The various proposals to make the Internet a stepping stone to formal health are consistent with the sociological models that assume that help-seeking behaviors are mostly driven by interpersonal systemic determinants (Chan et al., 2017). The Gateway Provider Model, in particular, predicts that involving intermediary actors who know the community resources, interact with people who need help and refer them to appropriate services would enhance general access to care (Stiffman et al., 2004). Several properties of the Web suggest that online prevention interventions could endorse the role of gateway to reduce both structural and personal barriers to help. (1) Accessibility from almost any private or public place helps to skirt the constraints of distance from local services (Robert et al., 2015; Chan et al., 2017). It also facilitates discretion, which can alleviate interpersonal inhibitions to seek help. (2) Affordability compensates the structural barrier of cost and eases access to care for financially dependent individuals. (3) Timeliness guarantees access to support including outside work hours. It allows for attunement with the short timescale within which both severity of suicide ideation and motivation to ask for help can fluctuate (Miller, 2009; Luxton et al., 2011). (4) Anonymity and privacy are supposed to make the interaction less confrontational (Miller, 2009) and foster expression and self-disclosure (Chester and Glass, 2006; Krysinska and De Leo, 2007; Robert et al., 2015). (5) Impression of control comes with anonymity. It can secure individuals who cannot afford strong interpersonal commitment by giving them the opportunity to exit the conversation at any point (Robert et al., 2015).

This facilitation role, however, has its downside. Anonymity, in particular, severely hampers the possibilities of emergency interventions in case of imminent suicide risk. In addition, low

interpersonal commitment gives the therapeutic link a labile dimension, with an increased risk of losing connection with the person. The Web could thus be placed at the extremity of a continuum ranging from high access probability but limited therapeutic engagement and possibilities of actions, to lower spontaneous contact probability but greater interpersonal commitment and larger scope of interventions. Under this perspective, the gateway function of Web-based interventions should not be regarded just as an entryway but also as a way to engage and reinforce the patient's therapeutic commitment.

### COMMUNICATION OUTREACH

As a first degree of proactivity, communication outreach consists in drawing on communication strategies to encourage suicidal individuals to use prevention services. Social media has opened new perspectives to the promotion of access to care. Beyond the simple setting up of passive websites, it offers to increase the outreach of prevention information. Literature has addressed two important related issues to inform communication strategies.

The first issue concerns the type of content that should be broadcasted to increase the probability that suicidal Web recipients will seek help. Indications come from "media effect studies" that have examined the impact of disseminating information on suicidal behaviors. In particular, Niederkrotenthaler et al. (2010) found that suicide stories can be linked to a significant decrease in suicide rates, provided that they respect some characteristics. The so-called "Papageno effect" has been described for reports of individuals who overcame a suicide crisis, but also suggested for similar fictional stories (Till et al., 2013; Notredame et al., 2017). Since numerous digital modules facilitate the broadcast of crisis-mastery stories to which suicidal individuals can identify (Luxton et al., 2012), spontaneous testimonials from celebrities or adolescents have flourished on social media (see, for example, Daoust, 2017; iamjordyndunlap, 2017). In terms of public health policies, the question is now about how to harness the collaborative nature and outreach potential of social networks to maximize the potential of preventive communication (Luxton et al., 2011). This would mean stimulating the production of such contents by both prevention stakeholders and lay Web users, but also structuring the creation process in an evidencedbased perspective. Several prevention organizations, such as Samaritans, have produced their own video storytelling depicting suicide survivors (Samaritans, 2017). In the same vein, Thiha et al. (2016) proposed to boost a school-based suicide prevention program with an interactive Web interface designed to help peer leaders make personal stories valuable contents to promote access to care.

The second issue has been raised by the applications of the network sciences to the field of suicidology. Two recent studies explored the architectural and dynamic properties of the networks formed by microbloggers who posted suicidal comments (Fu et al., 2013; Colombo et al., 2016) and led to similar observations. (1) The networks formed by suicideposting microbloggers are characterized by a low density (i.e., low number of effective connections regarding the virtual number of possible connections), but a high degree of interconnectivity (i.e., high number of reciprocal or triangle connections). While sparsity is supposed to increase the speed of dissemination of the information, the strong reciprocity between posters of suicidal messages suggests potential recursion of the information, thus augmenting the impact of the messages. (2) Some microbloggers play a key role in the networks. On the one hand, influential posters (influencers) are those microbloggers who have a lot of followers but few friends, and whose posts are widely spread over the network. On the other hand, influential reposters (linkers) have both a significant number of friends and followers, such that they bridge the small disconnected hubs of which the network is composed.

Although deserving replications, lessons could be drawn from these observations to build outreach communication strategies. The structural and functional properties of social media allow for fast dissemination of messages that may be received redundantly by users. This communication strength is versatile. On the one hand, it reinforces the reach and impact of suicide contents, thus majoring the risk of contagion. On the other hand, it could be an exceptional channel to broadcast and boost the influential potential of pro-help seeking messages; however, the optimization of a communication strategy on social media must be tightly tailored to the structure and function of the targeted network. For instance, involving influencers may be a relevant way to ensure the broadest dissemination of Papageno messages. Linkers could also be usefully recruited as gatekeepers because of their privileged position to detect and signal worrisome messages.

### OUTREACH INTERVENTION

A significant proportion of suffering Web users may remain impervious to the gateway or communication outreach strategies, although clearly needing support. The only way to compensate for this strong "help-negation" (Rudd et al., 1995) would thus be to bring help directly to them and try to reduce the barriers to formal help seeking in situ.

For practical and ethical reasons, proactivity should remain proportionate to the actual risk level. Estimation of the probability that Web users will engage in suicidal behaviors is an essential perquisite for any intervention outreach. In the field of suicidology, several authors have proposed to use artificial intelligence to automatically segregate high-risk messages from the mass of potentially concerning posts published on Twitter R (Abboute et al., 2014; Homan et al., 2014; Burnap et al., 2015), Weibo R (Lv et al., 2015), or Facebook R (Thompson et al., 2014). The process includes four steps: (1) social media data are mined to extract the messages that contain one of a list of warning key words or expressions; (2) detected posts are decomposed in quantifiable functional linguistic features; (3) a statistical classifier is trained on a sample of pre-labeled posts to distinguish between high and low-risk messages (Thompson et al., 2014; Moulahi et al., 2017); and (4) the performance of the trained machine is tested against human coders. Depending on the feature sets and the nature of the classifier, authors have found precision

they can come from any point of the whole network: direct contact by suicidal individuals or relatives whose help-seeking process was enabled by the gateway function of the platform (i1); or detection of at-risk posters through data mining and machine learning procedures (i3). The last input is said to be targeted because it is known to be coming from the network of suicidal-posting users. It consists in reporting worrisome messages by network members, either ordinary users or linkers formally involved as gatekeepers (i2). In i2 and i3 cases, the intervention team reaches out to the identified individuals and queries their actual suicide risk and need for help. The intervention team has four main missions: (1) provide a first relief (counseling function); (2) activate and support the emergency services (dark blue pastille) whenever necessary (crisis function); (3) progressively increase the commitment of Web users in the help process (motivational function); and (4) refer Web users to the appropriate conventional healthcare services (yellow pastille). To carry out its missions, the intervention team can progressively switch from private text messaging (pink pastille) to interactive means requiring greater interpersonal commitment (such as vocal or videoconferencing – mauve pastille). Icons retrieved for www.flaticon.com.

rates (i.e., proportion of truly high-risk messages among those classified as such by the algorithm) ranging between 0.6 and 0.8% (Abboute et al., 2014; Homan et al., 2014; Burnap et al., 2015, 2017; O'Dea et al., 2015) and recall rates (i.e., number of truly high-risk messages picked out by the algorithm among the total number of high-risk messages in the sample) between 0.65 and 0.75 (Homan et al., 2014; Burnap et al., 2015, 2017; O'Dea et al., 2015).

The detection performance that has been reached so far led some authors to argue for implementation as a first step in an online outreach process (Robert et al., 2015; Chan et al., 2017). Literature offers numerous promising examples of Web-based

interventions to prevent suicide (Barak, 2007; King et al., 2015; Robinson et al., 2015, 2016b; Mokkenstorm et al., 2017). The goal is either to extend the conventional care system with online psychotherapy or support groups or to serve as an entryway to this system. An example is the Israeli SAHAR program, which consists of an online platform that enables distressed Web users to have synchronous or asynchronous online interactions with helpers (Barak, 2007). With a further degree of proactivity, the American Foundation for Suicide Prevention developed organized systematic screenings of US college students via self-administered online questionnaires. All students were able interact with a counselor via a secured website. In addition, high-risk students were reached by e-mail and urged to attend in-person evaluation and treatment (Haas et al., 2008).

Nevertheless, to the best of our knowledge, no author has proposed online gateway intervention on an ecological outreach basis, i.e., for individuals who did not spontaneously ask for help, nor participated to formal screening procedures. Outreach intervention adds two important operational challenges to those of more traditional Web interventions. (1) Efficient and respectful messages, typically focusing on personalization, solicitude, or sense of belonging (Whiteside et al., 2014) would have to be designed to start the conversation with potentially unwilling individuals. (2) Formal clinical techniques would have to be developed to progressively increase the commitment of Web users who are not convinced a priori. There is no standard for online counseling (Miller, 2009). Nevertheless, outreach interventions should integrate several recognized characteristics of Web communication. For instance, textual interactions give no access to para-verbal cues but open to new possibilities of narration and allow for a posteriori quality control (Miller, 2009). The time of the therapeutic e-relationship is also less constrained than face-to-face interactions. It can either be contracted as chatting supposes a certain degree of immediacy, or dilated as the Web user can delay its responses. Overall, outreach intervention would require laying the foundation of a crisis e-clinic that would integrate counseling, motivational therapy, technological solutions, and Web-based communication.

### DISCUSSION

The Internet has become an intrinsic component of our social landscape and daily life. As such, it cannot be ignored when dealing with suicide prevention. We believe that conditions are met to leverage the Internet to address one of the major public mental health issues, namely access to care. More specifically, we propose a model that uses social media as a transitional tool to initiate and reinforce the connection between ambivalent suicidal individuals and the formal healthcare system. The model, presented in **Figure 1**, coordinates the three pro-help-seeking functions presented in this paper, i.e., gateway, communication outreach, and intervention outreach. It relies on the synergy of two operational teams, both taking action via the main community, network and microblogging social media platforms. The Web communication team is composed of community managers and e-communicators, i.e., Web specialists able to design efficient communication campaigns tailored to the social media codes and constrains. They must prove a strong mastery of technological tools and specific skills in networking and social marketing. The Web intervention team consists of Web clinicians, either social workers, psychiatric nurses, psychologists, or psychiatrists. They should be specially trained in text-mediated counseling and crisis intervention, as well as in the use of social media technologies.

In practical terms, the model operates in two stages. The first stage consists in "phishing" suicidal Web users to create a first contact, either blindly (universal outreach) or after detection of worrisome posts (targeted outreach). The machine learning algorithms and the alerts of the gatekeepers allow the intervention team to directly approach the users who posted suicidal contents. Complementarily, the pro-Papageno campaign lead by the communication team gives an opportunity to incite mute suicidal Web users (also called "passive users") to spontaneously contact the intervention team. The second stage begins as soon as the contact is established. Let us assume that the intervention team has intercepted a tweet stating "Life is meaningless. Goodbye," and it has successfully created an interaction with its author via the Twitter private messaging service. The intervention team will then have to handle four complementary missions: (1) bring a first relief to the distressed Web user by providing active chat counseling; (2) evaluate the actual suicidal risk and mobilize the emergency services if necessary; (3) progressively increase the commitment of the Web user in the help process thanks to motivational support; and (4) refer the suicidal Web user as soon as possible to appropriate mental health services, possibly by scheduling the appointment for him/her. To achieve these goals, the modularity of the social media can be relevant and useful. The Web clinicians may prompt the patient's therapeutic engagement by progressively proposing interfaces of growing inter-personal involvement, switching from text-based interactions (e-mails and chat), to online call, video-conferencing, and finally formal face-to-face meeting.

