M.D Nicolas Hoertel
email: nico.hoertel@yahoo.fr

M.D Julien Sabatier

M.D Carlos Blanco

M.D Mark Olfson

M.D Jean-Pierre Schuster

M.D Guillaume Airagnes

M.D Hugo Peyre

M.D Frédéric Limosin

Contributing factors to heterogeneity in the timing of the onset of nonfatal suicidal behavior: Results from a nationally representative study

Keywords: Suicide attempt, age, old, young, onset, risk factors, childhood maltreatment, psychiatric symptoms

Introduction: It remains unclear whether specific clinical factors contribute to heterogeneity in the timing of the onset of nonfatal suicidal behavior. This knowledge could have important implications for suicide prevention. Methods: Using a nationally representative US adult sample, the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions, we compared the characteristics of 4 different suicide attempter groups: those who first attempted (i) before 18 years, (ii) between 18 and 34 years, (iii) between 35 and 49 years, and (iv) at 50 years or older. Specifically, we examined psychiatric disorders that occurred before the first suicide attempt, childhood maltreatment experiences, parental history of psychiatric disorders, and sociodemographic characteristics. Results: Most first non-fatal suicide attempts (85.3%) occurred before age 35 years.

Compared with suicide attempts occurring between 18 and 34 years, suicide attempts occurring <18 years were more strongly associated with childhood maltreatment and less strongly linked to lifetime prior psychiatric disorders, whereas first suicide attempts occurring at 35 years and older were more strongly associated with a prior lifetime history of substance use disorders, including alcohol use disorder and nicotine dependence, and mood disorders, including mania/hypomania and dysthymic disorder between 35 and 49 years, and major depressive episode at 50 years and older (all p<0.05).

Conclusions:

Our results suggest age differences in risk factors for first non-fatal suicide attempt. Improving early detection and treatment of psychiatric disorders and preventing childhood maltreatment may have broad benefits to reduce the burden of suicidal behavior at all ages.

Introduction

Suicide continues to be a leading cause of preventable death worldwide, [START_REF] Rockett | Leading causes of unintentional and intentional injury mortality: united states, 2000-2009[END_REF] accounting for an estimated 800,000 deaths worldwide, [START_REF]Public health action for the prevention of suicide: a framework[END_REF] and there are many more suicide attempts, which are associated with significant morbidity. [START_REF]Public health action for the prevention of suicide: a framework[END_REF] Prior research suggests substantial age differences in suicide and suicide attempt rates. [START_REF]Public health action for the prevention of suicide: a framework[END_REF][START_REF] Conwell | Suicide in older adults[END_REF][START_REF] Turecki | Suicide and suicidal behaviour[END_REF][START_REF] Spicer | Suicide acts in 8 states: incidence and case fatality rates by demographics and method[END_REF][START_REF] Nock | Suicide and suicidal behavior[END_REF][START_REF] Olfson | National Trends in Suicide Attempts Among Adults in the United States[END_REF] Although older adults attempt suicide less often than younger ones, suicide completion rates increase as a function of age for both men and women to a peak in old age. [START_REF]Public health action for the prevention of suicide: a framework[END_REF] Understanding the factors that contribute to heterogeneity in the timing of the onset of nonfatal suicidal behavior may help clinicians identify individuals who are at greater risk for a first attempt, which is particularly important in older adults where a large percentage of first attempts are fatal, [START_REF] Byers | FATAL AND NON-FATAL FIRST SUICIDE ATTEMPTS IN LATER LIFE AND IMPLICATIONS FOR PREVENTION[END_REF] and help refine prevention interventions for this major public health problem. [START_REF] Peyre | Contributing Factors and Mental Health Outcomes of First Suicide Attempt During Childhood and Adolescence: Results From a Nationally Representative Study[END_REF] Several lines of evidence support potential age differences in risk factors profiles of suicide attempt. First, while the prevalence of most psychiatric disorders is lower in older than in younger adults, [START_REF] Hoertel | Childhood maltreatment and risk of suicide attempt: a nationally representative study[END_REF][START_REF] Mcmahon | Age differences in DSM-IV borderline personality disorder symptom expression: Results from a national study using item response theory (IRT)[END_REF][START_REF] De Raykeer | Effects of Psychiatric Disorders on Suicide Attempt: Similarities and Differences Between Older and Younger Adults in a National Cohort Study[END_REF][START_REF] Hoertel | Why does the lifetime prevalence of major depressive disorder in the elderly appear to be lower than in younger adults? Results from a national representative sample[END_REF] psychiatric disorders are among the strongest predictors of suicide attempt and completion across all ages. [START_REF] Peyre | Contributing Factors and Mental Health Outcomes of First Suicide Attempt During Childhood and Adolescence: Results From a Nationally Representative Study[END_REF][START_REF] Harris | Suicide as an outcome for mental disorders. A metaanalysis[END_REF][START_REF] Pokorny | Prediction of suicide in psychiatric patients. Report of a prospective study[END_REF][START_REF] Hoertel | Mental disorders and risk of suicide attempt: a national prospective study[END_REF][START_REF] Hoertel | A Comprehensive Model of Predictors of Suicide Attempt in Depressed Individuals and Effect of Treatment-Seeking Behavior: Results From a National 3-Year Prospective Study[END_REF][START_REF] Leo | Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study[END_REF][START_REF] Wiktorsson | Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group[END_REF][START_REF] Schuster | Personality disorders in older adults: findings from the National Epidemiologic Survey on Alcohol and Related Conditions[END_REF][START_REF] Szucs | Personality and Suicidal Behavior in Old Age: A Systematic Literature Review[END_REF] Prior studies [START_REF] Conwell | Suicide in older adults[END_REF][START_REF] Turecki | Suicide and suicidal behaviour[END_REF][START_REF] Leo | Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study[END_REF][START_REF] Szanto | Occurrence and course of suicidality during short-term treatment of late-life depression[END_REF][START_REF] Conwell | Suicide in later life: a review and recommendations for prevention[END_REF] have suggested age differences in the strength of associations between psychiatric disorders and suicide risk. For example, major depression may be associated with a stronger risk of suicide in older than in younger adults, whereas substance use disorders may play a lesser role in later life suicide risk. Second, the male to female ratio of suicide attempts and completions is higher in older than in younger adults. [START_REF] Wiktorsson | Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group[END_REF] Third, neurodegenerative, cerebrovascular and other chronic diseases may play a stronger contributing role in suicide risk in older than in younger adults. [START_REF] Conwell | Suicide in later life: a review and recommendations for prevention[END_REF][START_REF] Minayo | Suicide attempts among the elderly: a review of the literature (2002/2013)[END_REF] Finally, the detrimental effect of certain socioeconomic and environmental factors, such as loneliness, financial and social difficulties and the loss of loved ones on suicide risk may differ in magnitude between younger and older adults. [START_REF] Fassberg | A systematic review of social factors and suicidal behavior in older adulthood[END_REF][START_REF] Turvey | Financial loss and suicidal ideation in a rural community sample[END_REF][START_REF] Alexopoulos | Clinical determinants of suicidal ideation and behavior in geriatric depression[END_REF][START_REF] Pompili | Life events as precipitants of suicide attempts among first-time suicide attempters, repeaters, and non-attempters[END_REF] However, little is known about the similarities or differences between adults who first attempted suicide at an older or younger age. Because a substantial proportion of older adults who attempt suicide have a prior history of suicide attempt, [START_REF] De Raykeer | Effects of Psychiatric Disorders on Suicide Attempt: Similarities and Differences Between Older and Younger Adults in a National Cohort Study[END_REF] this distinction may help disentangle risk factors specifically related to emerging suicide risk in later life and progress in the understanding of suicidal behavior across the lifespan. [START_REF] Steele | Understanding Suicide Across the Lifespan: A United States Perspective of Suicide Risk Factors, Assessment & Management[END_REF] This knowledge may also have important implications for suicide prevention by informing identification of adults at greater risk for suicide attempt according to their age, and may help refine specific assessment and service provision according to the age of the first suicide attempt.

In this study, we investigated whether specific factors may explain differences in the timing of first suicide attempt across different age at first attempt groups. Specifically, we hypothesized that factors contributing to differences in the timing of first suicide attempt would include sociodemographic characteristics (sex, race/ethnicity, nativity and education), lifetime prior psychiatric disorders (i.e, disorders that occurred before the first/single suicide attempt), childhood maltreatment experiences and parental history of psychiatric disorders. described in detail elsewhere. [START_REF] Grant | Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions[END_REF] The target population included the civilian population aged 18 years and older residing in households and group quarters. Face-to-face interviews were conducted with 43,093 respondents. The overall survey response rate was 81%. In Wave 2, attempts were made to conduct face-to-face re-interviews with all 43,093 respondents of the Wave 1 interview. The cumulative response rate at Wave 2 was 70.2%, reflecting 34,653 completed Wave 2 interviews. The Wave 2 NESARC data were weighted to be representative of the US civilian population based on the 2000 census. [START_REF] Grant | Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions[END_REF] The research protocol, including informed consent procedures, received full human subjects review and approval from the US Census Bureau and the Office of Management and Budget. [START_REF] Grant | Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions[END_REF] The present analysis included the 34,653 participants who completed both NESARC waves.

