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Abstract Background People with serious mental health problems (SMHP) are more likely to be admitted to psychiatric hospital following contact with crisis services. Admissions can have significant personal costs, be traumatic and are the most expensive form of mental health care. There is an urgent need for treatments to reduce suicidal thoughts and behaviours and reduce avoidable psychiatric admissions. Methods A multi-stage, multi-arm (MAMS) randomised controlled trial (RCT) with four arms conducted over two stages to determine the clinical and cost effectiveness of three psychosocial treatments, compared to treatment as usual (TAU), for people with SMHP who have had recent suicidal crisis. Primary outcome is any psychiatric hospital admissions over a 6-month period. We will assess the impact on suicidal thoughts and behaviour, hope, recovery, anxiety and depression. The remote treatments delivered over 3 months are structured peer support (PREVAIL); a safety planning approach (SAFETEL) delivered by assistant psychologists; and a CBT-based suicide prevention app accessed via a smartphone (BrighterSide). Recruitment is at five UK sites. Stage 1 includes an internal pilot with a priori progression criteria. In stage 1, the randomisation ratio was 1:1:1:2 in favour of TAU. This has been amended to 2:2:3 in favour of TAU following an unplanned change to remove the BrighterSide arm following the release of efficacy data from an independent RCT. Randomisation is via an independent remote web-based randomisation system using randomly permuted blocks, stratified by site. An interim analysis will be performed using data from the first 385 participants from PREVAIL, SAFETEL and TAU with outcome data at 6 months. If one arm is dropped for lack of benefit in stage 2, the allocation ratio of future participants will be 1:1. The expected total sample size is 1064 participants (1118 inclusive of BrighterSide participants). Discussion There is a need for evidence-based interventions to reduce psychiatric admissions, via reduction of suicidality. Our focus on remote delivery of established brief psychosocial interventions, utilisation of different modalities of delivery that can provide sustainable and scalable solutions, which are also suitable for a pandemic or national crisis context, will significantly advance treatment options. Trial registration ISRCTN33079589. Registered on June 20, 2022.

Abstract Understanding the mechanisms underlying viable seed production of perennial bunchgrasses is critical to improving restoration and conservation success in Great Basin sagebrush steppe rangelands. We studied the effects of pre‐ and post‐anthesis flag‐leaf removal and post‐anthesis seed‐head shading on reproductive effort in two important rangeland restoration species, the exotic crested wheatgrass (Agropyron cristatum) and native squirreltail (Elymus elymoides). Flag‐leaf removal had distinct, species‐specific effects on seed filling. Pre‐anthesis flag‐leaf removal in crested wheatgrass reduced the proportion of filled seeds, while post‐anthesis removal did not. In contrast, squirreltail increased filled seed proportions regardless of flag‐leaf removal timing. Neither flag‐leaf removal treatment affected seed quality, as quantified by seed‐specific mass (in grams per square meter), which significantly reduced with seed‐head shading in both species. Seed‐head shading reduced total propagule production (unfilled + filled seeds) in crested wheatgrass but increased it in squirreltail, possibly due to our shading method protecting from seed‐head herbivory or high‐light stress. Flag‐leaf removal in the squirreltail also induced a negative shading effect on filled seed area, mass, and specific mass. These findings suggest flag leaves can modulate reproductive effort outside of seed provisioning, either by maintaining pre‐fertilized seed viability, as in crested wheatgrass, or acting as a competitive sink to the fully emerged seed‐head, as in squirreltail. Moreover, this study demonstrates photosynthetic activity by the seed‐head itself is critical to the expression of seed quality traits important to seedling establishment success of semiarid perennial bunchgrasses.

Background Childhood adversity is associated with increased later mental health problems and suicidal behaviour. Opportunities for earlier healthcare identification and intervention are needed. Aim To determine associations between hospital admissions for childhood adversity and mental health in children who later die by suicide. Method Population-based longitudinal case-control study. Scottish in-patient general and psychiatric records were summarised for individuals born 1981 or later who died by suicide between 1991 and 2017 (cases), and matched controls (1:10), for childhood adversity and mental health (broadly defined as psychiatric diagnoses and general hospital admissions for self-harm and substance use). Results Records were extracted for 2477 ‘cases’ and 24 777 ‘controls’; 2106 cases (85%) and 13 589 controls (55%) had lifespan hospitalisations. Mean age at death was 23.7; 75.9% were male. Maltreatment or violence-related childhood adversity codes were recorded for 7.6% cases aged 10–17 (160/2106) versus 2.7% controls (371/13 589), odds ratio = 2.9 (95% CI, 2.4–3.6); mental health-related admissions were recorded for 21.7% cases (458/2106), versus 4.1% controls (560/13 589), odds ratio = 6.5 (95% CI, 5.7–7.4); 80% of mental health admissions were in general hospitals. Using conditional logistic models, we found a dose-response effect of mental health admissions

