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This study investigated crisis intervention in three secondary schools after the suicides of five students, focusing on the relation between crisis intervention and suicide contagion. The contagion hypothesis was supported. Following a suicide, the number of suicides that occurred in secondary schools in one year were markedly increased beyond chance. No new suicides took place at schools where adequate first talk-throughs and psychological debriefing were conducted by a mental health professional. Proper crisis intervention is recommended to prevent suicide contagion in schools.
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International Journal of Emergency Mental Health 163
Adolescent Suicide and Suicide Contagion in Three
Secondary Schools
Soili Poijula, M.A., Karl-Erik Wahlberg, Ph.D., Atle Dyregrov, Ph.D.
ABSTRACT: This study investigated crisis intervention in three secondary schools after the suicides of
five students, focusing on the relation between crisis intervention and suicide contagion. The contagion
hypothesis was supported. Following a suicide, the number of suicides that occurred in secondary
schools in one year were markedly increased beyond chance. No new suicides took place at schools
where adequate first talk-throughs and psychological debriefing were conducted by a mental health
professional. Proper crisis intervention is recommended to prevent suicide contagion in schools.
[International Journal of Emergency Mental Health, 2001 3(3),pp 163-168].
KEY WORDS: suicide, contagion, intervention, psychological debriefing
Suicide is the third leading cause of death among
adolescents (Kochanek & Hudson, 1994). While suicide
research aims at prevention, the influence of preventive
strategies on suicide mortality has remained inconclusive
(Gunnell & Frankel, 1994; Lewis, Hawton & Jones, 1997).
Research on intervention to prevent suicide contagion is
almost non-existent.
Suicide contagion has been operationally defined as
when one persons suicide increases the likelihood of
anothers (Higgins & Range, 1996). Research indicates that,
although debatable, there is some evidence of suicide
contagion, but this occurs through modeling by friends when
crisis intervention has not been organized (Velting & Gould,
1997). The effect of suggestion on suicide is well established
(Taiminen, 1992). Adolescents are less likely to identify with
the deceased, and hence to commit suicide themselves, if
they learn that a suicide victim was psychiatrically disturbed,
was functioning in a psychopathological way, or was subject
to individual psychosocial stressors (Higgins & Range, 1996).
The majority of imitative suicides appears to take place within
Soili Poijula, Oy Synolon Ltd., Center for Trauma Psychology,
Oulu, Finland. Karl-Erik Wahlberg, Department of Psychiatry,
University of Oulu, Finland. Atle Dyregrov, Center for Crisis
Psychology, Bergen, Norway. Address correspondence concerning
this article to: Soili Poijula, Oy Synolon Ltd., Center for Trauma
Psychology, Valtatie 16 as 11, 90500 Oulu, Finland. Tel: 358 8 554
5814. Fax: 358 8 554 5801. E-mail: Soili.Poijula@netppl.fi.
the first ten days of exposure to suicide (Phillips & Carstensen,
1986). However, the latency period for imitative suicide has
been shown to be longer than six months (Väisänen &
Hägglund, 1981). The suicide risk of adolescents is higher if
they are exposed to suicide (Brent et al., 1989; Pelzer, Cherian,
& Cherian, 1998; Runeson, 1998). Brent et al. (1993) found
that seven months after the loss of an adolescent peer to
suicide, suicidal ideation with a plan or an attempt was elevated
in the suicide exposed. Bereavement can offer the adolescent
an opportunity to enhance values and coping skills or, by
contrast, the option to imitate a self-destructive response to
a crisis (Valente & Saunders, 1993)
After the suicide of a school-aged adolescent, the whole
school community, both students and teachers, suffers from
trauma and loss. Acknowledging the loss and reestablishing
normality within the school can be difficult. In many cases
school administrators are also very concerned about the
contagion aspects of suicide, and this is the single reason
why most school systems refrain from organizing crisis
intervention (Mauk & Weber, 1991). A community trauma,
such as suicide, requires that caretakers provide good
leadership to guide physical and emotional recovery (Williams,
Zinner, & Ellis, 1998). Cornell and Sheras (1998) conclude
that the results of school community crisis intervention
depend on the leaders ability to notice a crisis and
164 Poijula/ ADOLESCENT SUICIDE AND SUICIDE CONTAGION
acknowledge reactions. They claim that when leaders in some
school crises have not provided good leadership, they have
made the crisis worse. A nonsupportive, closed atmosphere
may result in students keeping traumatic grief internalized or
acting it out. The logical conclusion is that if the suicide is
publicly known and has caused reactions in students, it has
to be openly confronted.
