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Intro: Suicide is a public health concern globally. While suicide ideation and suicide attempts are strong risk factors for fatal suicide, most people with suicidal thoughts do not proceed to making a suicide attempt, and most people who have survived a suicide attempt do not eventually die by suicide. Researchers have established theories that describe an ideation-to-action framework, distinguishing suicide attempts from suicide ideation. Understanding this distinction is vital for developing and implementing effective suicide prevention strategies. It highlights the importance of early identification and intervention, and the need for ongoing mental health support and resources for individuals at risk of suicide. Methods: Sixteen participants with suicide ideation were interviewed to explore what protected against death by suicide despite different levels of suicidal thoughts. Results: Three recurrent themes were identified from interviewees’ stories: 1) suicidal thoughts as a space; 2) fear and concerns; and 3) coping strategies. Conclusion: We found synchronicity between our findings and common clinical intervention strategies that highlight protective factors in promoting mental health and saving lives from at-risk groups.

Rising social media use over the past decade has been linked with increasing suicide rates among young people. Previous studies that assessed the impact of social media on suicide have typically focused on single social media platforms, such as Twitter, and assumed unidirectional associations, where social media posts leads to suicide. Our study focused on the past decade (2012–2021) which has witnessed a rapid increase of social media platforms and use. Poisson and negative binominal auto-regression models were employed to examine the dynamic reciprocity between social media, traditional media and youth suicides in Taiwan. Increased volume in suicide-related social media posts positively correlated with increased youth suicide rates (β = 2.53 × 10-5, 95% CI= (0.83 × 10-5, 4.24 × 10-5), P

Background: Suicide and homicide have long been viewed in Western culture as moral, ethical and legal equivalents. This view has underpinned many theoretical and empirical explorations into their relationship over the centuries. However, there has been little evaluation of longitudinal heterogeneity. Methods: Suicide and homicide rates in 183 countries between 2000 and 2019 were collected from the World Health Organization Global Health Observatory Repository. Corresponding structural variables (i.e., GDP per capita, unemployment rate, percentage of urban population, percentage of elderly population, and Gini index) were acquired from The World Bank and Standardized World Income Inequality Database. Parallel-process latent class growth modelling was applied to identify different classes within the joint suicide and homicide rate trajectories. Multinomial logistic regression examined relationships between the structural covariates and trajectory classes. Results: Four trajectory classes were identified, two with inverse relationships between suicide and homicide, and two with parallel relationships: 1) countries with increasing suicide rates and decreasing homicide rates (“suicide up, homicide down”: UD, n = 41) or 2) countries with decreasing suicide rates and increasing homicide rates (“suicide down, homicide up”: DU, n = 17); and 3) countries where suicide and homicide rates both trended up (UU, n = 19), or 4) both trended down (DD, n = 106). A higher average annual growth rate (AAGR) of GDP per capita was related to an increased possibility of being in DD than in DU. Countries with higher AAGR in unemployment rates were more likely to be in UD and UU than in DD, while those with higher AAGR in urbanization were less likely to be in UD than in DD. Conclusion: The over-time relationship between suicide and homicide is heterogenous and complex. It is influenced differently by GDP per capita, urbanization and unemployment in different countries, and it is not well described by a single theory.

