Matthew J. Spittal

Introduction: Suicide‐related content online may contribute to social transmission of suicide‐related behaviors and interventions designed to improve communication safety may reduce risk and increase help‐seeking in young people. Methods: We conducted a randomized controlled trial (RCT) evaluating the #chatsafe intervention among young people aged 16–25 years. Participants were randomly assigned (1:1) to the #chatsafe intervention or the PROSPEct sexual health intervention (control), each comprising 24 pieces of social media content delivered over 8 weeks. Outcomes were measured at three timepoints and the primary outcome was change in safety when communicating online about suicide. Results: Nine hundred and six participants were included (453 per arm). Post‐intervention, mean safety scores changed by 0.04 in the #chatsafe arm and −0.23 in the control arm. The primary analysis showed a non‐significant mean difference of 0.27 (95% CI 0.00–0.54, p = 0.051). No significant between‐arm difference was observed at 4 weeks post‐intervention. Significant improvements were evident in secondary outcomes for confidence in safe online communication and willingness to intervene in the #chatsafe arm. Conclusions: This first RCT of #chatsafe demonstrates that social media can be used safely and acceptably to improve young people's confidence and willingness to intervene against suicide online, pointing to a potential scalable, under‐utilized lever in suicide prevention. Trial Registration: Australian New Zealand Clinical Trials Registry ( www.anzctr.org.au ) Identifier: ACTRN12622001397707

Purpose: The evidence on ethnic variation in self-harm risk is growing. This systematic review is the first to synthesise the global epidemiological evidence on absolute and relative rates of self-harm in individuals from ethnic minority backgrounds (including migrant and Indigenous populations). Methods: We identified empirical evidence through database searches (Medline, Embase, and PsycINFO published between 01/01/2000-19/12/2023). Studies were included if they reported absolute and/or relative rates of non-fatal self-harm in general population samples from ethnic minority groups. Lifetime self-harm was excluded. Due to limitations in the available data by country, we present a narrative synthesis and forest plots of the rates only. Synthesis was further stratified by sex, migration status, and self-harm method (where possible). Quality assessment was conducted using modified Newcastle Ottawa Scales. PROSPERO: CRD42021248646. Results: We included 36 studies from 14 countries. Seven (19%) were of reasonable quality. Most were conducted in North America (15/36; 42%) and/or in high-income countries (33/36; 92%). Self-harm risk was elevated amongst certain Indigenous and migrant groups, though there was not always statistical evidence of elevated rates compared to the majority population. High heterogeneity was present. Conclusion: The available evidence was of low quality and heterogeneous, indicating a need for improved reporting of self-harm by ethnicity and nuanced understanding of intersecting factors such as place of birth and migratory status. Appropriate surveillance, particularly in South America and Africa, is required to better understand international variations in self-harm prevalence for ethnic minority groups and inform population health suicide prevention.

Background: The cost-of-living crisis may be contributing to suicide rates, but this has not been adequately tested. Aims: We aimed to determine whether the cost-of-living crisis is associated with suicide rates in multiple countries and areas-within-countries. Method: We sourced country- and area-within-country-level monthly suicide data at a minimum from January 1, 2019, to December 31, 2022 (and at a maximum from January 1, 2016, to June 30, 2023), and population denominator and monthly headline consumer price index (CPI) data. We calculated the yearly change in inflation as the percentage change in CPI for one month versus the equivalent month in the previous year. We estimated associations between yearly change in inflation (lagged by one month) and suicide rates for each country and area-within-country, using autoregressive negative binomial regression. We summarized results using weighted means. Results: We obtained data on 1,372,994 suicides from 54 countries. At the country-level, for every 1.0% increase in yearly inflation in the previous month, there was an average 0.2% increase in suicide rates. The association was strongest in those aged 30–49 and 50–69; for every 1.0% increase in yearly inflation in the previous month, there were 0.3% and 0.6% increases in suicide rates for these age-groups, respectively. This pattern held for males in these age-groups, with increases of the same magnitude, and for females aged 50–69, with a 0.8% increase. At the area-within-country-level, the picture was even starker. Limitations: Study limitations include: the ecological design; the single measure of inflation; potential variations in suicide data quality; lack of representation by low-and-middle-income countries (LMICS); lack of availability of sex, age and sex/age breakdowns for some countries and areas-within-countries; and potential issues with multiple testing. Conclusions: There is an association between the cost-of-living crisis and suicide rates internationally. Public and social policies that improve people’s circumstances are critical.

