The Suicide Observatory in Cork and Kerry was established to address the urgent need for real-time suicide data in Ireland to enable timely suicide prevention. This study aimed to assess the performance and efficiency of the Suicide Observatory to inform decisions about its upscaling and wider implementation. We designed a mixed-methods approach and used Centers for Disease Control and Prevention evaluation guidelines to assess key attributes of the Observatory: sensitivity, positive predictive value, data quality, timeliness, simplicity, accessibility, acceptability, and the overall usefulness. We compared data obtained from an audit of the Observatory for 2019-2020 with coroner-determined suicide cases and national suicide mortality data, and conducted semistructured interviews with stakeholders. We found that the Suicide Observatory in Cork shows a high level of data quality (sensitivity: 83.72%; 95% CI = 74.20%-90.80%), positive predictive value: 75.79% (95% CI = 74.04%-77.46%), data missingness: <2%). It applied a fortnightly case submission interval, and participants generally regarded the data collection as straightforward. The Suicide Observatory data were made available to stakeholders and decision makers. Participants reported strong acceptability, primarily due to its simplicity and accessibility. The overall usefulness of the Suicide Observatory was considered to be high as it improved the understanding of the suicide demography in the regions and enabled timely suicide prevention initiatives and support for affected communities. It was concluded that the Suicide Observatory has high levels of performance and efficiency and has been crucial for timely suicide prevention. The findings support its wider implementation in Ireland.
Background: Suicide-related media is known to influence suicide rates. Large language models (LLMs), a form of generative artificial intelligence (AI), are increasingly being used as a writing tool. However, the quality of LLM-generated suicide-related content has yet to be assessed. Aims: We aimed to examine suicide-related outputs from three LLMs (GPT-4, Grok, ERNIE) to characterize output quality. Methods: We provided the LLMs with 11 prompts to write different types of suicide-related content common in public media, each in five writing/content styles (broadsheet news report, tabloid news report, adult fiction, teen fiction, social media influencer). We used 3 × 2 chi square tests to compare characteristics of the outputs particularly related to adherence to responsible media guidelines for suicide reporting and overarching narratives. Results: AI outputs were generated from March 12 to July 11, 2024. A total of 147, 263, and 143 responses from GPT-4, Grok, and ERNIE were analyzed, respectively. Willingness to respond to suicide-related prompts and narrative content varied substantially across the three LLMs, with Grok producing more responses than the other two (GPT-4 = 53%, Grok = 96%, ERNIE = 52%). GPT-4 was more likely to generate emotionally supportive and antistigma messaging. Grok more frequently included harmful details such as suicide methods and romanticized portrayals. ERNIE emphasized male suicide, social support, and societal/community solutions. The proportion of outputs communicating stories of hope and recovery from a suicide crisis was both relatively low and consistent across the LLMs (16-22%). Limitations: This study examined specific prompts posed to three specific LLMs during a single epoch of time. Conclusions: LLMs produce a variety of suicide-related story content when prompted. Some stories, particularly those generated by Grok, were inconsistent with responsible media guidelines and only a minority of stories focused on hope and recovery. Engagement with AI companies to promote safer and more accurate suicide-related content is warranted as the use of LLMs continues to expand.
Background: Clozapine is associated with decreased insomnia and suicidal ideation and behavior (SIB), both of which are prevalent in psychiatric disorders. Aims: To consider effects on insomnia underlying the antisuicidal properties of clozapine, we investigated the reported odds of suicidal ideation, suicide attempt and/or suicide death with and without concurrent insomnia as spontaneously reported psychiatric adverse drug reactions (ADRs) in adults using clozapine compared to other second-generation antipsychotics (SGAs) for schizophrenia or schizoaffective disorder. Methods: We searched the US FDA Adverse Event Reporting System from inception through September 2024 for which an SGA used for schizophrenia or schizoaffective disorder was the suspected agent of a psychiatric ADR. Results: Compared to clozapine, the unadjusted reported odds of concurrent insomnia and suicidal ideation (rORs = 1.39-3.44) were significantly increased for all other SGAs. Similarly, compared to clozapine, the unadjusted reported odds of concurrent insomnia and suicide attempt/death (rORs = 2.32-4.76) were significantly increased for all other SGAs. Controlling for age and sex did not change the pattern of findings. Our findings are consistent with existing evidence for decreased insomnia and SIB in individuals taking clozapine for schizophrenia or schizoaffective disorder. Limitations: Rigorous longitudinal studies with established measures of sleep and suicide are warranted to investigate this mechanism. Conclusion: Compared to clozapine, all other SGAs were associated with increased reported odds of concurrent insomnia SIB. Findings provide additional evidence for improved sleep as a potential pathway underlying the antisuicidal properties of clozapine.
