Suicide attempts are among the most serious public health challenges facing Colombia, a country where social vulnerability, economic strain, and deeply unequal access to care shape both who ends up at risk and who manages to recover. Globally, the burden is staggering: recent estimates from the Global Burden of Disease study and the Lancet Commission on self-harm have documented hundreds of thousands of suicide deaths each year, with nonfatal attempts many times more common. Each attempt carries direct medical costs, lost productivity, and long shadows of psychosocial disability that can persist for years after the crisis passes. Yet in low- and middle-income countries, where most suicides occur, the economics of surviving an attempt have rarely been studied at the level of individual households.

The research team, led by Felipe Agudelo-Hernández of the Universidad de Manizales together with colleagues at the Universidad Nacional de Colombia and a peer support worker with lived experience of suicidality, set out to fill that gap. They conducted a descriptive, cross-sectional, population-based study in Caldas using stratified random sampling, recruiting 622 participants who had attempted suicide. Rather than relying on hospital records alone, the researchers measured recovery from multiple angles, combining validated instruments with detailed questions about sociodemographic circumstances, service use, and money spent out of pocket on mental health care.

The measurement battery was deliberately comprehensive. Participants completed the Patient Health Questionnaire-9, or PHQ-9, a widely validated screen for depressive symptoms; the UCLA Loneliness Scale, capturing social isolation; the EBS-8, a short measure of subjective well-being; the CD-RISC-10, a brief resilience scale; and two instruments with particular relevance to the Colombian context. The Caldas Psychosocial Disability Scale, developed and validated by members of the same team, quantifies the functional impairment associated with mental disorders across daily life domains. The Alberta Continuity of Mental Health Services Scale, translated and adapted for Latin American populations by the researchers, assesses how well services connect and follow patients over time, a factor widely regarded as crucial after a suicide attempt.

Using multiple linear regression, the team identified a set of significant predictors of total psychosocial disability. Depressive symptoms emerged as a central driver, alongside educational level, age, perceived access to services, and, notably, out-of-pocket spending on individual psychotherapy. Together these variables explained roughly forty percent of the variance in psychosocial disability scores, an adjusted R-squared of .401 that is substantial for research of this kind. The model paints a coherent picture: younger people, those with more education, those with fewer depressive symptoms, those who perceive services as accessible, and those who can afford private therapy all tend to report less disability in the aftermath of an attempt.

The most striking and politically charged result concerns money. Across the analyses, private spending was associated with lower psychosocial disability and better recovery-related indicators, including greater well-being and resilience. At the same time, people who paid privately reported poorer perceived access to formal public services. In other words, paying out of pocket appears to function simultaneously as a recovery resource and as a signal of system failure. Those with the means to bypass the public pathway seem to obtain faster, more continuous, and more personalized care, while those without such means remain dependent on a system they experience as difficult to navigate.

This structural paradox sits uneasily with Colombia’s legal framework. Law 1751 of 2015 established health as a fundamental right and mandated access to mental health services without financial barriers. Yet earlier work by members of the same research group has documented persistent paradoxes in the implementation of Colombian mental health policy, and national data on household health spending show that out-of-pocket payments remain a significant burden, sometimes pushing families into catastrophic expenditure. The new findings extend that economic concern to one of the most vulnerable populations imaginable: people who have recently survived a suicide attempt and are navigating the fragile period in which the risk of a further attempt is highest.

The international literature reinforces the stakes. Systematic reviews have linked poverty, unemployment, and financial hardship to elevated suicide risk, and costing studies from low- and middle-income countries show that the economic burden of suicidality falls heavily on households as well as health systems. Research on continuity of care after self-harm consistently finds that structured follow-up reduces repeat attempts, which makes the Colombian pattern of fragmented public access and compensatory private spending particularly concerning. If the people most likely to die by suicide are also those least able to purchase the continuity of care that protects them, the health system is effectively concentrating risk among its poorest users.

The authors argue that the answer is not to normalize private payment but to close the implementation gaps it reveals. Improving the real-world availability of public mental health services, strengthening continuity between hospital discharge and community follow-up, and addressing the financing mechanisms that leave room for out-of-pocket charges are, they contend, essential to reducing inequities in post-attempt recovery. The inclusion of a co-author with lived experience of suicidality, and the involvement of the Caldas Territorial Health Directorate, reflect a growing movement to ground suicide prevention in the realities of survivors rather than in administrative statistics alone.