In previous studies of bereaved adolescents it has been
recommended that a school experiencing such a sudden death
should organize crisis intervention (Brent et al., 1993;
Dyregrov, Gjestad, Bie Wikander & Vigerust, 1999; Mauk &
Weber, 1991). School crisis management may include
developing a contingency plan; informing students about a
death at school; conducting immediate talk-throughs, rituals,
and psychological debriefings among students; allowing
students to view the body, participate in the funeral and/or
meetings with parents; and following up of students over
time (Dyregrov, 1991; Leenaars & Wenckstern, 1998; Mitchell
& Every, 1996). In organizing interventions, the grief hierarchy
and exposure to the suicide are used in prioritizing to whom
help is offered, but everyone exposed to suicide requires
some level of care (Mauk & Weber, 1991).
Few studies to date have evaluated such interventions,
nor have there been studies on psychological debriefing and
suicide contagion prevention for adolescents.This study
concerned school crisis intervention and suicide contagion,
using the crisis intervention methods consisting of first talk-
throughs (FTT) and psychological debriefings (PD).
The first talk-through or defusing depicts a meeting of
those who were involved in or experienced a critical event.
The meeting is conversational in tone and takes place on the
same day as the event, usually within the first 8 hours
(Mitchell, 1995). It aims at providing emotional first aid to
people. To help students in crisis, the school creates a caring
climate and structures the chaos by providing the possibility
of ventilating thoughts and experiences. In schools, the
concept of grief hierarchy is used to prioritize to whom help
is offered. Usually this means focusing on the classmates.
The first talk-through is organized at school after informing
all students about the death. The conductor of the first talk-
through can be a teacher, a school nurse or a mental health
professional. Adults lead the adolescents in a conversation
where facts are shared and mutual support can be activated
(Dyregrov & Raundalen, 1995).
Psychological debriefing is a helpers group discussion
of a traumatic event designed to mitigate the impact of a
severe stress experience. It is conducted by trained
professionals (Mitchell, 1995). When psychological debriefing
is adapted and used with survivors of sudden death at a
school, there are both differences and similarities from the
original model of PD. At school, PD is a group discussion in
a class. It can last 1-2 lesson periods depending on the age of
the children.The conductor of the PD is a trained mental
health professional or a teacher. If the teacher is to be a
conductor, it is recommended that a mental health professional
co-leads the process. If a mental health professional is a
conductor, the teacher of the class can co-lead. The phases
of the psychological debriefing in schools are introduction,
facts, reactions, information and closure (Dyregrov, 1991).
In this study the schools crisis interventions following
different suicides are described and compared with the post
stress interventions described by Dyregrov (1991). The
suicide contagion hypothesis was also addressed with data
from a four-year follow-up period. Our hypotheses were that:
1) after a suicide of a student there will be an increased risk of
other suicides at the school, and 2) appropriate intervention
will reduce the risk of suicide contagion.
Method
Suicide events
During the school year 1995-1996 five secondary school
students committed suicide in three schools of the Oulu area
in Northern Finland (Table 1). These three schools were all
located in small rural communities. Geographically they were
not neighboring communities. This cluster of unrelated
adolescent suicides was the starting-point for this study.
In August 1995, two weeks before the school term
started, a male 17 year-old ex-secondary school student (case
I) committed suicide by self-immolation in the schoolyard of
a secondary school (A). One month later, in September, a
male 15 year-old 9
th
grade student (case II) of this same school
(A) committed suicide with a firearm. He was a friend of the
first suicide victim (case I). In January 1996, 4 months later,
another male 15 year-old 9
th
grade student (case III) in school
(A) committed suicide with a firearm. He was a friend of the
second suicide victim (case II).
Again in August 1995, a 14 year-old female secondary
school (B) student (case IV) committed suicide with a firearm
one week before the school term started. In October 1995, a
14 year-old male student (case V) from the same school (B)
International Journal of Emergency Mental Health 165
committed suicide with a firearm. He was an acquaintance of
the first suicide victim of this school (case IV). In January
1996, a 13 year-old male secondary school (C) student (case
VI) committed suicide with a firearm. None of these
adolescents (cases I-VI) who committed suicide were known
to be psychiatrically disturbed or otherwise different from
other students.
School C had no contingency plan, but in case VI an
adequate crisis intervention (FTT and PD conducted by a
trained mental health professional) was organized and timed
appropriately. Here FTT was held during the first day after
the suicide and PD two days after the suicide. PD lasted for
one hour.
Participants
Participants in this study were the students of the three
schools and homeroom classmates of the suicide victims.
All together there were 270 students in school A, 346 in
school B and 585 students in school C. Of these, 89 were
classmates (46 boys and 43 girls). From school A 15 boys
and 16 girls participated, from school B 15 boys and 17 girls
and from school C 16 boys and 10 girls. Participants were of
the same age (age 13 to 17) and had equal gender distribution.
Measures, Procedure, and Statistical Methods
The incidence of new suicides in the three schools was
followed for a four year period (August 1995- August 1999).
The first author had an agreement with three local school
psychologists of being informed on any new suicides in the
three schools during the follow up period (1995-1999).
The Poisson distribution was calculated for determining
if the number of suicides was increased beyond chance
(Rothman & Greenland, 1998). The statistical software used
was SPSS (9.0).
