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Suicide Prevention for A Variety of Demographic and Focused Populations

Suicide death rates have been climbing from 6.4 to 9.6 per 100,000 among the young population aged 15-24 years according to government statistics in Taiwan in the recent five years during 2017 and 2021. Meanwhile, the middle-aged and elderly people have faced different biopsychosocial challenges during COVID-19. The suicide prevention strategies remain a broad coverage across the lifespan and base on local governments' plans of high-risk management and health promotion for those in need of protective effects toward suicide risks. Recent observations of world suicide prevention trend also reflect focuses on specific gender and age-group differences. For example, in UK "Suicide is the single biggest killer of men under the age of 45 in the country, but suicides among teenage girls and young women have almost doubled in recent years.", said Mental Health UK (https://reurl.cc/EXDgva). More research interest appeared to be put on various gender and age characteristics and/or other typical suicide risks such as psychosocial and environmental factors. This volume in the Journal of Suicidology (JoS) collected several issues that can be differentiated into the young (university students, adolescents, young pregnant women), the middle-aged ("karojisatsu"), the elderly (repeated-suicide case series), and other risk-factor (internet addiction, long-term media report, treatment-resistant depression, pet loss, hospitalization) related topics. Specifically, more international opinions or comments revealed in this volume will draw interesting discussions toward advanced understanding of non-suicidal self-injury in adolescents and suicide statistics under the topic of "hidden suicide". A novel topic about pet loss and suicide ideation/plan among the pet owner is worth further attention and calls for more investigations under the popularity of pet ownership in this era. Moreover, three major topics related to the nationwide telephone survey on representative samples performed by the Taiwan Society of Suicidology every year have been published with different focuses, including internet use correlates, suicide reports profile (2012-2021), and suicidality identification. In terms of protective factors, resilience for internet users among the public and social support interventions for young pregnant women to prevent depression were presented in one original and one review article. The readers of the JoS will find it interesting and reflective from the abundant contents in this volume. We welcome more local and international readers to share with the world your valuable opinions or works about suicide research.

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Challenges of the COVID-19 Pandemic on Suicide Prevention Beyond Humans

Suicide involves a complex dynamic process with multiple factors in bio-psycho-socio-cultural and ecological interaction. By December 25, 2022, over 660 million people had been infected by SARS-CoV-2 and approximately 6.6 million had died from COVID-19 around the world. The COVID-19 pandemic crisis associated with the disease itself, social restrictions, and subsequent economic depression had negative impacts on people's mental health and heightened suicide risk. In the post-COVID-19 era, the long-term risk factors included a wide range of physical, psychosocial, and economical issues such as the confirmed cases with long COVID-19 and multiple life stressors. In particular, the mental health of the ethnic minority and low-income groups in some countries has been badly affected. Although a report on suicide rates of 33 nations during the first 9-15 months of the pandemic indicated little evidence of increasing suicide risk in general, the potential impact on suicide rates cannot be overlooked for the affected demographic subgroups and regions with elevated risk prior to the pandemic. Therefore, the temporal trends in suicide rates among subpopulations need further investigation. Policymakers need to take preventive measures to protect the most vulnerable individuals, families, and communities after the pandemic. This is especially critical in the current challenges of global mental health issues due to extreme climate change, economic depreciation, civil unrest, and an armed conflict between nations. In Taiwan, 44% of the general population aged over 15 years suffered from various COVID-related stressors in terms of physical health, mental health, job or finances, interpersonal relationships, and 20% reported feeling stressed toward war. The effects of the COVID-19 pandemic were extensive and complicated. There were no consistent patterns of impacts on suicide risk because the extent and severity of COVID-19 as well as the preventive measures for viral spread and economic depreciation were greatly different between and within countries. Other than the direct impacts of the COVID-19 disaster on humans, it was clinically common to see that pet death could inflict a significant emotional impact upon the owner and result in a complicated grief response and suicidality. Nowadays, pets are part of families all over the world. A recent study from Australia revealed that pets were a source of much-needed comfort and companionship during the pandemic and lockdown. In addition, parents and children who were feeling anxious and unsettled were more likely to have stronger bonds with their pets. The human-pet relationship was unique because pets gave their owners unconditional love and companionship and helped them manage loneliness and sometimes depression during the pandemic. In Taiwan, pets grew much faster than newborns; in 2021, the number of registered pet dogs and cats in Taiwan exceeded the young population aged 0-14 years first time in history. Similarly, about 70 percent of households owned a pet in Australia with a 10 percent increase during the pandemic. Pets tended to enhance human well-being in both psychological and physical aspects such as enhancing self-esteem and increasing physical activity. There is a strong emotional tie between the pet and its owner. The death of a companion pet could be as devastating as the loss of a human significant other. The pandemic created a highly stressful environment for some families who were working and learning from home with pets in the absence of usual social support and outlets. A recent study conducted during a strict lockdown period of the pandemic in Australia noted that pet ownership was significantly associated with poorer quality of life. Thus, pets might increase owners' burden and contribute to poorer quality of life. Younger age, female gender, and pre-existing health conditions were reported as risk factors for a significant increase in mental health problems in the first year of the pandemic (WHO, Scientific Brief, 2022). According to the pet consumption behavior survey in Taiwan, female owners were 1.7 times more than male owners. The precise role and impacts of pets within the family in addition to demographics, internal and external stressors are worthy of further exploration in the context of psychological well-being and suicide prevention.

