BMJ openAbiodun O Adewuya, Olushola Olibamoyo, Olabisi E Oladipo, Olayinka Atilola, Adesegun Fatusi, Ife O Abodunrin, Kemi Akeju
INTRODUCTION: Adolescent suicide constitutes a critical public health challenge in low-income and middle-income countries (LMICs), where structural deficits in mental health infrastructure compound an already substantial burden. In Nigeria, where suicidal ideation among secondary school students has been documented at a lifetime prevalence of 22.9%, curative clinic-based responses are neither scalable nor sustainable. School-based universal interventions offer a pragmatic upstream alternative. The Youth Aware of Mental Health (YAM) programme has demonstrated robust efficacy in European contexts, reducing incident suicide attempts by approximately 50%; however, its transferability to the West African educational and cultural environment remains untested. This protocol describes a study designed to culturally adapt YAM for Nigerian secondary schools and assess the feasibility of conducting a definitive cluster randomised controlled trial in Lagos State. METHODS AND ANALYSIS: This study employs a hybrid type 1 effectiveness-implementation design, structured as a two-arm parallel-group cluster randomised feasibility trial across 10 public secondary schools in Lagos State. Approximately 600 adolescents aged 13-17 years will be recruited. Prior to the trial, YAM will be systematically adapted using the Method for Programme Adaptation through Community Engagement framework, producing the YAM-Nigeria curriculum. Schools will be randomised to receive either the culturally adapted YAM-Nigeria programme (five sessions of 45-60 min each delivered by trained external facilitators) or enhanced usual practice (standard health education curriculum supplemented with suicide awareness materials). Primary feasibility outcomes include school recruitment rates (target ≥60%), student consent rates (target ≥70%), retention at the 3-month follow-up (target ≥75%), implementation fidelity (target ≥80% adherence) and acceptability (target ≥70% student satisfaction). Secondary exploratory outcomes include suicidal ideation, depression, mental health literacy, stigma and help-seeking behaviour, measured to estimate the SD and intraclass correlation coefficient required to power a future definitive trial. Progression to a definitive phase III trial will be governed by pre-specified traffic light criteria. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Lagos State University Teaching Hospital Health Research Ethics Committee (Ref: LREC/06/10/2656) and the Liverpool School of Tropical Medicine Research Ethics Committee (Ref: RGETEM045). A two-stage consent process requiring written parental consent and adolescent assent will be implemented. Findings will be disseminated through open-access peer-reviewed publications, policy briefs for the Lagos State Ministries of Health and Education and plain-language summaries for participating communities. TRIAL REGISTRATION NUMBER: ISRCTN registry, ISRCTN69846459. Registered on 24 November 2025.
OBJECTIVE: This exploratory pilot study aimed to examine the potential effects of a shortened, individually delivered dialectical behavior therapy (DBT)-based intervention added to pharmacotherapy on suicide-related outcomes among Chinese outpatients with affective disorders. METHODS: Twenty-one participants recruited from the psychiatric outpatient clinics of the First Affiliated Hospital, School of Medicine, Zhejiang University, were randomly assigned to two groups. Participants in the research group received pharmacotherapy plus a shortened, individually delivered DBT-based intervention, whereas those in the control group received pharmacotherapy alone. Participants completed baseline assessments, 12 weeks of treatment, and 12 weeks of follow-up, with assessments performed every 4 weeks. Outcomes included suicide risk or severity, depression, anxiety, and hopelessness assessed using self-report scales. RESULTS: After adjustment for baseline values using repeated-measures analysis of covariance (RM-ANCOVA), the between-group effect on suicide risk showed a marginal trend favoring the DBT-based psychotherapy group, but did not reach conventional statistical significance (F = 4.26, p = 0.054). The time effect (F = 0.234, p = 0.965) and time-by-group interaction (F = 1.306, p = 0.261) for suicide risk were not statistically significant. Depressive symptoms showed a significant time effect across the follow-up period, whereas most suicide-related and hopelessness outcomes were not statistically significant. These findings should be interpreted as preliminary because of the small sample size and baseline imbalance. CONCLUSION: The results provided preliminary pilot evidence that a shortened DBT-based intervention may be feasible and potentially beneficial as an adjunct to pharmacotherapy in this clinical population. However, the primary suicide-risk outcome did not show a statistically significant between-group effect. Larger adequately powered trials with baseline-adjusted analyses and more comprehensive outcome assessment are needed before firm conclusions can be drawn.
Yonsei medical journalYou Sun Chung, Jeong-Ho Seok, Lois W Choi-Kain
South Korea has one of the highest suicide rates among developed countries, with suicide being the leading cause of death among individuals in their teens to 40s. Despite this serious situation, systematic interventions for suicide prevention remain limited, particularly concerning borderline personality disorder (BPD), which is strongly associated with suicidality. This narrative review examines 11 empirical studies involving clinically diagnosed BPD samples in South Korea, focusing on the prevalence, clinical characteristics, and treatment challenges of BPD within the Korean sociocultural context. The available evidence suggests that BPD is substantially underrecognized in South Korea, with a prevalence rate considerably lower than international estimates and a relatively older mean age of onset, likely reflecting the impact of mental health stigma and barriers to care. Korean individuals with BPD also demonstrate marked functional impairment and a strong association with suicidality, with sociocultural factors further complicating treatment engagement and outcomes. These findings highlight the need for earlier identification and timely diagnosis, broader implementation of evidence-based treatments, and greater dissemination of generalist treatment models and basic training for frontline clinicians. Such coordinated efforts may also contribute to suicide prevention efforts in the country.
International journal of mental health nursingErin Farmer, Marianne Wyder, Nahid Choudhury, Sarah Cox, Nicola Geffen, Jeremy Anson, Nomthandazo Masuku, Emma Lakin, Manaan Kar Ray
Post-discharge suicide risk remains highest among psychiatric inpatients, yet structured safety planning is rarely embedded into inpatient care. As part of a quality improvement project, in 2022, a major metropolitan hospital in Australia rolled out the 7 SAFE STEPS Programs to address this gap. The training included safety conversations and safety plans, which were introduced to become part of the discharge process. This mixed-methods study evaluated whether the structured safety planning was embedded into inpatient routine practice and explored staff and consumer experiences to identify barriers and enablers to meaningful implementation. A numerical count of the safety plans was undertaken. The quality of safety plans produced was assessed through an audit and benchmarking these to the essential components (recognising early warning signs, identifying adaptive internal coping mechanisms, engaging external supports, accessing professional services, addressing means restriction, and reaffirming reasons for living). Safety plans were given a numerical value based on if these were present or absent. Qualitative data about their experiences with the safety plans was also gathered through interviews and focus groups with nursing staff, peer workers, and recently discharged consumers. The qualitative component of the study was designed and reported according to the EQUATOR Network guidelines for qualitative research (COREQ). While there was an increase in the number of safety plans completed on the ward, the overall quality of these was low (average score of 7.67 out of 22). Themes from the qualitative data identified barriers to the introduction, which included time pressures, training gaps, and procedural drift. Nursing staff and consumers discussed the value of these plans and made suggestions for changes.
Health services researchJangho Yoon, Seungbeen Ghim, Michael Lindow, Daniel Gedeon, Patrick Richard
OBJECTIVE: To evaluate whether the Brandon Act, a 2021 legislation establishing confidential, self-initiated mental health referral pathways for US military service members, was associated with reductions in medically attended suicide attempts among active duty service members (ADSMs). STUDY SETTING AND DESIGN: We employed an interrupted time series design using person-quarter panel data from the Military Health System (MHS) from 2018 to 2024. Segmented regression and event study specifications estimated immediate and trajectory effects of the Brandon Act on suicide attempt rates. DATA SOURCES AND ANALYTIC SAMPLE: Data were drawn from the MHS Data Repository, comprising 39.1 million person-quarters from 2.5 million ADSMs aged 18-64. Suicide attempts were identified from inpatient, outpatient, and emergency department claims. PRINCIPAL FINDINGS: Prior to the Brandon Act, suicide attempt rates increased by 4.29 per 100,000 per quarter (95% CI: 3.56, 5.02). Enactment in December 2021 was associated with an immediate reduction of 6.51 per 100,000 (95% CI: -10.54, -2.47) and a downward trajectory shift of 2.25 per 100,000 per quarter (95% CI: -3.81, -0.70). Official implementation in May 2023 was associated with a further immediate reduction of 21.19 per 100,000 (95% CI: -26.83, -15.55) relative to the projected trend, with a compounding decline of 1.50 per 100,000 per quarter (95% CI: -2.34, -0.66). The policy was associated with approximately 3800 prevented suicide attempts over 3 years. Effects were largest among junior enlisted, female service members, and Army and Marine Corps personnel. CONCLUSIONS: The Brandon Act is associated with a sustained, compounding decline in medically attended suicide attempts among ADSMs. Immediate reductions upon enactment suggest a signaling effect, while intensifying effects following implementation underscore the role of confidential pathways in addressing structural barriers to care-seeking. These findings highlight the importance of non-financial policy levers in military mental health and offer a replicable model for other health systems where stigma limits care utilization.