Importantly, the model we propose should not be considered an alternative to the traditional mental healthcare system, but rather as potential that increases its scope, helps to reach typically inaccessible populations, and reinforces the alliance with patients. This implies close collaboration between the operational Web teams and both the emergency services and mental health professionals. The Web community resources are also integrated as a key component of the system. As outlined in the literature, Web users by far anticipated the involvement of mental health professionals in dealing with suicidal contents on social media (Robinson et al., 2016a; Chan et al., 2017). Notably, peer-support and peer-surveillance initiatives were formally fostered by several platforms that created dedicated reporting systems for concerning posts (Facebook, 2015; Twitter, 2018). In our model, Web users – either ordinary network members or linkers involved as gatekeepers – could play a role in informing about worrisome posts. Such collaboration is anchored on the principle of mutual support: while the intervention team assists Web users in helping distressed peers, signalers of suicidal messages help to carry out outreach interventions.

We acknowledge that our model could crystallize sensitive ethical concerns such as how to keep a balance between the duty of care for presumed at-risk posters who did not formally ask for help and the principles of freedom of speech or privacy (Eggertson, 2015; Robinson et al., 2016a). More generally, online interventions are still at their infancy, and guidelines related to confidentiality (Robinson et al., 2016a), clinical safety (Luxton et al., 2012), and acceptability (Barak, 2007) issues must still be developed (Christensen et al., 2002).

The efficacy of our model remains to be tested. Due to the specific challenges that both Web interventions and complex public health actions pose, such an evaluation would require research innovation. For instance, methods remain to be developed to deal with pseudonyms rather than actual identities in the sampling and follow-up procedures (Lai et al., 2014). Furthermore, any attempts to establish causality assumptions between the online global strategy and its putative impact on the population would require a special effort to combine high-standard designs on both the individual and population levels, with a thoughtful choice of distal, proximal, and intermediary outcomes. In that regard, infodemiology, a branch of epidemiology that uses digital meta-data (e.g., Google

#### REFERENCES

queries, number of tweets) as proxies for "real life" indicators, could be relevantly exploited (Jashinsky et al., 2014; Sueki, 2015). Finally, the combination of qualitative and quantitative methods would help gain insight on the intrinsic socio-psychological process that underlies the impacts of the system (Lai et al., 2014).

If proved efficient, our model could formalize a trend reversal in prevention policies. Rather than simply attempting to counteract the adverse effect of social media, it would be about using them as an opportunity to increase prevention strategies. We believe this would result in general efficacy improvement, organizational optimization, and possibly cost reductions.

#### AUTHOR CONTRIBUTIONS

C-EN conceived the original idea, conducted the review of literature, set of conceptual basis of the model, and led the writing of the manuscript. PG, NP, MM, and MW substantially contributed to the article by identifying relevant references, providing conceptual inputs, and helping with the writing of the manuscript. MS and GV supervised the general process.

Samaritans (2017). Small Talk Saves Lives. Ewell: Samaritans.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2018 Notredame, Grandgenèvre, Pauwels, Morgiève, Wathelet, Vaiva and Séguin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Looking to the Future: A Synthesis of New Developments and Challenges in Suicide Research and Prevention

Rory C. O'Connor1 \* and Gwendolyn Portzky2

1 Suicidal Behaviour Research Laboratory, Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom, 2 Unit for Suicide Research, Flemish Centre of Expertise in Suicide Prevention, Ghent University, Ghent, Belgium

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.

#### Keywords: suicide, theory, challenges, clinical, risk factors, new technologies

### INTRODUCTION

Suicide and attempted suicide are major public health concerns. At least 804,000 people take their own lives annually and 25 times that number attempt suicide (WHO, 2014). 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, many challenges remain. In this article, we explore both the recent developments and the challenges ahead for the field of suicide research and prevention. Instead of relying solely on our individual perspectives, we consulted experts in suicide research and prevention from across the globe. To this end, we contacted all of the contributors to the 2nd edition of the International Handbook of Suicide Prevention (O'Connor and Pirkis, 2016) and asked them to nominate, in their

#### Edited by:

Raffaella Calati, Mount Sinai Hospital, United States

#### Reviewed by:

Sabrina Cipolletta, Università degli Studi di Padova, Italy Said Shahtahmasebi, The Good Life Research Centre Trust, New Zealand Gianluca Serafini, Ospedale San Martino (IRCCS), Italy Guoqing Hu, Central South University, China

> \*Correspondence: Rory C. O'Connor<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Clinical and Health Psychology, a section of the journal Frontiers in Psychology

Received: 24 May 2018 Accepted: 17 October 2018 Published: 27 November 2018

#### Citation:

O'Connor RC and Portzky G (2018) Looking to the Future: A Synthesis of New Developments and Challenges in Suicide Research and Prevention. Front. Psychol. 9:2139. doi: 10.3389/fpsyg.2018.02139

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view (i) the top 3 most exciting new developments in suicide research and prevention in recent years, and (ii) the top 3 challenges in the field of suicide research and prevention. We were fortunate to receive responses from about one third of the authors representing 12 countries and spanning four continents (see section "Acknowledgments"). We reviewed their nominations, combined them where they described an overarching theme and then classified them into whether they referred to research or practice1 . We also expanded upon their brief comments and added supporting references (largely in the new developments sections) to elucidate the specific development or challenge. Needless to say, these are fuzzy boundaries and some of the entries could be classified into more than one category. It is important to highlight that 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. Given the nature of the task, some of the new developments/challenges are very specific and others are more general. The interpretations of the contributors' submissions are ours and do not necessarily reflect those of the individual contributors. It is also important to emphasize that this appraisal of the developments and challenges within the field is not exhaustive and it reflects our biases and those of the contributors; it is our combined view (together with our international experts' views) of the recent past within the field and our thoughts about the future. It could also be argued that, as the contributors all wrote chapters for a single handbook, they are all like-minded individuals with a particular view on suicide prevention. Nonetheless, we believe that this synthesis will be helpful to guide those involved in suicide research and prevention as it highlights hot topics in the field. We also highlight at the outset that despite the developments in understanding suicide risk, our ability to predict suicide remains no better than chance and in many countries across the globe suicide rates continue to increase (O'Connor and Pirkis, 2016; Franklin et al., 2017).

#### New Developments in Research

The use of new technologies (including social media and naturalistic real-time monitoring via smartphones) to increase understanding of suicidal behavior and to better identify suicide risk were the most frequently cited new research developments nominated by our contributors (see **Panel 1**). With the proliferation of smartphone ownership globally, in low- and middle-income countries (James, 2014) as well as in high-income countries, the growth in interest is not surprising (de Beurs et al., 2015). Given the field's continued inability to predict suicidal behavior with sufficient sensitivity/specificity (O'Connor and Nock, 2014; de Beurs et al., 2015; Franklin et al., 2017), the use of smartphone technologies affords the opportunity to assess risk factors repeatedly, in real-time and in naturalistic settings (de Beurs et al., 2015; Michaels et al., 2015). It is hoped that the use of such technologies will better capture the 'waxing and waning' nature of suicidal ideation (Joiner and Rudd, 2000; Zisook et al., 2009) and account for the complex interaction between the risk factors which predict the transition to suicide attempts (de Beurs et al., 2015; O'Connor and Kirtley, 2018). If the promise of new technologies is realized, individuals or clinicians may be able to better identify windows of acute risk in real-time (based, in part, on social media and moment-to-moment monitoring), alert others and hopefully receive interventions to alleviate that risk. Needless to say, there are many practical and ethical barriers that have yet to be overcome, but they are not insurmountable.

The use of ecological momentary assessment (via mobile phones) has already been shown to be feasible (Palmier-Claus et al., 2011; Husky et al., 2014) and it offers considerable promise in enhancing our prediction of the suicidal ideation–suicide attempts gap (Myin-Germeys et al., 2009). In terms of social media, Twitter and Facebook are now being harnessed to help understand the transmission of risk of suicide and self-harm. For example, a recent study from Japan has shown that social media coverage of celebrity suicides varies as a function of characteristics of the celebrity, with large volumes of traffic happening when the celebrity is a relatively young entertainer (Ueda et al., 2017). Also in Asia, text mining and machine learning approaches have been applied to Chinese social media to identify language markers of suicide risk and emotional distress (Cheng et al., 2017). Social media is also being used a lot by young people as a means of communicating distress (Marchant et al., 2017). More generally, although Facebook is rolling out safety protocols that aim to identify social media users at-risk of suicide via their online posts, it is not clear whether such interventions are effective. As such initiatives develop it is vitally important that they are rigorously evaluated and potential unintended consequences (e.g., do they lead to more social isolation as these initiatives lead to a reduction in sharing on social media?) considered. These developments have important implications for theories of suicide risk and contagion as well as suicide prevention efforts more generally. As noted above, although these developments are exciting, best practice guidelines need to be developed to ensure these technologies are implemented safely and ethically (Michaels et al., 2015).

The second most frequently cited development was the growth in theories of suicidal ideation and behavior. This is, perhaps, unsurprising given that at least 12 theories have been put forward since the mid-1980s (O'Connor et al., 2016) beginning with Shneidman's cubic model of suicide (Shneidman, 1985) [obviously Durkheim pre-dates all of these contemporary models (Durkheim, 1897)]. Three of the recent predominant theories (the interpersonal theory, the integrated motivational-volitional model and the three step theory) have received considerable research attention; each fitting within the ideation–to–action framework (Joiner, 2007; Van Orden et al., 2010; O'Connor, 2011; Klonsky and May, 2015; O'Connor et al., 2016; O'Connor and Kirtley, 2018; O'Connor and Portzky, 2018) which describes those theories which posit that the factors associated with suicidal ideation are distinct from those that govern behavioral enaction, i.e., a suicide attempt/suicide (O'Connor and Nock, 2014; Klonsky et al., 2016, 2017).

1 Some authors also noted new developments and challenges in policy that are beyond the scope of this article.

#### PANEL 1 | New developments in Research.

fpsyg-09-02139 November 23, 2018 Time: 15:54 # 3

Although each of these theories emphasizes different factors that lead to the emergence of suicidal ideation and behavior, they have shaped our understanding of the suicidal process: historically, theories of suicide did not explicitly specify the conditions that led to suicidal ideation as being distinct from those associated with a suicide attempt/death by suicide. In brief, these new theoretical developments have been important not only to enhance understanding of the complexities of the suicidal process but they are also forming the basis for the development of psychological interventions to reduce risk of suicide and self-harm. For example, a recent brief psychosocial intervention (a volitional helpsheet) which draws from the integrated motivational–volitional model of suicidal behavior offers promise in reducing risk of repeat self-harm in some individuals following a suicide attempt (Armitage et al., 2016; O'Connor et al., 2017). The recent focus on safety planning and crisis response planning interventions is also consistent with the ideation-to-action framework (Stanley and Brown, 2012; Bryan et al., 2018) and are welcome additions to the field.

Given that suicide and suicide attempts are transdiagnostic phenomena, the move away from a focus on individual mental disorders coupled with the introduction of the National Institute of Mental Health's Research Domain Criteria (RDoC) was identified as a positive development for the field (Glenn C.R. et al., 2017). Indeed, in a novel approach Glenn and colleagues conducted a meta-analysis of transdiagnostic dimensions (Glenn et al., 2018). Rather than focusing on risk factor domains, they viewed the predictors of suicidal behavior through the lens of the RDoC domains. Perhaps unsurprisingly, they found that limited prospective research, to date, fits within the RDoC transdiagnostic framework and even less addresses protective factors. Where there was evidence, it tended to be for the Negative Valence Systems domain (e.g., hopelessness) but there was also growing evidence for suicide theory-related factors (e.g., burdensomeness, defeat/entrapment) (Van Orden et al., 2010; O'Connor, 2011; Glenn et al., 2018). One of the key messages for future research from Glenn and colleagues' recent meta-analysis is that we need to move beyond "the 'usual suspects' of suicide risk factors (e.g., mental disorders, sociodemographics) to understand the processes that combine to lead to this deadly outcome."(Glenn et al., 2018).