Summary: Background: Autistic people are a high-risk group for self-harm and suicide. There are no evidence-based suicide prevention interventions developed specifically for autistic people. We undertook a pilot feasibility randomised controlled trial of autism adapted safety plans (AASP) to reduce self-harm and suicide for autistic people. Methods: This study took place in the United Kingdom and followed a randomised, two-arm, controlled design. Autistic adults (n = 53, mean age = 39, gender = 49% female, 29% not male or female) were recruited via third sector organisations and self-referral between 11.8.21 and 19.10.22. Participants were randomised without stratification to usual care with or without AASP. The AASP was completed by the autistic adults together with someone trained to support them. Research staff who completed follow-up assessments were blind to participant allocation. Primary outcomes were feasibility and acceptability. Participants were assessed at baseline, 1 and 6 months. Primary data were analysed under the intention to treat principle. Study protocol is published. The trial is closed to new participants. This study is registered with the ISRCTN registry, ISRCTN70594445. Findings: 53 participants consented, 49 were randomised to either AASP with usual care (n = 25) or usual care (n = 24). 68% of participants in the AASP arm were satisfied with the AASP and 41% rated it as useable. Feedback on the AASP and research methods were positive with suggested adaptations to some outcome measures. Retention and completion of outcomes measures in both arms was excellent, as was fidelity of delivery of the AASP. Interpretation: Study progression criteria were met, suggesting that the parameters of a future definitive trial of clinical and cost effectiveness of AASP to reduce self-harm and suicide in autistic adults are achievable, with minor recommended adaptions to outcome measures and AASP. Future research should explore the use of AASP in routine clinical practice. Funding: This study is funded by the NIHR [Public Health Research Programme (NIHR129196)].

Abstract Background Participant feedback is an important consideration for increasing intervention acceptability, yet whether incorporating such feedback actually improves acceptability is rarely tested. Purpose The present study describes a theory-based approach to assessing whether refining an intervention based on participant feedback increases acceptability. Methods Three hundred and ninety-three UK adults who had previously self-harmed were exposed to the same intervention at baseline and, six months later, were randomly allocated to receive either: (a) the same version of the intervention (control group), or (b) a version of the intervention that had been refined following participant feedback (experimental group). The main outcome measure was acceptability ratings for each of the seven domains specified in the Theoretical Framework of Acceptability (TFA). Results Mixed ANOVAs, with control versus experimental group as the between-participants factor and time (baseline versus follow-up) as the within participants factor showed no significant changes in acceptability. Conclusions The null effects reported here imply that participants found both the original and modified versions of the intervention equally acceptable, and that our process of refining an intervention based on participant feedback did not impact on acceptability. Nevertheless, we have operationalised a robust approach for examining whether participant feedback impacts on the acceptability of an intervention. Further research is required to understand better how participant feedback should be incorporated into the development of healthcare interventions.

Abstract Background Suicide prevention is a national priority for the UK government. Autistic people are at greater risk of experiencing self-harm and suicidal thoughts and behaviours than the general population. Safety plans are widely used in suicide prevention but have not yet been designed with and for autistic people. We developed the first safety plan specifically targeting suicidality in autistic adults: the Autism Adapted Safety Plan (AASP). It consists of a prioritised list of hierarchical steps that can be used prior to or during a crisis to mitigate risk of self-harm and suicidal behaviour. This is a pilot study that aims to assess the feasibility and acceptability of the AASPs and the research processes, including the response rates, potential barriers and reach of AASPs, methods of recruitment, what comprises usual care, and economic evaluation methods/tools. Methods This is an external pilot randomised controlled trial of a suicide prevention tool aimed at mitigating the risk of self-harm and suicidal behaviour in autistic adults: AASPs. Participants will be assessed at baseline and followed up 1 month and 6 months later. Assessments include questions about self-harm, suicidality, service use, and their experience of the AASP/taking part in the study. Autistic adults who have a clinical autism diagnosis and self-reported history of self-harm, suicidal thoughts, or suicidal behaviours within the last 6 months will be invited to take part in the study. Informed consent will be obtained. Participants will be recruited via community and third sector services (including community settings, autism charities, and mental health charities). They may also “self-refer” into the study through social media recruitment and word of mouth. Ninety participants will be randomised to either develop an AASP or receive their usual care in a 1:1 ratio. Discussion The present study will provide an evaluation of the suitability of the processes that would be undertaken in a larger definitive study, including recruitment, randomisation, methods, questionnaires, outcome measures, treatment, and follow-up assessments. Trial registration ISRCTN70594445, Protocol v4: 8/2/22.

