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BACKGROUND: Death by suicide during the perinatal period has been understudied in Canada. We examined the epidemiology of and health service use related to suicides during pregnancy and the first postpartum year. METHODS: In this retrospective, population-based cohort study, we linked health administrative databases with coroner death records (1994-2008) for Ontario, Canada. We compared sociodemographic characteristics, clinical features and health service use in the 30 days and 1 year before death between women who died by suicide perinatally, women who died by suicide outside of the perinatal period and living perinatal women. RESULTS: The perinatal suicide rate was 2.58 per 100000 live births, with suicide accounting for 51 (5.3%) of 966 perinatal deaths. Most suicides occurred during the final quarter of the first postpartum year, with highest rates in rural and remote regions. Perinatal women were more likely to die from hanging (33.3% [17/51]) or jumping or falling (19.6% [10/51]) than women who died by suicide non-perinatally (p = 0.04). Only 39.2% (20/51) had mental health contact within the 30 days before death, similar to the rate among those who died by suicide non-perinatally (47.7% [762/1597]; odds ratio [OR] 0.71, 95% confidence interval [CI] 0.40-1.25). Compared with living perinatal women matched by pregnancy or postpartum status at date of suicide, perinatal women who died by suicide had similar likelihood of non-mental health primary care and obstetric care before the index date but had a lower likelihood of pediatric contact (64.5% [20/31] v. 88.4% [137/155] at 30 days; OR 0.24, 95% CI 0.10-0.58). INTERPRETATION: The perinatal suicide rate for Ontario during the period 19942008 was comparable to international estimates and represents a substantial component of Canadian perinatal mortality. Given that deaths by suicide occur throughout the perinatal period, all health care providers must be collectively vigilant in assessing risk., In developed countries, maternal suicide is a leading cause of death during pregnancy and the first postpartum year. (1-5) Existing Canadian data suggest that suicide is the fourth leading cause [...]

ABSTRACT Objective: This qualitative study investigated the repeated use of the emergency department (ED) by men with a history of suicidal behaviour and substance abuse to understand the needs and [...]

Objectives: To present the 12-month prevalence and correlates of suicidal ideation and attempts in a sample of youth in Ontario.Methods: Data come from the 2014 Ontario Child Health Study, a provincially representative survey of families with children in Ontario. Youth aged 14 to 17 y (n= 2,396) completed a computer-assisted, self-administered questionnaire in their home to assess the occurrence of suicidal ideation, suicidal attempts, and associated correlates, including non-suicidal self-injury, mental disorders, substance use, peer victimization and exposure to child maltreatment. Socio-demographic information was collected from the parent. Logistic regression models were used to identify correlates that distinguished between youth reporting: 1) no suicidal ideation or attempts, 2) suicidal ideation but no attempts, and 3) suicidal ideation and attempts.Results: The 12-month prevalence of suicidal ideation and attempts was 8.1% and 4.3%, respectively. All clinical and behavioural correlates were significantly higher among youth reporting suicidal ideation or attempts, as compared with non-suicidal youth. In adjusted models, depression and non-suicidal self-injury were each independently associated with elevated odds of suicidal ideation (OR = 4.84 and 4.19, respectively) and suicidal attempt (OR = 7.84 and 22.72, respectively). Among youth who reported suicidal ideation, the only variable that differentiated youth who attempted suicide v. those who did not, in adjusted models, was non-suicidal self-injury (OR = 3.89).Conclusions: Suicidal ideation and attempts are common among youth in Ontario, often co-occurring with mental disorders and high-risk behaviours. These findings underscore the need for effective prevention and intervention strategies, particularly for youth depression and non-suicidal self-injury.

