first class (n = 39), the burden of adversity increased steadily from birth to death, which occurred at 23 (SE = 1.29). In the second class (n = 264), where individuals died at 43 years of age (SE = 0.96), the burden of adversity followed a similar trajectory during infancy but stabilized between 10 and 14 years and started to increase again at about 25. Childhood family instability, dependent events, exposure to suicide, intra-family sexual victimization and affective disorders at death were more frequent in class 1. Conclusions: A bifurcation in trajectories between early and late suicides occurs during adolescence. The dynamic pattern of adversity during this period is a key issue to understand the developmental heterogeneity in suicide risk.

Being pro-active in meeting the needs of suicide-bereaved survivors: results from a systematic audit in Montréal.

BACKGROUND: Suicide is a major public health concern. In 2017, the suicide rate in Canada was 11 per 100,000 inhabitants. According to literature, 1 in 5 people have experienced a death by suicide during their lifetime. The aim of this study was to describe the met and unmet needs of suicide-bereaved survivors and to provide postvention recommendations. METHODS: Further to an exploratory mixed-method audit of 39 suicides that occurred in Montreal (Canada) in 2016, suicide-bereaved survivors (n = 29) participated in semi-structured interviews and completed instruments to discuss and assess potential pathological grief, depression (PHQ-9), and anxiety (GAD-7), as well as health and social services utilization. A panel then reviewed each case and provided recommendations. The mean age of participants was 57.7 years and 23 were women. RESULTS: Although help was offered initially, in most cases by a health professional or service provider (16/29), 22 survivors would have liked to be contacted by telephone in the first 2 months post suicide. Four categories of individual unmet needs (medical/pharmacological, information, support, and outreach) and one collective unmet need (suicide pre/postvention training and delivery) emerged. CONCLUSIONS: Although Quebec provincial services have been developed and offered to suicide-bereaved survivors in the past decade, many dwindled over time and none has been applied systematically. Recommendations for different stakeholders (Ministry of Health and Social Services, coroners, NGOs, and representatives of suicide-bereaved survivors) outlined in this study could be an interesting first step to help develop a suicide pre/postvention strategy.

Supportive effect of body contact care with ylang ylang aromatherapy and mobile intervention team for suicide prevention: A pilot study.

OBJECTIVES: To assess understudied, alternative suicide prevention modalities in a mental health care setting. METHODS: This was a prospective study of patients (n = 140, 68 cases and 72 controls) who were admitted to hospital or who contacted an SOS suicide crisis line for suicidal ideation or attempts. Psychiatric diagnoses (Mini-International Neuropsychiatric Interview) and intensity of anxiety/depression/suicidality (Hamilton Anxiety Rating Scale, Montgomery-Åsberg Depression Rating Scale, and Beck Scale for Suicidal Ideation) were assessed. All intervention group subjects received a crisis card with a crisis line number, interviews with psychologists or volunteers and a telephone call on days 10 to 21, then 6 months later. These subjects also had a choice between two further 4-month interventions: body contact care or mobile intervention team visits. RESULTS: The interventions significantly reduced the number of suicide attempts and suicide (3%) at 6 months compared with the control condition (12%). There were fewer losses to follow-up in the intervention group (7.35%) than in the control group (9.72%). CONCLUSIONS: The results favour the implementation of integrated care and maintaining contact in suicide prevention.

Suicide amongst the Inuit of Nunavut: An Exploration of Life Trajectories.

This article reports results of the life trajectories from 92 Inuit who died by suicide, matched for age and gender with 92 living-controls. A proxy-based procedure and semi-structured interviews with informants were conducted to obtain trajectories of developmental events occurring over the life course for suicide and community-matched controls. Results from this research indicate two different trajectories that differentiate the control-group from the suicide-group throughout the life course. Even though the number of suicide attempts are similar between both groups, the suicide-group had a more important burden of adversity, which seemed to create a cascading effect, leading to suicide.

Differences and similarities in instant countertransference towards patients with suicidal ideation and personality disorders.