Summary: Background: Studies on the association between antidepressants and self-harm in adults were mostly conducted over a decade ago and have inconsistent findings. We aimed to compare self-harm risks by antidepressant classes among people aged 40 years or older with depression. Methods: Individuals aged ≥40 years with depression who initiated antidepressant treatment between 2001 and 2015 were retrieved from the Hong Kong Clinical Data Analysis & Reporting system, and were followed up until December 31, 2016. We conducted self-controlled case series (SCCS) analyses to estimate the incidence rate ratio (IRR) of self-harm comparing the pre-exposure (90 days before the first antidepressant use), index exposure (the first antidepressant use), and subsequent exposure (subsequent antidepressant use) periods to nonexposed periods. We applied Cox proportional hazard regressions to estimate the hazard ratio (HR) of self-harm comparing five antidepressant classes (tricyclic and related antidepressant drugs [TCAs], selective serotonin reuptake inhibitors [SSRIs], noradrenergic and specific serotonergic antidepressants [NaSSAs], serotonin–norepinephrine reuptake inhibitors [SNRIs], and others). Findings: A total of 48,724 individuals were identified. SCCS analyses (N = 3,846) found that the increased self-harm risk occurred during the pre-exposure (IRR: 22.24; 95% CI, 20.25-24.42), index exposure (7.03; 6.34-7.80), and subsequent exposure periods (2.47; 2.18-2.79) compared to the unexposed period. Cohort analyses (N = 48,724) found an association of higher self-harm risks in short-term (one year) for NaSSAs vs. TCAs (HR, 2.13; 95% CI, 1.53-2.96), SNRIs vs. TCAs (1.64; 1.01-2.68), and NaSSAs vs. SSRIs (1.75; 1.29-2.36) in the 40-64 years group. The higher risk remained significant in long-term (> one year) for NaSSAs vs. TCAs (1.55; 1.26-1.91) and NaSSAs vs. SSRIs (1.53; 1.26-1.87). In the 65+ group, only short-term differences were observed (SSRIs vs. TCAs [1.31; 1.03-1.66], SNRIs vs. SSRIs [0.44; 0.22-0.87], and SNRIs vs. NaSSAs [0.43; 0.21-0.87]). Interpretation: Within-person comparisons did not suggest that antidepressant exposure is causally associated with an increased risk of self-harm in people with depression. Between-person comparisons revealed differences in self-harm risks between certain pairs of antidepressant classes. These findings may inform clinicians’ benefit-risk assessments when prescribing antidepressants. Funding: Nil.

Summary: Background: Predicted increases in suicide were not generally observed in the early months of the COVID-19 pandemic. However, the picture may be changing and patterns might vary across demographic groups. We aimed to provide a timely, granular picture of the pandemic's impact on suicides globally. Methods: We identified suicide data from official public-sector sources for countries/areas-within-countries, searching websites and academic literature and contacting data custodians and authors as necessary. We sent our first data request on 22nd June 2021 and stopped collecting data on 31st October 2021. We used interrupted time series (ITS) analyses to model the association between the pandemic's emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed and expected numbers of suicides in the pandemic's first nine and first 10-15 months and used meta-regression to explore sources of variation. Findings: We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income; 25 with whole-country data, 12 with data for area(s)-within-the-country, four with both). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis; more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries’ COVID-19 mortality rate, stringency of public health response, economic support level, or presence of a national suicide prevention strategy. Nor were they explained by countries’ income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well. Interpretation: Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these countries/areas-within-countries are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue. Funding: None.

Summary: Background: China has experienced dramatic social changes in the last three decades. This study aimed to investigate socio-economic factors related to suicide rates in China from 1990 to 2015, and examine how the impacts of these factors on suicide rates changed over time. Methods: Suicide rates in 31 provinces in mainland China between 1990 and 2015 were obtained from the Global Burden of Disease (GBD) Study 2019. Temporal-spatial modelling was applied to assess the effects of GDP per capita, urbanization, migration, employment, divorce, proportions of children and older adults on provincial overall, male and female suicide rates. Findings: The overall suicide rate in China declined from 18·1 /100,000 in 1990 to 8·6 /100,000 in 2015, with considerable spatial variation in the magnitude of decline across provinces. The protective effects of increasing in GDP per capita, and urbanization, on provincial suicide rate were strong in 1990 (log GDP: -3·56 [95% CI: -6·15, -0·96], urbanisation: -0·07 [-0·14, -0·01]), however these effects were negligible by 2015. The association between employment and suicide rates has shifted from positive to negative over the study period, while migration remained a constant risk factor for high suicide rates (0·04 [0.00, 0·09]). Interpretation: This study highlighted the dynamic effects of economic and social factors on suicide rates in the context of transforming China. To maintain further reductions in suicide rates cannot rely simply on improving people's materialistic and economic conditions. A more holistic approach to improve overall population well-being is needed. Funding: Humanities and Social Sciences Prestigious Fellowship (37000320) and the General Research Fund (17611619) at the University of Hong Kong.

