Reducing suicides in mental healthcare: results from a 4-year follow-up implementation study in the Netherlands (SUPRANET).

Objective: In 2016, the SUicide PRevention Action NETwork (SUPRANET) was launched. The SUPRANET intervention aims at better implementing the suicide prevention guideline. An implementation study was developed to evaluate the impact of SUPRANET over time on three outcomes: 1) suicides, 2) registration of suicide attempts, and 3) professionals' knowledge and adherence to the guideline. Methods: This study included 13 institutions, and used an uncontrolled longitudinal prospective design, collecting biannual data on a 2-level structure (institutional and team level). Suicides and suicide attempts were extracted from data systems. Professionals' knowledge and adherence were measured using a self-report questionnaire. A three-step interrupted time series analysis (ITSA) was performed for the first two outcomes. Step 1 assessed whether institutions executed the SUPRANET intervention as intended. Step 2 examined if institutions complied with the four guideline recommendations. Based on steps 1 and 2, institutions were classified as below or above average and after that, included as moderators in step 3 to examine the effect of SUPRANET over time compared to the baseline. The third outcome was analyzed with a longitudinal multilevel regression analysis, and tested for moderation. Results: After institutions were labeled based on their efforts and investments made (below average vs above average), we found no statistically significant difference in suicides (standardized mortality ratio) between the two groups relative to the baseline. Institutions labeled as above average did register significantly more suicide attempts directly after the start of the intervention (78.8 per 100,000 patients, p<0.001, 95%CI=(51.3 per 100,000, 106.4 per 100,000)), and as the study progressed, they continued to report a significantly greater improvement in the number of registered attempts compared with institutions assigned as below average (8.7 per 100,000 patients per half year, p=0.004, 95%CI=(3.3 per 100,000, 14.1 per 100,000)). Professionals working at institutions that invested more in the SUPRANET activities adhered significantly better to the guideline over time (b=1.39, 95%CI=(0.12,2.65), p=0.032). Conclusion: Institutions labeled as above average registered significantly more suicide attempts and also better adhered to the guideline compared with institutions that had performed less well. Although no convincing intervention effect on suicides was found within the study period, we do think that this network is potentially able to reduce suicides. Continuous investments and fully implementing as many guideline recommendations as possible are essential to achieve the biggest drop in suicides.

The forever decision: a qualitative study among survivors of a suicide attempt.

Background: Suicide attempts have a profound emotional impact on both individuals and society as a whole. This qualitative study delves into three key aspects: 1) the progression through the suicidal process, 2) the influential factors facilitating the transition from ideation to attempt using the volitional moderators within the integrated motivational-volitional (IMV) model, and 3) preventive strategies impeding this transition from ideation to attempt. Methods: Between October 1, 2022 and March 7, 2023 we interviewed 27 adults (23 women, four men, mean age 33 years) who attempted suicide within the past 12 months. Participants were recruited through social media and in collaboration with several mental health institutions in the Netherlands. The participants were initially screened and interviewed based on the Pathway to Suicidal Actions Interview. Analysis was performed employing the constant comparative method. Findings: Despite the heterogeneity of the suicidal process, suicidal thoughts predominately emerged during adolescence (Mdn = 15, M = 17.8). In most participants, planning and preparatory actions occurred long before the attempt, with a median of six years prior to the attempt for the selection of the method. All volitional moderators were observed, although pain sensitivity in particular varied among participants. Access to lethal means and planning emerged as important moderators in the suicidal process. Asking the survivors what could have helped to prevent their attempts, most participants mentioned that they felt their suicidality was not taken seriously enough. Interpretation: We discussed the significance of planning in the suicidal process, challenges in conceptualizing planning and impulsivity, and individual differences in pain sensitivity. Based on the findings, we underscore the critical need for restricting access to means, giving greater consideration to preparatory actions within the suicidal process, and fostering open dialogues about suicidality. Funding: This research was funded by ProRail, the Dutch rail infrastructure manager in line with their work on mental health.

Sociodemographic and psychosocial risk factors of railway suicide a mixed-methods study combining data of all suicide decedents in the Netherlands with data from a psychosocial autopsy study.

