Background Digital interventions that deliver psychological self-help provide the opportunity to reach individuals at risk of suicide who do not access traditional health services. Our primary objective was to test whether direct (targeting suicidality) and indirect (targeting depression) digital interventions are effective in reducing suicidal ideation and behaviours, and our secondary analyses assessed whether direct interventions were more effective than indirect interventions.Methods In this systematic review and meta-analysis, we searched online databases MEDLINE, PubMed, PsycINFO, and Cochrane CENTRAL for randomised controlled trials published between database inception to May 21, 2019. Superiority randomised controlled trials of self-guided digital interventions (app or web based, which delivered theory-based therapeutic content) were included if they reported suicidal ideation, suicidal plans, or suicide attempts as an outcome. Non-inferiority randomised controlled trials were excluded to ensure comparability of the effect. Data were extracted from published reports, and intention-to-treat data were used if available. The primary outcome was the difference in mean scores of validated suicidal ideation measures (Hedges' g) with the associated 95% CI for the analysis of digital intervention effectiveness on suicidal ideation. We also present funnel plots of the primary outcome measure (suicidal ideation) for direct and indirect interventions to assess for publication bias. We calculated I² (with I² CI) values to test heterogeneity. We used random-effects modelling for the meta-analyses to assess the primary and secondary outcomes. This study is registered with PROSPERO, CRD42018102084. FindingsThe literature search yielded 739 articles (including manual searching) for suicidality and 8842 articles for depression. After screening, 14 papers reporting on 16 studies were included in the narrative review and metaanalysis. The 16 studies (ten on direct interventions and six on indirect interventions) provided baseline data for 4398 participants. The primary outcome of overall post-intervention effect for suicidal ideation was small but significant immediately following the active intervention phase (Hedges' g -0•18, 95% CI -0•27 to -0•10, p<0•0001; I²=0%, I² CI 0•0-47•9). The secondary objective, comparing direct and indirect interventions, showed that direct interventions (targeting suicidality) significantly reduced suicidal ideation at post-intervention (g -0•23, 95% CI -0•35 to -0•11, p<0•0001; I²=17•6%, I² CI 0•0-58•6), but indirect interventions (targeting depression) failed to reach significance (g -0•12, 95% CI -0•25 to 0•01, p=0•071; I²=0%, I² CI 0•0-30•7). Interpretation Self-guided digital interventions directly targeting suicidal ideation are effective immediately postintervention. Indirect interventions were not significant for reducing suicidal ideation. Our findings suggest that digital interventions should be promoted and disseminated widely, especially where there is a lack of, or minimal access...

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Regular methamphetamine use appears to be associated with an increased risk of violent offending, but not victimization, compared with heroin use.

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Introduction: Suicide is a leading cause of death in young people, which may in part be because young people are notoriously poor help-seekers. Improving the identiication of at-risk young people and connecting them to appropriate help is needed to prevent suicide in adolescents. The aim of this study is to examine the efectiveness of suicide prevention gatekeeper programs for parents and teachers, which are designed to improve their ability to recognise and respond to risks so that they may intervene before crisis occurs. Methods: Academic databases and reference lists were searched for gatekeeper training programs involving teachers and parents, and which aimed to prevent youth suicide, between journal inception and May 2018. Information directly reporting on suicide literacy (knowledge, conidence, attitudes) and/or gatekeeper behaviours (identiication, referral) was extracted and a qualitative synthesis was conducted. Results: Thirteen studies fulilled inclusion criteria. Signiicant moderate-to-large intervention efects were reported for suicide literacy outcomes among teachers and parents, with the largest gains among those with lowest baseline scores. No improvements in identiication and referral behaviors among gatekeepers were noted. A need to improve evaluation research designs and outcome measurements was evident. Conclusions: While gatekeeper programs lead to increased suicide literacy, there is little evidence for behavioural change. There is need to increase the reach and uptake of gatekeeper training by ofering digital versions, which may lead to improved behavioural outcomes, and to employ targeted strategies to engage parents in this training as one of the most trusted sources of support for vulnerable youth.

IMPORTANCESuicidal ideation is a widespread phenomenon. However, many individuals at risk for suicide do not seek treatment, which might be addressed by providing low-threshold, internetbased self-help interventions. OBJECTIVE To investigate whether internet-based self-help interventions directly targeting suicidal ideation or behavior are associated with reductions in suicidal ideation. DATA SOURCES A systematic search of PsycINFO, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and the Centre for Research Excellence of Suicide Prevention (CRESP) databases for trials from inception to April 6, 2019, was performed, supplemented by reference searches. Search strings consisted of various search terms related to the concepts of internet, suicide, and randomized clinical trials. STUDY SELECTION Two independent researchers reviewed titles, abstracts, and full texts. Randomized clinical trials evaluating the effectiveness of internet-based self-help interventions to reduce suicidal ideation were included. Interventions were eligible if they were based on psychotherapeutic elements. Trials had to report a quantitative measure of a suicide-specific outcome. Mobile-based and gatekeeper interventions were excluded; no further restrictions were placed on participant characteristics or date of publication.DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. Standardized mean differences were calculated using a randomeffects model. MAIN OUTCOMES AND MEASURESSuicidal ideation was the a priori primary outcome. RESULTS Six unique eligible trials (1567 unique participants; 1046 [66.8%] female; pooled mean[SD] age, 36.2 [12.5] years) were included in the systematic review and meta-analysis. All identified interventions were internet-based cognitive behavioral therapy (iCBT). Participants assigned to the iCBT condition experienced a significantly reduced suicidal ideation compared with controls following intervention in all 6 trials (standardized mean difference, −0.29; 95% CI, −0.40 to −0.19; P < .001). Heterogeneity was low (I 2 = 0%). The effect appeared to be maintained at follow-up in 4 trials (standardized mean difference, −0.18; 95% CI, −0.34 to −0.02; P = .03; I 2 = 36%). Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations. CONCLUSIONS AND RELEVANCEThese results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions. Considering their high (continued)

Anabolic-androgenic steroids (AASs) are frequently misused. To determine causes of death, characteristics, toxicology, and pathology of AAS positive cases, all cases (n = 24) presenting to the New South Wales Department of Forensic Medicine (1995-2012) were retrieved. All were male, and the mean age was 31.7 years. Deaths were mainly due to accidental drug toxicity (62.5%), then suicide (16.7%) and homicide (12.5%). Abnormal testosterone/epitestosterone ratios were reported in 62.5%, followed by metabolites of nandrolone (58.3%), stanozolol (33.3%), and methandienone (20.8%). In 23 of 24 cases, substances other than steroids were detected, most commonly psychostimulants (66.7%). In nearly half, testicular atrophy was noted, as was testicular fibrosis and arrested spermatogenesis. Left ventricular hypertrophy was noted in 30.4%, and moderate to severe narrowing of the coronary arteries in 26.1%. To summarize, the typical case was a male polydrug user aged in their thirties, with death due to drug toxicity. Extensive cardiovascular disease was particularly notable.