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Objective: Involvement of opioids in suicides has doubled during the past two decades, worsening a major public health concern. This study examined the characteristics of opioid-involved suicides., Methods: The sample of decedents ( N  = 12,038) in Maryland between 2006 and 2020 was used to compare the characteristics of opioid-involved suicides ( n  = 947) with suicides not involving opioids ( n  = 6,896) and accidental opioid deaths ( n  = 4,125). Direct comparisons were then made between opioid-involved suicides with and without the additional presence of non-opioid substances., Results: Opioid-involved suicides were significantly more likely than suicides not involving opioids to occur among those aged 18-64 years, non-Hispanic Whites, and unemployed or disabled individuals. Opioid-involved suicides were more likely than accidental opioid deaths to occur among females, those aged <18 years, non-Hispanic Whites, and employed individuals. Of all suicides involved opioids, 45% involved other non-opioid substances. Polysubstance opioid suicides were significantly more likely than suicides involving opioids only to occur among non-Hispanic Whites., Conclusions: Significant differences were observed in the demographic groups most at risk for opioid-involved suicide than other suicide or accidental opioid death. Among opioid-involved suicides, polysubstance involvement also represents a distinct group. These findings may enhance the targeting of prevention efforts.

Competing Interests: We declare no competing interests. We acknowledge Sarah Bosha and John Monahan of the O'Neill Institute for National and Global Health Law at Georgetown Law for their support in the conceptualisation of this work.

Objective: To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors)., Methods: Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period., Results: Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission., Conclusions: Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services., (© 2023 American Association of Suicidology.)

Objective: Clozapine is the most efficacious antipsychotic medication, but it is underutilized and its mechanism of action is still poorly understood. One aspect of its unique efficacy that requires further study is its effect on suicidality. A randomized controlled trial, the InterSePT study, yielded evidence that clozapine reduces suicidality more than olanzapine, after which it became the only medication indicated for recurrent suicidal behavior in schizophrenia and schizoaffective disorder. We present here the first study of population mortality data to investigate the effect of clozapine on suicide., Methods: We reviewed statewide autopsy records of Maryland's Office of the Chief Medical Examiner, which performs uniquely comprehensive death investigations that include full toxicologic panels with postmortem blood levels of antipsychotics. Our study compared clozapine- and olanzapine-positive decedents across demographic, clinical, and manner-of-death outcomes using contingency table analysis and logistic regression., Results: Of 53,144 decedents from 2003 to 2021, 621 had clozapine or olanzapine detected on autopsy, with the two groups showing no demographic differences. Decedents with clozapine were significantly less likely to have died by suicide than by accident compared to those with olanzapine (odds ratio = 0.47; 95% CI, 0.26-0.84; P  = .011)., Conclusions: Our study thus adds more naturalistic evidence to the growing literature on the beneficial effect of clozapine on suicidality. Our findings also highlight the utility of statewide autopsy records, an untapped resource for investigating the potential protective effect of psychiatric medications on suicide at a population level., (© Copyright 2023 Physicians Postgraduate Press, Inc.)

Objectives: In 2013, the state of Maryland passed the Firearms Safety Act limiting the private sales of handguns, which did not apply to long guns often used for hunting (e.g., rifles and shotguns). This decreased the accessibility of handguns relative to long guns. We assessed the frequency of long gun suicides in the years before and after the policy change during winter season, which encompasses hunting season in Maryland., Methods: We performed a retrospective analysis on all 4107 well-characterized adult suicides caused by firearms in Maryland from 2003 through 2019. Logistic regression was performed, stratifying by decedent sex, race, and age., Results: While handgun suicides decreased in the period after 2013's Firearm Safety Act (p < 0.008), wintertime long gun suicides increased after 2013 (p < 0.004). Caucasian race (p < 0.006), male sex (p < 0.005), and middle age (p < 0.001) were significantly associated with wintertime long gun suicides after 2013., Conclusion: Our findings suggest that while the 2013 Firearms Safety Act decreased handgun suicides significantly, it did not reduce long gun suicides and there may even have been replacement with long guns during hunting season, when rifles are out and accessible. This association was most prominent among the demographics most likely to hunt (Caucasian, middle-aged, and male)., (© 2022 American Association of Suicidology.)