Health expectations : an international journal of public participation in health care and health policyL La Sala, E R Carrotte, C Cooper, M Lamblin, E Brown, J Robinson
BACKGROUND: #chatsafe is a programme aiming to empower young people to communicate safely on social media about self-harm and suicide. This study aimed to assess the feasibility, acceptability, safety, and impact associated with attending a #chatsafe participatory workshop, using the #chatsafe Youth Participation Model. The workshops aimed to educate young people on safe communication practices and gather their insights to inform new #chatsafe social media intervention content. METHODS: Quantitative data were collected in a pre- and post-workshop survey using bespoke items measuring perceived feasibility, acceptability, and safety of the workshops, and self-efficacy in communicating online about suicide. Qualitative data were collected during the workshop (via participant feedback, field notes, audio recordings, and facilitator debriefing notes) and in open-text responses in the post-workshop survey. RESULTS: Nine workshops were held with 107 participants (age M = 19.7 years, SD = 2.7 years). Two thirds (64.5%) reported lifetime suicidal thoughts. Eighty-seven (81.3%) completed both the pre- and post-workshop survey. Feedback was positive, with 94.3% of participants reporting satisfaction with the workshop, 96.5% reported enjoying the workshop, and no adverse events were recorded. There was a significant increase in confidence when communicating online about suicide following participation in a #chatsafe workshop, z = -5.99, p < 0.001. Workshop insights informed two national Australian #chatsafe Instagram campaigns, that reached 950,000 young people and 818,000 young people respectively. CONCLUSIONS: The #chatsafe workshops were highly feasible, acceptable, safe, and led to young people feeling better equipped to communicate safely online about suicide. To further encourage the involvement of young people in the design of suicide prevention, mental health, and similar initiatives, a #chatsafe Youth Participation Toolkit is publicly available for other researchers and outlines the steps taken to plan, conduct, and translate the outcomes of such workshops. LIVED EXPERIENCE OR PUBLIC CONTRIBUTION: This study summarises the views of 87 young people who attended a #chatsafe participatory workshop and provided feedback. The #chatsafe Youth Participation Toolkit was also shaped by seven workshop participants who attended a subsequent focus group, which focused on what recommendations the researchers should share with others who wish to use these participatory methods in the future.
The Journal of school healthMitzi C Pestaner, Jessica C Reich, Brandy M Mechling, Hannah M Altergott, Deborah E Tyndall
BACKGROUND: School nurses play an important role in identifying students at risk for suicide, yet their screening methods remain understudied. The purpose of this study was to examine the methods of suicide risk screening used by school nurses, evaluate how district-level integration of school nurses into suicide prevention policies is associated with screening methods, and assess associations between screening methods, self-efficacy, and referral-making. METHODS: Data were derived from a national cross-sectional, correlational study examining school nurses' roles in youth suicide prevention (N = 578). RESULTS: School nurses whose responsibilities were explicitly defined in district suicide prevention policies were more likely to use standardized screening questions. In a separate analysis, use of standardized screening questions was indirectly associated with a greater number of referrals to community-based services through higher screening self-efficacy. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: District-level integration of school nurses into suicide prevention policies may strengthen school nurses' capacity to identify and refer students at risk. CONCLUSIONS: Within a multitiered system of supports (MTSS) framework, integrating school nurses into suicide prevention efforts may strengthen coordinated, equitable approaches to identifying and responding to students at risk for suicide.
Women's health (London, England)John Noel E Fermin
Brailovskaia et al. identified problematic social media use as a partial mediator between daily stress and suicide-related outcomes and found that positive mental health weakened the association between problematic social media use and such outcomes. This commentary argues that the moderating role of positive mental health warrants greater attention because it points to a preventive strategy beyond reducing problematic online engagement. Strengthening emotional, psychological, and social well-being may buffer individuals from the effects of stress and maladaptive digital behaviors, particularly in settings where stigma, financial limitations, and restricted service availability hinder access to formal mental health care. Future research should therefore examine positive mental health as a direct target of suicide prevention interventions and evaluate culturally responsive approaches that promote resilience, adaptive coping, and psychological flourishing.
Psychological medicineCuiling Wei, Jessie Ching Yan Su, Paco Chun Yeung Wong, Zijie Xu, Francisco Tsz Tsun Lai
Direct clinical comparisons between lithium and valproate for suicide prevention remain limited and inconclusive. We aimed to evaluate their effectiveness of suicide prevention using a retrospective cohort study and meta-analysis. We conducted a retrospective cohort study using electronic health records from the Hong Kong Hospital Authority, including patients with bipolar disorder who initiated lithium or valproate monotherapy between 2003 and 2023. Inverse probability of treatment weighting was applied to balance baseline characteristics, and weighted Cox proportional hazards regression estimated hazard ratios (HRs) for suicide risk. We also searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing lithium, valproate, and nontreatment controls. Pairwise meta-analyses and network meta-analyses were performed to synthesize direct and indirect evidence. The cohort study included 1,379 lithium users and 5,556 valproate users, with no significant difference in suicide risk between groups (weighted HR = 0.76, 95% confidence interval [CI]: 0.54-1.08). The meta-analysis identified 3 RCTs and 12 observational studies. Meta-analysis of RCTs was precluded due to methodological incompatibilities. Pairwise meta-analysis of eight observational studies showed no significant difference between lithium and valproate (pooled HR = 0.87, 95% CI: 0.69-1.09). Network meta-analysis showed that both lithium (network HR = 0.46, 95% CI: 0.33-0.64) and valproate (network HR = 0.63, 95% CI: 0.45-0.88) were associated with lower suicide risk than no treatment, with no significant difference between the two agents (network HR = 0.73, 95% CI: 0.52-1.02). Lithium and valproate showed comparable effectiveness in reducing suicide risk, while both were associated with lower risk than no treatment. The choice between these two mood stabilizers should be guided by individual patient characteristics and safety considerations.
Epidemiology and psychiatric sciencesSangsoo Shin, Jane Pirkis, Matthew Spittal, Lay San Too, Angela J Clapperton
AIMS: Fixed phone boxes enabling calls to a suicide crisis line have been established at a number of public sites where suicides occur. However, the evidence for the effectiveness of this intervention on suicide deaths is not well established. This study examined the effectiveness of fixed phone boxes by comparing suicide rates during the pre-intervention and post-intervention periods. METHODS: Using suicide mortality data from three sites in Australia and three sites in the United States, Poisson regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (95% CI) at each site. Pooled IRR (pIRR) was then calculated for all sites using a random-effects meta-analysis. RESULTS: IRRs and 95% CIs at each site were: Australian sites A: 1.32 (0.94-1.85); B: 2.45 (1.52-3.94); C: 0.32 (0.08-1.33); United States sites D: 3.28 (1.46-7.35); E: 0.57 (0.17-1.95); F: 1.65 (0.45-6.10). The pooled IRR was 1.46 (0.86-2.49). Between-site heterogeneity was large, I2 = 66.5%. CONCLUSIONS: Contrary to general expectation, these findings indicate that fixed phone boxes do not reliably reduce suicide mortality, with two sites even showing increased rates after installation. Their impact appears highly inconsistent across locations, providing no consistent evidence of benefit. This suggests that additional or alternative interventions are necessary to achieve meaningful reductions in suicide mortality at high-risk locations.
Frontiers in public healthSharon Friesen, Jacqueline Yu, Stephen MacGregor
Coordinated, multi-sectoral community responses to youth mental health represent a promising yet undertheorized approach to addressing the service fragmentation that characterizes collaborative work across education, health, policing, and community services. This article presents qualitative findings from a larger sequential mixed-methods study of Strathcona County's Violence, Trauma, and Suicide Prevention (VTSP) Protocol. The VTSP Protocol is a coordinated community framework designed to address youth mental health, community safety, and wellbeing in Alberta, Canada. The larger study combined social network analysis with qualitative inquiry; this article reports on the qualitative strand, which comprised 12 semi-structured interviews with key stakeholders purposively sampled from across the VTSP network. Thematic analysis of interview transcripts identified four interwoven themes that together describe the relational, communicative, and capacity-building labours through which the protocol is sustained: leadership as relational infrastructure, shared processes and communication structures, cross-sectoral relationships and joint purpose, and capacity building and shared language. Across all four themes, collaboration emerged not as a stable institutional achievement but as a fragile accomplishment, strong yet precarious, requiring continual renewal rather than resting on structural stability. The findings are theoretically grounded in Ecological Systems Theory and Relational Coordination Theory. Implications for the design, sustainability, and transferability of coordinated community response models in other communities and school authorities are discussed.
