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explored, which enables the stake- Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from Need to establish a new adolescent suicide holders to have a comprehensive prevention programme in South Korea insight and, most importantly, to propose a far-sighted­ and practical Jiacheng Liu ‍ strategy to deal with the issues in a more efficient way.12–14 In the medical and public health field, although Abstract set of Korea Youth Risk Behavior SWOT analysis is not a prospective, Adolescent suicide is the leading cause of death Web-based­ Survey (KYRBWS), it was double-­blind clinical trial, which can among South Korean (Korean) youth. Despite revealed that 12.4% (7443/59 984) provide the highest level of evidence, great efforts being made towards suicide of middle and high school students it is still an important technique to prevention in Korea, the suicide rate has not had a history of suicidal ideation/ decreased significantly. There is an urgent need alter and improve the disease preven- attempt.6 What is worse, only 11.1% for a new adolescent suicide prevention strategy. tion and treatment standards15 and is to 21.6% of the adolescents aged 15 This paper describes the seriousness of the helpful for future clinical and basic years or older with suicidal ideation issue of adolescent suicide in Korea, evaluates research.16 its current management by the SWOT analysis or attempt are receiving psychiatric treatment.7 (strengths, weaknesses, opportunities and Strengths threats) and further recommends a new suicide The causes of suicide in Korean The Korean government provides prevention programme that integrates national/ youth are complicated. Moreover, powerful leadership on suicide social involvement (State Suicide Intervention 34.3% of suicides are associated with prevention. A Five Year Plan for Committee, suicide posts’ monitoring, parental family problems,8 including family National Mental Health was released divorce information sharing and Adolescence history of suicide/mental disorders in 1998, and it is updated every Mental Health Promotion Foundation), school-­ and low family support9; 17.6% are based programmes (continuous monitoring 5 years.17 In 2004, media guidance was related to students’ own psychi- system, psychology consultation team and introduced, stressing the importance atric disorders, such as depression, mental health educational curricula) and family-­ of providing responsible reports and another 12% are due to the based programmes (parental education and related to suicides, and amendment academic burden at school.8 10 Other family-­school communication). In addition, 3.0 was announced in 2018.18 In addi- factors, including alcohol/substance genetic analysis, biochemical tests and tion, the Korea Suicide Prevention psychological disease registration are the abuse,9 11 peer bullying and social Centre (KSPC), which is supported indispensable elements that aid in suicidal stigma regarding a mental illness,10 directly by the government, was behaviour prevention and prediction. are all associated with suicide attempts established in 2011 with the primary by Korean adolescents. tasks of preventing high-­risk suicides, http://gpsych.bmj.com/ Considering the gravity of the Introduction to Korean adolescent improving media guidelines, building issue of suicide in Korean youth, the suicide internet monitoring system and so Korean Ministry of Education intro- Suicide is the second leading cause of on.18 The Korean Ministry of Educa- 1 duced a mandatory policy in 2015 that death among the youth worldwide. tion also held six vital prevention required a suicide report should be Nearly 3.4 million adolescents (aged projects for the young, including submitted by the school within 1 week 15–19 years) across the globe have evidence-­based prevention strate- of a student committing suicide.8 suicidal ideation, with half of them gies, de-stigmatised­ social mental 2 on September 28, 2021 by guest. Protected copyright. attempting suicide. In Korea, the health campaigns, early suicide detec- suicide rate was ranked the fourth in tion systems, liaisons between the 3 the world in 2018 with 7.2/100 000 SWOT analysis of current suicide medical support system and psychol- 4 young people committing suicide, management ogists, skills training for students and and the number of suicides among To perform an in-depth­ assessment teachers and prevention education adolescents aged 15–18 years is four of the current Korean suicide preven- for adolescents.8 times than that of adolescents aged tion strategies, a SWOT (strengths, In addition, non-governmental­ 12–14 years according to data from weaknesses, opportunities and organisations (NGOs) are actively the National Statistical Office of threats) analysis is used. SWOT is a involved in suicide prevention 5 Korea. Korean adolescents seem to widely used qualitative method in a programmes. The Korean Associa- be at a risk of having suicide ideation variety of fields, including business, tion for Suicide Protection launched or attempting suicide. In a recent medicine, public health, education, several programmes in 2011, such study that used a nationwide data politics and so on. Through a thor- as ‘Livingworks’ and its branches ough and structured analysis of the ‘ASIST’ and ‘safeTALK’, to train Melbourne School of Population & Global Health, Division of Medicine, Dentistry and Health Sciences, available data relating to a topic of mental health professionals and The University of Melbourne, Melbourne, Victoria, interest, all the intrinsic and extrinsic encourage young people with mental Australia factors, even the mechanism involved disorders to communicate openly 19 Correspondence to Jiacheng Liu; in the occurrence, progression and with others. By the end of 2017, jiachengl5@​ ​student.unimelb.​ ​edu.au​ outcome of a focused event, are 7342 help providers had joined the

Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 1 General Psychiatry

‘ASIST’ training programme, and lower than WHO’s recommendation Threats Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from 9102 adolescents had taken part in (15%–50%).17 The biggest threat of suicide in Korea ‘safeTALK’.20 comes from the lack of treatment. Other efforts are being made to Opportunities Only 15%–23% of individuals with prevent suicides in Korea. KSPC The great developments in infor- mental disorders receive treatment, developed an internet monitoring mation and computer technologies, which is far less than the 44% treat- 17 team to delete harmful online posts. especially the advances in artificial ment rate in western countries. According to the team, 3123 posts intelligence and deep learning, Another threat comes from the regarding suicide encouragement provide the opportunities to recog- internet. Currently, one can easily and recruitment are deleted on a nise and screen the students with post suicidal encouragement text and 18 8 18 normal day. The National Institute suicidal ideation at an early stage, video online anonymously, which of Mental Health and the Division of including those who have been previ- has immeasurably vicious mental Mental Health Services are devoted ously received a diagnosis of psychi- consequences, especially for young- to mental health research exploring sters. Other suicide-­inducing factors, atric disorders. As acknowledged by 8 the aetiology of suicides in Korean teachers, the information provided such as online game addiction and adolescents and prevention strat- loneliness, which are caused by poor 10 17 in their suicide reports may be biased 3 8 egies, the link between mental 8 social/family relationships, parental or incomplete. If closed-circuit­ tele- 8 disorders and a person’s genetic back- visions (CCTVs) could be installed divorce and social stigma towards ground,21 and so on. It is clear that the 26 27 in every school covering every mental diseases, have also been Korean government and NGOs have corner, detailed dynamic informa- identified. These diverse and complex paid close attention to youth suicide risk factors increase the difficulty tion on the students who committed and have adopted several strategies. of adolescent suicide prevention in suicides in the school could be Korea. traced. By analysing and comparing Weaknesses their behaviour 1 week or 1 month Although numerous efforts have before the incident, some question- been made, a significant decline Recommendations for current able and common behaviours might in the suicide rate has not yet been suicide prevention strategies 22 be recognised, which in turn could observed. The primary reason is the According to the aforementioned help implement suicide prevention social stigma towards mental illness SWOT analysis, there is a need to training programmes for teachers embedded in Korean culture. On update the current suicide preven- that would enable them to notice the one hand, most Korean people tion strategies in Korea and estab- such behaviours in the future. think it is shameful to admit that lish an integrated framework at the http://gpsych.bmj.com/ Furthermore, modern internet they have mental health problems. administration level and healthcare surveillance technologies can assist Seventy percent of students with level with factors related to nation/ the KSPC’s internet monitoring suicidal ideation do not display their society, schools, families, genetic 8 team to extend their job from simply problematic behaviours at school. architecture, biochemical markers deleting harmful suicide posts to Thus, it is hard for the teachers to and psychiatric disease registration identifying who posts this infor- observe any behavioural abnormal- (figure 1). Several specific measures mation online, which is extremely ities in these students. On the other could be taken as suggested in the helpful in offering timely help and on September 28, 2021 by guest. Protected copyright. hand, even if the Ministry of Educa- figure. tion introduced projects to intervene saving lives. and prevent suicide issues, schools Moreover, with the development of Suicide prevention strategies should prefer to conceal the suicidal inci- novel tools for analysing the genetics have a top-level design from central dents rather than seek help from the of psychiatric disorders, the precise government to research institutes and governmental institutions.23 This is molecular mechanism responsible for communities due to the fact that schools are reluc- the occurrence of mental diseases and National/social level tant to undertake the responsibilities suicidal behaviours could be unrav- Setting up the State Suicide Intervention and avoid being stigmatised given elled, and the link between disease Committee that the public often holds the school genotypes and phenotypes could be Similar to the coronavirus disease 2019 24 responsible for student suicide.23 established. It is highly likely that (COVID-19) pandemic where the Another weakness is insufficient if a nationwide database with clinical medical and public health staff alone financial investment. The Korean information, self-­report and teacher-­ cannot be relied on for controlling the government doubled the budget report questionnaires, CCTV records pandemic, there is an urgent need for for mental care–related fields from and blood samples could be estab- the central government in each country 18 million US $ in 2010 to 43 million lished, the interplay between the to take bold, innovative and coura- US $ in 2014,17 but it still only genetics of psychiatric diseases, social geous actions that are aimed at suicide accounted for less than 3% of total factors and suicide behaviour could prevention in adolescents.28 29 The healthcare expenditures, much be unravelled.25 current Korean mental health service