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Karojisatsu (Suicide Caused by Overwork) in the Nordic Countries. A call for Research

In the light of considerable research from Japan, the author hereby calls on the health and research community to also draw research interest to the Nordic countries on karojisatsu (suicide caused by overwork). No study has so far examined karojisatsu in the Nordic countries and to date no crossnational studies have yet been conducted. At the present time, looking at existing research from Japan and its relevance to psychiatric practice, the impact of work environment and the field of suicide prevention, it appears as a phenomenon that cannot be limited exclusively to the field of some countries or cultures. Rather, it may also concern several characteristics of a modern society like Denmark, Norway or Sweden. With the Japanese experiences, assessment tools, policy strategies and intervention programs, karojisatsu should therefore undergo research investigations in the Nordic countries as well. Karojisatsu may be a hidden factor into today's suicide numbers and to grasp its relevance and accurate awareness of the current situation, Nordic countries should be included in future studies.

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Recent Advances in Understanding Non-Suicidal Self-Injury in Adolescents

Non-suicidal self-injury (NSSI) is a prevalent and alarming behavior among adolescents. The aims of this narrative review are to present updated literature on epidemiology, risk factors and possible etiology, together with interventions with special consideration about the period of adolescence. Results demonstrate prevalence of around 16.9% in the community and 60.0% in clinical settings respectively. The main risk factors for NSSI include previous NSSI history, adverse experiences in childhood, bullying, social contagion, accompanying mental illnesses, as well as the neurobiological basis of abnormal stress processing and pain threshold. Using the Four-Function Model to delineate NSSI facilitates formulation and subsequent intervention. The double-edged effect of online activities on NSSI deserves further exhaustive clarification. There has been no particular type of psychotherapy confirmed to be superior to the others. Psychoactive prescription has yet been found to provide specific efficacy among adolescents engaging in NSSI. Lacking investigations into NSSI prevention programs warrant further approaches. Recommendations for future direction of studies are standardizing the conceptualization of NSSI, gathering evidence for etiology of the condition, and exploring prevention measures. Suggestions for principles of practice include paying attention to suicidality, warding off stigmatization by psychoeducation to the public, and avoiding sex stereotypes.

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Grief and Coping of the Owner Toward Pet Loss

The human-pet relationship is unique because pets give their owners unconditional love and companionship. Thus, pet loss may inflict a significant emotional impact upon the companion animal owner and result in a complicated grief response. This review aimed to examine the relationship between pet loss and owner's grief response. Major themes included: stages of grief, maladaptive grief, factors that influence the grief response, disenfranchised grief, and coping mechanisms used. Types of coping mechanisms used by owners toward pet loss included: isolation, social support, continuing bonds, memorialization, religion, and relationships with other animals. Grief interventions, coping mechanisms, and cognitive behavioral programs may be helpful for some vulnerable pet owners who have high levels of suicidal ideation and depressed feelings over bereavement. Suggestions for further research include the cultural differences in the conceptualization of disenfranchised grief and a focus on the effectiveness of coping mechanisms that bereaved pet owners use.