Methods

Sample

Measures

Assessment of suicide attempts and age at first suicide attempt

All NESARC respondents were asked the following questions: 1) "Did you ever attempt suicide?" and 2) "How old were you the first time it happened?" Based on prior research that identified age differences in suicide attempts rates, [START_REF] Spicer | Suicide acts in 8 states: incidence and case fatality rates by demographics and method[END_REF][START_REF] De Raykeer | Effects of Psychiatric Disorders on Suicide Attempt: Similarities and Differences Between Older and Younger Adults in a National Cohort Study[END_REF] a preliminary analysis of the distribution of age at first suicide attempt in NESARC, and assuming that we needed at least 40 suicide attempts by age group for adequate statistical power, we defined 5 mutually exclusive groups: participants who first attempted suicide (i) before 18 years, (ii) between 18 and 34 years, (iii) between 35 and 49 years, and (iv) at 50 years or older, and (v) those who never attempted suicide.

Sociodemographic characteristics

Sociodemographic characteristics included age, sex, race/ethnicity (White vs. non-White), nativity, education, and family poverty which was considered present if participants reported that their family received money from any government assistance program before they were 18 years of age.

Assessment of DSM-IV-TR Axis I and II disorders

Psychiatric disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (AUDADIS-IV), a structured diagnostic instrument administered by trained lay interviewers. [START_REF] Grant | Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions[END_REF] Axis I diagnoses included substance use disorders (alcohol use disorder, drug use disorder and nicotine dependence), mood disorders (major depressive episode, dysthymic disorder, mania or hypomania), anxiety disorders (panic disorder with and without agoraphobia, social anxiety disorder, specific phobia, generalized anxiety disorder and post-traumatic stress disorder), pathological gambling, conduct disorder and attention deficit hyperactivity disorder. All respondents with a lifetime history of Axis I psychiatric disorders were questioned about the age at onset of disorders to determine whether these disorders occurred before the first suicide attempt. The test-retest reliability and validity of AUDADIS-IV measures of DSM-IV psychiatric disorders is good to excellent for substance use disorders and fair to good for other disorders. [START_REF] Grant | Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions[END_REF]

Childhood traumatic experiences

Five types of childhood maltreatment were examined: emotional neglect, physical neglect, emotional abuse, physical abuse, and sexual abuse. Respondents completed 19 questions regarding exposure to the types of maltreatment occurring before age 17 years adapted from the Childhood Trauma Questionnaire (CTQ) [START_REF] Bernstein | Initial reliability and validity of a new retrospective measure of child abuse and neglect[END_REF] and the Conflict Tactics Scale (CTS). [START_REF] Straus | Measuring intrafamily conflict and violence: The conflict tactics (CT) scales[END_REF] Test-retest of these items was adequate, with Cronbach's alpha coefficients ranging from 0.78 for physical abuse to 0.90 for sexual abuse. [START_REF] Ruan | The alcohol use disorder and associated disabilities interview schedule-IV (AUDADIS-IV): reliability of new psychiatric diagnostic modules and risk factors in a general population sample[END_REF] Consistent with prior work, [START_REF] Peyre | Contributing Factors and Mental Health Outcomes of First Suicide Attempt During Childhood and Adolescence: Results From a Nationally Representative Study[END_REF][START_REF] Hoertel | Childhood maltreatment and risk of suicide attempt: a nationally representative study[END_REF][START_REF] Mcmahon | Childhood maltreatment and impulsivity as predictors of interpersonal violence, self-injury and suicide attempts: A national study[END_REF][START_REF] Mcmahon | Childhood maltreatment and risk of intimate partner violence: A national study[END_REF] participants were considered to have suffered a type of childhood maltreatment (e.g., physical abuse) if they reported frequent exposure (sometimes, often or very often), except for sexual abuse, which was considered present if they indicated at least 1 episode.

Parental history of psychiatric disorders

Parental histories of alcohol use disorder, drug use disorder, major depression and antisocial personality disorder were ascertained in separate modules of the AUDADIS [START_REF] Grant | Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions[END_REF] and defined in our study as having at least one parent with the disorder. All respondents were prompted with a definition that included examples for each condition. The definitions read to respondents included readily observable manifestations, since these are the most likely to be known by participants and therefore are likely to be more sensitive. [START_REF] Slutske | Reliability and reporting biases for perceived parental history of alcohol-related problems: agreement between twins and differences between discordant pairs[END_REF] The test-retest reliability of AUDADIS family history diagnoses is very good to excellent. [START_REF] Grant | The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample[END_REF]

Statistical analyses

Percentages and their standard errors (SE) were estimated using SUDAAN (Version 8.1 Research Triangle Institute Research Triangle Park) to adjust for the complex design of the NESARC. Binary logistic regression analyses were performed to compare the sociodemographic and clinical characteristics of each age at first suicide attempt group with the reference group of individuals who attempted suicide between 18 and 34 years. Because sex, age and race/ethnicity have been shown to influence the risk for attempting suicide, [START_REF] Peyre | Contributing Factors and Mental Health Outcomes of First Suicide Attempt During Childhood and Adolescence: Results From a Nationally Representative Study[END_REF][START_REF] Hoertel | Mental disorders and risk of suicide attempt: a national prospective study[END_REF][START_REF] Oquendo | Prospective studies of suicidal behavior in major depressive and bipolar disorders: what is the evidence for predictive risk factors?[END_REF] all analyses adjusted for these variables. Statistical significance was evaluated using a twosided alpha set a priori set at 0.05.

Results

Sample characteristics

Of the 34,654 participants, 25 (<0.01%) were excluded from our analyses because of missing data for age at suicide attempt. Of the remaining 34,629 participants, 1240 (3.6%) reported a lifetime history of suicide attempt. Among these individuals, 519 (45.2%, suicide attempts by age group revealed that first suicide attempts were significantly more common between 18 and 34 years than in other age groups (p<0.001), with no significant differences between the age groups <18 years and 35-49 years, whereas first suicide attempts were significantly less frequent among individuals aged 50 years and older than in other age groups (p<0.01) (Figure 1). Sociodemographic characteristics, prior lifetime psychiatric disorders, childhood maltreatment and family history of psychiatric disorders associated with age at first suicide attempt (Tables 1 and2) There were no significant differences across age at first suicide attempt groups in sociodemographic characteristics (i.e., sex, race/ethnicity, nativity, education and family poverty).

Compared to respondents who first attempted suicide between 18 and 34 years, those who first attempted suicide before 18 years were significantly less likely to have a prior lifetime history of psychiatric disorders, including substance use disorders, major depressive episode, mania or hypomania, panic disorder with or without agoraphobia and generalized anxiety disorder. Individuals who attempted suicide after 35 years were significantly more likely to have a prior lifetime history of alcohol use disorder and nicotine dependence than individuals who first attempted suicide between 18 and 34 years. Furthermore, individuals who first attempted suicide between 35 and 49 years were more likely to have a prior lifetime history of mania or hypomania and dysthymic disorder, and individuals who first attempted suicide at 50 years and older were significantly more likely to have a prior lifetime history of major depressive episode compared to respondents who first attempted suicide between 18 and 34 years.

All childhood maltreatment types were significantly more frequent among individuals who first attempted suicide before 18 years than in those who first attempted suicide between 18 and 34 years. There were no significant differences across the other age at first suicide attempt groups.

Finally, there were no significant differences across groups in family history of psychiatric disorders.

Discussion

In a large, nationally representative sample of adults, most first non-fatal suicide attempts (85.3%) occurred before age 35 years. Our results suggest that several clinical factors influence the timing of the onset of non-fatal suicidal behavior. Compared with first suicide attempts occurring between 18 and 34 years, first suicide attempts occurring <18 years were more strongly associated with childhood maltreatment and less strongly linked to prior lifetime psychiatric disorders, whereas first suicide attempts occurring at 35 years and older were more strongly associated with a prior lifetime history of substance use disorders, including alcohol use disorder and nicotine dependence, and mood disorders, including mania/hypomania and dysthymic disorder between 35 and 49 years, and major depressive episode at 50 years and older. Finally, we did not find any significant associations between family history of psychiatric disorders and sociodemographic characteristics (i.e., gender, race-ethnicity, nativity, education and family poverty) with age at first/single suicide attempt.

