The Epidemiology of Suicide Attempts and Suicidal Thoughts in Flanders

Primary outcomes

1. Baseline Demographic and Socioeconomic Characteristics

   Time frame: Day 1

   Sociodemographic information will be collected via standardized intake forms during the initial assessment interview. The following variables will be recorded:

   • Date of birth (continuous, in DD/MM/YYYY format)
   • Gender (Male / Female / X)
   • Marital status (Unmarried / Officially cohabitating / Married / Divorced / Widowed)
   • Housing situation (Alone / Not alone)
   • Presence of children (Yes / No)
   • Economic activity status (Economically active / Unemployed / Economically inactive)

   • If economically inactive: Pupil or student / Disability due to physical or psychological problems / Retirement / Other (specify) Profession (open text, if applicable)
   • School situation (if student):

   • Primary education
   • Secondary education (ASO / TSO / BSO / KSO / BuSO)
   • Higher education or university
   • Other (specify) All responses will be recorded and coded for analysis. Categorical variables will be summarized using frequency and percentage. Open-ended responses will be described narratively

2. Baseline Demographic, Socioeconomic and Clinical Admission Characteristics

   Time frame: Day 1

   Additional personal and contextual characteristics will be collected during the initial assessment interview. These include:

   Pregnancy status (Yes / No)

   Country of birth of the participant, their mother, and their father (Belgium / Other - specify)

   Current medication: Open-ended question regarding all prescribed or self-used medications at time of intake.

   Reason for admission (Suicidal thoughts / Suicide attempt)

   All categorical variables will be recorded using predefined categories. Open-text fields (e.g., country of birth, medication list) will be thematically categorized post-hoc where applicable. These variables are used to describe the population and examine their relationship with clinical outcomes.

3. Method of Suicide Attempt Classified by ICD-10 Category

   Time frame: Day 1

   The method of suicide attempt will be assessed through a semi-structured interview and classified according to the relevant ICD-10 codes for intentional self-harm (e.g., X60-X84). Each participant's attempt will be categorized based on the specific method used (e.g., poisoning, cutting, jumping, hanging), as defined by ICD-10 classification.

4. Assessment of Current Emotional State (Open-Ended Response)

   Time frame: Day 1

   Participants will be asked the open-ended question:

   "How are you feeling right now?" Responses will be collected verbatim during a clinical interview. A qualitative content or thematic analysis will be performed to identify and categorize emotional states (e.g., anxious, sad, calm, angry). The number and percentage of participants reporting each emotional category will be reported.

5. Suicidal Ideation Attributes (Modified SIDAS)

   Time frame: Day 1

   A modified version of the Suicidal Ideation Attributes Scale (SIDAS) will be used to assess the presence and characteristics of suicidal ideation in the past month. The following six items will be included:

   • Current suicidal thoughts: Response: Yes / No.
   • Frequency of suicidal thoughts in the past month
   • Duration of suicidal thoughts
   • Perceived control over suicidal thoughts
   • Emotional suffering due to suicidal thoughts
   • Functional interference (e.g. with work or household tasks)
   • Proximity to a suicide attempt in the past month (only asked if ideation present, not in case of actual attempt).

   This version retains the conceptual dimensions of the original SIDAS but uses predefined categorical response scales instead of numerical ratings. Results will be analyzed using frequency distributions and, where appropriate, ordinal scales. This adapted version allows for structured yet clinically nuanced evaluation of suicidal ideation during intake.

6. Assessment of Suicidal Planning and Intent (Mixed-Methods Interview)

   Time frame: Day 1

   Suicidal planning and intent will be assessed through a structured set of questions combining categorical responses and open-ended fields. The following domains will be evaluated:

   Presence of a current suicide plan (categorized as: no thoughts, thoughts without plan, detailed plan)

   Method(s) considered (open-ended response)

   Availability of method (Yes/No)

   Degree of preparation (No preparation, Minimal preparation, Extensive preparation)

   Timing and delay of planned action (open-ended response)

   Categorical data will be analyzed descriptively (counts and percentages per category). Open-ended responses will undergo thematic analysis to identify patterns in methods considered and perceived urgency or control over suicidal intent.