2 Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 General Psychiatry delivery system is led by the Ministry of Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from Health and Welfare.17 More powerful leadership is needed to gather all the necessary resources and strengths to prevent adolescent suicides. One suggestion is that the Korean govern- ment establishes a State Suicide Inter- vention Committee (SSIC) that is directly led by the state premier. This committee should comprise high-­ ranking officials from the Ministry of Education, Finance, Health, Justice and so on, in co-operation­ with top experts from the areas of computer science, internet monitoring, ethical issues and social networking services (SNS) as well as NGOs. Furthermore, Figure 1 Integrated programme to prevent suicides (in Korean adolescents). the SSIC should grant permission to collect all the necessary data and threefold: (1) identifying individuals under the SSIC. Its primary functions develop/evaluate/adjust its suicide who are attempting suicide or insti- are (1) seeking and accepting financial prevention strategies. gating suicidal action through 24/7 support from big enterprises, financial It should be emphasised that internet surveillance; (2) taking urgent groups and personal donations; and powerful leadership provided by measures to stop it through co-opera­ - (2) conducting mental health educa- the government on national adoles- tion with local government; (3) retro- tion programmes for adolescents. cent suicide prevention relies on the spectively obtaining and analysing all Adolescence is a special period char- mental health law legislation,30 with the information in social media and on acterised by great mental and physical the aim to screen students who are at websites posted by young people who changes. The lack of ability to regu- risk of harming themselves and others, have just committed suicide. These late emotions, social influence and provide sufficient financial budget to data are important for suicide predic- sensation-seeking­ behaviour are the expand and improve the mental health tion and prevention. major contributing factors for adoles- services, as well as to conduct high-­ cents committing self-injuries.­ 37 Thus, quality research in suicide prevention. http://gpsych.bmj.com/ Sharing parental divorce information mental health education programmes SSIC is also responsible for promoting Parental divorce is commonly seen in should address adolescent physical the development and amendment of suicide cases in female adolescents.8 and mental development. A recent mental health management law and SSIC should make a rule that the study conducted in Korean adolescents bills. parents’ divorce information be shared found an association between suicide with the local Education Bureau, with and the number of psychiatrists and Monitoring online suicide posts to identify the latter informing schools to pay adolescents at risk of suicide the availability of community health

more attention to these students. The on September 28, 2021 by guest. Protected copyright. services38; this finding further illus- The importance of monitoring and school should communicate with the trates the importance and necessity analysing suicide-related­ posts on the students’ parents, asking them and to provide more psychological care to internet is undeniable. The high view- their child(ren) to use 24/7 hotline adolescents. The following actions can ership of teenage suicide on social whenever they need help. Further- be taken: (1) a mental health educa- media has become a great concern, but more, SSIC should make comprehen- tion programme should be conducted at the same time, it provides the chance sive and consistent efforts to restrict online and offline on the WHO suicide to protect the young people expressing the access to lethal means, such as their intent to self-­harm and suicidal day (10 September), and periodically 31–33 control of analgesics, install platform thoughts on the internet. It was physical barriers in metro stations and (every 3 months) to introduce knowl- recently reported that by analysing so on.35 36 edge of mental health, the concept of the online posts to identify those cherishing life and how to deal with suggestive of suicide thoughts and Setting up the Adolescence Mental Health unhealthy moods; (2) setting up a 24/7 behaviour, individuals at risk of suicide Promotion Foundation hotline with the telephone number could be contacted and managed by The current financial resources for 910 to provide consultations and help trained counsellors.34 SNS and KSPC suicide prevention primarily come for adolescents experiencing psycho- should co-­operate to upgrade and from the Korean central government,17 logical distress or having difficulties set up a nationwide online suicide and they are not sufficient. This paper coping with challenging life events. information monitoring system. The suggests setting up the Adolescence The responsibilities of the Adoles- primary functions of this system are Mental Health Promotion Foundation cence Mental Health Promotion

Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 3 General Psychiatry

Foundation would be especially via training programmes and social current lessons/curriculum arrange- Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from crucial in emergency conditions, such media to alert the public to notice ment and suggestions about the as during the pandemic outbreak of these behaviours and adopt necessary prospective programmes on unmen- COVID-19 around the world including intervening measures. This strategy will tioned aspects. For example, according Asian countries such as Korea.39 People enable them to stop another student to an online questionnaire survey living in the affected areas have already from committing suicide and reduce through campus network conducted suffered from a variety of mental the suicide rate in the long term. in 466 undergraduate college students problems, such as fear, hopelessness, in China, some unique behavioural loneliness, guilt, discrimination, racist Psychology consultation team and mental features suggestive of depression attacks and even suicide.40–42 Special health educational curricula were identified.46 The results of physiological care should be given to According to an investigation these surveys should be discussed adolescents and students.43 44 In Korea, performed in 2402 adolescents in during the routine meetings of the schools are closed owing to COVID- Shanghai, it was revealed that 21.7% psychology consultation team along 19, and the Ministry of Education has of the students experienced non-­ with the need for further adjustments decided to extend the school closures.45 suicidal self-injur­ y behaviour largely in lessons and curriculum. The educa- Thus, attention should be paid to the because of deficient emotional regula- tion programme should also focus on 37 psychological changes in the local tion and social influence. Thus, it is the gatekeepers in school, including students and particularly those interna- necessary to set up or improve school-­ school staff members and school coun- tional students living alone because of wide awareness of mental health and sellors, to improve their ability to iden- lock-­downs,42 instructing them to avoid suicide and facilitate the access to tify and help at-risk­ students. untruthful information and to provide mental health services. The schools more online physiological consulta- should establish a psychology consul- Family-based programmes tions with any available methods, such tation team consisting of student and The Korean society places strong as social media–based approaches and teacher representatives, ethical profes- emphasis on family relations; on the necessary personal protection mate- sionals, lawyers and psychologists, with one hand, this cultural feature of rials, such as masks and so on.40 44 All the right to directly report to local family being at the core is good for the these supports can be delivered by the government and make a quick referral prevention of suicide, but on the other Foundation. in case of an emergency. They should hand, this may have a devastating effect hold routine meetings every 3 months when the close-knit­ relationship within School-based programmes or urgent meetings whenever neces- the family members is disturbed. For CCTV installation sary. The meeting topics are student example, experiencing parental verbal

The retrospective suicide report behaviours, moods and thoughts in or physical abuse will intensify the http://gpsych.bmj.com/ submitted by teachers may contain the family and in schools; the potential ideation of suicide in Korean adoles- subjective bias and miss some key infor- effects of a most recent social, family cents.49 Confucianism is another char- mation.8 To obtain more objective and or school event(s) on the students’ acteristic feature of the Korean culture. realistic information, installing CCTVs mental health; and ways to deal with Within the family, this likely translates in all the schools and making full use stress. to the boundless and excessive expec- of the campus surveillance system that A previous study has reported that tations from parents, which children runs day and night is a solution.46 The even medical students are reluctant must fulfil. Such an academic stress, on September 28, 2021 by guest. Protected copyright. benefits of this strategy will show in the to disclose their mental health prob- also called ‘education fever’ within the long term. It was shown that station lems.48 Thus, educational programmes, family, is one of the causes of suicide staff training programmes and CCTV curricula and various school activi- in Korean adolescents.49 In addition, analysis of particular behavioural ties should be presented to increase owing to the Korean cultural and social themes related to suicide potential student knowledge about mental stigma, it is shameful to admit having in stations could both contribute to health problems and literacy, their mental health problems.27 Thus, railway station suicide intervention suicide risk awareness, the capacity to family-­based programmes to educate and prevention efforts.47 In a Korean lessen academic pressure, and ways parents not to put undue pressure on adolescent suicide case, if a student to improve moods and a sense of their children and to improve parents’ takes his/her own life, CCTV record- well-­being, and, most importantly, to mental health literacy and family ings of his/her previous 1 week/month, encourage the students having suicidal support, especially in those families along with the teacher’s report, should ideation to actively seek help. The with a history of mental illnesses, are be submitted to the SSIC for detailed students also need to be instructed indispensable in suicide prevention in analysis using artificial intelligence what they should do when they find the young.8 techniques to identify any subtle or a classmate with suicidal ideation. A These educational programmes obviously abnormal behaviours sugges- psychology consultation team should containing psychological training tive of suicidal ideation.47 Thereafter, conduct anonymous and voluntary should also be held by the school these abnormal behaviours will be surveys regularly to enable the students psychology consultation team to introduced to teachers and the public to express their feedback about the improve parental awareness about