Almost half (45.2%) of individuals with a lifetime history of suicide attempt first attempted before 18 years, and most of them (85.3%) before 35 years. Several factors may contribute to explain the elevated incidence of suicide attempt in young people. First, childhood and adolescence constitute an important phase of neuropsychological development, including the development and the maturation of physical and cognitive abilities and emotional self-awareness. For example, a study [START_REF] Giedd | Structural magnetic resonance imaging of the adolescent brain[END_REF] found that the dorsolateral prefrontal cortex (linked to important behavioral changes such as the ability to inhibit impulsivity and to evaluate consequences of decisions) does not reach adult dimensions until the age of 20. This lag may explain why certain vulnerable children and adolescents are prone to maladaptive emotional (e.g., emotional coping), cognitive (e.g., self-criticism) and social (e.g., isolation) strategies [START_REF] Stoep | Thoughts of death and suicide in early adolescence[END_REF] , which may increase their risk of suicide attempt. Second, adolescence is a period marked by new social stressors (e.g., peer-rejection, bullying, academic pressure), [START_REF] Hoertel | Gender effects in bullying: results from a national sample[END_REF] less perceived support from adults [START_REF] Nansel | The association of bullying and victimization with middle school adjustment[END_REF] and for certain adolescents by a major identity developments (e.g., sexual, social) [START_REF] Zhao | Suicidal ideation and attempt among adolescents reporting "unsure" sexual identity or heterosexual identity plus same-sex attraction or behavior: forgotten groups?[END_REF] . Finally, the decrease in incidence of suicide attempts after 35 years may be explained by the greater case-fatality rate associated with suicide attempts in later life, as the ratio between suicide and suicide attempt tend to rise as a function of age for both men and women to a peak in old age, [START_REF]Public health action for the prevention of suicide: a framework[END_REF][START_REF] Bostwick | Suicide Attempt as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew[END_REF] and by the fact that those who completed suicide in earlier attempts do not reach older age.

Although it is noteworthy that most psychiatric disorders increase the risk of suicide attempt at all ages [START_REF] De Raykeer | Effects of Psychiatric Disorders on Suicide Attempt: Similarities and Differences Between Older and Younger Adults in a National Cohort Study[END_REF][START_REF] Harris | Suicide as an outcome for mental disorders. A metaanalysis[END_REF][START_REF] Hoertel | Mental disorders and risk of suicide attempt: a national prospective study[END_REF][START_REF] Hoertel | A Comprehensive Model of Predictors of Suicide Attempt in Depressed Individuals and Effect of Treatment-Seeking Behavior: Results From a National 3-Year Prospective Study[END_REF][START_REF] Nock | Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication[END_REF][START_REF] Bostwick | Affective disorders and suicide risk: a reexamination[END_REF][START_REF] Kessler | Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey[END_REF][START_REF] Hoertel | A comprehensive model of predictors of suicide attempt in heavy drinkers: Results from a national 3-year longitudinal study[END_REF] we found that several disorders may be associated with heterogeneity in the timing of the onset of nonfatal suicidal behavior. Specifically, compared with first suicide attempts occurring between 18 and 34 years, first suicide attempts occurring in later life (i.e., at 35 years and older) were more strongly associated with mood disorders and substance use disorders, whereas first suicide attempts occurring early in life (i.e., <18 years) were less strongly related to psychiatric disorders.

Our results are in line with those of prior studies [START_REF] Conwell | Suicide in older adults[END_REF][START_REF] Turecki | Suicide and suicidal behaviour[END_REF][START_REF] Leo | Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study[END_REF][START_REF] Szanto | Occurrence and course of suicidality during short-term treatment of late-life depression[END_REF][START_REF] Conwell | Suicide in later life: a review and recommendations for prevention[END_REF][START_REF] Kato | Frequency and clinical features of suicide attempts in elderly patients in Japan[END_REF][START_REF]Older Adults: Depression and Suicide Facts (Fact Sheet)[END_REF] that have suggested that mood disorders are more strongly associated with suicide risk in older than in younger adults. There is evidence that the brain circuitry and neurochemical abnormalities related to mood disorders can disrupt the underlying neurobiological structures involved in stress response and susceptibility to environmental influences. [START_REF] Mann | Neurobiology of suicidal behaviour[END_REF] Longer exposure to depression may account at least in part for the increased suicide risk in older adults, [START_REF] Zubrick | The continuity and duration of depression and its relationship to non-suicidal self-harm and suicidal ideation and behavior in adolescents 12-17[END_REF] possibly through greater neuroinflammation. [START_REF] Setiawan | Association of translocator protein total distribution volume with duration of untreated major depressive disorder: a cross-sectional study[END_REF][START_REF] Pandey | Proinflammatory cytokines in the prefrontal cortex of teenage suicide victims[END_REF][START_REF] Pandey | Abnormal protein and mRNA expression of inflammatory cytokines in the prefrontal cortex of depressed individuals who died by suicide[END_REF] Contrasting with prior studies suggesting that substance use disorders may play a lesser role in later life suicide risk, we found that first suicide attempts occurring in later life (i.e. at 35 years and older) may be more strongly associated with alcohol use disorder and nicotine dependence than those occurring between 18 and 34 years. Our use of a general population sample and our focus on age at first suicide attempt may partly explain these discrepancies since prior studies have often relied on clinical samples and their results might have reflected differences related to multiple suicide attempts rather than to age at first suicide attempt. A greater vulnerability to deleterious neurological effects of nicotine and alcohol in older adults, which may result from physiological changes that occur with ageing, such as reduced kidney clearance and volume of distribution, [START_REF] Molander | Pharmacokinetics of nicotine in healthy elderly people[END_REF][START_REF] Kleykamp | The older smoker[END_REF] might explain their stronger effect on suicide risk in older than in younger adults.

We found that all childhood maltreatment types were significantly more common among individuals who first attempted suicide before 18 years than in those who first attempted suicide between 18 and 34 years. These findings are in line with prior research showing that exposure to childhood maltreatment, which affects developmental processes related to the strengthening of interpersonal and emotion regulation, [START_REF] Johnson | Childhood adversities, interpersonal difficulties, and risk for suicide attempts during late adolescence and early adulthood[END_REF][START_REF] Etkin | Common abnormalities and disorder-specific compensation during implicit regulation of emotional processing in generalized anxiety and major depressive disorders[END_REF] possibly though epigenetic modifications, [START_REF] Teicher | Childhood maltreatment and psychopathology: A case for ecophenotypic variants as clinically and neurobiologically distinct subtypes[END_REF] can have detrimental long-term effects on suicide risk, [START_REF] Hoertel | Childhood maltreatment and risk of suicide attempt: a nationally representative study[END_REF][START_REF] Mcmahon | Childhood maltreatment and impulsivity as predictors of interpersonal violence, self-injury and suicide attempts: A national study[END_REF] particularly when it occurs at a younger age [START_REF] Andersen | Preliminary evidence for sensitive periods in the effect of childhood sexual abuse on regional brain development[END_REF] . The effect of maltreatment might also be less intense later in life because people may develop coping strategies as they age, decreasing its detrimental effect on suicide risk.

Although family history of psychiatric disorders and many psychosocial and environmental factors are established risk factors for suicide, [START_REF] Qin | Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers[END_REF][START_REF] Mann | A current perspective of suicide and attempted suicide[END_REF] we did not find that family history of alcohol and drug use disorders, antisocial personality disorder and major depression nor gender, race-ethnicity, nativity, education and family poverty differentially influenced the timing of the first non-fatal suicide attempt. This result is consistent with prior work that showed that genetic risk profiles associated with increased risk for suicide attempt may be shared to a large degree in older and younger adults and may have enduring effects on this risk, [START_REF] Demirkan | Genetic risk profiles for depression and anxiety in adult and elderly cohorts[END_REF][START_REF] Alexopoulos | The inflammation hypothesis in geriatric depression[END_REF] and that socioeconomic and environmental factors are important risk factors for suicidal behavior at all ages. [START_REF] Roy | Gene-environment interaction and suicidal behavior[END_REF][START_REF] Osvath | Life events and psychopathology in a group of suicide attempters[END_REF] Our findings have important implications. First, our results support the importance of assessing age at onset of first non-fatal suicide attempt because we found substantial age differences in associated risk factors. Second, given that almost half of individuals attempted suicide before 18 years and that these individuals were frequently exposed to childhood maltreatment, all children and adolescents who attempt suicide should be systematically assessed for childhood maltreatment. Preventing child maltreatment with evidence-based interventions [START_REF] Mikton | Child maltreatment prevention: a systematic review of reviews[END_REF] could strongly decrease the burden of suicidal behavior. Third, older adults with mood disorders and substance use disorders should be systematically assessed for suicide risk, particularly because a large percentage of first attempts are fatal in this population. [START_REF] Byers | FATAL AND NON-FATAL FIRST SUICIDE ATTEMPTS IN LATER LIFE AND IMPLICATIONS FOR PREVENTION[END_REF] Finally, our findings underscore the importance of performing regular suicide risk assessments in individuals with any psychiatric disorder and history of childhood maltreatment at all ages and the need for close follow-up of suicide attempters to reduce the risk of suicide.