Background: Mental Health Online, MindSpot, and THIS WAY UP are 3 Australian Government–funded digital mental health services (DMHSs). These services are free for consumers and deliver a range of (depression and anxiety disorder) psychological assessments and interventions using the internet, with or without clinician support. Objective: This study examines the uptake and effectiveness of these services. Methods: We used 3 data sources to examine the performance of the three DMHSs: (1) aggregated routinely collected service data to describe uptake of the services from January 2013 to December 2021, (2) peer-reviewed and gray literature reporting treatment outcomes, and (3) treatment outcome data from one evaluation conducted by Mental Health Online. The second and third data sources were used to analyze the effectiveness of the DMHSs compared to other mental health treatment programs (Australian primary, public, and low-intensity mental health care; UK stepped psychological care). We generated pooled mental health symptom (Cohen d ) effect sizes for each service’s clinician-supported and self-directed treatments and compared those with effect sizes we calculated for the alternative treatment programs. Results: The 3 DMHSs offered care to more than 282,000 consumers and therefore contributed to improving overall access to mental health care in Australia. Clinician-supported online treatment significantly improved the mental health of consumers who use these services (Mental Health Online, Cohen d =0.95; MindSpot, Cohen d =1.42; and THIS WAY UP, Cohen d =1.04), and self-directed treatment by Mental Health Online produced a moderate reduction (Cohen d =0.59) in anxiety disorder severity ratings. Clinician-supported treatments produced improvements in mental health symptoms that are close or equivalent to most (face-to-face, phone, and stepped or symptom severity–matched mental health care) comparison treatments examined. Conclusions: Mental Health Online, MindSpot, and THIS WAY UP are producing clinically significant improvement for consumers experiencing psychological distress and anxiety and depression symptoms. The magnitude of improvement produced by clinician-supported treatment is comparable with more resource-intensive face-to-face treatment options. Heterogeneity in the magnitude of improvements produced by the 3 DMHSs (and comparator interventions across levels of clinical need) indicates that findings should be interpreted with caution, particularly in relation to the populations for whom DMHSs may be most appropriate.

Background: Responsible media reporting of suicide is a population-level suicide prevention intervention, yet there is no experimental evidence from low-income settings. Aims: We assessed the effects of exposure to educative suicide prevention content and stories of surviving a suicide crisis in the print media on reducing suicidality in India. Method: A three-arm randomised controlled trial (Clinical Trials Registry of India, ref: CTRI/2022/09/045439) was conducted in Chennai, India, between August 2023 and March 2024. Participants were young adults (18–29 years), recruited through social media advertisements, randomised 1:1:1 to a control group and two intervention groups. Data were analysed during June–September 2024. All three groups were exposed to three 600-word purpose-designed Tamil-language print media articles on digital tablets. Intervention group 1 was exposed to three print media articles containing educative suicide prevention content. The same articles given to intervention group 2 were modified to contain brief accounts of young adults who had coped with experiences of suicidal ideation. The control group was exposed to three print media articles on diabetes. Suicidal ideation was measured using the 23-item Survival and Coping Beliefs subscale of the Reasons for Living Scale at baseline, post-test and 14-day follow-up. Results: Of 375 participants, randomisation resulted in 125 being assigned to the control group and 124 and 126 to intervention groups 1 and 2, respectively; 16 were lost to follow-up. At post-test, participants randomised to intervention group 1 demonstrated small improvements in suicidal ideation at post-test (standardised mean difference (SMD) = 0.15, p = 0.019) and follow-up (SMD = 0.17, p = 0.038). Larger effects were observed among participants with greater vulnerability (post-test, SMD = 0.25, p = 0.039; follow-up, SMD = 0.32, p = 0.023). There were no improvements in suicidal ideation in intervention group 2 at post-test, yet a marginal (SMD = 0.16, p = 0.053) effect was observed at follow-up. Conclusions: Exposure to educative print media articles can result in small improvements in suicidal ideation that would represent a substantial population-level impact.

Aims: Fixed phone boxes enabling calls to a suicide crisis line have been established at a number of public sites where suicides occur. However, the evidence for the effectiveness of this intervention on suicide deaths is not well established. This study examined the effectiveness of fixed phone boxes by comparing suicide rates during the pre-intervention and post-intervention periods. Methods: Using suicide mortality data from three sites in Australia and three sites in the United States, Poisson regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (95% CI) at each site. Pooled IRR (pIRR) was then calculated for all sites using a random-effects meta-analysis. Results: IRRs and 95% CIs at each site were: Australian sites A: 1.32 (0.94–1.85); B: 2.45 (1.52–3.94); C: 0.32 (0.08–1.33); United States sites D: 3.28 (1.46–7.35); E: 0.57 (0.17–1.95); F: 1.65 (0.45–6.10). The pooled IRR was 1.46 (0.86–2.49). Between-site heterogeneity was large, I ² = 66.5%. Conclusions: Contrary to general expectation, these findings indicate that fixed phone boxes do not reliably reduce suicide mortality, with two sites even showing increased rates after installation. Their impact appears highly inconsistent across locations, providing no consistent evidence of benefit. This suggests that additional or alternative interventions are necessary to achieve meaningful reductions in suicide mortality at high-risk locations.