4 Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 General Psychiatry mental health, recognise potential background of those who attempted lack of knowledge of physicians in Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from suicidal behaviours in their child(ren), suicide with different mental disor- the setting of primary care or general instruct the parents to communicate ders, such as major depression, bipolar hospitals and thus failure to screen with their child(ren) about how they disorder and schizophrenia.60 Suicidal patients for depression. Therefore, are feeling, provide information on behaviour is aggregated within the improving physician knowledge of how to support the child(ren) and family; the genetic transmission of depression and suicide risk evalua- teach them how to seek help from the suicide attempt has been recently tion is a central component in suicide school and society. These education confirmed in a large-scale­ case-control­ prevention. However, cultivating and programmes should also encourage study consisting of 6024 cases of suicide training these professionals is time parents to establish mutually trusting attempt and 44 240 controls with no consuming. Whether the supply of relationships with the school and to record of a suicide attempt.61 these experienced experts could meet report their concerns or observations In addition to the genetic back- the demand is doubtful. However, about their child(ren)’s mental health ground, peripheral and central inflam- WHO1 confirmed that the Secretariat conditions to the school psychology matory abnormalities are involved will provide the necessary support for consultation team. Because family-­ in the pathophysiology of suicidal technology improvement and training related issues are the leading cause behaviour.62 The changes of inflam- programmes. of adolescent suicide,8 parents are matory cytokines, neurotransmit- The third potential challenge strongly recommended to report their ters and other biochemical markers pertains to ethical and privacy family conflicts. such as serotonin, catecholamines, concerns. The ethical issues of privacy norepinephrine and dopamine with confidentiality in the implementation Upgrading the current suicide report suicidal behaviours have been widely of prevention programme initiatives, system to a new bio-information system reported.62 63 Although psychological such as sharing parental divorce infor- In the era of evidenced-based­ medi- status is also related to other diseases, mation and the installation of CCTVs cine and precision medicine, a such as cardiovascular diseases, at schools, also should be taken into systemic biology approach is crucially diabetes and their complications,64–66 serious consideration. How to ensure needed for disease prevention and suicidal attempts are mostly reported that all the information collected treatment.50 Although several suicide in subjects with pre-existing­ mental from schools, family and psychological prevention activities or strategies have illness.67 It is thus rational to upgrade services, and blood samples is safe and been implemented, strategies proven the current suicide report system to a does not aid discrimination is critical. effective in reducing suicide rates, such new bio-­information system covering Fourth, cultural barriers prevent as early intervention for youth with genetic, biochemical and psycholog- the public from talking about mental mental health disorders, are often not ical illness information. The function- health issues openly and discussing http://gpsych.bmj.com/ available. Only through a comprehen- alities of this new system are, but not family problems with others. The sive and in-­depth investigation on the limited to, data collection and analysis, attitude towards mental health issues genetic architecture, biomarkers and monitoring and surveillance, predic- may need generations to convert. comorbidities, can the high-­risk popu- tion and prevention, and education Fifth, some suicide-related­ infor- lation at pre-­diagnostic or prodromal and treatment. mation is only accessible through or asymptomatic stages be targeted,51–55 exclusive networks using dedicated and clinical patients can be classified56 software, which is unlikely to find its on September 28, 2021 by guest. Protected copyright. and be treated individually.50 57 Challenges users.68 Much work is needed to find Currently, Korea has implemented a The major challenges posed by this these networks. suicide report system with the informa- programme are its financial burden, Finally, another set of evaluation tion mainly provided by the teachers shortage of professionals, ethical and modification mechanisms is who have a suicidal student. Although concerns and cultural barriers. First, required to assess the