BACKGROUND: Previous findings showed that suicidal patients elicit mostly negative countertransference such as distress, hopelessness, feelings of inadequacy, and apprehension, and that a concurrent personality disorder is associated with more feelings of entrapment and mistreatment, among other adverse reactions. No studies were however conducted on instant countertransference (iCT), i.e., after a single encounter, for example in an emergency setting. We aimed to evaluate the impact of suicidal ideations, self-harm and presence of personality disorders on instant Countertransference (iCT). METHODS: Caregivers rated their iCT with two validated and standardized questionnaires after a first emergency or outpatient consultation. Suicidal ideation, self-harm and personality disorders were tested as predictors for iCT in a multivariate and multilevel analysis. RESULTS: Thirty caregivers rated their iCT towards 321 patients. Personality disorders and suicidal ideation, but neither recent nor past history of self-harm, predicted iCT. Common iCT included tension, lack of self-confidence and feeling of being tied. iCT specifically associated with suicidal ideation included distress, lack of hope, confusion, and sense that the patient's life had little worth. In contrast, iCT towards patients with personality disorders suggested tension in the therapeutic relationship (low affiliation with patient, anger, disappointment, devaluation). LIMITATIONS: Caregiver's characteristics were not considered in the analysis. Furthermore, while countertransference also includes unconscious phenomena, only conscious iCT was assessed. CONCLUSIONS: Patients with suicidal ideation and personality disorders elicit common but also specific negative iCT. Mental health institutions need to devote specific resources (such as clinical supervision and training) to help caregivers manage their iCT.

Are school difficulties an early sign for mental disorder diagnosis and suicide prevention? A comparative study of individuals who died by suicide and control group.

BACKGROUND: Suicide is the third leading cause of death worldwide among youth aged 10- to 19, and mental disorders are often associated in the etiology of suicidal behavior. Mental disorders are often under-diagnosed and under-treated in young people, a situation likely to increase the severity of the disorder and suicide risk. Presence of school difficulties may, in some cases, be a consequence of mental disorder, and theses difficulties are observable. Therefore, early detection and early intervention of school difficulties may alleviate the development of mental disorders and suicide vulnerability. The aim of this study is to understand the link between school difficulties and suicide risk. METHODS: We used the data bank gathered by the McGill Group on Suicide Studies over the past two decades through interviews with the relatives of individuals who died by suicide and with individuals from the community as a control group. We included data on common sociodemographic characteristics, life events and mental health characteristics identified before age 18, among individuals who died before the age of 35 or were interviewed before the age of 35. We identified 200 individuals who died by suicide and 97 living controls. We compared groups according to gender and characteristics. RESULTS: Within the total sample, 74% were male, 13% had met with academic failure, 18% had engaged in inappropriate behavior at school, and 18% presented combined school difficulties. Combined school difficulties (academic failure and inappropriate behavior) for both sexes and academic failure alone for males were associated with higher suicide risk before the age of 35. School difficulties generally began in early childhood and were linked to mental disorders/difficulties and substance abuse before age 18. CONCLUSIONS: This study underlines the importance for parents, teachers, and educators to identify children with school difficulties-academic failure and behavioral difficulties at school-as early as possible in order to be able to propose adapted interventions. Early identification and proper diagnosis may prevent chronicity of some disorders, accumulation of adverse events, and even suicide.

A Quantitative and Qualitative Study of Notes Left by Youth Who Died by Suicide in Quebec from 1895 to 1985.

The study of suicide notes and the evolution of their content could contribute to a better understanding of reasons conducive to suicide mortality and offer further prevention strategies. From 1895 to 1985, 706 coroner's inquests of individuals who died by suicide and were 20 years old or younger were found in the province of Quebec. Quantitative analysis compared those who left notes (n = 47) to those who did not leave notes (n = 659). Furthermore, notes were subjected to inductive thematic analysis. Sociodemographic characteristics of the deceased individuals did not change over time. Qualitative analysis revealed four superordinate themes: (1) last wishes, (2) to those I leave behind, (3) about me and how and why I did it, and (4) self-positioning in the world. Only the last theme evolved over the time period considered. Suicide notes shed light on the psychological state of the majority of young note leavers and suggest the persistent feelings of distress and entrapment before the suicide, which may be important factors for caregivers and family members to monitor.

Survey evidence of the decline in child abuse in younger Canadian cohorts.