Objective: We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care.Method: This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases (n= 697 males and n= 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated.Results: Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: ‘other’ injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, ‘undetermined’ injuries and poisonings in both sexes (aORs > 5), ‘unintentional’ poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days.Conclusions: The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

Objective: Prior year medical care was compared among youth dying by suicide to their peers. Effect modification of these associations by age or place of residency (rural versus larger community sizes) was examined in a large, medically insured population.Method: This population-based case control study used data from the Office of the Chief Coroner in Ontario, Canada, linked to health care administrative data to examine associations between medical care for mental health or other reasons (versus no medical care) and suicide. Decedents (n= 1203 males and n= 454 females) were youth (aged 10 to 25 years) who died by suicide in Ontario between April 2003 and March 2014, inclusive. Peers of the same ages were frequency matched to decedents on sex and place of residency. Logistic regression was used to calculate odds ratios and 95% confidence intervals and to test effect modification.Results: Associations with mental health care were stronger in decedents than peers with a gradation of care (i.e., outpatient only, emergency department [ED], inpatient care) in both sexes. However, these associations were weaker among youth living in rural communities. Furthermore, older males (aged 18 to 25 years) were less likely than younger males (aged 10 to 17 years) to access the ED (ambulatory care only). This decrease was observed in rural and larger communities alongside no increase in medical care for other reasons.Conclusions: Geographical and age-related barriers to mental health care exist for youth who die by suicide. Preventive efforts can address these barriers, intervening early and integrating services, including the ED.

Objective: The aims of this study were to estimate the: (1) 12-mo prevalence of suicidal thoughts, plans, and attempts in a population sample of adolescents and young adults with and without chronic illness; (2) associations among chronic illness and suicidal thoughts and behaviour (STB); and, (3) moderating roles of mood and substance use disorder on this association.Method: Individuals were aged 15 to 30 y (n= 5,248) from the Canadian Community Health Survey-Mental Health. Twelve-month STB and psychiatric disorder were measured using the World Health Organization Composite International Diagnostic Interview 3.0. Multinomial logistic regression examined associations between chronic illness and STB, adjusting for relevant sociodemographic and health characteristics. Product term interactions among chronic illness, mood, and substance use disorders were included in the regression models to examine potential moderating effects.Results: Prevalence of suicidal thoughts, plans, and attempts was higher in individuals with chronic illness (P< 0.01 for all). After adjustment, chronic illness increased the odds for suicidal thoughts [OR = 1.28 (1.01 to 1.64)], plans [OR = 2.34 (1.22 to 4.39)], and attempts [OR = 4.63 (1.52 to 14.34)]. In the presence v. absence of a mood disorder, the odds for suicidal thoughts were higher among individuals with chronic illness [OR = 1.89 (1.06 to 5.28)].Conclusions: Suicidal thoughts and behaviours are common among adolescents and young adults with chronic illness, particularly among those with comorbid mood disorders. Health professionals should routinely ask about STB during assessments of their adolescent and young adult patients.

Objective: The aim of this study is to compare Canadian suicide rates with other external causes of death to examine potential poisoning misclassifications as a contributor to suicide underreporting.Method: The study used Statistics Canada mortality data from 2000 to 2011 to calculate sex-and age-specific ratios by external cause of injury codes.Results: The overall Canadian suicide rate, as well as the poisoning suicide rate, declined over the study timeframe by an average annual percentage change (AAPC) of 1.0% each year. However, unintentional and undetermined poisonings increased significantly during the timeframe. Unintentional poisoning mortality (primarily narcotics and hallucinogens, including opioids) increased in proportion to suicides for both sexes, although females were consistently higher. The undetermined death to suicide ratio was higher and increasing for females. Poisonings of undetermined intent increased over time to comprise 47% to 80% of the undetermined death category for males and females combined.Conclusions: Canadian poisoning suicide rates declined, in contrast to rising unintentional and undetermined poisoning mortality rates. This trend is similar to that of the United States, supporting the hypothesis that misclassification of poisoning deaths may also be an issue in Canada.

