What are the Factors Associated with Suicide in Chinese Adults?

Research Paper Title

Factors associated with suicide risk among Chinese adults: A prospective cohort study of 0.5 million individuals.


Suicide is a leading cause of death in China and accounts for about one-sixth of all suicides worldwide. The objective of this study was to examine the recent distribution of suicide and risk factors for death by suicide. Identifying underlying risk factors could benefit development of evidence-based prevention and intervention programmes.


The researchers conducted a prospective study, the China Kadoorie Biobank, of 512,715 individuals (41% men, mean age 52 years) from 10 (5 urban, 5 rural) areas which are diverse across China in geographic locations, social economic developmental stages, and prevalence of disease patterns. After the baseline measurements of risk factors during 2004 to 2008, participants were followed up for suicide outcomes including suicide and possible suicide deaths. Risk factors, such as sociodemographic factors and physical and mental health status, were assessed by semi-structured interviews and self-report questionnaires.

Suicide and possible suicide deaths were identified through linkage to the local death registries using ICD-10 codes. The researchers conducted Cox regression to calculate hazard ratios (HRs) for suicide and for possible suicide in sensitivity analyses.


During an average follow-up period of 9.9 years, 520 (101 per 100,000) people died from suicide (51.3% male), and 79.8% of them lived in rural areas. Sociodemographic factors associated with increased suicide risk were male gender (adjusted hazard ratios [aHR] = 1.6 [95% CI 1.4 to 2.0], p < 0.001), older age (1.3 [1.2 to 1.5] by each 10-yr increase, p < 0.001), rural residence (2.6 [2.1 to 3.3], p < 0.001), and single status (1.7 [1.4 to 2.2], p < 0.001). Increased hazards were found for family-related stressful life events (aHR = 1.8 [1.2 to 1.9], p < 0.001) and for major physical illnesses (1.5 [1.3 to 1.9], p < 0.001). There were strong associations of suicide with a history of lifetime mental disorders (aHR = 9.6 [5.9 to 15.6], p < 0.001) and lifetime schizophrenia-spectrum disorders (11.0 [7.1 to 17.0], p < 0.001). Links between suicide risk and depressive disorders (aHR = 2.6 [1.4 to 4.8], p = 0.002) and generalized anxiety disorders (2.6 [1.0 to 7.1], p = 0.056) in the last 12 months, and sleep disorders (1.4 [1.2 to 1.7], p < 0.001) in the past month were also found.

All HRs were adjusted for sociodemographic factors including gender, age, residence, single status, education, and income. The associations with possible suicide deaths were mostly similar to those with suicide deaths, although there was no clear link between possible suicide deaths and psychiatric factors such as depression and generalised anxiety disorders. A limitation of the study is that there is likely underreporting of mental disorders due to the use of self-report information for some diagnostic categories.


In this study, the researchers observed that a range of sociodemographic, lifestyle, stressful life events, physical, and mental health factors were associated with suicide in China. High-risk groups identified were elderly men in rural settings and individuals with mental disorders. These findings could form the basis of targeted approaches to reduce suicide mortality in China.


Yu, R., Chen, Y., Li, L., Chen, J., Guo, Y., Bian, Z., Lv., Yu, C., Xie., Huang, D., Chen, Z. & Fazel, S. (2021) Factors associated with suicide risk among Chinese adults: A prospective cohort study of 0.5 million individuals. PLoS Med. doi: 10.1371/journal.pmed.1003545. eCollection 2021 Mar.

New Insights on Suicide Care from a Nursing Perspective

Research Paper Title

Suicide care from the nursing perspective: A meta-synthesis of qualitative studies.


To explore nurses’ experiences of suicide care and to identify and synthesize the most suitable interventions for the care of people with suicidal behaviour from a nursing perspective. A qualitative meta-synthesis.


Comprehensive search of five electronic databases for qualitative studies published between January 2015 and June 2019.

The PRISMA statement was used for reporting the different phases of the literature search and the Critical Appraisal Skills Programme (CASP) qualitative research checklist was used as an appraisal framework. Data synthesis was conducted using Sandelowski and Barroso’s method.


