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Abstract. This chapter draws on internationally available data to describe the epidemiology of suicide and self-harm in the World Health Organization (WHO) Western Pacific Region. It then describes the suicide prevention activities in the region, using in-depth case studies to highlight some key suicide prevention activities in certain countries/areas and the Global Survey on Suicide Prevention conducted in 2013 by the International Association for Suicide Prevention (IASP) and WHO. It demonstrates that there is considerable variability both between and within low and middle income countries and high income countries, both in terms of rates of suicide and self-harm and in terms of the preventive efforts that have been mobilised to address them. Adequate funding for suicide prevention efforts in the region should be a priority, as should the delivery of a range of suicide prevention approaches. Evaluation and monitoring efforts are also crucial.

Background Non-suicidal self-injury (NSSI) and suicide attempts are related, but distinct behaviors. The primary aim of the current study was to identify factors that distinguish those with different lifetime histories of self-injury. A secondary aim was to test whether lifetime history of self-injury at age 26 predicted current suicide ideation at age 32. Methods Participants were 26 year olds from a large birth cohort with a lifetime history of no self-injury ( n = 466), a lifetime history of NSSI ( n = 191), or a lifetime history of NSSI and a suicide attempt (NSSI+SA; n = 52). They were compared on a history of psychiatric disorders, 12-month suicide ideation, lifetime history of childhood sexual abuse, and lifetime exposure to suicide. Results An anxiety disorder, a substance dependence disorder, suicide ideation, and a history of childhood sexual abuse distinguished the NSSI+SA and NSSI only groups. Longitudinal results demonstrated that a history of NSSI predicted future suicide ideation after adjusting for other selected risk factors. Limitations The majority of analyses are cross-sectional which limits inferences about causality. The retrospective self-report for lifetime behavior could be subject to reporting biases. Conclusions Adults with a history of NSSI and adults with a history of NSSI and a suicide attempt are clinically distinct groups that are both at risk of future suicide ideation. Identifying and treating NSSI could be a key preventive factor in reducing subsequent suicide risk.

Summary Background We investigated whether a volitional helpsheet (VHS), a brief psychological intervention, could reduce repeat self-harm in the 6 months following a suicide attempt. Methods We did a prospective, single-site, randomised controlled trial. Patients admitted to a hospital in Edinburgh, UK, after a suicide attempt were deemed eligible for the study if they were over the age of 16 years, had a self-reported history of self-harm, were fluent in English, were medically fit to interview, and were not participating in other research studies within the hospital. Eligible patients were randomly assigned (1:1), via web-based randomisation, to receive either VHS plus usual treatment (intervention group) or only treatment as usual (control group). Randomisation was stratified by sex and self-reported past self-harm history. The Information Services Division of the National Health Service (NHS-ISD) staff and those extracting data from medical notes were masked to the study group the participant was allocated to. Clinical staff working within the hospital were also masked to participants' randomisation status. There were three primary outcomes: the proportion of paticipants who re-presented to hospital with self-harm during the 6-month follow-up period; the number of times a participant re-presented to hospital with self-harm during the 6-month follow-up period; and cost-effectiveness of the VHS as measured by estimated incremental cost per self-harm event averted. Primary outcomes were analysed in all randomised patients. Follow-up data collection was extracted from the Information Services Division of the NHS and from patient medical records. The trial is registered with International Standard Randomised Controlled Trial Number Registry, number ISRCTN99488269. Findings Between May 9, 2012, and Feb 24, 2014, we assessed 1308 people for eligibility. Of these, 259 patients were randomly assigned to the intervention group and 259 to the control group. We obtained complete follow-up data on 512 (99%) of 518 patients (five participants were lost to follow-up in the intervention group and one in the control group). 11 patients assigned to the intervention group did not complete the VHS in hospital. Overall, the intervention did not affect the number of people who re-presented with self-harm (67 [26%] of 254 patients in the intervention group vs 71 [28%] of 258 patients in the control group, odds ratio [OR] 0·90, 95% CI 0·58–1·39, p=0·63). The intervention had no effect on the number of re-presentations per patient (mean 0·67 [SD 2·55] re-presentations for the intervention group vs 0·85 [2·79] for the control group, incident rate ratio [IRR] 1·65, 95% CI 0·74–3·67, p=0·21). Mean total costs per person for NHS hospital services in the VHS intervention group over the 6 months were £513 versus £561 in the control group but this difference was not significant (95% CI–£353 to £257, p=0·76). Three patients died by suicide in the 6 months following their index suicide attempt (one in the intervention group and two in the control group). There were no reported unintended effects or adverse events in either group. Interpretation For the primary outcomes, there were no significant differences between groups. Although the VHS had no overall effect, post-hoc analyses suggest VHS might be effective in reducing the number of self-harm repetitions following a suicide attempt in people who complete the helpsheet and who have been previously admitted to hospital with self-harm. This is the first study to investigate the usefulness of the VHS to reduce self-harm among those who have attempted suicide. These subgroup findings require replication. The potential use of the VHS in those who self-harm for different motives requires further exploration. Funding Chief Scientist Office (CZH/4/704).

Both the United States and New Zealand have experienced tragic mass shootings. This commentary contrasts the responses to these tragedies in the 2 countries in the context of how they each view and...

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of the range of school‐based psychological or educational prevention programmes that are available to prevent suicide and suicidal behaviour in adolescents.

Abstract. Background: Suicidal behavior comprises a diverse set of behaviors with significant differences among several behavioral categories. One noteworthy category includes individuals who have made serious suicide attempts, epidemiologically very similar to those completing suicide. This behavioral category is important, since interviewing survivors of a potentially lethal incident of self-harm enables a detailed investigation of the psychological process leading to the suicidal act. Aim: To achieve a consensus definition and operational criteria of serious suicide attempts. Method: We reviewed studies that included the term serious suicide attempt or related terms (e.g., highly lethal), with a focus on the variety of operational criteria employed across studies. Results: More than 60 papers addressing various types of serious suicide attempt were explored. We found a large variety of operational definitions, reflecting the lack of consensus regarding terminology and criteria related to the term. Conclusion: We undertook the challenge of developing an integrative and comprehensive set of criteria of serious suicide attempt and suggest a definition comprising three key dimensions: medical lethality, potential lethality of the method used, and severity of the objective circumstances of the suicide intent. Clinicians and researchers are strongly encouraged to consider using the term serious suicide attempt with its attendant components.

