BACKGROUND:Theatre interventions such as psychodrama are increasingly being used to help individuals with mental health conditions. Previous findings provided mixed results on the impact of theatre interventions for reducing psychological symptoms. Given the growing use of theatre interventions, it is important to investigate their impact on specific mental health conditions. This systematic review and meta-analysis aims to examine the impact of theatre interventions on mental health outcomes and suicidality. METHODS:The review was prospectively registered on The International Prospective Register of Systematic Reviews (CRD42021212666), and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines for reporting. Embase, ProQuest Central, PsycInfo, PubMed and Scopus were searched. All English-language studies examining the impact of theatre interventions and on mental health outcomes and/or suicidality were included. RESULTS:In total, 42 papers met the inclusion criteria. Of these, 21 studies were included in meta-analyses that found significant reductions in standardised mean change using raw score standardisation symptoms of anxiety (k=10; -0.45 (95% CI -0.71 to -0.19)) depression (k=16; -0.79 (95% CI -1.07 to -0.51)) and post-traumatic stress disorder (k=6; -0.82 (95% CI -1.21 to -0.42)) among adult participants of theatre intervention studies. Results from studies excluded from meta-analyses indicated that theatre interventions helped reduce symptoms of schizophrenia and psychosis for adults and lowered the risk of suicidal ideation and suicide attempt among adolescents. Most studies had a high/serious risk or some concerns about bias. CONCLUSION:Theatre interventions may be useful to help reduce symptoms of mental health conditions. Further high-quality research is necessary to build on the existing evidence and to assess both the short- and long-term impacts of theatre interventions on mental health outcomes.

INTRODUCTION:Suicide rates remain elevated for current and ex-serving military populations, yet the effectiveness of suicide interventions for these populations is unclear. Therefore, a synthesis and analysis of interventions is needed. This systematic review and meta-analysis aims to identify which interventions may be effective for suicidal ideation and behaviors among current and ex-serving military personnel. METHOD:This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Datasets were drawn from the Suicide Prevention Trials Database. Meta-analyses of randomized controlled trials were conducted using standardized mean change for suicidal ideation and pooled log odds ratio for suicidal behaviors. RESULTS:In total, 24 studies were eligible. Most studies were randomized controlled trials (n = 17) from the United States (n = 21) and comprised indicated interventions (n = 17). Meta-analyses found no significant pooled effects for suicidal ideation and behaviors. Moderation analyses found that care management, follow-up, or monitoring; and nonpharmacological biological interventions were more effective than behavioral interventions for suicide attempts. Selective, multicomponent interventions demonstrated encouraging outcomes. CONCLUSION:The review found no evidence of overall effects for the current interventions on suicidal ideation and behaviors. Future interventions should be based on suicide theories and co-developed with individuals with military and suicidality lived experience.

Background Suicidality can extend beyond the acute phase and be a long-term condition. Known by various terms, including chronic or persistent suicidality (PS), this phenomenon is well recognized in clinical practice. However, a comprehensive synthesis and evaluation of the literature is missing, leaving the scope and focus of the current scientific evidence on PS unclear. Aims This review aims to identify and critically appraise the literature on PS. It seeks to provide an overview of how the evidence defines and operationalises PS, its occurrence, and the characteristics of individuals affected by it. Method A systematic scoping review was conducted following the PRISMA-ScR guidelines. After preregistration, searches were conducted in six databases: Embase, PubMed, APA PsycInfo, Web of Science, Scopus, and ERIC. Articles describing individuals with suicidal ideation or a death wish lasting a year or longer were included. Quality appraisal was performed using the National Institute of Health's quality assessment tools. Due to the pluriformity of the literature a narrative synthesis was conducted. Results In total, 63 articles met the criteria for inclusion. Around one-third of individuals experience suicidal ideation that persist over the long term. There is a strong overall association between PS and psychiatric or psychological distress. Results suggest that specific variables may help differentiate between individuals with transient suicidal ideation and those at risk for PS. Conclusions Despite sufficient quality of most studies reporting PS, the field is hindered by inconsistent operationalisations and a lack of study replication. This study highlights the need for a uniform understanding of PS and proposes a provisional definition.