Background: In Brazil, national surveillance indicates a rise in self-harm, but little is known about patterns of repeated presentations to healthcare services or changes in self-harm methods over time. Aims: To examine sociodemographic and clinical factors associated with two or more (repeated) presentations to healthcare services for self-harm, and to explore method switching among individuals presenting to healthcare services in Vitória, Brazil. Method: A retrospective cohort analysis was conducted using administrative data from the Brazilian Unified Health System in Vitoria City (Espírito Santo; 2012-2022). Records from the Notifiable Diseases Information System and e-SUS National Health Surveillance System were used to identify individuals with self-harm presentations. Modified Poisson Regression was employed to examine associations between repeated self-harm episodes and sociodemographic and clinical characteristics between 2018 and 2022. Results: Among 2,152 self-harm notifications, 69% involved repeated presentations. The results revealed that female sex [RR = 1.14, 95% CI: 1.06-1.23], presence of disorder [RR = 1.41, 95% CI: 1.27-1.57], and use of sharp objects [RR = 1.22, 95% CI: 1.12-1.32] were positively associated with repetition, whereas Black [RR = 0.87, 95% CI: 0.79-0.95], multiracial ethnicity [RR = 0.92, 95% CI: 0.87-0.98], and poisoning [RR = 0.92, 95% CI: 0.85-1.00] were negatively associated. Among those with multiple episodes, half re-presented within 77 days and three-quarters within 260 days. Method switching was common: 42% changed methods between their first and second episodes, with cutting most frequently transitioning to self-poisoning. Limitations: Findings rely on routine notification data, which vary in completeness. Some clinical information was based on collateral reports rather than diagnosis. Conclusion: Repeated self-harm presentations often occur within short intervals. High levels of method switching underscore the need for person-centered assessments.
Background: Crisis lines provide evidence-based suicide prevention support that often involves active listening, safety assessment, collaborative problem solving, and sharing resources (care as usual). Many crisis lines are also innovating by providing additional interventions to support service users. Aims: We conducted a scoping review of peer-reviewed literature to understand what crisis line interventions are currently used beyond usual care and which have been evaluated. Methods: We worked with a librarian to develop a comprehensive search strategy applied across six databases (PsycInfo, MEDLINE, Embase, CINAHL, Applied Social Sciences Index and Abstracts, and Web of Science). Results were screened by pairs of analysts. Data from eligible sources were extracted using a standardized form and synthesized by type of intervention. Results: We identified 42 relevant studies describing crisis line interventions other than care as usual. Of these, seven evaluated the intervention and four found support for the evaluated intervention. There are single-study evidence in support of: applied suicide intervention skills training (ASIST); a structured safety planning intervention; artificial intelligence (AI) to support messaging; and a crisis line-specific risk assessment scale developed in Beijing. The remaining studies described a variety of interventions including triaging, managing, and de-escalating crises; structured or standardized suicide risk assessment and safety planning; care coordination; and supporting responders using AI. However, these interventions were not formally assessed. Limitations: Variability in how interventions are described, operationalized, delivered, and evaluated limits comparisons across studies. Conclusion: Crisis lines continue to explore ways to meet the needs of the people they serve. However, many approaches have not been formally evaluated. More research and evaluation are needed in real-life contexts where information can be triangulated from various data sources (e.g., crisis line data, responder feedback, user experiences) to evaluate the impact and meaning of a given intervention.
