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Suicide Prevention Strategies Revisited - The Lancet
Suicide Prevention Strategies Revisited - The Lancet
Summary
Background Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence Lancet Psychiatry 2016
is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005. Published Online
June 8, 2016
http://dx.doi.org/10.1016/
Methods We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies
S2215-0366(16)30030-X
published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education,
See Online/Comment
media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were http://dx.doi.org/10.1016/
extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate S2215-0366(16)30068-2
or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, Geha Mental Health Center and
or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of Sackler School of Medicine,
evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal Tel Aviv University, Tel Aviv,
Israel (G Zalsman MD,
meta-analysis, we present a narrative analysis. R Barzilay MD); Division of
Molecular Imaging and
Findings We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials Neuropathology, Department
of Psychiatry, Columbia
(RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal
University, New York, NY, USA
means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall (G Zalsman); Centre for Suicide
decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School- Research, University of Oxford,
based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24–0·85; Oxford, UK (K Hawton FMedSci);
National Centre for Suicide
p=0·014) and suicidal ideation (0·5, 0·27–0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been
Research and Prevention of
substantiated, but might be less specific than previously thought. Effective pharmacological and psychological Mental Ill-Health (NASP),
treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for Karolinska Institute,
suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches Stockholm, Sweden
(D Wasserman MD, V Carli MD);
that need further investigation include gatekeeper training, education of physicians, and internet and helpline support.
Unit for Suicide Research,
The paucity of RCTs is a major limitation in the evaluation of preventive interventions. Ghent University, Ghent,
Belgium (K van Heeringen MD);
Interpretation In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the National Suicide Research
Foundation, Department of
others. Combinations of evidence-based strategies at the individual level and the population level should be assessed
Epidemiology and Public
with robust research designs. Health, University College Cork,
Cork, Ireland (E Arensman PhD);
Funding The Expert Platform on Mental Health, Focus on Depression, and the European College of Department of Medicine and
Health Science, University of
Neuropsychopharmacology. Molise, Via De Santis
Campobasso and National
Introduction prevention as a public health priority10 and national Institute for Health, Migration
Over 800 000 people worldwide die each year by suicide,1 prevention programmes have encouraged research, and Poverty, Roma, Italy
(M Sarchiapone MD); National
accounting for 1·4% of deaths worldwide. Suicide can detection, treatment, and management of people at risk Institute of Mental Health,
occur at any point in the lifespan, and is the second most for suicide in many countries.11,12 A major review of the Klecany, Czech Republic
frequent, and in some countries the leading, cause of effectiveness of approaches to suicide prevention was (C Höschl MD); Department of
death among young people aged 15–24 years.1 In addition, done by Mann and colleagues in 2005.13 We did a Developmental and Clinical
Child Psychology, Institute of
around 20–30 times as many suicide attempts occur.2 systematic review using similar methodology to assess Psychology, Eotvos Lorand
Suicide occurs because of a convergence of genetic,3 progress in suicide prevention research since that University, Budapest, Hungary
psychological,4 social, and cultural risk factors, combined influential study. (J Balazs MD); Institute of
with experiences of trauma and loss.5 Internal or external Behavioral Sciences,
Semmelweis University
risk factors and the relations between them can be Methods Budapest, Budapest, Hungary
explained in models of suicide, such as stress–diathesis,6 Search strategy (G Purebl MD); Université de
gene–environment,7 and gene–environment and timing We searched PubMed and the Cochrane library for Lorraine, Pôle de Psychiatrie et
interactions.8 all relevant English language studies published between Psychologie Clinique, Centre
Psychothérapique de