The use of innovative study designs and new techniques were also identified as important developments. Four such designs or techniques were highlighted by our contributors. The first is the use of big data and machine learning. Consistent with other areas of psychopathology, the statistical and computing power of big data and machine learning is now being applied to suicide risk assessment. Such approaches have the advantage of being able to combine a large number of risk factors in the prediction of suicide risk and they have already been shown to be moderately successful (Franklin et al., 2017; Hettige et al., 2017; Kessler et al., 2017). As the machine learning field develops, it will be interesting to determine the extent to which the algorithms can be applied to real-world clinical contexts to inform treatment planning (see also Research challenges below).

The second technique is the retrospective timeline followback (TLFB) methodology (Sobell and Sobell, 1992) which systematically assesses behaviors/events in the days/weeks preceding an index event. Although TLFB is not new (Sobell and Sobell, 1992), its application within a case-crossover design to understand suicide risk in the days and hours preceding a suicide attempt is novel. Building on the work of Conner et al. (2012) showing that interpersonal stressful life events may lead to a suicide attempt within the same day, Bagge et al. (2013) conducted a TLFB study but focused on the 48 h preceding a suicide attempt. In the first study of its kind, they demonstrated that negative life events (NLEs) were triggers for a suicide attempt and that NLEs occurred more often on the day of, rather than the day before, a suicide attempt (Bagge et al., 2013). Given that we know relatively little about the factors that trigger suicide attempts in the preceding hours, we would urge others to consider employing the TLFB method.

Third, the innovative work on predicting suicidal behavior using implicit cognitions toward death has been a welcome addition to the literature (Nock et al., 2010). Implicit cognitions assess one's automatic associations with life or death. For example, it may be possible that an individual's unconscious association with wanting to live or die changes as their mood decreases – and this could be incorporated into a real-time warning system. Not only do implicit measures overcome the issue of one's reluctance to disclose suicidal intent but they also tap directly into the automatic processes that govern behavior (alongside reflective processes) (Strack and Deutsch, 2004). Although this is an exciting development, there are many unanswered questions, including, how stable are implicit cognitions, how are they formed, over what time frame and

with whom are they predictive as well as how are they related to existing risk factors? (Dickstein et al., 2015; Hussey et al., 2016; Glenn J.J. et al., 2017). Indeed, a recent study, conducted across two research labs in United States and Scotland, found that implicit attitudes can be activated by low mood in those with a suicidal history (Cha et al., 2018).

Finally, network analysis is a new statistical technique that has been applied to psychopathology in general and suicidal behavior specifically in recent years (de Beurs, 2017; de Beurs et al., 2017; Fried et al., 2017). The advantage of network analysis is that it allows researchers to investigate the complex associations between risk factors or symptoms. It also determines which symptoms are central within a network thereby highlighting specific treatment targets with the potential to be most powerful in reducing risk of suicidal behavior. To our knowledge only one prospective study of suicidal behavior has been published to date (de Beurs et al., 2017) so it is unclear which symptoms will have optimal predictive power. Nonetheless, we urge researchers to embrace this new statistical technique.

The past 20 years of research has also been witness to new developments in brain imaging techniques and epigenetics (van Heeringen, 2014; van Heeringen and Mann, 2014; Sudol and Oquendo, 2016). With respect to the former, in a recent review of 12 neuroimaging techniques, 5 yielded important findings specific to suicide attempts [namely, magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), functional MRI (fMRI), positron emission tomography (PET), and single-photon emission tomography (SPECT)] (Sudol and Oquendo, 2016). Taken together the brain imaging studies have identified both structural and functional abnormalities in the prefronal and limbic areas of the brain in individuals with a suicidal history. Obviously, brain imaging is only part of the answer in piecing together the suicide risk puzzle, but such approaches continue to make an important contribution to our understanding of suicide-specific markers of risk. For example, such research helps to explain, in part, the deficits in emotional regulation and decision-making that often characterize suicide risk (Sudol and Oquendo, 2016).

The neurobiology of suicidal behaviour and epigenetics were also highlighted. There is an established body of research, employing different study designs (including in vivo, experimental and post-mortem techniques) finding that impairments in the serotonergic and hypothalamic-pituitaryadrenal axis stress response systems, in particular, are associated with increased vulnerability to suicide (van Heeringen and Mann, 2014; Lutz et al., 2017). The growing recognition of the influence of external factors, including early life adversity, on gene expression, has also led to a step change in our interpretation of the relationship between stress, mental disorders and suicide vulnerability (van Heeringen and Mann, 2014; Lutz et al., 2017). Indeed, there may be unique epigenetic processes (including altered cortisol responses and altered glutamate signaling) at play that increase suicide risk, with Lutz et al. (2017) arguing that understanding the former "has contributed to one of the most meaningful changes to the neuroscience landscape in the past 15 years (Lutz et al., 2017)". There is also evidence that microRNAs may play a critical role in suicide risk (Serafini et al., 2014). Finally, it is also noteworthy that neurobiological scientists are incorporating key psychological and social factors into their modeling of suicide risk (Turecki and Brent, 2016; Lutz et al., 2017).

No single discipline can address the complex challenge of understanding risk, as suicide is the end product of a complex interplay of neurobiological, psychological, and social processes. Indeed, social factors, including social isolation, disconnection (Stack, 2000; Macrynikola et al., 2018), loneliness (Bennardi et al., 2017) and social disadvantage (Batty et al., 2018) were flagged by a number of respondents as key determinants of suicide risk which have received welcome attention in recent years. What is more, social disconnection and social isolation (O'Connor and Nock, 2014) (including the absence of social support) feature in the interpersonal theory of suicide (Van Orden et al., 2010) the integrated motivational–volitional model of suicidal behavior in particular (O'Connor and Kirtley, 2018) and the 3 step theory (Klonsky and May, 2015).

The social context is crucial to understanding suicide risk especially given the evidence that suicide is socially patterned being significantly more prevalent in areas of social disadvantage compared to more affluent areas (Platt, 2016; Batty et al., 2018). Although there have been some developments in understanding how changes in the social role may contribute to suicide risk, more needs to be done to better understand how conceptualizations of masculinities may elevate suicide vulnerability (Scourfield et al., 2012). Finally, an incredibly positive development in the field in recent decades has been the recognition of the importance of postvention and those with lived experience (including suicide attempt survivors and suicide bereavement survivors) as key to suicide research and prevention activities. Lezine recently described the vital work of suicide prevention through personal experience (Lezine, 2016) which we would urge everyone involved in suicide research to read.

### Challenges in Research

The most frequently cited challenge was the issue of the reliability of suicide data due to low base rates and small samples in intervention studies, in particular (see **Panel 2**). This is a significant issue as we endeavor to build the evidence base for what works to prevent suicide. The lack of evidence for the efficacy of psychological and pharmacological treatments to prevent suicide specifically may be, in part, attributable to this issue of scale. As suicide is a low base-rate outcome, almost all clinical RCTs have been underpowered to detect changes in suicide rates and, at best, they have employed suicide attempts as the primary outcome. Even then, the sample sizes have tended to be modest, thereby precluding the a priori investigation of whether interventions may be effective in some groups of participants but not in others. For example, even where there is evidence for clinical efficacy of psychosocial interventions to reduce self-harm (Hawton et al., 2016), we cannot say whether they are effective for men as well as for women. One potential solution might be to include suicide-related measures as secondary outcomes in all psychological treatment trials and then potentially aggregating findings across studies, where appropriate (Holmes et al., 2018). Another solution relates to the

#### PANEL 2 | Challenges in Research.

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second challenge. Given that the size of suicide research field is relatively modest and the challenge around statistical power, the establishment of national and international networks may facilitate large-scale research opportunities.

Relatedly, the scarcity of translational research was also noted as a challenge. This is an important consideration, as new developments in suicide research are frequently not translated into saving people's lives. The issue of translation relates to ensuring that research evidence, for example the potential effect of government austerity policies on health, is translated into a change in government policy. Another example would be the limited interest in some countries in implementing strategies in restricting the access to the means of suicide (see also practice challenges). We also need to re-double efforts to increase the likelihood of evidence-based treatments for suicidal behavior being accessible to those who need them. Consistent with the call within the Lancet Psychiatry Commission on psychological treatments research (Holmes et al., 2018) to focus on implementation, the same onus is on suicide researchers specifically. The second challenge is also related to the issue of scale, arguably. Excluding large-scale national linkage database type research, the majority of risk factors/predictors research in the field has tended to focus on suicide ideation and attempts as outcome variables – as well as being limited to a small number of predictors. This is an important limitation and perhaps the establishment of the networks or suicide research hubs (as suggested above) can address this dearth in the literature.

As noted earlier in this paper, the field of suicide research has to continue to move beyond traditional risk factors (e.g., psychiatric illness) and to embrace complexity. We need a renewed focus on novel risk factors and multivariable risk factors; this is especially urgent as our ability to predict suicide has not improved since the 1960s and it remains no better than chance (Franklin et al., 2017). With a few exceptions, limited research has focused on short-term acute risk, with researchers often directing their attention to the long-term follow-up of patients who are high risk (O'Connor et al., 2009; Glenn et al., 2016; Glenn J.J. et al., 2017). Although the latter is important, arguably such studies have limited clinical utility and given that there is increased risk of suicidal behavior in the days and weeks following discharge from hospital (Owens et al., 2002; Chan et al., 2016; Ribeiro et al., 2016), we need to know more about this acute window. In addition, next on the list of challenges relates to the systematic exclusion of high-risk participants from our studies. We need to develop new protocols to include the very people who are most likely to benefit from our research findings. Obviously there are ethical and safety challenges, but, arguably it is unethical to exclude this vital group of participants in research studies.

There have been considerable improvements in terms of interdisciplinary working in recent years. For example, in 2008, one of us (RCOC) organized the European symposium on suicide and suicidal behavior (ESSSB12; the leading suicide research conference in Europe) in Glasgow, Scotland. This was a huge success; it had the theme of 'working together to prevent suicide: research, policy and practice' and there were countless examples of interdisciplinary research showcased therein. What is more, 10 years later, the other one of us (GP) organized the same conference in Ghent, Belgium (ESSSB17), again with the explicit plea for high-quality multidisciplinary research. Despite these developments, we should not be complacent; there remains a considerable need to continue building the linkages across disciplines and to involve everyone who has a stake in suicide prevention in our research. Indeed one of our experts highlighted that such working is essential especially to maximize the opportunities afforded by new technological developments. The lack of an international consensus in the terminology used in the field remains a challenge (Silverman, 2016); mutual cross-disciplinary respect is also required to ensure that interdisciplinarity flourishes.

Although Durkheim, one of the pioneers in suicide research, highlighted the central role of social context and social factors in the etiology of suicide in 1897 (Durkheim, 1897), without

question, their roles have not received adequate attention in the 121 years since. This is especially alarming given the scale of the socio-economic gradient in suicide and the established relationships with unemployment and disadvantage (Platt, 2016; Batty et al., 2018). However, the renewed focus on adverse childhood experiences in suicide risk is welcome (Turecki and Brent, 2016; O'Connor et al., 2018). At the other end of the social context spectrum are social media influences and other volitional factors (O'Connor and Kirtley, 2018) which are implicated in suicidal behavior and self-harm. We do not know enough about how such factors act to increase suicide risk in terms facilitating social modeling and increasing cognitive accessibility (O'Connor and Nock, 2014; O'Connor et al., 2014; Mars et al., 2015; Biddle et al., 2016). Another major challenge is the relative dearth of research into suicide in low and middle-income countries (LMIC). Despite the fact that the vast majority of the world's suicides occur in LMIC (WHO, 2014), (although this is changing) there is still insufficient research focus in LMIC.