Abstract The COVID-19 pandemic has been associated with psychological distress. In addition to physical effects including fatigue and cognitive impairment, contracting COVID-19 itself may also be related to subsequent negative mental health outcomes. The present study reports data from a longitudinal, national survey of the UK adult population investigating whether contracting suspected or confirmed COVID-19 at the early stages of the pandemic (March–May 2020) was associated with poorer mental health outcomes in May/June 2020, October/November 2020 and June/July 2021. A quota survey design and a sampling frame that permitted recruitment of a national sample (n = 3077) were utilised. Experience of contracting COVID-19 during the first UK lockdown was assessed along with levels of depression, anxiety, mental wellbeing and loneliness. Around 9% of participants reported contracting COVID-19 in March/May 2020 (waves 1–3) with just under 13% of the overall sample reporting COVID-19 at any one of the first three time points. Compared to those without probable COVID-19 infection, participants with probable COVID-19 had poorer mental health outcomes at follow-up with these effects lasting up to 13 months (e.g., May/June 2020:ORdepression = 1.70, p

Background: Suicidal ideation (SI) is a significant and long-lasting mental health problem, with a third of individuals still experiencing SI after two years. To date, most Ecological Momentary Assessment (EMA) studies of SI have assessed its day-to-day course over one to four consecutive weeks and found no consistent trends in average SI severity over time. Aim: The current proof of concept study assessed daily fluctuations of SI over a time span of 3 to 6 months to explore whether individual trends in SI severity could be detected, and if so, if the trajectory of changes were gradual or sudden. The secondary aim was to explore whether changes in SI severity could be detected at an early stage. Method: Five adult outpatients with depression and SI used an EMA app on their smartphone in addition to their regular treatment for 3 to 6 months, where SI was assessed 3 times a day. To detect trends in SI for each patient, three models were tested: a null model, a gradual change model and a sudden change model. To detect changes in SI before a new plateau was reached, Early Warning Signals and Exponentially Weighted Moving Average control charts were used. Results: In each patient, average SI severity had a unique trajectory of sudden and/or gradual changes. Additionally, in some patients, increases in both sudden and gradual SI could be detected at an early stage. Conclusions: The study presents a first indication of unique individual trends in SI severity over a 3 to 6 months period. Though replication in a larger sample is needed to test how well results generalize, a first proof-of-concept is provided that both sudden and gradual changes in SI severity may be detectable at an early stage using the dynamics of time-series data.

Abstract Background A previous suicide attempt is an important predictor of future suicide. However, there are no evidence-based interventions administered in UK general hospital contexts to reduce suicidal behaviour in patients admitted following a suicide attempt. Consequently, the objective of this pilot randomised controlled trial was to explore whether a safety planning and telephone follow-up intervention (SAFETEL) was feasible and acceptable for individuals treated in hospital following a suicide attempt. Methods In this three-phase study with an embedded process evaluation, a safety planning intervention was tailored to the UK context (Phase I), piloted (Phase II, n = 32), and tested in a feasibility randomised controlled trial (Phase III). In Phase III, participants were allocated to either the intervention (n = 80) or control group (n = 40) using telephone randomisation with a 2:1 ratio. The acceptability and feasibility of the trial and intervention procedures were evaluated using both qualitative (interviews and focus groups) and quantitative data. The number of hospital representations of suicidal behaviour was also collected 6 months after study recruitment based on electronic patient records. Results Findings indicated that SAFETEL was both acceptable and feasible. Hospital staff reported the intervention fitted and complemented existing services, and patients reported that they favoured the simplicity and person-centred approach of the safety planning intervention. Conclusions All progression criteria were met supporting further evaluation of the intervention in a full-scale clinical effectiveness trial. Trial registration ISRCT, ISRCTN62181241 , 5/5/2017

Abstract Background Relatively little is known about the characteristics of people living in the community who have previously self-harmed and may benefit from interventions during and after COVID-19. We therefore aimed to: (a) examine the relationship between reported self-harm and COVID-19-related fear, and (b) describe the characteristics of a community sample of people who reported a lifetime history of self-harm. Methods A cross-sectional national online survey of UK adults who reported a lifetime history of self-harm (n = 1029) was conducted. Data were collected May – June 2020. Main outcomes were self-reported COVID-19-related fear (based on the Fear of COVID-19 scale [FCV-19S]), lifetime history of COVID-19, and lifetime history of self-harm. Data were analysed using descriptive statistics and binary logistic regression. Chi-square was used to compare characteristics of our sample with available national data. Results Overall, 75.1, 40.2 and 74.3% of the total sample reported lifetime suicidal ideation, suicidal attempts and non-suicidal self-harm respectively. When adjusting for age, sex, ethnicity, social grade, and exposure to death and suicide, binary logistic regression showed higher levels of perceived symptomatic (or physiological) reactions to COVID-19 were associated with suicidal ideation (OR = 1.22, 95%CI 1.07, 1.39) and suicidal attempts (OR = 3.91, 95%CI 1.18, 12.96) in the past week. Conclusions Results suggest an urgent need to consider the impact of COVID-19 on people with a lifetime history of self-harm when designing interventions to help support people in reducing suicidal ideation and suicidal attempts. Experiencing symptomatic reactions of fear in particular is associated with self-harm. Helping to support people to develop coping plans in response to threat-related fear is likely to help people at risk of repeat self-harm during public health emergencies.

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.