BACKGROUND: Railway suicide has profound implications for the victims and their family, and affects train drivers, railway personnel, emergency services and witnesses. To inform a multilevel prevention strategy, more knowledge is required about psychosocial and precipitating risk factors of railway suicide. METHODS: Data from Statistics Netherlands of all suicides between 2017 and 2021 (n = 9.241) of whom 986 died by railway suicide and interview data from a psychosocial autopsy of railway suicide decedents (n = 39) were integrated. We performed logistic regression analyses to identify sociodemographic predictors of railway suicide compared to other methods of suicide. The Constant Comparative Method was subsequently employed on interview data from the psychosocial autopsy to identify patterns in psychosocial risk factors for railway suicide. RESULTS: The strongest predictors of railway suicide compared to other suicide methods were young age (< 30 years old), native Dutch, a high educational level, living in a multi-person household (especially living with parents or in an institution), living in a rural area and a high annual household income of > 150.000 euros. Several subgroups emerged in the psychosocial autopsy interviews, which specifically reflect populations at risk of railway suicide. These subgroups were [1] young adult males with autism spectrum disorder who strived for more autonomy and an independent life, [2] young adult females with persistent suicidal thoughts and behaviours, [3] middle-aged males with a persistent mood disorder who lived with family and who faced stressors proximal to the suicide in personal and professional settings, [4] male out-of-the-blue suicides and [5] persons with psychotic symptoms and a rapid deterioration. CONCLUSIONS: based on our findings we propose and discuss several recommendations to prevent railway suicide. We must continue to invest in a safe railway environment by training personnel and installing barriers. Additionally, we should adopt prevention strategies that align the needs of subgroups at increased risk, including young females who have attempted other methods of suicide and young males with autism spectrum disorder. Future research should determine the cost-effectiveness and feasibility of low-maintenance, automated interventions near crossings and psychiatric facilities.

The self-perceived needs of adolescents with suicidal behaviour: a scoping review.

Suicidal behaviour in adolescents is a major public health problem. Much research on this issue has focused on epidemiology and risk factors for suicidal behaviour, paying less attention to the self-perceived needs of adolescents. However, to increase engagement in suicide prevention, it is important to include the views of adolescents. A scoping review was performed to identify the available empirical study findings, of any study design, related to the self-perceived needs of adolescents with suicidal behaviour. The literature databases Medline, Embase, Psycinfo, CINAHL, ERIC, Scopus, and Web of Science were searched. Twenty-nine studies from 14 predominantly Anglo countries were included in the scoping review. The review showed that girls were overrepresented and that studies predominantly used qualitative approaches. The identified needs of adolescents with suicidal behaviour can broadly be grouped into needs related to the following areas: the importance of connecting with other people; adolescents' self-help strategies and personal growth after self-harm; mental healthcare; school or study programs; and needs related to society in relation to taboo on suicidal behaviour. Prevention of suicidal behaviour in adolescents will need to focus on development and strengthening of interventions fitting the needs of adolescents in these areas.

Guiding principles for the implementation of a standardized psychological autopsy to understand and prevent suicide: a stakeholder analysis.

Background: Around 700,000 people die by suicide each year. While the global number of suicides declined over the last decade, the rates remained unchanged in the Netherlands. With this study, we aimed to provide guiding principles for the implementation of a national standardized psychological autopsy to better understand and prevent suicide, by exploring stakeholder perceptions and needs, and barriers to implementation. Methods: We interviewed 47 representative stakeholders from various fields (e.g., mental healthcare professionals, policy advisors, researchers). A semi structured interview design was used, based on the RE-AIM and Consolidated Framework for Implementation Research (CFIR) theoretical frameworks. Results: Themes relating to stakeholder perceptions and needs for a standardized psychological autopsy included valorization, accountability, integrability and the needs of the bereaved. Stakeholders believed that participation in a psychological autopsy can help bereaved in their process of grief but noted that evidence to frame the psychological autopsy as postvention is insufficient. The primary focal point should accordingly be to better understand and prevent suicide. Several key limitations of the proposed psychological autopsy approach were detailed, both methodological and implementational. Conclusion: The stakeholder analysis delineates guiding principles for implementation. Stakeholders believe that a standardized psychological autopsy has merit, provided that key considerations, including valorization and accountability, are integrated in its design. Routine evaluation should be ensured. The findings may guide policy makers and researchers in their endeavors to support a learning, community-based approach for suicide prevention based on a standardized psychological autopsy.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis.

