Across the globe, suicide is regarded as a public health problem.1,2 Both the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) are calling for greater public awareness, improved health provider education, and better health care strategies to prevent suicide.1,2

The COVID-19 pandemic has increased the sense of loneliness and isolation. At the beginning of the pandemic in March 2020, emergency department visits for non-COVID emergencies decreased. However, when ED visits between March 15 and October 10, 2020, were compared with the same period in 2019, the counts were significantly higher for suicide attempts (n=4940 vs 4656, P =.02).3

Credit: Yard et al. MMWR4

According to a recent study, a 50.6% increase in the number of mental health-related emergency department visits occurred among girls aged 12 to 17 years during the winter of 2021 compared with the same period in 2019; among boys, ED visits for suspected suicide attempts increased 3.7%.4 Compared with the same period in 2019, the rate of suicide attempts among men and women aged 18 to 25 years was 1.6 times higher during spring 2020, 1.1 times higher during summer 2020, and 1.3 times higher during winter 2021.4


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Suicide Statistics

Suicide is the 10th leading cause of death for all ages in the US.1 It is the second leading cause of death for persons aged 10 to 34 years and the fourth leading cause of death for those aged 35 to 44 years.1 Suicide is a major cause of premature mortality and has been rising in incidence worldwide over the past 2 decades.1  

Nearly 48,000 people in the US and more than 700,000 persons worldwide died by suicide in 2019.1,2 Incidence rates of suicide are likely underestimated because misclassification of deaths is common.2,5,6 Suicides may be misclassified as accidents or unintentional injuries because of uncertainty about the decedent’s intent, social stigma, or the criminality of suicide in certain countries. Stigma may also be the reason why persons who die by suicide do not seek help.

However, many patients who die by suicide do seek help from health care providers but are not adequately evaluated. Research indicates that 80% of patients who died by suicide had contact with primary care clinicians within 1 year of their death, and 25% to 30% had contact with psychiatric clinicians within the year of their death.7,8 Studies also show that suicide decedents often have had contact with a mental health professional within a few months prior to their death.7-9

At-Risk Populations

Amongst racial and ethnic groups in the US, persons of American Indian/Alaska Native descent have the highest suicide rates (18.4%) followed by non-Hispanic White persons (16.7%).10 In 2019, rural vs urban disparities in suicides were especially notable, with most rural areas experiencing approximately 80% higher rates compared with most urban regions.11 Over the same period, suicide death rates were 3.5 to 4.5 times greater in men than women.12 Older adults, particularly those with chronic illness, military veterans, and those in the LGBTQ community are also at increased risk for suicide.1,2,13

Almost all patients who die of suicide have an underlying mental health disorder, most commonly major depressive disorder (MDD) and bipolar disorders I and II.14 Persons affected by bipolar depression are 20 to 30 times more likely to die of suicide than the general population.15 The depression in MDD and bipolar disorders I and II is characterized by a persistent feeling of sadness or loss of interest in activities and significantly impairs daily functioning. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), MDD is diagnosed when an individual presents with 5 or more specific symptoms nearly every day for  2 weeks (Table 1).16 

Table 1. DSM-5 Criteria for Major Depressive Disorder16

• Depressed mood
• Anhedonia
• Feelings of worthlessness or guilt
• Suicidal ideation or attempt
• Fatigue or loss of energy
• Decreased or increased sleep
• Decreased or increased weight or appetite
• Decreased ability to think or concentrate
• Psychomotor retardation or agitation
Source: American Psychiatric Association.

Major depressive disorder is particularly common in adults aged 55 years and older, and its prevalence rises with increasing age.17 An estimated 10% to 15% of older adults have clinically significant depressive symptoms in the absence of a diagnosis of MDD.17 Risk factors such as chronic diseases, disability, isolation, and lack of social support are related to depression in older adults.18 Cognitive impairment often accompanies MDD in older adults and can be mistaken for dementia. Older adults engage in suicidal behavior with greater planning and lethality of intent than younger individuals.19

During the past decade, emergency department visits for suicide attempts and suicide ideation have doubled among pediatric patients.20 Major depression may affect up to 12% of adolescents and has been observed in children as young as 3 years.21 However, because of symptom variation from adult diagnosis criteria, MDD is often left untreated in children and adolescents. Young children are less able to verbalize their feelings and thus unable to meet the DSM-5 criteria for MDD.21 Instead, they often present with more somatic complaints, anxiety, irritability, self-destructive behavior, and diminished social activity.21

