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Potential impact and psychological mechanisms associated with viewing self-harm imagery on the internet and social media platforms: a critical systematic review Background: Concerns regarding the harmful effects of the internet and social media have led to changes to online harms policy. This systematic review critically evaluated the potential impact of, and mechanisms associated with, viewing self-harm imagery on the internet and social media. Method: A literature search was conducing using CINAHL, Cochrane Library, EMBASE, HMIC, MEDLINE, PsycArticles, PsycINFO, PubMed, Scopus, Sociological Abstracts and Web of Science Core Collection databases. Titles and abstracts were screened, and potentially eligible articles were reviewed in full. Results: Across the fifteen included studies, ten areas of potentially harmful and helpful impact were identified, relating to self-harm behaviour, sharing and commenting, help-seeking, help-giving, emotional (dys)regulation, self-harm cognitions, physiological responses, social connection, comparison, and personal identity. All studies showed potentially harmful effects, including an escalation of self-harm and being emotionally triggered, and could lead to individuals sharing or commenting on content, thus reinforcing self-harm behaviour. Helpful effects included peer support and social connection. Most studies did not explicitly test or discuss potential mechanisms beyond contagion, and causality and directionality of impact could not be determined in any study. Conclusions: Viewing self-harm imagery online can lead to both helpful and harmful effects via several mechanisms. A Model of Online Self-Harm Imagery Impact was developed to direct future research exploring the factors that may contribute to these effects, and elucidate the mechanisms involved. Implications for clinical practice and policy are discussed. Service Improvement Project Improving Safety Planning in an NHS Adult Inpatient and aligned Community Mental Health Team Evidence suggests safety planning interventions (SPIs) are effective in reducing self-harm and suicide risk. As part of one NHS Trust’s suicide prevention strategy, this project used quality improvement methodology to improve SPIs across an adult inpatient and outpatient mental health team. The study examined whether SPI training, co-designed and co-delivered by Experts by Experience, would improve staffs’ knowledge and confidence, the perceived usefulness and likelihood of SPIs, and increase the frequency and quality of SPIs being completed with patients. Knowledge, confidence and likelihood of using SPIs significantly improved following training. An improvement in SPI frequency was observed for both teams, but was not statistically significant, suggesting further measures, beyond training, are required. Reviewing the quality of SPIs against competency criteria, training feedback and informal discussions with staff, helped to identify recommendations for further training and practice. As the project was undertaken in only one NHS Trust, these recommendations may have limited generalisability; however, the outcomes provide insight into SPIs in clinical settings and highlight some of the possible challenges and solutions when implementing SPIs and training. Theoretically Driven Research A Preliminary Investigation of Visual Self-Harm-Related Mental Imagery in Young People: A Mixed-Methods Approach Background: Growing evidence suggests that self-harm-related mental imagery (SH-MI) is involved in self-harm ideation-to-enactment. However, there has been little research in adolescent populations. Method: A mixed-method study, using both a questionnaire (Study 1: n=55) and qualitative interviews (Study 2: n=16), explored the role of SH-MI in a transdiagnostic clinical population of young people who had recently self-harmed (Study 1 & 2), and whether negative affect (NA) and future-oriented SH-MI could predict self-harm frequency (Study 1). Results: Study 1 found that SH-MI was highly prevalent with 96% of young people reporting future-oriented and past imagery. A hierarchical multiple regression found future-oriented imagery was a significant predictor of self-harm frequency, after accounting for depression, anxiety, age and NA. NA was inversely related to self-harm frequency, which may reflect divergent affect regulation functions of self-harm or lower thresholds. Study 2 identified three themes relating to SH-MI: 1) origins and context, 2) impact, and 3) the factors that affect the impact of imagery. Imagery could trigger self-harm but also be protective. Conclusion: SH-MI is likely to play a role in ideation-to-enactment in young people. However, further research with less reliance on retrospective self-report is required. Clinical implications are discussed.