This study has several limitations. First, the participants included in our study had experienced exclusively non-fatal suicide attempts, thus the results could not be extrapolated to individuals who died by suicide. Second, we cannot establish a causal relationship between explored contributing factors and initial suicide attempts. [START_REF] Strat | Correlation is no causation: gymnasium proliferation and the risk of obesity[END_REF] Third, the NESARC survey relies on retrospective self-reports and reporting of suicide attempts, history of psychiatric disorder and childhood maltreatment experiences may be subject to recall bias, particularly among older adults. Fourth, the number of participants who first attempted suicide at 50 years of age or older was relatively modest (N=41), which resulted in limited statistical power. Fifth, several disorders (e.g., psychotic disorders, major neurocognitive disorders) known to be linked to suicide attempts were not assessed in the NESARC. Finally, certain environmental risk factors such as loneliness and stressful life events and factors of suicide risk reduction such connectedness with family, mental health professionals and community organizations [START_REF] Turecki | Suicide and suicidal behaviour[END_REF][START_REF] Mcmahon | Psychotherapeutic Treatment of Bipolar Depression[END_REF][START_REF] Pringle | A strategic approach for prioritizing research and action to prevent suicide[END_REF] were not assessed in the NESARC.

Conclusion

Our results suggest substantial age differences in risk factors for first non-fatal suicide attempt. Improving early detection and treatment of psychiatric disorders and preventing childhood maltreatment may have broad benefits to reduce the burden of suicidal behavior at all ages.

Clinical points

-In a large, nationally representative sample of adults, we found that 85.3% of first non-fatal suicide attempts occurred before age 35 years and that several clinical factors may influence the timing of the onset of non-fatal suicidal behavior -First suicide attempts occurring <18 years may be more strongly associated with childhood maltreatment and less strongly linked to prior lifetime psychiatric disorders, whereas first suicide attempts occurring at 35 years and older may be more strongly associated with a prior lifetime history of substance use disorders, including alcohol use disorder and nicotine dependence, and mood disorders, including mania/hypomania and dysthymic disorder between 35 and 49 years, and major depressive episode at 50 years and older.

-We did not find any significant associations between family history of psychiatric disorders and sociodemographic characteristics with age at first/single suicide attempt.

  Data were drawn from the Wave 1 and Wave 2 NESARC, a nationally representative face-to-face survey of the US adult population, conducted in 2001-2002 (Wave 1) and 2004-2005 (Wave 2) by the National Institute on Alcoholism and Alcohol Abuse (NIAAA) and

[SE=1. 8 ]

 8 ) made a first/single suicide attempt before the age of 18 years, 535 (40.1% [SE=1.8]) between 18 and 34 years, 145 (11.7% [SE=1.2]) between 35 and 49 years, and 41 (3.0% [SE=0.6]) at 50 years and older. Stratified rates per 1,000 persons of first non-fatal

Figure 1 .

 1 Figure 1. Rates per 1,000 persons of suicide attempts by age at first/single attempt in the National Epidemiologic Survey on Alcohol and

Table 1 . Comparing sociodemographic characteristics and prior lifetime psychiatric disorders by age at onset of first/single suicide attempt group in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (n=34,629).

 1 Adjusted for sex, race/ethnicity (White vs non-White) and age at Wave 2.

		No history of
		suicide	Age at first/single suicide attempt groups
		attempt (A)
			Before 18 years (B)	Between years (C) 18 and 34	Between years (D) 35 and 49	Between years (E) 50 and 77	A vs C	B vs C	D vs C	E vs C
		(n=33388)	(n=519)	(n=535)	(n=145)	(n=41)
		% (SE)	% (SE)	% (SE)	% (SE)	% (SE)
							OR (95% CI) / p-value	OR (95% CI) / p-value	OR (95% CI) / p-value	OR (95% CI) / p-value
	SOCIODEMOGRAPHICS
	Age, years	48.4 (0.2)	36.3 (0.6)	43.8 (0.6)	50.0 (0.9)	60.4 (1.3)	1.02 (1.01-1.02) / <0.001	0.95 (0.94-0.96) / <0.001	1.04 (1.03-1.06) / <0.001	1.11 (1.08-1.14) / <0.001
	Sex (Male)	48.5 (0.4)	28.2 (2.6)	34.0 (2.7)	37.9 (5.6)	51.8 (9.9)	1.82 (1.44-2.31) / <0.001	0.76 (0.53-1.10) / 0.14	1.19 (0.71-1.97) / 0.51	2.08 (0.93-4.67) / 0.08
	Race/ethnicity
	White	70.9 (1.6)	71.0 (2.7)	73.1 (2.2)	75.0 (3.9)	72.7 (7.9)	0.90 (0.72-1.11) / 0.31	0.90 (0.67-1.22) / 0.51	1.10 (0.69-1.76) / 0.68	0.98 (0.45-2.13) / 0.96
	Non-White	29.1 (1.6)	30.0 (2.7)	26.9 (2.2)	25.0 (3.9)	27.3 (7.9)	1.00	1.00	1.00	1.00
	Nativity						AOR (95% CI) / p-value a	AOR (95% CI) / p-value a	AOR (95% CI) / p-value a	AOR (95% CI) / p-value a
	US-born	85.8 (1.4)	92.1 (1.9)	91.3 (1.5)	90.9 (2.3)	85.9 (6.0)	1.00	1.00	1.00	1.00
	Foreign-born	14.2 (1.4)	7.9 (1.9)	8.7 (1.5)	9.1 (2.3)	14.1 (6.0)	1.75 (1.25-2.45) / 0.001	0.72 (0.38-1.38) / 0.32	1.09 (0.60-1.99) / 0.76	1.54 (0.35-6.73) / 0.56
	Education
	Less than high school	5.7 (0.3)	2.4 (0.7)	3.7 (0.9)	9.4 (3.7)	13.8 (5.9)	1.15 (0.67-1.97) / 0.61	0.71 (0.30-1.67) / 0.43	2.43 (0.76-7.74) / 0.13	na
	High school graduate	37.9 (0.6)	42.9 (3.1)	40.0 (2.7)	27.3 (4.2)	45.2 (9.4)	0.90 (0.72-1.13) / 0.36	0.96 (0.67-1.36) / 0.80	0.64 (0.39-1.04) / 0.07	1.69 (0.62-4.58) / 0.30
	Some college or higher	56.3 (0.7)	54.7 (3.1)	56.3 (2.7)	63.3 (5.1)	41.1 (9.7)	1.00	1.00	1.00	1.00
	Family poverty	12.7 (0.4)	30.5 (2.5)	29.1 (2.6)	23.2 (5.1)	20.2 (7.3)	0.39 (0.30-0.50) / <0.001	0.90 (0.65-1.26) / 0.60	0.89 (0.48-1.64) / 0.70	0.94 (0.35-2.53) / 0.90
	PRIOR LIFETIME PSYCHIATRIC
	DISORDERS
	Substance use disorders
	Alcohol use disorder		3.5 (1.1)	27.7 (2.6)	41.8 (5.4)	39.5 (9.8)		0.10 (0.05-0.21) / <0.001	2.11 (1.21-3.68) / 0.009	2.57 (1.05-6.27) / 0.039
	Drug use disorder		4.8 (1.2)	17.4 (2.1)	16.6 (4.3)	15.1 (8.7)		0.24 (0.13-0.42) / <0.001	1.32 (0.67-2.60) / 0.40	1.39 (0.29-6.68) / 0.70
	Nicotine dependence		1.6 (0.6)	14.0 (1.8)	25.3 (5.2)	26.0 (8.2)		0.10 (0.04-0.23) / <0.001	2.37 (1.22-4.61) / 0.011	3.65 (1.66-9.47) / 0.008
	Mood disorders
	Major depressive episode		18.9 (2.3)	33.6 (2.6)	40.0 (5.2)	43.7 (9.7)		0.44 (0.31-0.63) / <0.001	1.53 (0.91-2.57) / 0.11	3.01 (1.20-7.56) / 0.019
	Mania or hypomania		5.9 (1.5)	12.7 (1.7)	22.8 (4.8)	11.6 (6.2)		0.41 (0.22-0.77) / 0.006	2.26 (1.21-4.25) / 0.011	1.27 (0.38-4.27) / 0.70
	Dysthymic disorder		7.5 (1.6)	10.7 (1.5)	23.1 (4.6)	13.7 (8.7)		0.67 (0.39-1.14) / 0.14	2.84 (1.52-5.32) / 0.001	2.25 (0.49-10.2) / 0.30
	Anxiety disorders
	Panic disorder with or without agoraphobia	4.0 (1.4)	9.0 (1.7)	12.7 (3.3)	14.0 (6.4)		0.39 (0.20-0.79) / 0.009	1.52 (0.77-3.00) / 0.20	2.28 (0.61-8.46) / 0.20
	Social anxiety disorder		14.3 (2.1)	13.2 (1.8)	21.0 (5.1)	11.5 (5.4)		1.09 (0.69-1.71) / 0.70	1.85 (0.92-3.75) / 0.09	1.15 (0.34-3.91) / 0.80
	Specific phobia		18.8 (2.4)	20.2 (2.3)	26.2 (5.2)	16.5 (8.6)		0.88 (0.59-1.32) / 0.50	1.68 (0.92-3.09) / 0.09	1.44 (0.39-5.40) / 0.60
	Generalized anxiety disorder		3.7 (1.3)	9.4 (1.8)	11.6 (2.9)	9.3 (4.6)		0.37 (0.19-0.75) / 0.006	1.35 (0.70-2.63) / 0.40	1.45 (0.45-4.62) / 0.50

a

Table 2 . Comparing childhood maltreatment experiences and parental history of psychiatric disorders by age at onset of first/single suicide attempt group in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (n=34,629). No history of suicide attempt (A) Age at first/single suicide attempt groups