Interventions Carried Out in the Three Schools
In school A there was no contingency plan. After suicide
cases I and II no crisis intervention was organized. After
suicide case III an adequate crisis intervention, consisting of
a first talk-through (FTT) and a psychological debriefing (PD)
was organized, conducted by a trained mental health
professional (clinical psychologist ) and timed appropriately
so that FTT was held during the first day after the suicide
and PD (that lasted for two hours) was conducted during the
following day.
Although school B had a contingency plan, in case IV
only classroom meetings (an adapted version of PD, that
lasted for 1 hour conducted by a teacher) were organized in
all but one 8
th
grade class, where no intervention was
performed. The timing of the classroom meeting was late
(one week after the suicide). In case V an adequate crisis
intervention (FTT, and PD that lasted for one hour and was
conducted by a trained mental health professional) was
organized and timed appropriately (FTT was held during the
first day after the suicide and PD four days after the suicide).
CASE DATE METHOD AGE SEX EXPOSURE RELATIONSHIP
I 08/95 Self-immol. 17 M No
II 09/95 Firearm 15 M Heard Friend
III 01/96 Firearm 15 M Heard Friend
IV 08/95 Firearm 14 F No
V 10/95 Firearm 14 M Heard Acquaintance
VI 01/96 Firearm 13 M 
Table 1. Characteristics of the Suicides of Students
166 Poijula/ ADOLESCENT SUICIDE AND SUICIDE CONTAGION
Results
Contagion of the Suicides
Two suicides of 15-year-old male students occurred after
the first suicide within 4 months in school A (270 students).
Assuming a rate of 21.6 per 100,000 students per year (the
national suicide rate among 15- to 19-year-old males reported
by Statistics Finland, 1998), one would expect to see 0.0311968
suicides in this secondary school of 148 male students in
one year and 0.00324 in the group of 15 boys in homeroom
classrooms. The observed rate was 62.6 times the expected
rate in the whole school and 617.3 in the two homeroom
classes.
In school B (346 students), two suicides of 14-year-old
students occurred in one month. Assuming a rate of 1.9 per
100,000 students per year (the national suicide rate among
10- to 14-year-old males reported by the Statistics Finland,
1998), one would expect to see 0.003249 suicides of male
students in this secondary school of 171 males per year and
0.00285 in the homeroom classes group of 15 boys. The
observed rate was thus 307.8 times that expected for the whole
school for males and 3508.8 for homeroom class males. For
females (rate of 1.8 per 100,000) in a school of this size the
expected number is 0.00315 and for homeroom classes group
of 17 girls 0.00306. The observed rate is 317.5 times that
expected for the whole school for girls and 3268.0 for the
homeroom classes girls.
Using the Poisson distribution, the number of suicides
that occurred in all secondary schools in one year were
markedly increased beyond chance (p < 0.001). Contagion
did not appear in the first ten days, but 1 (two suicides), 1½,
2 and 4 months after the first suicide.
Intervention and Suicide Contagion
In cases III, V and VI but not in the others, the intervention
SCHOOL A
Case I none
Case II none
Case III First day
SCHOOL B
Case IV none
Case V First day
SCHOOL C
Case VI First day
Table 2. Schools and Interventions after Suicides
Timing of First
Talk-through
Psychological Debriefings,
Duration and Conductor
Timing of debriefing
after suicide
none none
none none
2 days
1 week
4 days
Mental Health Professional
Debriefing, 2 hours,
Classroom meeting,
Exclusion of 1 class, 1 hour,
Teacher
Debriefing, 1 hour
Mental Health Professional
Debriefing, 1 hour,
Mental Health Professional 2 days
International Journal of Emergency Mental Health 167
of the school was adequate (FTT and PD). In schools and
classes where a first talk-through and psychological
debriefing were conducted by a mental health professional
as the intervention, no new suicides appeared during the
four year follow up period (August 1995  August 1999, Table
2). In school B teachers conducted a classroom meeting in
all but one 8th grade class. In that school, a second suicide
was committed two months later by a student whose class
had not had the classroom meeting.
Discussion
The contagion hypothesis was supported in this study.
A much higher probability for students to commit suicide
compared to the general population of the same age was
found. In contrast to a short delay between a death and a
new suicide found in a previous report (Phillips & Carstensen,
1986), the time interval from the death of the student before
a new suicide of a student took place in this study was from
1 to 4 months. The method of the suicides seemed also to be
an imitation from the first suicides of the students. All of the
victims of the second wave of suicides knew about the
method of suicide and had been friends of the student who
committed the initial suicide.
The second hypothesis about intervention reducing
suicide contagion was also supported. An appropriate
intervention (FTT and PD) by a trained mental health
professional seemed to be a factor in inhibiting new suicides
of the students. The intervention method varied in the
schools, from nothing to an adequate crisis intervention.
What we consider to be a complete intervention (well
conducted FTT and PD) was needed to prevent new suicides.