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design., Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification., Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021., Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type., Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification., Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (β = 4.362), labor underutilization rate (β = 0.728), manufacturing employment (β = -0.056), homelessness rate (β = -0.125), percentage nonreligious (β = 0.041), non-Hispanic White race and ethnicity (β = 0.087), prescribed opioids for 30 days or more (β = 0.117), and percentage without health insurance (β = -0.013) and 5 factors associated with the suicide rate: percentage male (β = 1.046), military veteran (β = 0.747), rural (β = 0.031), firearm ownership (β = 0.030), and pain reliever misuse (β = 1.131)., Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Introduction: In the United States, firearm suicide represents a major cause of preventable, premature death among veterans. The purpose of this systematic review was to characterize the body of literature on veteran firearm suicide and identify areas for future research, which may facilitate the development of firearm suicide interventions in Veterans Health Administration (VHA) and non-Veterans Health Administration clinical settings., Materials and Methods: All randomized controlled trials, quasi-experimental, naturalistic, observational, and case study designs published between January 1, 1990 and February 21, 2019 were included in our review. Following title and abstract review, 65 papers were included in our full-text review and 37 studies were included in our analysis. We based our approach on a modification of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were grouped into broad, nonmutually exclusive categories: (1) heterogeneity of datasets and veteran status determination for inclusion, (2) service histories, (3) firearm ownership, storage, behaviors, and risk perceptions, (4) patient and clinician attitudes toward firearm restriction interventions, (5) firearm suicide risk factors by study population, and (6) assessments of clinical firearm interventions., Results: This body of literature consists predominately of cross-sectional studies with mixed definitions and validation of veteran status, which revealed high concordance of increased risk of firearm suicide compared with nonveterans. Veterans have higher rates of firearm ownership than the general population, primarily citing personal protection as the reason for gun ownership. Veterans often exhibit risky firearm usage and storage behaviors but tend to favor measures that limit access to firearms by at-risk individuals. Despite this, there remains persistent hesitation among clinicians to screen and counsel veterans on firearm safety., Conclusions: This systematic review highlights an urgent need to produce higher quality evidence and new data with standard definitions that are critical to inform clinical practice and enhance public health measures to reduce firearm suicide among veterans., (© The Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To assess whether an enhanced category combining suicides with nonsuicide drug self-intoxication fatalities more effectively captures the burden of self-injury mortality (SIM) in the USA among US non-Hispanic black and Hispanic populations and women irrespective of race/ethnicity., Methods: This observational study used deidentified national mortality data for 2008-2017 from the CDC's Web-based Injury Statistics Query and Reporting System . SIM comprised suicides by any method and age at death plus estimated nonsuicide drug self-intoxication deaths at age ≥15 years. Measures were crude SIM and suicide rates; SIM-to-suicide rate ratios; and indices of premature mortality., Results: While the suicide rate increased by 29% for blacks, 36% for Hispanics and 25% for non-Hispanic whites between 2008 and 2017, corresponding SIM rate increases were larger at 109%, 69% and 55% (p<0.0001). SIM:suicide rate ratio gaps were widest among blacks but similar for the other two groups. Gaps were wider for females than males, especially black females whose ratios measured ≥3.71 across the observation period versus <3.00 for white and Hispanic counterparts. Total lost years of life for Hispanic, white and black SIM decedents in 2017 were projected to be 42.6, 37.1 and 32.4, respectively., Conclusion: Application of SIM exposed substantial excess burdens from substance poisoning relative to suicide for minorities, particularly non-Hispanic blacks and for women generally. Results underscored the need to define, develop, implement and evaluate comprehensive strategies to address common antecedents of self-injurious behaviours., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The Centers for Disease Control and Prevention (CDC) monitor accidental and intentional deaths to answer questions that are critical for the development of effective prevention and resource allocation. CDC's National Violent Death Reporting System (NVDRS) is a major innovation in surveillance linking individual-level data from multiple sources. However, suicide underreporting is common, particularly from drug overdose deaths. This study sought to assess machine learning (ML) techniques in quantifying drug overdose suicide underreporting rates., Methods: Clinical, sociodemographic, toxicological, and proximal stressor data on overdose decedents (n = 2,665) were extracted from Utah's NVDRS from 2012 to 2015. The existing well-determined cases were used to train and test our ML models. We assessed and compared multiple machine learning methods including Logistic Regression, Random Forest Classifier, Support Vector Machines, and Artificial Neural Networks. We applied a majority voting methodology to classify undetermined drug overdose deaths., Results: Overdose suicide rates were estimated to be underreported by 33% across all years, increasing yearly from 29% in 2012 to 37% in 2015. The overall test accuracies for all models ranged from 92.3% to 94.6%., Conclusions: This research identifies a cost-effective, replicable, and expandable ML-based methodology to estimate the true rates of suicide which may be partially masked during the opioid epidemic., (© 2019 The American Association of Suicidology.)

