Suicide attempts in the absence of depression: Differences between broad cultural groups.

Suicide is one of the leading causes of death worldwide (WHO, 2021). Depression is a common precursor to suicide and suicidality; however, individuals' experience of depression and the meaning of suicide differs depending on one's cultural background (Colucci, 2013; Goodmann et al., 2021; Kleinman, 2004). The current study explores the relationship between suicide and depression among six broad cultural groups in a large sample (N = 17,015) of adults representing six broad cultural groups (Latin America, South Asia, former Soviet Bloc, Western English-speakers, Chinese, and Arab World). Participants were recruited to a multilingual depression and suicide screening study via Google Ads (Leykin et al., 2012; Gross et al., 2014). As expected, the presence of depression was associated with suicide attempts. However, cultural group moderated this association, with Chinese participants being most likely to report suicide attempts while screening negative for depression. Although depression remains an important predictor of suicidality, it appears that certain cultural groups may be at higher risk even when depression is not present. Clinicians should consider using culturally adapted assessments for depression and suicidality.

Self-harm behaviors and their intentions: a cross-cultural analysis.

BACKGROUND: Self-harm behaviors (performed with either lethal and non-lethal intentions) are common, especially among individuals suffering from mood disorders, and the reasons individuals self-harm vary both by person and by the type of behavior. Understanding these variations may help clinicians determine levels of risk more accurately. AIMS: To understand whether culture and gender are associated with the likelihood of engaging in specific self-harm behaviors and whether the intention (lethal, ambivalent, non-lethal) of these behaviors vary with culture and gender. METHODS: 2826 individuals took part in an international multilingual online depression/suicidality screening study and reported at least one instance of self-harm in the past year. Participants were grouped into six broad cultural categories (Latin America, South Asia, Russian, Western English, Chinese, Arab). RESULTS: 3-way (culture x gender x intent) interactions were observed for several self-harm behaviors (overdosing, self-burning, asphyxiating, poisoning, and jumping from heights), suggesting that individuals engage in each of these behaviors with different intentions depending on gender and culture. Cultures and genders likewise differed in the likelihood of engaging in several self-harm behaviors. CONCLUSIONS: Clinicians should consider culture and gender when assessing for suicide risk, as similar self-harming behaviors may reflect different intentions depending on an individual's culture and gender.

Discrepancies in suicide screenings: Results from an international study.

BACKGROUND: When screening for suicidality, clinicians usually ask questions in ascending order of severity. Clinicians often discontinue questioning after negative responses to the first question or questions, presuming that these individuals are unlikely to endorse any further suicidality. In this study, the accuracy of this presumption is evaluated in a large international sample. METHODS: Participants were 21,385 individuals reporting a suicide attempt in the past two weeks. Participants were recruited, primarily via Google Ads, to a quintilingual (English, Spanish, Chinese, Arabic, and Russian) multinational depression and suicide screening study. RESULTS: Examining three initial screening questions (i.e., thoughts of death, wanting to die, and thinking about committing suicide), 14.8 % (n = 3179) of participants denied one or more question, 3.96 % (n = 847) denied two, and 1.95 % (n = 416) denied all three questions. The proportions of individuals with discrepant responses differed between linguistic-geographical groups, with Chinese and South Asian groups being more likely to be discrepant across all questions (all ps < .001). LIMITATIONS: Suicidality was assessed using an internet-based self-report measure, and linguistic-geographical groups explored in this study are very broad, which may limit generalizability. CONCLUSIONS: Results suggest that prematurely discontinuing suicide screening may fail to capture some individuals who made a recent attempt, and that in some groups, this discrepancy may be more pronounced. Clinicians should assess all individuals as thoroughly as possible regardless of initial responses, inquire about other significant risk factors, and be culturally sensitive.

Establishment and psychometric characteristics of emotional words list for suicidal risk assessment in speech emotion recognition.