The advent of machine learning techniques and the use of "big data" algorithms were identified as exciting new developments in the preceding section. However, caution is also urged by our contributors as such algorithms may not adequately appreciate the person-specific nature of suicide warning signs. This highlights the importance of adopting a multi-method approach to understanding suicide risk. As noted above, no single approach, method or discipline has all of the answers; if we are to make further progress in predicting suicide, this is most likely to succeed if we integrate multiple approaches and crucially we should not throw the baby out with the bathwater.

The next three challenges are inter-related as they each refer to a more fine-grained appreciation of sub-types of individuals who are at increased/decreased risk. The first in this triad is also featured in the new developments section, as it calls for a better understanding of the transition from suicidal thoughts to suicide attempts/suicide. As noted above, the ideation to action theories (Van Orden et al., 2010; Klonsky and May, 2015; O'Connor and Kirtley, 2018) are beginning to address this important challenge more systematically, though the findings from the World Mental Health surveys have also contributed to our understanding of these pathways (Nock et al., 2008). Nonetheless, we believe that this is one of the biggest challenges in the field as there are so many gaps in our understanding of this transition (Nock et al., 2008; O'Connor et al., 2012; Dhingra et al., 2015). We also need more research regarding the factors that differentiate between those who make low-lethality attempts versus those who make high-lethality attempts. Although a few high quality studies exist (Rivlin et al., 2013; Marzano et al., 2016; Anestis et al., 2018), focused on specific populations, more in-depth research is required. In addition, although there has been growing focus on the relationship between sleep and suicide risk (Littlewood et al., 2017), among those who have attempted suicide, insomnia may be associated with a more violent method (Pompili et al., 2013).

The final challenge in this group calls for increased understanding of the causes of suicidal behavior in people who do not have psychiatric illnesses. Despite the evidence that most people in Western countries who die by suicide have a diagnosed mental illness (Cavanagh et al., 2003), there are cultural variations (Phillips, 2010) and some argue that the association between mental illness and suicide is not as marked as is commonly reported (Hjelmeland and Knizek, 2017). As the relationship between mental illness and suicide is often ascertained via a psychological autopsy, researchers should implement the recommendations on the next generation of psychological autopsy studies that aim to increase the accuracy of data collected (Conner et al., 2011). These latter three challenges highlight the more general point that we still often treat people at risk of suicide as an homogeneous group but we need to move beyond such characterization and identify distinct profiles of people at risk: the precision medicine approach.

As the determinants of suicide are many, spanning neurobiology, psychology and social factors, it is not surprising that there is a tension between where our research effort should be focused. A number of contributors argued for an increase in attention to the neurobiological determinants of suicide as these would inform treatment targets and a reduced focus on epidemiology. As noted above, no one discipline has all of the answers so it is important that all areas receive attention.

### New Developments in Practice

The most frequently reported new development in research (i.e., the use of new technologies) is also the most frequently mentioned new development in practice (see **Panel 3**). So called 'new' technologies such as the internet and mobile phones not only increase our understanding of suicidal behavior but they can also be harnessed for treating and connecting with individuals who are suicidal (Hom et al., 2015; de Beurs et al., 2015; Hetrick et al., 2017; Nuij et al., 2018).

Given that less than one third of suicidal individuals seek help or make use of mental health services it is clear that there are numerous barriers to traditional forms of treatment such as stigma and shame, low perceived need, a preference for selfmanagement, availability and high cost of care (Bruffaerts et al., 2011; Andrade et al., 2014). Online interventions are well placed, therefore, to overcome many of these barriers as they are easily accessible anywhere at anytime, at low cost, and are mostly anonymous or highly confidential (Hom et al., 2015).

Although there have been several studies sharing positive effects of online interventions in the reduction of suicidal ideation (Christensen et al., 2013; Saulsberry et al., 2013; Williams and Andrews, 2013; Mewton and Andrews, 2015) many of these online interventions were developed to manage depression and were not designed to target suicidal ideation specifically. In a rare exception, van Spijker et al. (2014) examined the effectiveness of an online intervention specifically targeting suicidal ideation in a Dutch community sample. The results were promising, showing a significant reduction in suicidal ideation thereby highlighting the potential for managing suicidal ideation via an online intervention. However, in this study individuals with severe suicidal ideation were excluded and a controlled followup period was missing. This online intervention has also been examined in an Australian community sample by use of a randomized controlled trial (van Spijker et al., 2018). Although the intention-to-treat analyses showed significant reductions in the severity of suicidal thinking at post-intervention, 6 and

#### PANEL 3 | New developments in Practice.

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12 months, no overall group differences were found. It is, thus, clear that more research is needed and it is encouraging that this online intervention is currently being examined in other countries such as Denmark and Belgium (De Jaegere, submitted).

Although it is not surprising that suicide experts have focused on suicide-specific tailored interventions, it is important to direct attention at suicidal thoughts and behavior as treatment targets rather than viewing them exclusively as symptoms or epiphenomena of mental disorder. Indeed, many previous studies have focused on the treatment of depression and viewed suicidal ideation as a secondary outcome that may improve if the intervention for depression is effective. Therefore, the growth in clinical trials that have investigated the efficacy of suicide-specific prevention and intervention strategies aimed at reducing suicidal behavior is a welcome development.

To this end, there has been growing evidence for suicide-specific psychosocial interventions which show promise in reducing suicidal behavior (Hawton et al., 2016). For example, Gysin-Maillart et al.'s (2016) 24-month follow up randomized clinical trial (the Attempted Suicide Short Intervention Program; ASSIP) of a novel brief therapy for patients who had attempted suicide was effective in reducing suicidal behavior in a real-world clinical setting. ASSIP was associated with a circa 80% reduced risk of repetition of at least one suicide attempt and ASSIP participants spent 72% fewer days in the hospital during follow-up compared to controls. ASSIP consists of three therapy sessions followed by regular contact through personalized letters over 24 months (Tarrier et al., 2008). The development of the Collaborative Assessment and Management of Suicidality (CAMS) approach has been an exciting new development in the field which also offers considerable promise (Comtois et al., 2011; Jobes, 2016).

Another brief psychological intervention with a volitional helpsheet (VHS) has also yielded promising results (O'Connor et al., 2017). Although the VHS had no overall effect, post hoc analyses suggested that this brief adjunct intervention might be effective in reducing the number of self-harm repetitions following a suicide attempt among those with a self-harm history. In another modest sized RCT which compared a 6-week telephone-based positive psychology (PP) intervention with a cognition-focused (CF) control intervention, those who received the CF intervention reported greater improvements in hopelessness at 6 weeks but not at 12 weeks (Celano et al., 2017). This study recruited patients who had recently been hospitalized for depression and suicidal ideation or behavior. There was also greater improvement in suicidal ideation, depression and optimism at 6 and 12 weeks after receipt of the CF intervention. Contrary to the authors' hypothesis, however, it was the CF intervention that was superior in improving hopelessness, other suicide risk factors and positive psychological constructs rather than the PP intervention (Celano et al., 2017).

These latter studies add to the established evidence that CBT has a significant effect in reducing suicidal behavior (O'Connor and Nock, 2014; Hawton et al., 2016). However, a systematic review and meta-analysis from 10 years ago still nicely summarizes the gaps in our knowledge (Tarrier et al., 2008). Tarrier et al.'s (2008) subgroup analyses confirmed significant treatment effects for CBT in adult samples (but not in adolescent samples), for individual treatment delivery (but not for group administration) and for CBT when compared to minimal treatment or treatment as usual (but not when compared to another active treatment; Tarrier et al., 2008).

As noted in the new research developments section, the insights offered by those with lived experience into the design and improvement of suicide prevention programs were also highlighted by our experts. Although their contributions have taken different forms, there is now a considerable body of qualitative evidence on the aftermath of a suicidal crisis or attempt based on interviews with those with lived experience. Such studies have deepened our understanding of what it is like to be suicidal and how to help those who are vulnerable (Lin et al., 2009; Oliffe et al., 2012; Vatne and Naden, 2016).

More recently, attention has been paid to ensuring that such insights and testimonials inform the development and implementation of suicide prevention programs. For example, Jones et al. (2018) explored the views of health and human service workers with regard to the development of a suicide prevention training program. This included meaningful involvement of someone with lived experience in the development and delivery of the training. The authors concluded that the inclusion of a person with lived experience of suicidality resonated strongly with the participants and provided a powerful learning experience for those involved. A strong positive element was that the person with lived experience gave participants crucial insights into how to have conversations around suicide and how best to ask the questions about thoughts of suicide directly. Although this study indicates the positive effect of including people with lived experience the authors also caution that the

inclusion of a person with lived experience must be appropriate and safe. In addition, despite the progress in involving people with lived experience to improve research and practice, we should not be complacent; we have a long way to go in terms of maximizing their involvement to the mutual benefit of all.

The growth in specific interventions for high-risk groups was also highlighted as an important new development. By way of an example, Vijayakumar et al. (2017) reported the effectiveness of CASP, an intervention by community volunteers among refugees, to reduce suicidal behavior. This intervention involves contact between community volunteers and refugees and the use of safety planning cards. The findings from the RCT were positive as the intervention was associated with a significant reduction in suicidal behavior among the refugees. Interventions for another high-risk group, older adults, are also encouraging. Specifically, a recent systematic review of interventions to prevent and reduce suicidal behavior in older people showed that several interventions are effective, with at least some evidence for multi-faceted primary care-based depression screening and management programs, pharmacotherapy and psychotherapy, and telephone counseling (Okolie et al., 2017). In short, there is the increasing recognition that the one size fits all approach to suicide prevention initiatives is not effective and we must tailor interventions to fit specific at-risk populations.

The growing evidence for effective school-based programs was also highlighted by our experts. There is now some evidence for peer-support prevention programs and skills-based training programs, which show positive outcomes regarding coping skills and referral to help (Katz et al., 2013; Hetrick et al., 2014, 2017). There is also some evidence that screening programs have some utility in identifying young people at risk (Robinson et al., 2013). Although it is important to note that there are many challenges with screening programs including the issue of false positives and the need for available resources to support those who are identified as high risk. School-based awareness programs have also been shown to significantly improve knowledge, attitudes and help-seeking behavior (Cusimano and Sameem, 2011). However, the most promising findings are those from the Saving and Empowering Young Lives in Europe (SEYLE) study (Wasserman et al., 2015). In this multicentre clusterrandomized controlled trial, adolescents who received the youth aware of mental health (YAM) program reported a significant reduction in incident suicide attempts and severe suicidal ideation compared with the control group at 12-month followup. As with all areas of practice, it is important to replicate these findings.

New anti-psychotic drug treatments were identified as a final new development. Although there is "at least modest evidence suggesting that antipsychotic medications protect against suicidal risk" (Kasckow et al., 2011), a combination of psychosocial and pharmacological management is recommended. Of all the anti-psychotic medications, though, the best evidence is for clozapine (Kasckow et al., 2011). Consistent with the pharmacological treatment literature more generally, there remains a dearth of large-scale treatments of anti-psychotic medications.

### Challenges in Practice

The experts' opinions regarding the challenges in practice were diverse, with the majority of the suggestions only being mentioned by one expert (see **Panel 4**).