Objective: In Canada, emergency departments (EDs) are a frontline setting for treating suicide-related behaviours (SRBs) among adolescents, yet description of national trends in ED SRB visits is lacking. We determined whether the SRB incidence rate and method patterns between 2002 and 2010 previously shown for Ontario adolescents were also experienced in Alberta.Method: A retrospective, population-based study of ED visits for SRBs (self-poisoning or self-injury, irrespective of suicidal intent) by 12- to 17-year-olds was conducted using administrative health care data from 104 EDs across Alberta, Canada. Incidence rates and 95% confidence intervals (CIs) were calculated and graphed. Rate ratios (RRs) comparing rates between time periods (2002-2005 and 2006-2010) and corresponding 95% CIs were estimated. Changes in SRB methods were also described. The time periods chosen were based on published Ontario trends.Results: Decreases in yearly incidence rates levelled off after 2005. Crude RRs indicated a rate decrease in 2006 to 2010 for boys (RR, 0.77; 95% CI, 0.65 to 0.90) and girls (RR, 0.80; 95% CI, 0.67 to 0.95). From 2002 to 2010, the proportion of SRB visits for self-poisoning decreased (girls, –13%; boys, –10%) while visits for self-cutting increased (girls, +13%; boys, +14%).Conclusions: Alberta trends were similar to those previously published for Ontario. Determining if the trends and observed changes are associated with mental health care access or availability and/or provincial suicide prevention strategies would contextualize these findings and could shape future prevention efforts. Lack of identification of suicidal intent and exclusion of fatal SRB are limitations of the current study.

Objective: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts.Methods: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings.Results: No included review addressing school-based prevention (n= 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n= 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%.Conclusions: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Objective: To determine whether emergency department (ED) presentations for suicide-related behaviours (SRBs) in boys and girls were identified as more clinically acute in the ED in the period after the regulatory warnings against prescribing antidepressants and during the global economic recession, and to characterize the medical severity of SRBs among boys and girls to aid surveillance activities.Method: Among Ontario boys and girls (aged 12 to 17 years) presenting to the ED with an incident (index) ED SRB event between fiscal years (FYs) 2002 to 2010, we compared the number of high (compared with lower) acuity events in FYs 2005 to 2010 to those in FYs 2002 to 2004. We described the SRB method by its acuity and tested the linearity of varying trends in the SRB method in boys and girls.Results: In both boys and girls, high acuity events were 50% greater after FY 2004 than before, regardless of subsequent admission, and most common among boys and girls who self-poisoned. In girls, opposing linear trends before and after FY 2004 were observed in the proportion of self-poisonings and cut (or) pierce SRB methods. Throughout the study period, there was a linear decline in the proportion of boys presenting to the ED with other methods.Conclusions: The previously reported increase in hospital admissions after the warnings and during the recession is unlikely artifactual. An equivalent increase in high acuity events was also evident among those not subsequently admitted. The reasons for varying responses in boys and girls by SRB method warrant further study.

Objective: To examine the incidence and nature of emergency department (ED) presentations for nonfatal suicide-related behaviours (SRBs) over time, in boys and girls living in Ontario. We hypothesize declining rates (fiscal years [FYs] 2002/03 to 2006/07) ceased thereafter owing to renewed regulatory warnings against prescribing antidepressants and the economic recession.Method: We graphed and tested differences in ED SRB incidence rates for FYs 2002/03 to 2010/11. We estimated rate ratios and 95% confidence intervals using negative binomial regression controlling for changes in the underlying population (age, community size, and neighbourhood income quintile). We examined the nature of the incident (index) presentations over time in terms of the method(s) used and events occurring before and after the index event.Results: ED SRB incidence rates decreased by 30% in boys and girls from FYs 2002/03 to 2006/07, but not thereafter. This trend was most evident in girls who self-poisoned and in girls' presentations to hospital with mental illness in the preceding year. Within a year of the index event, the proportion of girls with a repeat ED SRB presentation also declined by about one-third, but beyond FYs 2005/06 to 2009/10. However, the proportion admitted subsequent to the index event increased by about one-third. In boys, their patterns of presentations to hospital with mental illness and SRB repetition over time were similar to girls, but estimated with greater variability.Conclusions: While the decline in ED SRB rates to FY 2006/07 is encouraging, the lack of decline thereafter and an increase in subsequent admissions merits ongoing monitoring and evaluation.

