Background The Toronto Transit Commission (TTC) operates the public transit system in Toronto, Canada. From 1954 to 1980, there were 430 suicide deaths/attempts on the TTC subway system. In 2011, TTC implemented Crisis Link, a suicide helpline to connect subway passengers with counsellors. Upstream factors such as media reporting about suicide incidents may also in fl uence suicidal behaviour. Our objectives were to investigate how Crisis Link and media reports about TTC suicide incidents in fl uenced suicide rates. Methods Suicide data were obtained from the TTC and Coroner, with Crisis Link data provided by Distress Centres of Greater Toronto (1998 - 2021). Media articles were identi fi ed through a database search of Toronto media publications. Interrupted time -series analysis investigated the association between Crisis Link calls, media articles, and quarterly suicide rates on the subway system. Findings There were 302 suicides on TTC ' s subway system from 1998 to 2021. The introduction of Crisis Link was associated with a large but non significant decrease in TTC-related suicide rate in the same quarter (IRR = 0.64, 95% CI = 0.36 - 1.12). Each subsequent post -Crisis -Link quarter experienced an average 2% increase in suicide rate (IRR = 1.02, 95% CI = 1.004 - 1.04). Furthermore, for each TTC-related media article in the previous quarter, the suicide rate on the TTC increased by 2% (IRR = 1.02, 95% CI = 1.004 - 1.04). Interpretation The Crisis Link helpline was associated with a large but non -significant short-term decrease in suicide rates. However, this outcome was not sustained; this may, in part, be attributable to media reporting which was associated with increased suicides. This should inform suicide prevention policies in Canada and worldwide. Funding No funding. Copyright (c) 2024 The Authors. 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/).

The COVID-19 pandemic initially raised concerns about increased suicides, particularly due to stressors such as unemployment, financial strain, and social disconnectedness, however data from the earliest months of the pandemic generally showed no increases, including in three Canadian provinces (Alberta, British Columbia, Manitoba) (see Supplemental file). Experts have recommended cautious media reporting about the pandemic’s potential effects on suicides, as suicide-related media discussions can influence populationlevel behavior. Specifically, reporters have been advised against presenting unbalanced, pessimistic statements about the pandemic’s impact on suicides, as such messages may increase suicide risk. In contrast, stories of hope and recovery that present suicide as preventable may be protective. The current study aimed to investigate whether reports of the pandemic’s effect on suicides were presented in a cautious and responsible manner by major Canadian media organizations both nationally and in the three provinces for which suicide data was available during study planning.