Objectives: Many factors influence the likelihood of suicide attempts or deaths in persons with bipolar disorder. One key aim of the International Society for Bipolar Disorders Task Force on Suicide was to summarize the available literature on the presence and magnitude of effect of these factors. Methods: A systematic review of studies published from 1 January 1980 to 30 May 2014 identified using keywords ‘bipolar disorder’ and ‘suicide attempts or suicide’. This specific paper examined all reports on factors putatively associated with suicide attempts or suicide deaths in bipolar disorder samples. Factors were subcategorized into: (1) sociodemographics, (2) clinical characteristics of bipolar disorder, (3) comorbidities, and (4) other clinical variables. Results: We identified 141 studies that examined how 20 specific factors influenced the likelihood of suicide attempts or deaths. While the level of evidence and degree of confluence varied across factors, there was at least one study that found an effect for each of the following factors: sex, age, race, marital status, religious affiliation, age of illness onset, duration of illness, bipolar disorder subtype, polarity of first episode, polarity of current/recent episode, predominant polarity, mood episode characteristics, psychosis, psychiatric comorbidity, personality characteristics, sexual dysfunction, first-degree family history of suicide or mood disorders, past suicide attempts, early life trauma, and psychosocial precipitants. Conclusion: There is a wealth of data on factors that influence the likelihood of suicide attempts and suicide deaths in people with bipolar disorder. Given the heterogeneity of study samples and designs, further research is needed to replicate and determine the magnitude of effect of most of these factors. This approach can ultimately lead to enhanced risk stratification for patients with bipolar disorder.

Economic recessions and severe weather events are often associated with increased suicide rates. The Global Dairy Crisis 2015/2016 led to an economic downturn in the New Zealand dairy farming industry and, coupled with droughts in some regions and floods in others, raised fears about increased suicide rates among farmers. However, little was known about suicides in the farming sector. This study reviews characteristics of recent farm-related suicides in New Zealand and assesses the extent to which financial stresses contributed to the deaths.Data were abstracted from coroners' records for a consecutive series of 185 people in farm- and agriculture-related occupations who died by suicide between 2007 and 2015 and for whom coronial inquiries had been completed.Farm suicides were heterogeneous: six distinct risk profiles were identified. Financial stresses made negligible contributions to farm suicides. Overall, risk factors for farm suicides differed little from risk factors for suicide in the general population. However, suicide risk in farmers was exacerbated by ready access to firearms: almost 40% of farm suicides involved firearms, compared to 8% in the general population over the same time. Among farm suicides, young male farm labourers predominated, rather than farm owners or managers. For many young men, relationship losses, acute alcohol intoxication and ready access to a firearm formed a common constellation of risk factors.While coroners' records are variable and do not record specific information about financial stresses and weather events, it was clear that these issues made a negligible contribution to farm suicides. A range of rural suicide prevention initiatives are needed to address various farm suicide risk profiles. In particular, young male labourers often had no contact with health services prior to death, suggesting that rural suicide prevention efforts need to be positioned within community, farming and sports organisations, as well as health and social service providers.

OBJECTIVES: Bipolar disorder is associated with a high risk of suicide attempts and suicide death. The main objective of the present study was to identify and quantify the demographic and clinical correlates of attempted and completed suicide in people with bipolar disorder. METHODS: Within the framework of the International Society for Bipolar Disorders Task Force on Suicide, a systematic review of articles published since 1980, characterized by the key terms bipolar disorder and 'suicide attempts' or 'suicide', was conducted, and data extracted for analysis from all eligible articles. Demographic and clinical variables for which ≥ 3 studies with usable data were available were meta-analyzed using fixed or random-effects models for association with suicide attempts and suicide deaths. There was considerable heterogeneity in the methods employed by the included studies. RESULTS: Variables significantly associated with suicide attempts were: female gender, younger age at illness onset, depressive polarity of first illness episode, depressive polarity of current or most recent episode, comorbid anxiety disorder, any comorbid substance use disorder, alcohol use disorder, any illicit substance use, comorbid cluster B/borderline personality disorder, and first-degree family history of suicide. Suicide deaths were significantly associated with male gender and first-degree family history of suicide. CONCLUSIONS: This paper reports on the presence and magnitude of the correlates of suicide attempts and suicide deaths in bipolar disorder. These findings do not address causation, and the heterogeneity of data sources should limit the direct clinical ranking of correlates. Our results nonetheless support the notion of incorporating diagnosis-specific data in the development of models of understanding suicide in bipolar disorder. Language: en

Objective Suicide is a significant public health problem in New Zealand, with the youth suicide rate being one of the highest among developed countries. Increased suicide rates in recent years suggest that the evidence base and research priorities for New Zealand suicide prevention need to be reassessed. To inform policy development, the aim of the present study was to evaluate all peer-reviewed New Zealand published suicide research and major grant allocations from 2006 to 2016. Methods The methodology duplicated a recent Australian review of suicide prevention research and funding. Publications and grant funding allocations were assessed independently. Key research databases were searched in April 2016 for all suicide-related publications. Identified papers were then classified by research type, population focus and type of self-injurious behaviour. Citation indices were obtained for each publication. Annual reports, newsletters and summary data from four major New Zealand funding bodies (the Health Research Council of New Zealand, Marsden Fund, Lottery Health Research and the Ministry of Health) were reviewed for funding allocations. Identified grants were coded for type of project, type of self-injurious behaviour and target population. Descriptive analyses were performed. Results In all, 104 published articles and 27 grants met review criteria. Total funding was NZ$12 677 261.62. Most published articles were epidemiological in nature and the most common type of grant was for an intervention. Conclusions In the past decade, a substantial number of articles has been published and significant funding was invested in New Zealand’s suicide research. The present review suggests that future research investments should focus on effective translation of research findings into suicide prevention programs. Several pragmatic recommendations are proposed to help improve the evidence base and reduce New Zealand’s suicide rates. What is known about the topic? Suicide prevention continues to be a national public health priority for New Zealand. Although much is known about the prevalence of suicidal behaviours in New Zealand, less is known about how well suicide research has addressed prevention priorities and specific target populations. Australian research found that research funding and publications were dominated by epidemiological studies rather than evaluation or intervention studies. It is yet to be determined whether these research and funding trends also apply for New Zealand. What does this paper add? This study examined all peer-reviewed and published suicide research and all major suicide prevention projects that have been funded in New Zealand between 2006 and 2016. The purpose of the review was to summarise the evidence base, evaluate funding and determine the ability of the evidence base to inform policy development. The findings demonstrate that the New Zealand research trends are similar to those found in Australia, with most studies being epidemiological and few representative of interventions. What are the implications for practitioners? This review highlights that there were few intervention and evaluation studies. Partnerships between practitioners and/or community organisations implementing interventions and researchers to systematically evaluate existing interventions and develop new evidence-based interventions would help improve the evidence base for New Zealand suicide prevention.