Persons with Parkinson's disease (PwP) have many known risk factors for suicide and suicidal ideation (SI). Despite this, there is limited understanding of suicidality in this population. We conducted a systematic review to synthesise the available literature on suicidality in PwP and highlight areas for potential intervention and further research. We identified 116 articles discussing SI, suicidal behaviours, suicide attempts and/or fatal suicide in PwP. These articles describe prevalence, suicide methods, risk factors for suicide and SI and treatment of suicidality. In this review, we summarise the current literature and provide suggestions for how clinicians can identify and treat PwP who are at risk for suicide, for example, through aggressive treatment of depression and improved screening for access to lethal means., Competing Interests: Competing interests: KAM receives support from Abbott for research support for his role as site PI for DBS trial, outside the submitted work. There are no other competing interests to report., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note., Methods: This multilevel (individual/county), multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011-2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note., Results: An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication (adjusted odds ratio [OR], 1.70; 95% CI, 1.56, 1.85) and other poisoning suicides (OR, 2.12; 1.85, 2.42) than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown (OR, 1.86; 95% CI, 1.61, 2.14) and (OR, 2.25; 95% CI, 1.86, 2.72) relative to the comparisons with a forensic autopsy (OR, 1.62, 95% CI, 1.45, 1.82 and OR, 2.01; 95% CI, 1.66, 2.43). Hanging/suffocation suicides did not differ from the firearm referent given an autopsy., Conclusions: Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To assess whether the use of firearms explains rural-urban differences in suicide rates., Methods: We performed a retrospective analysis on all 6196 well-characterized adult suicides in Maryland from 2003 through 2015. We computed rate ratios by using census data and then stratified by sex, with adjustment for age and race., Results: Suicide rates were higher in rural compared with urban counties. However, the higher rural suicide rates were limited to firearm suicides (incident rate ratio [IRR] = 1.66; 95% confidence interval [CI] = 1.20, 2.31). Nonfirearm suicide rates were not significantly higher in rural settings. Furthermore, 89% of firearm suicides occurred in men and the higher rural firearm suicide rate was limited to men (IRR = 1.36; 95% CI = 1.09, 1.69). Women were significantly less likely to complete suicide in rural areas (IRR = 0.63; 95% CI = 0.43, 0.94), regardless of method., Conclusions: Male firearm use drives the increased rate of suicide in rural areas. The opposite associations between urbanicity and suicide in men and women may be driven by the male preference for firearms as a method for committing suicide.

BACKGROUND: Little is known about specific obsessive-compulsive clinical features associated with lifetime history of suicide attempt in individuals with obsessive-compulsive disorder (OCD) and major depression. METHODS: The study sample included 515 adults with OCD and a history of major depression. In exploratory analyses, we compared the distributions of demographic characteristics and clinical features in those with and without a history of attempted suicide and used logistic regression to evaluate the association between specific obsessive-compulsive clinical features and lifetime suicide attempt. RESULTS: Sixty-four (12%) of the participants reported a lifetime history of suicide attempt. Those who had attempted suicide were more likely to report having experienced violent or horrific images (52% vs. 30%; p

AbstractObjectiveMethodResultsConclusionsThe safety planning intervention is an evidence-based practice shown to reduce suicide risk, but implementation of high-quality safety planning has proven challenging. We aimed to understand clinician perspectives on the safety planning intervention to inform future implementation efforts.This cross-sectional survey of clinicians who care for patients at risk of suicide in an academic medical center asked about comfort levels and fidelity to components of the safety planning intervention and assessed implementation barriers and facilitators. We used exploratory data analysis and regression analysis to explore clinician perspectives and assess the relationship between formal training and implementation.Ninety-two clinicians responded to the survey. Two-thirds of participants (64.9%) endorsed using all six core elements of the safety planning intervention. Participants who reported receiving formal training in safety planning were significantly more likely to report being comfortable completing a safety plan (p < .001); those with higher levels of comfort were significantly more likely to endorse using all of the core elements of the safety planning intervention (p < .001).Training in the evidence-based safety planning intervention is associated with clinician comfort and awareness of the core elements of the intervention. Our results suggest that there are gaps in clinician training and that formal safety planning intervention training could have a positive effect on clinician comfort and treatment fidelity. [ABSTRACT FROM AUTHOR]

This cross-sectional study analyzes trends in suicidality by race/ethnicity during the coronavirus disease 2019 (COVID-19) pandemic. [ABSTRACT FROM AUTHOR]

Objective: This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide. Methods: Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides. Results: Lithium and clozapine are the only two somatic treatments that have high‐quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low‐quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short‐term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term. Conclusions: Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances. Systemic review of controlled trials of effect of medications on suicide revealed that lithium and clozapine have a documented antisuicide effect in bipolar illness and schizophrenia, respectively. Antidepressants appear to be associated with an increase of suicide ideation for young people acutely, but there is weak evidence that they may reduce suicide ideation or completed suicide over the long term. Ketamine, and possibly esketamine, appear to have a transient antisuicide effect. [ABSTRACT FROM AUTHOR]

Introduction: People who are attracted to children may be at elevated risk for suicidal ideation and behavior compared to the general population. However, factors associated with suicidal ideation and behavior in this population represent a gap in the literature.Methods: The current study used multilinear regression to explore the impact of self-esteem and perceived social support on suicidal ideation and behavior in a sample of 154 adults attracted to children. Mediation analysis was conducted to investigate the role of lifetime major depressive disorder and hopelessness in these relationships.Results: Results showed high prevalence of past-year and lifetime suicidal ideation and behavior in the sample. Both self-esteem and perceived social support demonstrated significant, inverse relationships with suicidal ideation and behavior after adjustment for covariates. Mediation analyses provided support for the role of hopelessness, but not depression, in these relationships.Conclusion: Results demonstrate high rates of suicidal ideation and behavior among adults attracted to children and highlight important opportunities for prevention and intervention. Improving self-esteem, bolstering perceived social support, reducing hopelessness, and removing barriers to help-seeking may be targets for improving mental health and preventing suicidal ideation and behavior in this population. [ABSTRACT FROM AUTHOR]