Young adults and adolescents report higher rates of depression than any other group in the United States.21 Depressed teens often present with low self-esteem, impulsivity, anxiety, poor school performance, sleep and appetite disturbances, and substance use disorders.20-22 Adolescents with depression are often involved in risk-taking behaviors such as substance abuse or self-harm.20,21 They are also often exposed to risk factors such as cyberbullying and shaming on social media.20,23 Adolescents in the LGBTQ community are particularly at high risk for suicidal ideation and suicidal activity and have an earlier onset of suicidality and faster progression from suicidal ideation to an actual plan than heterosexual adolescents.23,24

In postpartum women, suicide accounts for between 1.8 to 4.5 maternal deaths per 100,000 births.25 However, suicide is an underreported cause of maternal death, and depression and suicidal ideation are underassessed conditions in postpartum women. Approximately half of pregnancy-related deaths include suicide, homicide, and nonintentional injuries.26 Numerous studies show that most women who die by suicide after giving birth have coexisting unassessed mental health disorders such as depression or anxiety.27,28 Many individuals facing postpartum depression and suicidal ideation are fearful of being deemed unfit mothers, which discourages them from seeking help.29 There is a need for mental health screening during the prenatal period as studies show that most women who die by suicide after giving birth never attended a postpartum visit.25,27

In 2019, the suicide rate in military veterans was 52.3% higher than in nonveterans. Younger veterans are more likely to have suicidal ideation and to follow through with a suicide attempt than older veterans.30,31 Combat veterans have elevated rates of suicide attempts and other conditions such as PTSD, substance abuse, and chronic pain compared with noncombat veterans.32 Childhood trauma has an even stronger association with suicide in veterans than combat experience.33

Nurses have a higher risk for suicide compared with the general population because of workplace stress.34 Most nurses who are at risk for suicide do not receive treatment because they are generally not able to take time off during the workday to seek mental health care and are too fatigued to seek care on days off.35

Suicide Risk Factors

A prior history of attempted suicide is the strongest single factor predictive of suicide.2 One out of every 100 suicide attempt survivors will die by suicide within 1 year of their index attempt, a risk approximately 100 times that of the general population.36 Major depressive disorder, bipolar disorder, anxiety disorders, alcohol and substance abuse, and schizophrenia are psychiatric diagnoses that are highly correlated with suicide.37

The risk for suicide is increased in patients with a family history of suicide. Twin studies have found that genetics contribute to 30% to 50% of the risk for suicide.38

Often, a combination of circumstances leads individuals to consider suicide. Major risk factors include previous suicide attempt; social isolation; criminal, legal, or financial problems; impulsive or aggressive tendencies; employment loss, major illness; substance use disorder; and mental illness.39 Interpersonal risk factors include adverse childhood experiences such as child abuse and neglect, bullying, family history of mental health problems or suicide, relationship problems such as a break-up or domestic violence, loss of a loved one, and sexual violence.39

Precipitating events for persons who take their own lives include the death of a loved one, loss of a job, breakup of a marriage, school or social failure, sexual identity crisis, or trauma. In addition, people may attempt suicide as an alternative to intolerable life circumstances, such as abusive relationships, occupational stresses, and chronic isolation. It is important to note that suicide is generally not caused by 1 event, but is rather an outcome of many underlying factors that accumulate into feelings of hopelessness.

Joiner et al outlined 4 factors that are commonly present in persons who attempt suicide (see Table 2).40 Persons without a strong support system of reciprocal, caring relationships are at highest risk.40 Persons at high risk fsuicide or exhibit behavioral changes, often sudden, which include apathy, withdrawal, thoughts regarding mortality, giving away possessions, depression, mood fluctuation, insomnia, and acute or chronic trauma.41

Table 2.  Factors Common Among People Who Die by Suicide40

• Perceive themselves as a burden to others
• Lack of a feeling of belonging
• Hopelessness
• Capability to enact suicide

Suicide Risk and Social Media

As of 2019, 90% of people aged 18 to 29 years used at least 1 form of social media regularly. Heightened rates of substance abuse, anxiety, and lack of socialization are associated with frequent use of social media.42 Social media use increases adolescents’ exposure to harmful and suicidal behaviors, normalizing the behaviors and possibly increasing the risk for suicide and self-harm in those who frequently use social media.43

Cyberbullying, in particular, is a behavior observed on social media that affects adolescents. Frequent cyberbullying is associated with higher rates of suicidal ideation and self-harm. Studies show when cyberbullying focuses on race, ethnicity, sexual orientation, or gender identity, those targeted are 7 times more at risk for suicidal ideation, and 8 times more likely to attempt suicide.44