The psychological autopsy (PA) is a systematic method of assessing the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of suicide decedents. Procedural challenges that need to be addressed to conduct PA interviews are described in this article and recommendations for meeting these challenges in future PA investigations are made. Procedures addressed include determining the timing of PA interviews after suicide, designing the structure and flow of interviews, selection of proxy respondents, integrating interview data with information gathered from records, and selecting and training interviewers. This methodological article is the second in a two-part series-the first article focused on interview content.

The psychological autopsy (PA) is a systematic method to understand the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of decedents. The methodological challenges that need to be addressed when determining the content of these research interviews for PA studies are described and recommendations are made for meeting these challenges in future PA investigations. Ways to improve the data collected about mental disorders and life events-domains that are assessed in almost all PA studies-are discussed at length. Other understudied content areas considered include the role of personality traits, medical illness and functional limitations, availability of lethal agents, medications, and select distal variables including child maltreatment and family history of mental disorders and suicide. The benefits and challenges to using common protocols across studies are also discussed. Language: en

We conducted a cross-sectional, random-digit-dial survey to evaluate public responses to a hypothetical question: "If someone you knew was suicidal, what would you do first?" Younger people were more likely to call a suicide hotline, and less likely to go to an emergency room (ER) or call 911; immigrants (in the U.S. Language: en

OBJECTIVE: To address issues concerning potential treatment-emergent "suicidality," a consensus conference was convened March 23-24, 2009. PARTICIPANTS: This gathering of participants from academia, government, and industry brought together experts in suicide prevention, clinical trial design, psychometrics, pharmacoepidemiology, and genetics, as well as research psychiatrists involved in studies in studies of psychiatric disorders associated with elevated suicide risk across the life cycle. The process involved reviews of the relevant literature, and a series of 6 breakout sessions focused on specific questions of interest. EVIDENCE: Each of the participants at the meeting received references relevant to the formal presentations (as well as the slides for the presentations) for their review prior to the meeting. In addition, the assessment instruments of suicidal ideation/behavior were reviewed in relationship to standard measures of validity, reliability, and clinical utility, and these findings were discussed at length in relevant breakout groups, in the final plenary session, and in the preparation of the article. Consensus and dissenting views were noted. CONSENSUS PROCESS: Discussion and questions followed each formal presentation during the plenary sessions. Approximately 6 questions per breakout group were prepared in advance by members of the Steering Committee and each breakout group chair. Consensus in the breakout groups was achieved by nominal group process. Consensus recommendations and any dissent were reviewed for each breakout group at the final plenary session. All plenary sessions were recorded and transcribed by a court stenographer. Following the transcript, with input by each of the authors, the final paper went through 14 drafts. The output of the meeting was organized into this brief report and the accompanying full article from which it is distilled. The full article was developed by the authors with feedback from all participants at the meeting and represents a consensus view. Any areas of disagreement at the conference have been noted in the text. CONCLUSIONS: The term suicidality is not as clinically useful as more specific terminology (ideation, behavior, attempts, and suicide). Most participants applauded the FDA's encouragement of standard definitions and definable expectations for investigators and industry sponsors. Further research of available assessment instruments is needed to verify their utility, reliability, and validity in identifying suicide-associated treatment-emergent adverse effects and/or a signal of efficacy in suicide prevention trials. The FDA needs to systematically monitor postmarketing events by encouraging the development of a validated instrument for postmarketing surveillance of suicidal ideation, behavior, and risk. Over time, the FDA, industry, and clinical researchers should evaluate the impact of the requirement that all central nervous system clinical drug trials must include a Columbia Classification Algorithm of Suicide Assessment (C-CASA)-compatible screening instrument for assessing and documenting the occurrence of treatment-emergent suicidal ideation and behavior. Finally, patients at high risk for suicide can safely be included in clinical trials, if proper precautions are followed. Language: en

BackgroundSelf-harm and suicidal behaviour are common reasons for emergency department presentation. Those who present with self-harm have an elevated risk of further suicidal behaviour and death.AimsTo examine whether a postcard intervention reduces self-harm re-presentations in individuals presenting to the emergency department.MethodRandomised controlled trial conducted in Christchurch, New Zealand. The intervention consisted of six postcards mailed during the 12 months following an index emergency department attendance for self-harm. Outcome measures were the proportion of participants re-presenting with self-harm and the number of re-presentations for self-harm in the 12 months following the initial presentation.ResultsAfter adjustment for prior self-harm, there were no significant differences between the control and intervention groups in the proportion of participants re-presenting with self-harm or in the total number of re-presentations for self-harm.ConclusionsThe postcard intervention did not reduce further self-harm. Together with previous results this finding suggests that the postcard intervention may be effective only for selected subgroups.

