Suicide Methods in Slovenia - Characteristics andTime Trends 2001-2020.

Background: Between 2001 and 2020, Slovenia lost 8,952 lives due to suicides, two thirds of them by hanging. Aim: To analyze trends in suicide methods between 2001 and 2020 and to explore relationships between suicide methods and selected sociodemographic characteristic. Methods: We focused on methods accounting for 95.7% of all suicides. We performed joinpoint regression to examine changes in suicide rates by respective methods and multivariate logistic regression analyses to study sociodemographics associated with specific suicide methods. Results: A gender-specific annual decrease in suicide rates was observed in all methods except for sharp objects and jumping or lying in front of a moving object. Age was statistically significant in the use of firearms and jumping or lying in front of a moving object, while gender was significant in all methods. Associations were found between education, marital status, region of residence, and various suicide methods. Limitations: The results are potentially culturally specific. Conclusion: Certain sociodemographics seem to be associated with the selection of the method.

Development and Evaluation of Online Suicide Preventive Tool iAlive to Increase Competences in Engaging With a Suicidal Person.

Background: Online implementation of suicide prevention interventions offers many advantages, facilitating the dissemination of large-scale suicide prevention interventions. An online tool iAlive aimed at raising awareness and increasing suicide prevention competences in lay people was developed and implemented in Slovenia. Aims: To develop, implement, and evaluate the iAlive tool. Method: Following the development and implementation of the tool, a nonrandomized controlled study with 310 participants was conducted. One hundred fifty-six of them fully completed the study [intervention group (used the iAlive tool): N = 85, control group (did not use the tool): N = 71]. Perceived competences in engaging with a suicidal person were assessed in both groups at baseline and at follow-up (3-4 weeks apart), which also represents the time of the intervention. Results: A significant effect of time and condition [F(1,149) = 6.62, p = .011, ηp2 = .043] showed that the intervention group assessed their perceived competences on intervention exposure more positively compared to the control group. Limitations: Additional data on different populations and people's engagement with the tool in relation to perceived competences are needed. Conclusion: The study suggests that the interactive online tool iAlive effectively increases perceived competences in engaging with a suicidal person. These results provide a background for further dissemination of the tool.

Psychological Well-Being and Resilience of Slovenian Students During the COVID-19 Pandemic.

Introduction: Students' mental health is recognised as an important public health issue, and the strict measures and many changes resulting from the COVID-19 pandemic may have exacerbated this. The aims of the study were thus to explore psychological well-being among university students in Slovenia during the beginning of the second lockdown, and to assess associations among their psychological well-being, demographic characteristics, presence of a chronic health condition, and resilience. Methods: The Slovenian online cross-sectional survey was performed as part of a large-scale international survey led by the COVID-HL Consortium, between the 2nd and 23rd November 2020. The study was carried out on a sample of 3,468 university students (70% female) in Slovenia, aged between 18 to 40 (M=22/SD=3). In addition to sociodemographic data and that on the presence of a chronic health condition, data on subjective social status (SSS), psychological well-being (WHO-5) and resilience (CD-RISC 10) was also gathered. Results: In our study 52% of university students reported good psychological well-being. Hierarchical binary logistic regression revealed that male, older students, those with higher perceived subjective social status, students without a chronic health condition, and those with higher score on resilience were more likely to have good psychological well-being. Resilience was the strongest predictor of psychological well-being in our study. Conclusions: Systematic preventive approaches/interventions in the field of mental health should be implemented among students in Slovenia. In this context it is important to develop and deliver programmes for enhancing resilience, which is an important protective factor in times of mental distress.

Positive mental health in Slovenia before and during the COVID-19 pandemic.