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Social Support Interventions for Preventing Depression in Young Pregnant Women

Depression is a major issue of mental health and the leading cause of maternal mortality during the perinatal period. Young pregnant women have a higher rate of depression than adult pregnancies. The high prevalence of depression is associated with a diversity of negative impacts on both maternal and their children. However, interventions regarding depression care and support provision have been limited. Social support intervention has been shown to be effective in reducing the risk of depression during pregnancy in young pregnant women and their children. Currently, no prior study integrated evidence about social support interventions. Therefore, the study reviewed related literature using the following keywords: depression, social support, young pregnancy. The findings suggested that social support interventions can decrease the risk of depression during pregnancy, which leads to positive health and pregnancy outcomes. Therefore, midwives need to create social support interventions to prevent or reduce the risk of associated depression during pregnancy in young mothers.

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Hidden Suicides in East and South-East Asia

This article focuses on the accuracy of suicide statistics in 14 jurisdictions in East and South-East Asia. Inaccuracies most commonly occur when (1) registration of a country's deaths (whatever the cause) is markedly incomplete, and (2) there is mis-recording or mis-coding of the cause of death (c.o.d.), sometimes despite almost complete registration. The World Health Organization (WHO) criticizes those certifying death who assign inexact ICD (International Classification of Diseases) codes such as 'old age', which cannot clearly indicate the underlying c.o.d. WHO refers to these as 'unusable' or 'garbage' codes. Two examples are 'Ill-defined and unknown cause' (ICD-10 code R99) and 'event of undetermined intent' (EUI, coded Y10-Y34); significant numbers of suicides have, to an extent that varies between nations, been assigned one of these codes. Suicides coded in this way, along with others mis-coded as accidental or to other codes have been called 'hidden suicides'. The quality of mortality statistics in 5 of the above 14 nations, and of one third of WHO's member states (mostly high income), has been rated as high, though commonly with caveats regarding earlier years. Lower income nations that lack resources to attempt collection of data regarding all deaths may use randomized household surveys. Where countries report low death registration rates and/or unacceptable garbage code rates, WHO publishes estimated suicide rates, based on the mortality data supplied by member states to the WHO Mortality Database. Rates of suicide, R99, EUI and accidental death vary considerably. It is recommended that all such rates be published at the same time as the suicide rates, and that WHO make ICD-11 mortality rates easily accessible online (as they were before October 2019). Well-resourced nations should be encouraged to help fund collection and analysis of suicide and hidden suicide data in under-resourced nations.

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Suicide and Psychiatric Hospitalization in Taiwan

Mental illness is strongly associated with an increased risk of suicide. Psychiatric hospitalization provides the most intensive care for those with high suicide risk. Nevertheless, mental illness necessitating psychiatric hospitalization was strongly associated with suicide death. In contrast to the downsizing trend of psychiatric beds in the Western world, the psychiatric bed capacity in Taiwan has steadily increased in recent decades. This report aimed to address the relationship between suicide and psychiatric hospitalization concerning the trend of change in rates of inpatient and postdischarge suicide, help-seeking behaviors of suicide cases, and length of stay in relation to inpatient and postdischarge suicide in Taiwan. There is a low recognition rate of psychiatric diagnosis, mainly by nonpsychiatric physicians, among individuals who died by suicide. Despite the rate of psychiatric service contacts in the preceding year before suicide in Taiwan was comparable to that in Western countries, there was a substantially lower rate of psychiatric hospitalization in the previous year in Taiwan than in Western countries. The inpatient suicide rate in Taiwan was at the lower end of those identified in all studies worldwide and declined among psychiatric inpatients admitted from 2002 to 2013 in Taiwan. In contrast, postdischarge suicide rate was comparable to the pooled estimates of postdischarge suicide in a meta-analysis and remained stable over the study period. A longer stay in psychiatric hospitalization consistently decreases both inpatient and post-discharge suicides. These findings revealed the underdiagnosis and undertreatment of mental disorders for suicide prevention work in Taiwan. Our report underscores the proper use of psychiatric hospitalization for suicide prevention in the current context in Taiwan.