Mental health smartphone apps could increase the safety and self-management of patients at risk of suicide, but it is still unclear whether it is feasible to integrate such apps into routine mental healthcare. This study reports on the feasibility of using a safety planning app (BackUp) and a self-monitoring app (mEMA) as components of the routine treatment of depressed outpatients with suicidal ideation. Clinicians were trained in working with both of the apps, and they invited their eligible patients with suicidal ideation for study participation. Patients used the apps for 3 months and discussed these with their clinician during treatment. Patients completed assessments at baseline (T0), 4 weeks (T1) and post-test (T2, 12 weeks after baseline). Both patients and clinicians also participated in telephone interviews. Feasibility was assessed in terms of usability (score > 70 on System Usability Scale, SUS), acceptability (score > 20 on Client Satisfaction Questionnaire-8, CSQ-8), and uptake (sufficient rates of component completion and app usage in treatment). The sample included 17 adult outpatients (52.9% male, age range 20–50 years) diagnosed with a depressive disorder and suicidal ideation at baseline. BackUp was rated by patients at above the cut-off scores for usability (SUS mean score at T1 75.63 and at T2 77.71) and acceptability (CSQ-8 mean score at T1 23.42 and at T2 23.50). mEMA was similarly rated (SUS mean score at T1 75.83 and at T2 76.25; CSQ-8 mean score at T1 23.92 and at T2 22.75). Telephone interviews with patients and clinicians confirmed the usability and acceptability. The uptake criteria were not met. Our findings suggest that mobile safety planning and mobile self-monitoring can be considered acceptable and usable as treatment components for depressed suicidal outpatients, but the integration of apps into routine treatment needs to be further explored.

Objectives This study provides an in-depth understanding of the impact of physical distancing restrictions and other quarantining measures during the first 6 months of the COVID-19 pandemic on physical and mental health and well-being.Design Longitudinal qualitative research using semistructured interviews at two time points (21 May to 10 June 2020 when the first restrictions were eased, and 2 to 26 August 2020 when many restrictions had been eased, but physical distancing measures remained) and framework analysis.Setting Interviews by telephone or video call in Scotland.Participants Thirty participants: 16 women, 93% reporting white ethnicity, 18+ years, 47% from deprived areas, 47% reported mental and/or physical health conditions.Results Four main themes described the impact of physical distancing restrictions on (1) health behaviours; (2) healthcare access; (3) physical health; and (4) mental health. Changes in impact over the two time points were compared. For example, health behaviours in May/June, such as reduced physical activity and increased calorie intake, appeared to improve by August. From May/June to August, an increasing number of participants expressed dissatisfaction with healthcare they received. Participants with existing physical health conditions reported continued negative impact of restrictions on their physical health. All participants reported some negative mental health impact, mostly anxiety. An increasing number reported mental health improvements in August, with those with mental health conditions or under 30 years reporting improvement most frequently.Conclusions In line with previous research, our participants felt able to return to prepandemic health habits. Our findings corroborate evidence of reduced preventive healthcare use and help-seeking behaviours. People with existing health conditions appear to be most vulnerable to negative mental and physical health impacts of physical distancing. These negative impacts and periods of unhealthy behaviours have potential long-term consequences, especially among already underserved groups. We recommend public health and policy strategies to mitigate long-term impacts of physical distancing.

Suicide prevention is an important public mental health issue that can be significantly brought forward by recent advances in psychological research methods and assessment. The project “TempRes” aims to harness the power of Ecological Momentary Assessment (EMA) to investigate the transdiagnostic risk and resilience factors associated with suicidal ideation drawn from the most recent research in suicide prevention and personality assessment. Participants will comprise the general population (planned: N = 100) and a risk group (patients currently in psychosomatic or psychiatric treatment) (planned: N = 50). After a comprehensive baseline assessment, they will complete up to ten short assessments per day over the course of 10 days at roughly equidistant intervals. In detail, the project examines the interplay of biography (previous suicidal behavior, experiences of childhood maltreatment), individual differences (level of personality functioning), and time-varying factors (entrapment, loneliness, mood) with respect to the emergence and fluctuation of suicidal ideation. There are two main research foci: First, the project will provide an operationalization and empirical verification of a core assumption of the integrated motivational-volitional model of suicide (IMV model). It will test whether the interaction of the time-varying predictors entrapment with loneliness (as a motivational moderator) explains reports of suicidal ideation over time. Second, it will be the first to examine personality functioning (a transdiagnostic, psychodynamically grounded conceptualization of vulnerability to psychological crises over the life span) as a time-invariant predictor of suicidal ideation assessed within an intensive longitudinal study design. The main analyses will be built on linear mixed models. The overarching aim of the project is to gain a better understanding of the psychological dynamics underlying suicidal ideation in different populations by bringing together concepts from different theoretical traditions. This will inform prevention efforts geared toward the general public as well as intervention in clinical populations.

Summary: Background: The aim of the study was to crystallize the nature of relationships between impulsivity, aggression, and suicidality. We reviewed studies of adults with published, psychometric measures of impulsivity and aggression, and measures of suicidality. Methods: Our primary data source was Web of Science (from inception to 31st December 2021). Quality of articles was assessed using a Joanna Briggs Appraisal Tool and publication bias using Trim and Fill. We synthesised results using random effects meta-analyses and explored moderation by measure of impulsivity, aggression, and suicidality, and population. Findings: 77 studies were included in our analysis. We found weak positive relationships between impulsivity (r = 0·19 [95% CI: 0·15–0·22]), aggression (0·23 ([0·17, 0·29]), and impulsive aggression (0·16 [0·1, 0·22]) with suicidality. Heterogeneity was significant and only partially explained by moderators. Limitations included the lack of studies which assess impulsivity or aggression proximal to suicidality. Interpretation: Given small effect sizes and significant heterogeneity, the study suggests that additional studies are needed in the field to analyze the relation between impulsivity and aggression with suicidality. Funding: None.