Background: The World Health Organization (WHO) emphasizes surveillance of suicide and suicide attempts as a core component of national suicide prevention strategies. Aims: In Sri Lanka, police registers serve as the main source for national suicide reporting. This study evaluated the completeness of police suicide records by linking them with hospital and civil registration data and examining the extent to which suicide deaths identified across these sources were captured in police registers. Method: A secondary analysis was conducted on a case series of suicides identified through a prospective surveillance system established for a randomized controlled trial in Anuradhapura District, Sri Lanka (April 2019-September 2023). Police records were linked with hospital and civil registration data. Sensitivity and 95% confidence intervals (CIs) were calculated overall and stratified by hospital admission status and method of suicide. Results: A total of 663 suicide deaths were identified across the three sources, with 310 reported by all. Police registers recorded 615 deaths, with a sensitivity of 91.0% (95% CI: 86.8%-93.8%) for hospital deaths and 94.0% (95% CI: 91.2%-95.8%) for nonhospital deaths. Method-specific sensitivity was 93.2% (95% CI: 89.1%-95.8%) for pesticide ingestion (n = 237), 70.7% (95% CI: 55.5%-82.6%) for nonpesticide poisoning (n = 41), 97.3% (95% CI: 94.8%-98.7%) for hanging (n = 336), and 77.6% (95% CI: 63.6%-87.0%) for other methods (n = 49). Limitations: Findings are limited to one district and may not be generalizable nationally. Conclusions: Police registers are a largely comprehensive source of suicide data in Sri Lanka, although some cases are missed, particularly for less common methods. This underreporting suggests national suicide rates may be slightly underestimated. In countries lacking a WHO-recommended robust civil registration and vital statistics system, police data remain an important source for suicide surveillance and public health planning.
: Background: Previous research has showed that exposure to a postsuicide railway announcement stating that a delay was due to a collision with a person yielded suicide associations and negative emotions. In 2021, the Dutch Railways implemented a new announcement that simply stated a collision had occurred, but its impact has not yet been tested. Aims: This follow-up study investigates the impact of this new announcement on suicide-related explicit associations, negative and positive emotions, and announcement appreciation. We compare it to the previously used announcement collision with a person, as well as to announcements stating that a delay was due to the presence of emergency services and to a collision with an animal (control announcement). Method: A randomized controlled online experiment was conducted in which participants (N = 346) were exposed to one of eight conditions varying across two factors: announcement and personal relevance of the delay. Participants were recruited from the Dutch railway customer panel. Results: The new announcement stating that a delay was due to a collision was less likely to yield associations with suicide than the collision with a person announcement, but more likely to elicit suicide associations compared to the announcement indicating presence of emergency services. However, the latter was the least appreciated delay announcement. Regarding positive and negative emotions, the new collision announcement did not significantly differ from the other announcements. Personally relevant delays yielded greater suicide associations and stronger negative emotions than nonrelevant delays but more willingness to help other passengers. Limitations: The extent to which the scenarios used in the online experiment reflect real-life situations may be limited. Conclusion: Announcement of collision or emergency services is more appropriate than stating collision with a person in a delay announcement.
Background: Despite increasing use of Google Ads in public health campaigns, few studies have described their use in suicide prevention and/or examined application to lethal means safety (LMS), a priority for suicide prevention efforts in military veterans. Aims: The objective of this study was to evaluate the effectiveness of an LMS campaign for US veterans by analyzing engagement rates across different types of Google Ad search terms included in the campaign. Methods: We conducted a secondary data analysis of Google Ads from July 2022 and May 2023 in Keep It Secure, the Department of Veterans Affairs (VA) first national LMS campaign. Our primary outcome was click-through rate (CTR). Our predictor variable was category of Google search. Categories were identified from the user queries employing a team-based immersion/crystallization process, an inductive, iterative qualitative approach. We then used generalized mixed modeling to compare CTR across search categories. Results: Using Google Ads, the campaign resulted in a total of 1,849,077 impressions and 342,747 clicks to the campaign website, for an overall 18.5% CTR of 59,587 unique searches, and we categorized 47,387 into 10 categories (Firearm Storage, General VA Inquiries, Veteran Resources, Suicide Prevention, Mental Health, Crisis Line, Suicidal Ideation, Safety Class, Firearm Policy, and Homelessness). Campaign engagement varied significantly across categories (p < .001). Searches related to general VA inquiries (30.0% CTR) and veteran resources (23.0% CTR) demonstrated the highest engagement, whereas firearm storage (4.6% CTR) and suicidal ideation (1.3% CTR) were the lowest. Limitations: Since this study was a secondary analysis, causal inferences cannot be made. Conclusions: Google Ads resulted in high overall engagement in an LMS educational campaign. For LMS outreach to veterans who are not in acute crisis, a "side-door" approach targeting people searching for general VA information and veteran benefits and resources may be more effective than using firearm or suicide-related keywords.