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Forecasting call and chat volumes at online helplines for mental health.

BACKGROUND: Each year, many help seekers in need contact health helplines for mental support. It is crucial that they receive support immediately, and that waiting times are minimal. In order to minimize delay, helplines must have adequate staffing levels, especially during peak hours. This has raised the need for means to predict the call and chat volumes ahead of time accurately. Motivated by this, in this paper, we analyze real-life data to develop models for accurately forecasting call volumes, for both phone and chat conversations for online mental health support. METHODS: This research was conducted on real call and chat data (adequately anonymized) provided by 113 Suicide Prevention (Over ons | 113 Zelfmoordpreventie) (throughout referred to as '113'), the online helpline for suicide prevention in the Netherlands. Chat and phone call data were analyzed to better understand the important factors that influence the call arrival process. These factors were then used as input to several Machine Learning (ML) models to forecast the number of call and chat arrivals. Next to that, senior counselors of the helpline completed a web-based questionnaire after each shift to assess their perception of the workload. RESULTS: This study has led to several remarkable and key insights. First, the most important factors that determine the call volumes for the helpline are the trend, and weekly and daily cyclic patterns (cycles), while monthly and yearly cycles were found to be non-significant predictors for the number of phone and chat conversations. Second, media events that were included in this study only have limited-and only short-term-impact on the call volumes. Third, so-called (S)ARIMA models are shown to lead to the most accurate prediction in the case of short-term forecasting, while simple linear models work best for long-term forecasting. Fourth, questionnaires filled in by senior counselors show that the experienced workload is mainly correlated to the number of chat conversations compared to phone calls. CONCLUSION: (S)ARIMA models can best be used to forecast the number of daily chats and phone calls with a MAPE of less than 10 in short-term forecasting. These models perform better than other models showing that the number of arrivals depends on historical data. These forecasts can be used as support for planning the number of counselors needed. Furthermore, the questionnaire data show that the workload experienced by senior counselors is more dependent on the number of chat arrivals and less on the number of available agents, showing the value of insight into the arrival process of conversations.

Nudging General Practitioners to explore suicidal thoughts among depressed patients.

BACKGROUND: While frank discussion of suicidal thoughts in patients with depression is important for the prevention of suicide, suicide exploration of General Practitioners (GPs) is suboptimal. This study aimed to assess whether an intervention that prompts pop-up screens nudges GPs to more frequently explore suicidal thoughts over the course of two years. METHODS: From January 2017 to December 2018, the intervention was incorporated in the information system of the Dutch general practice sentinel network. New registration of an episode of depression triggered a pop-up screen referring to a questionnaire about GPs' behaviour with regard to exploring suicidal thoughts. In two years, 625 questionnaires were completed by GPs and analysed using multilevel logistic regression analyses. RESULTS: Compared to the first year, GPs were 50% more likely to explore suicidal thoughts among patients in the second year (OR 1.48; 95%CI 1.01-2.16). When adjusting for patients' gender and age we found that the effect of the pop-up screens disappeared (OR 1.33; 95% CI 0.90-1.97). Suicide exploration occurred less frequently in women than in men (OR 0.64; 95% CI 0.43-0.98) and in older compared to younger patients (OR 0.97; 95% CI 0.96-0.98 per year older). In addition, 26% of variation in suicide exploration was because of differences in general practice. There was no evidence that general practices developed differently over time. CONCLUSIONS: Although low cost and easy to administer, the pop-up system was not effective in nudging GPs to explore suicidality more frequently. We encourage studies to test whether implementing these nudges as part of a multifaceted approach will lead to a stronger effect. Moreover, we recommend researchers to include more variables, such as work experience or previous mental health training, to better understand the effects of the intervention on GPs' behaviour.

Breaking Down Barriers to a Suicide Prevention Helpline: Protocol for a Web-Based Randomized Controlled Trial.

