been more encouraging. The trial should therefore not be regarded as a definitive dismissal of the promise of these or related agents. 3 Theoretically, depression in bipolar disorder is a more heterogeneous construct than mania, which is more monothematically biological in its causation. Depression is driven by a far wider array and admixture of biological factors, consequences of behaviours while manic, losses in domains such as educational and vocational horizons, relationships, personality, finances, guilt, stigma, and self-stigma, among others. Therefore, it is arguably ambitious at the outset to expect a singular biological therapy targeting one biological marker of the disorder to address all phenotypes of this heterogeneous clinical presentation. The complexity of bipolar depression might be an explanation more broadly for the relatively common failure of singular treatment approaches. These failures suggest that polyvalent and personalised therapies predicated on individualised profiles are needed to select from the diverse pharmacological, neurostimulatory, nutraceutical, lifestyle, and psychological approaches that are available. 10 In sum, this might not be the last word on the potential role of anti-inflammatory drugs in the treatment of bipolar depression, but notwithstanding the methodological issues that accompany any clinical trial, the promise of targeting the inflammation pathway in the management of this challenging condition is today somewhat weaker.

The impact of suicide reporting may not be restricted to harmful effects; rather, coverage of positive coping in adverse circumstances, as covered in media items about suicidal ideation, may have protective effects.

Background The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world. MethodsWe sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries' ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms "suicide" and "cause of death", before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis).Findings We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales

Objective To examine the association between reporting on suicides, especially deaths of celebrities by suicide, and subsequent suicides in the general population. Design Systematic review and meta-analysis. Data sources PubMed/Medline, PsychInfo, Scopus, Web of Science, Embase, and Google Scholar, searched up to September 2019. Review methods Studies were included if they compared at least one time point before and one time point after media reports on suicide; follow-up was two months or less; the outcome was death by suicide; and the media reports were about non-fictional suicides. Data from studies adopting an interrupted time series design, or single or multiple arm before and after comparisons, were reviewed. Results 31 studies were identified and analysed, and 20 studies at moderate risk of bias were included in the main analyses. The risk of suicide increased by 13% in the period after the media reported a death of a celebrity by suicide (rate ratio 1.13, 95% confidence interval 1.08 to 1.18; 14 studies; median follow-up 28 days, range 7-60 days). When the suicide method used by the celebrity was reported, there was an associated 30% increase in deaths by the same method (rate ratio 1.30, 95% confidence interval 1.18 to 1.44; 11 studies; median follow-up 28 days, range 14-60 days). For general reporting of suicide, the rate ratio was 1.002 (0.997 to 1.008; five studies; median follow-up 1 day, range 1-8 days) for a one article increase in the number of reports on suicide. Heterogeneity was large and partially explained by celebrity and methodological factors. Enhanced funnel plots suggested some publication bias in the literature. Conclusions Reporting of deaths of celebrities by suicide appears to have made a meaningful impact on total suicides in the general population. The effect was larger for increases by the same method as used by the celebrity. General reporting of suicide did not appear to be associated with suicide although associations for certain types of reporting cannot be excluded. The best available intervention at the population level to deal with the harmful effects of media reports is guidelines for responsible reporting. These guidelines should be more widely implemented and promoted, especially when reporting on deaths of celebrities by suicide. Systematic review registration PROSPERO CRD42019086559.

Reports on celebrity suicide are associated with increases in suicides. Study region and celebrity type appear to have an impact on the effect size.

The present results clearly support the hypothesis that the media guidelines have had an impact on the quality of reporting as well as on suicidal behaviour in Austria, and stress the importance of collaborating with nationwide, but also with regional media to achieve efficacy. Further research is needed to provide an international insight into this public health issue.

Suicide is a major, global public health issue that accounts for at least 800 000 deaths per year worldwide.1 A substantial body of literature shows that media reports relating to suicide can influence some people to end their lives. [2][3][4][5][6][7][8][9][10][11][12] This phenomenon, known as the Werther effect, is thought to occur via social learning, whereby a vulnerable person identifies with someone portrayed in the media and copies his or her behaviour. [5][6][7][13][14][15][16][17][18][19][20][21] Studies in Australia, Austria and the United States have identified potentially harmful elements of media reporting associated with increased rates of subsequent suicide. 5,6,21 These include repetitive reporting, front-page story placement, reports about suicides by jumping, suicide death (rather than ideation or attempts), suicide pacts, including the word "suicide" or the suicide method in the headline, accompanying photos, "monocausal" (single cause and effect) explanations for suicide, and reports that included misinformation ("public myths") about suicide. 5,6,21 However, these elements were not tested or significant in all studies.A second phenomenon, called the Papageno effect, has been proposed whereby protective factors in reports on suicide may lead readers to initiate adaptive behaviours, resulting in fewer suicide deaths.5 In Austria, newspaper articles depicting "mastery of suicide," in which people experienced suicidal ideation but found solutions other than suicidal behaviour, were associated with decreased subsequent suicides. 5Responsible media reporting is one of a limited number of strategies, which also include restriction of means and schoolbased awareness programs, that may affect suicide rates at a popu lation level. [22][23][24] Worldwide, numerous guidelines have been developed to advise the media on best practices. ABSTRACT BACKGROUND: Exposure to media reporting on suicide can lead to suicide contagion and, in some circumstances, may also lead to help-seeking behaviour. There is limited evidence for which specific characteristics of media reports mediate these phenomena.

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