Clinical Assessment of Suicidality

The evaluation of a patient who may be suicidal includes an assessment of ideation, method, plan, and intent. The clinician should first determine the presence of suicidal ideation (thoughts), including their content and duration. The patient should be questioned about their intended method and if there is a suicide plan. The clinician should consider the patient’s accessibility to the means of carrying out the act of suicide.38

Firearms are the most commonly used method of self-inflicted injury or suicide. The second and third leading methods are suffocation (eg, hanging; approximately 25% of suicides) and poisoning (eg, drug overdose; approximately 15%).38 More than 20,000 firearm suicides occur each year in the US, and estimates of the annual prevalence of firearm suicides range from 6 to 10 per 100,000 individuals.45 About one-third of veterans possess firearms, and those with suicidal thoughts tend to store firearms less safely than those without suicidal thoughts.46

Clinical assessment of a patient to predict if they will attempt or carry out suicide is difficult. Clinical assessments performed by primary care clinicians, emergency department clinicians, and mental health professionals have shown low predictive value.47 Depression assessment tools have been used in clinical practice, but are better measures of depression severity rather than suicide risk.47 The Columbia-Suicide Severity Rating Scale (C-SSRS) is the gold standard assessment tool used in clinical trials; however, it has been criticized as labor-intensive and insensitive to severity of suicidal risk.48,49

QPR: A Suicide Assessment and Emergency Response Strategy

The recognition of suicide as a public health issue has resulted in the development of evidence-based prevention programs to decrease suicide-related mortality. The QPR tool is an internationally recognized suicide prevention program that stands for Question, Persuade, and Refer.50 This training teaches laypersons and health care providers to recognize and respond effectively to someone exhibiting suicide warning signs and behaviors50:

  • Question: The at-risk person needs to be directly questioned about their intent to take their own life.
  • Persuade: The trainee must use their influence and training to persuade the at-risk person to obtain help.
  • Referral: Immediate action is necessary in terms of referring the person to the proper source, either emergency personnel or mental health professionals. It is recommended that the trainee accompany the suicidal person to the resource to ensure transfer to safety

For the QPR strategy to be effective, the following 4 elements must be in place51:

1. Early recognition of suicide warning signs. The QPR trainee learns to detect distress and early warning signs of suicidal ideation in an at-risk person (see Tables 3 and 4).

2. Early initiation of QPR. The QPR trainee immediately and directly asks the at-risk person exhibiting suicide warning signs to confirm or deny their meaning. The action of questioning opens a potentially life-saving dialogue. This can reduce anxiety and distress, enhance protective factors, and decrease risk factors. Direct questioning regarding suicidal intent communicates hope, decreases isolation, and conveys social and spiritual support for the at-risk person.

3. Early referral. Linking the at-risk person to local resources or calling a toll-free crisis number for evaluation is essential to reducing immediate risk (See Tables 3 and 4). As most people thinking about suicide are suffering from an undiagnosed and/or untreated mental illness or substance abuse disorder, accessible professional services are essential as soon as possible.

4. Early professional assessment and treatment. As with any life-threatening crisis or illness, early detection, assessment, and treatment results in reduced morbidity and mortality.

Table 3. Warning Signs for Suicide That Require Immediate Emergency Action5

• Someone threatening to hurt or kill themselves
• Someone looking for ways to kill themselves: seeking access to pills, weapons, or other means
• Someone talking or writing about death, dying, or suicide
Source: QPR Institute

Table 4. Warning Signs for Suicide That Require Intervention by a Mental Health Professional51

• Hopelessness
• Rage, anger, seeking revenge
• Acting reckless or engaging in risky activities, seemingly without thinking
• Feeling trapped, like there’s no way out
• Increasing alcohol or drug use
• Withdrawing from friends, family, or society
• Anxiety, agitation, unable to sleep or sleep all the time
• Dramatic changes in mood
• No reason for living, no sense of purpose in life
Source: QPR Institute

The QPR intervention is available as an online curriculum divided into tutorial sessions with an expert trainer. It involves a short program of study, learning through role-play, case scenarios, gaming, and after completion, a certification examination. The training can also be specialized for specific populations such as nurses, coaches, caregivers of veterans, and teachers.