Background: Despite increasing use of Google Ads in public health campaigns, few studies have described their use in suicide prevention and/or examined application to lethal means safety (LMS), a priority for suicide prevention efforts in military veterans. Aims: The objective of this study was to evaluate the effectiveness of an LMS campaign for US veterans by analyzing engagement rates across different types of Google Ad search terms included in the campaign. Methods: We conducted a secondary data analysis of Google Ads from July 2022 and May 2023 in Keep It Secure, the Department of Veterans Affairs (VA) first national LMS campaign. Our primary outcome was click-through rate (CTR). Our predictor variable was category of Google search. Categories were identified from the user queries employing a team-based immersion/crystallization process, an inductive, iterative qualitative approach. We then used generalized mixed modeling to compare CTR across search categories. Results: Using Google Ads, the campaign resulted in a total of 1,849,077 impressions and 342,747 clicks to the campaign website, for an overall 18.5% CTR of 59,587 unique searches, and we categorized 47,387 into 10 categories (Firearm Storage, General VA Inquiries, Veteran Resources, Suicide Prevention, Mental Health, Crisis Line, Suicidal Ideation, Safety Class, Firearm Policy, and Homelessness). Campaign engagement varied significantly across categories (p < .001). Searches related to general VA inquiries (30.0% CTR) and veteran resources (23.0% CTR) demonstrated the highest engagement, whereas firearm storage (4.6% CTR) and suicidal ideation (1.3% CTR) were the lowest. Limitations: Since this study was a secondary analysis, causal inferences cannot be made. Conclusions: Google Ads resulted in high overall engagement in an LMS educational campaign. For LMS outreach to veterans who are not in acute crisis, a "side-door" approach targeting people searching for general VA information and veteran benefits and resources may be more effective than using firearm or suicide-related keywords.
Peer support specialist services aimed at reducing suicide risk are becoming more prominent in professional roles in healthcare systems and community settings. Such services may directly or indirectly contribute to suicide prevention efforts. Despite some evidence suggesting the feasibility and acceptability of this strategy, major research gaps exist regarding effectiveness and sustained implementation success. The National Institute of Mental Health convened a 2-day workshop in February 2024 to inform the field on the state of the science in peer support suicide prevention research. This summary presents several cross-cutting challenges in research on peer support in suicide prevention and how they can be addressed.
Background: Newspapers can highlight sociocultural assumptions of acceptable gender behavior that are used to frame suicide, with males depicted as aggressive and independent, and females portrayed as dependent and submissive. Aims: This mixed-methods study builds on existing research by examining how female suicide is reported in Indian newspapers. Method: The database Pressreader was used to identify English-language newspaper articles in India that covered suicides between May 2021 and May 2022. In total, 205 articles were identified. Descriptive statistics and critical discourse analysis were used to explore the data in the articles. Results: Themes such as the possible misclassification of the death of minors, the use of euphemism to describe certain relationships, and attribution of blame through the criminal charge of abetment to suicide were identified. Women's suicides were usually framed as a result of interpersonal problems and viewed sympathetically. Limitations: Analyzing traditional broadsheets and local language newspapers, as well as comparing gender differences would allow for more robust conclusions to be drawn about reporting styles in India. Conclusion: This study provides recommendations, such as the use of reporting guidelines that are country-specific, and the need for further research that focuses on newspaper reporting and perception of suicide in India.