[cat] Aquest capítol pretén continuar la línia de treball iniciada en l’Anuari de la joventut 2018 sobre el suïcidi en infants i joves. Conscients de la importància d’aquesta realitat, sovint silenciada, es fa una anàlisi de les línies principals d’actuació i d’orientacions a nivell internacional, a través de l’Organització Mundial de la Salut i a nivell eur opeu. Aquestes línies generals ens ajudaran a disposar de criteris per poder analitzar els protocols de prevenció i d’intervenció en suïcidi i en ideació o planificació suïcida en infants i joves de les diferents comunitats autònomes, amb atenció especial a si es disposa o no d’una atenció específica envers els infants i joves. Com s’ha pogut comprovar, a totes les comunitats no hi ha els plans o protocols esmentats per a població infantil i juvenil, però sí hem pogut constatar que la majoria provenen de l’àmbit sanitari, si bé en alguns territoris ja disposen, com a element basat en l’evidència, de protocols interdisciplinaris, bàsicament relacionats amb l’àmbit educatiu. Cal, doncs, seguir avançant, ampliant l’àmbit de prevenció i d’intervenció a tota la comunitat, especialment a familiars i, sobretot, als iguals, pilars bàsics a l’adolescència, sense deixar de banda tots els àmbits on un infant o jove pot manifestar conductes o ideari suïcida: espais d’oci, esportius, comunitaris, etc., [spa] El presente capítulo pretende continuar la línea de trabajo iniciada en el Anuari de la Joventut 2018 sobre el suicidio en niños y jóvenes. Conscientes de la importancia de esta realidad, a menudo silenciada, se realiza un análisis de las principales líneas de actuación y orientaciones a nivel internacional, a través de la Organización Mundial de la Salud, y a nivel europeo. Estas líneas generales, nos ayudarán a disponer de criterios para analizar los protocolos de prevención e intervención en suicidio y en ideación o planificación suicida en niños y jóvenes de las diferentes comunidades autónomas, con especial atención a si se dispone o no, de una mención específica sobre este colectivo. Como se ha podido comprobar, no todas las comunidades disponen de dichos planes o protocolos para la población infantil y juvenil, pero sí hemos podido constatar como la mayoría provienen del ámbito sanitario, si bien en algunos territorios ya disponen, como elemento basado en la evidencia, de protocolos interdisciplinares, básicamente relacionados con el ámbito educativo. Debemos pues, seguir avanzando, ampliando el ámbito de prevención e intervención a toda la comunidad, especialmente a familiares y, sobre todo, a los iguales, pilares básicos en la adolescencia, sin dejar de lado a todos los ámbitos donde un niño o joven puede manifestar conductas o ideario suicida: espacios de ocio, deportivos, comunitarios, etc.

Suicide is a significant health concern among U.S. veterans. The Department of Veterans Affairs released a report indicating that the rate of suicide for veterans is 1.5% greater in comparison to non-veterans. The rise in suicide among veterans has shown to be associated with the transition from military to civilian life. Approximately, 25% of veterans reported difficulty after deployment in major life domains including social functioning, productivity, community involvement and self-care (Sayer, Carlson, & Fraizer, 2010). The research has demonstrated that social problem-solving (SPS) can buffer the negative effects of stressful life events and daily problems (Nezu, Nezu, & D'Zurilla, 2013). Among the population of veterans, SPS has shown to be associated with reduced distress levels and increased resilience. To date, no research has investigated the relationship between postdeployment reintegration difficulties and SPS, or how they affect suicidal behaviors. The present study aimed to examine whether SPS moderates the relationship between postdeployment reintegration difficulties and suicide ideation. A sample of 198 veterans completed an online survey that included a demographic questionnaire and the following validated self-report measures: Military to Civilian Questionnaire (M2C-Q), Social Problem- Solving Inventory-Short Form (SPSI-R:S), and Beck Scale for Suicide Ideation (BSS). As expected, postdeployment reintegration difficulties and SPS were both found to be significantly correlated with suicide ideation. Additionally, SPS was found to moderate the relationship between postdeployment reintegration difficulties and suicide ideation. In other words, when participants reported high levels of postdeployment reintegration difficulties, "effective problem solvers" experienced significantly lower levels of suicide ideation compared to "ineffective problem solvers." These findings demonstrate the importance of adaptive social problem-solving abilities in decreasing suicidal behaviors in individuals with postdeployment reintegration difficulties and provides the preliminary rationale for utilizing Emotion Centered Problem-Solving Therapy (EC-PST) treatment approach. Future research that evaluates the efficacy of EC-PST could provide evidence for the use of this intervention in veterans experiencing reintegration difficulties at increased risk for suicide.