Background: More so than face-to-face counseling, users of online text-based services might drop out from a session before establishing a clear closure or expressing the intention to leave. Such premature departure may be indicative of heightened risk or dissatisfaction with the service or counselor. However, there is no systematic way to identify this understudied phenomenon. Purpose: This study has two objectives. First, we developed a set of rules and used logic-based pattern matching techniques to systematically identify premature departures in an online text-based counseling service. Second, we validated the importance of premature departure by examining its association with user satisfaction. We hypothesized that the users who rated the session as less helpful were more likely to have departed prematurely. Method: We developed and tested a classification model using a sample of 575 human-annotated sessions from an online text-based counseling platform. We used 80% of the dataset to train and develop the model and 20% of the dataset to evaluate the model performance. We further applied the model to the full dataset (34,821 sessions). We compared user satisfaction between premature departure and completed sessions based on data from a post-session survey. Results: The resulting model achieved 97% and 92% F1 score in detecting premature departure cases in the training and test sets, respectively, suggesting it is highly consistent with the judgment of human coders. When applied to the full dataset, the model classified 15,150 (43.5%) sessions as premature departure and the remaining 19,671 (56.5%) as completed sessions. Completed cases (15.2%) were more likely to fill the post-chat survey than premature departure cases (4.0%). Premature departure was significantly associated with lower perceived helpfulness and effectiveness in distress reduction. Conclusions: The model is the first that systematically and accurately identifies premature departure in online text-based counseling. It can be readily modified and transferred to other contexts for the purpose of risk mitigation and service evaluation and improvement.

Despite the increasing use of electronic devices, the associations between specific online involvement, such as online sexual exposure and cyberbullying victimization, and suicide risk are under-explored among young people. This study examines whether online sexual exposure and cyberbullying victimization are associated with suicide ideation among Hong Kong adolescents and whether gender and sexual orientation influence the associations. Online sexual exposure was categorized as online sexual talk and online sexual dating. A hierarchical regression analysis was employed to examine the relationships between the two types of online sexual exposure and cyberbullying victimization and suicide ideation, as well as the moderating roles of gender and sexual orientation on the relationships. Among the 3772 participants, adolescents with experiences of sexual talk online, sexual dating online, and cyberbullying victimization had 1.34-, 1.28-, and 2.16-times higher odds to have suicide ideation than their counterparts, respectively. There were significant gender differences in the association between cyberbullying victimization and suicide ideation, stronger in girls (p ​

Background: A history of self-harm is strongly associated with future self-harm attempts. Large-scale Asian cohort studies examining risk factors for repeated self-harm are lacking. This paper reports on annual prevalence, cumulative risk, annual risk of non-fatal self-harm repetition, and risk factors among Hong Kong patients with a history of self-harm. Methods: The Hong Kong Clinical Data Analysis and Reporting System (CDARS) provided all accident & emergency department and inpatient self-harm records between Jan 1, 2002 and Dec 31, 2016. Demographic and clinical characteristics were extracted. Annual prevalence, over-time cumulative and annual risks of non-fatal self-harm repetition were estimated, and the adjusted hazard ratios (HR; plus 95% CIs) of putative risk factors associated with repetition were estimated using Wei-Lin-Weissfeld (WLW) generalization of the Cox model for recurrent event analysis. Findings: There were 127,801 self-harm episodes by 99,116 individuals. Annual prevalence of repeated self-harm, of all self-harms, ranged from 7•36% to 28•71% during the study period. Risk of self-harm repetition within one year of the index event was 14•25% (95% CI, 14•04%-14•46%). People with four or more previous self-harm episodes carried the highest risk of self-harm repetition (adjusted HR 4•81 [95% CI 4•46–5•18]). Significant risk factors for non-fatal self-harm repetition included male gender (1•08 [1•05–1•11]), older age (65+ years) (1•07 [1•01–1•13]), social welfare for payment (1•30 [1•27–1•34]), psychiatric admission (1•60 [1•50–1•72]), self-injury only (1•19 [1•15–1•23]), self-injury combined with self-poisoning (1•38 [1•24–1•53]), depression and bipolar disorders (1•09 [1•04–1•14]), personality disorders (1•18 [1•06–1•32]), substance misuse (1•31 [1•27–1•36]), and asthma (1•18 [1•02–1•36]). Interpretation: Hong Kong self-harm patients with non-fatal self-harm events should be supported by effective, timely and ongoing aftercare plans based on their risk profiles, to reduce risk of self-harm reoccurrence. Funding: Research Grants Council, General Research Funding: 17611619.