Physical and sexual abuse in childhood is a worldwide phenomenon with potentially dramatic consequences of both a psychological and physical nature. Measures of primary prevention have been developed in some countries. In the USA, child protection services reports and research surveys indicate that child sexual abuse has been on the decline in recent decades. Results are less clear for physical and overall abuse. The aim of this study was to describe how childhood abuse has changed over the years in Canada through an analysis of the 2012 Canadian Community Health Survey: Mental Health Edition data. The sample comprised 22,775 respondents ages 20 and over who completed a child abuse questionnaire. Respondents born from 1983 to 1992 reported significantly less overall abuse, physical abuse, and sexual abuse than did older generations, with the exception of people born in 1942 or earlier. The decrease was observed among men and women and across all the regions of Canada.Conclusion: The results are encouraging in that they may have an impact on life expectancy, severity of various chronic disorders, and suicide in the population. They also support policies that have focused on improving the childhood environment in the 1990s. Results also underline the importance of using different kinds of data sources for evaluating child abuse. What is Known: • Physical and sexual abuse in childhood has been associated with lower life expectancy in connection with an array of chronic diseases, including mental disorders, and with suicide. • Measures of primary prevention have been developed in some countries, such as the USA and Canada. What is New: • Canadians born from 1983 to 1992 report significantly less overall abuse, physical abuse, and sexual abuse than older generations do. • These encouraging results support policies implemented in the 1990s focused on improving the childhood environment.

Leveraging the Web and Social Media to Promote Access to Care Among Suicidal Individuals.

After two decades of exponential development, the Internet has become an inseparable component of suicide prevention matters. More specifically, social media has turned out to be a privileged space for suicidal individuals to express their distress and seek support. Although this tendency carries with it specific risks and challenges, it creates unprecedented opportunities to face the challenges of help seeking and access to care. In this paper, we present the empirical, technological, and theoretical evidence supporting the implementation of a digitally augmented prevention policy that would increase its reach. Congruent to the clinical observations and theories on the help-seeking process, we argue that social media can help undertake three main functions of increasing proactivity to bring suffering Web users to care. The gateway function relates to the properties of social media interactions to leverage help-seeking barriers and enable ambivalent individuals to access the mental healthcare system. The communication outreach function aims to broadcast pro-help-seeking messages, while drawing on the functional structure of the social media network to increase its audience. The intervention outreach function consists in using machine learning algorithms to detect social media users with the highest risk of suicidal behaviors and give them a chance to overcome their dysfunctional reluctance to access help. We propose to combine these three functions into a single coherent operational model. This would involve the joint actions of a communication and intervention team on social networks, working in close collaboration with conventional mental health professionals, emergency service, and community resources.

Protective Factors in the Inuit Population of Nunavut: A Comparative Study of People Who Died by Suicide, People Who Attempted Suicide, and People Who Never Attempted Suicide.

Epidemiological data shows an alarming prevalence of suicide in Aboriginal populations around the world. In Canada, the highest rates are found in Inuit communities. In this article, we present the findings of a secondary analysis conducted with data previously collected as part of a larger study of psychological autopsies conducted in Nunavut, Canada. The objective of this secondary analysis was to identify protective factors in the Inuit population of Nunavut by comparing people who died by suicide, people from the general population who attempted suicide, and people from the general population who never attempted suicide. This case-control study included 90 participants, with 30 participants in each group who were paired by birth date, sex, and community. Content analysis was first conducted on the clinical vignettes from the initial study in order to codify the presence of protective variables. Then, inferential analyses were conducted to highlight differences between each group in regards to protection. Findings demonstrated that (a) people with no suicide attempt have more protective variables throughout their lifespan than people who died by suicide and those with suicide attempts within the environmental, social, and individual dimensions; (b) people with suicide attempts significantly differ from the two other groups in regards to the use of services; and (c) protective factors that stem from the environmental dimension show the greatest difference between the three groups, being significantly more present in the group with no suicide attempt. Considering these findings, interventions could focus on enhancing environmental stability in Inuit communities as a suicide prevention strategy.

[Addictions]. / Addictions.

This year, the actuality for addictions in this edition addresses four points. The disease model of addiction is criticized by the cognitive neurosciences which need to consider the agentivity of the persons. Regarding the societal actuality, clinical pharmacology review of cannabidiol presents an update on legal cannabis. The suicidality of excessive gamblers may be prevented specifically. Addiction and first psychotic episodes need an integrated care.

Cette année, l'actualité des addictions pour ce numéro concerne quatre points. Le modèle de la maladie de l'addiction est critiqué par les neurosciences cognitives qui demandent de reconnaître l'agentivité des personnes. Au vu de l'actualité sociétale, une revue pharmacologique clinique du cannabidiol vient mettre à jour nos connaissances sur le cannabis légal. La suicidalité des joueurs excessifs peut faire l'objet de prévention spécifique. L'addiction et le premier épisode psychotique nécessitent une prise en charge intégrée.