Suicide prevention strategies: a systematic review.
World Health Organization1, University of Otago2, Columbia University3, American Foundation for Suicide Prevention4, Ludwig Maximilian University of Munich5, National Institute for Health and Welfare6, University College Dublin7, University of Oslo8, Uppsala University9, University of Würzburg10, National Defense Medical College11, Karolinska Institutet12, University of Hong Kong13
TL;DR: Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates, and other interventions need more evidence of efficacy.
Abstract: ContextIn 2002, an estimated 877 000 lives were lost worldwide through
suicide. Some developed nations have implemented national suicide prevention
plans. Although these plans generally propose multiple interventions, their
effectiveness is rarely evaluated.ObjectivesTo examine evidence for the effectiveness of specific suicide-preventive
interventions and to make recommendations for future prevention programs and
research.Data Sources and Study SelectionRelevant publications were identified via electronic searches of MEDLINE,
the Cochrane Library, and PsychINFO databases using multiple search terms
related to suicide prevention. Studies, published between 1966 and June 2005,
included those that evaluated preventative interventions in major domains;
education and awareness for the general public and for professionals; screening
tools for at-risk individuals; treatment of psychiatric disorders; restricting
access to lethal means; and responsible media reporting of suicide.Data ExtractionData were extracted on primary outcomes of interest: suicidal behavior
(completion, attempt, ideation), intermediary or secondary outcomes (treatment
seeking, identification of at-risk individuals, antidepressant prescription/use
rates, referrals), or both. Experts from 15 countries reviewed all studies.
Included articles were those that reported on completed and attempted suicide
and suicidal ideation; or, where applicable, intermediate outcomes, including
help-seeking behavior, identification of at-risk individuals, entry into treatment,
and antidepressant prescription rates. We included 3 major types of studies
for which the research question was clearly defined: systematic reviews and
meta-analyses (n = 10); quantitative studies, either randomized
controlled trials (n = 18) or cohort studies (n = 24);
and ecological, or population- based studies (n = 41). Heterogeneity
of study populations and methodology did not permit formal meta-analysis;
thus, a narrative synthesis is presented.Data SynthesisEducation of physicians and restricting access to lethal means were
found to prevent suicide. Other methods including public education, screening
programs, and media education need more testing.ConclusionsPhysician education in depression recognition and treatment and restricting
access to lethal methods reduce suicide rates. Other interventions need more
evidence of efficacy. Ascertaining which components of suicide prevention
programs are effective in reducing rates of suicide and suicide attempt is
essential in order to optimize use of limited resources.
Citations
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Harvard University1, University of Otago2, Universidad Autónoma Metropolitana3, Stony Brook University4, Katholieke Universiteit Leuven5, Utrecht University6, University College Hospital, Ibadan7, Peking University8, St George's Hospital9, University of Tokyo10, University of Paris11, Mental Health Services12, Pontifical Xavierian University13, All India Institute of Medical Sciences14, New Bulgarian University15, University of São Paulo16
TL;DR: Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts.
Abstract: Background: Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts. Methods and Findings: Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies. Conclusions: This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
661 citations
Cites background from "Suicide prevention strategies: a sy..."
...For instance, some programs designed to train primary care physicians in the recognition and treatment of depression have demonstrated reductions in the suicide rate [76–78]; however, not all such programs have yielded positive effects [79]....
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Harvard University1, Carlos III Health Institute2, University of São Paulo3, State University of New York System4, Katholieke Universiteit Leuven5, University of Paris6, The Chinese University of Hong Kong7, Pontifical University of the Holy Cross8, All India Institute of Medical Sciences9, New Bulgarian University10
TL;DR: An analysis of a large cross-national epidemiologic survey database that estimates the 12-month prevalence of suicidal behaviors, identifies risk factors for suicide attempts, and combines these factors to create a risk index for 12- month suicide attempts separately for developed and developing countries finds risk indices can predict suicide attempts with fairly good accuracy.