This program has been likened to CPR in that it is a life-saving intervention.50 Numerous studies have found that QPR training changes trainee attitudes about mental illness, enhances knowledge about suicide, teaches assessment of suicidal behavior, and increases preparedness for mental health emergencies.52-54 Despite these positive trends, research has not yet shown that training programs such as QPR decrease suicide rates in the community since this measure is difficult to study in a randomized controlled trial.54

Conclusion

Every suicide death is preventable, however, numerous studies find that clinical assessment of a patient to predict if they will attempt or carry out suicide is difficult. The recognition of suicide as a public health issue has resulted in the need for evidence-based prevention programs. While not all health care providers are expected to provide the services of a specialized mental health care professional, each health care provider does have a role in assessing an individual for suicide risk and referring them to appropriate emergency resources.

Resources

National Suicide Prevention Lifeline: 800-273-8255  
• Ayuda en Español: 888-628-9454  
• For TTY users: 711 then dial 800-273-8255
Crisis Text Line: text HOME to 741714
Veterans Crisis Line: text 838255 or dial 800-273-8255 and press 1
Military OneSource: 800-342-9647
National Sexual Assault Hotline: 800-656-4673
National Domestic Violence Hotline: 800-799-7233 or text START to 88788
American Foundation for Suicide Prevention: https://afsp.org/
Brown Stanley Safety Plan Template: https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf
Know the Signs: https://www.suicideispreventable.org/
Suicide Awareness Voices of Education (SAVE): https://save.org/

Theresa Capriotti, DO, MSN, CRNP, RN, is clinical professor at Villanova University M. Louise Fitzpatrick College of Nursing, in Villanova, Pennsylvania. Kelly Bratton, Mia Hamel, and Jane Stilwell are honors BSN students at Villanova University M. Louise Fitzpatrick College of Nursing.

References

1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS): leading causes of death reports, 1981-2019. Accessed November 15, 2021. https://wisqars.cdc.gov/fatal-leading

2. World Health Organization. Suicide. June 17, 2021. Accessed November 15, 2021. https://www.who.int/news-room/fact-sheets/detail/suicide

3. Holland KM, Jones C, Vivolo-Kantor AL, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2021;78(4):372-379. doi:10.1001/jamapsychiatry.2020.4402

4. Yard E, Radhakrishnan L, Ballesteros MF, et al. Emergency department visits for suspected suicide attempts among persons aged 12–25 years before and during the COVID-19 pandemic — United States, January 2019–May 2021. MMWR Morb Mortal Wkly Rep. 2021;70(24):888-894. doi:10.15585/mmwr.mm7024e1

5. Rockett IRH, Caine ED. Reconciling suicides with “accidental” drug-intoxication deaths: a behaviorally based definition of self-injury mortality. Am J Public Health. 2020;110(1):73-74. doi:10.2105/AJPH.2019.305422

6. Olfson M, Wall M, Wang S, et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016;73(11):1119-1126. doi:10.1001/jamapsychiatry.2016.2035

7. Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: a systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019;47(1):9-17. doi:10.1177/1403494817746274

8. Walby FA, Myhre MØ, Kildahl AT. Contact with mental health services prior to suicide: a systematic review and meta-analysis. Psychiatr Serv. 2018;69(7):751-759. doi:10.1176/appi.ps.201700475

9. Soriano Barceló J, Portes Cruz J, Cornes Iglesias JM, Portela Traba B, Brenlla González J, Mateos Álvarez R. Health care contact prior to suicide attempts in older adults. A field study in Galicia, Spain. Actas Esp Psiquiatr. 2020;48(3):106-115.

10. Ivey-Stephenson AZ, Crosby AE, Jack SPD, Haileyesus T, Kresnow-Sedacca MJ. Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death – United States, 2001-2015. MMWR Surveill Summ. 2017;66(18):1-16. doi:10.15585/mmwr.ss6618a1

11. Stone DM, Jones CM, Mack KA. Changes in suicide rates – United States, 2018-2019. MMWR Morb. Mortal. Wkly Rep. 202;70(8):261-268. doi:10.15585/mmwr.mm7008a1

12. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999–2018. NCHS Data Brief, no 362. Hyattsville, MD: National National Center for Health Statistics. 2020. https://www.cdc.gov/nchs/products/databriefs/db362.htm

13. National Strategy for Preventing Veteran Suicide 2018–2028. US Department of Veterans Affairs; 2018. https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf

14. Paris J. Can we predict or prevent suicide?: an update. Prev Med. 2021;152(Pt 1):106353. doi:10.1016/j.ypmed.2020.106353

15. McIntyre RS, Berk M, Brietzke E, et al. Bipolar disorders. Lancet. 2020;396(10265):1841-1856. doi:10.1016/S0140-6736(20)31544-0