Seventeen articles met the inclusion criteria. The data analysis revealed 13 subcategories from which four main categories emerged: ‘Understanding suicidal behaviour as a consequence of suffering’, ‘Nurses’ personal distress in suicide care’, ‘The presence of the nurse as the axis of suicide care’ and, ‘Improving nurses’ relational competences for a better therapeutic environment’.


Further training of nurses on the therapeutic relationship, particularly in non-mental health care work settings, and monitoring of the emotional impact on nurses in relation to suicide is required to promote more effective prevention and care.


This review provides new insights on how suicide is interpreted, the associated emotions, the way suicide is approached and proposals for improving clinical practice from the point of view of nurses. The results demonstrate that the nurse-patient relationship, ongoing assessment, and the promotion of a sense of security and hope are critical in nursing care for patients who exhibit suicidal behaviour. Consequently, to promote an effective nursing care of suicide, nurses should be provided with further training on the therapeutic relationship. Thus, health institutions do not only provide the time and space to conduct an adequate therapeutic relationship, but also, through their managers, they should supervise and address the emotional impact that is generated in nurses caring for patients who exhibit suicidal behaviour.


Clua-Garcia, R., Casanova-Garrigos, G. & Moreno-Poyato, A.R. (2021) Suicide care from the nursing perspective: A meta-synthesis of qualitative studies. Journal of Advanced Nursing. doi: 10.1111/jan.14789. Online ahead of print.

Overview of Mental Health First Aid


Mental health first aid is a training programme that teaches members of the public how to help a person developing a mental health problem (including a substance use problem), experiencing a worsening of an existing mental health problem or in a mental health crisis. Like traditional first aid, mental health first aid does not teach people to treat or diagnose mental health or substance use conditions. Instead, the training teaches people how to offer initial support until appropriate professional help is received or until the crisis resolves.

While first aid for physical health crises is a familiar notion in developed countries, conventional first aid training has not generally incorporated mental health problems.

Refer to Crisis Intervention and Psychological First Aid.


Mental health problems are common in the community, so members of the public are likely to have close contact with people affected. However, many people are not well informed about how to recognise mental health problems, how to provide support and what are the best treatments and services available. Furthermore, many people developing mental disorders do not get professional help or delay getting professional help Someone in their social network who is informed about the options available for professional help can assist the person to get appropriate help. In mental health crises, such as a person feeling suicidal, deliberately harming themselves, having a panic attack or being acutely psychotic, someone with appropriate mental health first aid skills can reduce the risk of the person coming to harm.

There is also stigma and discrimination against people with mental health problems, which may be reduced by improving public understanding of their experiences.

Brief History

The Mental Health First Aid Programme was developed in Australia by Betty Kitchener and Anthony Jorm in 2000. Since 2003, this Mental Health First Aid Programme has spread to a number of other countries (Bermuda, Canada, Denmark, England, Finland, France, Germany, Hong Kong, India, Ireland, Japan, Malaysia, Malta, Netherlands, New Zealand, Northern Ireland, Saudi Arabia, Scotland, Sweden, Switzerland, United States, United Arab Emirates, Wales). By 2019, over 3 million people had been trained in mental health first aid worldwide.

Research on Mental Health First Aid Training

A number of studies have been carried out showing the people who are trained in mental health first aid showed improved knowledge, confidence, attitudes and helping behaviour. A meta-analysis of data from 15 evaluation studies concluded that mental health first aid training “increases participants’ knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems”.

There has been research to develop international guidelines on the best strategies for mental health first aid. Mental health first aid training has been included in the US Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programmes and Practices.

By Country


In Australia, mental health first aid training is run by the not-for-profit charity Mental Health First Aid International (trading as Mental Health First Aid Australia). A range of training courses are offered:

  • Standard Mental Health First Aid is a 12-hour face-to-face course for adults to learn to assist other adults.
    • Culturally adapted versions of this course are available for Chinese and Vietnamese Australians.
    • eLearning and blended versions of the Standard course have been tailored for a range of professional groups, including pharmacists, the legal profession, financial counsellors, medical students and nursing students.
  • Youth Mental Health First Aid is a 14-hour face-to-face course for adults to learn to assist adolescents.
  • Aboriginal and Torres Strait Islander Mental Health First Aid is a 14-hour face-to-face culturally adapted course for adults to learn to assist Aboriginal and Torres Strait Islander adults.
    • It is run by Aboriginal or Torres Strait Islander instructors.
  • Teen Mental Health First Aid is a 3.5-hour classroom-based course that teaches high school students in years 10-12 how to provide mental health first aid to their friends.
  • Older Person Mental Health First Aid is a 12-hour face-to-face course for adults to learn to assist people aged 65 and over.