Objective: To examine the impact of the Health Canada regulatory warnings regarding antidepressant (AD) prescribing on suicide rates in boys and girls under the age of 18 and aged 18 to 19 years in Canada between 2004 and 2009. We hypothesized that an increase in suicide rates would be specific to girls, reflecting higher AD prescribing rates in girls than boys.Method: We graphed and tested the difference between Canada-wide suicide rates before and after the regulatory warning periods (either from 1995 to 2006 or from 1995 to 2009) in boys and girls under the age of 18 or aged 18 to 19 years. For comparison with prior studies, we estimated rate ratios and 95% confidence intervals using either Poisson regression or negative binomial regression.Results: There was no statistically significant increase in suicide rates in girls under the age of 18, or aged 18 to 19 years in response to the AD regulatory warnings. In boys under the age of 18 or aged 18 to 19 years, suicide rates declined after 2003.Conclusions: We did not find increased rates of suicide after the AD regulatory warnings in boys or girls under the age of 18 or aged 18 to 19 years in Canada-wide rates. However, this does not rule out the possibility that such an effect occurred in some jurisdictions in girls and (or) the regulatory warnings prevented the trend toward declining suicide rates. Factors influencing the downward trend in boys merit further attention.

Objective: To describe sex differences in health service use among children and youth who died by suicide.Method: This is a retrospective study of children and youth (aged 10 to 25 years) living in Ontario who died by suicide between April 1, 2003, and December 31, 2007. Coroner records were individually linked to outpatient physician visit, emergency department (ED) presentation, and inpatient stay administrative health care records for 724 people (192 girls and 532 boys). Only 77 (10.6%) were aged 10 to 15 years. The health services types used, number of contacts made, and the last contact were compared in boys and girls.Results: About 80% of subjects had contact with the health care system in the year before their death, typically to an outpatient physician and (or) the ED. However, not all were seen for mental health reasons. Girls had more outpatient physician and ED contact than boys and closer in time to their death. Further, girls were more likely than boys to have contact in more than one setting. Still, boys and girls did not differ in their use of an outpatient psychiatrist, some ED presentations, and in the nature and number of inpatient stays.Conclusions: While most people were seen by an outpatient physician and (or) in the ED in the year before their death, not all received mental health care. Further research is needed to determine whether boys and girls who died by suicide differ from their peers in their health service use to guide preventive interventions.

Given the public health importance of suicide-related behaviors and the corresponding gap in the performance measurement literature, we sought to identify key candidate process indicators (quality of care measures) and structural measures (organizational resources and attributes) important for emergency department (ED) management of pediatric suicide-related behaviors.

Objectives: We examined whether established sex differences in suicide rates persist when adjustments are made for potential misclassification of deaths in children and youth. Methods: This is a retrospective, descriptive study of 1,294 suicides, 961 accidental and 254 undetermined deaths occurring between January 1, 2000 and December 31, 2007, among persons aged 1 0 to 25 years in Ontario, Canada. Using data from Coroner’s records, causes of death were reclassified based on two different misclassification criteria. Actual and reclassified suicide rates were calculated by sex and age group (with 95% confidence intervals) and by year of death. Results: Males aged 16–25 years accounted for the majority of suicides (68.9%). Asphyxia was the most common cause of suicide in both sexes. While suicides by shooting were almost exclusive to males, suicides due to alcohol/drug toxicity were significantly higher in females. Both before and after reclassification of suicide deaths, sex differences in suicide rates emerged in the 16–25 years age group. In each study year, both actual and reclassified suicide rates were higher in males than females. Conclusions: Sex differences in suicide rates emerging in adolescence are unlikely to be due to misclassification. Other proposed explanations for sex differences in youth suicide rates should be investigated further.