Background: Mental health has been heavily affected during the COVID-19 pandemic. In this study we compared the prevalence of flourishing and languishing mental health during the pandemic and examined which factors are associated with either category of positive mental health respectively. Methods: Data from two cross-sectional surveys with nationally representative samples of adult population in Slovenia conducted in 2019 (n = 9,047) and in 2021 (n = 3,429) are used. Positive mental health was measured with Mental Health Continuum-Short Form instrument. Logistic regression was used to examine the associations between flourishing and languishing mental health and relevant COVID-19 specific and other health-related factors. Results: There was a substantial decrease in the prevalence of flourishing and an increase in the prevalence of languishing mental health during the pandemic. Distribution of both flourishing and languishing mental health followed the socio-economic gradient. Resilience, COVID-19 literacy and changes in family relations, social interactions, and dietary habits were associated with both flourishing and languishing mental health. Conclusion: Positive mental health of the population worsened during the pandemic, more so in traditionally disadvantaged populations. Public health efforts need to be focused appropriately with an increased emphasis on strengthening resilience and health literacy.

Anticipated Self and Public Stigma in Suicide Prevention Professionals.

Background: Stigma about mental illness-both public and self-is one of the most important factors hindering help-seeking. Stigma can occur during an acute episode of mental illness or be anticipatory. One group affected by stigma, but often neglected, is mental health professionals. This study examined the anticipated form of mental-illness and help-seeking self-stigma and the anticipated form of public stigma of suicidal behavior among members of the International Association for Suicide Prevention. We hypothesized that suicidologists with a history of suicidality or mental illness would anticipate greater stigma from the public and self. Methods: The study received ethical approval from the Commission for Medical Ethics of the Republic of Slovenia. Data from 83 participants who completed an online survey (February to May 2020) with informed consent were analyzed using path analysis. We tested a model predicting help-seeking self-stigma based on (i) personal experience of mental illness using anticipated self-stigma of mental illness as a mediating variable and (ii) history of suicidal behavior using anticipated public stigma of suicidal behavior as a mediating variable. Results: Personal experience of mental illness predicted anticipation of self-stigma of mental illness (ß = 0.26). History of suicidality predicted anticipation of public stigma of suicidal behavior (ß = 0.29). Anticipated self-stigma of mental illness proved to be a stronger predictor of help-seeking self-stigma (ß = 0.40) than anticipated public stigma of suicidal behavior (ß = 0.07). Conclusions: It is important to intentionally support the mental health of suicide prevention professionals, as they are not immune to mental illness or various types of stigma. Because our sample was small and diverse, further research to better understand stigma concepts in this population is warranted.

Writing about suicide in graduation exam essays in Slovenia.

In 2017, senior year high school students in Slovenia wrote a graduation exam essay entitled "Suicide as an exit from the wheels of the system". Students had to explain the motives for suicide of the protagonists of two novels and take a stand on this action. We examined the relevant paragraphs of 142 essays. Negative attitudes prevailed towards suicide in general, but one quarter of students showed positive attitudes towards the protagonists' suicidal actions. A few students communicated their personal experience of hopelessness and revealed that they identified with the protagonists' suicidal behavior. Discussing suicide requires alertness for vulnerable individuals who should be offered help if needed.

Association of Selected Area-Level Indicators With Suicide Mortality in Slovenian Municipalities.

Background: With an average suicide rate of 20 per 100,000 in the last decade, Slovenia is above the EU average. There are considerable regional differences in suicide mortality within the country. Aim: We aimed to investigate the relationship between selected indicators at area level and the suicide rate in Slovenian municipalities. Method: Sociodemographic, socioeconomic, and (mental) health data in the years 2012-2016 were analyzed for 212 municipalities. Robust correlation and regression analyses were performed to determine the relationship between different variables and the suicide rate. Results: The suicide rate was positively associated with the percentage of male inhabitants, the high social cohesion in the neighborhood, and the number of sick leave days per capita. It was negatively related to the net income per capita, the marriage rate, the divorce rate, and the availability of professional mental healthcare services. Limitations: The small suicide frequencies within municipalities constitute a limitation of the study. Conclusion: Factors at local, municipal level can be linked to the risk of suicide. In Slovenia, neighborhood cohesion is one of the factors that should be considered when designing suicide prevention measures in a community.

The Prevalence and Predictors of Suicidal Ideation Among Slovene Adolescents.