The only challenge which was mentioned multiple times was the need for more research and evidence for universal and selective prevention strategies. This is, perhaps, unsurprising as the USI (Universal, Selective, Indicated) prevention model forms the basis for much suicide prevention activity worldwide. Despite its use as an overarching framework, it is obvious from the research literature that there are extensive gaps in our knowledge about what works to prevent suicide and how the different levels of intervention (USI) interact. However, there have been recent efforts to investigate the synergies between the different components of suicide prevention strategies (Harris et al., 2016). Given that suicide rates continue to rise in some countries (e.g., in the United States), perhaps it is time to reconsider whether a paradigm shift, rather than a 'more of the same' approach to suicide prevention is required.

As highlighted above, there has been welcome attention on indicated prevention strategies, focusing on those who are already suicidal. However, new thinking about universal and selective prevention is urgently required so that we can promote populations to be more resilient, to increase their coping skills and protect them from suicide risk. It is a major problem for those involved in suicide prevention including policy makers that there is so little evidence for universal and selective prevention strategies. Indeed, one of the few evidence-based strategies within universal prevention is the implementation of universal school awareness programs (Zalsman et al., 2016); much more research is urgently required.

More broadly, we also need to challenge attitudes, beliefs and knowledge regarding the preventability of suicide. Although suicide prevention is very difficult in practice, it is not impossible; but the existence of negative attitudes and beliefs that suicide is inevitable, that it cannot be prevented, are unhelpful. The establishment of the Zero Suicide (https://zerosuicide.sprc.org) movement has been very important in this regard, promoting the message that every suicide is one death too many. Related to the latter are the attitudes toward means restriction, especially in the context of restricting access to guns in the United States. Although restricting access to the means of suicide is one of the most effective suicide prevention strategies (Zalsman et al., 2016) in practice it is challenging to convince policy makers, gatekeepers, or mental health professionals of the need to implement a means restriction strategy. It is hoped that the recent focus on means safety (Anestis et al., 2018) rather than means restriction per se may help in this regard. The major challenge of integrating conversations about lethal means safety into standard primary care, mental health and substance use clinics was also identified by one of our experts.

There is also a lack of evidence regarding the most effective ways of implementing suicide prevention methods and strategies in different institutions/organizations including hospitals, mental health institutions, local governments and schools. However, there is evidence from the UK that implementing mental health

#### PANEL 4 | Challenges in Practice.

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service recommendations in particular the provision of 24 hour crisis care, having local policies for dual diagnosis and conducting a multidisciplinary review after a suicide are associated with falling suicide rates (While et al., 2012). Indeed, a major challenge is the reality that at least one quarter of people who die by suicide have had previous contact with mental health services (NCISH, 2017). We await with considerable interest the findings from on-going evaluations of the implementation of Zero Suicide (Mokkenstorm et al., 2017) initiatives as they will provide valuable insights into the challenges and facilitators of rolling out multi-level suicide prevention interventions in health care settings.

The chain of care and the need for continuity and high quality care are key to successful suicide prevention efforts especially among those who present to clinical services following selfharm. Indeed, in many countries throughout the world there are recommended standards of care and aftercare, but the reality is that these standards are frequently not implemented. Mehlum and Mork describe these challenges but crucially they have also identified key solutions which should improve adherence and sustainability over time (Mehlum and Mork, 2016). There is also considerable need for better linkages between crisis intervention, statutory services, therapists and the myriad of community and voluntary sector organizations that work in suicide prevention. Although it is difficult to set up studies to evaluate optimal chains of care, we urgently need more evidence about how to organize and implement linkages between different services and mental health settings.

There have been several studies regarding the clinical management of patients who present to hospital following suicidal behavior, nonetheless there is still a need for more evidence to inform best practice for the evaluation, treatment and follow-up of these patients. Although it is recommended that all patients who attempt suicide or self-harm should receive a comprehensive psychosocial assessment, at the hospital level there are wide variations in the clinical management such that the proportion of clinical presentations receiving psychosocial assessment (range 22–88%), medical (22–85%) or psychiatric (0–21%) admission and referral to non-statutory services (4–62%) (Cooper et al., 2013) varies markedly. However, there seems to be little association between these differences in hospital management and the repetition rate of self-harm (Cooper et al., 2015). As this is surprising, future studies should focus more on understanding the processes underlying the different management and treatment styles of suicidal people at hospital level and their relationship to patient outcomes.

As mentioned in the new developments in practice section the increased involvement of people with lived experience can only be positive for the field. Moreover, there is the possibility that including people with lived experience of suicidal ideation and/or behavior in suicide prevention programs might have other positive effects by providing a more powerful learning experience. Their involvement may yield similar effects to the Papageno effect that has been shown in relation to the media portrayal of suicide. The Papageno effect describes the positive and preventive effects of using positive testimonials of people with lived experience who have survived a suicide attempt and who have learned to overcome a suicidal crisis in a media portrayal of suicide. See Pirkis et al. (2016) for an overview of media influences and suicidal behavior literature.

Whereas the positive effect of including positive testimonials of people with lived experience in media portrayal is well established (Niederkrotenthaler et al., 2009, 2010) it ought to be extended to other areas of suicide prevention. Although there are some studies reporting the involvement of people with lived experience in the field of mental health these studies have tended not to evaluate this approach (Repper and Breeze, 2007). The Jones et al. (2018) study noted in the new developments in practice section is one of the few studies to explore the benefits of involving people with lived experience of suicidality in such studies. There is a strong need, therefore, for more evaluation studies investigating the effects, opportunities, and risks of involving people with lived experience in suicide prevention programs.

Given that male deaths by suicide vastly outnumber female suicides (Turecki and Brent, 2016), there is a huge challenge to gain more knowledge regarding how to approach and more effectively reach men with suicide prevention strategies. Men seek less help and communicate less about mental health problems so the challenge is how to motivate them for prevention and treatment. We also need to be careful that we do not blame men for not seeking help especially given that the support and services may not have been designed with them in mind. The stigma regarding mental health problems is also higher for men than for women, therefore, it is important that public health campaigns should direct their focus on men, specifically. As noted earlier, the extent to which existing interventions to reduce risk of suicide are effective for men is largely unknown.

Another challenge identified by our experts was the need to focus more on suicide risk in adolescents. In particular we need to identify and treat first onset suicidal ideation in adolescents. Indeed, if we are to better identify adolescents early on in the suicidal process we need to learn more about how to help them manage their suicidal ideation, how to enhance their coping skills, their social skills and capacity to solve social problems. We need to develop evidence-based interventions to increase their resilience that could help to buffer against suicide risk early in life. Targeting suicidal ideation in early adolescence should thus be a specific focus for suicide prevention efforts. As noted above, school-based suicide prevention programs should be considered in this regard (Katz et al., 2013; Robinson et al., 2013).

As a discipline, we should remain open to learning from other areas of public health and applying any such lessons to suicide prevention. For example, a very novel but intriguing suggestion by one of our experts is to study the effects of a dental health approach to determine whether it could be effective in improving mental health and prevent suicide. Translating the dental health approach into a mental health approach could involve us engaging in mental health self-care for a few minutes, say twice a day and this could be supplemented by an annual or 6 months check-up by a health care professional. Needless to say, a key challenge for such an approach would be around how we change existing attitudes, beliefs and knowledge regarding mental health to ensure that mental health self-care becomes an obvious and vital part of our daily health care, just like dental health care is. We should also look at what has been done with respect to stroke, heart disease and cancer; all areas of public health where the death rates have decreased markedly in recent decades while suicide rates have remained stable or increased.

Another fundamental methodological challenge for both practice and research is how to increase the integration of clinical knowledge into the clinical evidence-base. Indeed, well designed empirical studies and theoretical models to understand suicidal behavior often lack clinical knowledge; their translatability and implementation would benefit markedly from such knowledge. The complexity of the suicidal process and the individual differences associated with the development of suicidal ideation and behavior that are often observed in clinical practice are frequently overlooked in research, thereby limiting their clinical utility. A related issue is that there are few suicide-specific treatments that are actually available in the real world. It is incumbent on health care managers and policy makers to prioritize the accessibility of evidence-based treatments to those who need them when they need them. In short, the clinical management of patients who are suicidal remains a huge challenge, both in terms of the evidence base for tailored interventions and the accessibility of such interventions for those who are most vulnerable.

### CONCLUSION

It is an exciting time to be working in suicide research and prevention. In many countries throughout the world there have been important developments in understanding and preventing suicide. The four panels highlight key opportunities, challenges and pointers to move the field forward. We hope that their contents will guide the future research agenda, acting as a catalyst for new thinking in suicide prevention research and practice. However, it is important to reiterate the limitations of this Perspective article. Although the new developments and challenges outlined herein are extensive, they are not exhaustive but represent the views of 32 researchers or practitioners in the field. Nonetheless, the new developments identified by our experts are exciting, harnessing new technologies and approaches to better understand who is most at risk of suicide and why. However, many challenges remain; first, our ability to predict suicide is still not much better than chance and although there has been a welcome focus on suicide prevention interventions (both at the public health and clinical level), many gaps in our knowledge remain. None of us has all of the answers, and we hope that the suggestions reported herein will encourage new synergies and opportunities for interdisciplinary research. Finally, we are optimistic that the new developments and the field's determination to overcome the identified challenges will combine to save more lives across the globe.

### CONSENT AND ETHICAL APPROVAL

All contributors named in the section "Acknowledgments" were asked for their views on new developments and challenges in suicide research and prevention. They all provided written informed consent (by email) that their views could be collated by the authors for use in publication. Consistent with the University of Glasgow's Medical, Veterinary and Life Sciences ethics committee's institutional policy, no ethical approval was sought as contributors were giving their views in their expert capacities. It is important to note, however, that the views and interpretations expressed in the article are those of the authors and not the contributors.

## AUTHOR CONTRIBUTIONS

Both authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

## FUNDING

RO'C received funding support from United States Department of Defense (W81XWH-12-1-0007).

## ACKNOWLEDGMENTS

Many thanks to the following authors who contributed new developments and challenges for this article: Karl Andriessen (Australia), Deb Azrael (United States), Shu-Sen Chang (Taiwan), Seonaid Cleare (Scotland), Kate Comtois (United States), Kenneth Conner (United States), Catherine Crane (England),

Nadine Dougall (Scotland), Cassie Glenn (United States), Bergljot Gjelsvik (England), Onja Grad (Slovenia), David Gunnell (England), Peter Gutierrez (United States), Yari Gvion (Israel), Gergo Hadlaczky (Sweden), Keith Hawton (England), David Jobes (United States), Ad Kerkhof (Netherlands), Olivia Kirtley (Belgium), Karolina Krysinska (Australia), Mark Ilgen

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challenges, and future research considerations, Clin. Psychol. Sci. 5, 568–592. doi: 10.1177/2167702616686854

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2018 O'Connor and Portzky. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Strategies to Deal With Suicide and Non-suicidal Self-Injury in Borderline Personality Disorder, the Case of DBT

#### Paco Prada, Nader Perroud\*, Eva Rüfenacht and Rosetta Nicastro

TRE Unit, Division of Psychiatric Specialties, Department of Mental Health and Psychiatry, Geneva University Hospitals, Geneva, Switzerland

One of the most problematic aspects of borderline personality disorder resides in repeated non-suicidal self-injury (NSSI) and suicide attempts. These behaviors constitute the prime therapeutic target and a factor that complicates patient care, namely in terms of therapeutic continuity. It has been demonstrated that Dialectical Behavior Therapy (DBT) is efficient in reducing the symptomatology of this disorder, as well as NSSI and suicide. DBT is a multi-component psychotherapeutic treatment, and the effectiveness of its individual constituents is therefore a relevant question. Studies comparing its various components (individual therapy, group therapy, and standard DBT) have not revealed any marked difference between them, other than a tendency toward improved patient retention rates in the standard version of the treatment. The aim of this study is to review the various components of DBT and their constituent parts, in order to highlight the importance of focusing on self-harm behaviors within the therapy as a whole. Although therapeutic strategies may differ and target directly suicide or NSSI, managing the quality of life, and the persistence of the therapeutic alliance (and of the interpersonal alliance) is equally important in terms of treatment efficacy.