By 2015, Mental Health First Aid training had been received by over 350,000 people, which is more than 2% of the Australian adult population.

Mental health first aid training programmes in Australia have won a number of awards for excellence including:

  • Gold Achievement Award 2007 – winner of the Mental Health Promotion Mental Illness Prevention Programme or Project category at the MHS Conference.
  • Suicide Prevention Australia – 2005 Life Award.
  • Victorian Public Health Programmes Award for Innovation, 2006.
  • Enterprise and Resourcefulness Award – NSW Aboriginal Health Awards 2010.
  • Silver Achievement Award for Aboriginal and Torres Strait Islander Programme – Mental Health Promotion or Mental Illness Prevention Programme or Project category at the MHS Conference 2010.
  • Silver Achievement Award for Youth Mental Health First Aid Programme – TheMHS, Mental Health Promotion or Mental Illness Prevention Programme Category, 2014.
  • TheMHS Medal (the top award of the Mental Health Service Awards of Australia and New Zealand which “honours a unique and inspiring contribution to Mental Health by an individual or organisation”), 2017.


Mental health first aid (MHFA) came to England in 2007 and was developed and launched under the National Institute for Mental Health in England, part of the Department of Health, as part of a national approach to improving public mental health. Mental Health First Aid England was launched as a community interest company in 2009.

MHFA England offer a range of courses:

  • Standard MHFA, a two-day course which qualifies a participant to become a Mental Health First Aider
  • Youth MHFA, a two-day course which qualifies a participant to become a Youth Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with young people.
    • It was first launched in England in 2010 and revised and re-launched in October 2013.
  • Youth MHFA Schools & Colleges, a one-day course which is based on Youth MHFA and designed to fit into school training timetables.
  • Armed Forces MHFA, a two-day course which qualifies participants to become an Armed Forces Mental Health First Aider.
    • This course was designed for the whole Armed Forces community, including veterans, serving personnel and their families.
    • It was launched 2013.
  • MHFA Lite, a three-hour introductory awareness course launched which is based on the Standard MHFA course.
    • MHFA Lite was launched in 2011.
    • There is also a Lite version of the Youth MHFA course.
  • MHFA Instructor Training, a seven-day course accredited by the Royal Society for Public Health to qualify as a Mental Health First Aid instructor who can deliver one or all of the two-day courses (Standard, Youth and Armed Forces).

Since 2007, more than 114,000 Mental Health First Aiders have been trained in England and more than 1,600 people have trained as Mental Health First Aid instructors. The Department of Health encouraged all employers in England to provide mental health first aid training as one of three steps in its 2012 “No Health Without Mental Health: Implementation Framework”. In 2016 Mental Health First Aid was recommended for all workplaces by the charity Business in the Community.

Scotland, Wales, and Northern Ireland have broadly similar courses to the above.

You can find further information on the various UK courses here.


In May 2014 Saint John of God Hospital signed a Memorandum of Understanding with MHFA Australia to adapt the course for Ireland and in October 2014 Betty Kitchener came to Saint John of God Hospital to advise on the rollout of the MHFA Ireland Programme.

United States

In 2008, the National Council for Behavioural Health, in partnership with the Missouri Department of Mental Health, brought mental health first aid to the United States. Since 2008, more than 1.5 million people have been trained on the Mental Health First Aid USA course by an instructor base of more than 15,000. There are people trained in mental health first aid in all 50 states, Puerto Rico and Guam. The course is offered to a variety of audiences, including hospital staff, employers and business leaders, faith communities and law enforcement.

In 2012, youth mental health first aid was introduced in the United States to prepare trainees to help youth ages 12-18 that may be developing or experiencing a mental health challenge. Specialised versions of Mental Health First Aid USA including the Veterans, Public Safety, Higher Education, Rural and Older Adults modules and a Spanish version of the Youth and Adult curriculum are also available.