Background: The COVID-19 pandemic has had an impact on the mental health of healthcare and social care workers, and its potential effect on suicidal thoughts and behaviour is of particular concern. Methods: This systematic review identified and appraised the published literature that has reported on the impact of COVID-19 on suicidal thoughts and behaviour and self-harm amongst healthcare and social care workers worldwide up to May 31, 2021. Results: Out of 37 potentially relevant papers identified, ten met our eligibility criteria. Our review has highlighted that the impact of COVID-19 has varied as a function of setting, working relationships, occupational roles, and psychiatric comorbidities. Limitations: There have been no completed cohort studies comparing pre- and post-pandemic suicidal thoughts and behaviours. It is possible some papers may have been missed in the search. Conclusions: The current quality of evidence pertaining to suicidal behaviour in healthcare workers is poor, and evidence is entirely absent for those working in social care. The clinical relevance of this work is to bring attention to what evidence exists, and to encourage, in practice, proactive approaches to interventions for improving healthcare and social care worker mental health.

Background: The COVID-19 pandemic has caused considerable morbidity, mortality and disruption to people’s lives around the world. There are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review synthesises findings from emerging literature on incidence and prevalence of suicidal behaviour as well as suicide prevention efforts in relation to COVID-19, with this iteration synthesising relevant evidence up to 19th October 2020. Method: Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. We exclude one-off cross-sectional studies without either pre-pandemic measures or comparisons of COVID-19 positive vs. unaffected individuals. Results: Searches identified 6,226 articles. Seventy-eight articles met our inclusion criteria. We identified a further 64 relevant cross-sectional studies that did not meet our revised inclusion criteria. Thirty-four articles were not peer-reviewed (e.g. research letters, pre-prints). All articles were based on observational studies. There was no consistent evidence of a rise in suicide but many studies noted adverse economic effects were evolving. There was evidence of a rise in community distress, fall in hospital presentation for suicidal behaviour and early evidence of an increased frequency of suicidal thoughts in those who had become infected with COVID-19. Conclusions: Research evidence of the impact of COVID-19 on suicidal behaviour is accumulating rapidly. This living review provides a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide risk as the longer term impacts of the pandemic on suicide risk are researched.

Abstract Background Self-harm, an act of self-poisoning or self-injury irrespective of motivation, is a major public health concern. Use of alcohol prior to or alongside acts of self-harm is common but little is known about the alcohol-related mechanisms of self-harm enaction. We utilised an ideation-to-action approach to clarify the extent to which volitional alcohol factors differentiated those who have thoughts of self-harm but do not act on them (self-harm ideation) and those who engage in self-harm (self-harm enaction). Methods Cross-sectional analyses of the baseline phase of the Health Lifestyle and Wellbeing study: 1546 adults (1079 female; Mean age = 34 y; 92% White) resident in Scotland completed measures of demographics, lifetime self-harm, volitional alcohol factors and psychosocial factors. Multinomial logistic regression compared those with a history of self-harm thoughts (‘ideation’, n = 297), self-harm acts (‘enaction’, n = 346) and ‘controls’ (n = 897) to identify volitional alcohol factors associated with self-harm enaction. Results Volitional alcohol factors differentiated those with a history of self-harm enaction from those with a history of self-harm ideation (as well as those with no history) in initial models adjusted for demographics and depressive symptoms: the self-harm enaction group reported stronger alcohol-related negative urgency (OR = 1.74, 95% CI 1.41–2.16, p

Abstract Background An emerging literature suggests that autistic adults are at increased risk of experiencing suicidal thoughts, making suicidal plans and attempts, and dying by suicide. However, few studies have investigated whether autistic traits are related to suicidal behaviour. The current study examined autistic traits in a sample of adults who reported at least one suicide attempt. Methods An online questionnaire was advertised between June and September 2017 on suicide prevention websites, research databases, and social media. Participants reported whether they had ever attempted suicide (yes/no), and if so, how many times they had attempted (once/more than once). They also reported diagnosed and suspected mental health or neurodevelopmental conditions, and completed the Autism Spectrum Quotient (AQ). Two hundred forty-five adults accessed the survey; 132 reported having attempted suicide and also completed the AQ. It was hypothesised that AQ total scores and subscale scores would be higher in adults who had attempted suicide more than once compared to adults who had attempted once. These hypotheses were tested using an independent samples t test, Mann-Whitney U tests, and binary logistic regression. Results Most participants were female (83.3%, male = 12.9%, other = 3.8%), and ages ranged from 18 to 65 (median = 36.00; IQR = 19.00). Total AQ scores, as well as communication and imagination subscale scores were significantly higher in adults who had attempted suicide more than once compared to adults who had attempted suicide once. Even after removing participants with diagnosed or suspected autism (n = 34), 40.6% had an AQ score indicative of clinical concern (≥ 26). Conclusions The findings suggest that high levels of autistic traits may frequently be present in adults who have attempted suicide, and that AQ scores are higher in those with a history of more than one suicide attempt. It may be possible to better identify suicide risk by screening autistic adults with mental health conditions for suicidal thoughts and behaviours, and by screening people with suicidal thoughts and/or behaviours for autism.