: Background: Veterans separating from military service are at disproportionate risk for suicide underscoring the need for strategies to increase treatment seeking among this group. Public health campaigns are a popular community-level strategy used to facilitate help seeking in veteran populations. Yet current knowledge of what types of messages effectively change related behaviors among at-risk veterans is extremely limited. Aims: The primary objective of this study was to identify feasible, acceptable public messages that increase the likelihood for treatment seeking among at-risk veterans surrounding military separation. Method: Semistructured telephone interviews (N = 21) were conducted with at-risk veterans recently separated from the military from July 2021 to July 2022. The interview guide examined the mechanisms of persuasive communication. Interview transcripts were analyzed using a constant comparison analytic strategy. Results: Acceptable suicide prevention messages involved authentic veteran stories of seeking help to better navigate life stressors experienced during transition. Messages were believed to be particularly effective if framed to support the veteran in making informed decisions about their own health. Possible adverse responses were also reported. Limitations: Findings are subject to several biases inherent to qualitative methods and are not generalizable to the larger targeted population. Conclusion: This study points to promising messaging areas as well as potential obstacles for effectively promoting help seeking during separation from military service.
Background: Burns are a major global public health issue, causing 180,000 deaths worldwide each year. Self-inflicted burns are more prevalent in low- and middle-income countries and are associated with high morbidity and mortality. Understanding its frequency, demographics, and contributing factors is critical for prevention. Aims: To determine the frequency, demographic distribution, methods, and outcomes of self-inflicted burns (self-harm and suicide) in Pakistan. Methods: This scoping review followed Arksey and O'Malley's framework. We searched MEDLINE (PubMed), Google Scholar, SCOPUS, PakMediNet, and gray literature via Open Access Theses and Dissertations up to December 2023. Studies on self-inflicted burns in Pakistan were included without date restrictions. Two reviewers independently screened articles, and data were extracted using a structured form and analyzed descriptively. Results: A total of 67 studies were included, comprising 1,684 cases of self-inflicted burns of 50,283 total burn cases (3.35%). Of 67 studies, two focused solely on self-inflicted burns, 19 on burns generally, and 46 on suicide/self-harm involving burns. Of these, 39% (n = 661) were suicide and 61% (n = 1,023) were self-harm. Sex distribution was reported in 33 studies, with 443 males and 564 females affected. The method of self-inflicted burns was specified in 21 studies, including 11 studies on self-immolation and 10 on fire/flame burns. Mortality data were reported in eight studies, indicating a 42% mortality rate (143/340 cases) and a 54.7% survival rate (186/340 cases). Only 25% of the studies had authors from a mental health background, and psychiatric comorbidities or referrals to psychiatric services were rarely documented. Sociodemographic and clinical variables (age, occupation, marital status, burn extent) were frequently not reported. Limitations: A key limitation is the reliance on authors' classification of intent, which may be subject to misclassification. Discussion: Self-inflicted burns are a significant public health concern in Pakistan, particularly among females. Incomplete reporting of age, occupation, and burn extent limits understanding of at-risk groups. A national surveillance system is needed to track trends and identify high-risk populations. Integrating psychiatric evaluations into burn care can enhance outcomes and suicide prevention.
Background: In 2018, the Missouri Department of Mental Health was awarded a five-year federal grant to provide immediate mental health services to adults 25 years and older presenting at emergency departments (EDs) or admitted to inpatient psychiatric units (IPUs) for suicide attempts or suicidal ideation. Trained suicide prevention professionals from two mental health agencies were placed in hospitals or immediately contacted by hospital staff to recruit suicidal adults into mental health services, eliminating the need for patients to follow-up on referrals themselves. Aims: This article explored the effectiveness of these programs in reducing suicide attempts, IPU hospitalization, ED visits and suicidal ideation. Method: The researchers used a repeated-measures design to explore changes in these outcome variables between program intake and three months after intake. Results: Analyses revealed highly significant reductions of all outcome variables regardless of age, gender identity, race, referral source, or provider. Limitations: Due to limited funding, the research design could not include a control-group design or methods to reduce attrition at follow-up. Conclusion: The findings from this continuity-of-care approach suggest program replication within other hospital systems.