OBJECTIVES:Mental health providers (MHPs) hold varying attitudes about suicide prevention, and these beliefs can impact personal and client well-being. To date, suicide prevention attitude measures are limited by appropriate population use, poor psychometrics and a lack of theoretical foundation. The present study rectified a measurement gap in the literature by articulating initial development of the Inventory of Clinician Attitudes about Suicide Prevention (ICASP). DESIGN:MHPs (N = 410) across three countries (United States, Canada and Australia) took part in a cross-sectional online survey about suicide prevention competencies. METHODS:A community-engaged convenience sampling approach was used followed by splitting the sample to perform parallel exploratory factor analysis and item response theory analyses. RESULTS:Analyses yield a four-factor ICASP with 22 items: (1) Clinician's Approach (ω = 0.79); (2) Clinician Avoidance (ω = 0.76); (3) Moral Rights (ω = 0.84); and (4) Clinician Comfort (ω = 0.72). Exploratory findings suggest convergent validity via significant, yet modestly sized, correlations with attitudes glorifying suicide and three elements of compassion fatigue (i.e. compassion satisfaction, burnout and secondary traumatic stress). CONCLUSIONS:The ICASP represents a promising tool for measurement of MHP suicide prevention attitudes in clinical supervision, self-reflective practice and training evaluation. Findings support portions of the Dynamic Balance Model of MHP suicide prevention attitudes. Future psychometric research directions are discussed.

Background: Although there have been assumptions about the link between eco-emotions and suicidality, there is currently no systematic evidence. Aim: To systematically examine literature analyzing the link between eco-emotions and suicidal ideation and behaviors. Methods: A systematic literature review, registered in PROSPERO (CRD42022352379) following the PRISMA checklist, involved searches in seven databases for peer-reviewed articles published from January 2000 until January 2026. All study designs that presented primary empirical analyses of eco-emotions in connection with suicidal ideation and behaviors were included. The Joanna Briggs Institute's tools were used for quality assessment. Results: Searches revealed 2,074 records. After removal of duplicates, 1,505 articles were screened for abstracts and 79 for full text. Twelve papers satisfied the inclusion criteria: eight cross-sectional, two qualitative studies, a quasiexperimental, and a case report. Eight studies statistically analyzed the link between eco-emotions and suicidality on individual level. The univariate analyses showed positive correlations between different eco-emotions and suicidality. However, in some studies, the multivariate analyses, adjusting for confounding factors, found the association to be mediated by other factors such as mental health or feelings of entrapment. Limitations: Our searches were limited to English language. Conclusions: There is limited research regarding the association between eco-emotions and suicidality. Our review suggests an association between eco-emotions and suicidality, which might be mediated by other factors. Caution needs to be exercised in the interpretation of these results considering the design limitations of the studies. In keeping with advancing climate change research, our review emphasizes an urgent need for high level research.

Suicide prevention training programs can enhance the capacity for suicide prevention by improving the attitudes and comprehension of individuals regarding suicide and increasing their skills in supporting a suicidal person. However, little is known about how training programs are implemented and how implementation is assessed. Thus, our review aims to identify the strategies and evaluation methods underpinning the implementation of suicide prevention training programs. The systematic review adhered to the PRISMA guidelines and involved searches in MEDLINE, Embase, Emcare, PsycINFO, EBM Reviews, Scopus, and a forward and backward citation search following the full-text screening. Eligible studies (n = 28) reported the implementation strategy or implementation evaluation of a suicide prevention training program (PROSPERO #CRD42021288621). The implementation strategies varied among three categories of training programs. Gatekeeper training predominantly utilized a train-the-trainer format and collaborations with stakeholders. Professional development training focused more on establishing supportive organizational infrastructure and extended post-training supervision. School-based curriculum training programs emphasized the distribution of educational materials and role-play activities. Surveys were the primary evaluation method, often complemented by interviews, observations, progress tracking, or focus groups. Evaluations primarily assessed acceptability, fidelity, and feasibility. While certain training categories tend to employ specific strategies and evaluation measures more frequently than others, stakeholder collaboration, assessing content relevance, and follow-up supervision could be valuable across training programs. Tailored strategies may cater for groups with varying levels of knowledge and training in suicide prevention to enhance acceptability and feasibility. Future research should evaluate approaches that facilitate adoption and sustainability of suicide prevention training programs.