For a department like Caldas, and for Colombia more broadly, the study offers both a warning and a roadmap. The warning is that a legally guaranteed right means little when the pathways to exercise it are opaque, slow, or unavailable, and when recovery becomes a commodity that families must buy. The roadmap lies in the study’s own variables: reducing depressive symptoms through timely treatment, supporting educational attainment, combating loneliness, building resilience, and ensuring that perceived access reflects genuine access for everyone, not just those who can pay. As global health authorities push for national suicide prevention strategies, this research is a reminder that the economics of recovery, the small monthly sums families hand over for a therapy session, can be as decisive for survival as any clinical protocol. Recovery after a suicide attempt should never depend on a wallet, and this study shows exactly what happens when, in practice, it does.

Subject of Research: Out-of-pocket mental health spending and recovery among suicide attempt survivors in Colombia

Article Title: Recovery and pay out-of-pocket on mental health services among people who attempted suicide in Colombia

Article References: Agudelo-Hernández, F., Vélez-Botero, H., Aldana-Naranjo, C., Marín, S., Mejía-Chaves, M., & Vega, K. (2026). Recovery and pay out-of-pocket on mental health services among people who attempted suicide in Colombia. Current Psychology, 45(18), Article 1522. https://doi.org/10.1007/s12144-026-10080-1

Image Credits: AI Generated

DOI: 10.1007/s12144-026-10080-1

Keywords: suicide attempt, out-of-pocket payment, mental health services, psychosocial disability, Colombia, recovery, access to care, depressive symptoms, resilience, continuity of care, public health policy, health inequity

The study, published in Pediatric Research by Ramesh Vidavalur of Cayuga Medical Center and Weill Cornell Medical College, Ramesh Agarwal of the All India Institute of Medical Sciences in New Delhi, and Vinod K. Bhutani of Stanford University School of Medicine, examined trends in congenital heart disease related infant and neonatal mortality in India from 1990 to 2021. The findings are stark: of the approximately 8.6 million infants worldwide who died from congenital heart defects over that 31-year period, about 1.5 million were Indian, representing roughly 18 percent of the entire global burden.

Congenital heart defects affect approximately 9 per 1,000 live births in India, a prevalence consistent with global estimates but applied to one of the world’s largest birth cohorts. Because most critical lesions manifest within the first days or weeks of life, congenital heart disease has become an increasingly visible share of India’s residual infant mortality as other causes, such as infections and prematurity complications, decline. Yet the analysis shows the country’s response has not kept pace.

Between 1990 and 2021, India’s congenital heart disease related neonatal mortality declined at an annual rate of just 1.5 percent, significantly slower than the global rate of 2.2 percent per year. That gap, compounded over three decades, means the relative weight of congenital heart disease within India’s infant mortality profile has grown even as absolute numbers of deaths have fallen.

The segmental analysis reveals a more troubling pattern beneath the long-term trend. Progress stagnated almost entirely between 2003 and 2013, a decade in which mortality reduction essentially flatlined. Only in recent years did the pace of decline recover, with a nearly threefold acceleration observed between 2019 and 2021. The researchers suggest this late acceleration may reflect expanding neonatal care infrastructure and growing recognition of critical congenital heart disease, but they caution that the gains remain fragile and unevenly distributed.

Indeed, subnational analysis identified substantial inequities in mortality reduction across Indian states. States with stronger health systems, better access to pediatric cardiac surgery, and more developed newborn screening programs achieved far greater declines than those where diagnosis is often delayed until infants arrive at referral centers in critical condition. Prior studies from South India have shown that transport delays alone dramatically worsen outcomes for newborns with heart disease, a problem concentrated in lower-income and rural regions.

The economic toll is enormous. Applying human capital and value of statistical life frameworks, the authors estimated that congenital heart disease related infant deaths cost India approximately 11.7 billion US dollars in lost economic value in 2021 alone, with a plausible range of 9 to 12 billion dollars. Each infant death from a treatable cardiac defect represents not only a family tragedy but also decades of lost productive capacity, underscoring that investment in early detection and surgical capacity is not merely a health priority but an economic one.