Summary The relationship between preventive health care utilisation rates and family social background was examined in a birth cohort of two-year-old children. There was a highly significant association between social background and the utilisation of preventive health care. Factors found to reduce preventive health care utilisation included: mother of non-European ethnic origin; single parent family; low maternal education; high residential mobility and large family size. Maternal age and family income were unrelated to health care utilisation when other variables were taken into account. The theoretical and practical implications of the results are discussed.

Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas.

An integrative suicide prevention program was implemented to tackle an outbreak of visitor charcoal burning suicides in Cheung Chau, an island in Hong Kong, in 2002. This study evaluated the effectiveness of the program. The numbers of visitor suicides reduced from 37 deaths in the 51 months prior to program implementation to 6 deaths in the 42 months post-implementation period. The number of visitor suicide pacts decreased from 7 pacts (15 individuals) to 1 pact (2 individuals). No statistically significant differences in the numbers of visitor suicide attempts and resident suicides were observed in the two time periods. No statistically significant changes in visitor suicides during the study period were observed on the comparison islands. The consistency and timing of reduction in visitor suicides correlated with the development and delivery of the integrative program on the intervention island, suggesting a causal association between program delivery and reduction of visitor suicides. The possibility of displacement seems small because there was no increase in visitor suicides on the comparison islands during the study period. This integrative approach in preventing target-specific suicides may serve as an example for other communities to develop suicide prevention programs that make use of the existing local resources.

Abstract. Research on suicide by jumping is summarized. The incidence of suicide by this method varies but tends to be higher in cities, city states, or countries that have extensive high-rise housing. Most suicides by jumping occur from high-rise residential housing units. However, our knowledge about suicide by jumping tends to be limited to a small number of reports from sites, often bridges, which become well-known as places from which to take one's life. Media reports of newsworthy suicides from these sites appear to encourage imitative behavior. Prevention strategies have focused upon limiting suicides from iconic sites by surveillance, barriers, muted media reporting, and signage offering help and telephone hotlines. A small number of studies provides evidence that installing barriers at popular jumping sites reduces suicides from those sites. There are few reports of efforts to reduce suicides from high-rise residential buildings.

There is now a large body of research literature suggesting that restricting access to a particular method of suicide may successfully reduce suicides by that method. However, the extent to which reductions in rates of suicide by one method that is restricted are paralleled by reductions in overall suicide rates is less clear, and this has led to debates about the extent to which restriction of one method may lead to substitution through an equally lethal method. While the risk of substitution has often been used as an argument against restricting access to specific methods of suicide, even in cases in which substitution may occur, method restriction may still be justified. In particular, if it becomes apparent that some particular feature of the environment facilitates or encourages suicidal behavior it may be ethical to remove access to that feature even though there is a risk of substitution. The accumulated evidence suggests that restricting access to a wide range of means and sites of suicide can be an effective, relatively simple approach to suicide prevention – an approach that is, perhaps, sometimes undervalued. At the very least, restriction of method should be considered as one component of any integrated plan for local, regional, and national suicide prevention. This supplement presents a series of papers focusing on specific means of suicide and discusses, for each method, current developments in restricting access to that method and the impact thereof on suicide. Hawton (2007) provides an overview of major issues in restricting access to means of suicidal behavior, including the rationale for this approach, the feasibility of suicide prevention by restricting access to methods of suicide, and the fact that suicidal behavior is often ambivalent and impulsive and may not be pursued if access to a favored method of suicide is thwarted. He summarizes evidence from a range of studies reviewing the impact of restricting access to particular methods of suicide on suicidal behavior. In addition, studies that have explored subsequent suicidal behavior among persons who have survived near-fatal suicide attempts have found that most of those who survive such attempts do not go on to make further attempts by the same – or some alternative – method. Hawton, notes, in particular, that clinical assessment of suicide risk should routinely inquire about access to means of suicide, and that clinicians should strongly advocate the removal of potentially dangerous means of suicide from the households of vulnerable individuals. In the 21st century there has been increasing recognition of the contribution to world rates of suicide from countries in Asia, and a corresponding focus on restricting access to pesticides, which account for many of these deaths. In fact, poisoning by pesticides is the most common method of suicide worldwide. Mishara (2007a) explores the extent of pesticide suicide around the world. In rural Asia the ready availability of highly lethal pesticides, often coupled with limited access to prompt and adequate medical treatment, results in a profile of suicide as less planned, more impulsive, and less likely to be associated with mental illness than in the West. The pesticides available in Asia are often highly toxic (compared with those in the West) and, moreover, highly toxic even in small doses. This feature contributes to high case fatality coupled with inadequate training in medical interventions for pesticide poisoning, limited access to appropriate medical care, and lack of antidotes. Mishara also discusses the context within which pesticide suicides occur, often as impulsive responses to short-term family conflicts and stresses. A range of strategies might be employed to reduce pesticide suicides, including controlling or restricting access to the most dangerous pesticides, reducing the use of highly lethal agents, safer storage practices, education concerning the lethality of pesticides, improved medical training, treatment, and facilities, and developing supportive approaches to address the sources of family conflicts. In 1998 a single case of suicide by charcoal burning was widely publicized by the Hong Kong media as a novel way to end one’s life. The media accounts were explicit and graphic, and they provided, in effect, an advertorial guide to the use of this method. This event occurred during the Asian financial crisis of the late 1990s; the media linked charcoal burning with personal financial despair and portrayed suicide by this method as a painless, peaceful solution to such stress. Within the year charcoal burning had