 2

			Before 18 years (B)	Between years (C) 18 and 34	Between years (D) 35 and 49	Between years (E) 50 and 77	A vs C	B vs C	D vs C	E vs C
		(n=33388)	(n=519)	(n=535)	(n=145)	(n=41)
		% (SE)	% (SE)	% (SE)	% (SE)	% (SE)
							OR (95% CI) / p-value	OR (95% CI) / p-value	OR (95% CI) / p-value	OR (95% CI) / p-value
	CHILDHOOD MALTREATMENT
	Physical neglect	6.0 (0.0)	8.4 (0.2)	7.7 (0.2)	7.8 (0.4)	8.2 (0.9)	0.85 (0.84-0.87) / <0.001	1.03 (1.01-1.06) / 0.009	1.00 (0.96-1.04) / >0.90	1.02 (0.95-1.10) / 0.60
	Emotional abuse	4.3 (0.0)	7.7 (0.2)	6.8 (0.2)	6.9 (0.4)	6.7 (0.7)	0.78 (0.76-0.80) / <0.001	1.06 (1.02-1.10) / 0.003	1.01 (0.96-1.07) / 0.70	1.02 (0.93-1.12) / 0.60
	Physical abuse	2.8 (0.0)	4.9 (0.2)	4.3 (0.1)	4.5 (0.3)	4.3 (0.5)	0.70 (0.67-0.73) / <0.001	1.02 (1.04-1.16) / <0.001	1.02 (0.94-1.12) / 0.60	1.02 (0.89-1.17) / 0.80
	Sexual abuse	4.3 (0.0)	7.2 (0.2)	6.4 (0.2)	6.1 (0.4)	5.4 (0.5)	0.78 (0.76-0.80) / <0.001	1.04 (1.01-1.07) / 0.009	0.99 (0.94-1.05) / 0.80	0.98 (0.88-1.08) / 0.60
	Emotional neglect	8.1 (0.0)	12.2 (0.3)	10.9 (0.3)	11.4 (0.6)	11.3 (0.9)	0.89 (0.88-0.91) / <0.001	1.04 (1.02-1.07) / 0.001	1.01 (0.97-1.04) / 0.70	1.00 (0.95-1.05) / >0.90
	FAMILY HISTORY OF
	PSYCHIATRIC DISORDER
	Alcohol abuse	21.3 (0.4)	48.7 (2.7)	41.4 (2.7)	51.7 (5.7)	39.3 (9.5)	0.42 (0.34-0.52) / <0.001	1.28 (0.94-1.74) / 0.12	1.59 (0.96-2.65) / 0.07	1.15 (0.48-2.75) / 0.70
	Drug abuse	3.4 (0.1)	18.0 (2.3)	10.5 (1.7)	9.0 (3.3)	5.2 (5.0)	0.39 (0.26-0.58) / <0.001	1.36 (0.83-2.24) / 0.20	1.13 (0.45-2.84) / 0.80	1.09 (0.14-8.43) / 0.90
	Major depression	23.5 (0.5)	56.9 (3.0)	53.6 (3.0)	54.0 (6.3)	33.6 (10.4)	0.30 (0.24-0.37) / <0.001	1.02 (0.76-1.38) / 0.90	1.10 (0.64-1.90) / 0.70	0.60 (0.22-1.60) / 0.30
	Antisocial personality disorder	8.1 (0.3)	31.2 (2.9)	24.6 (2.3)	30.6 (5.3)	16.3 (8.0)	0.31 (0.24-0.40) / <0.001	1.17 (0.82-1.68) / 0.40	1.57 (0.89-2.75) / 0.12	0.88 (0.27-2.79) / 0.80
	Percentages are weighted.

a Adjusted for sex, race/ethnicity (White vs non-White) and age at Wave 2.

Limosin has received speaker and consulting fees from AstraZeneca, Janssen, Lundbeck, Otsuka Pharmaceuticals, Roche and Servier outside the submitted work. The National Epidemiologic Survey on Alcohol and Related Conditions was sponsored by the National Institute on Alcohol Abuse and Alcoholism and funded, in part, by the Intramural Program, NIAAA, National Institutes of Health. Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the US government. Additional information: The original data set for the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is available from the National Institute on Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov).

-Improving early detection and treatment of psychiatric disorders and preventing childhood maltreatment may have broad benefits to reduce the burden of suicidal behavior at all ages.


Mathieu

Measures of Verbalizations

Keywords: Victimization, Terrorism, Victimology, Violence, Mental Health, Traumatic -applied-research.org

Acts of terrorist violence have several consequences), as well as other effects post-traumatic stress disorder). The produced by victims of terrorism reflect who suffered directly or indirectly the 2015 (in Paris) and in 2016 (in Nice), and social media). A detailed analysis processing tools, made it possible represent the consequences of the attacks

tudy of the errorism psychological, social, financial memory, vicarious trauma, extent to which the speeches study concerns 20 subjects took place in France in posted online (on the internet using automatic language victimization, and to visually Traumatic Memory, Disorders.


Mathieu Guidère

Psychocriminological Assessment of Radical Verbalizations

Keywords:

Most clinical tools make it possible relational factors, but some make it the subject's history, that is his past However, this information is essentially purpose of this article is to examine predict violent action. The study focuses France, based on their written and networks). The detailed analysis of the of risk, based on the techniques of predictive

The Journal of Applied Research to assess the criminal's personality based on various it possible to assess the probability of the risk of past (experience), his present (introspection) and essentially accessible through the subject's language examine the extent to which the rhetoric produced by focuses on 20 subjects who have been convicted of and audiovisual productions posted online (on the content of these verbalizations made it possible predictive linguistics and natural language processing Management, Predictive Linguistics, Terrorism, Violence, Verbalization,

-applied-research.org of Radical various psychological and taking action, based on and his future (intention). and verbalizations. The by radicalized people can of defending terrorism in the internet and social possible to highlight predictors processing tools (NLP). erbalization, NLP.

  Human & Social Sciences (JARHSS) N°3 -Pages 11-20 -ISSN 2677-7193. www.journal-of-criminological Assessment of Verbalizations Mathieu GUIDERE (INSERM / PARIS VIII)


M Mathieu

Keywords:

Mystical delirium is a form of alteration clinically by the presence of various and disorganized thinking. These verbalizations. The purpose of this radicalized people contain signs of online written and/or video productions The detailed analysis of the content markers of the grip, insertion and blocking the tools of natural language processing

The Journal of Applied Research

  Human & Social Sciences (JARHSS) N°2 -Pages 11-20 -ISSN 2677-7193. www.journal-of-


Mathieu

Psycholinguisti Effec

Keywords: Psycholinguistics, Pandemic, Containment

There are a wide range of questionnaires containment, but most of them are effects of confinement, including for disorders. Interested in how people well as how they felt during this experience, and online posts. The purpose of this contained people manifest markers posted online written and/or video content of these verbalizations made psychological effects of containment,

The Journal of Applied Research questionnaires that can be used to assess the psychological designed to be used only in specific cases. However, for example stress, anxiety, motivation, cognitive manage containment related to the coronavirus experience, we conducted a small-scale study that included this article is to examine the extent to which verbalizations markers relating to their mental health. The study relates video productions describing their mental state. A detailed made it possible to highlight psycholinguistic markers containment, by using data mining and text mining.

  Human & Social Sciences (JARHSS) N°1 -Pages 11-20 -ISSN 2677-7193. www.journal-of-linguistic Assessment cts of Containment Mathieu GUIDERE (INSERM / PARIS VIII)

Containment

  However, there are various disorders or even mood pandemic (covid-19), as included a written survey verbalizations produced by relates to 20 subjects having detailed analysis of the markers of the physical and ining, NLP.


Benjamin Noury
email: benjamin.noury@irstea.fr

Celine Pascual Espuny

Nils Ferrand
email: nils.ferrand@irstea.fr

Celine Pascual
email: celine.pascual@univ-amu.fr

How can participation and communication

Introduction

Climate change exposes freshwater resources of our planet to intense pressure. Extreme events are intensifying with more water-related natural disasters. Some territories are subject to more frequent droughts. Two-thirds of the world's population live in conditions of water scarcity for at least one month a year [START_REF] Mekonnen | Four billion people facing severe water scarcity[END_REF]. A deficit of 300 million m3 is currently observed between water available and the current withdrawals. Projections anticipate that this "Water Gap" will reach 2.8 billion m3 in 2030 (The 2030Water Resources Group, 2009).