BACKGROUND: Globally, suicide is among the leading causes of death, with men being more at risk to die from suicide than women. Research suggests that people with suicidal ideation often struggle to find adequate help. Every month, around 4000 people fill in the anonymous self-test for suicidal thoughts on the website of the Dutch suicide prevention helpline. This self-test includes the Suicidal Ideation Attributes Scale (SIDAS), which educates users about the severity of their suicidal thoughts. The vast majority (70%) of people who complete the self-test score higher than the cutoff point (≥21) for severe suicidal thoughts. Unfortunately, despite this, less than 10% of test-takers navigate to the web page about contacting the helpline. OBJECTIVE: This protocol presents the design of a web-based randomized controlled trial that aims to reduce barriers to contacting the suicide prevention helpline. The aim of this study is 2-fold: (1) to measure the effectiveness of a brief barrier reduction intervention (BRI) provided in the self-test motivating people with severe suicidal thoughts to contact the Dutch suicide prevention helpline and (2) to specifically evaluate the effectiveness of the BRI in increasing service use by high-risk groups for suicide such as men and middle-aged people. METHODS: People visiting the self-test for suicidal thoughts on the website of the suicide prevention helpline will be asked to participate in a study to improve the self-test. Individuals with severe suicidal thoughts and little motivation to contact the helpline will be randomly allocated either to a brief BRI, in which they will receive a short tailored message based on their self-reported barrier to the helpline (n=388) or care as usual (general advisory text, n=388). The primary outcome measure is the use of a direct link to contact the helpline after receiving the intervention or control condition. Secondary outcomes are the self-reported likelihood of contacting the helpline (on a 5-point scale) and satisfaction with the self-test. In the BRI, participants receive tailored information to address underlying concerns and misconceptions of barriers to the helpline. A pilot study was conducted among current test-takers to identify these specific barriers. RESULTS: The pilot study (N=1083) revealed multiple barriers to contacting the helpline. The most prominent were the belief that a conversation with a counselor would not be effective, fear of the conversation itself, and emotional concerns about talking about suicidal thoughts. CONCLUSIONS: Our study will provide insight into the effectiveness of a brief BRI designed to increase the use of a suicide prevention helpline provided in a self-test on suicidal thoughts. If successful, this intervention has the potential to be a low-cost, easily scalable, and feasible method to increase service use for helplines across the world. TRIAL REGISTRATION: ClinicalTrials.gov NCT05458830; https://clinicaltrials.gov/ct2/show/NCT05458830. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/41078.

Social media use of adolescents who died by suicide: lessons from a psychological autopsy study.

BACKGROUND: while there are many benefits for young people to use social media, adverse effects such as cyberbullying, online challenges, social comparison and imitation may provoke and aggravate suicidal thoughts and behaviors. The influence of social media on mental health and suicidal thoughts and behaviours has been amply studied, but there is little empirical evidence for its potential role in adolescent suicides. The current study aimed to inform digital suicide prevention strategies by examining the meaning of social media in the lives of young suicide victims and elucidating the harmful and supportive effects of social media use on their wellbeing and distress. METHODS: data were analyzed from a psychological autopsy study of 35 adolescents who died by suicide in the Netherlands (43% of all adolescents who died by suicide in that year). These were 18 girls and 17 boys. All were under the age of twenty years, with an average of seventeen years. Interpretative Phenomenological Analysis was performed of 55 semi structured interviews with peers and parents of the decedents. RESULTS: young people benefitted from peer support and recovery stories. However, various themes were discussed relating to the harmful effects of social media, including dependency, triggers and imitation, challenges, cybervictimization and psychological entrapment. The themes of dependency and triggers and imitation were more salient in young females. A group of girls cultivated an online identity around their suicidal thoughts and behaviours. Next-of-kin, particularly parents, faced various challenges to talk to the adolescents about social media use, including technological illiteracy, online anonymity, and the youths' closedness. CONCLUSIONS: based on the findings, we recommend education to stimulate the digital literacy of parents, health workers and educators, supporting conscientious social media use in young people, and extending the prevention of cyberbullying. We encourage future research to examine how virtual social networks may sustain suicidal thoughts and behaviour, and to further investigate the effectiveness of digital interventions, like moderated peer support and the use of positive role models.

Identifying populations at ultra-high risk of suicide using a novel machine learning method.