Mental Health First Aid USA was included in President Barack Obama’s plan to reduce gun violence and increase access to mental health services. In 2014, Congress appropriated $15 million to SAMHSA to train teachers and school personnel in youth mental health first aid. In 2015, an additional $15 million was appropriated to support other community organizations serving youth. The Mental Health First Aid Act of 2015 (S. 711/H.R. 1877) had broad bi-partisan support and would authorise $20 million annually for training the American public. Fifteen states have made Mental Health First Aid a priority by appropriating state funds, including Texas which allocated $5 million.


Mental health first aid debuted in Canada in 2007, and has operated under the leadership of the Mental Health Commission of Canada since early 2010.

MHFA Canada offers a range of courses, which, upon completion, certify a participant in mental health first aid:

  • MHFA Basic, a two-day 12 hour course.
  • MHFA for Adults who Interact with Youth, a two-day 14 hour course.
  • MHFA Seniors, a two-day 14 hour course.
  • MHFA Veteran Community, a two-day 13 hour course.
  • MHFA Northern Peoples, a three-day 18 hour course.
  • MHFA First Nations, a three-day 20 hour course.
  • MHFA Inuit, a three-day 24 hour course.
  • MHFA Police, an eight-hour course including 15-30 minutes online.
  • MHFA Instructor Training, a course which allows the participant to become a Mental Health First Aid instructor.

Different instructor courses are required to become a MHFA Basic, Youth, Seniors, Veteran Community, First Nations or Northern Peoples instructor. The duration of these courses vary from five to six days. First Nations & Northern People versions require two instructors/facilitators to deliver the course.

Since 2007, more than 400,000 Canadians have been trained in Mental Health First Aid, and more than 1,200 people have been trained as instructors.

United Arab Emirates

Mental health first aid debuted in the UAE in December 2017. MHFA UAE operates under the leadership of the Lighthouse Centre for Wellbeing, an out-patient mental health clinic in Dubai composed of more than 25 licensed psychologists. The Lighthouse is the only accredited provider of MHFA in the UAE.

MHFA UAE offers 3 courses:

  • Adult to Adult MHFA, a 12-hour training which qualifies a participant to become a Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with other adults.
  • Adult to Adolescent MHFA, a 14-hour course which qualifies a participant to become a Youth Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with young people.
  • Teen to Teen MHFA, a 4-hour course which qualifies teens to become Teen Mental Health First Aiders.

What are the Correlates of Suicidal Ideation & Behaviours Among Former Military Personnel Not Enrolled in the Veterans Health Administration?

Research Paper Title

Correlates of Suicidal Ideation and Behaviours Among Former Military Personnel Not Enrolled in the Veterans Health Administration.


The current study sought to explore suicidal concomitants, both demographic and psychological, among former military personal.


The sample included 645 veterans who are at increased risk for suicide but have not yet pursued Veterans Health Administration (VHA) services.


Descriptive statistics revealed that these veterans are primarily young Caucasian males who served in the US Army.

In terms of psychological characteristics, the current sample reported clinically significant levels of depression, post-traumatic stress, and insomnia.

Furthermore, respondents acknowledged use of various substances and high levels of perceived burdensomeness and thwarted belongingness.


The demographic and psychological makeup of the researchers sample was somewhat similar to that of VHA-connected veterans except that their sample was slightly more educated and reported less physical pain.


Raines, A.M., Allan, N.P., Franklin, C.L., Huet, A. Constans, J.I. & Stecker, T. (2020) Correlates of Suicidal Ideation and Behaviors Among Former Military Personnel Not Enrolled in the Veterans Health Administration. Archives of Suicide Research. 24(4), pp.517-533. doi: 10.1080/13811118.2019.1660286. Epub 2019 Dec 2.

Book: Reasons to Stay Alive

Book Title:

Reasons to Stay Alive.

Author(s): Matt Haig.

Year: 2015.

Edition: First (1st).

Publisher: Canongate Books Ltd.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.


Aged 24, Matt Haig’s world caved in. He could see no way to go on living. This is the true story of how he came through crisis, triumphed over an illness that almost destroyed him and learned to live again.