BACKGROUND: Suicide is a leading cause of preventable mortality and a major contributor to years of life lost. Many people who later die by suicide present to emergency departments in the months before death, often for reasons not explicitly related to self-harm and without receiving a risk assessment. Universal suicide risk screening in emergency care can improve detection but is difficult to implement because of time constraints, workflow disruption, and limited capacity to respond to increased identification. OBJECTIVE: The Clinical Risk Alert System for Suicide Risk Screening in Emergency Settings (CARES) project aims to lower the practical threshold for universal screening by developing a risk alert system software prototype for use among patients presenting to emergency care, prompting a brief, validated suicide risk screening and clinician-led assessment. METHODS: CARES will develop machine learning-based prediction models for subsequent nonlethal intentional self-harm and suicide within 1, 6, and 12 months after discharge from an index emergency department visit, using linked, population-based electronic registries from Catalonia (Spain), including electronic health records, mortality data, administrative sociodemographic variables, and a specific self-harm register. Index visits will include emergency department contacts in individuals aged 6 years or older without self-harm-related chief complaints, with predictors defined from information recorded in the prior 12 months. Models will be trained with approaches addressing rare outcomes and unequal sampling probabilities, and evaluated using an independent test set and temporal validation. The risk alert system software prototype will be designed as a web-based application with a backend hosting trained models and a frontend that allows data entry and displays risk as descriptive text and visualizations in absolute and relative terms compared with same-age and same-sex peers. Implementation research will use a co-design process with a user advisory group (UAG; clinicians, people with lived experience, caregivers, and stakeholder organizations), guided by the Medical Research Council framework for complex interventions, to define alert thresholds, response pathways, usability requirements, and training needs. RESULTS: The CARES project was funded in March 2023. The project uses linked electronic registry data from Catalonia covering 2014-2019, including 2,982,736 eligible emergency department index visits from 603,098 patients. The first UAG meeting was held in December 2024. As of May 2026, the project is developing the initial prediction models and software backend, while iteratively refining the frontend through UAG meetings. Data analysis is ongoing, and the main results are expected to be published in spring 2027. CONCLUSIONS: CARES will deliver an experimental proof-of-concept risk alert system designed to support future targeted suicide risk assessment within emergency workflows while keeping clinical decision-making with clinicians and patients. If feasible and acceptable, this approach could improve detection of otherwise unrecognized risk and inform future real-time integration and evaluation within routine emergency care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/100498.
Current psychiatry reportsSergio Sanz-Gómez, Adrián Alacreu-Crespo, Diego De la Vega-Sánchez, María Isabel Perea-González, Julio Guija, Lucas Giner
PURPOSE OF REVIEW: Psychological autopsy (PA) is a methodological approach aimed at reconstructing the psychological and contextual factors leading to an individual's death, particularly in cases of suicide. This article provides a comprehensive review of Psychological Autopsy Protocols, examining their evolution across the decades from the first generation of psychological autopsy studies to a second generation focusing on methodological improvements. RECENT FINDINGS: Methodological aspects of psychological autopsies are discussed, emphasizing both strengths and limitations of the approach. The review then delves into specific PA protocols, showcasing prominent initiatives such as the National Suicide Prevention Project in Finland, McGill Group for Suicide Studies, Chinese PA Project, and the Spanish FRienDS project, as well as notable methodologies such as the SSIPA (Semi-Structured Interview for PA) and other psychological autopsy research efforts conducted globally. In conclusion, review consolidates knowledge on psychological autopsy protocols, providing a valuable resource for researchers, clinicians, and policymakers engaged in suicide prevention. The findings underscore the importance of refining methodologies and advancing the field to enhance our understanding of the aetiology of suicide.
Fortschritte der Neurologie-PsychiatrieXenia Kersting, Ute Lewitzka
ABSTRACT: Suicidality represents a common and potentially life-threatening phenomenon that can occur across a wide range of psychiatric, somatic, and psychosocial contexts. In this article, we provide a clinically oriented classification of suicidality and present epidemiological data as well as relevant risk factors. Suicidality is conceptualized as a dynamic, multifactorial process that should not be understood as a linear stage model, but rather as the result of an interaction between individual vulnerabilities, situational stressors, and protective factors.We place a particular focus on the exploration and assessment of suicide risk, including the limitations of predictive approaches and the role of standardized assessment instruments in routine clinical practice. The importance of the therapeutic relationship and of alliance-forming capacity as central protective factors is highlighted. In addition, we present evidence-based concepts of suicide prevention at the primary, secondary, and tertiary levels. ABSTRACT: Finally, we give a short review of current therapeutic approaches to the treatment of suicidality. The article emphasizes the need for continuous, context-sensitive risk assessment, structured follow-up care, and interdisciplinary prevention strategies to reduce suicidal crises and behaviors.
Global health actionLisa Becker, Olivia Biermann, Per-Olof Östergren, Sara Holsbrink, Jesper Sundewall
BACKGROUND: Mental ill-health is increasingly recognised as one of today's major public health challenges. Many possible causes exist, distributed across all socio-political arenas. It is generally agreed that promotive, and preventive policies should be multisectoral, yet there is a lack of empirical studies concerning such endeavours. In a collaborative effort of 26 national governmental agencies, a proposal for a new national mental health and suicide prevention strategy was developed in Sweden. OBJECTIVES: To explore key stakeholders' perceptions of the process for developing a new national strategy proposal. METHODS: This is a qualitative study based on interviews with 25 representatives from 20 national governmental agencies and two external organisations. We used Directed Content Analysis and applied the Health Policy Triangle as analytical framework. RESULTS: We found that the multisectoral collaboration led to agencies' realisation of their limited knowledge about each other's way of operating. The development process has been perceived as uncharacteristically long and loosely directed. Exploring contextual factors shed light on a need for better care, prevention, and promotion. For a successful implementation of the strategy, respondents demanded clear tasks from the government. Ultimately, respondents highlighted the collaborative implementation of the strategy over its content. CONCLUSIONS: The multisectoral developmental process was perceived as successful in convening various stakeholders to establish a basis for more collaborative work, particularly regarding the strategy's implementation. The process did not only serve the purpose to develop a new strategy, but also allowed national agencies to learn about each other and how to collaborate going forward.
JMIR human factorsJocelyn I Meza, Joan R Asarnow, Natalia Jaramillo, Juliane L Martinez, Candice Biernesser, Brandie George-Milford, David Brent
BACKGROUND: Self-injurious thoughts and behaviors, including suicidal ideation, planning, attempts, and nonsuicidal self-injury, are a significant public health concern among college students. Community college students face elevated mental health risks and persistent barriers to traditional services, particularly those from underserved and ethnoracially minoritized backgrounds, underscoring the need for scalable, accessible digital mental health interventions. OBJECTIVE: This study conducted a mixed methods evaluation of the initial reactions of college students to a novel technology-enhanced suicide prevention intervention (TE-SPI), with particular focus on feedback regarding a mobile app prototype (BRITE) designed to support coping skill use and mood monitoring, as well as proposed nondemanding caring contact text messages. METHODS: A mixed methods approach using the technology acceptance model (TAM) was used to assess the TE-SPI among 20 ethnoracially diverse college students (mean age 22.8, SD 3.9) from a community college (n=10) and a 4-year university (n=10). Participants were shown the BRITE app prototype on a study iPad and asked to provide feedback on its perceived ease of use, usefulness, and relevance to student needs. Quantitative measures assessed initial impressions of satisfaction and usability, while qualitative analyses examined participants' reactions to the app prototype and preferences regarding potential caring contact text messages. RESULTS: Participants generally reported favorable initial impressions of the BRITE app prototype, with 90% (18/20) describing it as helpful and 85% (17/20) user-friendly; 90% (18/20) also indicated that they would recommend it to peers in distress. Qualitative feedback supported these findings, highlighting the app's perceived accessibility, relevance to student life, and potential usefulness during moments of distress. Participants also offered concrete suggestions for app refinements (eg, mood scale customization, gamification, and language options) and for useful caring contact messages they would want to receive. In total, 55% (11/20) of participants said that they would want to receive text messages as part of TE-SPI, while 25% (5/20) reported maybe or possibly wanting to receive messages. CONCLUSIONS: Findings offer preliminary insight into how college students perceive the BRITE app prototype and proposed caring contact message, highlighting concrete feedback for app refinement prior to real-world testing. This study provides early user feedback that can inform further development of the TE-SPI model. Future research should examine actual use, acceptability, feasibility, and clinical impact among diverse college students.