Abstract: Objective: Although suicide is a leading cause of death worldwide, clinicians and researchers lack a data-driven method to assess the risk of suicide attempts. This study reports the results of an analysis of a large cross-national epidemiologic survey database that estimates the 12-month prevalence of suicidal behaviors, identifies risk factors for suicide attempts, and combines these factors to create a risk index for 12-month suicide attempts separately for developed and developing countries. Method: Data come from the World Health Organization (WHO) World Mental Health (WMH) Surveys (conducted 2001–2007), in which 108,705 adults from 21 countries were interviewed using the WHO Composite International Diagnostic Interview. The survey assessed suicidal behaviors and potential risk factors across multiple domains, including sociodemographic characteristics, parent psychopathology, childhood adversities, DSM-IV disorders, and history of suicidal behavior. Results: Twelve-month prevalence estimates of suicide ideation, plans, and attempts are 2.0%, 0.6%, and 0.3%, respectively, for developed countries and 2.1%, 0.7%, and 0.4%, respectively, for developing countries. Risk factors for suicidal behaviors in both developed and developing countries include female sex, younger age, lower education and income, unmarried status, unemployment, parent psychopathology, childhood adversities, and presence of diverse 12-month DSMIV mental disorders. Combining risk factors from multiple domains produced risk indices that accurately predicted 12-month suicide attempts in both developed and developing countries (area under the receiver operating characteristic curve = 0.74–0.80). Conclusions: Suicidal behaviors occur at similar rates in both developed and developing countries. Risk indices assessing multiple domains can predict suicide attempts with fairly good accuracy and may be useful in aiding clinicians in the prediction of these behaviors.
611 citations
TL;DR: How common paralinguistic speech characteristics are affected by depression and suicidality and the application of this information in classification and prediction systems is reviewed.
607 citations
Cites background or methods from "Suicide prevention strategies: a sy..."
...Additional methods for early diagnosis could have a significant effect on suicide prevention, given that in up to 66% of suicides, patients have contacted a primary health care provider within a month prior to their death (Mann et al., 2005)....
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...Given the associations between depression and suicide, effective diagnosis and treatment of depression has been identified as a key strategy in suicide prevention (Mann et al., 2005)....
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...Therefore the continual assessment of suicide risk for patients undergoing depression treatments is an integral part of suicide prevention in this at-risk group (Hawton and van Heeringen, 2009; Hawton et al., 2013; Mann et al., 2005)....
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TL;DR: How the immune system regulates mood and the potential causes of the dysregulated inflammatory responses in depressed patients are described, and inflammation is likely a critical disease modifier, promoting susceptibility to depression.
604 citations
TL;DR: To reduce suicides during the COVID-19 crisis it is imperative to decrease stress, anxiety, fears and loneliness in the general population, and there should be traditional and social media campaigns to promote mental health and reduce distress.
Abstract: Multiple lines of evidence indicate that the coronavirus disease 2019 (COVID-19) pandemic has profound psychological and social effects. The psychological sequelae of the pandemic will probably persist for months and years to come. Studies indicate that the COVID-19 pandemic is associated with distress, anxiety, fear of contagion, depression and insomnia in the general population and among healthcare professionals. Social isolation, anxiety, fear of contagion, uncertainty, chronic stress and economic difficulties may lead to the development or exacerbation of depressive, anxiety, substance use and other psychiatric disorders in vulnerable populations including individuals with pre-existing psychiatric disorders and people who reside in high COVID-19 prevalence areas. Stress-related psychiatric conditions including mood and substance use disorders are associated with suicidal behavior. COVID-19 survivors may also be at elevated suicide risk. The COVID-19 crisis may increase suicide rates during and after the pandemic. Mental health consequences of the COVID-19 crisis including suicidal behavior are likely to be present for a long time and peak later than the actual pandemic. To reduce suicides during the COVID-19 crisis, it is imperative to decrease stress, anxiety, fears and loneliness in the general population. There should be traditional and social media campaigns to promote mental health and reduce distress. Active outreach is necessary, especially for people with a history of psychiatric disorders, COVID-19 survivors and older adults. Research studies are needed of how mental health consequences can be mitigated during and after the COVID-19 pandemic.
589 citations
References
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TL;DR: A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression and resulted in more favorable depressive outcomes.
Abstract: Objective. —To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of "usual care" by the primary care physician. Design. —A randomized controlled trial among primary care patients with major depression or minor depression. Patients. —Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression. Interventions. —Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials. Main Outcome Measures. —Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms. Results. —In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%;P Conclusion. —A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression. (JAMA. 1995;273:1026-1031)
1,424 citations
TL;DR: Alternative approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.
Abstract: OBJECTIVE: This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide. METHOD: The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects. RESULTS: Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults. CONCLUSIONS: While it is not known to what degree contact with mental health care and pr...