Background: Emotional disturbance is an important risk factor of suicidal behaviors. To ensure speech emotion recognition (SER), a novel technique to evaluate emotional characteristics of speech, precision in labeling emotional words is a prerequisite. Currently, a list of suicide-related emotional word is absent. The aims of this study were to establish an Emotional Words List for Suicidal Risk Assessment (EWLSRA) and test the reliability and validity of the list in a suicide-related SER task. Methods: Suicide-related emotion words were nominated and discussed by 10 suicide prevention professionals. Sixty-five tape-recordings of calls to a large psychological support hotline in China were selected to test psychometric characteristics of the EWLSRA. Results: The results shows that the EWLSRA consists of 11 emotion words which were highly associated with suicide risk scores and suicide attempts. Results of exploratory factor analysis support one-factor model of this list. The Fleiss' Kappa value of 0.42 indicated good inter-rater reliability of the list. In terms of criteria validities, indices of despair (Spearman ρ = 0.54, P < 0.001), sadness (ρ = 0.37, P = 0.006), helplessness (ρ = 0.45, P = 0.001), and numbness (ρ = 0.35, P = 0.009) were significantly associated with suicidal risk scores. The index of the emotional word of numbness in callers with suicide attempt during the 12-month follow-up was significantly higher than that in callers without suicide attempt during the follow-up (P = 0.049). Conclusion: This study demonstrated that the EWLSRA has adequate psychometric performance in identifying suicide-related emotional words of recording of hotline callers to a national wide suicide prevention line. This list can be useful for SER in future studies on suicide prevention.

Guidelines to Address Barriers in Clinical Training for Trainees with Sensory Disabilities.

Disability is an important facet of diversity. Although diversity in clinical training in health service psychology has improved considerably, training often neglects accessibility and inclusion for individuals with sensory disabilities. The limited research to date documents that trainees with sensory disabilities (TSD) report extensive barriers and are consistently under-represented in clinical settings. Further, few resources have been developed to guide accommodating TSD in clinical training. Accordingly, our goals in this article are two-fold: (1) to highlight the barriers in clinical training faced by TSD and (2) to provide recommendations for trainees, supervisors, clinical leadership, and directors of clinical training to improve accessibility and inclusion for TSD. We offer vignettes to illustrate barriers faced by TSD and suggest guidelines to improve access for TSD.

Mental health problems among hotline callers during the early stage of COVID-19 pandemic.

Background: The study aims to explore the mental health of the hotline callers during the COVID-19 pandemic in China. Methods: Callers (N = 10,490) from the Beijing Psychological Support Hotline from January 21st to June 30th in 2019 and 2020 were enrolled and divided into two groups (during (2020) and before (2019) COVID-19 pandemic). The severity of depressive symptoms, psychological distress, hopefulness, and suicidal ideation (SI) was assessed. Demographic characteristics and major concerns were also collected. Mann-Whitney U and chi-square test were used to compare the differences in mental health conditions and major concerns between two years and between different age groups. The multivariable logistic regression was used to explore whether mental health conditions were associated with pandemic and demographic factors. Results: Results from multivariable logistic regression analysis indicated that the change in suicidal ideation (OR = 1.52, 95% CI: 1.21-1.92) was significantly different across age groups. Callers during the pandemic reported a higher level of hopefulness (OR = 1.13, 95% CI [1.03-1.24]), a lower level of depressive symptoms (OR = 0.81, 95% CI [0.74-0.89]) and psychological distress (OR = 0.89, 95% CI [0.81-0.98]), and were less likely to report SI (OR = 0.69, 95% CI [0.61-0.77]) compared with callers before the pandemic. Conclusions: Compared with callers before the pandemic, hotline callers during the early stage of COVID-19 pandemic did not present significant mental health problems. Younger callers during the pandemic were more vulnerable for the presence of suicidal ideation. Hotline-based crisis interventions might provide specific psychological support to cope with troubles during the pandemic.