BACKGROUND: Targeted interventions for suicide prevention rely on adequate identification of groups at elevated risk. Several risk factors for suicide are known, but little is known about the interactions between risk factors. Interactions between risk factors may aid in detecting more specific sub-populations at higher risk. METHODS: Here, we use a novel machine learning heuristic to detect sub-populations at ultra high-risk for suicide based on interacting risk factors. The data-driven and hypothesis-free model is applied to investigate data covering the entire population of the Netherlands. FINDINGS: We found three sub-populations with extremely high suicide rates (i.e. >50 suicides per 100,000 person years, compared to 12/100,000 in the general population), namely: (1) people on unfit for work benefits that were never married, (2) males on unfit for work benefits, and (3) those aged 55-69 who live alone, were never married and have a relatively low household income. Additionally, we found two sub-populations where the rate was higher than expected based on individual risk factors alone: widowed males, and people aged 25-39 with a low level of education. INTERPRETATION: Our model is effective at finding ultra-high risk groups which can be targeted using sub-population level interventions. Additionally, it is effective at identifying high-risk groups that would not be considered risk groups based on conventional risk factor analysis.

"I Don't Feel at Home in This World" Sexual and Gender Minority Emerging Adults' Self-Perceived Links Between Their Suicidal Thoughts and Sexual Orientation or Gender Identity.

OBJECTIVES: To examine whether sexual and gender minority (SGM) emerging adults perceived their SGM status was linked to suicidal ideation, and to explore if their responses fell within tenets of the minority stress framework. METHOD: Open text (survey) responses of Dutch and Flemish SGM emerging adults (n = 187) were thematically analysed using the constant comparative comparison method for qualitative analysis. RESULTS: We identified 8 themes in our qualitative analysis. Two themes fell within the scope of the minority stress framework that has received little attention: (1) concerns about relationships and family planning and (2) feeling different (internal stressor). Two additional themes emerged largely beyond the scope of existing minority stress framework studies on suicidality: (3) SGM-related questioning; (4) negativity in LGBT communities. Four established minority stress framework themes emerged: (5) gender identity stress; (6) victimization; (7) coming-out stress; (8) psychological difficulties linked to SGM status. CONCLUSION: Suicide prevention needs to focus on supporting SGM emerging adults who worry about feeling "different", or who have concerns over their romantic and family life, on reducing gender minority stress, as well as on caring for those who are victimized due to their sexual or gender identity.

The Impact of COVID-19 on the Suicide Prevention Helpline in The Netherlands.

Background: Although the number of suicides did not increase in 2020, there are concerns about the mental health consequences of the COVID-19 pandemic. Aims: To present the demand for the Dutch suicide prevention helpline during times of lockdown and to describe the coronavirus-related problems discussed. Methods: An observational and exploratory study analyzing the frequency of helpline requests and registration data (n = 893 conversations). Results: Demand for the helpline did increase, but with no distinctive relation with the lockdown measures. During the first lockdown, approximately a quarter of the analyzed helpline conversations were registered as coronavirus-related by the counselors. Most frequently mentioned conversation topics were the interruption to or changes in professional help, social isolation and loss of structure, and ways to find a distraction from suicidal thoughts/rumination. Limitations: Observational study design prevents causal inferences, and demand for the helpline is impacted by multiple factors. Conclusion: These coronavirus-related problems made help-seekers vulnerable to suicidal thoughts and a reduced desire to live. That many suffered from loneliness is concerning as this contributes to the risk of suicidal ideation. The distress among help-seekers due to the sudden loss of mental health care underscores the importance of maintaining contact with those in care and lowering the threshold for help.

The feasibility of using smartphone apps as treatment components for depressed suicidal outpatients.