Keywords: borderline personality disorder, suicide attempts, dialectical behavioral therapy, self-harm, psychotherapy

## INTRODUCTION

Borderline Personality Disorder (BPD) is a disorder affecting from 1 to 6% of the population (Torgersen et al., 2001; Gross et al., 2002; Lenzenweger et al., 2007). Despite a relatively favorable spontaneous evolution, with 80% of patients no longer meeting the DSM diagnostic criteria after a 10-year period, it nonetheless gives rise to significant suffering and functional limitations (Skodol et al., 2002; Zanarini et al., 2006; Niesten et al., 2016). The associated suicide rate is tragically high and estimated at 8–10% (Oldham, 2006). Over the course of the past two decades, various therapies specifically adapted to this disorder have been developed and include Dialectical Behavior Therapy (DBT), Mentalization-Based Treatment (MBT), Transference Focused Psychotherapy (TFP) and Good Psychiatric Management (GPM) (Linehan et al., 1991; Clarkin et al., 2001; Bateman and Fonagy, 2010; Links et al., 2015). Each treatment relies on a consistent theoretical model and provides psychotherapeutic interventions that target the disorder's central dimensions, which include a perturbed sense of identity, intense and unstable interpersonal relations, emotional

#### Edited by:

Jorge Lopez-Castroman, Centre Hospitalier Universitaire de Nîmes, France

#### Reviewed by:

Mahesh Menon, University of British Columbia, Canada Sebastian Euler, UniversitätsSpital Zürich, Switzerland

\*Correspondence:

Nader Perroud<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Clinical and Health Psychology, a section of the journal Frontiers in Psychology

Received: 13 March 2018 Accepted: 03 December 2018 Published: 17 December 2018

#### Citation:

Prada P, Perroud N, Rüfenacht E and Nicastro R (2018) Strategies to Deal With Suicide and Non-suicidal Self-Injury in Borderline Personality Disorder, the Case of DBT. Front. Psychol. 9:2595. doi: 10.3389/fpsyg.2018.02595

**54**

dysregulation, poor impulse control and suicidal, and self-harm behaviors (Lieb et al., 2004; Leichsenring et al., 2011).

### NON-SUICIDAL SELF-INJURY AND SUICIDE

Non-suicidal self-injury (NSSI) and suicide are the treatment's primary targets. They are associated with a high rate of emergency care, hospital treatment and outpatient treatment (Crowell et al., 2009). In the past, self-harm was viewed as suicide equivalent, but clinicians have gradually started drawing purpose-based differences between these behaviors in order to provide specific therapeutic responses (Linehan et al., 1991).

Between 17 and 80% of BPD patients are prone to repeated NSSI (the most frequent being self-injury by cutting or burning), and for the same population, suicide attempts range from 46 to 92% (Zanarini et al., 2008). NSSI has a higher prevalence among adolescents and young adults, and is associated with an array of psychosocial issues and is believed to be a transdiagnostic manifestation arising from an underlying vulnerability inherent to the psychopathology (Crowell et al., 2009; Selby et al., 2015). NSSI differs from suicide in that it is not associated with suicidal inclinations: furthermore, the strategies implemented for behaviors aiming at regulating negative emotions are different from those used to manage behaviors aiming at causing death (Crowell and Kaufman, 2016). Unlike suicide, NSSI has an immediate and short-term impact, and must be carried out repeatedly to produce the desired outcome (Shaffer and Jacobson, 2009). Furthermore, patients who are disposed to NSSI generally resort to other methods when attempting suicide, a fact that suggests that suicide is not a severe manifestation of NSSI, and that NSSI does not amount to failed suicide (Stanley et al., 2001). However, NSSI and suicide are bound by a complex relationship, and it is often difficult to draw a clear distinction between both categories. Therefore, individuals do not always fit into one category or the other.  The presence of NSSI is the strongest predictor of future suicide attempts. Indeed, a study has shown that 70% of adolescents with NSSI report a suicide attempt in the course of their life (Nock et al., 2006).  Finally, it appears that NSSI has some protective value, as long as it provides relief from mental suffering during dissociative episodes (as a coping strategy) (Kliem et al., 2010).

Several theoretical elaborations have examined the passage from suicidal ideation to suicide. These "ideation to action theories," such as the interpersonal theory of suicide (IPTS) by Joiner, and the three-step theory (3ST) by Klonsky, highlight the role of pain, of hopelessness and of perceived interpersonal disconnection in the emergence of suicidal ideation. People who commit suicide differ from those who merely entertain suicidal thoughts by their capability for suicide. In particular, this capability is acquired through traumatic life experiences and NSSI (Klonsky et al., 2018).

Studies reveal that the efficacy of therapeutic interventions is improved when NSSI and suicide are considered globally and that the effect of therapies seems stronger on NSSI (Ougrin et al., 2015).

Dialectical behavior therapy has been shown to have a statistically significant effect on the reduction of personality disorder symptoms (Kliem et al., 2010; Cristea et al., 2017). For NSSI, a number needed to treat of 14 to prevent 1 incident is better than in other medical intervention (Ougrin et al., 2015). Patients receiving psychotherapeutic treatment are less likely to attempt suicide than patients receiving treatment as usual, in particular for those who suffer from BPD (Calati and Courtet, 2016).

## DIALECTICAL BEHAVIORAL THERAPY AND SUICIDE

Dialectical behavior therapy is a structured cognitive-behavioral treatment initially designed to treat chronically suicidal patients suffering from BPD. It is based on a biosocial theory of emotion dysregulation.  The term "dialectical" refers to a philosophy defining the nature of reality, and to persuasive dialog and relationship. Dialectics are at the heart of the therapy, from the very conceptualization of emotional dysregulation to the implementation of DBT core strategies. For instance, the balance between acceptance and change is crucial in DBT. Core strategies include change-oriented interventions like contingency management or cognitive restructuring and acceptance-orientated interventions including the practice of mindfulness. These skills are implemented in a constant effort to strike a dialectical balance between accepting the reality as it is, and changing behaviors that need to be changed. The four treatment modes of standard DBT described herein are as follows: individual therapy, group skills training, telephone coaching, and the therapist consultation team. Each plays a role in the therapy's main functions (Linehan et al., 1991, 2015), which are: (1) Improving the patient's skills, (2) Extending these skills to the environment, (3) Increasing and maintaining the patient's motivation to change, (4) Increasing the therapist's motivation and skills, and (5) Structuring the environment to optimize the implementation of the treatment.

Although treating NSSI is a priority in the hierarchy of therapeutic targets, it is not explicitly mentioned as one of the therapy's main functions. It is theorized that these behaviors are reduced or eliminated as a result of a range of factors, such as the acquisition of skills in various areas, and the acceptance of life's difficulties. In DBT, NSSI and suicidal behaviors are viewed as responses to unbearable emotional suffering, and though they may be dysfunctional, they are highly effective emotion regulation strategies. Indeed, they dramatically reduce

emotion intensity and immediately relieve from intense suffering. Besides, they can generate social consequences, such as obtaining more presence and help from the environment, or justifying a hospital admission. DBT aims to change dysfunctional patterns in emotion regulation, impulse control, identity and interpersonal relationships to construct a life worth living. Emotionally dysregulated patients are encouraged to change their maladaptive problem-solving strategies by learning skills to tolerate distress with more effective and adaptive means. Four skills modules are proposed: mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation.

Dialectical behavior therapy has been shown to be effective in terms of its therapeutic objectives: reducing NSSI and suicide, reducing therapy-interfering behaviors as well as behaviors interfering with the quality of life (Linehan et al., 1991, 2006; Bohus et al., 2004; Burmeister et al., 2014).

The fact that DBT relies on four treatment modes naturally gives rise to the question of the relative effectiveness of each component. The usefulness of individual and group therapy has been tested separately, without revealing any significant difference in terms of suicide attempts, NSSI occurrence, and the number of hospitalizations or emergency consultations. The superiority of the standard treatment appears to reside in increased patient retention rates – which is a feature of interest given that high dropout rates are one of the greater problems among this group of patients - but also in globally improved mental health (Linehan et al., 2015).

However, identifying the key factors driving the efficacy of DBT remains delicate, in particular as far as NSSI or suicide and change mechanisms are concerned (Calati and Courtet, 2016).

#### INDIVIDUAL THERAPY

Two important factors should be noted: The quality of the therapeutic alliance in DBT, and compliance with the target hierarchy in individual therapy.

In Dialectical behavior therapy, it is essential to establish a therapeutic alliance that combines warmth and structure (Robins and Koons, 2000). For patients, this is often the first positive experience of therapy. The demeanor, attitude and words of the therapist should be considered as therapeutic in themselves, as they encourage the creation of a relationship stemming from understanding, validation and trust, which in turn increases motivation and promotes therapeutic change. From the therapist's point of view, considering the BPD in a non-judgemental and empathic way is conducive to collaboration, despite difficult behaviors that can push the therapist to his or her limits. This kind of relationship helps increase patient retention rates (Linehan et al., 2015).

In a study pertaining to therapeutic alliances and introjection comparing DBT and community treatment by experts (Bedics et al., 2012), patients reported major improvements in terms of self-affirmation, self-love, self-protection, as well as fewer instances of self-attack, during the course of treatment and the 1-year follow-up period. The quality of the therapeutic alliance combines with the treatment itself to yield positive results. Patients undergoing DBT who perceived their therapist as self-assured and protective reported fewer cases of NSSI.

### NSSI AS PRIMARY TARGET

Dialectical behavior therapy individual therapists are responsible for the management of suicidal crises. For example, the therapist faced with a suicidal patient can refer to specific DBT strategies including the therapist survival protocol, which defines what to do when the patient is in crisis. The therapist has the responsibility to provide a clear and active response to prevent the patient from committing NSSI or suicide, for example by removing lethal means available to the patient. Mean restriction is a way to reduce the capacity to attempt suicide while teaching the patient to survive the crisis by tolerating acute distress using skills with the support of the therapist.

The structure of individual therapy also helps the therapist to target, directly and overtly, any change in the pattern of ideas and of speech, and any evolution of suicidal behaviors. The individual therapy schedule in DBT is set according to the hierarchy of targets established when the patient and therapist enter into a therapeutic alliance. It relates to specific behaviors that need to be reduced: (1) Life-threatening behaviors, (2) noncollaboration and non-participation behaviors or behaviors that threaten to interfere with the therapy or push the therapist to his/her limits, and (3) behaviors that interfere with the quality of life. Any recent NSSI is thereby systematically addressed as a priority by conducting a behavioral chain analysis. The aim of a chain analysis is to describe the chain of components leading to a specific behavior and to establish a plan for problem solving. It helps to understand what prompts and what maintains the behavior and to figure out what problems must be solved and which skills are missing to stop the behavior. The chain analysis provides information on what motivates NSSI or suicide and allows therapist and patient to figure out how to prevent these behaviors. Motivations for suicide are frequently related to acute emotional distress and hopelessness (internal motivations) or to a need to communicate and influence others (external motivations); internal motivations appear to be more strongly correlated to a desire to die and to a higher level of intent and preparation (Klonsky et al., 2016). The individual therapist has to focus on the patient's specific motivations for NSSI or suicide and reasons for living, and help him/her apply the needed skills to build a life worth living and reduce internal and external motivations for suicide.