: Background: Globally over 720,000 deaths yearly are due to suicide, approximately 20% due to pesticide self-poisoning. Poor school-connectedness has been shown to be associated with increased risk of suicidal thoughts and behaviors in high-income countries, while good school-connectedness is protective of suicidality. This study investigated associations between poor school-connectedness and self-poisoning in a low- and middle-income country. Methods: We used data collected in a hospital-based case-control study in rural Sri Lanka. Cases (n = 298) were adults admitted due to self-poisoning, and controls (n = 596) frequency matched on age and sex. Structured interviews assessed school-connectedness using four questions, and data on confounders (ethnicity, parental migration, child adversity, and parental education) were also collected. Associations were quantified using logistic regression. Results: Individuals with poorer relationships with other students (OR = 1.90, 95% CI 1.22, -2.95) and lower levels of school enjoyment (OR = 1.34, 95% CI 0.94, -1.92) were more likely to present for self-poisoning in adulthood. They were also more likely to report poor relationships with teachers, but this relationship was not as strong (OR = 1.30, 95% CI 0.90, -1.88). Limitations: The questionnaire used is not validated in this setting. Additionally, this is a retrospective study using a hospital sample, which may be impacted by recall bias and/or excluding individuals who did not seek hospital treatment. Conclusions: Interventions to improve school-connectedness in Sri Lanka, with a particular focus on relationships between students, may reduce self-poisoning in adulthood. Further research is needed to explore how to achieve this, and to understand the reasons for association between school-connectedness and self-poisoning.
Background: Little is known about the underreporting of suicide deaths to the police in India. Aim: To document the extent and reasons of underreporting suicide deaths to the police by socio-demography of the deceased in India. Methods: Interviews documented if a suicide death was reported to the police for suicide deaths that occurred between 2019 and 2022 in India, identified as part of a national all-cause mortality survey in nine states. Further interviews in three of these states explored the reasons for underreporting of suicide deaths to the police. Results: The prevalence of underreporting suicide deaths to the police in India was 35.5% (95% CI 30.8, -40.6), 34.1% (95% CI 28.5, -40.2), and 38.6% (95% CI 30.1, -47.9) for both sexes combined, male, and female suicide deaths, respectively. The underreporting was significantly higher in 15-19 years (46.7%; 95% CI 32.7, -61.2) and in 50+ years (42.5%; 95% CI 32.1, -53.6) compared to those in 30-39 years (19.0%; 95% CI 10.8, -31.1). Avoidance of postmortem was the most cited reason for underreporting followed by compromise between the affected parties, with variations in reasons seen by sex of the deceased and state. Concerns related to social stigma, maintaining family reputation, and securing custody of young children were mentioned as reasons more for female than male suicide deaths. Limitations: Underreporting estimates rely on self-report subject to recall and social desirability bias. Reasons for nonreporting were collected postevent and may not reflect real-time family or community decision-making. Conclusion: One in three suicide deaths are not reported to the police in India, with variations in this underreporting by age, urbanicity, and state of the suicide deaths. These findings can allow for developing targeted awareness campaigns and community engagement in high underreporting areas rather than a one-size-fits-all approach, and simplifying the police protocols around postmortem can help to reduce this underreporting.
: Background: Suicide-related media reporting can influence suicidal thoughts and behaviors. Stories describing suicide methods can increase suicides (Werther effect), whereas those highlighting coping with suicidal crises can prevent them (Papageno effect). Aims: To assess the impact of media guidelines for suicide reporting on reporting quality and suicides. Method: Following PRISMA guidelines, we searched PubMed, Scopus, Embase, PsycInfo, and Web of Science up to February 10, 2025, with an update on November 17, 2025. We included ecological pre-post studies assessing changes in reporting quality and time-series analyses assessing changes in suicides after guideline release. Random-effects meta-analyses estimated pooled risk ratios (RRs) for reporting quality and incidence rate ratios (IRRs) for suicides. Results: Fifteen studies from 11 countries (2003-2025) were included (14 on reporting quality, three on suicides, two measuring both). Following guideline release, reporting quality improved for "Do educate the public about the facts of suicide and suicide prevention based on accurate information" (k = 13, RR = 1.56, 95% CI = 1.30, -1.88), "Don't describe the method used" (k = 12, RR = 1.33, 95% CI = 1.15, -1.53), and "Don't oversimplify the reason for a suicide or reduce it to a single factor" (k = 0, RR = 1.16, 95% CI = 1.02, -1.33). For other recommendations, pooled estimates generally favored the guidelines but were often imprecise, and in some cases, had substantial heterogeneity. We could not draw firm conclusions on their impact on suicides as only three studies assessed this outcome. Contour-enhanced funnel plots and Egger's tests suggested possible small-study effects for some recommendations. Limitations: All included studies included ecological before-and-after designs. Implementation strength was inconsistently reported, preventing analysis of its influence. Conclusions: Media guidelines appear to improve several aspects of reporting quality. Although evidence for impact on suicides is limited, guidelines are unlikely to cause any harm and may confer benefits through improved reporting standards. Further research is urgently needed to quantify their impact on suicides.