A moving, funny and joyous exploration of how to live better, love better and feel more alive, Reasons to Stay Alive is more than a memoir. It is a book about making the most of your time on earth.

“I wrote this book because the oldest clichés remain the truest. Time heals. The bottom of the valley never provides the clearest view. The tunnel does have light at the end of it, even if we haven’t been able to see it . . . Words, just sometimes, really can set you free.”

Book: Suicide Prevention Handbook

Book Title:

Suicide Prevention Handbook: A Mental Health Guide For Saving Lives.

Author(s): Ben Oakley.

Year: 2020.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.


The book includes our detailed four-step guide for suicide prevention:

  • Warning Signs include social signs, personal signs and planning signs.
  • Risk Factors include isolation and social inequality, violence or abuse, self-harm and mental health disorders.
  • Intervention includes social intervention, personal intervention including exactly what to say to start a mental health conversation and how to seek help.
  • Coping Strategies include distraction, grounding and relaxation.

With real-world examples and concrete ways of how to help yourself or another.

Many mental health advocates and organisations recommend you talk about mental health but they don’t tell you how to get the conversation started. This book provides you with Conversation Starters, Direct Questions, Indirect Questions, Example Lists, Guidance and ways to move a conversation from negative emotions to positive ones.

Along with the extensive four-step suicide prevention handbook, there is a guide to writing your own suicide prevention life plan with tips on creating priorities, goals, action plans and how to write it.

You’ll also find a list of UK mental health organisations, what not to say, myths debunked and a series of essays about the misconception of man.

Supreme Movement is a mental health awareness social enterprise in the United Kingdom whose mission is to raise awareness of mental health issues, specifically suicide and self-harm among males.

Ben Oakley is an established non-fiction author, researcher, mental health advocate and founder of Supreme Movement.

Book: Critical Suicidology

Book Title:

Critical Suicidology: Transforming Suicide Research and Prevention for the 21st Century.

Author(s): Jennifer White, Ian Marsh, Michael J. Kral, and Jonathan Morris (Editors).

Year: 2015.

Edition: First (1st).

Publisher: UBC Press.

Type(s): Paperback and EPUB.


This book is a must-read for practitioners, policy makers, and researchers working in mental health services, psychology, counselling, social work, psychiatry, medicine, philosophy, sociology, suicidology, feminism, anthropology, critical disability studies, and cultural studies.

World Suicide Prevention Day


World Suicide Prevention Day (WSPD) is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides, with various activities around the world since 2003.

The International Association for Suicide Prevention (IASP) collaborates with the World Health Organisation (WHO) and the World Federation for Mental Health (WFMH) to host World Suicide Prevention Day.

In 2011 an estimated 40 countries held awareness events to mark the occasion. According to WHO’s Mental health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 10% of lower-middle income countries, and almost a third of upper-middle and high-income countries had.

On its first event in 2003, the 1999 WHO’s global suicide prevention initiative is mentioned with regards to the main strategy for its implementation, requiring:

  1. “The organisation of global, regional and national multi-sectoral activities to increase awareness about suicidal behaviours and how to effectively prevent them.”
  2. “The strengthening of countries’s capabilities to develop and evaluate national policies and plans for suicide prevention.”

As of recent WHO releases, challenges represented by social stigma, the taboo to openly discuss suicide, and low availability of data are still to date obstacles leading to poor data quality for both suicide and suicide attempts: “given the sensitivity of suicide – and the illegality of suicidal behaviour in some countries – it is likely that under-reporting and misclassification are greater problems for suicide than for most other causes of death.”


An estimated one million people per year die by suicide or about one person in 10,000 (1.4% of all deaths), or “a death every 40 seconds or about 3,000 every day”. As of 2004 the number of people who die by suicide is expected to reach 1.5 million per year by 2020.

On average, three male suicides are reported for every female one, consistently across different age groups and in almost every country in the world. “Conversely, rates of suicide attempts tend to be 2-3 times higher in women than in men, although the gender gap has narrowed in recent years.” More people die from suicide than from murder and war; it is the 13th leading cause of death worldwide. According to the WHO there are twenty people who have a suicide attempt for every one that is fatal, at a rate approximately one every three seconds. Suicide is the “most common cause of death for people aged 15 – 24.”