Mental health smartphone apps could increase the safety and self-management of patients at risk of suicide, but it is still unclear whether it is feasible to integrate such apps into routine mental healthcare. This study reports on the feasibility of using a safety planning app (BackUp) and a self-monitoring app (mEMA) as components of the routine treatment of depressed outpatients with suicidal ideation. Clinicians were trained in working with both of the apps, and they invited their eligible patients with suicidal ideation for study participation. Patients used the apps for 3 months and discussed these with their clinician during treatment. Patients completed assessments at baseline (T0), 4 weeks (T1) and post-test (T2, 12 weeks after baseline). Both patients and clinicians also participated in telephone interviews. Feasibility was assessed in terms of usability (score > 70 on System Usability Scale, SUS), acceptability (score > 20 on Client Satisfaction Questionnaire-8, CSQ-8), and uptake (sufficient rates of component completion and app usage in treatment). The sample included 17 adult outpatients (52.9% male, age range 20-50 years) diagnosed with a depressive disorder and suicidal ideation at baseline. BackUp was rated by patients at above the cut-off scores for usability (SUS mean score at T1 75.63 and at T2 77.71) and acceptability (CSQ-8 mean score at T1 23.42 and at T2 23.50). mEMA was similarly rated (SUS mean score at T1 75.83 and at T2 76.25; CSQ-8 mean score at T1 23.92 and at T2 22.75). Telephone interviews with patients and clinicians confirmed the usability and acceptability. The uptake criteria were not met. Our findings suggest that mobile safety planning and mobile self-monitoring can be considered acceptable and usable as treatment components for depressed suicidal outpatients, but the integration of apps into routine treatment needs to be further explored.

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

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

Detecting changes in help seeker conversations on a suicide prevention helpline during the COVID- 19 pandemic: in-depth analysis using encoder representations from transformers.

BACKGROUND: Preventatives measures to combat the spread of COVID- 19 have introduced social isolation, loneliness and financial stress. This study aims to identify whether the COVID-19 pandemic is related to changes in suicide-related problems for help seekers on a suicide prevention helpline. METHODS: A retrospective cohort study was conducted using chat data from a suicide prevention helpline in the Netherlands. The natural language processing method BERTopic was used to detect common topics in messages from December 1, 2019 until June 1, 2020 (N = 8589). Relative topic occurrence was compared before and during the lock down starting on March 23, 2020. The observed changes in topic usage were likewise analyzed for male and female, younger and older help seekers and help seekers living alone. RESULTS: The topic of the COVID-19 pandemic saw an 808% increase in relative occurrence after the lockdown. Furthermore, the results show that help seeker increased mention of thanking the counsellor (+ 15%), and male and young help seekers were grateful for the conversation (+ 45% and + 32% respectively). Coping methods such as watching TV (- 21%) or listening to music (- 15%) saw a decreased mention. Plans for suicide (- 9%) and plans for suicide at a specific location (- 15%) also saw a decreased mention. However, plans for suicide were mentioned more frequently by help seekers over 30 years old (+ 11%) or who live alone and (+ 52%). Furthermore, male help seekers talked about contact with emergency care (+ 43%) and panic and anxiety (+ 24%) more often. Negative emotions (+ 22%) and lack of self-confidence (+ 15%) were mentioned more often by help seekers under 30, and help seekers over 30 saw an increased mention of substance abuse (+ 9%). CONCLUSION: While mentions of distraction, social interaction and plans for suicide decreased, expressions of gratefulness for the helpline increased, highlighting the importance of contact to help seekers during the lockdown. Help seekers under 30, male or who live alone, showed changes that negatively related to suicidality and should be monitored closely.

Identifying socio-demographic risk factors for suicide using data on an individual level.

BACKGROUND: Suicide is a complex issue. Due to the relative rarity of the event, studies into risk factors are regularly limited by sample size or biased samples. The aims of the study were to find risk factors for suicide that are robust to intercorrelation, and which were based on a large and unbiased sample. METHODS: Using a training set of 5854 suicides and 596,416 control cases, we fit a logistic regression model and then evaluate the performance on a test set of 1425 suicides and 594,893 control cases. The data used was micro-data of Statistics Netherlands (CBS) with data on each inhabitant of the Netherlands. RESULTS: Taking the effect of possible correlating risk factors into account, those with a higher risk for suicide are men, middle-aged people, people with low income, those living alone, the unemployed, and those with mental or physical health problems. People with a lower risk are the highly educated, those with a non-western immigration background, and those living with a partner. CONCLUSION: We confirmed previously known risk factors such as male gender, middle-age, and low income and found that they are risk factors that are robust to intercorrelation. We found that debt and urbanicity were mostly insignificant and found that the regional differences found in raw frequencies are mostly explained away after correction of correlating risk factors, indicating that these differences were primarily caused due to the differences in the demographic makeup of the regions. We found an AUC of 0.77, which is high for a model predicting suicide death and comparable to the performance of deep learning models but with the benefit of remaining explainable.