efficacy and the system is good, it needs to be the funding provided to the mental efficiency of all the measures already improved substantially. The aetiology health sector within the overall health- taken with specific targets and time of suicides is multi-factorial­ involving care system is very low (3%) compared table. The ultimate goal of the new genetic, biochemical abnormalities with WHO’s suggestions (15%–50%).17 system is a significant reduction in the and mental disorders. Understanding Setting up a foundation may partly suicide rate among Korean adoles- the genetic architecture of suicidal solve this problem. cents in 5–10 years. behaviours and exploring its relation- Second, this programme requires ship with other biological traits to the involvement of a large number of generate quantitative risk probability psychologists and general practitioners Conclusion of suicide is extremely important for in the communities. Unfortunately, The aetiologies of adolescent suicides suicide prevention and is now tech- depression and other psychiatric disor- are complex. The Korean government nically feasible.58 59 For example, the ders are under-recognised­ and under- has already implemented a series of most recent genome-wide­ association treated in the primary care setting administrative and technical strate- study confirmed the common genetic or general hospitals because of the gies to address suicides in the general

Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 5 General Psychiatry Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from population, including adolescents, To cite Liu J. General Psychiatry Epub ahead of methamphetamine abusers in Shanghai, which has led to some improvements. print: [please include Day Month Year]. doi:10.1136/ China. Gen Psychiatr 2019;32:e100062. gpsych-2020-100200 15 Alteri A, Corti L, Sanchez AM, et al. However, a great deal of work could Assessment of pre-­implantation genetic be done to make further progress. testing for embryo aneuploidies: a SWOT Received 18 January 2020 analysis. Clin Genet 2019;95:479–87. This paper proposes to adopt a new Revised 4 June 2020 16 Costantino C, Mazzucco W, Marotta C, holistic programme with top-level­ Accepted 4 June 2020 et al. Methodological issues in a cross-­ sectional survey on cervical cancer design integrating administrative and screening using telephone interviews in General Psychiatry 2020;33:e100200. technical forces to prevent suicide Sicily (Italy): a SWOT analysis. J Int Med doi:10.1136/gpsych-2020-100200 Res 2019;47:5174–84. in adolescents. The Korean central 17 Roh S, Lee S-­U, Soh M, et al. Mental health government still plays a predominant ORCID iD services and R&D in South Korea. Int J role in this system. The stakeholders Jiacheng Liu http://orcid.​ ​org/0000-​ ​0002-5663-​ ​0154 Ment Health Syst 2016;10:45. 18 Kim H, Kwon SW, Ahn YM, et al. at nation/society, school and family Implementation and outcomes of suicide-­ levels work together to provide a prevention strategies by restricting access healthy environment necessary for References to lethal suicide methods in Korea. J Public 1 World Health Organization. Mental Health Health Policy 2019;40:91–102. the development of mental health in Action Plan 2013–2020, 2013. Available: 19 Korean Association for Suicide Protection, adolescents. A nationwide bio-bank­ https://www.​who.​int/​mental_​health/​action_​ 2011. Available: http://​suicideprevention.​or.​ kr/​new2/​contents/​sub0301.​php [Accessed collecting genetic, biochemical, psychi- plan_​2013/​en/ [Accessed 6 Oct 2019]. 2 Zalsman G. The neurobiological basis of 13 Sept 2019]. atric disease and comorbidity informa- suicide (Chapter 14). Boca Raton (FL): CRC 20 Korea Association for Suicide Prevention. tion should be established to explore Press/Taylor & Francis, 2012. Work introduction—Livingwork suicide 3 World Population Review. Suicide rate by preventive education, 2017. Available: detailed mechanisms explaining country 2019, 2019. Available: http://worl​ ​ http://​suicideprevention.​or.​kr/​new2/​ suicidal ideation and behaviour and dpop​ulat​ionr​eview.​com/​countries/​suicide-​ contents/sub0501.​ ​php [Accessed 26 Sept rate-by-​ country/​ [Accessed 6 Dec 2019]. 2019]. uncover novel biomarkers and genetic 4 Lee K, Lee D, Hong HJ. Text mining 21 Duffy A, Goodday SM, Keown-­ risk factors, which in turn will assist analysis of teachers’ reports on student Stoneman C, et al. Epigenetic markers in in developing a model suitable for suicide in South Korea. Eur Child Adolesc inflammation-r­elated genes associated Psychiatry 2020;29:453–65. with mood disorder: a cross-sectional­ and suicide prediction, surveillance and 5 Kim G-­M, Kim J, Hyun MK, et al. longitudinal study in high-risk­ offspring education. Comparison of the risk factors of Korean of bipolar parents. Int J Bipolar Disord adolescent suicide residing in high suicidal 2019;7:17. regions versus those in low suicidal regions. 22 Choi Y-­S, Shin HK, Hong D-Y­ , et al. Self-­ Acknowledgements The author thanks Michelle Psychiatr Danub 2019;31:397–404. esteem as a moderator of the effects Williamson and Anna Ross from Melbourne School 6 Jung JS, Park SJ, Kim EY, et al. Prediction of happiness, depression, and hostility of Population & Global Health at The University of models for high risk of suicide in Korean on suicidality among early adolescents Melbourne for their comments on this paper. adolescents using machine learning in Korea. J Prev Med Public Health techniques. PLoS One 2019;14:e0217639. 