Revista da Escola de Enfermagem da U S PErika Augusta do Amaral Coelho Bezerra, Ivonete Teresinha Schulter Buss Heidemann, Aldalice Aguiar de Souza, Eliana Rosa da Fonseca, Camila Trindade Coelho, Pa…
OBJECTIVE: To map strategies for promoting the health of adolescents with suicidal behavior. METHOD: Scoping review in accordance with JBI methodological guidelines, without language or time limitations. Inclusion criteria for the studies: adolescents aged ten to 19 years with suicidal behavior to explore the concept of health promotion, in any health service, but without limiting this context. Sources consulted: MEDLINE/PubMed, PubMed Central/NLM, CINAHL, Academic Search Premier, Fonte Acadêmica/EBSCO, Scopus, Embase/Elsevier, LILACS, BDENF, INDEXPSI, CUMED, BINACIS, LIPECS, MedCarib, BBO, ARGMSAL, BDNPAR, BIGG, BRISA, HomeoIndex, PAHOIRIS, SES-SPBVS, SciELO, PsycInfo/APA. RESULTS: Of the 22 articles selected, two strategic approaches emerged targeting adolescents: development of life skills - peer support, mental health literacy, youth engagement - and involvement of different social actors - family, professionals, community leaders, intersectoral support networks. CONCLUSION: Health promotion strategies were identified and mapped using two strategic approaches: first, they were directed at adolescents; then, they involved different social actors, broadening the scope of health promotion.
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitationCraig J Bryan, Ennio Ammendola, C Rosie Bauder, Samantha E Daruwala, Jaryd Hiser, Lauren Khazem, Jarrod Hay, AnnaBelle Bryan, Justin C Baker
PURPOSE: Suicidal thoughts and behaviors are associated with severe impairment in daily functioning and reduced quality of life, yet clinical trials of suicide-focused psychotherapies have focused almost exclusively on suicidal ideation and behavior as outcomes. This study examined change in patient-reported functional outcomes (pain interference, physical functioning, and social functioning) during two evidence-based psychotherapy treatments for elevated suicide risk. METHODS: This is a secondary analysis of a two-arm parallel randomized controlled trial comparing Brief Cognitive Behavioral Therapy (BCBT) and Present-Centered Therapy (PCT) delivered to 85 adults with active suicidal ideation or a recent suicide attempt. Physical functioning, pain interference, and ability to participate in social roles and activities were assessed using the 43-item Patient Reported Outcomes Measurement Information System (PROMIS-43) at baseline and at 3, 6, 9, and 12 months. Generalized estimating equations were used to estimate change over time and between-group differences. Clinically meaningful change was defined as ≥ 5-point PROMIS-43 T-score change [44]. RESULTS: At baseline, functional impairment was prevalent: 50.0%, 65.9%, and 81.0% of patients reported at least mild impairment in physical functioning, pain interference, and social functioning, respectively. Mean scores improved significantly over time across all three domains (all p's ≤ 0.028), with the largest gains occurring in the first three months. Trajectories did not differ significantly between treatment groups. By the end of follow-up, more BCBT than PCT patients had returned to within-normal-limits functioning for pain interference (58.9% vs. 42.5%) and social functioning (58.4% vs. 45.4%). Rates of meaningful improvement substantially exceeded rates of meaningful worsening for pain interference and social functioning in both treatments. CONCLUSIONS: Suicide-focused psychotherapy is associated with clinically meaningful improvements in pain interference and social functioning, with more modest gains in physical functioning. These findings support expanding outcome assessment in suicidal populations beyond ideation and symptoms to include functional domains central to quality of life.
The purpose of this review is to investigate the relationship between emotional dysregulation and adolescent suicide, as well as advancements in assessment and treatment methods. A literature search was conducted using the CINAHL and MEDLINE databases. The database search occurred during the month of December 2022. This article summarizes the commonly used assessment tools for emotional dysregulation in clinical settings, as well as psychological interventions and research advancements in the field. Emotional dysregulation has a strong correlation with adolescent suicide; however, there is a need for further improvement in assessment tools, particularly focusing on longitudinal observation and assessment. Regarding psychological interventions, it is important to explore more efficient and shorter modalities while including family members to ensure treatment effectiveness.
BACKGROUND: High-quality nursing documentation is crucial for patient safety, continuity of care, and legal accountability, particularly in suicide-related care. Despite its importance, documentation practices in such sensitive contexts are influenced by multiple interacting factors. This study aimed to explore the determinants of high-quality nursing documentation in suicide cases from the perspectives of nurses and clinical supervisors in Iran. METHODS: A qualitative study using conventional content analysis was conducted in 2024 across multiple hospitals in Iran. Purposive sampling with maximum variation was used to recruit 25 participants, including registered nurses, head nurses, and clinical supervisors involved in suicide care. Maximum variation was ensured across hospital types (general hospitals with emergency departments and specialized psychiatric units), clinical roles, years of experience, and geographical regions. Data were collected through in-depth, semi-structured interviews, transcribed verbatim, and analyzed following Graneheim and Lundman's approach. MAXQDA 2022 software was used for data management. Trustworthiness was ensured using Lincoln and Guba's criteria. RESULTS: Analysis revealed eight main interrelated themes encompassing organizational, professional, interpersonal, and systemic determinants of nursing documentation quality. These included Work Environment and Organizational Support, Professional Knowledge and Competence, Training and Continuing Education, Communication and Collaboration, Staffing and Workload Balance, Motivation and Accountability, Use of Technology and Resources, and Supervision and Feedback. Together, these factors acted as both facilitators and barriers, shaping the accuracy, completeness, and consistency of nursing documentation in suicide- related care. Beyond common documentation factors, the findings highlighted suicide-specific challenges, including the need for precise recording of fluctuating suicide risk, documentation of sensitive patient disclosures, ethical tensions between confidentiality and safety, and the impact of high-stress, time-critical decision-making on documentation accuracy. CONCLUSION: The findings indicate that improving documentation requires a multifaceted approach that strengthens professional capacity, fosters supportive organizational cultures, optimizes workload and resources, leverages appropriate technologies, and ensures constructive supervision. Particularly in suicide care, where documentation has critical clinical and legal implications, targeted strategies are needed to support accurate recording of risk, patient behavior, and interdisciplinary decision-making. Addressing these determinants through targeted training, supportive organizational policies, adequate staffing, and structured supervision can enhance patient safety, continuity of care, and the effectiveness of suicide prevention efforts.
JAMA network openNhan Tran, Yifan Zhang, Jessica Handy, Sean MacAllister, Matthew Miller, Veronica A Pear, David M Studdert, Sonja A Swanson
IMPORTANCE: Extreme risk protection orders (ERPOs) are state laws intended to prevent gun violence by preemptively and temporarily removing firearms from gun owners judged to be at risk of self-harm or violence against others. Evidence of their population-level impact on suicide remains limited and mixed. OBJECTIVE: To assess the association of California's ERPO law with suicide risk among lawful handgun owners. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a difference-in-differences model, comparing suicide risk before (2012-2015) and after (2016-2021) implementation of California's ERPO law among handgun owners and nonowners, assuming parallel trends and that the law had no impact on suicide among nonowners. Data were from the Longitudinal Study of Handgun Ownership and Transfer (LongSHOT), which includes more than 38 million registered voters in California with firearm transaction and mortality records. Statistical analyses were conducted from March to June 2026. EXPOSURE: Implementation of California's ERPO law on January 1, 2016. MAIN OUTCOMES AND MEASURES: Death by all-cause suicide, firearm suicide, and nonfirearm suicide identified from mortality records using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes. Risk differences were expressed as 1-year suicide deaths per 100 000 persons. RESULTS: The analytic sample included approximately 172 million person-years (5 542 471 [nonunique] handgun owners and 166 624 345 [nonunique] nonowners aged 21 years or older). Handgun owners had a mean (SD) age of 44.4 (14.8) years in the prepolicy period and 47.2 (14.9) years in the postpolicy period. In both periods, most handgun owners were male (prepolicy period, 80.7%; and postpolicy period, 78.2%). Analyses showed a risk difference of -4.1 (95% CI, -9.5 to 1.3) suicide deaths per 100 000 persons in 1-year suicide risk among handgun owners following the implementation of the ERPO laws. Effect estimates were larger for firearm suicide (-3.0 [95% CI, -7.9 to 1.9]) compared with nonfirearm suicide (-1.1 [95% CI, -3.3 to 1.1]). Event study, subgroup, and negative control outcome analyses supported the main findings. CONCLUSIONS AND RELEVANCE: This cohort study of California's ERPO law and suicide risk among handgun owners estimated a modest population-level reduction in suicide risk, although a null effect cannot be ruled out, and such aggregate estimates do not necessarily imply ERPOs are ineffective among the individuals subjected to them. The findings reinforce the need for further research to understand the ways in which ERPOs can be used to reduce suicide.