The contrast with high-income countries is instructive. In the United States, the rollout of mandatory pulse oximetry screening for critical congenital heart disease in newborn nurseries has been associated with measurable reductions in early infant cardiac deaths. Randomized and observational evidence has also shown that prenatal diagnosis substantially lowers the risk of death from cardiovascular collapse before planned surgery. India has validated pulse oximetry screening in its own newborn populations and issued national consensus guidelines on the timing of intervention, but implementation across public facilities remains patchy.

The authors argue that sustaining and accelerating the recent gains will require system-level reform on several fronts simultaneously: expanding pediatric cardiology and cardiac surgery training, improving service delivery in public healthcare facilities where most Indian children are treated, strengthening national surveillance so that the true burden is no longer obscured by sparse mortality data, and building longitudinal follow-up for children who survive initial interventions. Kerala’s population-based approach to congenital heart disease offers one domestic model of what coordinated, state-level planning can achieve.

As India pursues its sustainable development targets for child survival, the study makes clear that congenital heart disease is no longer a marginal contributor that can be deferred. With nearly one in five global deaths from these defects occurring in India, closing the gap between Indian and global rates of improvement could save tens of thousands of lives each year and unlock billions of dollars in economic value, provided the political will matches the scale of the problem.

Subject of Research: Trends and economic impact of infant mortality from congenital heart disease in India, 1990–2021

Article Title: Burden, trends and economic impact of infant mortality from congenital heart diseases in India, 1990–2021

Article References: Vidavalur, R., Agarwal, R., & Bhutani, V. K. (2026). Burden, trends and economic impact of infant mortality from congenital heart diseases in India, 1990–2021. Pediatric Research. https://doi.org/10.1038/s41390-026-05430-5

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05430-5

Keywords: congenital heart disease, infant mortality, neonatal mortality, India, Global Burden of Disease, pediatric cardiology, economic burden, newborn screening, health inequity, pulse oximetry, neonatal care, Pediatric Research

The rationale behind EXIT begins with a candid assessment of why conventional cessation programs fail this population. The researchers identify structural inequities as central barriers: the lack of stable housing, limited access to treatment services, and the fragmentation of care that forces people to navigate multiple disconnected systems. Layered on top of these structural obstacles are high rates of serious mental illness and substance use disorders among homeless smokers, which compound the physiological grip of nicotine dependence. Existing cessation treatments, the authors note, are often brief in duration, rarely integrated into community service settings, and short on the kind of ongoing behavioral support that sustained quitting demands. A single counseling session and a starter pack of patches, in other words, is poorly matched to the realities of life without a home.

EXIT was engineered around two design principles that distinguish it from prior efforts. The first is duration: rather than offering weeks of support, the intervention extends pharmacotherapy and coaching across a full six months, reflecting evidence that longer treatment courses improve cessation odds. The second is accessibility: the intervention routes treatment through community pharmacies and delivers behavioral support by telephone, so participants do not need to travel to clinics, keep rigid appointments, or negotiate unfamiliar healthcare bureaucracies. Community pharmacies have long been recognized as a promising venue for expanding access to evidence-based tobacco treatment, because pharmacists are numerous, trusted, geographically distributed, and empowered in many states to prescribe or recommend nicotine replacement products. Until now, however, pharmacy-based approaches have mostly been tested in short-duration interventions, leaving open the question of whether they can sustain quitting over the long term.

The trial itself is a two-arm, parallel-group randomized controlled trial conducted in transitional shelters in Los Angeles and San Francisco, two cities where homelessness has reached crisis scale. The investigators plan to enroll 150 adults experiencing homelessness who smoke at least five cigarettes per day, whose tobacco exposure is confirmed objectively by an expired carbon monoxide reading of at least 8 parts per million, and who report an intention to quit within six months. That carbon monoxide threshold is an important methodological safeguard, ensuring that self-reported smoking status is corroborated by a biochemical marker before randomization. Participants will then be allocated, in equal numbers, either to the full EXIT intervention or to a pharmacist-only comparator condition, allowing the trial to isolate the added value of extended pharmacotherapy and wellness coaching.

The comparator arm is deliberately pragmatic. Dubbed the pharm-only condition, it consists of a single pharmacist-delivered telephone session structured around the 5As framework, the established clinical sequence of asking about tobacco use, advising cessation, assessing readiness, assisting with a quit plan, and arranging follow-up, plus three months of nicotine replacement therapy. This condition represents a reasonable standard of care that a person might receive through a well-functioning pharmacy-based service, making it a meaningful benchmark against which to measure EXIT’s incremental benefits. Any advantage observed for the full intervention can therefore be attributed with some confidence to the additional months of medication and the intensive coaching component, rather than to mere contact with the healthcare system.