2019;52:30–40. Contributors This paper was prepared and completed 7 Park CHK, Lee JW, Lee SY, et al. The 23 Cha JM, Kim JE, Kim MA, et al. Five http://gpsych.bmj.com/ by JL alone. Korean cohort for the model predicting months follow-up­ study of school-­based crisis intervention for Korean high school Funding The author has not declared a specific a suicide and suicide-­related behavior: study rationale, methodology, and baseline students who experienced a peer suicide. J grant for this research from any funding agency in the sample characteristics of a long-­term, Korean Med Sci 2018;33:e192. public, commercial or not-­for-­profit sectors. large-­scale, multi-­center, prospective, 24 Hoffman GE, Bendl J, Voloudakis G, Competing interests None declared. naturalistic, observational cohort study. et al. CommonMind Consortium provides Compr Psychiatry 2019;88:29–38. transcriptomic and epigenomic data for Patient consent for publication Not required. 8 Lee K, Lee D, Hong HJ. Text mining schizophrenia and bipolar disorder. Sci analysis of teachers’ reports on student Data 2019;6:180. Not commissioned; Provenance and peer review suicide in South Korea. Eur Child Adolesc 25 Schwabe I, Milaneschi Y, Gerring Z, et al. externally peer reviewed. Psychiatry 2020;29:453-465. Unraveling the genetic architecture of on September 28, 2021 by guest. Protected copyright. 9 Jung S, Lee D, Park S, et al. Subtypes of major depressive disorder: merits and suicidal ideation in Korean adolescents: a pitfalls of the approaches used in genome-­ multilevel latent profile analysis. Aust N Z J wide association studies. Psychol Med Psychiatry 2019;53:158–67. 2019;49:2646–56. 10 Kwak CW, Ickovics JR. Adolescent suicide 26 Kwon H, Kim R, Roh B-­R, et al. in South Korea: risk factors and proposed Suicide prevention program in schools: multi-­dimensional solution. Asian J teacher’s perception of benefits and Psychiatr 2019;43:150–3. barriers. J Korean Neuropsychiatr Assoc Open access This is an open access article 11 Jung S, Lee D, Park S, et al. Gender 2014;53:8–14. distributed in accordance with the Creative Commons differences in Korean adolescents who 27 Young Health Programme. YHP South Attribution Non Commercial (CC BY-NC­ 4.0) license, died by suicide based on teacher reports. Korea—safeTALK, 2011. Available: https:// which permits others to distribute, remix, adapt, build Child Adolesc Psychiatry Ment Health www.​youn​ghea​lthp​rogr​ammeyhp.​com/​ programmes/​korea.html​ [Accessed 13 Sept upon this work non-commercially­ , and license their 2019;13:12. 12 Giusti A, Maggini M, Colaceci S. The 2019]. derivative works on different terms, provided the burden of chronic diseases across Europe: 28 Guest JL, Del Rio C, Sanchez T. The original work is properly cited, appropriate credit is what policies and programs to address three steps needed to end the COVID-19 given, any changes made indicated, and the use is diabetes? A SWOT analysis. Health Res pandemic: BOLD public health leadership, non-­commercial. See: http://​creativecommons.​org/​ Policy Syst 2020;18:12. rapid innovations, and courageous licenses/​by-​nc/​4.​0/. 13 Kumar P, Jangid P, Sethi S. Undergraduate political will. JMIR Public Health Surveill psychiatry in India: a SWOT analysis. Asian 2020;6:e19043. © Author(s) (or their employer(s)) 2020. Re-­use J Psychiatr 2018;33:46–51. 29 Murdoch D, Addidle M, Andersson H-­S, permitted under CC BY-­NC. No commercial re-use.­ See 14 Zhu Y, Zhong N, Su H, et al. Strengths, et al. Politicians: please work together to rights and permissions. Published by BMJ. weaknesses, opportunities and threats minimise the spread of COVID-19. N Z Med (SWOT) analysis of reinitiation into J 2020;133:7–8. methamphetamine abusers: qualitative 30 Moran-­Bates J. Youth suicide legislation findings from an exploration of in the 2019 session of the North

6 Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 General Psychiatry

Carolina General Assembly. N C Med J the COVID-19 outbreak. Lancet Psychiatry discrimination between type 1 and type 2 Gen Psych: first published as 10.1136/gpsych-2020-100200 on 9 July 2020. Downloaded from 2020;81:108–9. 2020;7:e22. diabetes in young adults. Diabetes Care 31 Kirtley OJ, O'Connor RC. Suicide 45 Kim S, Kim YJ, Peck KR, et al. School 2016;39:337–44. prevention is everyone’s business: opening delay effect on transmission 57 Chen Y, Zhou T, Sun D, et al. Distinct challenges and opportunities for Google. dynamics of coronavirus disease 2019 in genetic subtypes of adiposity and glycemic Soc Sci Med 2020;18:112691. Korea: based on mathematical modeling changes in response to weight-­loss diet 32 Phillips JG, Diesfeld K, Mann L. Instances and simulation study. J Korean Med Sci intervention: the pounds lost trial. Eur of online suicide, the law and potential 2020;35:e143. J Nutr 2020. doi:10.1007/s00394-020- solutions. Psychiatr Psychol Law 46 Mei G, Xu W, Li L, et al. The role of campus 02244-x 2019;26:423–40. data in representing depression among 58 Ruderfer DM, Walsh CG, Aguirre MW, et al. 33 Dagar A, Falcone T. High viewership of college students: exploratory research. Significant shared heritability underlies videos about teenage suicide on YouTube. JMIR Ment Health 2020;7:e12503. suicide attempt and clinically predicted J Am Acad Child Adolesc Psychiatry 47 Mackenzie J-­M, Borrill J, Hawkins E, probability of attempting suicide. Mol 2020;59:1–3. et al. Behaviours preceding suicides at Psychiatry 2019. doi:10.1038/s41380-018- 34 Liu X, Liu X, Sun J, et al. Proactive suicide railway and underground locations: a 0326-8 prevention online (PSPO): machine multimethodological qualitative approach. 