### SKILLS TRAINING GROUPS

The goal of skills training is to teach the patient the general skills to help him/her solve problems in living. Skills training is probably a key element of DBT as it directly addresses behavioral,

cognitive, emotional, and interpersonal dysfunctional patterns which lead to NSSI and suicide. There are two acceptance skills modules (mindfulness and distress tolerance) and two change skills modules (emotion regulation and interpersonal effectiveness) that are balanced to address one of the major dialectics for the patient: to accept himself/herself and reality as it is, and to change what needs to be changed. Mindfulness skills teach to focus attention on the present moment and to observe reality as it is. It addresses patient's dysregulation of the sense of self and reduces the feeling of being disconnected from others. Distress tolerance skills address the ability to tolerate and survive crisis situations and to accept painful events or emotions, in order to reduce suffering. These skills are essential to avoid NSSI which are often related to overwhelming suffering. Interpersonal effectiveness skills help maintain and improve relationships, deal with conflict situations and obtain what the person needs while maintaining self-respect. These skills are necessary to solve interpersonal conflicts without having to rely on extreme and dysfunctional behaviors such as threats or verbal aggression. The goals of emotion regulation skills are to improve emotion observation and understanding and to reduce emotional vulnerability. The skills acquisition allows patients to achieve better emotional and behavioral control, which translates primarily into reduced NSSI and suicide (Neacsiu et al., 2010). Moreover, two studies showed that DBT with skills training is more efficient in reducing NSSI than DBT without skills training (Linehan et al., 2015; Euler et al., 2018).

Furthermore, by sharing personal experiences with others (during groups), bonds can be created, with the probable outcome of increasing the feeling of interconnectedness, in a context of reinforcement and non-judgement.

### TELEPHONE COACHING

In Dialectical behavior therapy, phone calls are encouraged for many reasons (Linehan, 1993). Firstly, BPD patients often have difficulties in asking for help and will rely on extreme behaviors, such as NSSI and suicide, to ask for help or to increase presence and support from the environment. Secondly, patients need help to implement and generalize skills acquired during group sessions into everyday life. The patient is encouraged to call before engaging in NSSI so that he or she may receive coaching and be reminded to use his or her skills. Telephone coaching is an essential prevention means as it focuses on NSSI and suicidal risk assessment and the use of alternative solutions to solve the problem. Phone calls are also an effective way of healing the therapeutic alliance and improving patient satisfaction and reducing the risk of therapy dropout (Chalker et al., 2015). It seems obvious that the availability of the therapist outside scheduled individual sessions helps develop a sense of security and connectedness for the patient, and probably for the therapist too. A study (Coyle et al., 2018) shows that visits to crisis centers were linked to suicide risks. DBT, with its telephone coaching mode and skills training, namely in terms of distress tolerance strategies, helps reduce dependence on these services, indirectly lowering the risk of suicide (Stanley et al., 2001).

### CONSULTATION TEAM

Dialectical behavior therapy assumes that an effective therapy should pay as much attention to the therapist as it does to the patient; that is why the consultation team is an integral component of DBT. Each DBT therapist must be part of a consultation team and attend weekly meetings. The consultation team is responsible for helping the therapist to stay motivated and within the DBT therapeutic frame, applying DBT strategies and techniques to maintain an effective therapeutic relation with the patients. The consultation team encourages adherence to DBT philosophy and allows therapists to consolidate their skills and receive support, strengthening the implementation of DBT in the care they provide, and within the treatment team. Therapists who treat BPD patients need this supervision because they are often reinforced by the patient in engaging in ineffective behaviors, while being punished when engaging in effective behaviors (Linehan, 1993). For example, the patient becomes very friendly when the therapist gives up the hierarchy of targets allowing him/her to avoid talking about a recent NSSI. Furthermore, progress is slow and the therapist can become vulnerable to criticism or discouragement. The consultation team refers to dialectics, uses encouragements, avoids judgment or team divide and searches for alternative solutions when needed. Regarding NSSI and suicide behaviors, therapists are often confronted with intense emotions and such extreme behaviors can generate a high level of stress. The consultation team plays an important role in helping therapists to observe their limits and avoid a burnout. A recent study on clinicians' experiences of the consultation team shows that the meetings help maintain the therapists' motivation (Walsh et al., 2018).

## DISCUSSION AND CONCLUSION

Despite mounting evidence of the positive impact of DBT in the treatment of BPD, the relative effects of specific therapeutic interventions on suicidal behaviors remain difficult to assess. It would appear that some components of DBT, such as skills training groups and individual therapy, have the same positive impact on NSSI (Linehan et al., 2015).

Suicide and NSSI are obviously targets of the therapy and elements that interfere with its prognosis and positive outcome.

Elements that have an impact on reducing NSSI and suicide among BPD patients are numerous and exist at different levels of DBT, in its range of targets, modes, strategies or types of therapeutic intervention, and in the consistency of the theoretical model and therapeutic structure. This is in keeping with various therapeutic models that have shown comparable efficacy, such as MBT, TFP and GPM, and that consider NSSI and suicide as priorities in their treatment structure, while maintaining the fundamental objective of improving quality of life (Keuroghlian et al., 2016).

Nevertheless, we still need to better understand which and how specific components of DBT reduce suicidal behaviors and for which patients. Further researches are clearly needed in this field.

#### PERSPECTIVES AND NEW ELEMENTS

Clinicians caring for patients exhibiting self-destructive behaviors are keenly interested in the use of new technologies. The advantage of such technologies is their immediate availability

#### REFERENCES

to patients. Smartphone applications have therefore been developed, either for the benefit of patients (Rizvi et al., 2011; Prada et al., 2017), or to help clinicians treating suicidal patients (Harned et al., 2017).

### AUTHOR CONTRIBUTIONS

PP, NP, ER, and RN participated in equally in designing the study, in writing the different sections of the paper, and in giving their final approval for the paper to be submitted.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2018 Prada, Perroud, Rüfenacht and Nicastro. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Viewpoint: Toward Involvement of Caregivers in Suicide Prevention Strategies; Ethical Issues and Perspectives

Valérie Le Moal 1 \*, Christophe Lemey 1,2, Michel Walter 1 and Sofian Berrouiguet 1

1 Brest Medical University Hospital at Bohars, Adult Psychiatry, Bohars, France, 2 IMT Atlantique, Lab-STICC, Brest, France

Keywords: suicide, attempted-caregiver, designated-ethics-responsibility-vulnerability, prevention strategies, ethical issues

### AIM

The aim of this article is to investigate the potential impacts implication of caregivers as a resource in care management of patients at risk of suicide.

## SUICIDE PREVENTION CHALLENGES

#### Edited by:

Jorge Lopez-Castroman, Centre Hospitalier Universitaire de Nîmes, France

#### Reviewed by:

Gianluca Serafini, Dipartimento di Neuroscienze e Organi di Senso, Ospedale San Martino (IRCCS), Italy

\*Correspondence:

Valérie Le Moal<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Clinical and Health Psychology, a section of the journal Frontiers in Psychology

Received: 15 May 2018 Accepted: 20 November 2018 Published: 18 December 2018

#### Citation:

Le Moal V, Lemey C, Walter M and Berrouiguet S (2018) Viewpoint: Toward Involvement of Caregivers in Suicide Prevention Strategies; Ethical Issues and Perspectives. Front. Psychol. 9:2457. doi: 10.3389/fpsyg.2018.02457 Suicide prevention research faces specific challenges related to characteristics of suicide attempts and attempters (Wasserman, 2004). Suicide attempters have been described as poorly adhering to intensive treatment over time, and delivery of interventions in the emergency department can be difficult, where psychiatric staff availability is often limited or absent. The post-discharge period constitutes a critical challenge for emergency and mental health care services both in the short and long terms (Hunt et al., 2009). Given these issues, there has been growing interest in assessing the efficacy of post discharge intervention after a suicide attempt. For example, brief contact interventions (BCIs) are low resources interventions seeking to maintain long-term contact with patients after a suicide attempt (Milner et al., 2015). These interventions intent to reinforce the health care networking around the patient but only rely on mental health and emergency services. Depression, drug misuse, family and social situations are well established suicide risk factors (Zalsman et al., 2016). Recent findings also showed the correlation between sleep disturbances and suicidality from a clinical point of view (Pompili et al., 2013). Including protective factors in suicide risk management might be of great interest. However, prevention strategies often exclude form the preventative procedure an essential preventative component of patients social network: the caregiver (Mann et al., 2005). Indeed, studies showed the potential positive impacts of caregivers in the management of important suicide risk factors as depression (Joling et al., 2012), and social isolation (Chatterjee et al., 2014).

### INVOLVING THE CAREGIVERS IN THE SUICIDE PREVENTION PROCESS

A caregiver, or carer, is an unpaid or paid member of a person's social network who helps them with activities of daily living. Caregiving is most commonly used to address impairments related to old age, disability, a disease, or a mental disorder (Berk et al., 2013).

Referred to as informal caregivers, caregivers provide a complex array of support tasks that extend across physical, psychological, spiritual, and emotional domains. Studies have shown that caregivers and close contacts are reliable sources of information about patients with psychiatric disorders. Caregivers do not exactly provide medical care, but can be considered as partners in the care as suggested by Fredman and Daly (Fredman and Daly, 1993). Traditional psychiatric assessment, however, does not always include information from caregivers due to time constraints, concerns about confidentiality and the risk of caregiver burden (Adelman et al., 2014). By excluding caregivers from assessments, clinicians may miss an opportunity to obtain additional valuable information about the illness course. Including caregivers in innovative prevention strategies could strongly improve the insight regarding patients' suicide risk situation.

Moreover, the involvement of the caregivers in a patient's assessment may facilitate the implementation of a step-bystep personalized prevention program during care transitions (e.g., hospital to home). This strategy may evolve into an all-embracing, tailored partnership involving healthcare professionals, patients, and their caregiver. Furthermore, the involvement of the caregivers means that they are able to play an important part in providing support and detecting warning signs when indicated. Caregivers are potential allies in the suicide prevention without, however, taking the place of healthcare professionals (Sun and Long, 2008).

## CAREGIVER INVOLVEMENT: OPPORTUNITIES AND ISSUES

Despite these promising opportunities, issues are raised regarding the assimilation of caregivers designated by patients at risk of suicide. Support for the patient on the part of his/her network in the vast majority of cases creates opportunities to relieve relatives of the strain of overwork. However, some studies have intended to involve the caregiver in a suicide prevention approach. For example, according to Sun et al., caregivers are able to play an important part in providing support and detecting warning signs and are potential allies in suicide prevention (Sun et al., 2009).

Family caregivers' suicide caring competence is important to prevent their relatives with suicidal tendencies from attempting suicide. Authors stated that clinicians and nurses are typically educated and trained to care for patients with suicidal tendencies, but family caregivers of suicidal individuals do not receive the same level of suicide care education. Family caregivers may lack competence to care for their relatives with suicidal ideations and/or behaviors. In this perspective, Sun et al. proposed an assessment of suicide caring competence which may help clinicians to assess the caring competence of family caregivers and provide proper suicide care education. In this perspective, caregiver could be involved systematically at the time of discharge of patients at suicide risk (Sun et al., 2014).

## REFERENCES

Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., and Lachs, M. S. (2014). Caregiver Burden. JAMA 311,1052–1060. doi: 10.1001/jama.2014.304

Caregivers and healthcare professionals should strive to create between themselves and with the suicidal patient a back-and-forth dynamic, wherein the risk of caregiver burden is a constant threat and urges caution on the part of all involved.

Tacitly taken for granted, the role of caregivers is at best reduced to that of auxiliaries, providing little more than emotional or material support to the patient, for whom they may as a last resort act as a spokesperson (Fredman and Daly, 1993). The patient will surely benefit from the implication of his/her caregiver in a preventative approach.

### TOWARD THE INVOLVEMENT OF CAREGIVERS IN SUICIDE PREVENTION STRATEGIES?

Few studies have emphasized the family caregivers of suicidal individuals. No study has explored the relationship between family caregivers' caring stress with suicidal attitudes and suicide care ability. What does the caregiver paper adds to existing knowledge (Chiang et al., 2015)? Caregivers may be the primary interface with the health care system often receive inadequate support from health professionals and frequently feel abandoned and unrecognized by the health care system.