Abstract Background Physical illness and mental disorders play a significant role in fatal and non-fatal suicidal behaviour. However, there is no clear evidence for the effect of physical and mental illness co-occurrence (multimorbidity) in suicidal ideation and attempts. The aim of the current study was to investigate, whether physical/mental health multimorbidity predicted suicidal thoughts and behaviours as outcomes. Methods Data from the West of Scotland Twenty-07 cohort were analysed. Twenty-07 is a multiple cohort study following people for 20 years, through five waves of data collection. Participants who responded to past-year suicidal thoughts and suicide attempt items were grouped into four distinct health-groups based on having: (1) neither physical nor mental health condition (controls); (2) one or more physical health condition; (3) one or more mental health condition and; (4) multimorbidity. The role of multimorbidity in predicting suicidal ideation and suicide attempts was tested with a generalised estimating equation (GEE) model and odds ratios (ORs) and 95% CIs are presented. Whether the effect of multimorbidity was stronger than either health condition alone was also assessed. Results Multimorbidity had a significant effect on suicidal thoughts and suicide attempts, compared to the control group, but was not found to increase the risk of either suicide-related outcomes, more than mental illness alone. Conclusions We identified an effect of physical/mental multimorbidity on risk of suicidal thoughts and suicide attempts. Considering that suicide and related behaviour are rare events, future studies should employ a prospective design on the role of multimorbidity in suicidality, employing larger datasets.

In the face of the COVID-19 pandemic, the swift response of mental health research funders and institutions, service providers, and academics enabled progress toward understanding the mental health consequences. Nevertheless, there remains an urgent need to understand the true extent of the short- and long-term effects of the COVID-19 pandemic on mental health, necessitating ongoing research. Although the speed with which mental health researchers have mobilized to respond to the pandemic so far is to be commended, there are valid concerns as to whether speed may have compromised the quality of our work. As the pandemic continues to evolve, we must take time to reflect on our initial research response and collectively consider how we can use this to strengthen ensuing COVID-19 mental health research and our response to future crises. Here, we offer our reflections as members of the UK mental health research community to discuss the continuing progress and persisting challenges of our COVID-19 response, which we hope can encourage reflection and discussion among the wider research community. We conclude that (1) Fragmentation in our infrastructure has challenged the efficient, effective and equitable deployment of resources, (2) In responding quickly, we may have overlooked the role of experts by experience, (3) Robust and open methods may have been compromised by speedy responses, and (4) This pandemic may exacerbate existing issues of inequality in our workforce.

Background: Exposure to residential greenery accumulates over people’s lifetimes, and possibly has a protective association with suicide later in life. Objectives: To examine the associations between suicide mortality and long-term residential greenery exposure in male and female adults. Methods: Our population-based nested case-control study used longitudinally georeferenced Dutch register data. Suicide cases aged 18–64 years between 2007 and 2016 were matched by gender, age, and date of suicide to 10 random controls. We measured long-term greenery exposure along people’s 10-year residential address histories through longitudinal normalized difference vegetation indices (NDVI) from Landsat satellite imagery between 1997 and 2016. We assigned accumulated greenery exposures, weighted by people’s exposure duration, within 300, 600, and 1,000 m concentric buffers around home addresses. To assess associations between suicide and greenery, we estimated gender-specific conditional logistic regressions without and with adjustment for individual-level and area-level confounders. Stratified models were fitted for areas with a high/low level of urbanicity and movers/non-movers. Results: Our study population consisted of 9,757 suicide cases and 95,641 controls. In our models adjusted for age, gender, and date of suicide, the odds ratios decreased significantly with higher quartiles of accumulated NDVI scores. NDVI associations were attenuated and did not remain significant after adjustment for socioeconomics, urbanicity, air pollution, social fragmentation, etc. for either males or females. For females, but not males, our model with 300 m buffers for areas with a low level of urbanicity showed a significant suicide risk reduction with increasing levels of NDVI. Individual risk factors (e.g., lack of labor market participation) outweighed the contribution of greenery. Conclusion: We found limited evidence that long-term greenery exposure over people’s lifetimes contributes to resilience against suicide mortality. Ensuring exposure to greenery may contribute to suicide prevention for specific population groups, but the effectiveness of such exposure should not be overstated.

