Madelyn S. Gould

Universal interventions are essential to reduce suicide rates. This study describes a hybrid effectiveness-implementation cluster RCT of Sources of Strength, a program that prepares diverse student peer leaders to disseminate a healthy coping framework. Forty predominantly small-town and rural high schools (four serving American Indian Nations and federal reservations) were randomized to Sources of Strength for 2 years or wait-list. Of 21,053 students, 17,280 participated in ≥ 1 of four waves. Students reported on suicide attempts and theory-informed mediators. Sources of Strength did not reduce suicide attempts overall, and impact differed by implementation quality and grade. Sources of Strength increased communication and help-seeking from adults in year 1, with findings supporting an indirect program effect reducing suicide attempts through increased adult help with emotions. However, declining implementation adherence in year 2, particularly in messaging activities, coincided with loss of impact. Program benefits were not found for 9th graders. In schools with poor adherence including deviation from peer leader selection guidelines, 9th graders showed increased new suicide attempts vs. controls. From this and other trials combined—including a recent trial showing program impact reducing suicide attempts among 9th–11th graders—we conclude that Sources of Strength implemented with strong adherence can reduce suicide attempts through its theoretical pathway of increased protective adult relationships. However, implementation drift eliminates those benefits. Poor adherence to messaging and peer leader selection may accelerate negative peer influences and increase risk particularly for younger students. Findings underscore the critical importance of maintaining fidelity in peer-based prevention programs. Trial registration at ClinicalTrials.gov #NCT02043093, 01/23/2014.

Introduction: With the 988 Suicide and Crisis Lifeline's expanding role in the crisis care continuum in the U.S., assessments of its effectiveness are more important than ever. The current study estimated the extent to which suicidal Lifeline callers perceived their crisis calls as helping them and stopping them from killing themselves, whether their suicidal thoughts recurred after the call, and the caller characteristics and counselor practices associated with these outcomes.Methods: Telephone interviews were conducted with 437 adult suicidal callers to 12 Lifeline crisis centers between April 15, 2020 and August 15, 2021. The interview collected callers' demographic and clinical characteristics and their perceptions of counselor practices and call outcomes. A series of logistic regression analyses assessed the association of caller characteristics and counselor practices with call outcomes.Results: The vast majority of suicidal Lifeline callers thought their crisis call helped them (nearly 98%) and stopped them from killing themselves (88.1%). Callers' perceptions of counselor behaviors in the domains of fostering engagement/connection, collaborative problem‐solving, and safety assessment/management were strongly associated with callers' perceived effectiveness of the crisis call.Conclusions: Our study offers empirical evidence for the effectiveness of the Lifeline's (now 988 Lifeline's) telephone crisis services from the caller's perspective.

We appreciate Reierson’s thoughtful commentary on our 2019 paper, which described our experiences, ethical process, judgment calls, and lessons from a 2016-2017 data-sharing pilot between Crisis Text Line and academic researchers. The commentary raises important questions about the ethical conduct of health research in the digital age, particularly regarding informed consent, potential conflicts of interest, and the protection of vulnerable populations. Our article focused specifically on the noncommercial use of Crisis Text Line data for research purposes, so we restrict our reply to points relevant to such usage. While we acknowledge the limitations of Crisis Text Line’s Terms of Service as a means of informing users about data sharing for research, we maintain that our guidelines were ethically sound and aligned with well-established practices for institutional review board (IRB) review and researcher training. We emphasize the critical role of IRBs in ensuring that research involving vulnerable populations, including minors, is conducted ethically and with appropriate safeguards. Regarding potential conflicts of interest, we argue that unpaid, nonfiduciary advisory board service for a nonprofit organization does not constitute a conflict requiring disclosure. The transparent nature of our collaboration with Crisis Text Line, as evidenced by the authorship and acknowledgments in our paper, further underscores our commitment to ethical research practices. We recognize the complexity and evolving nature of the challenges surrounding data-sharing partnerships in digital health research. As the field progresses, we remain committed to ongoing, transparent engagement and to refining best practices in collaboration with colleagues, stakeholders, and the public. Our response aims to provide clarity and context for the concerns raised in the commentary while reaffirming the integrity and value of our original work. Ultimately, we maintain that our paper contributed meaningfully to the ongoing discourse on ethical data sharing and laid the groundwork for future improvements in this critical area of digital health research.

