The girl who waits for her young soldier/Learns from the cadence of a songReference Raine¹

The ‘Werther effect’ describes the concern that (at least sensationalist) portrayal of suicide risks its replication. It derives from Goethe's 1774 novel The Sorrows of Young Werther that tells of the protagonist taking his life in the face of unrequited love;Reference Goethe² subsequently, there were widely reported cases of individuals being found dead by suicide with copies of the book beside them. The converse idea is the ‘Papageno effect’: describing ways of coping with suicidal ideation might reduce such risks (Papageno is a character from Mozart's opera The Magic Flute, who contemplates taking his life until shown alternative solutions by others). Niederkrotenthaler & Till (pp. 693–700) test the latter, randomising 266 adults with recent self-reported suicidal ideation or attempt to read either an educational, hopeful, article by a lay person with lived experience of suicidality, a similar piece by an expert or an unrelated article. Questionnaires showed that the piece by the expert by experience had an immediate and sustained benefit in participants’ sense of coping and reasons for living, with no adverse increase in risk. The gains were most pronounced for those with a recent suicide attempt. Hanzla Amir discusses this in more detail in this month's Mental Elf blog at elfi.sh/bjp-me27

We are certainly offered regular opportunities to share such information. Crump et al (pp. 710–716) report on a Swedish national cohort study exploring healthcare utilisation by individuals with alcohol use disorder prior to their death by suicide. This is a notably vulnerable group: even after adjusting for various socioeconomic confounders, the risk of death by suicide is about four times greater in those with alcohol use disorder. Almost 40% of this cohort had a healthcare encounter within the previous fortnight, and over three-quarters within the 3 months before their death. John and colleagues (pp. 717–724) looked at data from Wales, with a case–control study of everyone who died by suicide between 2001 and 2017. This group had over twice the contact rate (31.4%) of the general population with healthcare services in the week prior to their death. In both the work by Crump et al and John et al, the majority of contact was with primary care: thoughtfulness is required to optimise encounters in this inevitably very busy and more general setting.

How deep her love, how long the waiting/Sorrow is older than the heartReference Raine¹

Several papers in this month's BJPsych explore background factors that might have an impact on suicide ideation and attempts. A strong association with cigarette smoking has previously been described, but causality has not been tested. How might smoking cause suicide? There are pathophysiological hypotheses, including: through reducing serotonin levels and increasing impulsivity; alteration of the hypothalamic–pituitary axis; and via secondary physical ill health. In a rather cleverly designed study, Harrison et al (pp. 701–707) confirmed the observed association through data from the UK Biobank, and thereafter used Mendelian randomisation to triangulate the relationship. This crucial latter aspect found no evidence for causality. Perhaps more controversial has been the discussion regarding any impact for groundwater lithium. Memon et al (pp. 667–678) synthesised the global evidence on the topic in 15 ecological studies. Their findings confirmed a significant inverse relationship between lithium intake from public water supplies and population suicide mortality rates. They conclude by revisiting the always controversial question as to whether to prospectively test the intentional addition of lithium to water supplies.

Grateful to randomly have been born into a relatively stable society, I can scarcely imagine the profound burdens carried, and hurdles endured, by refugees whose lives have so differently been hit by other, adverse, tides outside of their control. Hollander et al (pp. 686–692) examined the suicide risk of refugees to Sweden, in an interesting design that also included non-refugee migrants from the same areas of origin. Fascinatingly, there were no differences between the two immigrant groups, and both had lower suicide rates than those Swedish born. Despite the very many other pressures being a refugee brings, these data do not support it increasing suicide rates – at least in this cohort in Sweden – and the authors suggest that acculturation and socioeconomic challenges may be aligning the two foreign-born cohorts. None of this undermines the difficulties refugees face, and we are reminded that, of course, this very term umbrellas large and very heterogeneous groups.

Already old when love is young/The song is older than the sorrowReference Raine¹

This month's BJPsych contains some very challenging papers on self-harm and suicide. It raises the inevitable questions of whether things are improving and what might we do better. Several editorials take this on. House & Owens (pp. 661–662) argue that there has not been much improvement over the past quarter century – when they first summarised the state of UK services – for those attending general hospitals with self-harm. I was particularly struck by their comment on how small trials have repeatedly shown benefits for brief psychological interventions in self-harm, but this has never resulted in the necessary well-funded large randomised controlled trial that might move practice. Nav Kapur pushes back (pp. 663–664), arguing that self-harm has never had a higher profile from a policy perspective and that research and service provision are getting better. Liaison psychiatry departments are now ubiquitous, and the Multicentre Study of Self-Harm in England is held up as a large high-quality research endeavour. Professor Kapur reminds us that the National Institute for Health and Care Excellence guidelines for the management of self-harm are undergoing an ambitious revision, and will be published in 2022.

Mou and colleagues (pp. 659–660) round this off with an editorial proposing next steps for suicide research. Noting the general failure of suicide prediction modelling, they call to borrow strategies from other medical fields to shift this, in a three-pronged approach. First, prospectively observing and characterising the outcome of interest before developing interventions; second, designing actionable risk assessments; third, decreasing complexity by clustering meaningful clinical subgroups. They provide stimulating examples of clinical challenges that have been so delineated and tackled, such as how oncologists better understood various cancers, and how neurologists created stroke-risk calculators.

Finally, Kaleidoscope (pp. 728–729) discusses the complex area of sexual intimacy and the rights of individuals with dementia as they lose capacity to consent to such acts.