Background: The COVID-19 pandemic has caused morbidity and mortality, as well as, widespread disruption to people’s lives and livelihoods around the world. Given the health and economic threats posed by the pandemic to the global community, there are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review (LSR) focuses on suicide prevention in relation to COVID-19, with this iteration synthesising relevant evidence up to June 7th 2020. Method: Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. Results: Searches identified 2070 articles, 29 (28 studies) met our inclusion criteria, of which 14 articles were research letters or pre-prints awaiting peer review. All articles reported observational data: 12 cross-sectional; eight case series; five modelling; and three service utilisation studies. No studies reported on changes in rates of suicidal behaviour. Case series were largely drawn from news reporting in low/middle income countries and factors associated with suicide included fear of infection, social isolation and economic concerns. Conclusions: A marked improvement in the quality of design, methods, and reporting in future studies is needed. There is thus far no clear evidence of an increase in suicide, self-harm, suicidal behaviour, or suicidal thoughts associated with the pandemic. However, suicide data are challenging to collect in real time and economic effects are evolving. Our LSR will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide. PROSPERO registration: CRD42020183326 01/05/2020

Abstract Background Although research has identified a wide range of risk factors for suicidal behavior in prisoners, it does not establish who is most likely to act on their suicidal thoughts while incarcerated. Methods Self-report data were collected from a random sample of 1,203 adult men incarcerated across 15 prisons in Belgium, who represent 12% of all male prisoners nationwide. Results One-third (33%) of participants reported having suicidal thoughts during their incarceration, of whom 26% attempted suicide in prison (9% of all prisoners). Factors independently associated with suicide attempt among prisoners with suicidal ideation were violent offending (adjusted odds ratio [aOR] = 2.64, 95% confidence interval [CI] 1.33–5.23), in-prison drug use (aOR = 2.30, 95% CI 1.25–4.22), exposure to suicidal behavior (aOR = 1.96, 95% CI 1.04–3.68), and a lifetime history of nonsuicidal self-injury (aOR = 1.90, 95% CI 1.08–3.36). While related to suicidal thoughts, markers of psychiatric morbidity and aspects of the prison regime were not associated with the progression to suicide attempt. Conclusions Many prisoners who think about suicide do not attempt suicide while incarcerated. Factors associated with suicidal ideation are distinct from those that govern the transition to suicidal behavior. Our findings lend support to the hypothesis that behavioral disinhibition might act as a catalyst in the translation of suicidal thoughts into action.

Background: It remains difficult to predict and prevent suicidal behaviour, despite growing understanding of the aetiology of suicidality. Clinical guidelines recommend that health care professionals develop a safety plan in collaboration with their high-risk patients, to lower the imminent risk of suicidal behaviour. Mobile health applications provide new opportunities for safety planning, and enable daily self-monitoring of suicide-related symptoms that may enhance safety planning. This paper presents the rationale and protocol of the Continuous Assessment for Suicide Prevention And Research (CASPAR) study. The aim of the study is two-fold: to evaluate the feasibility of mobile safety planning and daily mobile self-monitoring in routine care treatment for suicidal patients, and to conduct fundamental research on suicidal processes. Methods: The study is an adaptive single cohort design among 80 adult outpatients or day-care patients, with the main diagnosis of major depressive disorder or dysthymia, who have an increased risk for suicidal behaviours. There are three measurement points, at baseline, at 1 and 3 months after baseline. Patients are instructed to use their mobile safety plan when necessary and monitor their suicidal symptoms daily. Both these apps will be used in treatment with their clinician. Conclusion: The results from this study will provide insight into the feasibility of mobile safety planning and self-monitoring in treatment of suicidal patients. Furthermore, knowledge of the suicidal process will be enhanced, especially regarding the transition from suicidal ideation to behaviour.The study protocol is currently under revision for medical ethics approval by the medical ethics board of the Vrije Universiteit Medical centre Amsterdam (METc number 2017.512/NL62795.029.17). Keywords: Suicide prevention, Mobile health, Feasibility, Safety planning, Ecological momentary assessment

BackgroundThere are few prevalence studies of suicide attempts and non-suicidal self-harm (NSSH).AimsWe aimed to estimate the prevalence of thoughts of NSSH, suicidal thoughts, NSSH and suicide attempts among 18- to 34-year-olds in Scotland.MethodWe interviewed a representative sample of young adults from across Scotland.ResultsWe interviewed 3508 young people; 11.3 and 16.2% reported a lifetime history of suicide attempts and NSSH, respectively. The first episode of NSSH tended to precede the first suicide attempt by about 2 years. Age at onset of NSSH and suicide attempt was younger in females. Earlier age at onset was associated with more frequent NSSH/suicide attempts. Women are significantly more likely to report NSSH and suicide attempts compared with men.ConclusionsOne in nine young people has attempted suicide and one in six has engaged in NSSH. Clinicians should be vigilant, as suicide attempts and NSSH are relatively common.Declaration of interestNone.

Abstract Background Risk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known. Method We compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months. Results The episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24–29% and 9–12% respectively) and high specificity (76–77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm. Conclusions The scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.