Several strategies are implemented to address local water shortages (FAO, 2012). Options for additional withdrawals from so-called conventional resources (rivers, aquifers) are considered as a priority. Then, water saving measures are carried out to reduce consumption (search for leaks in the networks, change in agricultural practice, etc.). Finally, non-conventional resources, such as Norms and standards development on WWR1 has introduced technological and sanitary requirements. However, socio-economic issues, sometimes referred to as "social acceptability", was soon acknowledged as a key element for the development of WWR in the same way as technical issues [START_REF] Baumann | Public acceptance of renovated waste water: Myth and reality[END_REF]. In response, many studies have identified sociotechnical factors influencing stakeholders' perceptions [START_REF] Fielding | Public acceptance of recycled water[END_REF] Among these factors, information and knowledge are identified as central instruments to overcome social barriers. A recent World Bank report (2018) states that "The most successful cases of potable reuse have addressed community outreach through education and marketing." However, in the literature, there is no consensus on the influence of information. The highly commented projects in Toowoomba (Australia) and San Diego (USA) demonstrate that despite consistent communication, the social protest raised by WWR can compromise project implementation. In their analysis of the San Diego case, [START_REF] Jansen | Development of indirect potable reuse in impacted areas of the United States[END_REF] point out that late public involvement is partly responsible for this failure. Beyond communication strategies, Jansen implies the need to implement stakeholder engagement strategies. However, there are few examples of concrete implementation of a participatory approach to support dialogue around WWR project.

The ambition of our work is to link communication and participation in an action research approach. In the context of the Read'Apt pilot project, we aim to assess the effect of different communication facilities on citizens' perception of WWR. These facilities have different participatory intensities. In other words, we seek to gradually involve the citizen in the final decision following a co-construction process inspired by the principles of participatory communication [START_REF] Freire | Pedagogy of the oppressed. Herder and Herder[END_REF]. Our reflections also echo those developed by Deway, who sees participation as a criterion for prioritizing the degree of communication [START_REF] Quéré | Le modèle esthétique de la communication de John Dewey. Présenté à Communication, culture et communauté[END_REF]. The higher the degree of communication, the more meaningful is its social impact.

First, we trace the genesis of the research project and present the materials used for this article. Then, we detail the methodological elements used for our participatory approach. Finally, we describe the first results, the difficulties encountered and the reflexive questions raised by an action-research on social acceptability.

Territorial context and epistemological choice

Genesis of the Read'Apt project

The Calavon and the Largue, two tributaries of the Durance, are Mediterranean rivers located in the departments of Vaucluse and Alpes-de-Haute-Provence in the south of France. They are characterized by extremely severe low water regimes with many dry river areas. This water scarcity is a challenge for users, mainly for drinking water supply and agricultural irrigation. In consultation, all the water stakeholders in the territory have set objectives to reduce water withdrawals. Others alternatives to secure the water resources are also explored such as water transfers, drilling, storage, etc.

The Read'Apt project, supported by the French Water Agency Rhône-Méditérranée-Corse, is one of this alternative developed specifically for assessing the potential of WWR from some 20 wastewater treatment plants for local irrigation. The project started in 2017. It brings together local authorities, private partners and researchers. The project seeks to couple different dimensions of WWR [START_REF] Condom | Treated wastewater reuse in the Mediterranean: lessons learned and tools for project development[END_REF] to develop an integrated approach that combines technical feasibility, economic relevance and social acceptability.

In this paper, we focus on explaining the steps carried out to address the "embarrassing notion" of social acceptability [START_REF] Barbier | Acceptabilité sociale : partager l'embarras[END_REF]. This notion has led a lot of work to identify the main sociotechnical factors influencing stakeholders' perceptions [START_REF] Fielding | Public acceptance of recycled water[END_REF][START_REF] Hurlimann | Understanding behaviour to inform water supply management in developed nations -A review of literature, conceptual model and research agenda[END_REF][START_REF] Po | Literature Review of Factors Influencing Public Perceptions of Water Reuse[END_REF]. These works, based on Ajzen's planned behaviour theory, aims to prioritize the socio-demographic and psychological variables that influence behavioral attitudes and intentions.

Information as a factor of acceptability?

Information and awareness-raising are frequently cited as central instruments to overcome social barriers. It can go as far as finding the best name [START_REF] Menegaki | What's in a name: Framing treated wastewater as recycled water increases willingness to use and willingness to pay[END_REF] or using foreign languages [START_REF] Geipel | Barriers to sustainable consumption attenuated by foreign language use[END_REF] to facilitate acceptance of WWR. The Joint Research Center of the European Commission recommends in 2014 "to establish an effective consultation and communication strategies to promote public understanding and acceptance for WWR" In practice, communication experiences are diverse. Windhoek City regularly communicates in the media about drought. Singapore has created a brand, NeWater, to change public opinion about recycled water. The Water Reuse & Reuse Foundation (WERF) has developed a series of educational and awareness materials for large-scale communication campaigns for the cities of Perth (AUS) and Orange County (US).

However, the influence of information does not reach consensus in the literature. Some researchers argue that acceptability is not directly related to good information or communication [START_REF] Goodwin | Evaluating media framing and public reactions in the context of a water reuse proposal[END_REF][START_REF] Po | Literature Review of Factors Influencing Public Perceptions of Water Reuse[END_REF]. Empirical approaches from other studies [START_REF] Dolnicar | The effect of information on public acceptance -The case of water from alternative sources[END_REF][START_REF] Fielding | Providing information promotes greater public support for potable recycled water[END_REF][START_REF] Price | Developing effective messages about potable recycled water: The importance of message structure and content[END_REF] demonstrate that dissemination of information about WWR may have a measurable and positive influence on participants' attitudes towards this practice.

In these approaches referring to the information deficit model, information is considered in a linear way. Skepticism of WWR is attributed to a lack of understanding resulting from a lack of information. This model is strongly questioned. Critics point out its inability to take into account the social, cultural and institutional contexts in which attitudes and behaviors are formed [START_REF] Bulkeley | Common knowledge? Public understanding of climate change in Newcastle, Australia[END_REF][START_REF] Owens | How to change attitudes and behaviours in the context of energy[END_REF]. These approaches neglect the water culture forged in a long history that distinguish wastewater from other water resources [START_REF] Barbier | Le buveur d'eau et le recyclage des eaux usées[END_REF][START_REF] Barraqué | L'évolution de la problématique de l'assainissement au XXe siècle : hygiène, confort, environnement (Commentaire)[END_REF]. The other major criticism is that the model sets apart experts from laypersons [START_REF] Mcnie | Reconciling the supply of scientific information with user demands: an analysis of the problem and review of the literature[END_REF][START_REF] Wesselink | Technical knowledge, discursive spaces and politics at the science-policy interface[END_REF]. One explains and the other just listens. In the event of a contestation, it is considered that the scientist and/or the politician have not managed to make themselves understood by the actors concerned.

One way to overcome this model is to set up deliberative processes where communication is effective, inclusive and transformative between citizens and decision makers [START_REF] Fernandez | How to be a more effective environmental scientist in management and policy contexts[END_REF]. The central idea is that the legitimacy of collective decisions is based on the right, ability, and opportunity of those affected by a decision to participate in the deliberations that determine the content of that decision [START_REF] Dryzek | Foundations and Frontiers of Deliberative Governance[END_REF]. In line with the Aarhus Convention (1998), the promotion of a more transparent communication between citizens and political decision makers has been a priority objective for the European Commission and the water institutions (ministries, river basin organizations, local commissions, etc.). Participatory management and stakeholder involvement are criteria used by the governance literature and many institutions (OECD, GWP, SIWI2 ) to define the principles of good water governance.

Participatory approaches are popular to support WWR project implementation [START_REF] Harris-Lovett | Beyond User Acceptance: A Legitimacy Framework for Potable Water Reuse in California[END_REF][START_REF] Hartley | Public perception and participation in water reuse[END_REF][START_REF] Marks | Taking the public seriously: the case of potable and non potable reuse[END_REF]. These works highlight the impact of participatory arrangements on trust, the perception of equity and legitimacy that applies to both the decision-making process and its outcome. The decision is considered fair when it comes from a legitimate mechanism. In 2003, Birkhoff emphasized that for complex projects such as WWR, the involvement of different interests, knowledge and expertise in the decision-making process leads to better decisions. However, few participatory approaches have been implemented to support WWR projects.

With Read'Apt, we want to stimulate dialogue on WWR. The aim is not to persuade or subtly secure acceptance of WWR in a logic of "democratic persuasion" (Claeys-Mekdade, 2003) but rather to reveal an unknown alternative within the prime space [START_REF] Noury | Water reuse in France -Social perception of an unknown practice[END_REF]. In this perspective, the research project is seen more as an inductive approach in which the participatory process must be an opportunity to create knowledge, to stimulate mutual learning between decisionmakers and stakeholders [START_REF] Seguin | Effet d'engagement des acteurs et support de réflexivité : L'exemple d'une conférence de citoyens sur l'eau. Éducation relative à l'environnement[END_REF] and to support local actors in building their own options and choices (which may not be the implementation of WWR).