EXIT builds on that foundation in two decisive ways. Participants in the intervention arm receive the same initial 5As session, but their nicotine replacement therapy extends to a full six months, doubling the comparator’s treatment duration. More distinctive still is the behavioral component: 14 wellness-focused telephone coaching sessions delivered over six months by trained health coaches. The framing of these sessions as wellness-focused rather than narrowly cessation-focused is a deliberate design choice. Coaching conversations encompass broader health behaviors, including diet and physical activity, alongside smoking cessation goals. The investigators anticipate that this holistic approach may improve engagement and retention among participants for whom smoking is only one of many competing health and survival concerns, and for whom a single-issue intervention may feel disconnected from their priorities.

The trial’s primary outcome is adherence itself, an unusually honest choice for a feasibility-stage study. Adherence will be measured by the number of coaching sessions attended and by participants’ adherence to the nicotine replacement regimen, since an intervention only works if people actually use it. Secondary outcomes include biochemically verified seven-day point prevalence abstinence at three and six months, again confirmed by carbon monoxide readings of 5 parts per million or below. Assessment visits occur at baseline and at one, three, and six months, capturing a rich panel of measures: tobacco use and nicotine dependence, health behaviors such as diet and physical activity, mental health, substance use, and adherence to nicotine replacement therapy. This longitudinal design allows the team to track not only whether people quit, but how the intervention reshapes the broader health landscape that sustains addiction.

Methodologically, the protocol reflects the iterative logic of modern behavioral intervention science. Rather than leaping directly to a large, fully powered effectiveness trial, the EXIT team is first testing feasibility, acceptability, and preliminary efficacy in the very settings where a scalable program would ultimately operate. This staged approach guards against the familiar failure mode of cessation interventions that perform well in controlled academic clinics but collapse when transplanted into community environments with high participant mobility, competing survival needs, and limited staffing. By embedding the trial within transitional shelters and partnering with pharmacy infrastructure from the outset, the investigators are stress-testing the delivery model under real-world conditions. The findings are explicitly intended to inform a future fully powered trial that could establish a scalable model for delivering tobacco cessation treatment to people experiencing homelessness nationwide.

The scientific significance of the trial extends beyond its immediate population. Smoking among homeless adults is a major driver of the stark mortality gap between housed and unhoused populations, contributing to cardiovascular disease, respiratory illness, and cancer at rates that dwarf the risks posed by many problems that receive far more public attention. Yet tobacco is frequently deprioritized in homeless services, treated as a concern to be addressed only after housing, addiction, and mental health needs are met. EXIT challenges that triage logic by demonstrating that evidence-based tobacco treatment can be woven directly into homeless services and pharmacy systems rather than deferred. The trial is funded by the California Tobacco-Related Disease Research Program, with additional support to the first author from the National Institute on Drug Abuse, and it is registered at ClinicalTrials.gov under identifier NCT07148232.

If EXIT proves feasible, acceptable, and even preliminarily effective, the implications could ripple across public health practice. A model that pairs six months of nicotine replacement with sustained telephone coaching, initiated through a pharmacist visit and anchored in transitional shelters, could be replicated in cities across the country at comparatively low cost, since it relies on existing pharmacy networks and remote coaching rather than new clinics. The trial also contributes a methodological template for studying cessation in transient populations, combining biochemical verification, extended follow-up, and outcome measures that respect participants’ full health context. For the roughly seven in ten homeless adults who smoke, most of whom express a desire to quit but lack access to sustained treatment, EXIT represents a rigorous test of whether the healthcare system can finally meet them where they are, for as long as quitting truly takes.

Subject of Research: A randomized controlled trial testing an extended pharmacy-linked tobacco cessation intervention with telephone coaching for adults experiencing homelessness.

Article Title: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial

Article References: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial. (n.d.). https://doi.org/10.1186/s13722-026-00720-z

Image Credits: AI Generated

DOI: 10.1186/s13722-026-00720-z

Keywords: tobacco cessation, homelessness, nicotine replacement therapy, randomized controlled trial, community pharmacies, telephone coaching, health inequity, smoking prevalence, transitional shelters, public health, clinical trial protocol, addiction science