IntroductionOnline chat services have increased mental health care access for young people (12–25 years), yet their effectiveness remains unclear. This is partly due to a lack of consensus about primary client outcomes and clinician actions facilitating positive service outcomes. This study sought to identify (a) outcomes most important for young people accessing mental health support via online chat, and (b) clinician actions most relevant to achieving these outcomes.MethodA comprehensive list of potential outcomes and actions was developed through literature review and consultation with youth online chat service providers. A three-round Delphi study was conducted with three panels of youth, researchers, and clinicians (n = 100; 84% retention rate), primarily from Australia and Ireland. Consensus was reached if ≥75% of participants within at least two panels rated an outcome/action as very important or essential.ResultsEleven client outcomes reached consensus: Feeling heard and validated; Reduced distress; Increased help-seeker capacity; Feeling safe; Optimism and hope; Connection with clinician and service; Feeling better; Reduced hopelessness; Reduced overwhelm; Increased coping; and Goals, answers and direction. Fifteen clinician actions reached consensus: Manage risk; Respect diversity; Validation; Welcoming environment; Active listening; Manage distress; Compassion; Checking in; Give choice; Youth friendly; Set expectations and focus; Provide resources; Holistic approach; Highlight strengths; and Problem-solving.ConclusionsThe identified client outcomes and clinician actions offer preliminary guidance for monitoring and evaluating youth online chat support. Future research should test and refine these domains within service contexts to inform robust measurement tool development for evaluating youth online chat services.

Our study explored the link between body mass index (BMI) and symptoms of depression, anxiety, and suicidality among university students in China. We conducted a cross-sectional study involving 11 251 undergraduates from seven provinces. Body mass index, physical health status, economic status, depression and anxiety symptoms, and suicidality were self-reported using validated questionnaires. Multiple logistic regression models were fitted for males and females. Results showed that of 11 251 participants (mean age = 20.7 ± 1.3), 22.6% were with underweight, 6.1% with overweight, and 2.7% with obesity. Females with class III obesity had higher suicide risk (adjusted odds ratio [aOR] = 2.05) and suicide attempt history (aOR = 3.55). Males with overweight and class I obesity had lower odds of depressive symptoms. Suicide attempt history was associated with higher odds of overweight for males (aOR = 2.58). Clinicians and public health authorities should take into consideration the implications of overweight and obesity levels on suicidality.

Objective: People with different psychiatric diagnoses use certain suicide methods more frequently. These findings could have implications for reducing suicide. Therefore, the aim of this study was to assess associations between three severe mental illnesses (SMIs) and suicide methods, while adjusting for other confounding factors that could influence choice of suicide methods.Methods: We used information on all individuals dying by suicide in Queensland, Australia, from 1989 to 2021. Methods were compared to hanging, strangulation and suffocation for people with three different SMIs with adjusted risk ratios in multinomial logistic regression models.Results: People with psychotic disorders were over three times more likely to jump from a high place, jump or lie before a moving object, or use a sharp object. They were also more than twice as likely to use explosive material or smoke, fire and flames; or drowning and submersion and 60% more likely to use crashing of a motor vehicle. Poisoning by drugs was around 50% higher in those with psychotic disorders or depression. No other methods were substantially elevated relative to hanging, strangulation and suffocation (HSS). People with bipolar and depression had a lower risk ratios (RR) for several suicide methods.Conclusion: People with psychotic disorders were the most likely to use diverse methods and would benefit the most from means restriction interventions. Trialling interventions to ensure that people with psychotic disorders can avoid situations where they could use these methods may reduce suicides in this group. Further analysis of what drugs people with depression and bipolar might use is needed.

