Suicidality is still an understudied problem in Bulgaria especially on a subnational (regional) level.

To collect data on suicidality in two major regions of Bulgaria with a population over 250,000 each (Plovdiv and Pleven) for a six years period (2009–2015).

To analyze demographic, health-related and other characteristics associated with suicidal behavior as well as motives and methods of suicide.

Data were extracted from relevant documentation (medical records, public health reports, etc.) and statistically processed upon collection.

Majority of suicide victims were males between 45 and 64 years while most suicide attempts occurred among 18–29 years old females.

Leading method of suicide was hanging, followed by jumping from high places and use of firearm.

Prevailing suicidal motives were psychotic symptoms, serious somatic illnesses and family problems. Depression accounted for 25% of all suicide cases and in another 25% motivation could not be identified because of insufficient data.

The proportion of unemployed among suicide committers was not significantly higher than that of employed and retired.

Severe mental disorders are a major trigger of suicidal behavior.

Personal relationships should be targeted by suicide prevention interventions.

Somatic illnesses are increasingly important suicide risk factor driven by the ongoing process of population aging.

Frontline healthcare professionals should be trained to explore underlying suicidal motives and actively probe for depression in each case of suicidal behavior.

Unemployment related suicide risk is most likely mediated through an adaptation crisis mechanism induced by the abrupt change of social status.

The authors have not supplied their declaration of competing interest.

A substantial proportion of persons with mental disorders seek treatment from complementary and alternative medicine (CAM) professionals. However, data on how CAM contacts vary across countries, mental disorders and their severity, and health care settings is largely lacking. The aim was therefore to investigate the prevalence of contacts with CAM providers in a large cross-national sample of persons with 12-month mental disorders.

In the World Mental Health Surveys, the Composite International Diagnostic Interview was administered to determine the presence of past 12 month mental disorders in 138 801 participants aged 18–100 derived from representative general population samples. Participants were recruited between 2001 and 2012. Rates of self-reported CAM contacts for each of the 28 surveys across 25 countries and 12 mental disorder groups were calculated for all persons with past 12-month mental disorders. Mental disorders were grouped into mood disorders, anxiety disorders or behavioural disorders, and further divided by severity levels. Satisfaction with conventional care was also compared with CAM contact satisfaction.

An estimated 3.6% (standard error 0.2%) of persons with a past 12-month mental disorder reported a CAM contact, which was two times higher in high-income countries (4.6%; standard error 0.3%) than in low- and middle-income countries (2.3%; standard error 0.2%). CAM contacts were largely comparable for different disorder types, but particularly high in persons receiving conventional care (8.6–17.8%). CAM contacts increased with increasing mental disorder severity. Among persons receiving specialist mental health care, CAM contacts were reported by 14.0% for severe mood disorders, 16.2% for severe anxiety disorders and 22.5% for severe behavioural disorders. Satisfaction with care was comparable with respect to CAM contacts (78.3%) and conventional care (75.6%) in persons that received both.

CAM contacts are common in persons with severe mental disorders, in high-income countries, and in persons receiving conventional care. Our findings support the notion of CAM as largely complementary but are in contrast to suggestions that this concerns person with only mild, transient complaints. There was no indication that persons were less satisfied by CAM visits than by receiving conventional care. We encourage health care professionals in conventional settings to openly discuss the care patients are receiving, whether conventional or not, and their reasons for doing so.