JAMA network openJonathan Purtle, Michal Weiss, Ryan K McBain, Jonathan H Cantor, Jennifer L Pomeranz, Sachini Bandara, Fernanda Montoya, Elizabeth A Stuart
IMPORTANCE: States have autonomy in developing suicide prevention and crisis service infrastructure, but little is known about the magnitude of funding for suicide prevention and crisis services and how it has changed over time or varies across the US. OBJECTIVES: To quantify funding explicitly allocated for suicide prevention and crisis services in enacted state budgets and assess differences in budget allocations over time, across US Census regions, among states with varying suicide rates, and among states that have vs have not enacted 988 telecom fee legislation. DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional state-year panel study included the enacted budgets of every US state and the District of Columbia for fiscal years 2021 to 2026. EXPOSURES: Year, US Census region, state suicide rate quartile, and state 988 telecom fee enactment status. MAIN OUTCOME AND MEASURES: The primary outcome was state per capita annual funding explicitly allocated for suicide prevention and crisis services. The secondary outcome was the percentage of each state's total annual budget allocated for suicide prevention and crisis services. RESULTS: Across 306 enacted state budgets, the mean (SD) annual per capita budget amount explicitly allocated for suicide prevention and crisis services was $3.63 ($8.23) and the mean (SD) annual percentage of the total state budget allocated was 0.054% (0.111%). Annual mean state per capita funding for suicide prevention and crisis services increased significantly during the study period (eg, state mean [SD] budget, $1.05 [$2.04] in 2021 vs $6.55 [$12.76] per capita in 2025; B [SE]: $0.96 [$0.31]; 95% CI, $0.34-$1.57; P = .003), as did annual percentage budget allocations (B [SE]: 0.010 [0.004] percentage points; 95% CI, 0.004-0.021 percentage points; P = .005). Unadjusted mean (SD) state-level per capita allocations for suicide prevention and crisis services were highest among states in the Western Census region ($7.19 [$14.52]) and lowest among states in Southern ($2.12 [$3.56]) and Midwestern ($2.07 [$3.12]) regions. There was no significant association between state suicide death rate quartile and state per capita or percentage budget allocations for suicide prevention and crisis services. The mean (SD) state-level per capita allocation for suicide prevention and crisis services was more than twice as large in states that had enacted a 988 telecom fee in the prior year or earlier than in states that had not ($7.73 [$5.32] vs $3.13 [$8.38]; P = .003). CONCLUSIONS AND RELEVANCE: This repeated cross-sectional state-year panel study found that funding explicitly allocated for suicide prevention and crisis services in state budgets has increased over time, but was larger in states that have enacted a 988 telecom fee. These findings suggest that 988 telecom fees could be a promising legislative approach to finance suicide prevention and crisis service initiatives.
Health promotion internationalMax Tran, Jaelea Skehan, Jon Eddy, Jessica Wilcox, Lennart Reifels
Evidence-based decision-making in suicide prevention is shaped not only by research evidence but also by population needs, resources, and the implementation context. While lived and living experience is a core focus of contemporary suicide prevention policy and practice in Australia, little is known about how it is valued, integrated, and reconciled with other decision-making factors. The present study explored how lived and living experience knowledge informs evidence-based decision-making in suicide prevention, how factors that affect decision-making can be reconciled, and what resources are needed to improve it. Eighty-nine participants from the Australian suicide prevention sector engaged in a qualitative, participatory workshop at the 2025 Lived Experience of Suicide Summit. Participants included people with lived and living experience of suicide and those working across policy, service delivery, funding, and research. Data were collected through structured activities and analysed using reflexive thematic analysis and descriptive content analysis. Participants perceived lived and living experience knowledge to inform a small proportion of suicide prevention decisions. Findings indicated mixed effectiveness of current engagement practices, with tokenism and disengagement being key markers of ineffective engagement. Systemic issues, such as power dynamics and sector culture, were identified as factors that impact how knowledge and expertise are valued and integrated into decision-making. Strengthening the integration of lived and living experience into decision-making requires a paradigm shift that positions lived and living experience knowledge as a legitimate and integral form of evidence. This includes resources to support embedding engagement into suicide prevention approaches, structural supports, and increased implementation capacity.
Journal of psychiatric practiceLauren M Borges, Sean M Barnes, Ryan Holliday, Bridget B Matarazzo, Hal S Wortzel
Therapy-interfering behavior (TIB), although commonly encountered in clinical practice, often goes unaddressed. But if behaviors preventing treatment engagement are not addressed, patients will struggle to achieve their treatment goals, will remain at high chronic risk for suicide, and may drop out of treatment. Therefore, to truly help our patients approach their stated goals and target suicide risk, it is critical to address TIB. In this first column of a 2-part series, we discuss how to identify TIBs in both patients and providers to facilitate therapeutic risk management of patients at risk for suicide.
Asia-Pacific psychiatry : official journal of the Pacific Rim College of PsychiatristsJulia Teng Jia Ru, David J Castle, Myles N Moore, Adriana G Nevarez-Flores
OBJECTIVES: To map and summarize evidence on means restriction activities that have been implemented for the prevention of suicide across Australia. Further, to provide an overview of the impact of the activities on suicide rates and ascertain barriers/challenges, costs, and any other relevant associated information. METHODS: We conducted a scoping review of the literature following JBI-formerly known as Joanna Briggs Institute-methodology for scoping reviews and recommendations by Cochrane Rapid Reviews. Four databases were searched for identifying all published material in English. Gray literature was searched through Google Scholar and state-based and national health commission websites. RESULTS: We identified five publications addressing means restriction activities implemented for suicide prevention. All studies describe restriction of access to places where there had been suicides by jumping from a height. The studies concluded that mean restriction activities were valuable in the prevention of suicide by jumping. Further, we reviewed four additional publications describing activities that restricted access to means (e.g., firearms legislation) but where the intervention was not aimed at suicide prevention per se, albeit suicide rates were reported. CONCLUSION: Despite there being few studies available, our review identifies evidence on means restriction activities for the prevention of suicide implemented within Australia and provides a summary of implemented interventions that have been reported to be associated with a decrease in suicide rates. In particular, the apparent benefit of structural interventions at jumping sites supports their broader adoption: any such future activities require careful evaluation.
BMJ openStephanie Andreasen, Kathryn Birnie, Yona Lunsky, Carly A McMorris
INTRODUCTION: Autistic children and adolescents (herein, youth) are at 3.5 times greater risk of suicide attempts and deaths than the general population, with attempts beginning as early as 10 years of age. However, little is known about the predictors of suicidality or how to provide adequate support to prevent premature mortality in autistic youth. This study will fill critical research and knowledge gaps by identifying the needs and preferences for future research on suicidality in autistic youth. By completing this process alongside the perspectives of caregivers, clinicians and policymakers, we will also determine critical knowledge-to-action steps that will inform future clinical practice and policy directions. METHODS AND ANALYSIS: Using a modified James Lind Alliance priority-setting process (JLA PSP) grounded in a patient engagement approach, the current study will identify key research priorities on suicidality in autistic youth. Our modified JLA PSP process will include: (1) forming a steering committee, (2) conducting a rapid literature review, (3) carrying out a survey across Canada, and (4) collaboratively identifying and disseminating consensus-based research priorities. Questions generated from survey responses will be summarised and then discussed in a priority-setting workshop to identify and agree on a list of the top research priorities for suicidality in autistic youth. ETHICS AND DISSEMINATION: This study has received ethics approval by the University of Calgary Conjoint Faculties Research Ethics Board (REB24-1761). A risk protocol is in place, which outlines the procedure to be undertaken if a participant contacts the research team in distress. Survey respondents will provide informed consent before participation and have access to a resource page containing contact details for a range of support services. Members of the steering committee will have an opportunity to debrief and process difficult discussions with a researcher and clinician with training in suicide and mental health in autism.The top research priorities list will be disseminated through peer-reviewed publications and conference publications on both the top priorities and the engagement process with partners, as well as policy briefs for national mental health and suicide strategies, community presentations and social media. In partnership with our community partner organisations, we will conduct webinars for researchers and clinicians as well as community events. Steering committee members (including autistic youth and their caregivers) will be included in co-creating knowledge translation activities.With more than one-third of autistic people experiencing suicidality, and a quarter making at least one attempt, better understanding the priorities in this under-researched area has the potential to save many lives as the identification of autism in youth and adults continues to increase.