59 Grimmond J, Kornhaber R, Visentin D, identification and crisis management for BMJ Open 2018;8:e021076. et al. A qualitative systematic review of Chinese social media users with suicidal 48 Fletcher I, Castle M, Scarpa A, et al. An experiences and perceptions of youth thoughts and behaviors. J Med Internet Res exploration of medical student attitudes suicide. PLoS One 2019;14:e0217568. 2019;21:e11705. towards disclosure of mental illness. Med 60 Mullins N, Bigdeli TB, Børglum AD, et al. 35 Matsumoto T, Imamura F, Chiba Y, et al. Educ Online 2020;25:1727713. GWAS of suicide attempt in psychiatric Analgesia during self-cutting:­ clinical 49 Park Y, Baik SY, Kim H-­S, et al. The disorders and association with major implications and the association with influence of traditional culture and the depression polygenic risk scores. Am J suicidal ideation. Psychiatry Clin Neurosci interpersonal psychological theory on Psychiatry 2019;176:651–60. 2008;62:355–8. suicide research in Korea. Psychiatry 61 Erlangsen A, Appadurai V, Wang Y, et al. 36 Xing Y, Lu J, Chen S. Evaluating the Investig 2017;14:713–8. Genetics of suicide attempts in individuals effectiveness of platform screen doors for 50 Hampel H, Caraci F, Cuello AC, et al. with and without mental disorders: a preventing Metro suicides in China. J Affect A path toward precision medicine for population-­based genome-­wide association Disord 2019;253:63–8. neuroinflammatory mechanisms in study. Mol Psychiatry 2018. doi:10.1038/ 37 Zhang F, Cloutier PF, Yang H, et al. Non-­ Alzheimer’s disease. Front Immunol s41380-018-0218-y suicidal self-­injury in Shanghai inner bound 2020;11:456. 62 Brundin L, Bryleva EY, Thirtamara middle school students. Gen Psychiatr 51 Habtewold TD, Islam MA, Liemburg EJ, Rajamani K. Role of inflammation 2019;32:e100083. et al. Polygenic risk score for schizophrenia in suicide: from mechanisms to 38 Song J, Park S, Lee K, et al. Influence of was not associated with glycemic level treatment. Neuropsychopharmacology area-level­ characteristics on the suicide (HbA1c) in patients with non-­affective 2017;42:271–83. rate in Korean adolescents. Psychiatry psychosis: genetic risk and outcome 63 Sudol K, Mann JJ. Biomarkers of suicide Investig 2019;16:800–7. of psychosis (group) cohort study. J attempt behavior: towards a biological 39 Kim ES, Chin BS, Kang CK, et al. Clinical Psychosom Res 2020;132:109968. model of risk. Curr Psychiatry Rep course and outcomes of patients with 52 Liyanarachchi S, Gudmundsson 2017;19:31. severe acute respiratory syndrome J, Ferkingstad E, et al. Assessing 64 Elgendy R, Deschênes SS, Burns RJ, coronavirus 2 infection: a preliminary report thyroid cancer risk using polygenic et al. Alcohol consumption, depressive of the first 28 patients from the Korean risk scores. Proc Natl Acad Sci U S A symptoms, and the incidence of diabetes-­ cohort study on COVID-19. J Korean Med 2020;117:5997–6002. related complications. J Diabetes Sci 2020;35:e142. 53 Koo BK, Joo SK, Kim D, et al. Development 2019;11:14–22.

40 Mamun MA, Griffiths MD. First COVID-19 and validation of a scoring system, based 65 He J, Li S, Liu F, et al. Glycemic control is http://gpsych.bmj.com/ suicide case in Bangladesh due to fear on genetic and clinical factors, to determine related to cognitive dysfunction in Chinese of COVID-19 and xenophobia: possible risk of steatohepatitis in Asian patients children with type 1 diabetes mellitus. J suicide prevention strategies. Asian J with nonalcoholic fatty liver disease. Clin Diabetes 2018;10:948–57. Psychiatr 2020;51:102073. Gastroenterol Hepatol 2020. doi:10.1016/j. 66 Morone J. Systematic review of 41 Monteith LL, Holliday R, Brown TL, et al. cgh.2020.02.011 sociodemographic representation and Preventing suicide in rural communities 54 Xie K, Zhang Y, Wen J, et al. Genetic cultural responsiveness in psychosocial and during the COVID-19 pandemic. J Rural predisposition to gestational glucose behavioral interventions with adolescents Health 2020. doi:10.1111/jrh.12448 metabolism and gestational diabetes with type 1 diabetes. J Diabetes 42 Stop the coronavirus stigma now. Nature mellitus risk in a Chinese population. J 2019;11:582–92. 2020;580:165. Diabetes 2019;11:869–77. 67 Plans L, Barrot C, Nieto E, et al. Association 43 Dalton L, Rapa E, Stein A. Protecting the 55 Song C, Wang M, Fang H, et al. Effects between completed suicide and bipolar on September 28, 2021 by guest. Protected copyright. psychological health of children through of variants of 50 genes on diabetes risk disorder: a systematic review of the effective communication about COVID-19. among the Chinese population born in the literature. J Affect Disord 2019;242:111–22. Lancet Child Adolesc Health 2020;4:346–7. early 1960s. J Diabetes 2019;11:857–68. 68 Mörch C-­M, Côté L-­P, Corthésy-­Blondin 44 Zhai Y, Du X. Mental health care for 56 Oram RA, Patel K, Hill A, et al. A type L, et al. The Darknet and suicide. J Affect international Chinese students affected by 1 diabetes genetic risk score can aid Disord 2018;241:127–32.

Jiacheng Liu is in a master's program on public health in Melbourne School of Population & Global Health, Division of Medicine, Dentistry and Health Sciences, The University of Melbourne from 2019 to 2021. His research interests include global epidemiology, prevention and treatment of psychological disorders and other non-­communicable diseases, with a special focus on the area of suicide prevention strategies aimed at improving the public awareness and knowledge about mental health problems and increasing the standard of basic and clinical research on psychiatric disorders.

Liu J. General Psychiatry 2020;33:e100200. doi:10.1136/gpsych-2020-100200 7