Objectives: Bipolar disorder is associated with elevated risk of suicide attempts and deaths. Key aims of the International Society for Bipolar Disorders Task Force on Suicide included examining the extant literature on epidemiology, neurobiology and pharmacotherapy related to suicide attempts and deaths in bipolar disorder. Methods: Systematic review of studies from 1 January 1980 to 30 May 2014 examining suicide attempts or deaths in bipolar disorder, with a specific focus on the incidence and characterization of suicide attempts and deaths, genetic and non-genetic biological studies and pharmacotherapy studies specific to bipolar disorder. We conducted pooled, weighted analyses of suicide rates. Results: The pooled suicide rate in bipolar disorder is 164 per 100,000 person-years (95% confidence interval = [5, 324]). Sex-specific data on suicide rates identified a 1.7:1 ratio in men compared to women. People with bipolar disorder account for 3.4–14% of all suicide deaths, with self-poisoning and hanging being the most common methods. Epidemiological studies report that 23–26% of people with bipolar disorder attempt suicide, with higher rates in clinical samples. There are numerous genetic associations with suicide attempts and deaths in bipolar disorder, but few replication studies. Data on treatment with lithium or anticonvulsants are strongly suggestive for prevention of suicide attempts and deaths, but additional data are required before relative anti-suicide effects can be confirmed. There were limited data on potential anti-suicide effects of treatment with antipsychotics or antidepressants. Conclusion: This analysis identified a lower estimated suicide rate in bipolar disorder than what was previously published. Understanding the overall risk of suicide deaths and attempts, and the most common methods, are important building blocks to greater awareness and improved interventions for suicide prevention in bipolar disorder. Replication of genetic findings and stronger prospective data on treatment options are required before more decisive conclusions can be made regarding the neurobiology and specific treatment of suicide risk in bipolar disorder.

This article describes patterns of suicide and attempted suicide among the indigenous (Ma ̄ori) population of New Zealand using official data from the New Zealand Health Information Service (NZHIS). The majority of Ma ̄ori suicides (75%) occurr in young people aged

There is strong evidence for the existence of the Werther effect, or the phenomenon of an observer copying suicidal behavior he or she has seen modelled in the media. As a consequence, a number of countries have developed guidelines that promote responsible reporting of suicide. Using nine such guidelines as examples, this paper demonstrates that they tend to have similar content (emphasizing, for example, that suicide should not be glamorized or sensationalized and that explicit descriptions should be avoided, and stressing the importance of providing information about help services), but differ in the way in which they have been developed (e.g., the extent to which media professionals have been involved) and implemented (e.g., whether their “roll-out” has involved a considered dissemination strategy). The paper also reviews the evidence from evaluations of media guidelines, and concludes that it is too limited to determine whether the guidelines have had an impact on the behavior of media professionals or on completed and attempted suicide rates. It makes recommendations for further evaluative work, and suggests that the lessons from well-designed evaluations should be shared.

Objective: To examine the impact of introducing more restrictive firearms legislation (Amendment to the Arms Act, 1992) in New Zealand on suicides involving firearms. Method: National suicide data were examined for 8 years before, and 10 years following the introduction of the legislation. Results: After legislation, the mean annual rate of firearm-related suicides decreased by 46% for the total population (p < 0.0001), 66% for youth (15–24 years; p < 0.0001) and 39% for adults (≥25 years; p < 0.01). The fraction of all suicides accounted for by firearm-related suicides also reduced for all three populations (p < 0.0001). However, the introduction of firearms legislation was not associated with reductions in overall rates of suicide for all three populations. Conclusions: Following the introduction of legislation restricting ownership and access to firearms, firearm-related suicides significantly decreased, particularly among youth. Overall rates of youth suicide also decreased over this time but it is not possible to determine the extent to which this was accounted for by changes in firearms legislation or other causes.

The use of measures of suicidal ideation and behavior with sound measurement properties is critical in identifying people most at risk of suicide. In particular, brief self-report measures of suicidal ideation and behaviors are needed for use in large-scale population-based research and in the development and evaluation of suicide prevention programs in the community. This review aimed to identify and recommend psychometrically sound self-report measures of suicidal ideation and behaviors that could be used in population-based research of adults. To identify existing self-report measures for adult use, a systematic search was conducted using MEDLINE (Medical Literature Analysis and Retrieval System Online) and PsycINFO (Psychological Information Database) databases. Abstracts, reference lists, and previous review papers were screened. Once measures were identified, we used a hierarchical criterion-based approach to assess their utility, psychometric properties, and appropriateness for population-based research. Nineteen measures were evaluated against 6 criteria. Three brief measures that met all criteria of the evaluation and demonstrated adequate psychometric properties were the Depressive Symptom Index Suicidality Subscale (DSI-SS), Suicidal Behaviors Questionnaire-Revised (SBQ-R), and Suicidal Ideation Attributes Scale (SIDAS). None of the comprehensive measures met all criteria for use in population-based studies, due to financial costs imposed on use, although the Beck Scale for Suicide Ideation (BSSI) and the Adult Suicidal Ideation Questionnaire (ASIQ) had considerable evidence of psychometric robustness. Suicide researchers are encouraged to further establish the validity of scores on these measures across diverse adult populations.

Suicide rates of young people are increasing in many geographic areas. There is a need to recognize more precisely the role of specific mental disorders and their comparative importance for understanding suicide and its prevention. The authors reviewed the published English-language research, where psychiatric diagnoses that met diagnostic criteria were reported, to reexamine the presence and distribution of mental disorders in cases of completed suicide among young people worldwide. The number and geographical distribution of cases were limited (N = 894 cases). The majority of cases (88.6%) had a diagnosis of at least 1 mental disorder. Mood disorders were most frequent (42.1%), followed by substance-related disorders (40.8%) and disruptive behavior disorders (20.8%). Those strategies focusing exclusively on the prevention and treatment of depression in young people need to be reconsidered. A comprehensive suicide prevention strategy among young people should target mental disorders as a whole, not depression alone, and consider contextual factors.