If an incomplete crisis intervention was conducted, a new
suicide was committed. The connection between crisis
intervention and the systemic effects of intervention, and
how to prevent possible negative effects of incomplete
intervention, demand further study. Early crisis intervention
fosters an open discussion of facts, thoughts and reactions.
This open and direct handling of death may prevent
fantasizing and idealization of death. It may prevent acting
out of unspoken trauma, and imitation of suicidal behavior. It
may also have long term effects in preventing suicidality of
potentially bereaved and depressed youth, exposed to
suicide.
Limitations of the Study
The phenomenon of adolescent suicide contagion is rare.
This research is based on a small number of cases, not optimal
for statistical analysis, lacking sufficient statistical power.
Although problematic, the natural research design we used
was a way of developing new knowledge on the phenomenon
and the findings serve as hypotheses for further testing. The
conclusions should be considered as tentative, leading to
more research on preventive measures in this area.
Conclusion
Preliminary findings of this study show that early crisis
intervention and use of first talk-throughs and psychological
debriefing do not cause suicide contagion, but lack of
intervention may do so. In organizing interventions, leaders
in schools dont need to be afraid of interventing in a
supportive and open atmosphere, but should provide
systematic crisis intervention for exposed peers to guide
physical and emotional recovery.
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International Journal of Emergency Mental Health 169
170
The Society of Clinical Psychology, Division 12 of the
American Psychological Association introduces a new
section for clinical emergencies and crises.
APA Division 12 has approved an innovative new Section that gives
recognition to the difficult clinical work that psychologists do with patients
or clients who engage in life threatening behaviors. The Section has been
established to advance the clinical and scientific understanding of
psychological/behavioral emergencies and crises as well as the clinical
abilities needed to evaluate and manage them. Emergencies include life
threatening behaviors such as acute suicidality, potential violence, and risk
to vulnerable victims of violence. The Section provides a forum for the
exchange of clinical information and research findings related to the
emergencies noted above and to the crises from which they so often develop.
It has the further purposes of fostering education and training in the
evaluation and management of these high risk clinical situations, as well as
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Telephone: 617-232-9500 x4106 E-mail: Kleespies.Phillip_M_PHD@Boston.VA.GOV
... The absence of a gold-standard definition of suicide clusters has resulted in considerable methodological heterogeneity in the way suicide clusters are operationalised and detected. For example, early studies of suicide clusters described the relationships between suicide descendants and found that many cluster members shared social links as friends or acquaintences (Bechtold, 1988;Davidson et al., 1989;Wilkie et al., 1998;Poijula et al., 2001;Wissow et al., 2001). This led to the common cited hypothesis that suicide contagion, more accurately known as the social transmission of suicidal behaviour (whereby exposure to suicide facilitates suicidal behaviour in others), is a key mechanism underlying the development of suicide clusters (Hawton et al., 2019). ...
... These studies used population data from suicide registries combined with geoinformation systems to determine whether suicides are greater than statistically expected within a particular time and place (Gould et al., 1990a;Williamson et al., 2014;Robinson et al., 2016;Sy et al., 2019). Whilst early descriptive studies of suicide clusters were reported in small community settings such as a schools (Poijula et al., 2001), inpatient units (Taiminen et al., 1998) and remote indigenous communities (Bechtold, 1988;Wilkie et al., 1998;Wissow et al., 2001), the shift towards inferential studies of suicide clusters has established the presence of suicide clusters in large nationwide studies (Gould et al., 1990a, b;Cheung et al., 2012;Jones et al., 2013;Williamson et al., 2014;Robinson et al., 2016;Sy et al., 2019). ...
Article
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Aims: There is currently no gold-standard definition or method for identifying suicide clusters, resulting in considerable heterogeneity in the types of suicide clusters that are detected. This study sought to identify the characteristics, mechanisms and parameters of suicide clusters using three cluster detection methods. Specifically, the study aimed to: (1) determine the overlap in suicide clusters among each method, (2) compare the spatial and temporal parameters associated with different suicide clusters and (3) identify the demographic characteristics and rates of exposure to suicide among cluster and non-cluster members. Methods: Suicide data were obtained from the National Coronial Information System. N = 3027 Australians, aged 10–24 who died by suicide in 2006–2015 were included. Suicide clusters were determined using: (1) poisson scan statistics, (2) a systematic search of coronial inquests and (3) descriptive network analysis. These methods were chosen to operationalise three different definitions of suicide clusters, namely clusters that are: (1) statistically significant, (2) perceived to be significant and (3) characterised by social links among three or more suicide descendants. For each method, the demographic characteristics and rates of exposure to suicide were identified, in addition to the maximum duration of suicide clusters, the geospatial overlap between suicide clusters, and the overlap of individual cluster members. Results: Eight suicide clusters (69 suicides) were identified from the scan statistic, seven (40 suicides) from coronial inquests; and 11 (37 suicides) from the descriptive network analysis. Of the eight clusters detected using the scan statistic, two overlapped with clusters detected using the descriptive network analysis and one with clusters identified from coronial inquests. Of the seven clusters from coronial inquests, four overlapped with clusters from the descriptive network analysis and one with clusters from the scan statistic. Overall, 9.2% (12 suicides) of individuals were identified by more than one method. Prior exposure to suicide was 10.1% (N = 7) in clusters from the scan statistic, 32.5% (N = 13) in clusters from coronial inquest and 56.8% (N = 21) in clusters from the descriptive network analysis. Conclusion: Each method identified markedly different suicide clusters. Evidence of social links between cluster members typically involved clusters detected using the descriptive network analysis. However, these data were limited to the availability information collected as part of the police and coroner investigation. Communities tasked with detecting and responding to suicide clusters may benefit from using the spatial and temporal parameters revealed in descriptive studies to inform analyses of suicide clusters using inferential methods.