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Identification of Suicidality by Five-Item Suicide Crisis Scale (SCS-5) in an Online General Population Survey in Taiwan

Background: Suicide crisis syndrome (SCS) was defined as a pre-suicidal mental condition comprising five components of affective disturbances, loss of cognitive control, hyperarousal, social withdrawal and entrapment. A revised Suicide Crisis Inventory (SCI-2) for assessing SCS has been validated to identify recent week suicidal ideation (SI) in Taiwan. The study aimed to develop and validate a shorter form of SCI-2 named five-item suicide crisis scale (SCS-5) to detect SCS and suicidality.Method: An anonymous online questionnaire survey was conducted on psychopathology and associated suicide risks among community residents. The participants were enrolled online and completed the survey questions including demographics, SCI-2, 5-item Brief Symptom Rating Scale (BSRS-5) and Suicide Narrative Inventory (SNI) to measure psychological distress as well as suicidality (i.e., SI and attempts). The SCS-5 contained five items derived from the SCI-2; each item had the highest correlation with the corresponding subscale of SCI-2. The factor structure and validity of the SCS-5 were examined using confirmatory factor analyses (CFA) and correlations with the SCI-2, BSRS-5, SNI and suicidality. Stepwise multiple regression and receiver operating characteristic (ROC) curve were performed to predict suicidal ideation.Results: A total of 4846 participants were eligible for analysis. Results of the one-factor CFA for SCS-5 indicated a good model fit. The SCS-5 demonstrated excellent internal consistency (Cronbach alpha: .92) and good correlations with all items of the BSRS-5, SNI and suicidality measures. Regression analysis revealed that all SCS-5 items significantly explained 28.0% of the variance of one-week SI. ROC curve indicated that the optimal cut-off (4/5) of the SCS-5 could significantly differentiate the one-week SI. Conclusion: The study revealed that the SCS-5 performed satisfactory psychometric properties to identify recent SI among the general adult population in Taiwan. Its predictive validity for future suicide behaviors in different clinical settings needs further investigation.

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Prevalence of Suicidal Ideation and Thought of Hurting-Others and Associated Psychopathology Among University Students

Purpose: Suicide is the second leading cause of death among adolescents in many countries including Taiwan. Youth mental health issue including suicide and homicide has become a focus of attention worldwide. The present study investigated the prevalence of suicidal ideation (SI) and thoughts of hurting others (THO) and their associations with the psychopathology among University students.Method: The cross-sectional survey was conducted on the first-year students of a National university in northern Taiwan. The questionnaire comprised basic information on gender, the 5-item Brief Symptom Rating Scale (BSRS-5), and questions about the personal experience of SI and THO over the previous week. All 4066 students (female : male = 2314:1752) finishing the registration for administration were invited to participate in the survey. In total, 3961 students (56.5% males) completed the questionnaire. The ROC curve analysis was used to determine the validity of the BSRS-5 to identify the recent one-week SI and THO. Moreover, regression analysis was performed to examine the associations between BSRS-5 subscales and one-week SI and THO, respectively. Moreover, the path analysis with the structural equation model was conducted to examine the associations of the psychological distress and with one-week SI and THO.Results: The results indicated that SI and THO were significantly inter-correlated (r=0.574) and the prevalence of SI, THO and psychiatric morbidity was 5.9%, 5.8% and 19.8%, respectively. and Logistic regression revealed the significant predictors for SI and THO included psychiatric morbidity (OR=22.7, 11.8), hostility (OR=21.2, 14.5), inferiority (OR=15.0, 8.3), depression (OR=27.8, 11.5), anxiety (OR=23.9, 7.4), and insomnia (OR=11.3, 7.1). The stepwise multiple regression demonstrated 4 items (except for insomnia) of BSRS5 explained 22.2% and 14.5% of the variances of SI and THO, respectively. Using 4/5 of the BSRS-5 score as a cut-off to predict SI and THO, the rate of accurate classification was 84% and 83%, respectively. Conclusion: SI and THO were prevalent among the university's incoming students. The BSRS-5 scale is an efficient way to identify SI, THO, and psychological distress and provides timely investigation for the targeted population at risk.