Additional Value of Peer Informants in Psychological Autopsy Studies of Youth Suicides.

In this study, we examined the feasibility and added value of including peer informants in a psychological autopsy study of youth suicides. Peer semi-structured interview data from 16 cases were analyzed qualitatively and compared to parent data. Results show that peers added information to parents' narratives in general and particularly on social relationships, bullying, school experiences, social media, and family relations. Peers also provided additional information on the presence of certain issues (such as social media contagion) as well as on the emotional impact from certain adverse events that seemed to have functioned as precipitating factors. We conclude that including peers in psychological autopsy studies of youth suicides is feasible and of added value but that more research is desirable. The results initially can be used in the design of psychological autopsies so that the maximum amount of information about each suicide will be learned.

The effect of local Suicide Prevention Action Networks (SUPRANET) on stigma, taboo and attitudes towards professional help-seeking: an exposure-response analysis.

PURPOSE: In 2017, the European Alliance against Depression (EAAD) programme was introduced in the Netherlands through the creation of six local Suicide Prevention Action Networks (SUPRANET Community). This programme consists of interventions on four levels: (1) a public awareness campaign, (2) training local gatekeepers, (3) targeting high-risk persons in the community and (4) training of primary care professionals. This study aims to gain insight into the effectiveness of the SUPRANET programme on attitudinal changes in the general public by studying the exposure-response relationship. METHODS: A repeated cross-sectional design, using general population surveys to measure key variables over time. The surveys were conducted in the six intervention regions (N = 2586) and in the Netherlands as a whole as a control region (N = 4187) and include questions on socio-demographic variables, brand awareness of the Dutch helpline, perceived taboo on suicide, attitudes towards depression and help-seeking. To examine the exposure-response relationship, regions were differentiated into 3 groups: low, medium and high exposure of the SUPRANET programme. RESULTS: The results revealed that respondents in the intervention regions considered professional help to be more valuable and were more likely to be familiar with the Dutch helpline than respondents in the control region. In the exposure-response analyses, the grading of effects was too small to reach statistical significance. CONCLUSION: Our study provides the first evidence for the effectiveness of the SUPRANET Community programme on creating attitudinal change in the general public.

Guidelines improve patient outcomes in specialised mental health care: A systematic review and meta-analysis.

OBJECTIVE: The uptake of evidence-based guideline recommendations appears to be challenging. In the midst of the discussion on how to overcome these barriers, the question of whether the use of guidelines leads to improved patient outcomes threatens to be overlooked. This study examined the effectiveness of evidence-based guidelines for all psychiatric disorders on patient health outcomes in specialist mental health care. All types of evidence-based guidelines, such as psychological and medication-focused guidelines, were eligible for inclusion. Provider performance was measured as a secondary outcome. Time to remission when treated with the guidelines was also examined. METHOD: Six databases were searched until 10 August 2020. Studies were selected, and data were extracted independently according to the PRISMA guidelines. Random effects meta-analyses were used to pool estimates across studies. Risk of bias was assessed according to the Cochrane Effective Practice and Organization of Care Review Group criteria. PROSPERO: CRD42020171311. RESULTS: The meta-analysis included 18 studies (N = 5380). Guidelines showed a positive significant effect size on the severity of psychopathological symptoms at the patient level when compared to treatment-as-usual (TAU) (d = 0.29, 95%-CI = (0.19, 0.40), p < 0.001). Removal of a potential outlier gave globally the same results with Cohen's d = 0.26. Time to remission was shorter in the guideline treatment compared with TAU (HR = 1.54, 95%-CI = (1.29, 1.84), p = 0.001, n = 3). CONCLUSIONS: Patients cared for with guideline-adherent treatments improve to a greater degree and more quickly than patients treated with TAU. Knowledge on the mechanisms of change during guideline-adherent treatment needs to be developed further such that we can provide the best possible treatment to patients in routine care.