We assume a "calculated" and planned participation. However, this does not mean that its social scope is reduced to the creation of a simulacrum. We envision that participants will be able to contribute to define the form and nature of the experience they will have. Participating cannot be reduced to fulfill a role over which they have no control [START_REF] Zask | Participer : Essai sur les formes démocratiques de la participation[END_REF].

Our approach is anchored in a logic of participatory communication as opposed to a diffusionist approach. This means that we want to put the population at the heart of the communication process with a set of activities which contribute towards individual and social change [START_REF] Bessette | Eau, terre et vie: communication participative pour le développement et gestion des ressources naturelles[END_REF]. We do not aim at the politicization and confrontation presented in the pedagogy of the oppressed [START_REF] Freire | Pedagogy of the oppressed. Herder and Herder[END_REF] but at an awareness of the various facets of WWR and the structuring of a collective reaction to this alternative.

Our posture is therefore engaged. We are part of a mutual learning process where knowledge is built through action and, in return, citizen action is guided by the scientific process. Scientific knowledge is embedded in a social and political context. It is socially constructed [START_REF] Latour | Science in Action, How to Follow Scientists and Engineers through Society[END_REF] with many influences linked to their production conditions: project funding, institutional partnership, researcher's personality [START_REF] Moscovici | Les méthodes des sciences humaines[END_REF], etc. Our questioning is also reflexive, as emphasized by Egan Sjölander et al. ( 2018), on the place and the consequences of a research in Information and Communication Sciences that comes under action research.

Methodology

We distinguish two phases in our methodological approach. A qualitative preparatory phase based on the concept of Social Site Characterisation developed by [START_REF] Brunsting | Social Site Characterisation for CO2 Storage Operations to Inform Public Engagement in Poland and Scotland[END_REF] and an "action" phase with a repeated experimentation plan.

Social Site Characterisation

Any communication process, whether participatory or not, begins with a territorial analysis to define the issues, the actors involved, their expectations and perceptions. Social Site Characterisation tested on complex environmental issues such as CO2 storage seems relevant to question the social feasibility of a project before starting a socially and financially costly participatory approach. The objective of this step is not so much to ensure the success of the project in a territory as to ensure the relevance of initiating a dialogue there.

This method combines four distinct tools:

-A bibliographic research to understand the territorial hydrographic situation (local water management reports), to position the place of water in local history (municipal archives) and to evaluate social sensitivity (minutes of public meetings).

-A media analysis conducted with Factiva from 2000 to 2017. "Treated wastewater reuse" and "recycling treated wastewater" concepts were scanned in fifty national, regional and specialized press titles. Only daily and weekly publications were studied.

-Semi-directive interviews with the main stakeholders. 31 interviews were conducted with individuals concerned by the challenges of water scarcity in the Calavon and Largue rivers: farmers, government services, local authorities, environmental associations. There are no industrialists in the study area.

-A local population survey to test the dependence between the variables identified in semi-directive interviews. These surveys were conducted by Master 2 students from the University of Aix Marseille on the markets and supermarkets of 7 municipalities in the area. 120 questionnaires were collected.

Experimental setup for participatory communication

We do not consider a Participatory Action Research (PAR) in the sense of Reason [START_REF] Reason | The Sage handbook of action research: participative inquiry and practice[END_REF]. Participants and researchers will not jointly decide on objectives and methods. On the other hand, they participate in the collection, analysis and final decision.

The objectives are defined by the researchers based on the literature and the results of the Social Site Characterisation. The aim is to test different participation and communication mechanisms and to evaluate the transformations they generate in social representation. The hypothesis is that the more actors are engaged in the final decision, the more they modify their representation.

To do this, we have chosen four levels of participation: information, consultation, collaboration and codecision. methods proposed for each level are defined in consultation with the partners of Read'Apt project during a specific workshop.

Information: this level is considered "non-participatory" in the literature. It is more in line with the diffusionist and monological model. However, in practice, the term "participatory" is mobilized for very different approaches. As trendy concept, participation is used for all approaches with citizens, even if they are manipulative. In our research project, a website (www.reut-luberon.fr) is designed to present the project, the hydrological situation and WWR practices. This website is publicized through partners' websites and their social networks.

Consultation: at this stage, the experimentation enters into a dialogical logic where project partners and citizens can exchange. These exchanges do not guarantee the modification of the project. It is rather a matter of awareness and taking time to answer the population's questions. A public meeting is organized for this purpose. The partners present the ongoing experimental project, its genesis and the first results obtained.

Collaboration: still in a logic of exchanges, collaboration differs from consultation by a co-production dimension. 3 successive participatory workshops are proposed to citizens. They are open to all. The objective of the workshops is to define the conditions for implementation (and non-implementation) of treated wastewater reuse projects in the Calavon and Largue basins. Each workshop corresponds to a distinct participatory time with 1/ knowledge: exploration of local water issues with a role-playing game, visit of the wastewater treatment plant, meetings with experts, 2/ Exchange: elaboration of the main principles of implementation via a focus group; 3/ Synthesis and evaluation: drafting of a citizen charter and validation of its content by all participants.

Co-decision: In this last level, the participatory ambition is to involve citizens in the final decision on a WWR pre-project. In the classic scheme of a WWR project, the social feasibility is only questioned once the technical and economic feasibility has been validated with a pre-selected scenario. At this level, there is no longer any possibility of modifying the technical system. Contributions from the local consultations do not change the technical proposal. A social touch is developed in order to make this technical solution more acceptable. In our methodology, we plan to organize a meeting between the citizens and consultants who carry out the feasibility study to discuss the scenarios envisaged, modify them, or even abandon them if necessary.

The participants' perception and attitudes are systematically assessed during the different stages of the experiment in accordance with a repeated experimental plan. Our control group is made up of citizens who responded to the survey carried out on markets and supermarkets in the Social Site Characterisation phase.

Presented at Waterlines: Confluence and Hope through Environmental Communication

The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019

Results

The participatory experimentation is underway. The results of this phase cannot be presented. Nonetheless On the other hand, we come back to some of the pitfalls encountered during the preparation and the organization of this experimentation.

Social Site Characterisation

There is a long history related to water rights on the Calavon. The availability of the resource is not a new issue in this river basin. From the 12th century, development began to transfer waters from the Durance River. The canals built over the centuries allow the progressive development of irrigation. Many acts regulate access to the resource and organize its distribution between different uses: agricultural irrigation, mills and cities.

In the upstream part of Calavon, the area covered by the Read'Apt project, several hydraulic investment plans have been drawn up. However, none of these plans have been successful, although several initiatives have tried to revive, at different times. This historical reading sheds light on the feelings of abandonment and injustice that prevail among current farmers during the interviews.

The lack of water has marked this territory geographically and socially for several centuries. The Calavon has always been a dry torrent most of the time but the actual demographic and economic pressure exacerbate water imbalances. Water saving measures are carried out by all actors in the basin: leakage control in drinking water networks, drip irrigation, water-saving cultivation, public awareness, etc. Water scarcity is unanimously highlighted by the water stakeholders met during the interviews. However, this unanimity is not reflected in the general public survey. 50% of the citizens think that water resources are sufficient in the area.

Three other issues are identified in the Largue and Calavon management documents: improving water quality, preserving and enhancing the environment and involving stakeholders. Discussions for water policy in these basins were held as early as 1983 after a press release [START_REF]Calavon -La Rivière assassinée[END_REF] describing the river as "pestilential cloaca". Then, the Luberon Regional Natural Park impulsed in 1993 a consultation processes to develop a Water Development and Management Plan (SAGE). It is one of the first rivers in France to initiate this type of approach one year only after the 1992 National Water Act which sets this institutional mechanism. There is therefore a significant experience of concerted action for water in this territory.

It is interesting to point out that WWR is mentioned in regional management documents such as the Source3 and the SDAGE4 . However, it is not included in the local documents for the Largue and the Calavon basins. The practice is known but not discussed or promoted as an option to explore to address water scarcity issues. This observation is confirmed by the analysis of the semi-directive interviews. Preventing leaks, raising awareness of water saving, water-saving agricultural cultivation and hillside retention are the priority options invoked.

Exploration of WWR alternative via the Read'Apt project seems to correspond more to a political and financial opportunity than to a current need in the river basins. The emergence of the project was facilitated by a shared vision among partners and Water Agency funding to cover up to 50% of the costs. Partners' objectives are different but concomitant as shown in table 1.

Table 1: Partners' objectives

Local authority

Implement water saving experiment that can help farmers, which are well represented in municipal councils.

Facilitator of the local water management plan (Regional Park)

Study an innovative solution, especially since innovation and experimentation is a founding mission of the Regional Natural Parks in France.

Regional water development corporations

Obtain new references on treated wastewater reuse Farmers Explore a potential security of water resources.