Mental health clinicians could help caregivers become aware of the emotional pain that suicidal people experience and then promote their positive attitudes toward their suicidal relatives. Caregivers could increase their ability to care for their suicidal relatives, which could reduce the numbers of suicides. Caregivers naturally play an essential role in supporting the well-being and care of patient at risk of suicide. Clinicians should identify their patients' caregivers, inquire about their caregiving experience, and benefit from a caregiver assessment. They should engage caregivers as proactive partners in care based on the involvement they can handle and the help they may need. We advocate that, as other preventative interventions, the efficacy of the involvement of caregivers in a suicide prevention strategy should be assessed in further researches.

## AUTHOR CONTRIBUTIONS

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

## FUNDING

This study was funded by the Fondation de l'avenir.

Berk, L., Berk, M., Dodd, S., Kelly, C., Cvetkovski, S., and Jorm, A. F. (2013). Evaluation of the acceptability and usefulness of an information website for caregivers of people with bipolar disorder. BMC Med. BioMed. Central 11:162. doi: 10.1186/1741-7015-11-162

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2018 Le Moal, Lemey, Walter and Berrouiguet. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Psychosocial Suicide Prevention Interventions in the Elderly: A Mini-Review of the Literature

Patrizia Zeppegno1,2 \*, Eleonora Gattoni2 , Martina Mastrangelo3 , Carla Gramaglia1,2 and Marco Sarchiapone3,4 \*

1 Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy, 2 Institute of Psychiatry, University Hospital Maggiore della Carità, Novara, Italy, 3 Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy, 4 National Institute for Health, Migration and Poverty, Rome, Italy

In Europe the elderly population is projected to increase from 18.5% (93.9 million) in 2014 to 28.7% (149.1 million) by 2080. In the United States it is estimated that by 2030 more than 20% of the population will be aged 65 years or over. This specific population is at high risk of unrecognized or untreated psychiatric illnesses and suicide. It is well known that completed suicide rate increases with age in both men and women. Although elderly people attempt suicide less often than other age groups, they show a higher completion rate. Generally, the methods chosen by elderly are more lethal, the intent is more serious, they are more determined, and they show fewer warning signs than the younger population. A recent systematic review and meta-analysis of psychosocial intervention, following self-harm in adults, found that cognitive behavioral therapy was the most effective therapy in these patients. Unfortunately, there have been few reported trials of other potentially effective interventions. Because the scientific literature on psychosocial suicide prevention interventions in the elderly is still scant, we conducted a mini-review in order to take stock of the situation. Studies were identified through electronic searches of the Cochrane library, MEDLINE, Scopus and the Web of Science databases. PRISMA guidelines were followed and only seven articles met the inclusion criteria. No firm conclusions can be drawn about this topic because there is still very little data and studies use inconsistent outcome measures and designs. Nonetheless, the existing data suggests that psychosocial interventions are promising.

#### Keywords: suicide, attempted suicide, elderly, psychosocial intervention, mini-review

## INTRODUCTION

According to the World Health Organisation's (WHO) estimates, 800,000 people die from suicide every year (WHO, 2017). Although in some countries the suicide rate is higher amongst the young (15–29 years old), generally people aged 70 years and over have the highest suicide rate. When it comes to gender differences, men over 50 years old are particularly at risk and women 70 years old and over are twice as likely to die through suicide than younger (15–29 years old) women (Pearson and Conwell, 1995; WHO, 2014).

In Europe the elderly population is projected to increase from 18.5% (93.9 million) in 2014 to 28.7% (149.1 million) of the population by 2080 [Eurostat (n.d.)] and it is estimated that by 2030 more than 20% of the United States population will be aged 65 years or over. The elderly population is at a high risk of unrecognized or untreated psychiatric illnesses and suicide. In 2012 there was about one elderly suicide every 80 min in the United States (Ortman et al., 2014).

#### Edited by:

Jorge Lopez-Castroman, Centre Hospitalier Universitaire de Nîmes, France

#### Reviewed by:

Federica Sancassiani, Università degli Studi di Cagliari, Italy Brooke Schneider, University Medical Center Hamburg-Eppendorf, Germany

#### \*Correspondence:

Patrizia Zeppegno<EMAIL_ADDRESS>Marco Sarchiapone<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Clinical and Health Psychology, a section of the journal Frontiers in Psychology

Received: 15 March 2018 Accepted: 17 December 2018 Published: 09 January 2019

#### Citation:

Zeppegno P, Gattoni E, Mastrangelo M, Gramaglia C and Sarchiapone M (2019) Psychosocial Suicide Prevention Interventions in the Elderly: A Mini-Review of the Literature. Front. Psychol. 9:2713. doi: 10.3389/fpsyg.2018.02713

**63**

It is widely acknowledged that compared to other age groups, attempted suicide is less common in the elderly, whereas completed suicide is more common, probably due to the choice of more lethal means (McIntosh, 1994). Moreover, it is noticeable that intention to die tends to be greater in elderly suicide cases and elderly people usually show fewer warning signs than the younger population (Bennett and Collins, 2001). Risk factors underlying elderly suicidal behavior include: psychiatric illness (particularly affective disorders), recent loss, alcohol abuse, social isolation, perceived meaning of physical illness (pain, impact on global function), family discord, retirement, cognitive deficits, and institutionalization (Linden and Barnow, 1997; Conwell et al., 2002; Duberstein et al., 2004; Dombrovski et al., 2008).

Given this pattern of risk factors, prevention and intervention strategies targeting the specific needs of the elderly population are recommended. The current global trend in aging means it is necessary to deal with the peculiarities and specific needs of the elderly population and to plan ad hoc structured interventions aimed at reducing their suicide risk. Age-sensitive interventions (including psychiatric treatment if necessary), focused on physical health perception and facilitating adjustment to change, may be helpful in reducing elderly suicide risk (Crandall et al., 2007). Psychosocial interventions could be useful, including traditional psychotherapy interventions, as well as self-help groups, case management strategies and psychosocial rehabilitation techniques.

A recent systematic review and meta-analysis of psychosocial interventions following self-harm in adults, suggested that cognitive behavioral therapy is the most effective approach in these patients (Hawton et al., 2016). Unfortunately, there is a dearth of literature on psychosocial interventions focused on suicide prevention in the elderly.

Our aim was therefore to perform a mini-review of the literature on suicide prevention in the elderly, using the search string shown in **Appendix 1**.

### MATERIALS AND METHODS

#### Selection of Studies

The inclusion criterions were:

Exclusion criteria were:

### Data Sources and Search Strategy

Four electronic databases (PubMed, Scopus, Cochrane Library, and the Web of Science) were searched from their inception up to 31st January 2018, with the search strings reported in **Appendix 1**. Articles were selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2015; Shamseer et al., 2015).

Two reviewers (EG and MM) independently selected titles, abstracts and full-text publications using the inclusion and exclusion criteria specified above. Disagreements were resolved through discussion with a third reviewer (CG).

We extracted the following information from all publications: country, design, characteristics of study participants, characteristics of the psychosocial interventions described, and a summary of the main study findings which focused on suicide. Ethical statements were not provided in the studies included.

### RESULTS

The search retrieved 144 articles; 127 articles remained after duplicates were removed. Twelve articles were excluded because they were not written in English, 23 were excluded based on the title (not relevant to the topic) and six were excluded due to the type of publication (reviews and meta-analyses). A further 68 articles were excluded based on the abstract (not relevant) and one full text article was not available. Most of the articles which were excluded were not focused on the selected study population (elderly population), on the selected intervention (psychosocial intervention) or on the intervention target (suicide prevention). Three eligible articles were identified through the database search and four from other sources, thus seven articles were included in this mini-review. The PRISMA flowchart is shown in **Figure 1**.

One of the selected articles (Bruce and Pearson, 1999) described the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), a study involving 18 primary care practices that aimed to promote the recognition and treatment of depression and identifying depression as one of the most important risk factors for suicide behaviors in the elderly population. PROSPECT implemented procedures designed to facilitate the use of an algorithm for detecting and treating depression. The PROSPECT algorithm recommended antidepressant pharmacotherapy as the first-line intervention and psychotherapy – in particular interpersonal therapy – as the second-line treatment. At each step the physician could request a psychiatric consultation or refer the patient to a specialist. The PROSPECT intervention added a mental health specialist to the primary care setting. The role of these specialists was to obtain information from patients that would help physicians recognize depression, to offer recommendations and to help educate patients, families and physicians about depression and suicidal ideation. The patients involved were >60 years old, cognitively intact and not institutionalized. Telephone screening for depression was carried out using the Center for Epidemiologic Studies Depression (CESD) scale. People identified with having depression and a small percentage of patients without depression were recruited and invited to a face-to-face interview, to assess depression and other clinical, neuropsychological and social variables necessary for the evaluation of depression and suicide

risk. After the assessment the patient's chart was reviewed by a mental health specialist, who then contacted the physician with recommendations after which intervention procedures started. Recruited patients were contacted again by telephone 4 and 8 months later, in order to assess depressive symptoms, suicide ideation and use of health care services.

In a later article, Bruce et al. (2004) compared the method described above with usual care. Patients who received the PROSPECT intervention showed a greater decrease in depressive symptoms than those who received the usual care (p < 0.001). Moreover, a faster reduction in suicidal ideation rate was observed in the PROSPECT group (p = 0.01).

Another article (Fiske and Arbore, 2001) evaluated a geriatric outreach program for older people potentially at risk of suicide. The intervention group comprised of 148 elderly people (M = 76.9 years, SD = 9.0) and the control group of 70 individuals (mean age ± SD, 73.6 ± 7.9). The program consisted of scheduled calls that included well-being checks and emotional support, and weekly home counseling visits. Participants also had access to a 24 h telephone hotline. Suicide risk was evaluated by asking participants about their current and prior suicidal behavior (e.g., "Have you ever thought of killing yourself?", "Have you ever tried to kill yourself?", "Are you feeling suicidal now?"), 42% of the intervention group had a lifetime history of suicidal thoughts and 14% had attempted suicide previously; in the control group the corresponding percentages were 30 and 7%. Participants who reported a history of suicidal thoughts were more likely to have a high level of depressive

symptoms (measured with the short form of the Geriatric Depression Scale; p < 0.01) and a high level of hopelessness (measured with the Geriatric Hopelessness Scale; p < 0.01). The 218 participants were contacted for another interview after 1 year. The results showed that after the intervention, the intervention group showed a reduction in hopelessness levels, which may indicate a reduction in suicide risk given that numerous studies have shown a link between hopelessness and suicidality.

Heisel et al. (2009, 2015) conducted a pre- to posttreatment psychotherapy trial involving 17 older patients (M age = 70.1 years, SD = 5.4) who were assessed for multiple late-life suicide risk factors using specific tests. Suicidal ideation was evaluated with the Geriatric Scale for Suicide Ideation (GSIS). Participants were offered a course of 16 weekly 50 to 60-min sessions of outpatient interpersonal psychotherapy, tailored to older adults at risk for suicide. Participants were helped to identify the factors that were contributing to their psychological pain and to alleviate feelings of desperation, which are common amongst depressed older patients, and opportunities to enhance social connections were identified. In the later phase of treatment, patients were encouraged to continue to develop interpersonal relationships and meaningful post-therapy pursuits. Participants, when they wished, were allowed to continue with therapy after the 16 scheduled sessions. A safety protocol was implemented to try to prevent potentially dangerous situations; this provided suggestions for family members or caregivers of the participants and 24/7 mobile phone access to the study therapist in case of emergency. The intervention produced reductions in suicide ideation (p = 0.003) and severity of depression symptoms (p = 0.001) whilst social adjustment, enjoyment of social and leisure activities increased (p = 0.001).