Suicide prevention strategies: what does the evidence tell use?
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Suicide prevention strategies revisited: 10-year systematic review

This recent piece from Lancet Psychiatry reviews the current evidence in suicide prevention and tells use where the evidence is strong and where it is lacking.  It provides an overview of the current literature and the effectiveness of what we are currently doing to help those that are feeling suicidal...

This article is a very thorough review of the evidence for the effectiveness of different approaches to suicide prevention. In the current climate of public dissatisfaction with our mental health system (linked to ongoingly poor statistics for suicide in Aotearoa), and the implied inefficacy of existing suicide prevention strategies in this country, it seems timely to be looking closely at a review like this.

Summary of the evidence

 The review grouped interventions into 7 categories: public and physical education, media strategies, screening, restricting access to means, treatments, and internet/hotline support (for quick-reference I’ve put a table below that summarises the findings).  The stand-out conclusions (from a wide array of studies with varying degrees of scientific rigour) in many ways point back to things that we already knew. Restricting access to means of suicide (and the fact that substitution to other methods seems to be limited) clearly reduces risk. (but there’s still a question around the application of this to our context given the prevalence of hanging as a means of completed suicide – the studies in the review were particularly focused around jumping and access to analgesic medication).  Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) came out as effective and the evidence seems to show that the benefits of antidepressant medication (including sertraline, which has previously been found to increase suicidal ideation in adolescents) outweigh the risks. The review concluded that there was strong evidence for the impact of lithium on reducing suicidality in mood disorders and, perhaps surprisingly, concluded that Electroconvulsive Therapy (ECT) should be considered earlier as a legitimate option for reducing suicidal ideation (however, the review noted the lack of controlled trials around ECT use). Availability of mental health services (in combination with “other resources”) was clearly shown to reduce suicidality.   School-based interventions emphasising suicide risk awareness, mental health literacy and skills training look promising (3 RCTs showed clear reduction in ideation and attempts which was sustained for 12 months after delivery). There was insufficient or conflicting evidence for effectiveness of screening in primary care, the development/implementation of media guidelines, and public education. Then there was the old “more research is needed” recommendation around the usefulness of gatekeeper training, and internet (lots of new initiatives here but not yet much solid research around efficacy) and helpline support.

A summary of findings is presented belowIntervention

Evidence

public education

Limited evidence around general public but good evidence for school-based interventions (but only those that include mental health literacy, suicide risk awareness and skills training)

physician education: Targeting recognition and treatment of depression

“One of the most effective interventions in lowering suicide rates” but statements in the conclusion less clear and call for more RCTS (!).

media strategies

Mixed results – media depiction good for general population (if emphasising positive coping) but detrimental for vulnerable populations. Better reporting associated with reduced suicidal behaviour

Screening programmes and service referrals

Not strong evidence for positive predictive value or for reducing suicide ideation and attempts but does increase referrals and service use by high-risk adolescents.

restricting access to means

Good evidence around jumping locations and access to medication/poison. Very little around interventions for hanging.

Treatments

Access to community-based pharmacological and psychological treatment reduces suicidality.

 

Top performers:

SSRIs (esp Fluoxetine), Clozapine, Lithium

CBT, DBT (but noted need to tease out the impact of different components – therapeutic alliance, case management etc)

ECT – for relieving suicidal thoughts

Follow-up of suicide attempters – strong evidence.

Weak evidence for:

Creation of own ‘reasons to live’

Skills training.

internet/hotline support

Low levels of evidence. Lots of initiatives but a lack of research demonstrating efficacy.

Gatekeeper training

Difficult to tell given that it is often used in conjunction with other interventions. More RCTS required.

The discussion starts by acknowledging that the strength of conclusions that can be drawn is limited due to the heterogeneity of outcome measures and methodology, as well as the varying quality of research.  We also need to be careful to not assume that the outcomes apply to our context. The authors make the following recommendations in relation to future research directions:

“Future research on the efficacy of combined evidenced-based prevention strategies should focus on specific targeted populations (psychiatric patients, children and adolescents, older people, and ethnic minorities)…data suggest that each specific risk group might need a tailored preventive approach. Priority should be given to reaching out to those who fail to seek medical or psychological help” [emphasis added].

Turning toward our own shores, and particularly considering the higher risk of Maori, it strikes me that many of those at highest risk in Aotearoa fall into this category of not accessing medical or psychological support. Several interventions have been shown to be effective, but we are still faced with questions around how to actually reduce access to a means like hanging, how school-based interventions work for young people who are not at school, and how to facilitate identification and treatment of depression when the highest risk groups don’t engage with screening processes or trust the service providers. Much of this can be linked back to the ripples of colonisation. Disenfranchised (and highest-risk) groups don’t actually experience the system as being theirs or for them. Maori might be more likely to access educational and health services if they perceived that these services were there primarily for them and as being run by people that they felt connected to. Without addressing these deep systemic issues around ownership and control we run the risk of just “rearranging the deck chairs”. We need to look at collaborative approaches to strengthening and better resourcing those agencies (such as Iwi Social Services, mentoring programmes, Maori mental health and alternative education providers) that are regarded as accessible by the highest risk members of our communities.

- Leigh Harrington, Clinical Advisor for TWB