PloS oneDonna L Schuman, Micki Washburn, Regina T Praetorius, Jaci S Mester, Minjaal Raval, Joshua Wilson, Suzanne Lohman, Renee Castillo
BACKGROUND: Suicide risk is disproportionately higher for rural veterans who often lack access to specialty-trained health professionals equipped to deliver effective prevention interventions. Virtual reality offers a scalable training solution to address these gaps. This mixed-methods feasibility study systematically developed and evaluated a prototype virtual reality simulation for a training module in suicide risk identification and lethal means safety counseling during rural veteran home visits. METHODS: Thirty participants (10 nursing/social work students, 10 health professionals, and 10 rural community members) completed the veteran suicide prevention simulation using Meta Quest 2 headsets. Sense of presence (including negative effects) was assessed with the ITC-Sense of Presence Inventory; additional outcomes included representativeness, acceptability, and cue recall. RESULTS: Participants reported high engagement, with moderate spatial presence, and ecological validity, and low negative effects (e.g., nausea). Prominent lethal means cues were highly recalled (firearms: 93.3%; alcohol: 83.3%), while subtler cues (e.g., isolation) were less frequently noted. Most endorsed representational accuracy, with qualitative feedback praising authenticity and suggesting improvements in interactivity and navigation. CONCLUSIONS: Findings support the preliminary feasibility and acceptability of the VET-SAVR prototype for suicide risk identification and lethal means counseling training. Refinements to navigation, cue salience, and mitigation of negative VR effects are warranted before future efficacy testing.
Health policy (Amsterdam, Netherlands)Jaelea Skehan, Max Tran, Lennart Reifels, Jose Cuenca
BACKGROUND: A mental health lens has historically been used to describe suicide and its prevention, however increasing research evidence and policy advice indicates that collaboration between multiple government agencies, service sectors and communities would more appropriately address the underlying drivers of distress. This has contributed to growing support internationally for a whole-of-government approach to suicide prevention, but there are varied descriptions of how this is applied. OBJECTIVE: This paper identifies mechanisms for whole-of-government action, as written into Australian suicide prevention policies and provides a narrative review of existing governance structures and potential future actions. METHODS: Nineteen suicide prevention policy documents were identified via an online search of government and other websites. Document analysis was used to assess whole-of-government arrangements between levels of government (vertical), across government portfolios (horizontal), and between departments at different levels of government (mixed). RESULTS: All nine Australian jurisdictions had between one and four policy documents guiding suicide prevention. While extracts referencing whole-of-government mechanisms were relatively sparse (N = 91), all documents included examples of one or more whole-of-government mechanisms (horizontal = 34%, vertical = 25% and mixed = 41%). The most common mechanism function was joint oversight and collaboration, with joint funding arrangements, policy linkages, formal agreements, and legislation less common. CONCLUSIONS: Despite variations across jurisdictions, there is evidence that contemporary Australian suicide prevention policies include arrangements to facilitate whole-of-government action. However, strengthened arrangements between governments and across portfolios are needed to advance suicide prevention as a whole-of-government priority.
BACKGROUND: Suicide remains a leading preventable cause of death, and patients presenting with self-harm constitute a high-risk group. The Oxford Suicide Assessment Tool for Self-Harm (OxSATS) is a validated model estimating suicide risk. While its statistical performance is established, its clinical utility remains unexplored. OBJECTIVE: To understand clinicians' views on the feasibility, acceptability and potential workflow integration of OxSATS. METHODS: Semistructured interviews with 15 multidisciplinary National Health Service clinicians explored current suicide risk assessment practice, experience with structured tools and views on OxSATS. Participants applied OxSATS to standardised vignettes to simulate real-world decision-making. Interviews were analysed using reflexive thematic analysis. FINDINGS: Clinicians valued OxSATS for its simplicity, objectivity and percentage-based outputs. OxSATS was viewed as promoting a shared language around suicide risk and supporting assessment consistency. Alignment between OxSATS estimates and clinical judgement was good. However, some clinicians perceived the tool as underestimating risk associated with violent methods. Key implementation barriers included limited scope for wider psychosocial context and potential over-reliance on the tool by inexperienced clinicians. Participants emphasised that OxSATS should complement, not replace, clinical formulation and highlighted the need for clear guidance to support adoption. CONCLUSION: OxSATS was viewed as a promising adjunct to suicide risk assessment following self-harm. Addressing concerns around scope, interpretation of percentage risk and integration into wider suicide risk training will be key to successful implementation. CLINICAL IMPLICATIONS: This study highlights clinicians' interest in evidence-based adjuncts to suicide risk formulation and supports the use of probability-based models to enhance decision-making.
BACKGROUND: Crisis helplines are a vital component of a robust public health approach to suicide prevention as they are often free, accessible, and provide immediate support to individuals in distress. AI presents an opportunity for novel applications to support and improve crisis line services across a variety of functions, including assessing suicide risk, identifying issues, tracking responder behaviors, and providing prompts and reminders. However, the use of AI in the crisis sector also raises critical questions regarding safety, ethics, privacy, efficacy, feasibility, and acceptability among interest holders. The extent to which AI is currently being explored and implemented in crisis line contexts is unknown. OBJECTIVE: The objective of this scoping review is to examine how AI is being used in crisis line services and to explore the perspectives of different interest holders regarding its application. METHODS: This scoping review will be conducted in accordance with a validated methodological framework and reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A comprehensive search strategy will be developed with an experienced health sciences librarian and implemented in multiple databases, including Ovid MEDLINE, Embase, APA PsycInfo, CINAHL, IEEE Xplore, ACM Digital Library, and Web of Science. We will include primary research describing AI applications and implementation in the crisis line sector and studies exploring interest holder perspectives. Screening of titles and abstracts and of full texts will be performed independently and in duplicate following a screening calibration process. Disagreements will be resolved through discussion. Expert opinions will be sought as needed to make final determinations regarding included and excluded sources. A data extraction form will be created and piloted to capture information on study characteristics, study findings and outcomes, AI use cases, and considerations for various concepts relevant to crisis line services (eg, safety, trust, equity, ethics, and privacy). Extracted data will be synthesized using descriptive and narrative approaches. RESULTS: As of June 2026, the search strategy has been finalized and translated across databases. Screening of 3380 unique records is ongoing and will conclude by September 2026. Results will be available by winter 2027. CONCLUSIONS: AI is changing public mental health by creating new opportunities to optimize interventions and enhance care. However, several implementation challenges remain regarding the use of AI applications in the crisis sector. This review is a timely and comprehensive exploration into the state of AI in the crisis sector and will identify existing knowledge and evidence gaps to help inform practice, policy, and future research. By systematically mapping current AI applications; interest holder perspectives; and how core domains such as safety, privacy, and equity are addressed, this review will provide a foundational evidence base to guide responsible, person-centered AI integration and a robust research agenda tailored to crisis line contexts. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/95087.
Current psychiatry reportsNick Waldvogel, Hyo Ryu, Michelle Riba
PURPOSE OF REVIEW: Glioblastoma multiforme (GBM) is an aggressive primary brain tumor associated with poor prognosis, rapid functional decline, and psychological distress. An updated review of the literature is lacking, despite that patients with GBM appear to be among the highest risk for suicide among cancer patients. This review summarizes up-to-date evidence of suicide risk factors, screening approaches, and suicide mitigation strategies in patients with GBM. RECENT FINDINGS: Suicide risk is the highest in the first year following GBM diagnosis. It is also associated with older age, male gender, and tumor-related factors such as supratentorial location. Other factors such as neurocognitive decline and poor functional status may also contribute. Evidence emerging from broader oncology populations suggests that demoralization and existential distress may be factors, though these have not been studied in GBM cohorts. Treatment-related psychiatric adverse effects from corticosteroids, anti-epileptic drugs, chemotherapy, and radiotherapy may also influence psychiatric illness and mediate suicide risk. Screening tools such as the Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale, and Colombia-Suicide Severity Rating Scale have been effectively used to screen for suicide in conjunction with clinical interviewing in GBM patients. Evidence-based suicide reduction interventions include psychotherapy, safety planning, lethal means restriction, and caregiver support. GBM is a diagnosis that is associated with higher rates of suicide than almost all other cancers, and the extant literature identifies demographic and tumor features that are associated with suicide in this population. Effective interventions exist to identify and support these patients. Future studies should systematically measure risk factors identified in broader oncology populations to identify additional GBM-specific risk factors for suicide.