According to the WHO, suicide accounts for nearly half of all violent deaths in the world. Brian Mishara, IASP president, noted that, “more people kill themselves than die in all wars, terrorist acts and interpersonal violence combined.” As of 2008, the WHO refers the widest number of suicides occur in the age group 15 – 29, while the lowest in the 80+ although representing as well the one with the highest rate (per 100,000) of all age groups, with 27.8 suicides and 60.1 for females and males respectively. In 2015 the reported global age-standardised rate is 10.7 per 100,000.

Social norms play a significant role in the development of suicidal behaviours. Late 19th century’s sociological studies recorded first ever observations on suicide: with statistics of the time at hand, sociologists mentioned the effects of industrialisation as in relations between new urbanised communities and vulnerability to self-destructive behaviour, suggesting social pressures have effects on suicide. Today, differences in suicidal behaviour among different countries can be significant.


  • 2003 – Suicide Can Be Prevented!.
  • 2004 – Saving Lives, Restoring Hope.
  • 2005 – Prevention of Suicide is Everybody’s Business.
  • 2006 – With Understanding New Hope.
  • 2007 – Suicide prevention across the Life Span.
  • 2008 – Think Globally, Plan Nationally, Act Locally.
  • 2009 – Suicide Prevention in Different Cultures.
  • 2010 – Families, Community Systems and Suicide.
  • 2011 – Preventing Suicide in Multicultural Societies.
  • 2012 – Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope.
  • 2013 – Stigma: A Major Barrier to Suicide Prevention.
  • 2014 – Light a candle near a Window.
  • 2015 – Preventing Suicide: Reaching Out and Saving Lives.
  • 2016 – Connect, Communicate, Care.
  • 2017 – Take a Minute, Change a Life.
  • 2018 – Working Together to Prevent Suicide.
  • 2019 – Working Together to Prevent Suicide.
  • 2020 – Working Together to Prevent Suicide.


Suicide prevention’s priorities, as declared on the 2012 World Suicide Prevention Day event, are stated below:

  • We need to continue to research suicide and non-fatal suicidal behaviour, addressing both risk and protective factors.
  • We need to develop and implement awareness campaigns, with the aim of increasing awareness of suicidal behaviours in the community, incorporating evidence on both risk and protective factors.
  • We need to target our efforts not only to reduce risk factors but also to strengthen protective factor, especially in childhood and adolescence.
  • We need to train health care professionals to better understand evidence-based risk and protective factors associated with suicidal behaviour.
  • We need to combine primary, secondary and tertiary prevention.
  • We need to increase use of and adherence to treatments shown to be effective in treating diverse conditions; and to prioritise research into effectiveness of treatments aimed at reducing self-harm and suicide risk.
  • We need to increase the availability of mental health resources and to reduce barriers to accessing care.
  • We need to disseminate research evidence about suicide prevention to policy makers at international, national and local levels.
  • We need to reduce stigma and promote mental health literacy among the general population and health care professionals.
  • We need to reach people who do not seek help, and hence do not receive treatment when they are in need of it.
  • We need to ensure sustained funding for suicide research and prevention.
  • We need to influence governments to develop suicide prevention strategies for all countries and to support the implementation of those strategies that have been demonstrated to save lives.


Suicide has a number of complex and interrelated and underlying contributing factors … that can contribute to the feelings of pain and hopelessness. Having access to means to kill oneself – most typically firearms, medicines and poisons – is also a risk factor.

The main suicide triggers are:

  • Poverty;
  • Unemployment;
  • The loss of a loved one;
  • Arguments; and
  • Legal or work-related problems.

Suicide results from many complex sociocultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved one, unemployment, sexual orientation, difficulties with developing one’s identity, disassociation from one’s community or other social/belief group, and honour).

In richer countries, three times as many men die of suicide than women do, but in low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman.

In the United States, for example, males are four times more likely to die from suicide than are females. However, females are more likely to attempt suicide than are males.

The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die in men than women.

Physical and especially mental health disabling issues such as depression, are among the most common of the long list of complex and interrelated factors, ranging from financial problems to the experience of abuse, aggression, exploitation and mistreatment, that can contribute to the feelings of pain and hopelessness underling suicide. Usually substances and alcohol abuse also play a role.