Purpose: Therapists are often charged with the seemingly impossible task of predicting their client’s future behavior, particularly behavior that may result in harm or death. Adverse events (AE) refer to a constellation of behaviors or events that interfere with treatment and exhibit a risk to the safety of the patient, which include suicide attempts, non-suicidal self injury (NSSI) and suicidal ideation. This is the first study that seeks to identify and associate in-session markers in DBT prior to AEs. Method: The proposed study sought to identify whether ruptures in therapeutic alliance (3RS; Eubanks-Carter, Muran & Safran, 2015), the frequency and intensity of negative-self referential speech (LIWC2015; Pennebaker, Booth, Boyd & Francis, 2015) and periods of psychomotor agitation are associated with AEs within a course of Dialectical Behavior Therapy (DBT). By coding videotaped psychotherapy sessions (n = 98) across 21 patients diagnosed with Borderline Personality Disorder (BPD), the researchers prospectively examined the association between in-session phenomena during the session prior to an AE. Exploratory logistic multilevel modeling, mean comparison and latent profile analysis (LPA) techniques were used to identified in-session markers associated with adverse events across the course of DBT treatment. Results: Using a multilevel model building approach to account for the nested structure, increases in content/affect split was associated with increased likelihood (36% increase in log-odds) of NSSI occurrence reported in the subsequent session when controlling for frequency of past NSSI episodes. When controlling for prior suicide attempts, withdrawal and confrontation ruptures did not predict the occurrence of suicide attempts in the subsequent session. To further examine the heterogeneity of the Level 1 variables (i.e., in-session markers), the LPA fitted afive-profile solution that captured relative differences in mean frequencies of coded markers.The latent “session types” were named based on their in-session characteristics, with AEs identified post-hoc within the identified profiles. While AEs were distributed across multiple profiles, visual inspection aligned with the findings in the multilevel model. Sessions characterized by elevations in content/affect split and behaviors that distance from the therapist preceded NSSI during treatment. The majority of the sessions prior to suicide attempts (70%) during the study period were assigned to the profile with the lowest mean frequency of in-session markers. Clinical implications: The strength of the therapeutic alliance in DBT is an essential component of effective treatment. Therapeutic ruptures, particularly withdrawal ruptures, occur frequently in DBT treatment. Attending to these ruptures, especially occasions when a patient’s affect and verbal content are not congruent, may signal to the therapist that the patient requires additional support. In-session content/affect split may represent a vulnerability factor that puts the patient at increased risk of NSSI behavior due difficulty attuning to their internal experiences and limitations in their emotional flexibility. Limitations: Similar to other studies that examine self-harm, the low base-rate of suicide attempts and NSSI behavior complicates empirical study. Since the study utilized strict inclusion criteria for only individuals diagnosed with BPD, findings cannot be generalized to patients with other psychiatric diagnoses. While some therapist effects are controlled for in the study since one therapist treated all the patient included in the study, the study does not account for therapist factors that may influence the therapy dyad. Given the limited sample size, there was not adequate power to fit more complicated models (e.g., inter-level and intra-level interactions, random effect predictor variables, etc.).

This article examines suicide prevention among children in India's “suicide capital” of Kerala to interrogate the ways temporalization practices inform the cultivation of ethical, life-avowing subjects in late capitalism. As economic liberalization and migration expand consumer aspiration in Kerala, mental health experts link the quickening of material gratification in middle-class parenting to the production of insatiable, maladjusted, and impulsively suicidal children. Experiences of accelerated time through consumption in “modern” Kerala parenting practice reflect ideas about the threats of globalization that are informed both by national economic shifts and by nostalgia for the state's communist and developmentalist histories, suggesting that late capitalism's time–space compression is not a universalist phenomenon so much as one that is unevenly experienced through regionally specific renderings of the past. I demonstrate how experts position the Malayali child as uniquely vulnerable to the fatal dangers of immediate gratification, and thus exhort parents to retemporalize children through didactic games built around the deferral of desires for everyday consumer items. Teaching children how to wait as a pleasurable and explicitly antisuicidal way of being reveals anxieties, contestations, and contradictions concerning what ought to constitute “quality” investment in children as temporal subjects of late capitalism. The article concludes by bringing efforts to save elite lives into conversation with suicide prevention among migrants to draw out the ways distinct vulnerabilities and conditions of precarity situate waiting subjects in radically different ways against the prospect of self-destruction.