Objective: To identify alcohol-related factors that influence mortality rates from suicide.Method: We examined the impact of per capita consumption of total alcohol, spirits, beer, and wine; unemployment rate; and Alcoholics Anonymous (AA) membership rate on total, male and female suicide mortality rates in Manitoba during 1976 to 1997. Time series analyses with autoregressive integrated moving average modelling were applied to total, male and female suicide rates. The analyses performed included total alcohol consumption, spirits consumption, beer consumption, and wine consumption. Missing AA membership data were interpolated with cubic splines.Results: Total alcohol consumption, and consumption of beer, spirits, and wine individually, were significantly and positively related to female suicide mortality rates. Spirits and wine were positively related to total and male mortality rates. AA membership rates were negatively related to total and female suicide rates. Unemployment rates were positively related to male and total suicide rates.Conclusions: The data confirm the important relations between per capita consumption measures and suicide mortality rates. Additionally, the results for AA membership rates are consistent with the hypothesis that AA membership and alcohol abuse treatment can exert beneficial effects observable at the population level.

Objectives: To describe individuals who reported suicidal ideation but neither met the criteria for major depression (MD) nor were in contact with mental health services in the previous year.Method: Data were drawn from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Conducted in 2002, the CCHS 1.2 was a cross-sectional population-based survey of 36 984 Canadian household residents aged 15 years or more. First, we described the individuals who reported suicidal ideation, were without MD, and were not in contact with mental health services (n= 584) as well as their nonsuicidal counterparts (n= 31 382) based on various demographic and health status variables. Second, to analyse whether these same variables are associated with mental health service contact(s) among suicidal individuals without MD, we compared those who were in contact with mental health services (n= 209) to those who were not (n= 584).Results: Almost one-half (47.9%) of the suicidal ideators were without both MD and a mental health service contact in the previous year. Individuals in this group were younger and exhibited greater morbidity than their nonsuicidal counterparts (without MD or mental health service contact) but did not differ by sex. Although male and female respondents were equally represented among the suicidal ideators without MD, male respondents were less likely to contact mental health services. Such contact was more likely among female respondents and individuals with an anxiety disorder.Conclusions: These findings underscore the need for further research evaluating early intervention programs that succeed in capturing suicidal youths, particularly male youths.

Objective: To determine whether, and to what extent, those who reported suicidal ideation and (or) attempts in the previous year, without meeting the criteria for major depressive episode (MDE), might still have experienced subthreshold depression.Method: Data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) were examined to estimate and compare the prevalence of depressed mood, a core symptom of MDE and subthreshold depression, within the previous month for the following 4 population groups: MDE within the previous month [D(1 month)], MDE within the previous year but not the previous month [D(1 year)], suicidality without MDE within the previous year (D-S+), and no MDE or suicidality within the previous year (D-S-).Results: As expected, the D(1 month) group showed the highest prevalence of depressed mood in the previous month. However, the D-S+ group had a significantly higher prevalence of depressed mood than the D-S-group and only a slightly lower level than that of the D(1 year) group.Conclusions: A fraction of those who reported suicidality in the previous year met the criteria for MDE during that time; however, subthreshold depression might be common in the suicidal population. Future epidemiologic research in the areas of suicidality and depression will benefit from a comprehensive assessment of subthreshold depression.

This qualitative study examines the experience of suicidal, substance‐abusing men with severe personality disorders presenting to an emergency department (ED). Semi‐structured interviews were conducted with ED patients (n = 25), ED physicians (n = 5), ED nurses (n = 6), other ED staff (n = 6) and family physicians (FPs) (n = 7). Interviews were tape‐recorded, transcribed verbatim and managed using a comprehensive qualitative software program N6. Transcripts were coded using an iterative process and team involvement to capture emergent themes. Negative expectations were found to be held by participants from all perspectives, patients, ED staff and FPs, and these overarching negative expectations appear to interact with prior negative experiences and current negative behaviours to foster negative outcomes from these encounters. The suicidal men, ED staff and FPs offered suggestions, both systemic and within the ED interactions between providers and patients, that could minimize negative outcomes. Copyright © 2007 John Wiley & Sons, Ltd.