Suicide is a leading cause of death among young adults, with university students representing a particularly vulnerable subgroup. Although prevention efforts often depend on psychopathological symptom assessments, these are resource-intensive and less practical for large-scale screening. This study evaluated whether easily collectable contextual and psychosocial variables can independently predict suicidal risk in university students. Data from 470 university students were analyzed using random forest machine learning (ML) algorithm. Three models were developed: Model 1 included 53 contextual and psychosocial variables (sociodemographic, lifestyle, social support, academic stressors, and health); Model 2 relied solely on 10 psychopathological symptom scales; and Model 3 integrated all variables. Predictive performance improved progressively across the three models (AUC = 0.72, 0.77, and 0.80, respectively). Key predictors included both contextual and psychosocial variables (e.g. low social support, diminished university belonging) and psychometric evaluation of symptoms (anxiety, depression, coping strategies). Taken together, these results show that contextual and psychosocial variables provide meaningful information for identifying university students at risk for suicide, and psychometric symptom measures offer further refinement of risk detection. Findings are discussed in relation to the Interpersonal Theory of Suicide and Escape Theory. This ML approach offers a scalable framework for suicide risk screening in academic settings.
BMJ mental healthAlejandro G Szmulewicz, Hanna Gerlovin, Nick Rezaee, William Robb, Gonzalo Martínez-Alés, Howard Liu, Robert M Bossarte, Eric G Smith, Ira Katz, Ryan Ferguson,…
BACKGROUND: Lithium has long been considered to reduce suicidal behaviour in patients with affective disorders, but evidence from large real-world populations remains limited. OBJECTIVE: To estimate the effects of lithium initiation and continuation on suicide deaths and non-lethal suicidal behaviours among adults with bipolar disorder or major depressive disorder. METHODS: We emulated two target trials using electronic health records and administrative claims from US veterans between January 2010 and December 2022. The first trial benchmarked results against the CSP-590 randomised trial by estimating the 1-year risk of suicide-related events (non-fatal suicide attempts, hospitalisations to prevent suicide or suicide deaths) among patients with a recent suicide attempt initiating lithium versus not initiating lithium. The second trial extended follow-up to 10 years to estimate risks of suicide deaths and non-lethal suicidal behaviours separately, including subgroup analyses by age and diagnosis. An additional analysis removed the requirement of a prior suicide attempt. FINDINGS: In the benchmarking analysis, the 1-year risk ratio for suicide-related events comparing lithium initiation with no initiation was 1.06 (95% CI 1.01 to 1.12), consistent with findings from the CSP-590 trial. In the extended analysis, the 10-year per-protocol risk ratio for suicide death was 1.00 (95% CI 0.86 to 1.15) and for non-lethal suicidal behaviours was 0.96 (95% CI 0.90 to 1.02). Results were similar among individuals with and without a prior suicide attempt. CONCLUSION: When added to ongoing pharmacological treatment for patients with affective disorders, lithium may not substantially reduce suicide risk highlighting the need for additional suicide prevention strategies in this population. Limitations include lack of information on adherence, dosage or blood levels of lithium which may have obscured existing differences. CLINICAL IMPLICATIONS: Our findings suggest that adding lithium therapy to the ongoing treatment regimens of patients with affective disorders for the sole purpose of reducing suicide may not be well-tolerated or meaningfully reduce suicide risk.
BMC psychiatryMariam Yunusah, Lena Marie Hensel, Tobias Teismann, Peter Brieger, Hermann Spießl, Yekaterina Pashutina, Sarah Sophia Michna, Chiara Spielmann, Marlene Stadler…
BACKGROUND: Individuals undergoing acute inpatient psychiatric treatment or who have recently been discharged face an especially elevated risk of suicide. Nevertheless, suicide-specific interventions are still not routinely implemented in inpatient psychiatric care in Germany. Safety plan interventions (SPIs), which involve developing individualised safety plans, have been shown to be highly effective in reducing the number of suicide attempts. Due to their simplicity and low resource requirements, they may be suitable for broad implementation. However, there is currently a lack of evidence regarding their effectiveness in inpatient psychiatric settings in Germany. This study addresses this critical research gap by investigating whether the SAFETY+ intervention can reduce suicide attempts within twelve months of discharge from a German inpatient psychiatric setting compared to usual care. Additionally, the research project will focus on the implementation of the intervention. METHOD: This mixed-methods study combines a randomised controlled trial (RCT) with qualitative interviews of participants and professionals involved in treatment and study implementation. In the RCT, 450 patients with acute suicidality will be recruited from three large psychiatric clinics in Bavaria. Participants will be randomly assigned to either the SafetyPlan group (n = 225) or the treatment-as-usual group (n = 225). The intervention includes a manualised SafetyPlan intervention (SPI) session during hospitalisation and telephone follow-up sessions one and four weeks after discharge. Data will be collected at five time points: after consenting to participate (T0a) and shortly before discharge (T0b), as well as at follow-ups six weeks (T1), six months (T2) and twelve months (T3) after discharge. DISCUSSION: The findings of this study can be transferred directly into standard psychiatric practice since the study is embedded in routine clinical care. The study encompasses both urban areas (Munich) and rural areas with limited outpatient resources (e.g., the Bavarian Forest region, a rural area in Eastern Bavaria), thereby enhancing the generalisability of the results to other psychiatric care settings with similar structures across Germany. Should the procedure prove effective, the findings may promote future nationwide implementation efforts. TRIAL REGISTRATION: This trial is registered with the German Clinical Trials Register (DRKS), ID: DRKS00037168, registered on 07 July 2025. URL: https://www.drks.de/DRKS00037168 .
Frontiers in public healthMan Li, Wendi Huang, Jingjing Wu, Nanyu Kuang, Yong Luo, Juan Huang, Nanqu Huang
Adolescent suicide risk is often expressed through language before it becomes visible in clinical encounters, yet current prevention still relies heavily on episodic screening and limited specialist resources. Large language models (LLMs) may help interpret crisis chats, clinical notes, school-counseling records, and online disclosures, but their relevance to public mental health depends on a practical question: can language signals lead to timely and accountable human action? This mini review examines LLMs in adolescent suicide prevention through this Evidence-to-Action perspective. Current evidence is strongest for supervised risk-signal flagging and more preliminary for context summarization and extraction of suicide-related information from unstructured text. Evidence is much weaker for autonomous generative crisis intervention, especially for adolescents. The main barriers are not only technical accuracy, but also adolescent-specific validation, privacy and consent, cultural variation in distress expression, unsafe generated responses, and unclear responsibility after an algorithmic alert. We argue that near-term deployment should remain under human review and should be judged by whether it improves review timeliness, proportional escalation, safety planning, linkage to care, and equity. LLMs may contribute to adolescent suicide prevention only when embedded in clinically accountable and ethically governed systems. As a focused mini review, this paper maps conceptual boundaries and evidence gaps rather than proposing a validated deployment protocol.
Health expectations : an international journal of public participation in health care and health policyYvonne Awenat, Rebecca Crook, David Honeywell, Charlotte Lennox, Dawn Edge, Patrcia Gooding, Gillian Haddock, Helen Brooks, Caroline Hendricks, Daniel Pratt
INTRODUCTION: Psychological therapies are rarely available for UK suicidal prisoners. A pilot feasibility clinical trial of Cognitive Behavioural Suicide Prevention therapy showed that it was possible to deliver therapy offering the potential to improve outcomes for suicidal prisoners. However, there were challenges to engaging male prisoners in therapy as many experienced difficulties in accessing and talking about their emotions. Difficulty in talking about emotions is common amongst male prisoners, yet this is essential for successful engagement in a talking therapy. The current co-production study aimed to further understand the contextual influences that impact male prisoners' ability to engage with a psychological intervention focused on suicide prevention and to explore user-generated solutions. METHODS: Community-residing male ex-prisoners with past experience of suicidal thoughts or behaviour during imprisonment participated in individual qualitative interviews followed by a series of six focus groups. Due to COVID-19 restrictions in place at that time, recruitment and data collection were conducted by remote methods. Data were analysed according to the principles of reflexive thematic analysis. RESULTS: Fifteen individuals participated: twelve completed individual interviews, ten participated in the focus groups, with seven individuals participating in both. Three main themes were formed. 1. Negotiating prison personas and identities - Pressures to hide emotions, act tough, and distrust professionals. 2. Command and control in prison - Prison regimes impact on interpersonal relationships with staff and other prisoners to worsen suicide risk, with prisoner's healthcare needs often neglected. 3. Making therapy accessible and acceptable - Prisoners must be able to trust a compassionate therapist for engagement to be successful. CONCLUSION: This study epitomises the feasibility and value of meaningful co-production in research involving populations from marginalised groups such as ex-prisoners. Our results reveal how the combination of individual prisoner and prison institution socio-cultural contextual influences impact suicidal prisoners' engagement in psychotherapy. User-defined suggestions are provided to promote development of potential remedies. PATIENT OR PUBLIC CONTRIBUTION: Co-production was achieved by the leading role of a salaried peer-researcher co-investigator in liaison with members of our Suicide Risk and Safety Research Group (SSRG) comprised of Experts-by-Experience (EbEs). Co-decision making featured throughout all stages of the research, influencing the protocol design and interview schedule. The personal experience knowledge of the peer-researcher/co-investigator enabled targeted recruitment strategies and successful engagement of participants. Shared past experiences of prison life and language positively influenced rapport and engagement of participants during data collection, enabling attainment of rich data. Similarly, the peer researcher/co-investigator's unique personal experiential knowledge ensured a 'real-world' perspective to analysis and co-authorship of publications.