Objectives:Suicide research and prevention are complex. Many practical, methodological and ethical challenges must be overcome to implement effective suicide prevention interventions. Implementation science can offer insights into what works, why and in what context. Yet, there are limited real-world examples of the application of implementation science in suicide prevention. This study aimed to identify approaches to employ principles of implementation science to tackle important challenges in suicide prevention. Methods:A questionnaire about promoting implementation science for suicide prevention was developed through thematic analysis of stakeholder narratives. Statements were categorised into six domains: research priorities, practical considerations, approach to intervention design and delivery, lived experience engagement, dissemination and the way forward. The questionnaire (n=52 statements-round 1; n=44 statements-round 2; n=9 statements-round 3) was administered electronically to a panel (n=62-round 1, n=48-round 2; n=45-round 3) of international experts (suicide researchers, leaders, project team members, lived experience advocates). Statements were rated on a Likert scale based on an understanding of importance and priority of each item. Statements endorsed by at least 85% of the panel would be included in the final guidelines. Results:Eighty-two of the 90 statements were endorsed. Recommendations included broadening research inquiries to understand overall programme impact; accounting for resources in the translation of evidence into practice; embedding implementation science in intervention delivery and design; meaningfully engaging lived experience; considering channels for dissemination of implementation-related findings and focusing on next steps needed to routinely harness the strengths of implementation science in suicide prevention research, practice and training. Conclusion:An interdisciplinary panel of suicide prevention experts reached a consensus on optimal strategies for using implementation science to enhance the effectiveness of policies and programmes aimed at reducing suicide.

Suicide is a growing public health concern in Brazil, with significant increases in mortality rates over the last decade and disparities among vulnerable populations. This study aimed to systematically synthesize the recent literature reviews on suicidality and suicide prevention in Brazil, providing an overview of key findings, research gaps, and implications for future studies. This systematic review of reviews follows a pre-registered PROSPERO protocol (CRD42024561892). Searches across five databases (MEDLINE, Scopus, CINAHL, SciELO and LILACS) identified 10 eligible reviews, published between 2019 and 2024, including systematic, integrative, narrative reviews, and meta-analyses. The reviews examined populations such as Indigenous peoples, adolescents, university students, older adults, and healthcare professionals. Findings showed that the risk of suicidal behavior was associated with mental health conditions, social vulnerability, and limited access to mental health services. Particularly high suicide rates were observed among Indigenous populations and adolescents. Across reviews, a lack of interventional studies, limited geographical coverage, and the inadequate training of health professionals were recurrent themes. This review highlights the urgent need for culturally sensitive suicide prevention strategies, greater research investment in underserved populations, and improved healthcare training and coordination. These findings aim to support the development of more effective national suicide prevention policies.