... Although recent meta-analyses have shown exposure to suicide is associated with increased risk of subsequent death by suicide (Hill et al, In Press), much of what is known about the association between suicide contagion and the development and maintenance of suicide clusters involves small descriptive case studies. These studies showed that individuals involved in suicide in a cluster were often linked psychosocially through friends or acquaintances (Bechtold, 1988;Brent et al, 1989;Davidson et al, 1989;Poijula et al, 2001;Wilkie et al, 1998;Wissow et al, 2001). However these studies were typically from small community settings such as a schools (Poijula et al, 2001), inpatient units (Mattews, 1968;Taiminen et al, 1998), or remote indigenous communities (Bechtold, 1988;Wilkie et al, 1998;Wissow et al, 2001). ...
... These studies showed that individuals involved in suicide in a cluster were often linked psychosocially through friends or acquaintances (Bechtold, 1988;Brent et al, 1989;Davidson et al, 1989;Poijula et al, 2001;Wilkie et al, 1998;Wissow et al, 2001). However these studies were typically from small community settings such as a schools (Poijula et al, 2001), inpatient units (Mattews, 1968;Taiminen et al, 1998), or remote indigenous communities (Bechtold, 1988;Wilkie et al, 1998;Wissow et al, 2001). Thus, it is unclear whether these findings are generalisable to broader populations and settings. ...
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Aims: Suicide clusters are significantly more common in young people. Yet, there is currently no gold-standard method for detecting suicide clusters and there is some evidence that the different methods for detecting clusters give inconsistent results. Our aim was to conduct a comparative analysis of suicide clusters in young people using 1) The scan statistic; 2) A systematic search of coronial inquests into suicide clusters and; 3) Descriptive network analysis. We sought to identify similarities and differences in cluster detection methods and to quantify rates of exposure to suicide among cluster members. Methods: Suicide data were obtained from the National Coronial Information System from 2006-2015 for Australians aged 10-24 years. We included N=3027 suicides from seven Australian state and territories. Suicide clusters were determined using: 1) Poisson discrete scan statistics; 2) A systematic search of coronial inquests; and 3) Descriptive network analysis involving psychosocial links between three or more cluster members. We analysed the prevalence of suicide clusters, the geospatial overlap between clusters, the proportion of overlap among cluster members and quantified rates of exposure to suicide for each cluster method. We examined the narrative text of police and coronial reports for evidence exposure to suicide and psychosocial links between cluster members. Results: Eight suicide clusters (69 suicides) were identified using the scan statistic; seven (40 suicides) from coronial inquests into suicide clusters; and 11 (37 suicides) using descriptive network analysis. Of the eight clusters detected using the scan statistic, two suicide clusters were identified using descriptive network analysis and one was identified in coronial inquest reports. Of the seven coronial inquests into suicide clusters, four suicide clusters were detected using descriptive network analysis and one was detected using the scan statistic. Geospatial congruence among overlapping clusters ranged from 25 to 100%. Overall, 9.2% (12 suicides) of 3 individuals were identified using more than one cluster method. Prior exposure to suicide was 10.1% (N=7) for suicide clusters identified using the scan statistic; 32.5% (N=13) for clusters identified using coronial inquests reports; and 56.8% (N=21) for clusters identified using descriptive network analysis. Conclusion: Different methods for determining suicide clusters identified different suicide clusters and cluster members. The use of multiple cluster detection methods has the potential to increase cluster response activities and suicide prevention interventions in communities that would not otherwise be detected by a single cluster method.
... The corpus of studies that have been conducted in this area have generally been descriptive, identifying clusters of suicide using statistical techniques [7][8][9][10], or mapping the relationships between members of given clusters [11]. Social links between individuals who died in suicide clusters have been observed in studies of small community settings [12,13] and in nationwide studies [14,15]. ...