7. History of Suicidal Behavior and Post-Attempt Treatment (Structured Interview)

   Time frame: Day 1

   Participants will be asked a structured set of questions to assess the history of suicidal behavior and care received following previous suicide attempts. The following aspects will be recorded:

   Number of lifetime suicide attempts (0, 1, 2, 3, ≥4)

   Time since last attempt (≤6 months, 6-12 months, >12 months)

   Psychological treatment received after attempt (Yes/No)

   Satisfaction with treatment (Yes/No)

   Type of provider or setting (e.g., psychiatrist, school guidance center, residential care, mental health center, other)

   Whether the attempt required medical treatment (Yes/No) and location (e.g., hospital, general practitioner, other)

   Method used in previous attempt(s) (open-ended)

   Categorical data will be summarized using frequencies and percentages. Open-ended responses on method used will be analyzed qualitatively and grouped by ICD-10 method category (e.g., poisoning, cutting, jumping).

8. History and Recency of Self-Harming Behavior (Structured Interview)

   Time frame: Day 1

   Participants will be asked whether they have ever deliberately hurt or injured themselves (Yes/No). If the response is Yes, they will be asked to indicate when they last engaged in self-harming behavior:

   < 6 months ago > 6 months ago

   Responses will be recorded categorically to assess lifetime presence and recency of non-suicidal self-injury (NSSI) or deliberate self-harm.

9. Perceived Social Support and Help-Seeking Behavior (Semi-Structured Interview)

   Time frame: Day 1

   Social support will be assessed using a semi-structured interview consisting of both categorical and open-ended questions, focusing on:

   Perceived emotional support: "Do you feel there are people who care about you?" (Yes/No)

   Identified source(s) of support: Open-ended response if Yes

   Availability of support when struggling: (Not inclined to seek support / No / Yes)

   Identified support figure: Open-ended response if Yes

   Actual help-seeking behavior: (No / Sometimes / Yes)

   Open-ended responses (e.g., to whom the participant turns) will be categorized using inductive thematic coding. Categorical responses will be summarized as frequencies and proportions.

10. Participant's Experience of Hopelessness (Open-Ended Response)

    Time frame: Day 1

    Participants will be asked the following open-ended questions:

    "Do you feel completely stuck, as if there is no way out?" "Do you feel hopeless, like there's no way out of your situation?" "Is there anything that might help you get through this period?" Responses will be collected in written form. Qualitative analysis (e.g., thematic analysis or content coding) will be used to identify recurring expressions of hopelessness or related emotional states. Results will be reported as the number and percentage of participants expressing each identified theme.

11. Openness to Professional Help When Experiencing Suicidal Thoughts

    Time frame: Day 1

    Participants will be asked about their willingness to engage in professional help when struggling with suicidal thoughts. The question is phrased as:

    "When struggling with suicidal thoughts, it is recommended to get professional help. Would you be open to have a conversation with [healthcare provider] to gain more insight into the things you are struggling with and possible next steps?"

    Response options are:

    • Does not want professional help
    • Neutral
    • Is open to professional help

    Responses will be recorded categorically and reported as frequencies and proportions across the three levels.

12. Suicide Intent Severity Assessed by Suicide Intent Scale (SIS)

    Time frame: Day 1

    The severity of intent during the most recent suicide attempt will be assessed using the Suicide Intent Scale (SIS). The SIS is a 8-item clinician-administered scale evaluating objective circumstances and subjective expectations associated with the attempt.

    Each item is scored from 0 to 2 (range total score: 0-16), with higher scores indicating greater suicidal intent.

    Scores will be reported as continuous outcomes (mean, SD), and optionally categorized (e.g., low intent: ≤5; high: >6).

13. Motives for Suicide Attempt Based on Structured Clinician Classification

    Time frame: Day 1

    Motives for the suicidal behavior will first be explored through an open-ended question:

    "What motives did you have for your suicide attempt / suicidal thoughts?"

    Based on the participant's narrative, the clinician will categorize the motives using a predefined set of thematic categories:

    • Internal conflict (e.g., emotional overwhelm, self-punishment, feeling of failure)
    • Interpersonal motives (e.g., desire to be heard, influence others, show love, revenge)
    • Death wish
    • Magical thinking (e.g., rebirth, reunion with deceased)

    Multiple categories may be selected per participant. Open-text responses will be retained for qualitative analysis; category selections will be summarized as frequencies and proportions.

14. Sources of Ambivalence Toward Suicide Attempt (Open-Ended Interview Question)

    Time frame: Day 1

    Participants will be asked the open-ended question:

    "What is currently stopping you from attempting suicide?"

    Responses will be documented verbatim. No predefined answer categories will be provided. The data will be used for qualitative analysis of protective factors, barriers, or ambivalent thoughts associated with suicidal ideation or behavior.