Background: Suicide-related media reporting can influence suicidal thoughts and behaviors. Stories describing suicide methods can increase suicides (Werther effect), whereas those highlighting coping with suicidal crises can prevent them (Papageno effect). Aims: To assess the impact of media guidelines for suicide reporting on reporting quality and suicides. Method: Following PRISMA guidelines, we searched PubMed, Scopus, Embase, PsycInfo, and Web of Science up to February 10, 2025, with an update on November 17, 2025. We included ecological pre–post studies assessing changes in reporting quality and time-series analyses assessing changes in suicides after guideline release. Random-effects meta-analyses estimated pooled risk ratios (RRs) for reporting quality and incidence rate ratios (IRRs) for suicides. Results: Fifteen studies from 11 countries (2003–2025) were included (14 on reporting quality, three on suicides, two measuring both). Following guideline release, reporting quality improved for “Do educate the public about the facts of suicide and suicide prevention based on accurate information” (k = 13, RR = 1.56, 95% CI = 1.30, −1.88), “Don’t describe the method used” (k = 12, RR = 1.33, 95% CI = 1.15, −1.53), and “Don’t oversimplify the reason for a suicide or reduce it to a single factor” (k = 0, RR = 1.16, 95% CI = 1.02, −1.33). For other recommendations, pooled estimates generally favored the guidelines but were often imprecise, and in some cases, had substantial heterogeneity. We could not draw firm conclusions on their impact on suicides as only three studies assessed this outcome. Contour-enhanced funnel plots and Egger’s tests suggested possible small-study effects for some recommendations. Limitations: All included studies included ecological before-and-after designs. Implementation strength was inconsistently reported, preventing analysis of its influence. Conclusions: Media guidelines appear to improve several aspects of reporting quality. Although evidence for impact on suicides is limited, guidelines are unlikely to cause any harm and may confer benefits through improved reporting standards. Further research is urgently needed to quantify their impact on suicides.

Objective: This study examined the effectiveness of the Better Access initiative using outcome data from real-world practice settings. Methods: We used anonymised data from four datasets to assess outcomes for consumers over 86,121 episodes of care. The datasets contained routinely captured episode-level data from the practices of psychologists and other eligible Better Access providers. Across the datasets, outcomes were assessed on 11 different measures (mostly consumer-rated measures of depression and anxiety symptoms, psychological distress, functioning and wellbeing). We conducted purpose-designed analyses with three of the datasets (83,346 episodes), examining score changes on given measures between the first and last assessment occasion within an episode. We used preexisting outputs for the fourth dataset (2775 episodes), again considering change from the beginning to the end of the episode. Results: In the purpose-designed analyses, consumers’ mental health improved in around 50–60% of episodes. However, consumers showed no change or experienced deterioration in their mental health in 20–30% and 10–20% of episodes, respectively. Those with more severe baseline scores had a greater probability of showing improvement. The preexisting outputs also identified significant improvements, particularly in episodes where treatment was complete. Conclusion: Better Access is achieving reductions in symptoms and improvements in functioning and wellbeing for the majority of consumers. A minority of consumers do not have these sorts of positive outcomes, however, and further work is required to understand why. Routine measurement of outcomes – particularly consumer-rated outcomes – would enable ongoing monitoring of the extent to which Better Access is achieving its goals.

Objective: We sought consumers’ views about Better Access, which funds sessions of care with eligible providers via the Medicare Benefits Schedule (MBS). Methods: We surveyed a stratified random sample of consumers who saw a clinical psychologist, psychologist, social worker or occupational therapist (OT) via Better Access during 2021. The survey focussed on consumers’ experiences with receiving treatment through Better Access, and the outcomes of this treatment. Survey data were linked to MBS claims data for consenting participants. Results: In total, 2013 individuals completed the survey; linked MBS data were available for 1317 (65.4%). The majority (85.2%) were satisfied with their care, although they raised some issues, particularly around affordability. When asked to rate their mental health before and after treatment, 91.9% indicated it had significantly improved. Overall, 77.5% attributed this improvement to treatment by the mental health professional. For the full sample, baseline self-rated mental health was predictive of improvement, as was the number of sessions. For the sub-sample with linked data, these factors also predicted improvement, as did whether they paid a co-payment. Conclusion: In general, consumers who use Better Access appear to appreciate the programme and benefit from the care it provides. However, affordability remains an issue.