Searches for “pro-suicide” websites in the United States peaked during the week a high-profile news story was published and remained elevated for 6 months afterward, highlighting the need to avoid mentioning specific sources of explicit suicide instructions in media publications.

Background: Between April 7 and 14, 2019, the “Breaking the Silence” media engagement campaign was launched in Oregon. Aims: We aimed to assess the consistency of media content related to the campaign with media guidelines and the quantitative footprint on Twitter (now X) over time. Method: Media items related to the campaign were analyzed regarding focus and consistency with media guidelines for suicide reporting and compared with other suicide-related reports published in the same time frame, as well as with reporting in Washington, the control region. Tweets related to the campaign were retrieved to assess the social media footprint. Results: There were n = 104 media items in the campaign month, mainly in the campaign week. Items typically used a narrative featuring suicide advocacy or policy/prevention programs. As compared to other items with a similar focus, they scored better on several protective characteristics listed in media recommendations. Stories of coping with adversity, however, were scarce. The social media footprint on Twitter was small. Limitations: Inability to make causal claims about campaign impact. Conclusion: Media items from the Breaking the Silence campaign appeared mainly consistent with media guidelines, but some aspects, such as stories of recovery, were under-represented.

Teen-to-teen (t2t) crisis lines are a special type of crisis service where youth volunteers help their peers. Although prior research has examined the experience of adult crisis line responders, no research has examined the experience of adolescents who do this work. In collaboration with two of the largest t2t lines in the U.S., this pilot study is the first examination of t2t crisis line work. Volunteers (ages 14–20) reported: their primary motivation for joining the crisis lines was to help others and give back to the community; responding to a range of peers’ problems on the t2t crisis line, including high-risk suicide contacts; and a range of ways the crisis line work impacted their lives. Findings provide preliminary information about the experience of adolescents engaging in t2t crisis line work. Additional research is needed in larger and more diverse samples to understand the impact of crisis line work for youth.

UNSTRUCTURED We appreciate Reierson’s thoughtful commentary on our 2019 paper, which described our experiences, ethical process, judgment calls, and lessons from a 2016-2017 data-sharing pilot between Crisis Text Line and academic researchers. The commentary raises important questions about the ethical conduct of health research in the digital age, particularly regarding informed consent, potential conflicts of interest, and the protection of vulnerable populations. Our article focused specifically on the noncommercial use of Crisis Text Line data for research purposes, so we restrict our reply to points relevant to such usage. While we acknowledge the limitations of Crisis Text Line’s Terms of Service as a means of informing users about data sharing for research, we maintain that our guidelines were ethically sound and aligned with well-established practices for institutional review board (IRB) review and researcher training. We emphasize the critical role of IRBs in ensuring that research involving vulnerable populations, including minors, is conducted ethically and with appropriate safeguards. Regarding potential conflicts of interest, we argue that unpaid, nonfiduciary advisory board service for a nonprofit organization does not constitute a conflict requiring disclosure. The transparent nature of our collaboration with Crisis Text Line, as evidenced by the authorship and acknowledgments in our paper, further underscores our commitment to ethical research practices. We recognize the complexity and evolving nature of the challenges surrounding data-sharing partnerships in digital health research. As the field progresses, we remain committed to ongoing, transparent engagement and to refining best practices in collaboration with colleagues, stakeholders, and the public. Our response aims to provide clarity and context for the concerns raised in the commentary while reaffirming the integrity and value of our original work. Ultimately, we maintain that our paper contributed meaningfully to the ongoing discourse on ethical data sharing and laid the groundwork for future improvements in this critical area of digital health research.