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Social media may play a role in the “contagion” mechanism thought to underpin suicide clusters. Our pilot case-control study presented a novel methodological approach to examining whether Facebook activity following cluster and non-cluster suicides differed. We used a scan statistic to identify suicide cluster cases occurring in spatiotemporal clusters and matched each case to 10 non-cluster control suicides. We identified the Facebook accounts of 3/48 cluster cases and 20/480 non-cluster controls and their respective friends-lists and retrieved 48 posthumous posts and replies (text segments) referring to the deceased for the former and 606 for the latter. We examined text segments for “putatively harmful” and “putatively protective” content (e.g., discussion of the suicide method vs. messages discouraging suicidal acts). We also used concept mapping, word-emotion association, and sentiment analysis and gauged user reactions to posts using the reactions-to-posts ratio. We found no “putatively harmful” or “putatively protective” content following any suicides. However, “family” and “son” concepts were more common for cluster cases and “xx”, “sorry” and “loss” concepts were more common for non-cluster controls, and there were twice as many surprise- and disgust-associated words for cluster cases. Posts pertaining to non-cluster controls were four times as receptive as those about cluster cases. We hope that the approach we have presented may help to guide future research to explain suicide clusters and social-media contagion.
... One factor that may contribute to clustering is suicide contagion, the process by which suicidal behaviors of one or more persons promote the occurrence of subsequent suicidal behaviors in others [6,7]. Transmission of behaviors is theorized to take place both directly, through interaction or friendship with someone who dies by suicide, and indirectly, such as through exposure to media [5]. ...
Article
Purpose Youth suicide clusters may be exacerbated by suicide contagion—the spread of suicidal behaviors. Factors promoting suicide contagion are poorly understood, particularly in the advent of social media. Using cross-sectional data from an ongoing youth suicide cluster in Ohio, this study examines associations between suicide cluster-related social media and suicidal behaviors. Methods We surveyed 7th- to 12th-grade students in northeastern Ohio during a 2017–2018 suicide cluster to assess the prevalence of suicidal ideation (SI), suicide attempts (SAs), and associations with potential contagion-promoting factors such as suicide cluster–related social media, vigils, memorials, news articles, and watching the Netflix series 13 Reasons Why before or during the cluster. Generalized estimating equations examined associations between potential contagion-promoting factors and SI/SA, adjusting for nonmodifiable risk factors. Subgroup analyses examined whether associations between cluster-related factors and SI/SA during the cluster varied by previous history of SI/SA. Results Among participating students, 9.0% (876/9,733) reported SI and 4.9% attempted suicide (481/9,733) during the suicide cluster. Among students who posted suicide cluster–related content to social media, 22.9% (267/1,167) reported SI and 15.0% (175/1,167) attempted suicide during the suicide cluster. Posting suicide cluster–related content was associated with both SI (adjusted odds ratio 1.7, 95% confidence interval 1.4–2.0) and SA during the cluster (adjusted odds ratio 1.7, 95% confidence interval 1.2–2.5). In subgroup analyses, seeing suicide cluster–related posts was uniquely associated with increased odds of SI and SA during the cluster among students with no previous history of SI/SA. Conclusions Exposure to suicide cluster–related social media is associated with both SI and SA during a suicide cluster. Suicide interventions could benefit from efforts to mitigate potential negative effects of social media and promote prevention messages.
... Further, the advent of social media and new electronic media requires additional research to assess the impact of the transmission of information regarding completed suicides within one's social network [10,42]. In the wake of a death by suicide of someone in the community or a suicide that receives media attention, additional resources need to be allocated to postvention efforts with vulnerable groups, as it has been suggested that this may contain the effects of suicide contagion [43,44]. Further research needs to examine the risk factors that lead to the formation of suicide clusters, with the goal of implementing multifactorial suicide prevention and postvention strategies. ...
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Purpose: This study aims to describe and characterize the spatial and temporal clustering patterns of suicide in the ten states with the greatest suicide burden in the United States from 1999 to 2016. Methods: All suicide deaths from January 1, 1999 to December 31, 2016 in the United States were identified using data from the Wide-ranging Online Data for Epidemiologic Research (WONDER) dataset. The ten states with the highest age-adjusted suicide rates were Montana, Alaska, Wyoming, New Mexico, Nevada, Utah, Idaho, Colorado, Arizona, and Oklahoma. A spatiotemporal scan statistic using a discrete Poisson model was employed to retrospectively detect spatiotemporal suicide clusters. Results: From 1999 to 2016, a total of 649,843 suicides were recorded in the United States. Nineteen statistically significant spatiotemporal suicide mortality clusters were identified in the states with the greatest suicide rates, and 13.53% of the suicide cases within these states clustered spatiotemporally. The risk ratio of the clusters ranged from 1.45 to 3.64 (p < 0.001). All states had at least one cluster, with three clusters spanning multiple states, and four clusters were found in Arizona. While there was no clear secular trend in the average size of suicide clusters, the number of clusters increased from 1999 to 2016. Conclusions: Hot spots for suicidal behavior in the United States warrant public health intervention and continued surveillance. As suicide rates in the US continue to increase annually, public health efforts could be maximized by focusing on regions with substantial clustering.
... A Finnish study reported the response to five student suicides in a school year across three schools (Poijula et al., 2001). First talk-through and psychological debriefing were conducted by a mental health professional which seemed to reduce suicide contagion. ...