All the partners have an interest in the implementation of this project even if it is not a priority in view of the actual territorial context. Some stakeholders interviewed believe that the practice may not be relevant in 2019 in the area. However, in the perspective of climate change, it is important to prepare for the future and explore alternatives that could be socially misunderstood.

Communication and awareness-raising initiatives are praised by stakeholders as an essential condition for the implementation of WWR projects. Most stakeholders interviewed are skeptical about the reception of this innovation by citizens. They believe that WWR practice is not well known. They suggest a dedicated communication strategy.

The general public survey reveals that 57% of respondents had already heard about the WWR, mainly through the media (TV and radio). These figures are surprising because the media analysis carried out reveals very low media coverage of the topic. Only 156 press articles mentioning WWR between 2000 and 2017 have been identified. 30% of these articles are devoted exclusively to WWR. In other cases, it is generally an option cited in a list of solutions to address water scarcity. The results can be explained by a greater media coverage in 2018 due to several parliamentary reports and the publication of two methodological guides on WWR (ARPE,2017;INEC, 2018). In addition, we focused on the print media, while the information seems to have been disseminated mainly on television and radio. Two weeks before the surveys, WWR was broadcasted on national prime time radio and television channels on the occasion of World Water Day [START_REF] Leibowitch | Les eaux usées bientôt recyclées[END_REF][START_REF] Munos | On va aller vers une réutilisation des eaux usées[END_REF][START_REF] Relat | Les eaux usées, ce trésor caché[END_REF].

In terms of attitude, the results below corroborate national water surveys in which a very large majority of individuals (75% in the CIEAU 2018 survey) support the use of WWR for fruit and vegetable irrigation. (C.I.Eau, 2018) These results confirm trends in the literature [START_REF] Smith | Public responses to water reuse -Understanding the evidence[END_REF] on the relationship between attitude and use. People are less favorable to use treated wastewater for market gardening (66%) than for watering green spaces (83%). This distinction is also confirmed when questioning consuming intentions. 91% of people interrogated would continue to frequent green spaces irrigated with WWR. 59% would continue to purchase from grocers who sell fruits and vegetables irrigated with WWR.

Finally, surveys and interviews reveal a need for information. It is expressed by both the population and water stakeholders. 60% of the population surveyed feel that they are not sufficiently informed about water. The stakeholders interviewed would like more information on the WWR (20/33).

When reading the results of the Social Site Characterisation, one can see that water scarcity is an important issue in the territory. It is shared by water stakeholders but not necessarily at the level of the local population. WWR is a known but not discussed practice. Actors and citizens are not opposed to it, but practicing it does not seem to take priority over other management options. The Read'Apt project therefore responds more to a political and financial opportunity than to a current local need in terms of water resources. However, this need could evolve in a context of climate change. The majority of stakeholders and citizens believe that water resources will be reduced. Should this happen, WWR could be a potential alternative and they would like to have more information.

The participatory approach presented below is not an end in itself. It must be a means for citizens to learn about water and to define together the future conditions for the implementation WWR projects, when relevant. The purpose of opening up spaces for dialogue is not to make WWR accepted but rather to make it appear as one option in the prime space. Our work as researchers is to evaluate the effect of participatory processes on social representations and not to encourage the implementation of WWR projects in the territory.

Experimental setup for participatory communication

The experimental setup is currently being implemented. We do not have sufficient hindsight to present the results of this approach. Nevertheless, we will share a first feedback on the difficulties encountered during its design and implementation. The pitfalls encountered stem from the reconciliation of operational and research objectives to the difficulties inherent in the organisation of the participatory process itself.

The interest and difficulties of implementing participatory action research have been widely researched in the literature [START_REF] Reason | The Sage handbook of action research: participative inquiry and practice[END_REF]. Along this line, we have favoured the anchoring of our work in a local reality to the detriment of a control of all the variables of our experimentation. The main difficulty in our case is the reconciliation of operational and research objectives. Some want to communicate on the project while others are setting up a research project.

This negotiation between research and operations cannot end with a simple juxtaposition of tools that would encompass the researcher applying a monitoring and evaluation approach to the defined communication strategy. Effective participation requires the opening of the decision-making space and transparency in the information disseminated. This therefore leads to changes in the very functioning of the project and its decision-making process.

Discussions were therefore held with the partners on a common definition of participation and codecision. The latter could lead to the refusal to set up a WWR project in the territory. Some partners modified their utilitarian vision of the humanities and social sciences during the discussions. At the beginning, the presence of humanities and social sciences in the Read'Apt project was seen as a way to legitimize a socio-technical approach.

However, the space for dialogue and decision-making is limited to WWR. This was primarily the funding partner's request. The main reason, however, is the lack of political will to open up the discussion to water resources management more broadly. Such a participatory ambition would challenge the current institutional approaches to water management in Calavon and Largue. The consultation mechanisms in place involve various actors in a form of representative democracy since citizens are represented through their elected representatives or environmental associations but without direct interaction with them. The opening of a participatory approach on water and not focused on WWR would call into question the work carried out in these bodies. This is considered as not politically desirable at the moment.

The setup of a participatory action research approach requires a significant amount of time which should not be neglected. Timescales issues are frequently cited as a difficulty in cooperations between economic actors and researchers. Economic actors often require a faster operationality of the research results than researchers are able to provide. The current project experienced timescales issues, but of different nature. It is researchers who stressed partners to be more responsive in the field. The participatory process on WWR is not considered as a priority for the territory. It sometimes struggles to find its place on actors' agenda.

The pace of the research project is therefore imposed by the field and the partners. This requires flexibility and a high degree of adaptability. In our case, we have made sure to allow sufficient time between the various stages of the process. This allowed us to implement alternative solutions without distorting the steps of the experimental setup. For example, the website (information phase) was made available online 1.5 months later than initially planned. This was due to administrative and content validation difficulties. The site was still able to be released 15 days before the date of the public meeting (consultation phase).

Finally, the organization of a participatory action research process leads researchers to play different roles: designer, facilitator, observer and evaluator. These roles can overlap and be assigned to the same person. It is therefore essential to carry out reflective work on the researcher's place in the process in order to estimate his influence. To facilitate this reflexivity, we ensured that the observer researcher who observed the process did not also facilitate the participatory workshops. A project partner facilitated the public meeting while a senior researcher facilitated the consultation and codecision workshops.

Discussion

Social acceptability is not an easy question to address in a participatory research approach in communication sciences. We have the impression of constantly walking a fine line that we denounce, acceptology5 .

Talking about the problem rather than a solution would allow to move away from this fine line. Rather than talking about WWR, ethically we should have opened a broader dialogue around drought and possible actions to be taken. WWR would then be one alternative among others.

This option was quickly eliminated so as not to jeopardize the ongoing water management efforts. It was neither the objective of the partners nor that of the donor to open such a reflection. In addition, such a participatory process would take longer than the 3 years of a doctorate. It would require strong political support to integrate citizen action proposals in institutional planning processes.

First, we moved away from the notion of acceptability to the question of social feasibility. Currently, feasibility studies for WWR in France only include technical and economic components. The Social Site Characterisation approach resulting from CO2 storage projects seems to be adapted to other environmental issues to measure the social feasibility of a project. It allows exploring social issues linked to WWR and taking them into account before a development decision is made, rather than considering them as an objective to be achieved.

The methodological proposal presented here seeks to couple scientific questions with a territorial reality. On the one hand, we question the effects of participatory communication setups on perceptions of WWR. On the other hand, we seek to open spaces for dialogue to bring out an alternative in the prime space.

Communication researchers sometimes underestimate the challenge of implementing conceptual strategies and models outside a laboratory, especially at the scale necessary to observe significant changes in public opinion and public policy. In our experimentation, the challenge is to distinguish between changes resulting from the process and those related to the environment. We also need to accept that a total capture of all the social interactions linked to our process is not possible. Most of them will take place outside the planned arenas.

Table 2 : Citizens' attitude towards WWR. Parks and green spaces Streets cleaning Orchards Market gardening Meadows for livestock

 2

	Favorable	83%	81%	69%	66%	53%
	Mitigated	7%	5%	12%	10%	16%
	Unfavorable	9%	7%	17%	21%	24%
	Wthout	2%	3%	2%	3%	7%
	notice
	Against	0%	3%	0%	0%	0%
	irrigation

NRMMCEPHC-NHMRC,

;USEPA, 2012 et CDPH, 2014

Organisation for Economic Co-operation and Development, Global Water Partnership, Stockholm International Water Institute

Strategy for a rational and harmonize use of the water resource

Masterplan for Water Development and Management

« Acceptology is the art of making others accept what they do not want to accept -in other words, making recalcitrant people swallow the pill, making the unacceptable pass through » translated from[START_REF] Chateauraynaud | La radicalité est-elle soluble dans l'argumentation ? La sociologie des controverses et l'endogénéisation de la critique sociale[END_REF]

Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019 Presented at Waterlines: Confluence and Hope through Environmental Communication The Conference on Communication and Environment, Vancouver, Canada, June 17-21, 2019 https://theieca.org/coce2019