This second volume of our Research Topic ties in with the previous one spotlighting most important issues in emergency psychiatry: suicidality, coercive measures and coping of psychological challenges for health care providers.

Suicidality is without doubt one of the most alerting and urgent symptomatology in mental health. More than 700,000 people worldwide die by suicide every year, and the number of suicide attempts (SA) is estimated as 20-times higher (1). While risk factors for suicidal behavior such as childhood maltreatment, non-suicidal self-injury, and previous SA have been identified across psychiatric disorders (2, 3), up to 70% of suicides have been linked to affective disorders (4). Since the knowledge of suicide predictors has shown limited effect reducing suicide risk in clinical practice over the years according to a recent meta-analysis (5), we still need to improve our understanding of the neurobiology, contributing psychosocial factors and efficient clinical approaches of suicidality. With respect to these needs, dysregulation of the stress hormone system, namely the hypothalamic-pituitary-adrenocortical (HPA) axis, is one of the most consistent neurobiological findings in both, major depression and suicidality. Interestingly, Hennings et al. show that previous SA—which is also an important clinical suicide risk factor—not only have an attenuating effect on the HPA axis activity during a depressive episode but also impact on the recovery of altered HPA axis reactivity due to depression indicating both, acute effects on HPA axis as well as persistent alteration on stress hormone regulation related to a history of suicide attempts.

Chronic pain as well as serious physical conditions associated with somatic disorders like cancer are well known contributors to suicidality (6, 7). But also, psychosocial stress of people living with HIV can induce suicide ideations as shown in the study of Wang et al. Further stressing the need of effective suicide prevention and in line with a world-wide phenomenon, Li et al. describe in a large dataset of North China that most suicide attempters admitted to hospital were relatively young (15–34 years) in both, urban and rural areas. While pesticide self-poisoning accounts for about one-third of the world's suicides (8), it is further documented in this study that in rural areas ingestion of lethal pesticides is still the leading cause (52.1%) suggesting that regulatory restrictions on the accessibility of these poisons would be an promising and easy mean to prevent a significant number of SA and suicides. Given the fact that suicide rates after discharge from psychiatric facilities is about 100 times the global suicide rate during the first 3 months after discharge, and that patients admitted with suicidal thoughts or behaviors had rates near 200 times the global rate in this period of time (9), knowledge on the necessity of immediate follow-up appointments after discharge of patients hospitalized due to suicidality (according to national guideline recommendation for the treatment of suicidal depressed patients) was alarmingly low in a study of German psychotherapists (Teismann et al.).

Despite significant negative impact on mental health including the development of symptoms of PTSD (10, 11) but poor scientific evidence for its general practical and clinical effectiveness (12–14), coercive means are still widely used in psychiatry and even mental health care providers are convinced that their application is inevitable in many cases (15). The Recovery-orientated psychiatric care concept “Weddinger Modell” was initiated to reduce coercive measures in acute psychiatric settings (16). Interestingly, while it has been shown to reduce mechanical coercive measures (17) and post-coercion PTSD symptoms (18), Czernin et al. now demonstrate that in the same time incidence of forced medication did not increase but that the maximum doses of psychiatric drugs needed for acute symptom control can even be reduced including maximum forced haloperidol dose. These findings support the development of a more participating and recovery-orientated psychiatric care also in acute settings and may improve the public recognition of mental health care provided by psychiatric hospitals and their acceptance of the patients.

Although the emotional distress occurring in health professionals while being confronted to coercive means (19), as suicide first responders (20) or in medical emergencies in general intuitively has a psychological impact, mental health in health professionals is a dramatically under-investigated field. As shown in the review of Abdulaziz Alghamdi for disaster emergency medicine services including those occupied in terror attacks, earthquake and COVID-19 pandemics, health care providers can significantly suffer from anxiety and affective disorders as well as PTSD symptoms. Indeed, they themselves need professional support in many cases. Modern technologies like app-based programs (21, 22) my provide a low-threshold opportunity to address affected individuals or individuals at risk to develop serious mental health issues.