AIMS: To examine the relationship between cannabis use in adolescence/young adulthood and levels of educational attainment. DESIGN: Data were gathered over the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand children. MEASUREMENTS: Measures analysed included (a) frequency of cannabis use in adolescence and young adulthood (15-25 years); (b) levels of educational achievement to age 25 years; and (c) social, family and individual characteristics assessed prior to age 16. FINDINGS: Increasing cannabis use was associated with increasing risks of leaving school without qualifications, failure to enter university and failure to obtain a university degree. The association between cannabis use and leaving school without qualifications persisted after control for confounding factors. When due allowance was made for pre-existing levels of cannabis use there was no evidence to suggest the presence of reverse causal pathways in which lower educational achievement led to increased cannabis use. CONCLUSIONS: Findings support the view that cannabis use may act to decrease educational achievement in young people. It is likely that this reflects the effects of the social context within which cannabis is used rather than any direct effect of cannabis on cognitive ability or motivation. Language: en

Objective: To document mortality in a consecutive series of 302 individuals who made medically serious suicide attempts and were followed-up for 5 years. Method: All sources of mortality were examined in a 5 year prospective study of 302 individuals who made medically serious suicide attempts. Mortality data were obtained by checks with the national mortality database and, for suicide and accidental deaths, were confirmed by review of coronial records. Results: Within 5 years of making a medically serious suicide attempt, one in 11 (8.9%) participants had died. Most deaths (59.2%) were by suicide. Comparison of mortality in this series with rates expected in a comparable general population sample showed the excess mortality was attributable to death by suicide and by motor vehicle accidents. Conclusion: Mortality among those who make medically serious suicide attempts is high. These findings imply the need for the development of enhanced and long-term treatment, follow-up and surveillance programmes for those who make medically serious suicide attempts.

BACKGROUND: Preliminary data indicate that age, gender, and mood disorder moderate the association of alcohol dependence and suicide. The purpose of this study was to evaluate potential moderators of the relationship between alcohol dependence and suicide and medically serious suicide attempts by using case-control data gathered in the Canterbury region of New Zealand for the Canterbury Suicide Project. METHODS: Data on 193 suicide decedents, 240 medically serious suicide attempters, and 984 community controls, all age 18 and over, were gathered by using psychological autopsy methodology. Multinomial logistic analyses were used to compare the two case groups to controls on demographic and diagnostic variables. Moderating effects were evaluated based on significant statistical interactions of predictors with alcohol dependence. RESULTS: The association of alcohol dependence and suicide (but not medically serious attempts) was amplified with increased age. Neither mood disorder nor gender moderated the relationship between alcohol dependence and suicide. Increased age amplified the association of mood disorder and suicide, whereas decreased age strengthened the association of mood disorder and medically serious suicide attempts. CONCLUSIONS: Older age may serve as a marker for a construct (e.g., aggression/impulsivity) that underlies the failure to mature out of alcoholism, or a late-onset subtype of alcoholism prone to negative affect, accounting for the association of older age and suicide in this population. Older age also may merely reflect longer duration of the deleterious effects of alcoholism. Language: en

This article reviews the major life course factors and processes associated with the development of suicidal behaviors in young people. Key issues examined include (a) the spectrum of suicidal behaviors in young people; (b) changing risks of suicidal behavior during childhood, adolescence, and young adulthood; and (c) key risk and protective factors. It is concluded that suicidal tendencies are frequently the culmination of adverse life course sequences that involve multiple risk factors. Future research priorities include a focus on (a) greater understanding of the role of genetic and biologic factors in the development of suicidal behaviors, (b) exploration of factors that may protect young people against suicidal behaviors, and (c) evaluation of public health and clinical programs designed to minimize risk of suicidal behaviors in young people.

Treharne, Brickell, and Chinn (2011) raised concerns about three aspects of our article on sexual orientation (Wells, McGee, & Beautrais, 2011), namely the methodology, the aims, and the languageused.Theyhaveaclearpreference forqualitativestudies and we agree that such studies can provide in-depth information and explore the complexity and fluidity of sexual orientation. However, that is not the type of study we did, so our work should be judged by the standards of survey research. Treharneetal. objected,firstofall, toourhavingsampledone person per household, stating that we assume that ‘‘this facilitates a representative sample in a national survey. In reality, this approach may lead to under-sampling of minority groups living in shared households that diverge from the traditional.’’In the statistical methods section, we stated that all estimates were weighted according to the study design variables. As anyone familiar with survey sampling would understand, when one person has been selected per household, this is dealt with by weighting by the inverse of the number of eligibles within a household, as has been standard in surveys for many decades (Kish, 1965). An extremely detailed account of weighting in the New Zealand Mental Health Survey was provided in a report to theMinistryofHealth, theprimary fundersof thesurvey (Wells, McGee,&OakleyBrowne,2006).This reportwas referenced in our article and we even provided a URL to facilitate easy access as the report ispublicallyavailable.Becauseof theweightingwe used, there is no bias in our estimates from sampling one person per household. Consideration of confidentiality also led us to choose one person per household, as we were concerned that, if multiple peoplewere interviewed,oneperson mightask another how they had responded to specific questions from the interview. The second concern of Treharne et al. is that we did not use stratified sampling to obtain approximately equal numbers in our comparison groups. It is true that for a fixed total sample size, N, power is greatest for detection of differences between two groups if they are of equal size. Hence, most clinical trials have equal numbers in each arm. In population surveys, however, many comparisons will be made and stratification cannot cover all such comparisons. Stratified sampling is possible only if thereareknownstrata tosample from,which isnot thecase for sexual orientation. Even oversampling was not possible for sexualorientation in theNewZealandMentalHealthSurvey.There were no prior data, such as from census data, so that areas with higher density of sexual orientation minority groups could be targeted. Nor was screening feasible: consider asking about sexual orientation at the doorstep to screen sexual orientation minority groups into the survey. Moreover, which of the multiple aspects of sexual orientation would be included in screening? We asked about sexual orientation well into the surveyand had very few refusals. For population estimates, a very large survey provides the bestopportunity for obtaining contact withall groups in the population, not just people who belong to particular organizations or who volunteer to participate. For a given number in a particular group, comparisons are more precise the larger the comparison group whereas Treharne et al. seem to imply that the opposite is the case and that a small group is disadvantaged compared with a large group. They stated: ‘‘We do not wish to downplay those participants’ experiences, but they were compared to many thousands of heterosexual participants who were used as the reference group with a vastly disproportionate denominator in analyses.’’ There were J. E. Wells (&) M. A. McGee Department of Public Health and General Practice, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand e-mail: elisabeth.wells@otago.ac.nz