15. Presence and Duration of Stressful or Traumatic Life Events (Clinician-Coded Intake Observation)

    Time frame: Day 1

    During the assessment, clinicians will code the presence and estimated duration of any significant life events or psychosocial stressors spontaneously reported by the participant, based on a predefined list of known suicide-related risk factors. These include:

    • Health-related: psychiatric symptoms, physical illness, disability
    • Loss-related: death or illness of a significant person, suicide or suicide attempt of a significant other
    • Trauma: abuse (physical/emotional/sexual), neglect, assault
    • Social/relational: problems with parents, children, partner, friends, bullying
    • Environmental stressors: financial, housing, work/school, legal, identity-related problems

    Each event is coded by the clinician if mentioned, and the duration of suffering related to each event is estimated using a 3-point scale:

    • = weeks
    • = months
    • = years

16. Substance Use Risk Assessed by CRAFFT Screening Tool

    Time frame: Day 1

    Substance use risk will be assessed using the CRAFFT Screening Interview, a validated 6-item questionnaire designed to identify risky substance use behaviors among adolescents and young adults. Each item is scored 0 (No) or 1 (Yes), resulting in a total score ranging from 0 to 6. A score of ≥2 indicates high risk of problematic substance use.

17. History of Mental Health Problems and Prior Treatment (Categorical and Narrative Assessment)

    Time frame: Day 1

    Participants will be asked whether they have experienced previous mental health problems and whether they sought or received professional treatment. Responses will be recorded using the following categories:

    • No previous mental health problems
    • Yes, previous mental health problems but no treatment
    • Yes, previous mental health problems and received treatment

    For those indicating previous problems, clinicians will document:

    Nature of past mental health issues (open-ended) Type of treatment received (e.g., psychologist, psychiatrist, residential care) and experience with care (open-ended) Whether a formal psychiatric diagnosis was given (open-ended)

    Open text responses will be used for qualitative description and may be thematically coded if relevant to the analysis.

18. Coping Strategies in Response to Stress (Narrative and Structured Clinician Assessment)

    Time frame: Day 1

    Participants will be asked an open-ended question exploring how they typically deal with stress and difficult emotions:

    "How do you deal with problems in general? What do you do when you are worried or upset? What helps you keep going?"

    The clinician will document the participant's narrative response and will also indicate the presence or absence of specific coping behaviors based on a predefined checklist:

    • Talks to someone about it
    • Blames self for being in trouble
    • Gets angry
    • Withdraws/stays in room
    • Reflects on previous coping experiences
    • Uses alcohol or drugs
    • Avoids thinking about worries
    • Tries to sort things out Multiple behaviors can be selected per participant.

19. Perceived Positive and Negative Future Events (Open-Ended Interview Questions)

    Time frame: Day 1

    Participants will be asked two open-ended questions to explore their short-term future outlook:

    "Are there any positive things or events in the near future that could affect your suicidal thoughts?"

    "Are there any negative things or events in the near future that could affect your suicidal thoughts?"

    Responses will be documented verbatim. No predefined response categories are used. Responses will provide insight into the participant's subjective experience of hope, anticipatory stress, or protective/risk factors linked to future-oriented thinking.

20. Patient-Reported Care Needs and Expectations (Open-Ended Interview Response)

    Time frame: Day 1

    Participants will be asked open-ended questions regarding their perceived care needs and expectations for support.

    Formal Care Setting: The participant's responses will be categorized into care delivery modes such as ambulatory care, residential care, general practitioner (GP) involvement.

    Content of Care: The narrative responses will be analyzed for themes related to the nature of care needed, including but not limited to psychological support (individual or group therapy), practical assistance, need for rest or stabilization.

    Responses will be documented verbatim and later coded using thematic analysis.

21. Post-Assessment Care Pathways and Treatment Agreements

    Time frame: Day 1

    Following the clinical intake, the treating clinician will document the planned care pathway for the participant by selecting one or more of the following options:

    No further treatment

    • Discharge (advised) (e.g., returning home)
    • Discharge (counter-advised) (e.g., patient runs away)
    • Return to another facility (e.g., detention unit, sheltered housing, medical pedagogical institution)

    Outpatient treatment (e.g., psychotherapy)

    Inpatient treatment

    • Somatic unit
    • Emergency psychiatry
    • Child/adolescent psychiatric crisis unit
    • Child/adolescent psychiatric unit
    • Psychiatric Ward General Hospital (PAAZ)
    • Psychiatric Hospital (PZ) / Psychiatric Care Home (PVT)
    • Other settings (specify): ____________________________

    In addition, any concrete treatment agreements made with the participant will be documented in free text. Monitoring these aspects is essential for evaluating care continuity, adherence to treatment plans, and subsequent clinical outcomes.