16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

17. Kok RM, Reynolds CF 3rd. Management of depression in older adults: a review. JAMA. 2017;317(20):2114-2122. doi:10.1001/jama.2017.5706

18. Cheruvu VK, Chiyaka ET. Prevalence of depressive symptoms among older adults who reported medical cost as a barrier to seeking health care: findings from a nationally representative sample. BMC Geriatr. 2019;19(1):192. doi:10.1186/s12877-019-1203-2

19. Price JH, Khubchandani J. Firearm suicides in the elderly: a narrative review and call for action. J Community Health. 2021;46(5):1050-1058. doi:10.1007/s10900-021-00964-7

20. Greenfield B, Jolicoeur-Martineau A, Brown M, et al. Frequent follow-up of suicidal youth assessed in the emergency room: long-term trajectory and predictors of suicidality. Prev Med. 2021;152(Pt 1):106737. doi:10.1016/j.ypmed.2021.106737.

21. Mullen S. Major depressive disorder in children and adolescentsMent Health Clin. 2018;8(6):275-283. doi:10.9740/mhc.2018.11.275

22. Reed-Fitzke K, Withers MC, Watters ER. Longitudinal connections of self-esteem and depression among adult children and their parents. J Adult Develop. 2021;28(3): 237-250.

23. Dorol-Beauroy-Eustache O, Mishara BL. Systematic review of risk and protective factors for suicidal and self-harm behaviors among children and adolescents involved with cyberbullying. Prev Med. 2021;152(Pt 1):106684. doi:10.1016/j.ypmed.2021.106684

24. Gage SH, Patalay P. Associations between adolescent mental health and health-related behaviors in 2005 and 2015: a population cross-cohort study. J Adolesc Health. 2021;69(4):588-596. doi:10.1016/j.jadohealth.2021.03.002

25. Rodriguez-Cabezas L, Clark C. Psychiatric emergencies in pregnancy and postpartum. Clin Obstet Gynecol. 2018;61(3):615-627. doi:10.1097/GRF.0000000000000377

26. Mehta PK, Bachhuber MA, Hoffman R, Srinivas SK. Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy in Philadelphia. Am J Public Health. 2016;106(12):2208-2210. doi:10.2105/AJPH.2016.303473

27. Metz TD, Rovner P, Hoffman MC, Allshouse AA, Beckwith KM, Binswanger IA. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol. 2016;128(6):1233-1240. doi:10.1097/AOG.0000000000001695

28. Grigoriadis S, Wilton AS, Kurdyak PA, et al. Perinatal suicide in Ontario, Canada: a 15-year population-based study. CMAJ. 2017;189(34):E1085-E1092. doi:10.1503/cmaj.170088

29. Holland C. The midwife’s role in suicide prevention. Br J Midwifery. 2018;26(1):44-50. 10.12968/bjom.2018.26.1.44

30. George BJ, Ribeiro S, Lee-Tauler SY, et al. Demographic and clinical characteristics of military service members hospitalized following a suicide attempt versus suicide ideation. Int J Environ Res Public Health. 2019;16(18):3274. doi:10.3390/ijerph16183274

31. Nichter B, Monteith LL, Norman SB, et al. Differentiating U.S. military veterans who think about suicide from those who attempt suicide: a population-based study. Gen Hosp Psychiatry. 2021;72:117-123. doi:10.1016/j.genhosppsych.2021.08.007

32. Thomas MM, Harpaz-Rotem I, Tsai J, Southwick SM, Pietrzak RH. Mental and physical health conditions in US combat veterans: results from the National Health and Resilience in Veterans study. Prim Care Companion CNS Disord. 2017;19(3). doi:10.4088/PCC.17m02118

33. Afifi TO, Taillieu T, Zamorski MA, Turner S, Cheung K, Sareen J. Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA Psychiatry. 2016;73(3):229-238. doi:10.1001/jamapsychiatry.2015.2732

34. Freire FO, Marcon SR, Espinosa MM, et al. Factors associated with suicide risk among nurses and physicians: a cross-section study. Rev Bras Enferm. 2020;73Suppl 1(Suppl 1):e20200352. doi:10.1590/0034-7167-2020-0352

35. Davidson JE, Zisook S, Kirby B, DeMichele G, Norcross W. Suicide prevention: a healer education and referral program for nurses. J Nurs Adm. 2018;48(2):85-92. doi:10.1097/NNA.0000000000000582