Background Presentation to the emergency department (ED) with an index episode of self-harm is recognised as a risk factor for subsequent repeated self-harm and suicide. We describe demographic and clinical characteristics of adults (>18 years) presenting with mental health problems and self-harm to EDs in Queensland, Australia, and identify risk factors associated with repeated self-harm and suicide. Methods This was a state-wide retrospective cohort study of adults presenting with an index self-harm presentation to any of the 27 public EDs in Queensland, Australia, over six years (1st January 2012 to 31st December 2017). We linked ED records with a state-wide death register. Primary outcomes were re-presentation with self-harm, or death by suicide. We constructed a multivariable Cox regression model to identify independent risk factors for re-presentation with self-harm, or death by suicide. We calculated the risk of repeated ED presentation for self-harm and suicide at 12- and 24-months. Findings During the study period, 43,797 individuals presented to Queensland EDs with a self-harm related diagnosis. Half of the cohort were female (n = 20,980, 47.9%) and under age 35 (n = 23,871, 54.5%). A quarter (n = 10,991; 25.1%) had a repeated episode of self-harm and 515 (1.2%) died by suicide. Socioeconomic disadvantage, arrival by ambulance, self-presentation, small/medium hospital size, less-urgent triage category, not admitted status and previous mental health or physical health visits were associated with a re-presentation with self-harm. Suicide was associated with male sex, older age, and hospital admission. The repeated self-harm risk was 18.9% (95%CI, 18.5%-19.3%) at 12-months and 24.3% (95%CI, 23.9%-24.7%) at 24-months. The suicide risk was 0.7% (95%CI, 0.6%-0.7%) at 12-months and 1.0% (95%CI, 0.9%-1.1%) at 24-months. Interpretation One in four people re-presented to ED with self-harm. Suicide was particularly associated with older males. Implementing evidence-based interventions to support people presenting to ED with self-harm should be a public health priority. Copyright (c) 2024 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

OBJECTIVE:Evidence for Gatekeeper Training (GKT) has shown that training outcomes are generally maintained at follow-up. Research on how improvements in GKT outcomes translate to intervention behavior is inconclusive, and some studies show that despite significant positive effects on GKT outcomes, there is no effect on GK behaviors. METHOD:A non-experimental pre-post and follow-up survey design was used with a sample of 60 participants who voluntarily completed one of 12 half-day (4-hour) GKT sessions. Path Analysis was applied to pre- and post-intervention training outcomes, and a third model assessed the behavioral effect of the change in participant scores from pre- to post. RESULTS:Suicide prevention knowledge retained by participants at 6-months after GKT was predictive of increased GK behavior in the 6-months following GKT. Knowledge at follow-up was the only significant predictor of behavior (p < .05), no other regression pathways were significant. CONCLUSIONS:Gatekeeper preparedness, efficacy, and reluctance outcomes were not predictive of GK behavior. The findings of this study represent a lack of understanding regarding how the specific aims of GKT are translated into intervention behavior to identify, intervene, support, and refer potentially at-risk individuals.

Background: This systematic review aims to update and extend the findings of an earlier review on the suicidogenic impact of natural disasters.Methods: A systematic search of research published in 17 bibliographic databases was conducted (PROSPERO CRD42020216722). The review following PRISMA checklist identified 64 primary studies, published between 2012 and 2022, investigating the association between natural disasters and suicidal behaviour and ideation.Results: The majority of studies related to natural disasters in Japan, China, USA, India and Australia. Over half the studies (n=39) investigated the impact of earthquakes. Other disasters included hurricanes, floods, tsunamis, droughts, wildfires, tornadoes and multiple disasters. Concerning suicide mortality (the most studied suicide-related outcome), there was variability in the suicidogenic impact of earthquakes depending on location, age, sex and time elapsed since the event. While there appeared to be an increase in suicide mortality following drought, investigations of hurricanes/tornadoes and floods found no evidence of suicidogenic impact. Findings relating to other suicide-related outcomes are more consistent, suggesting that exposure to droughts, hurricanes, tsunamis, floods, and other natural disasters is associated with increased risk of suicidal ideation and non-fatal suicidal behaviour. Limitations: Publications in languages other than English, French, Spanish, Italian and Portuguese may have been missed.Conclusions: The considerable inconsistency in the findings reported across these studies, particularly relating to suicide mortality, is noteworthy. This may reflect substantive (‘real’) differences in the impact of natural disasters on suicidal behaviour linked to the type of disaster, the socioeconomic and sociocultural context, the type of suicidal behaviour, or other explanatory factors.