1,367 citations
"Suicide prevention strategies: a sy..." refers background in this paper
...Suicide prevention is possible because up to 83% of suicides have had contact with a primary care physician within a year of their death and up to 66% within a month.(17,18) Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression....
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...Prevention is possible because most suicides have had contact with a primary care physician within a month of death.(17,18) Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides....
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TL;DR: Two recent American studies have shown more than 90 per cent of suicides to be mentally ill before their death, and the familiar clinical observation that suicidal thoughts disappear when the illness is successfully treated provide a strong case for a medical policy of prevention.
Abstract: One hundred suicides were investigated retrospectively by interviewing surviving relatives. Nine-three per cent were diagnosed mentally ill, 85 per cent suffering from depression or alcoholism. Eighty per cent were seeing a doctor and 80 per cent were prescribed psychotropic drugs. Over a half had given warnings of suicidal thinking. Some suicides may be preventable with modern psychiatric treatment, but our investigation showed that these methods were not always being effectively deployed.
1,246 citations
"Suicide prevention strategies: a sy..." refers background in this paper
...Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.(7,8,10,15,16) Other contributory factors include availability of lethal means, alcohol and drug abuse, access to psychiatric treatment, attitudes to suicide, help-seeking behavior, physical illness, marital status, age, and sex....
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TL;DR: A limited range of diagnoses--most commonly a mood disorder alone or in combination with conduct disorder and/or substance abuse--characterizes most suicides among teenagers.
Abstract: Background: The age, sex, and ethnic distribution of adolescents who commit suicide is significantly different from that of the general population. The present study was designed to examine psychiatric risk factors and the relationship between them and demographic variables. Methods: A case-control, psychologic autopsy study of 120 of 170 consecutive subjects (age, Results: By using parent informants only, 59% of subjects who committed suicide and 23% of control subjects who metDSM-IIIcriteria for a psychiatric diagnosis, 49% and 26%, respectively, had had symptoms for more than 3 years, and 46% and 29%, respectively, had had previous contact with a mental health professional. Best-estimate rates, based on multiple informants for these parameters, for suicides only, were 91%, 52%, and 46%, respectively. Previous attempts and mood disorder were major risk factors for both sexes; substance and/or alcohol abuse was a risk factor for males only. Mood disorder was more common in females, substance and/or alcohol abuse occurred exclusively in males (62% of 18-to 19-year-old suicides). The prevalence of a psychiatric diagnosis and, in particular, substance and/or alcohol abuse increased with age. Conclusion: A limited range of diagnoses—most commonly a mood disorder alone or in combination with conduct disorder and/or substance abuse—characterizes most suicides among teenagers.
1,243 citations
TL;DR: While tremendous strides have been made in understanding of who is at risk for suicide, it is incumbent upon future research efforts to focus on the development and evaluation of empirically based suicide prevention and treatment protocols.
Abstract: Objective To review critically the past 10 years of research on youth suicide. Method Research literature on youth suicide was reviewed following a systematic search of PsycINFO and Medline. The search for school-based suicide prevention programs was expanded using two education databases: ERIC and Education Full Text. Finally, manual reviews of articles' reference lists identified additional studies. The review focuses on epidemiology, risk factors, prevention strategies, and treatment protocols. Results There has been a dramatic decrease in the youth suicide rate during the past decade. Although a number of factors have been posited for the decline, one of the more plausible ones appears to be the increase in antidepressants being prescribed for adolescents during this period. Youth psychiatric disorder, a family history of suicide and psychopathology, stressful life events, and access to firearms are key risk factors for youth suicide. Exciting new findings have emerged on the biology of suicide in adults, but, while encouraging, these are yet to be replicated in youths. Promising prevention strategies, including school-based skills training for students, screening for at-risk youths, education of primary care physicians, media education, and lethal-means restriction, need continuing evaluation studies. Dialectical behavior therapy, cognitive-behavioral therapy, and treatment with antidepressants have been identified as promising treatments but have not yet been tested in a randomized clinical trial of youth suicide. Conclusions While tremendous strides have been made in our understanding of who is at risk for suicide, it is incumbent upon future research efforts to focus on the development and evaluation of empirically based suicide prevention and treatment protocols.
1,242 citations
"Suicide prevention strategies: a sy..." refers background in this paper
...Other specific education strategies are aimed at youth, including school and community-based programs.(114,115) Few such programs are evidencebased, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior....
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...Few such programs are evidencebased, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.(114) A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support....
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