Objective: To determine the magnitude of depression and suicidal populations, the overlap between these populations, and the associated patterns of mental health service use.Method: We examined depression, suicidality (ideation and nonfatal behaviours), and the mental health service use of participants in the Canadian Community Health Survey Cycle 1.2: Mental Health and Well-Being. The sample comprised 36 984 household members aged 15 years or over.Results: Approximately 4% to 5% of the population suffered from a major depression or suicidality. About 2 of 3 of those who were suicidal did not suffer from depression, and over 70% of those with depression did not report suicidality. Persons with depression and suicidality or depression (but no suicidality) were the 2 groups most likely to report ambulatory mental health contacts, and the provider groups contacted most often included physicians. The use of provider groups was considerably lower for those who were suicidal (but had no depression). Whereas the latter were more likely to report contacts than not, suicidality, in and of itself, did not exert a strong effect on contact with any particular provider group. For those who were suicidal (but who had no depression), less than 1 in 3 reported any mental health service contact, including an inpatient mental health stay.Conclusions: The lack of contact by those who are suicidal (but who have no depression) is provocative, given that almost 2 of 3 of the suicidal subjects had no depression. Detrimental outcomes such as depression may develop without effective early interventions and uptake by a sufficient supply of appropriately trained and financially accessible personnel.

Using qualitative methods, this study examined how, and under what circumstances, suicidal men used mental health services. In particular, the analyses focused on fragmented pathways to care. Fifteen men with a history of suicidal and aggressive behaviors and a diagnosis of borderline personality disorder and/or antisocial personality disorder participated in semistructured interviews that consisted of questions about their mental health status and experiences with mental health and addiction services. Interviews were taped and transcribed. An iterative, inductive qualitative analytic process was used. Men followed a cyclical pattern wherein negative experiences with health care providers were said to be followed by avoidance of health care settings, crisis, and then by involuntary service utilization. Men identified five health care provider and three personal practices, and two types of episodes they believed to contribute to their fragmented pathways to care. Implementation of specialized interventions, and providing patients with more information and more opportunity to participate in decisions, may improve interactions between patients and providers and improve patients' mental health status.

Studies of mental health services have emphasized that people in need are not receiving treatment. However, these studies, based on self‐reported use, may not be consistent with administrative records. This study compared self‐reports of mental health service use with administrative records in a large representative sample. Respondent reports within the Ontario portion of the 1994/95 Household Component of the National Population Health Survey (NPHS) were individually linked to the provincial mental‐health physician reimbursement claims. A total of 5,187 Ontarians, aged 12 years or more, reported on their use of mental healthcare within the NPHS and 4,621 (89%) consented and were successfully linked to administrative records.

When one variable is studied to try to explain another, the relationship between them may be biased by a third variable. This bias, known as “confounding,” is common and must be minimized in research. This description is deceptively simple, though. Identifying confounding is complex but can be reduced to a stepped procedure. By way of examples, this article describes confounding and how to recognize it.

Objective: To examine what is known about engaging and maintaining suicidal individuals in treatment and what can be learned from the randomized, controlled trials of psychosocial interventions concerning the reduction of suicidal behaviours.Method: Review of the relevant literature.Results: Treatment follow-through is low among those who attempt suicide. The evidence to date is inconclusive as to whether psychosocial interventions can reduce the repetition of suicidal behaviour.Conclusions: Certain groups may benefit from psychosocial interventions. Future research must overcome several methodological issues. As treatment relies on adequate follow-through, changes in the delivery of care may enhance treatment effectiveness.