Comparison of Psycho-Social Factors Associated With Suicidal Ideation and Suicide Attempts Among People Living With HIV in Central West China.

Background: Previous studies have described the correlation of suicidal ideation (SI) or suicide attempts (SA) in people living with HIV (PLWH), whereas few studies compare the correlation between SI and SA in PLWH. Understanding specific risk factors for SI and SA among PLWH will help with developing tailored and effective suicide prevention strategies among this high-risk group. Methods: A cross-sectional study was conducted from December 2020 to April 2021 in Baoji municipality, Shaanxi Province. The PLWH registered with the Baoji Municipal Center for Disease Control and Prevention (CDC) were recruited and interviewed. Questionnaires and interviews for this study consisted of socio-demographic variables, mental health history, and psychosocial characteristics. The HIV-related clinical features were obtained from CDC medical records. The PLWH included were divided into three groups, i.e., those with a history of suicide attempts (SA group), those with suicidal ideation only (SI group), and those without any suicidal behavior (NSB group). Multinomial logistic regression was used for three-way comparisons among these three groups of PLWH. Results: In total, 995 PLWH were interviewed. The prevalence of probable depression, probable anxiety, SI, and SA in PLWH after being diagnosed as HIV+ was 18.6%, 13.5%, 26.7%, and 3.2%, respectively. Compared with the NSB group, the SI or SA groups were more likely to report probable depression [adjusted odds ratio (AOR) = 2.43, 4.44, respectively], probable anxiety (AOR = 2.80, 5.62, respectively), and high HIV-related stigma (AOR = 2.05, 2.65, respectively). The SI group was more likely to experience high HIV-related stress (AOR = 1.91) and lower quality of life (AOR = 0.56) than the NSB group. Social support and HIV-related clinical features were not associated with SI or SA in this sample. The SA group did not differ from the SI group on any of the psychosocial or HIV-related clinical features. Conclusions: Mental health problems are serious in community residents identified with having an HIV infection in a Central West China municipality. It is important to deliver low-cost and effective psychological services tailored for PLWH that are focused on reducing mental health problems. Future studies should utilize sensitive screening measures and further clarify factors potentially associated with the transition from SI to SA in PLWH.

Cultural adaptations of dialectical behavior therapy: A systematic review.

OBJECTIVE: Adapting mental health-care interventions to the race, ethnicity, or culture of the target group can enhance the acceptance and effectiveness of the treatment. Dialectical behavior therapy (DBT) is an evidence-based treatment that is principle-driven, rendering it well-suited for adaptations across cultural contexts. This article conducts a systematic review of the literature to determine the nature and extent of cultural adaptations of DBT to date. METHOD: We searched databases for original articles describing cultural adaptations of DBT, as applied to both (a) people of color within Western countries and (b) populations within non-Western countries. Consistent with the focus on descriptively characterizing extant DBT cultural adaptations, we included both published and nonpublished studies, as well as both observational and experimental studies. RESULTS: Our search yielded 18 articles that met inclusion criteria. Of these articles, half described adaptations made with people and communities of color within the U.S. Most adaptations involved modifications to language, metaphors, methods, and context. CONCLUSIONS: Culturally adapted DBT has been implemented and accepted among several racial, ethnic, and cultural groups, although there is insufficient evidence to determine whether culturally adapted DBT is more efficacious than nonadapted DBT. We conclude with recommendations for best practices for DBT researchers and clinicians, and situate our findings among larger efforts to render existing evidence-based psychotherapies more optimal for people of color and people from non-Western countries. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Comparisons of Characteristics Between Psychological Support Hotline Callers With and Without COVID-19 Related Psychological Problems in China.