Understanding the context of suicidal behaviors is critical for effective suicide prevention strategies. Although suicide is an important topic for Asian Americans, there is limited information about what Asian Americans’ attitudes are towards suicide and their perceptions about the effectiveness of prevention efforts. These questions are critical to examine to provide foundational knowledge for determining how best to intervene. In this study, Asian American (n = 87) and White (n = 87) participants completed self-report indexes on their knowledge of depression and suicide (e.g., estimates of suicide rates), coping attitudes (e.g., help-seeking) and suicide prevention attitudes (e.g., usefulness of PSAs). The results indicate that in comparison to Whites, Asian Americans perceived suicidal behavior to be more common, perceived a stronger link between depression and suicide, less frequently endorsed help-seeking strategies, and reported more concern or distress after viewing a suicide prevention PSA. These preliminary results also suggest the possibility of cultural differences in perceptions of suicide prevention messages. The implications of these findings are discussed with a focus on providing recommendations for exploring suicide prevention efforts for Asian Americans.

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5–13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures. This review paper is the results of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophenia patients.

Background: Mental health problems and risk behaviours among young people are of great public health concern. Consequently, within the VII Framework Programme, the European Commission funded the Saving and Empowering Young Lives in Europe (SEYLE) project. This Randomized Controlled Trial (RCT) was conducted in eleven European countries, with Sweden as the coordinating centre, and was designed to identify an effective way to promote mental health and reduce suicidality and risk taking behaviours among adolescents. Objective: To describe the methodological and field procedures in the SEYLE RCT among adolescents, as well as to present the main characteristics of the recruited sample. Methods: Analyses were conducted to determine: 1) representativeness of study sites compared to respective national data; 2) response rate of schools and pupils, drop-out rates from baseline to 3 and 12 month follow-up, 3) comparability of samples among the four Intervention Arms; 4) properties of the standard scales employed: Beck Depression Inventory, Second Edition (BDI-II), Zung Self-Rating Anxiety Scale (Z-SAS), Strengths and Difficulties Questionnaire (SDQ), World Health Organization Well-Being Scale (WHO-5). Results: Participants at baseline comprised 12,395 adolescents (M/F: 5,529/6,799; mean age=14.9±0.9) from Austria, Estonia, France, Germany, Hungary, Ireland, Israel, Italy, Romania, Slovenia and Spain. At the 3 and 12 months follow up, participation rates were 87.3% and 79.4%, respectively. Demographic characteristics of participating sites were found to be reasonably representative of their respective national population. Overall response rate of schools was 67.8%. All scales utilised in the study had good to very good internal reliability, as measured by Cronbach’s alpha (BDI-II: 0.864; Z-SAS: 0.805; SDQ: 0.740; WHO-5: 0.799). Conclusions: SEYLE achieved its objective of recruiting a large representative sample of adolescents within participating European countries. Analysis of SEYLE data will shed light on the effectiveness of important interventions aimed at improving adolescent mental health and well-being, reducing risk-taking and self-destructive behaviour and preventing suicidality. Trial registration: US National Institute of Health (NIH) clinical trial registry (NCT00906620) and the German Clinical Trials Register (DRKS00000214).

Background: The 21st-century epidemic of pharmaceutical and other drug-intoxication deaths in the United States (US) has likely precipitated an increase in misclassified, undercounted suicides. Drug-intoxication suicides are highly prone to be misclassified as accident or undetermined. Misclassification adversely impacts suicide and other injury mortality surveillance, etiologic understanding, prevention, and hence clinical and public health policy formation and practice. Objective: To evaluate whether observed variation in the relative magnitude of drug-intoxication suicides across US states is a partial artifact of the scope and quality of toxicological testing and type of medicolegal death investigation system. Methods: This was a national, state-based, ecological study of 111,583 drug-intoxication fatalities, whose manner of death was suicide, accident, or undetermined. The proportion of (nonhomicide) drug-intoxication deaths classified by medical examiners and coroners as suicide was analyzed relative to the proportion of death certificates citing one or more specific drugs and two types of state death investigation systems. Our model incorporated five sociodemographic covariates. Data covered the period 2008–2010, and derived from NCHS’s Multiple Cause-of-Death public use files. Results: Across states, the proportion of drug-intoxication suicides ranged from 0.058 in Louisiana to 0.286 in South Dakota and the rate from 1 per 100,000 population in North Dakota to 4 in New Mexico. There was a low correlation between combined accident and undetermined drug-intoxication death rates and corresponding suicide rates (Spearman’s rho = 0.38; p