Background Suicidal behaviour is the end result of the complex relation between many factors which are biological, psychological and environmental in nature. Network analysis is a novel method that may help us better understand the complex association between different factors. Aims To examine the relationship between suicidal symptoms as assessed by the Beck Scale for Suicide Ideation and future suicidal behaviour in patients admitted to hospital following a suicide attempt, using network analysis. Method Secondary analysis was conducted on previously collected data from a sample of 366 patients who were admitted to a Scottish hospital following a suicide attempt. Network models were estimated to visualise and test the association between baseline symptom network structure and suicidal behaviour at 15-month follow-up. Results Network analysis showed that the desire for an active attempt was found to be the most central, strongly related suicide symptom. Of the 19 suicide symptoms that were assessed at baseline, 10 symptoms were directly related to repeat suicidal behaviour. When comparing baseline network structure of repeaters (n=94) with the network of non-repeaters (n=272), no significant differences were found. Conclusions Network analysis can help us better understand suicidal behaviour by visualising the complex relation between relevant symptoms and by indicating which symptoms are most central within the network. These insights have theoretical implications as well as informing the assessment and treatment of suicidal behaviour.

BackgroundSuicide attempts and non-suicidal self-harm (NSSH) are major public health concerns that affect millions of young people worldwide. Consequently, there is a strong need for up-to-date epidemiological data in this population.AimsTo provide prevalence and trend estimates of suicidal thoughts and behaviours and NSSH thoughts and behaviour in university students.MethodData are from a 2018 national health survey for higher education in Norway. A total of 50 054 full-time students (69.1% women) aged 18–35 years participated (response rate 31%). Suicidal ideation, suicide attempts and NSSH were assessed with three items drawn from the Adult Psychiatric Morbidity Survey, and thoughts of NSSH were assessed with one item from the Child and Adolescent Self-Harm in Europe study.ResultsLifetime suicidal thoughts were reported by 21.0%, and 7.2% reported having such thoughts within the past year. In total, 4.2% reported a suicide attempt, of whom 0.4% reported attempting suicide within the past year. The prevalence of lifetime NSSH behaviour and thoughts was 19.6% and 22.6%, respectively. All four suicidal behaviour and NSSH variables were more common among students who were single, living alone and with a low annual income, as well as among immigrants. There was an increase in suicidal thoughts from 2010 (7.7%) to 2018 (11.4%), which was evident in both men and women.ConclusionsThe observed high and increasing prevalence of suicidal thoughts and NSSH among college and university students is alarming, underscoring the need for further research, preferably registry-linked studies, to confirm whether the reported prevalence is representative of the student population as a whole.Declaration of interestNone.

Suicide and attempted suicide are major public health concerns. In recent decades, there have been many welcome developments in understanding and preventing suicide, as well as good progress in intervening with those who have attempted suicide. Despite these developments, though, considerable challenges remain. In this article, we explore both the recent developments and the challenges ahead for the field of suicide research and prevention. To do so, we consulted 32 experts from 12 countries spanning four continents who had contributed to the International Handbook of Suicide Prevention (2nd edition). All contributors nominated, in their view, (i) the top 3 most exciting new developments in suicide research and prevention in recent years, and (ii) the top 3 challenges. We have synthesized their suggestions into new developments and challenges in research and practice, giving due attention to implications for psychosocial interventions. This Perspective article is not a review of the literature, although we did draw from the suicide research literature to obtain evidence to elucidate the responses from the contributors. Key new developments and challenges include: employing novel techniques to improve the prediction of suicidal behavior; testing and applying theoretical models of suicidal behavior; harnessing new technologies to monitor and intervene in suicide risk; expanding suicide prevention activities to low and middle-income countries; moving toward a more refined understanding of sub-groups of people at risk and developing tailored interventions. We also discuss the importance of multidisciplinary working and the challenges of implementing interventions in practice.

Background: The COVID-19 pandemic has caused widespread morbidity and mortality as well as disruption to people’s lives and livelihoods around the world; this has occurred as a result of both infection with the virus itself and the health protection measures taken to curb its spread. There are concerns that rates of suicide, suicidal behaviours and self-harm may rise during and in the aftermath of the pandemic. Given the likely rapidly expanding research evidence base on the pandemic’s impact on rates of suicide, suicidal behaviours and self-harm and emerging evidence about how best to mitigate such effects, it is important that the best available knowledge is made readily available to policymakers, public health specialists and clinicians as soon as is possible. To facilitate this, we plan to undertake a living systematic review focusing on suicide prevention in relation to COVID-19. Method: Regular automated searches will feed into a web-based screening system which will also host the data extraction form for included articles. Our eligibility criteria are wide and include aspects of incidence and prevalence of suicidal behaviour, effects of exposures and effects of interventions in relation to the COVID-19 pandemic, with minimal restrictions on the types of study design to be included. The outcomes assessed will be death by suicide; self-harm or attempted suicide (including hospital attendance and/or admission for these reasons); and suicidal thoughts/ideation. There will be no restriction on study type, except for single case reports. There will be no restriction on language of publication. The review will be updated at three-monthly intervals if a sufficient volume of new evidence justifies doing so. Conclusions: Our living review will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide. Protocol registration: PROSPERO CRD42020183326 01/05/2020