Background: To compare the characteristics between hotline callers with and without the Coronavirus Disease 2019 (COVID-19) related psychological problems. Methods: From January 25 to March 31, 2020, 581 callers with COVID-19 related psychological problems (COVID-19 callers) and 695 callers without COVID-19 related psychological problems (non-COVID-19 callers) to the Beijing Psychological Support Hotline were recruited. The demographic characteristics, primary concerns, suicidal ideation, depression and other psychological problems were compared between the two groups of callers. Results: Both groups of the callers were predominantly female and highly educated. The primary concerns reported by the COVID-19 callers were depression (38.4%) and family relationship problems (26.0%). As compared to the non-COVID-19 callers, COVID-19 callers reported more financial (7.4%) and work related problems (4.1%), but revealed lower prevalence of suicidal ideation (47.9% v 71.3%), lower degrees of psychological distress (74.3 v 79.1), intensity of suicidal ideation (0 v 50), severity of depression (57.9 v 65.1), and higher degree of hopefulness (41.1 v 33.6) (all p values < 0.01). Additionally, a lower proportion of COVID-19 callers met the criteria of depressed mood (51.6% v 61.4%) and other 4 symptoms than the non-COVID-19 callers (p values < 0.01). Conclusions: Based on the content of the primary concerns and the relatively low level of depression of the COVID-19 callers, the psychological intervention for them during the pandemic should focus on "psychological supports." Coping strategies for daily life stressors and promotion of scientific knowledge about the pandemic should also be included in the hotline-related interventions.

Factor analysis of depression symptoms across five broad cultural groups.

INTRODUCTION: Core symptoms of depression are likely universal, however cultural groups differ in their experience of the condition. The purpose of this study was to examine differences and similarities of depression symptom groupings between broad cultural groups. METHOD: 6,982 adults took part in an online multilingual depression screening study, and completed an 18-item major depression screener. Participants were categorized into five broad cultural groups by language and country of residence: Spanish speakers from Latin America (n = 3,411); English speakers from Southeast Asia (n = 1,265); Russian speakers from the former Soviet bloc (n = 642); English speakers from English-speaking Western countries (n = 999); and Chinese speakers from China (n = 665). Principal components analysis with promax rotation was used. RESULTS: Both similarities and noteworthy differences in symptom clustering between groups were observed. For instance, though suicide-related items formed a separate cluster for most cultures, for the Latin-American group, worthlessness loaded with suicidality. Changes in appetite and changes in weight tended to load on different factors (except for Chinese and Russian groups). Hypersomnia tended to load with psychomotor agitation, and core depression symptoms tended to load with physical symptoms (except for the Russian group). LIMITATIONS: Depression was assessed by a self-report measure aligned to DSM-IV. CONCLUSION: The analysis contributes to a nuanced understanding of depression manifestations of various cultures, which may inform culturally sensitive clinical practice.

Trends in suicide rates and the case-fatality of pesticide self-poisoning in an agricultural county in china, 2009 to 2014.

BACKGROUND: Suicide rates in China have declined substantially in the last two decades, however, the correlates of the decreases are still unclear. METHODS: Using hospital-based suicidal acts registry system in Meixian county, we reviewed all episodes of suicidal behaviors presented at hospitals from 2009 to 2014. The data was combined with the suicides reported in the same period by the county's Center for Disease Prevention and Control. Stratified by gender and method, age-standardized incidences of suicide death, suicide attempts, suicidal acts, as well as the case-fatalities of suicidal acts, were calculated. Joinpoint regression analysis was applied to test the time trends changes of the annual incidences and case-fatalities. Correlation coefficients between suicide rates and case-fatality were estimated. RESULTS: Age-standardized suicide rates among females declined by 20.4% per year, meanwhile, overall suicide rates were characterized by downward trend without statistical significance. The annual proportions of suicide deaths by pesticide self-poisoning ranged from 57.1% to 82.6%. There were positive or marginally positive correlations between suicide rates and case-fatalities of suicidal acts in gender- and method-specific groups (r values range from 0.77 to 0.89). LIMITATIONS: Underreporting in the hospital-based registry system and misclassification in the death reporting system. Changes in other related factors are not yet accessible. CONCLUSION: Suicide rates in females declined prominently in Meixian from 2009 to 2014, even though overall suicide rates remained steady. Pesticide ingestion were most common suicide method. Restriction of pesticide and reduction in the case-fatality are critical targets of suicide prevention in rural China.