... Received 10 January 2018; Received in revised form 24 June 2018; Accepted 13 August 2018 context. Particularly, in the area of suicidal related behaviors where issues of contagion are paramount (Dishion and Piehler, 2009;Jarvi et al., 2013;Poijula et al., 2001), a multi-level model is essential. In non-suicidal self-injuries (NSSI), for example, it was found that the association between teachers' support and students' incidents of NSSI was negative at the individual level, while positive at the classroom level (Madjar et al., 2017a). ...
Article
School-related factors have been found to be associated with adolescents' suicidal ideation and behaviors, including teacher and peer support. Research has tended to ignore the nested nature of school-related data, which may be critical in this context. The current study implemented a multi-level approach on data from the 2013-14 Health Behaviors in School-aged Children (HBSC-WHO) Israeli survey among high school children (N = 4241; 56% female). Participants completed measures of teacher-, peer-, and parental-support (coded reversely from 1 = high to 5 = low), and suicidal ideation and behaviors in the last 12 months. Hierarchical Linear Modeling (HLM), controlling for gender and age, revealed that classroom-level teachers' support was significantly related to students' suicidal ideation and behaviors (OR = 1.71, 95% CI = 1.20-2.44; OR = 1.39, 95% CI = 1.04-1.86; respectively), whereas parental (OR = 1.56, 95% CI = 1.40-1.75; OR = 1.41, 95% CI = 1.30-1.55; respectively) and peer support (OR = 1.21, 95% CI = 1.12-1.31; OR = 1.11, 95% CI = 1.02-1.21; respectively) were significant at the individual-level. The school environment can play a significant role in reducing risk for suicidal ideation and behaviors. Findings can inform future research and practice in planning and implementing evidence-based intervention programs within schools.
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Background: Postvention aims to implement services adapted to the needs of a population that may be vulnerable after suicide. While a plethora of postvention programs exist, they are generally based less on solid evidence than on the judgment of health professionals. Using the Delphi method, an Australian study obtained a consensus among experts as to which postvention actions are to be engineered in a postvention program. Since no similar study has been carried out for programs in French-speaking countries, it seemed important to reproduce the same type of study and to compare the respective results. The present study is aimed at establishing a French inventory of postvention actions and at achieving a consensus among experts as to the actions to be included in a postvention program. Methods: A systematic review of the scientific literature (PRISMA method) and the gray literature (documentation on the WEB) made it possible to identify the different actions that have been included in various postvention programs. Using the DELPHI method, experts endeavored to assess their relevance. Results: An inventory of 190 postvention actions was established and they were classified according to a sequential axis (pre-event, at the time of the event, and post-event), according to type of action (environment-centered or people-centered). The experts identified 128 actions to be included in a postvention program. Conclusion: Convergence was observed among the experts, as they identified the practices to be encouraged following a suicide. When comparing the results in French-speaking countries to the 548 actions selected in the Australian study, we observe similarities between the two studies regarding types of postvention actions. This study provides an update for health professionals on the most relevant practices to be included in a postvention program.
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Across the domains of youth risk behavior, suicidality is a significant concern for parents and professionals alike, requiring ongoing efforts to better understand and prevent rising trends. Recent examinations of suicidal behaviors in the United States over the last decade revealed an increase in emergency and inpatient hospital settings. Of importance, seasonal variations were demonstrated, finding the lowest frequency of suicidality encounters in summer months, and observed peaks in the fall and spring, during the school year. Given these findings and the fact that youth spend nearly half of their time at school, consideration of youth suicide in the school environment is critical. This paper will review the trends of youth suicide within the school context, exploring factors such as at-risk youth, bullying, relevant legal issues, and the current state of crisis response in school settings. Recommendations for prevention, intervention, and postvention will be provided. The authors propose that school professionals play a vital role in addressing youth suicide and will aim to provide guidance on effective crisis response within the school context.
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Suicide is the second leading cause of death among adolescents in the United States. Imitation plays an important role in adolescent suicides. Identification theory suggests that media coverage of adolescent suicides can increase imitation suicides among adolescents. The present study examines this possibility using data collected from South Korea. It also explores the relationship between media coverage of celebrity suicides and suicide rates among adolescents. We found that adolescent suicides increase after media coverage of either an adolescent’s suicide or a domestic celebrity’s suicide.
Chapter
An adolescent commits suicide by shooting in his mouth after firing with the shotgun against a group of children skating on a playground beneath the apartment.
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This article describes five school crises involving alcohol-related fatality, self-injurious behavior, school homicide, racial/ethnic conflict, and community violence. In each case example, errors in crisis management by school staff exacerbated the crisis and resulted in deleterious consequences for the school, its students, and the surrounding community. We identify common themes of leadership, teamwork, and responsibility that are critical to successful crisis management. (C) 1998 John Wiley & Sons, Inc.