We set out to investigate the prevalence of suicidal ideation among Slovene adolescents and to examine the predictive value of gender, depression, loneliness, multiple health complaints, bullying and degree of family support for the presence of suicidal thoughts. Our sample consisted out of 1547 15-year-old high-school students which took part in the Health Behaviour in School-Aged Children (HBSC) in 2014. Suicidal ideation was more present in girls, in adolescents with depressive feelings, and in those reporting higher levels of loneliness and multiple health complaints. Being a bully, loneliness and depression were important risk factors, while family support acted as a protective factor.

Attitudes within the general population towards seeking professional help in cases of mental distress.

BACKGROUND: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes. AIM: To examine attitudes within the general population towards seeking professional help in times of mental distress. METHODS: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour. RESULTS: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes. CONCLUSION: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.

The adaptation and implementation of guidelines for responsible media reporting on suicide in Slovenia.

INTRODUCTION: The existing literature provides evidence of the link between media reporting and suicide in terms of either preventive or provocative effects. Hence, working with media representatives on responsible reporting on suicide is of great importance. Until recently in Slovenia, there has been an obvious lack of communication between media representatives and suicidologists. The aims of the present study were twofold; firstly, to introduce the adaptation and dissemination of intervention on responsible media reporting, and secondly, to evaluate the effectiveness of the implemented intervention on suicide reporting. METHODS: We used a pre-post research design. Newspaper articles were retrieved over two 12-month periods: the baseline period and the follow-up period. In between, we had a year of implementation of our intervention program (launching and disseminating the Guidelines via workshops). Each retrieved article was rated qualitatively with respect to its adherence to the Guidelines. RESULTS: The comparison of baseline and follow-up periods revealed some significant differences. Reporting in the follow-up period was less sensationalistic, there was less reporting about specific cases of suicides and more about causes of suicide and pathways out of mental distress. Furthermore, in the follow-up period, there was a significant improvement related to headlines of media articles. Contact information about where to seek help was more often included in the articles. CONCLUSION: The findings are promising, but working with the media needs to be continuous and ongoing if sustainable results are to be achieved.

Celebrity suicide on the railway network: Can one case trigger international effects?

BACKGROUND: After the railway suicide of the German national goalkeeper Robert Enke in 2009, a significant increase of railway suicides was observed nationally. This study analyses whether this incident also triggered copycat effects in other European countries. Additionally, media coverage proxied by Google Trends and long-term changes taking into account general changes in suicide rates and kilometres driven by trains were examined. METHODS: The numbers of railway suicides before and after Enke´s suicide were analysed for short and long-term periods (2 weeks and 2 years post-event) across five European countries. Incidence ratios and resulting percentage changes were computed. RESULTS: Similar to Germany, there were significant short and long-term effects for the combined data of the four other countries (increase of 93.9%; p=0.004 and 16.7%; p=0.003). There was no indication that long-term effects are a mere reflection of an overall increase in suicide frequencies or due to increased numbers of kilometres driven by trains. Analyses on country level revealed heterogeneous results. LIMITATIONS: Due to incomplete data, analyses regarding age and gender were not performed. Media coverage was only proxied by a Google Trends analysis. The study includes a small sample of European countries. CONCLUSIONS: Enke's suicide in 2009 was followed by increasing train suicide numbers in Europe. Although this incident may have reinforced an existing European trend of growing railway suicides, an international copycat effect and/or an increased overall awareness about this particular suicide method appears to be one likely explanation for the changes.

Suicide in Slovenia Between 1997 and 2010.

Background: With an average suicide rate of approximately 30 per 100,000, Slovenia has been regarded as a country with a high suicide rate. In the last decade, however, the suicide rate has gradually decreased to 20.3 per 100,000. Aim: To undertake an analysis of the suicide rate and its characteristics between 1997 and 2010 and to establish whether preventive activities had a significant effect on the suicide rate in the period studied. Method: Data on all 7,317 completed suicides between 1997 and 2010 were obtained from the National Mortality Database. Trends over this period were assessed separately for gender, age, method of suicide, and regional distribution. Data on implemented suicide preventive activities were assessed via regional Public Health Institutes. Results: The suicide rate declined in both genders and in all age groups, except in males aged 10-19 years. The most frequently used method in both genders was hanging. Regions with the highest suicide rate are concentrated in the eastern part of Slovenia. The suicide rate significantly decreased in six regions, but no firm association with preventive activities could be established. Conclusion: Suicide in Slovenia declined significantly during the study period. Preventive activities appear not to have had any notable effect on this decline.

Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews.

BACKGROUND: Evidence-based best practices for incorporation into an optimal multilevel intervention for suicide prevention should be identifiable in the literature. AIMS: To identify effective interventions for the prevention of suicidal behavior. METHODS: Review of systematic reviews found in the Pubmed, Cochrane, and DARE databases. Steps include risk-of-bias assessment, data extraction, summarization of best practices, and identification of synergistic potentials of such practices in multilevel approaches. RESULTS: Six relevant systematic reviews were found. Best practices identified as effective were as follows: training general practitioners (GPs) to recognize and treat depression and suicidality, improving accessibility of care for at-risk people, and restricting access to means of suicide. Although no outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies. CONCLUSIONS: A number of evidence-based best practices for the prevention of suicide and suicide attempts were identified. Research is needed on the nature and extent of potential synergistic effects of various preventive activities within multilevel interventions.

Suicide risk and its relationship to change in marital status.

BACKGROUND: Different types of marital status are associated with different levels of suicidal risk. AIMS: To study marital status change and the effect of its recency in relation to suicidal behavior. METHODS: Suicide victims (1614) in Slovenia and matched controls (4617) were compared for incidence and recency of marital status change during the last 5 years of their lives. RESULTS: A higher percentage of suicide victims (10.7%) had a marital status change in the last 5 years compared with the controls (5.6%). All types of marital status changes (becoming widowed, getting divorced, getting married) proved to be risk factors for suicidal behavior. Almost half of all marital status changes in suicide victims occurred in the year prior to suicide, whereas marital status changes in the control group were equally distributed over the last 5 years. For recently married and divorced people, the increase in suicide risk depended on age: The risk was higher in older people. CONCLUSIONS: Marital status change represents a risk factor for suicidal behavior. The first year after the change is critical for elevated suicidal risk, in particular for older people.

Drug suicide: a sex-equal cause of death in 16 European countries.

BACKGROUND: There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84). METHODS: Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated. RESULTS: No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk. CONCLUSIONS: Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Effects of training program on recognition and management of depression and suicide risk evaluation for Slovenian primary-care physicians: follow-up study.

AIM: To implement and evaluate an educational program for primary care physicians on recognition and treatment of depression and suicide prevention. METHOD: The study was conducted in 3 Slovenian neighboring regions (Celje, Ravne na Koroskem, and Podravska) with similar suicide rates and other health indicators. All primary care physicians from Celje (N=155) and Ravne na Koroskem (N=35) were invited to participate in the educational program on depression treatment and suicide risk recognition. From January to March 2003, approximately half of them (82 out of 190; educational group) attended the program, whereas the other half (108 out of 190; control group 1) and physicians from the Podravska region (N=164; control group 2) did not attend the program. The prescription rates of antidepressants and anxiolytics before and after the intervention were compared between the studied regions. Also, suicide rates three-years before and after the intervention were compared. RESULTS: From 2002 to 2003, there was a 2.33-fold increase in the rate of antidepressant prescriptions in the educational group (P<0.05) and only 1.28-fold (P<0.05) and 1.34-fold (P<0.05) increase in control groups 1 and 2, respectively. However, the 12% decrease in suicide rate in the intervention regions was not significantly greater than the 4% decrease in the non-intervention region (P>0.05). CONCLUSION: Our training program was beneficial for primary care physicians' ability to recognize and manage depression. However, there was no significant decrease in local suicide rates.

Suicide victims' last contact with the primary care physician: report from Slovenia.