Longitudinal Association Between Smoking Abstinence and Depression Severity in Those With Baseline Current, Past, and No History of Major Depressive Episode in an International Online Tobacco Cessation Study.

INTRODUCTION: We use multilevel modeling to parse out the effects of time-varying smoking abstinence and baseline depression (history and severity) on depression severity over 1 year. AIMS AND METHODS: Participants were 1000 smokers recruited worldwide for an online randomized controlled tobacco cessation trial. We examined whether changes in depression severity over time were associated with self-reported 7-day point prevalence smoking status assessed at 1-, 3-, 6-, and 12-month follow-up (FU) using baseline major depressive episode (MDE) history and baseline depression severity as time-invariant covariates. We present depression severity means and smoking abstinence at each FU. RESULTS: Regardless of concurrent abstinence status, baseline MDE history was significantly related to depression severity over time: those reporting a past MDE had worse depressive symptoms over time compared with those reporting no MDE history. Baseline depression severity interacted significantly with time-varying abstinence status: for every 1-unit increase in baseline scores on the Center for Epidemiological Studies-Depression Scale (CES-D), individuals who were smoking at FU reported CES-D scores that were 0.17 points higher than those who were abstinent. In this context, nicotine dependence, gender, age, or marital status did not affect depression severity. CONCLUSIONS: In the context of cessation, having an MDE history plays a significant role in the trajectory of depression severity over the course of 1 year, regardless of abstinence status. Abstinence is related to lower depressive symptoms at each FU, and this effect was stronger at higher levels of baseline depression severity. IMPLICATIONS: This study indicates that depressive symptoms are not exacerbated among individuals who are quitting smoking at 1-, 3-, 6-, and 12-month FUs. Depression severity is worse with a baseline history of MDE. Further, those with high baseline depression severity who continue smoking have worse depressive symptoms throughout a 1-year period compared with their abstinent counterparts.

Children and adolescents attempting to participate in a worldwide online depression screener.

Depression rates are increasing among minors. Internet is central to the lives of many minors, and many of them look online for depression information. This report describes minors who attempted to screen themselves for depression in a worldwide online study. Google Ads were used to recruit individuals to a multilingual depression screening study that was meant to target and recruit adults. Of 158,170 individuals accessing the site, 30,396 (19.22%) were minors from 190 countries. Proportions of minors varied considerably between different cultures. Given youth's interest in depression information, online services to ethically and effectively address youth depression are needed.

Creating a Practice-Based Implementation Network: Facilitating Practice Change Across Health Care Systems.

A proof-of-concept practice-based implementation network was developed in the US Departments of Veteran Affairs (VA) and Defense to increase the speed of implementation of mental health practices, derive lessons learned prior to larger-scale implementation, and facilitate organizational learning. One hundred thirty-four clinicians in 18 VA clinics received brief training in the use of the PTSD checklist (PCL) in clinical care. Two implementation strategies, external facilitation and technical assistance, were used to encourage the use of outcomes data to inform treatment decisions and increase discussion of results with patients. There were mixed results for changes in the frequency of PCL administration, but consistent increases in clinician use of data and incorporation into the treatment process via discussion. Programs and clinicians were successfully recruited to participate in a 2-year initiative, suggesting the feasibility of using this organizational structure to facilitate the implementation of new practices in treatment systems.

Differences between medically treated and untreated non-fatal self-harm reported by hotline callers in China.