Objective: To describe the epidemiology and characteristics of all suicide deaths among under 15-year-olds in New Zealand over a 10-year period. Method: In a 10-year retrospective study the features of all 61 children and young adolescents aged less than 15 years who died by suicide in New Zealand from 1989 to 1998 were examined by review of coronial files. Results: Suicide among under 15-year-olds is very rare but increasing. Suicide risk increases with age: the majority of those who die are aged 14 years (57.4% of the total) or 13 years (26.2%). Boys (72.1%) and Maori (57.4%) predominate. Most suicides occurred in children not living in intact biological families (67.2%). Hanging was the predominant method (78.7%). One in three children left suicide notes. One in four had a history of contact with social welfare authorities. There was a family history of suicide in 10% of cases. A minority had a documented history of prior suicide attempts (13.1%) or mental health problems (23%). One in four (23%) was reported to have made threats of suicide within the year prior to their death. A majority of deaths appeared to have been precipitated by relatively minor family arguments or disciplinary events, which, however, occurred in the context of actual or anticipated disruptions or transitions in family living arrangements or school circumstances, or severe family problems. Conclusions: In general, the impression of young adolescent suicide was of a disadvantaged, vulnerable and distressed group of adolescents growing up in extremely difficult circumstances. Maori children predominate in this group. There is clearly a need to verify these impressions with an in-depth investigation of the familial and social circumstances of children who die by suicide. Such investigations might best be conducted by annual mortality review and monitoring of all young adolescent suicides.

Background. Few studies have examined the extent to which populations of suicides and attempted suicides are similar, or different. This paper compares suicides and serious suicide attempts in terms of known risk factors for suicidal behaviour.Methods. Using case–control methodology, risk factors for suicidal behaviour were examined in 202 individuals who died by suicide, 275 individuals who made medically serious suicide attempts and 984 randomly selected control subjects. Based on data from significant others, measures used spanned sociodemographic factors, childhood experiences, psychiatric morbidity and psychiatric history, exposure to recent stressful life events and social interaction.Results. Multiple logistic regression identified the following risk factors that were common to suicide and serious suicide attempts: current mood disorder; previous suicide attempts; prior out-patient psychiatric treatment; admission to psychiatric hospital within the previous year; low income; a lack of formal educational qualifications; exposure to recent stressful interpersonal, legal and work-related life events. Suicides and suicide attempts were distinguished in the following ways: suicides were more likely to be male (OR = 1·9, 95% CI 1·1, 3·2); older (OR = 1·03, 95% CI 1·02, 1·04); and to have a current diagnosis of non-affective psychosis (OR = 8·5, 95% CI 2·0, 35·9). Suicide attempts were more likely than suicides to have a current diagnosis of anxiety disorder (OR = 3·5, 95% CI 1·6, 7·8) and to be socially isolated (OR = 2·0, 95% CI 1·2, 3·5). These findings were confirmed by discriminant function analysis, which identified two functions that described the three subject groups: the first function discriminated the two suicide groups from control subjects on a dimension corresponding to risk factors for suicide; the second function discriminated suicide from suicide attempt subjects on a series of factors including gender, non-affective psychosis and anxiety disorder.Conclusions. Suicides and medically serious suicide attempts are two overlapping populations that share common psychiatric diagnostic and history features, but are distinguished by gender and patterning of psychiatric disorder.

Objectives: Safety barriers to prevent suicide by jumping were removed from Grafton Bridge in Auckland, New Zealand, in 1996 after having been in place for 60 years. This study compared the number of suicides due to jumping from the bridge after the reinstallation of safety barriers in 2003. Methods: National mortality data for suicide deaths were compared for three time periods: 1991–1995 (old barrier in place); 1997–2002 (no barriers in place); 2003–2006 (after barriers were reinstated). Results: Removal of barriers was followed by a fivefold increase in the number and rate of suicides from the bridge. These increases led to a decision to reinstall safety barriers. Since the reinstallation of barriers, of an improved design, in 2003, there have been no suicides from the bridge. Conclusions: This natural experiment, using a powerful a-b-a (reversal) design, shows that safety barriers are effective in preventing suicide: their removal increases suicides; their reinstatement prevents suicides.

Aims. To compare the relationship between cannabis abuse/dependence and risk of medically serious suicide attempts in individuals making serious suicide attempts and randomly selected comparison subjects. Design. Case-control comparison. Setting. Cases, a general hospital; controls, the local community. Participants. Cases were 302 consecutive individuals making medically serious suicide attempts; 1028 randomly selected control subjects. Measurements. DSM-III-R mental disorder diagnoses; measures of socio-demographic characteristics and childhood and family experiences. Findings. Of those making serious suicide attempts, 16.2% met DSM-III-R criteria for cannabis abuse/dependence at the time of the attempt, compared with 1.9% of comparison subjects (OR=10.3; 95%CI, 5.95-17.8, p 0.0001). Risks of serious suicide attempt were significantly related to a series of socio-demographic and childhood characteristics, and to mental disorders that were co-morbid with cannabis abuse/dependence. When the association between cannabis abuse/dependence and suicide attempt risk was controlled for socio-demographic factors, childhood factors and concurrent psychiatric morbidity, there was a marginally significant association (OR=2.0; 95%CI, 0.97-5.3, p 0.06) between cannabis abuse/dependence and serious suicide attempt risk. Conclusions. These results suggested that much of the association between cannabis abuse/dependence and suicide attempt risk arose because: (a) individuals who develop cannabis abuse/dependency tend to come from disadvantaged socio-demographic and childhood backgrounds which, independently of cannabis abuse, are associated with higher risk of suicide attempt, or (b) because cannabis abuse/dependence is co-morbid with other mental disorders which are independently associated with suicidal behaviour. Nevertheless, the possibility remains that cannabis abuse/dependence may make an independent contribution to risk of serious suicide attempt, both directly and through the possible effects of cannabis abuse on risk of other mental disorders.

The goals of the Postvention Taskforce of the International Association for Suicide Prevention (IASP) are to increase awareness of postvention and survivor issues. One of the strategies is to organize meetings. We report on the 1st International Suicide Postvention Seminar, held as a 1-day preevent at the 11th European Symposium on Suicide and Suicidal Behavior in Portoroz, Slovenia, September 2006. The seminar provided a state of the art review of the postvention field, with plenary presentations on research, psychotherapeutic care, development of national networks, and of postvention materials. We summarize the presentations below.