Objective Effective suicide postvention services provide immediate and ongoing support for suicide loss survivors. This review synthesizes peer-reviewed and grey literature exploring which suicide postvention service models have demonstrated effectiveness in reducing distress and supporting recovery in families, friends, and communities impacted by suicide. Methods The scoping review adhered to the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We conducted searches in five databases which included MEDLINE, PsycINFO, Embase, EBM Reviews, and Web of Science for peer reviewed studies and through Google search for grey literature. Results We identified 19 peer-reviewed studies and 14 guidelines (2014-2024) from the US, Canada, Australia, New Zealand, and Europe, which varied in measures, settings, and populations but lacked quality and generalizability. Guidelines based on theoretical models, particularly the public health model, aligned postvention with addressing the diverse needs of suicide loss survivors. Conclusions The review identified potentially effective postvention components, such as the use of trained volunteers in support and therapy groups, workplace training programs and arts-based interventions, which could benefit those bereaved by suicide in Australia.

Background: There are increasing efforts to better understand suicidal behaviour among current and former military personnel in Australia. More research using innovative methodologies is needed to identify risk and protective factors that could be addressed within the military. Objective: To better understand perceived risk and protective factors associated with suicidal behaviour within the military context. Methods: Three groups of stakeholders were recruited: people with lived experience of suicide in a military context, military mental health clinicians, and researchers with expertise in suicide in a military context. Using concept mapping, participants individually generated risk and/or protective factors for suicidal behaviour in a military context, before organising and rating all statements. Data were collected, analysed, and visually represented using the GroupWisdom platform. Results: In total, 57 stakeholders participated in at least one stage of the study (i.e., brainstorming, sorting and/or rating). Brainstorming generated 97 perceived risk-factors and 63 perceived protective factors, which were thematically grouped by participants. A multidimensional scaling and hierarchical cluster analysis generated a 7-cluster solution for risk factors and a 5-cluster solution for protective factors. Most of the risk and protective factors rated highly both in terms of importance and feasibility for the military to address were from workplace-related clusters. Conclusions: The risk and protective factors for suicidal behaviours within a military context were identified on three social-ecological levels: workplace (community), relational, and individual. The results of this study may inform future suicide research and prevention activities targeted to military personnel.

BACKGROUND:Suicide is recognised as a significant issue in Guyana and several interventions have been implemented to improve media reporting practices. To our knowledge, Guyana is the only country in the world with a current restriction on the reporting of suicide incidents. This observational case series study aims to examine the impact of different media interventions on the quantity and quality of suicide-related newspaper reporting in Guyana from 2013 to 2023. This is the first study to compare the impact of the different types of media interventions and the second to assess the impact of media legislation. METHODS:Eligibility screening identified 1670 articles. Descriptive data extraction and quality assessment was conducted for a stratified random sample of 545 (32 %) articles using the WHO 16 item media assessment tool. Logistic regression and Joinpoint regression were performed to assess statistical significance. RESULTS:There was a significant sustained reduction in quantity of suicide-related reporting. Whilst adherence to protective reporting factors was low overall, there was a significant increase in the provision of support service contact provision. There were also significant reductions in the use of stigmatising language and reporting of suicide method. CONCLUSION:The overall improvement in quality is attributed to sustained media engagement, rather than the strength of any intervention. Guideline clarity, monitoring feedback, and applied training may be needed to achieve greater adherence to guidelines. The reduction in quantity of reporting is associated with a prominent media training and legislation.

The need for involvement of people with lived experience of suicide in the conduct of suicide research and intervention has been recognised in research and policy. However, there is limited understanding and guidance on how to support their genuine and safe engagement in suicide research. This qualitative study considered the perspectives of 19 people with lived experience of suicide, and 17 researchers engaged in suicide-related research to explore their needs, expectations and experience of co-produced suicide-related research. Data was collected between October and December 2020 via semi-structured interviews. Thematic analysis resulted in five themes: (1) towards co-production, (2) power imbalances, (3) heterogeneity of lived experience, (4) enhancing safety and (5) value of co-production. Participants considered lived experience involvement at all stages of research to improve research impact and outcomes. However, persisting power imbalances were experienced by participants and participatory approaches did not always align with existing research systems and organisational structures. Complexities identified by participants related to accommodating different skills, experiences and social identities of those with a lived experience perspective and balancing safeguarding principles with strength-based approaches that may capitalise on participants' existing strengths. Delphi guidelines developed from an associated consensus study on active involvement of people with lived experience of suicide in suicide research address some of the concerns mentioned by study participants and form a useful resource to guide future research endeavours.