Prevention strategies generally emphasise public awareness towards social stigma and suicidal behaviours.

Cultural and Religious Attitudes

In much of the world, suicide is stigmatised and condemned for religious or cultural reasons.

In some countries, suicidal behaviour is a criminal offence punishable by law. Suicide is therefore often a secretive act surrounded by taboo, and may be unrecognised, misclassified or deliberately hidden in official records of death.

Stigma, particularly surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need.

The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it.

Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.


COVID-19 and the Role of Primary Care in Suicide Prevention

Research Paper Title

Role of Primary Care in Suicide Prevention During the COVID-19 Pandemic.


Primary care providers have an important role in suicide prevention, knowing that among people who die by suicide, 83% have visited a primary care provider in the prior year, and 50% have visited that provider within 30 days of their death, rather than a psychiatrist.

The psychosocial impact of the coronavirus disease 2019 pandemic poses increased risk for suicide and other mental health disorders for months and years ahead.

This article focuses on screening tools, identification of the potentially suicidal patient in the primary care setting, and a specific focus on suicide prevention during widespread, devastating events, such as a pandemic.


Nelson, P.A. & Adams, S.M. (2020) Role of Primary Care in Suicide Prevention During the COVID-19 Pandemic. The Journal for Nurse Practitioners. doi: 10.1016/j.nurpra.2020.07.015. Online ahead of print.

Developing a Behavioural Health Readiness & Suicide Risk Reduction Review for Military Personnel

Research Paper Title

Development of the US Army’s Suicide Prevention Leadership Tool: The Behavioural Health Readiness and Suicide Risk Reduction Review (R4).


Although numerous efforts have aimed to reduce suicides in the US Army, completion rates have remained elevated.

Army leaders play an important role in supporting soldiers at risk of suicide, but existing suicide-prevention tools tailored to leaders are limited and not empirically validated.

The purpose of this article is to describe the process used to develop the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) tools for Army leaders that are currently undergoing empirical validation with two US Army divisions.


Consistent with a Secretary of the Army directive, approximately 76 interviews and focus groups were conducted with Army leaders and subject matter experts (SMEs) to obtain feedback regarding existing practices for suicide risk management, leader tools, and institutional considerations.

In addition, reviews of the empirical literature regarding predictors of suicide and best practices for the development of practice guidelines were conducted. Qualitative feedback, empirical predictors of suicide, and design considerations were integrated to develop the R4 tools.

A second series of 11 interviews and focus groups with Army leaders and SMEs was also conducted to validate the design and obtain feedback regarding the R4 tools.


Leaders described preferences for:

  • Tool processes (e.g. incorporating engaged leadership, including multiple risk identification methods);
  • Formatting (e.g. one page);
  • Organisation (e.g. low-intermediate-high risk scoring system);
  • Content (e.g. excluding other considerations related to vehicle safety, including readiness implications); and
  • Implementation (e.g. accounting for leadership judgement, tailoring process to specific leadership echelons, consideration of institutional barriers).

Evidence-based predictors of suicide risk and practice guideline considerations (e.g. design) were integrated with leadership feedback to develop the R4 tools that were tailored to specific leadership echelons.

Leaders provided positive feedback regarding the R4 tools and described the importance of accounting for potential institutional barriers to implementation. This feedback was addressed by including recommendations regarding the implementation of standardized support meetings between different echelons of leadership.


The R4 development process entailed the simultaneous integration of leadership feedback with evidence-based predictors of suicide risk and design considerations.

Thus, the development of these tools builds upon previous Army leadership tools by specifically tailoring elements of those tools to accommodate leader preferences, accounting for potential implementation barriers (e.g. institutional factors), and empirically evaluating the implementation of those tools.

Future studies should consider utilising a similar process to develop empirically based resources that are more likely to be incorporated into the routine practice of leaders supporting soldiers at risk of suicide, very often located at the company level and below.


Curley, J.M., Penix, E.A., Srinivasan, J., Sarmiento, D.S., McFarling, L.H., Newman, J.B. & Wheeler, L.A. (2020) Development of the U.S. Army’s Suicide Prevention Leadership Tool: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4). Military Medicine. 185(5-6), pp.e668-e677. doi: 10.1093/milmed/usz380.