BACKGROUND: Many self-harmers do not present in hospitals due to the self-harm. It is still unclear on the differences between medically treated and untreated self-harm in China. This study described the differences of the two groups of self-harmers using the largest psychological aid hotline data. METHODS: The present observational study recruited 3,403 hotline callers who reported episodes of self-harm before the call. In routine assessment, information about the most recent episode of self-harm was collected, including the method of self-harm, the wish to die, goals of the self-harm, and any medical treatment (irrespective of psychological services) in the hospital. The callers were divided into two groups: those who received hospital-based medical treatment due to the most recent self-harm (treated self-harm callers) and those who did not (untreated self-harm callers). RESULTS: In the most recent episode of self-harm, 65% (n = 2,217) of callers were untreated and 55% (1,226/2,217) of the untreated self-harm callers reported a wish to die. A total of 67% of the callers reported that their main goal of self-harm was to relieve suffering. The most common self-harm methods were using instruments (knife or rope) and overdosing on medicines. Compared with treated self-harm callers, the untreated self-harm callers were less likely to have a wish to die (OR = 0.57), engage in self-harm outside the home (OR = 0.71 and 0.78), and attribute their self-harm to romantic relationship problems (OR = 0.76); however, they were more likely to use instruments, to jump, or to choose other methods (OR = 3.73, 3.83, and 7.71, respectively). CONCLUSIONS: Among hotline callers, many episodes of self-harm did not receive medical treatment, despite over half reporting a wish to die. Characteristics of self-harm behaviors were different between treated and untreated self-harm callers. Our findings suggest that more strategies should improve access to hospital-based medical treatment and coverage for post-intervention for self-harmers who are not presented in hospitals.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas.

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

Sexual orientation and treatment-seeking for depression in a multilingual worldwide sample.

BACKGROUND: Prior research has found higher rates of mental health problems among sexual minority individuals. We examine treatment-seeking for depression, as well as its relationship with sexual orientation, in a large, multilingual, international sample. METHOD: Participants in an automated, quintilingual internet-based depression screening tool were screened for depression, and completed several background measures, including sexual orientation (with an option to decline to state) and past and current depression treatment seeking. RESULTS: 3695 participants screened positive for current or past depression and responded to the sexual orientation question. Those who declined to state their sexual orientation were far less likely to seek any treatment than individuals endorsing any orientation; they were especially unlikely to seek psychotherapy. Individuals identifying as bisexual sought both psychotherapy and alternative treatments at a higher rate than other groups. An interaction was observed between sexual orientation and gender, such that lesbian women were especially likely to have used psychotherapy. Other variables that emerged as significant predictors of treatment-seeking for depression included age and participant's language. LIMITATIONS: Limitations include possible misinterpretation of translated terms due to regional differences, and possible limits to generalizability due to this study being conducted on the internet. CONCLUSIONS: Our results suggest that individuals who decline to state their sexual orientation may be more likely to forgo effective treatments for depression. Further studies of depression service utilization should focus on developing treatment modalities that could better engage sexual minority individuals, especially those who are reluctant to disclose their orientation.

Women's preferences and mode of delivery in public and private hospitals: a prospective cohort study.

BACKGROUND: Rates of caesarean section have steadily increased in most middle- and high-income countries over the last few decades without medical justification. Maternal request is one of the frequently cited non-medical factors contributing to this trend. The objectives of this study were to assess pregnant women's preferences regarding mode of delivery and to compare actual caesarean section rates in the public and private sectors. METHODS: A prospective cohort study was conducted in two public and three private hospitals in Buenos Aires, Argentina. 382 nulliparous pregnant women (183 from the private sector and 199 from the public sector) aged 18 to 35 years, with single pregnancies over 32 weeks of gestational age were enrolled during antenatal care visits between October 2010 and September 2011. We excluded women with pregnancies resulting from assisted fertility, women with known pre-existing major diseases or, with pregnancy complications, or with a medical indication of elective cesarean section. We used two different approaches to assess women's preferences: a survey using a tailored questionnaire, and a discrete choice experiment. RESULTS: Only 8 and 6% of the healthy nulliparous women in the public and private sectors, respectively, expressed a preference for caesarean section. Fear of pain and safety were the most frequently expressed reasons for preferring caesarean section. When reasons for delivery mode were assessed by a discrete choice experiment, women placed the most emphasis on sex after childbirth. Of women who expressed their preference for vaginal delivery, 34 and 40% ended their pregnancies by caesarean section in public and private hospitals, respectively. CONCLUSIONS: The preference for caesarean section is low among healthy nulliparous women in Buenos Aires. The reasons why these women had a rate of more than 35% caesarean sections are unlikely related to their preferences for mode of delivery.