IntroductionAlthough there has been some investigation into what works in suicide prevention, exploration into the mechanisms by which implementation strategies impact outcomes or how and why strategies work remains largely under-studied. Consequently, implementation efforts often lack a clear strategy, and may contribute little toward the desired outcomes. This study aims to explore and examine the role of context and mechanisms involved in the implementation of complex suicide prevention interventions.Methods and materialsIn-depth qualitative interviews were used to explore relevant stakeholder experiences of implementing complex suicide prevention interventions. Stakeholders (nine intervention leaders, five implementors and two lived experience advocates) from six interventions were purposively recruited for their experiences involved in implementing complex interventions in real-world settings. The Normalisation Process Theory translational coding manual was used to map data related to the primary and secondary constructs defined in the theory and its extensions.ResultsThree domains pertaining to implementation context, mechanisms, and outcomes (CMO) were explored. Participants expressed their agency by: using contextual influences to modify the design and plan for delivery; making adaptations to the form and function of interventions and characteristics of the implementation environment to suit intervention needs; and, leveraging the intervention environment to integrate the intervention into existing systems and practices. Activities and strategies served multiple mechanisms involved in: understanding what the work entails; who does the work; developing the capacity to implement the work; and, understanding the work. An interdependent and interacting relationship between mechanisms emerged. Outcomes related to: change in existing practices; the ways in which people are organised; changes in existing norms; and, incorporation of the intervention into daily practice were observed.ConclusionThis study is notable in its exploration of mechanisms underlying implementation of complex suicide prevention interventions. Data from this study can help inform the development, refinement and use of specific implementation strategies and understand the applicability of strategies across varied contexts. The study also demonstrates the use of an implementation theory to inform practice and potentially contributes to an understanding of what works, why, for whom and in what context. There is a need for a paradigm shift towards the use of more theory based and informed approaches to understand causal links between implementation strategies, context, mechanisms, and outcomes.

INTRODUCTION:Prevention of suicidal behaviour is complex, and a host of effective interventions have now been recognised in addressing this concern. However, adoption, delivery, and sustainment of these interventions within real-life settings is challenging; and the translation process, often overlooked. Examining the impact of context is necessary to explain how implementation outcomes are achieved and aid generalisability of findings. This study aims to explore factors influencing implementation outcomes (contextual determinants) across the implementation lifecycle of complex suicide prevention interventions. METHODS:A qualitative design was adopted. Semi structured interviews were conducted with 16 stakeholders (leaders, project managers/implementors, lived experience advocates) involved in implementation of complex suicide prevention interventions across the world. A purposive and snowball sampling approach was used to identify participants with requisite experiences. An understanding of determinants was deduced from participant narratives. These were mapped using the Exploration, Preparation, Implementation and Sustainment (EPIS) framework. RESULTS:Across different phases of implementation, outer context barriers were predominantly reported and pertained to service environmental factors, pre-existing dynamics, and engaging leadership. Several inner context barriers including individual characteristics, staffing and resources, and challenges in maintaining fidelity were reported during the implementation phase. Bridging factors (such as interrelationships and partnerships) were identified as important facilitators throughout different phases of implementation and levels of context. Implementation strategies related to stakeholder relationship building were prioritised across different phases of implementation. CONCLUSION:This study helps expand the notion of an evidence-base for complex suicide prevention interventions. Determinants salient across different levels of the social-ecology and phases of implementation address questions related to what works and under what circumstances.