36. Bostwick JM, Pabbati C, Geske JR, McKean AJ. Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. Am J Psychiatry. 2016;173(11):1094-1100. doi:10.1176/appi.ajp.2016.15070854

37. Ribeiro JD, Huang X, Fox KR, Franklin JC. Depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies. Br J Psychiatry. 2018;212(5):279-286. doi:10.1192/bjp.2018.27

38. Fazel S, Runeson B. Suicide. N Engl J Med. 2020;382(3):266-274. doi:10.1056/NEJMra1902944

39. Centers for Disease Control and Prevention. Suicide prevention: risk and protective factors. Updated May 13, 2021. Accessed November 16, 2021. https://www.cdc.gov/suicide/factors/index.html

40. Joiner TE, Jeon ME, Lieberman A, et al. On prediction, refutation, and explanatory reach: a consideration of the Interpersonal Theory of Suicidal Behavior. Prev Med. 2021;152(Pt 1):106453. doi:10.1016/j.ypmed.2021

41. Becker M, Correll CU. Suicidality in childhood and adolescence. Dtsch Arztebl Int. 2020;117(15):261-267. doi:10.3238/arztebl.2020.0261

42. Keating SR, Rudd-Ariet, M. Emerging adults’ attitudes and beliefs about suicide and technology/social media. J Nurse Practitioners. 2021;17(7):833-839. doi:10.1016/j.nurpra.2021.04.010

43. Memon AM, Sharma SG, Mohite SS, Jain S. The role of online social networking on deliberate self-harm and suicidality in adolescents: a systematized review of literature. Indian J Psychiatry. 2018;60(4):384-392. doi:10.4103/psychiatry.IndianJPsychiatry_414_17

44. Dorol-Beauroy-Eustache O, Mishara BL. Systematic review of risk and protective factors for suicidal and self-harm behaviors among children and adolescents involved with cyberbullying. Prev Med. 2021;152(Pt 1):106684. doi:10.1016/j.ypmed.2021.106684

45. Kaufman EJ, Morrison CN, Branas CC, Wiebe DJ. State firearm laws and interstate firearm deaths from homicide and suicide in the United States: a cross-sectional analysis of data by county. JAMA Intern Med. 2018;178(5):692-700. doi:10.1001/jamainternmed.2018.0190

46. Bryan CJ, Bryan AO, Anestis MD, et al. Firearm availability and storage practices among military personnel who have thought about suicide. JAMA Netw Open. 2019;2(8):e199160. doi:10.1001/jamanetworkopen.2019.9160

47. Runeson B, Odeberg J, Pettersson A, Edbom T, Jildevik Adamsson I, Waern M. Instruments for the assessment of suicide risk: a systematic review evaluating the certainty of the evidencePLoS One. 2017;12(7):e0180292. doi:10.1371/journal.pone.0180292

48 Alphs L, Brashear HR, Chappell P, et al. Considerations for the assessment of suicidal ideation and behavior in older adults with cognitive decline and dementia. Alzheimers Dement (N Y). 2016;2(1):48-59. doi:10.1016/j.trci.2016.02.001

49. Giddens JM, Sheehan KH, Sheehan DV. The Columbia-Suicide Severity Rating Scale (C-SSRS): has the “gold standard” become a liability? Innov Clin Neurosci. 2014;11(9-10):66-80

50. Substance Abuse and Mental Health Services Administration. QPR (Question, Persuade, Refer) suicide prevention training. Accessed November 1, 2021. https://www.samhsa.gov/resource/dbhis/qpr-questionpersuade-refer-suicide-prevention-training

51. QPR Institute. QPR gatekeeper training for suicide prevention the model, theory and research. 2012. Accessed November 16, 2021. https://qprinstitute.com/uploads/qpr-theory-2017.pdf

52. Hangartner RB, Totura CMW, Labouliere CD, Gryglewicz K, Karver MS. Benchmarking the “question, persuade, refer” program against evaluations of established suicide prevention gatekeeper trainings. Suicide Life Threat Behav. 2019;49(2):353-370. doi:10.1111/sltb.12430

53. Samuolis J, Harrison AJ, Flanagan K. Evaluation of a peer-led implementation of a suicide prevention gatekeeper training program for college students. Crisis. 2020;41(5):331-336. doi:10.1027/0227-5910/a000638

54. Hawgood J, Woodward A, Quinnett P, De Leo D. Gatekeeper training and minimum standards of competency. Crisis. 2021 Jun 30. doi:10.1027/0227-5910/a000794