Assessing suicide attempts and depression among Chinese speakers over the Internet.

BACKGROUND: In populations where mental health resources are scarce or unavailable, or where stigma prevents help-seeking, the Internet may be a way to identify and reach at-risk persons using self-report validated screening tools as well as to characterize individuals seeking health information online. AIMS: We examined the feasibility of delivering an Internet-based Chinese-language depression and suicide screener and described its users. METHOD: An Internet-based depression and suicide screener was created and advertised primarily through Google AdWords. Participants completed a suicide and depression screening measure and received individualized feedback, which, if necessary, included the suggestion to seek additional mental health resources. RESULTS: In 7 months, 11,631 individuals visited the site; 4,709 provided valid information. Nearly half reported a current major depressive episode (MDE) and 18.3% a recent suicide attempt; however, over 75% reported never having sought help, including 77.7% of those with MDEs and 75.9% of those reporting a suicide attempt. As participants found the site by searching for depression information online, results may not generalize to the entire Chinese-speaking population. CONCLUSION: Online screening can feasibly identify and reach many at-risk Chinese-speaking persons. It may provide resources to those with limited access to services or to those reluctant to seek such services.

Using Google AdWords for international multilingual recruitment to health research websites.

BACKGROUND: Google AdWords, the placement of sponsored links in Google search results, is a potent method of recruitment to Internet-based health studies and interventions. However, the performance of Google AdWords varies considerably depending on the language and the location of the target audience. OBJECTIVE: Our goal was to describe differences in AdWords performance when recruiting participants to the same study conducted in four languages and to determine whether AdWords campaigns can be optimized in order to increase recruitment while decreasing costs. METHODS: Google AdWords were used to recruit participants to the Mood Screener, a multilingual online depression screening tool available in English, Russian, Spanish, and Chinese. Two distinct recruitment periods are described: (1) "Unmanaged", a 6-month period in which ads were allowed to run using only the AdWords tool itself, with no human intervention, and (2) "Managed", a separate 7-week period during which we systematically sought to optimize our recruitment campaigns. RESULTS: During 6 months of unmanaged recruitment, our ads were shown over 1.3 million times, resulting in over 60,000 site visits. The average click-through rate (ratio of ads clicked to ads displayed) varied from 1.86% for Chinese ads to 8.48% for Russian ads, as did the average cost-per-click (from US $0.20 for Chinese ads to US $0.50 for English ads). Although Chinese speakers' click-through rate was lowest, their rate of consenting to participate was the highest, at 3.62%, with English speakers exhibiting the lowest consent rate (0.97%). The conversion cost (cost to recruit a consenting participant) varied from US $10.80 for Russian speakers to US $51.88 for English speakers. During the 7 weeks of "managed" recruitment, we attempted to improve AdWords' performance in regards to the consent rate and cost by systematically deleting underperforming ads and adjusting keywords. We were able to increase the number of people who consent after coming to the site by 91.8% while also decreasing per-consent cost by 23.3%. CONCLUSIONS: Our results illustrate the need to linguistically and culturally adapt Google AdWords campaigns and to manage them carefully to ensure the most cost-effective results.