Suicide & life-threatening behaviorSamuel McKay, Christina Ng, Jennifer Nicholas, Vivienne Browne, Gina Chinnery, Isabella Choi, Bailey Nation-Ingle, Kristal Allison, Ella Perlow, Michelle Lambl…
BACKGROUND: International students frequently report suicidal thoughts, yet often do not access support. Bud is a co-designed, self-guided mobile app developed as an upstream suicide-prevention intervention targeting transdiagnostic mechanisms related to suicide risk. AIM: To evaluate the effectiveness, acceptability, engagement, and safety of Bud compared with an active and structured psychoeducational comparator. MATERIALS AND METHODS: A two-arm, parallel-group randomized controlled trial was conducted with international students in Australia. Participants were randomized 1:1 to Bud (n = 156) or psychoeducational fact sheets (n = 156), completing assessments at baseline, 2 weeks and 4 weeks. The primary outcome was psychological distress (K10). Secondary outcomes included help-seeking intentions, interpersonal risk processes, emotion regulation, suicidal ideation, and mental health literacy. Analyses used intention-to-treat mixed-effects models. RESULTS: Contrary to the hypotheses, psychological distress decreased from baseline to 4 weeks (Bud: -2.23; Comparator: -2.15), with no group × time interaction (F(2,342.45) = 0.43, p = 0.652); emotion regulation and suicidal ideation showed similar patterns across groups, and other secondary outcomes remained stable across groups. As expected, Bud was rated as enjoyable, worthwhile, and usable. Engagement was moderate (median 10 activities), and no iatrogenic effects occurred. CONCLUSION: Bud was feasible, acceptable, and safe but did not outperform an active psychoeducational comparator over 4 weeks. TRIAL REGISTRATION: ClinicalTrials.gov identifier: ACTRN12625000584437.
Military medicineElizabeth White Baker, Nancy G Leveson, Dale W Russell
INTRODUCTION: The Navy and other organizations have developed various programs, policies, and interventions to address harmful behaviors (HB), primarily focusing on individual actions from psychological and sociological perspectives. However, an organizational systems perspective can reveal how broader organizational structures influence these behaviors. This study applies systems-theoretical modeling and analysis to explore why current efforts fall short and how organizational redesign can better mitigate HB. MATERIALS AND METHODS: Systems Theoretic Accident Model and Process (STAMP), a framework for modeling causality in complex systems, views losses as failures in control or unsafe interactions rather than simply malfunctions or human behaviors. It emphasizes system constraints and control structures. Applied to suicide and suicide-related behaviors (SRB), STAMP examined underreporting of Sailor contact with nonmandatory reporters (e.g., Chaplains, Fleet & Family Services, Military and Family Life Counselors, and Military OneSource) and inconsistencies in SRB reporting during safety position changes. The study identified control relationships and feedback mechanisms through policy reviews and interviews with current and former Navy personnel. Policy analysis established an initial "ideal" control structure, whereas interviews refined the final model. RESULTS: Significant underreporting of HB incidents was found, primarily due to nonmandatory reporters' roles in the SRB system. Since no data are collected on Sailor interactions with these reporters, current methods fail to capture the full scope of HB interventions. Additionally, inconsistencies in reporting arise as safety-related personnel rotate, leading to varying prioritization of SRB prevention efforts. Personnel turnover affects policy implementation, disrupting intervention continuity. Standardized reporting mechanisms are needed to ensure consistency despite staff changes. CONCLUSIONS: The U.S. Department of Defense's Integrated Primary Prevention efforts target HB through systemic changes at organizational and leadership levels. Systems-theoretical approaches, such as control structure modeling and System-Theoretic Process Analysis , offer a structured framework for guiding these changes. Future research will apply the STAMP model to other HB categories, including sexual harassment and substance abuse, to further validate its effectiveness and improve HB prevention in military environments.
The lancet. PsychiatryCathryn Rodway, Su-Gwan Tham, Pauline Turnbull, Nav Kapur, Louis Appleby
BACKGROUND: Suicide in young people is a global priority and strengthening mental health support in education is central to England's suicide prevention strategy. Few studies have examined in detail the individual characteristics of higher-education students nationally who died by suicide. We aimed to describe individual and institutional characteristics of suspected student suicide, contact with support services, and adherence to sector guidance on serious incident investigations. METHODS: We used a national case-series design to identify suspected suicide deaths in higher-education students in the 2023-24 academic year (from Aug 1, 2023, to July 31, 2024). Anonymised serious incident reports were obtained from higher-education providers in England. Data were systematically extracted using a structured pro forma developed with bereaved families and sector organisations and charities. Serious incident reports were also assessed for adherence to national guidance. FINDINGS: Higher-education providers in England informed us of 107 suspected suicide deaths during the 2023-24 academic year. A serious incident report was completed for 86 of these deaths, of which 79 were obtained from 50 providers. Most students who died were men (50 [71%] of 70 with available data were men and 18 [26%] were women). Where known (n=24), mean age was 23·9 years (SD 7·0; range 19-47). Ethnicity was unknown for most students (70 [89%] of 79). Most students were undergraduates (45 [71%] of 63) who lived away from home (44 [72%] of 61). 11 (22%) of 50 deaths with available data occurred in university-managed or privately managed student accommodation. Six reports indicated potential suicide clusters. Mental health difficulties (45 [62%] of 73), academic problems (38 [52%] of 73), and neurodivergence (30 [41%] of 73) were the most common features reported before death, often alongside relationship problems (24 [33%] of 73), self-harm (16 [22%] of 73), social isolation (11 [15%] of 73), housing or financial problems (15 [21%] of 73), and violence (nine [12%] of 73). 52 (69%) of 75 students had previous contact with university support services, although reports highlighted recurring issues with access to support, information sharing, monitoring engagement, and joint working between academic and pastoral supports. Despite national guidance, family involvement in serious incident investigations was only reported for 19 (24%) of 79. INTERPRETATION: A range of actions, including prioritising mental health on campus and offering targeted support to those at risk (eg, neurodivergent or financially insecure students) could contribute to suicide prevention. Universities should ensure the safety of accommodation and routinely involve families in an independent investigation process, promoting openness and transparency from the earliest point. FUNDING: UK Department for Education.
Suicide & life-threatening behaviorJetta E Hanson, Ryan Clarke, Peter M Gutierrez
BACKGROUND: Community Helper Training (CHT) equips people to identify and support individuals thinking about suicide. Most CHT occurs in person, but interest in online delivery is growing. Living Works Start is a 90 min online CHT designed to improve recognition of warning signs, confidence, and willingness to help. AIMS: Evaluate learning outcomes from Start using quality assurance (QA) data, examine the efficacy of online CHT, and determine if prior suicide prevention training influences gains. METHODS: Pre- and post-training surveys from 44,003 learners assessed willingness to talk, ability to recognize signs, confidence to help, and knowledge of how to get help. Paired t-tests and effect sizes examined changes. Subgroup analyses explored differences by quantity and recency of prior training. RESULTS: Significant improvements were observed across all outcomes (p < 0.001). Learners with no prior training showed the greatest gains, though all improved. LIMITATIONS: QA data lacked randomization, comprehensive demographics, and follow-up, limiting generalizability, understanding of skill use, or long-term retention. CONCLUSIONS: Start was associated with self-reported learning gains. Benefits were observed across learners and were strongest among those with no or more distant prior training. Future research should test efficacy under controlled conditions and examine long-term outcomes and real-world use of skills.