Introduction: Research has established that suicide‐related media can impact suicide rates both positively and negatively, supporting efforts to engage the media in the service of suicide prevention. The goal of the current study is to evaluate the impact of a suicide prevention media campaign implemented April 7–14, 2019 in Oregon.Methods: Several indices of help‐seeking behavior and suicide risk were employed: suicide‐related Google Health API searches, National Suicide Prevention Lifeline (Lifeline) (currently known as the 988 Suicide and Crisis Lifeline) call volume, and state suicide mortality data from April 7, 2016—May 6, 2019. Eight states with similar 2016–2018 average suicide rates were compared with Oregon. Bayesian structural time‐series modeling in R was used to test intervention effects.Results: During the 30 days following the start of the campaign, there was a significant increase in Lifeline calls from Oregon area codes (2488 observed vs. 2283 expected calls, p = 0.03). There were no significant changes in suicide mortality or suicide‐related Google searches in Oregon.Conclusions: The campaign appeared to increase help‐seeking behavior in the form of Lifeline calls, without any indication of an iatrogenic suicide contagion effect. However, the campaign's potential to reduce suicide mortality was unmet.

Suicide rates in the United States have increased over the past 15 years, with substantial geographic variation in these increases; yet there have been few attempts to cluster counties by the magnitude of suicide rate changes according to intercept and slope or to identify the economic precursors of increases. We used vital statistics data and growth mixture models to identify clusters of counties by their magnitude of suicide growth from 2008 to 2020 and examined associations with county economic and labor indices. Our models identified 5 clusters, each differentiated by intercept and slope magnitude, with the highest-rate cluster (4% of counties) being observed mainly in sparsely populated areas in the West and Alaska, starting the time series at 25.4 suicides per 100,000 population, and exhibiting the steepest increase in slope (0.69/100,000/year). There was no cluster for which the suicide rate was stable or declining. Counties in the highest-rate cluster were more likely to have agricultural and service economies and less likely to have urban professional economies. Given the increased burden of suicide, with no clusters of counties improving over time, additional policy and prevention efforts are needed, particularly targeted at rural areas in the West.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: The rate of suicide death has been increasing, making understanding risk factors of growing importance. While exposure to explicit suicide-related media, such as description of means in news reports or sensationalized fictional portrayal, is known to increase population suicide rates, it is not known whether pro-suicide website forums, which often promote or facilitate information about fatal suicide means, are related to change in suicide deaths overall or by specific means. Objective: The present study aimed to estimate the association of the frequency of Google searches of known pro-suicide web forums and content with death by suicide over time in the US, by age, sex, and means of death. Methods: National monthly Google search data for names of common pro-suicide websites between January 2010 and December 2021 were extracted from Google Health Trends API. Suicide deaths were identified using the CDC National Vital Statistics System (NVSS), and three primary means of death were identified (poisoning, suffocation, and firearm). Distributed lag non-linear models (DLNMs) were then used to estimate the lagged association between the number of Google searches on suicide mortality, stratified by age, sex, and means, and adjusted for month. Sensitivity analyses, including using ARIMA modelling approaches, were also conducted. Results: Months in the US in which search rates for pro-suicide websites increased had more documented deaths by intentional poisoning and suffocation, among both adolescents and adults. For example, the risk of poisoning suicide among youth and young adults (age 10-24) was 1.79 (95% CI 1.06, 3.03) times higher in months with 22 searches per 10 million as compared to 0 searches. The risk of poisoning suicide among adults aged 25-64 was 1.10 (95% CI 1.03, 1.16) times higher one month after searches reached 9 per 10 million compared with zero searches. We also observed that increased search rates were associated with fewer youth suicide deaths by firearm with a three-month time lag for adolescents. These models were robust to sensitivity tests. Conclusions: Although more analysis is needed, the findings are suggestive of an association between increased pro-suicide website access and increased suicide deaths, specifically deaths by poisoning and suffocation. These findings emphasize the need to further investigate sites containing potentially dangerous information and their associations with deaths by suicide, as they may affect vulnerable individuals.