BACKGROUND: Previous studies have reported that many suicide victims have had contact with their physicians a week or month prior to their suicide. AIMS: To assess the date of the last appointment (and complaint) of suicide victims in the Skofja Loka region within Slovenia. METHOD: We included all suicide victims in the region in the period 1993-2003. Each of the cases was assigned the closest control in terms of age and gender. Medical death certificates served as a source of demographic data information and information about suicide method. From personal medical records we obtained the date of the last appointment (and the complaint) with the primary care physician. The same was done for the control group. The groups were compared for their last appointment with their physician (date and complaint). RESULTS: Thirty out of 77 suicide victims visited their physician in the last month before suicide (14/77 in the last week); only 16/77 controls did so before the index day (3/77 in the last week). In 30% of suicide victims, the reason for the last visit was mental health problems (only 3% in the control group). CONCLUSION: The results emphasize the important role of primary care physicians in suicide prevention.

Optimizing suicide prevention programs and their implementation in Europe (OSPI Europe): an evidence-based multi-level approach.

BACKGROUND: Suicide and non-fatal suicidal behaviour are significant public health issues in Europe requiring effective preventive interventions. However, the evidence for effective preventive strategies is scarce. The protocol of a European research project to develop an optimized evidence based program for suicide prevention is presented. METHOD: The groundwork for this research has been established by a regional community based intervention for suicide prevention that focuses on improving awareness and care for depression performed within the European Alliance Against Depression (EAAD). The EAAD intervention consists of (1) training sessions and practice support for primary care physicians,(2) public relations activities and mass media campaigns, (3) training sessions for community facilitators who serve as gatekeepers for depressed and suicidal persons in the community and treatment and (4) outreach and support for high risk and self-help groups (e.g. helplines). The intervention has been shown to be effective in reducing suicidal behaviour in an earlier study, the Nuremberg Alliance Against Depression. In the context of the current research project described in this paper (OSPI-Europe) the EAAD model is enhanced by other evidence based interventions and implemented simultaneously and in standardised way in four regions in Ireland, Portugal, Hungary and Germany. The enhanced intervention will be evaluated using a prospective controlled design with the primary outcomes being composite suicidal acts (fatal and non-fatal), and with intermediate outcomes being the effect of training programs, changes in public attitudes, guideline-consistent media reporting. In addition an analysis of the economic costs and consequences will be undertaken, while a process evaluation will monitor implementation of the interventions within the different regions with varying organisational and healthcare contexts. DISCUSSION: This multi-centre research seeks to overcome major challenges of field research in suicide prevention. It pools data from four European regions, considerably increasing the study sample, which will be close to one million. In addition, the study will gather important information concerning the potential to transfer this multilevel program to other health care systems. The results of this research will provide a basis for developing an evidence-based, efficient concept for suicide prevention for EU-member states.

Problem solving for depressed suicide attempters and depressed individuals without suicide attempt.

BACKGROUND: Next to feelings of hopelessness, certain cognitive features such as problem solving deficiency, attentional bias and reduced future positive thinking are involved in the development and maintenance of suicidal behavior. The aim of this study was to examine feelings of hopelessness and problem solving ability in depressed suicide attempters and depressed individuals without a suicide attempt and to see whether these features change over time. METHOD: Three groups of participants, depressed suicide attempters (N=23), psychiatric control group (N=27) and healthy volunteers (N=27) completed measures of hopelessness and executive planning and problem solving abilities. The two clinical groups completed all measures shortly after admission and then again 7 weeks later whereas the non-clinical control group completed measures at baseline only. RESULTS: Both clinical groups displayed a higher level of hopelessness and poorer problem solving ability when compared to non-clinical volunteers. However, no differences were found between the two clinical groups. In neither of the clinical groups was improvement in problem solving ability between baseline and retesting observed despite the lowering of feelings of hopelessness. LIMITATIONS: The diagnoses in the psychiatric controls group were only obtained by the psychiatrist and not checked by further documentation or questionnaires. Furthermore we did not control for personality traits which might influence cognitive functioning. CONCLUSION: Since feelings of hopelessness decreased over time and problem solving ability nevertheless remained stable it is important that treatment not only focuses on mood improvement of depressed suicidal and depressed non-suicidal individuals but also on teaching problem solving techniques.