Objective: The social and demographic characteristics of a New Zealand sample of young people making medically serious suicide attempts were examined and compared with those of a control sample of similar age.Method: Using a case control design, 129 young people making serious suicide attempts were contrasted with 153 randomly selected community controls on a series of social and demographic characteristics including educational achievement, socioeconomic status, income, occupation, religious affiliation and ethnicity. The age and gender distribution of the sample, and the methods of suicide attempt, were examined.Results: Almost equal numbers of young males (45.7%) and females (54.3%) made medically serious suicide attempts. The clear majority of serious suicide attempts were by overdose or poisoning (78.3%), with tricyclic antidepressants (38.6%) and paracetamol (37.6%) together accounting for three-quarters (76.2%) of all drug overdoses. Young people who were less well educated and who were from lower socio-economic backgrounds had elevated risk of serious suicide attempts. Conclusions: Young people from socially disadvantaged backgrounds have elevated risk of serious suicide attempt.

Background. This study used a case–control design to examine the association between unemployment and risk of medically serious suicide attempt.Method. A sample of 302 individuals who made serious suicide attempts was contrasted with 1028 randomly selected community control subjects.Results. Individuals who made serious suicide attempts reported higher rates of current unemployment (OR=4·2) than control subjects. This association was similar for males and females. However, even before adjustment for confounding factors it was evident that exposure to unemployment made only a small contribution to suicide attempt risk. The population attributable risk for exposure to unemployment was 7·3%. After adjustment for antecedent childhood, family and educational factors the association between unemployment and risk of serious suicide attempt was reduced but remained significant (OR=2·1), suggesting that common antecedent factors made a large contribution to risks of both unemployment and serious suicide attempt. When both antecedent family and childhood factors, and psychiatric morbidity were taken into account, unemployment was not significantly related to risks of serious suicide attempt.Conclusion. The results of this study provide support for the contention that much of the association between unemployment and suicidal behaviour is non-causal, and reflects common or correlated factors that contribute to risks of both unemployment and suicidal behaviour. Any remaining association between unemployment and suicide attempt risk appears to arise from the correlation that exists between unemployment and psychiatric disorder.

The available data suggest that suicide deaths in Asia may account for the majority of suicides that occur in the world every year. This significant contribution occurs primarily because of the large population sizes of some Asian countries. Together, China, India, and Japan account for more than 40% of all world suicides, and Asia in total may in fact account for up to 60% of all suicides (World Health Organization, accessed 2006). If we apply to Asia commonly used estimates (namely, that there are approximately one million suicides in the world each year, 10 to 20 times as many suicide attempts as deaths, and 5 to 6 people affected by each suicide death or serious suicide attempt), then these figures suggest that up to 60 million people, each and every year, may be affected by suicide in Asia. These estimates provide a compelling case for more research into the etiology of suicidal behavior in Asian countries and for the development of suicide prevention programs tailored to fit the specific profiles of suicidal behavior in Asian countries. Currently, much of our research about suicide is dominated by a rather Western perspective, and we know much less about suicidal behavior in Asia than we do about suicidal behavior in the West.

Objective Precipitating factors and life events associated with medically serious suicide attempts were examined in young people making serious suicide attempts and control subjects. Method Using a case-control design, the authors contrasted 129 young people making serious suicide attempts with 153 randomly selected community controls on a series of life event occurrences within the preceding year. Precipitating factors for serious suicide attempts were also examined. Results The most common precipitants of serious suicide attempts were relationship breakdowns, other interpersonal problems, and financial difficulties. However, one third of those attempting suicide were unable to describe any precipitating factor. Individuals who made serious suicide attempts had elevated rates of life events which were associated principally with interpersonal difficulties, work issues, financial difficulties, and legal problems. When due allowance was made for intercorrelations between life event measures and antecedent social, family, and personality factors, interpersonal losses and conflicts and legal problems remained significant risk factors for serious suicide attempts. Conclusions Important proximal occurrences for serious suicide attempts among young people include a series of life events associated principally with interpersonal conflicts, relationship difficulties, and legal problems.

Objective: This study examined the association between access to a firearm and risk of suicide in a consecutive sample of individuals who had made serious suicide attempts. Method: The study used a case control design in which a sample of 197 individuals who died by suicide and 302 individuals who made medically serious suicide attempts was contrasted with 1028 randomly selected community control subjects. Results: Suicide attempts by gunshot accounted for 1.3% of all serious suicide attempts (with non-fatal outcome) and 13.3% of suicides. However, among those making serious suicide attempts, gunshot had a high rate of fatality (83.3%). While access to a firearm was associated with increased risks that gunshot would be chosen as the method of suicide attempt (OR = 107.9; CI = 24.8-469.5), this access was not associated with significant increases in the risk of suicide (OR = 1.4; CI = 0.96-1.99). Conclusions: For this sample, access to a firearm was not associated with a significant increase in the risk of suicide, although such access was associated with an increased probability that gunshot would be chosen as the method of suicide attempt.

To examine associations between a series of sociodemographic factors, childhood experiences, and mental disorders and risk of serious suicide attempt in young people aged 13 through 24 years and to explore the joint relationship between these factors and vulnerability to serious suicide attempt.The study used a case-control design in which a sample of 129 young people who had made serious suicide attempts was contrasted with 153 randomly selected community controls. Measures included sociodemographic factors (educational qualifications, annual income, residential mobility), childhood experiences (parental relationship, parental care, childhood sexual abuse), and psychiatric morbidity.On the basis of multiple logistic regression, those making serious suicide attempts reported elevated rates of sociodemographic disadvantage (p.0001), higher rates of disadvantageous childhood experiences (p.05), and elevated rates of psychiatric morbidity (p.0001).Risks of serious suicide attempt among young people increased with extent of exposure to childhood adversity, social disadvantage, and psychiatric morbidity, with each of these factors making independent contributions to risk of serious suicide attempt.