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Postvention refers to those things done to address and alleviate possible aftereffects of trauma. It serves to mollify the pain inflicted by an unusual event, whether suicide, homicide, terrorist attack, and so on. The authors define such concepts as posttraumatic stress, suicide, and postvention and then, from the classical and current literature as well as almost 20 years of experience in schools and communities, explicate some basic guiding principles. These principles are presented as heuristic; there is no "cookbook" to address the complexity of traumatic, including suicidal, effects. It is concluded that there have been past errors in the field and that strong effort, by clinicians and researchers together, is needed for evaluation and research.
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Suicide is the second leading cause of death among adolescents. The peer survivors of an adolescent suicide experience a normal but individually variant grieving process. It is important that the survivors be understood and that they receive appropriate ameliorative affective attention through postvention efforts by significant adults in their environment. An important setting for this postvention is the school, where adolescents spend many of their waking hours. Components of a grief time frame for adolescent suicide survivors, referral guidelines, and factors to consider when implementing a school postvention program are discussed.
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This article describes five school crises involving alcohol-related fatality, self-injurious behavior, school homicide, racial/ethnic conflict, and community violence. In each case example, errors in crisis management by school staff exacerbated the crisis and resulted in deleterious consequences for the school, its students, and the surrounding community. We identify common themes of leadership, teamwork, and responsibility that are critical to successful crisis management. © 1998 John Wiley & Sons, Inc.
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This chapter reviews 2 distinct traditions within the literature on suicide contagion: (1) studies investigating clusters or "outbreaks" of suicide defined by temporal-spatial factors and (2) efforts to determine the nature and scope of media influence on subsequent suicide-related behavior. Studies in suicide contagion among adolescents as well as adults are included. A discussion of cluster suicides highlights the methodological and qualitative shift from descriptive to inferential studies that has occurred in recent years. Additional topics include the influence of media portrayals of suicide, the mediational role of instructional suicide manuals in the development of subsequent suicidal behavior, and a discussion of alternative research strategies. Overall, the evidence to date suggests that suicide contagion is a real effect, albeit of a smaller effect size than other psychiatric and psychosocial risk factors for suicide. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
For example, psychological disturbance is stigmatizing, so knowledge that the suicide victim was psychiatrically disturbed may decrease the possibility that others will imitate the act. To assess this possibility, 306 undergraduate volunteers read a fictitious newspaper article about a 16-year-old high school sophomore, Pat, who committed suicide. There were 7 variations of the article, 4 containing negative circumstances (psychiatric disturbance, romantic relationship breakup, parents’ divorce, alcohol problems), and 2 containing positive circumstances (being a varsity athlete, being an honors student). A control group received no information about circumstances. Knowledge of Pat's life circumstances had no effect on respondents’ estimates of the possibility of the suicide being imitated, but did affect attitudes about the suicidal act itself and attitudes toward Pat's family. Apparently the circumstances surrounding the suicide have no affect on respondents’ estimates of themselves following suit, but do affect how they see the victim and bereaved family.
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The effect of suggestion on suicide is well established. However, the intrapsychic mechanisms of the contagion of suicides are poorly understood. In this article I first present the literature about suicide clustering and about projective identification. In the following clinical vignette I try to understand a patient's suicidal behaviour, referring to William Goldstein's clarifying model of projective identification. I aim to illustrate that his model has heuristic value in the treatment of suicidal patients when the effect of suggestion or identification is suspected.
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In a high school of 1,496 students, two students committed suicide within 4 days. During an 18-day period that included the two suicides, seven students attempted suicide and an additional 23 manifested suicidal ideation. Compared to expected rates, the rates of both completed and attempted suicide were markedly elevated. Seventy-five percent of the members of the cluster had at least one major psychiatric disorder antedating their exposure. One hundred ten students thought to be at high risk were psychiatrically screened on site. Within this group, students who became suicidal after exposure were more likely than their nonsuicidal counterparts to be currently depressed and to have had past episodes of depression and suicidality. Close friends of the victims manifested suicidality at a lower psychopathological threshold than those who were less close to the victims. Students who are friends of a victim or who have a history of affective disorder and/or previous suicidality should be screened for suicidality after exposure.
Article
We examined the relation between 38 nationally televised news or feature stories about suicide from 1973 to 1979 and the fluctuation of the rate of suicide among American teenagers before and after these stories. The observed number of suicides by teenagers from zero to seven days after these broadcasts (1666) was significantly greater than the number expected (1555; P = 0.008). The more networks that carried a story about suicide, the greater was the increase in suicides thereafter (P = 0.0004). These findings persisted after correction for the effects of the day of the week, the month, holidays, and yearly trends. Teenage suicides increased more than adult suicides after stories about suicide (6.87 vs. 0.45 percent). Suicides increased as much after general-information or feature stories about suicide as after news stories about a particular suicide. Six alternative explanations of these findings were assessed, including the possibility that the results were due to misclassification or were statistical artifacts. We conclude that the best available explanation is that television stories about suicide trigger additional suicides, perhaps because of imitation.