Background: Suicide remains a leading cause of early mortality, particularly among young adults under 35 years, with college students showing high rates of suicidal ideation and attempts. Student-veterans represent a unique group facing distinct stressors that may increase suicide risk compared to their nonmilitary counterparts. Aims: This study aimed to examine the relationships among military service history and suicidal ideation, planning, and attempts among college students. Specifically, this investigation tested whether depressive symptoms and feelings of belonging mediate these relationships. Method: To answer these questions, this study analyzed data from 119,664 respondents aged 18-45 years drawn from the 2020-2021 Healthy Minds Study, a national survey of mental health among US college students. Generalized structural equation modeling was used to test the mediating influence of depression (PHQ-9 scores) and belonging on the relationship between military service and suicide outcomes, adjusting for covariates and the complex sampling design. Results: Military service was significantly associated with higher levels of suicidal ideation (β = .391, 95% CI [0.095, 0.684]) and suicide planning (β = .531, 95% CI [0.123, 0.940]), but not suicide attempts (β = .637, 95% CI [-0.057, 1.360]). Depression and low belonging were strong predictors of suicidality. Indirect-effect analysis indicated that belonging was the only significant mediator of the association between military service and suicidal outcomes. Limitations: The limitations of this study include the cross-sectional design, self-reported data, voluntary participation of institutions, and relatively low prevalence of suicide attempts which reduced statistical power. Future longitudinal and qualitative studies are needed to validate findings and explore moderating factors. Conclusion: Military-affiliated college students have higher risk for suicidal ideation and planning. This relationship was partially explained by reduced feelings of belonging. Interventions to increase campus social integration among student-veterans have the potential to mitigate suicide risk in this population.
Background: Nondisclosure of suicidal thoughts is common and impedes suicide prevention. Consistent predictors of suicide disclosure have not been identified, and it is unclear how depression impacts various aspects of disclosure. Disclosure occurs within relationships, but few studies have used social network measures to understand structure, quality, and functional factors influencing disclosure. Aims: This study aimed to understand whether social network characteristics predict likelihood to disclose suicidal thoughts and intent. Methods: N = 87 adults experiencing suicidal ideation and/or depressive, anxious, or psychotic symptoms completed an egocentric social network measure assessing relationship features, likelihood to disclose suicidal thoughts and intent, and perceived benefits and risks of disclosure for each network member. Participants also completed a general suicide help-seeking scale. Generalized estimating equations with participant-level clustering evaluated associations between disclosure likelihood (thoughts and intent) and structural, functional, and quality social characteristics, as well as perceived benefits (e.g., emotional support) and risks (e.g., embarrassment) of disclosure. Spearman's correlations assessed associations between disclosure likelihood and depression symptoms, as well as general help-seeking. Results: On average, networks had 4.7 people (SD = 1.7). Higher closeness and emotional support, but not network size, predicted greater likelihoods of disclosing suicidal thoughts and intent. Depression severity was negatively correlated with disclosure likelihood, and the association between emotional support and disclosure likelihood was attenuated at higher depression levels. Perceived benefits, but not risks, were correlates of disclosure intentions. Limitations: Analyses were cross-sectional; it is unknown how social network changes would influence future disclosure. Most of the participants were not experiencing active suicidal ideation, which limits generalizability to more acutely distressed populations. Conclusions: Social network measurement facilitates understanding of suicide disclosure, and quality and functional aspects of relationships may be more impactful than structural aspects. Depression severity may attenuate the positive influence of emotional support on disclosure. Increasing perceived benefits of disclosure could be a novel suicide prevention strategy.