The complexity of this multifaceted phenomenon and Jan 1, 2005, and Dec 31, 2014. The initial search used the Nancy-Laxou, Nancy-Laxou,
low base rates, make research on suicide prevention Medical Subject Headings identifiers for “suicide” France (J P Khan MD);
highly challenging.9 However, the recognition of suicide (including the subheadings “suicide, attempted”, and Department of Psychiatry,
and women with borderline personality disorder.82,83 and support through telephone or face-to-face contacts
Preliminary trials have shown effectiveness of low-cost appeared to reduce suicides in low-income and
alternatives to classical DBT,90,91 as well as their acceptability middle-income countries, where mental health resources
for treatment for non-help-seeking suicidal patients.92 in the community are scarce, but paradoxically did not
Group therapy with elements of CBT, DBT, and problem- affect repetition of attempted suicide.108,109,111 Structured
solving therapy was effective in reducing self-harm for follow-up of people who attempt suicide decreased the
adolescents in one study79 but showed a negative effect in
another.127 Specific elements for which evidence is weak or
absent include skill development,83 the creation of a so- Level of Study type
evidence
called own reasons to live list,88 and the use of modelling
in skill development.128 A multi-systemic therapy approach Lithium
that addresses improving parenting skills, community, Unipolar and bipolar patients 1a Meta-analysis49
school and peer support, and engagement in pro-social Patients with major affective disorder 1a Meta-analysis50
activities was associated with a reduction of suicidal Patients with major affective disorder 1b RCT53
attempts when compared with hospitalisation in General population in Denmark 2b Cohort study51
adolescents.128 A variety of other treatments have shown Lithium and valporic acid
effectiveness in reducing suicidality,89,93,95 although the Patients with bipolar disorder, with a previous suicide 1b RCT55
level of evidence was relatively low. Psychosocial attempt
treatments have not shown clear effectiveness in reducing Antiepileptics* and lithium
deaths by suicide, perhaps because of small sample sizes.78 Patients with bipolar disorder 2b Cohort study (retrospective) 54
Community, family, and group-based interventions were Clozapine
not identified by Mann and colleagues.13 We found two Patients with schizophrenia 1a Meta-analysis56
meta-analyses96,97 that did not show community mental- Quetiapine and typical antipsychotics*
health services for people with serious mental illness to be Patients with schizophrenia 1a Systematic review57
superior to standard management in preventing suicide. Antidepressants*
However, results of one study97 showed greater acceptance Patients prescribed antidepressants 2c Ecological58
of treatment, and proposed the possibility of reduced Patients prescribed antidepressants 2c Ecological59
hospital admissions and suicide deaths. A meta-analysis Patients with major depressive disorder, prescribed 2c Cohort study (prospective) 60
conducted in Japan100 showed a reduction in suicides antidepressants
among people aged over 75 years following a community- Patients with major depressive disorder, with past 2b Cohort study62
suicide attempt
based intervention with screening and follow-up
Patients prescribed antidepressants 2c Ecological68
components based on pre-implementation versus post-
General population in Sweden 2c Ecological69
implementation changes, but with no comparative
condition. General population in Austria 2c Ecological70
Other studies assessing social support strategies in General population in Europe 2c Ecological72
different populations and settings showed inconsistent Patients prescribed antidepressants 3a Systematic review77
effects on suicide attempts and ideation,98,99,101,102 but Bipolar patients 3a Systematic review71
positive effects on depressive symptoms.101,102 One Ketamine
systematic review103 of family-based interventions for Suicidal patients 1a– Systematic review74
patients with schizophrenia found no effect on suicide. SSRIs
RCTs evaluating family-based interventions in suicidal Patients with major depressive disorder taking SSRIs 1a Meta-review of systematic reviews61
adolescents have consistently shown a clear decrease in Patients with major depressive disorder 1b RCT66
suicidal ideation and suicide risk factors,104–106 and Elderly patients with major depressive disorder, with 3b Case-control (retrospective)65
enhanced protective factors105 compared with routine past suicide attempt
suicide or suicidal behaviour was reported, but they Adolescents with suicide risk 2b RCT113
Discussion
Level of evidence Level of evidence
The heterogeneity of strategies and outcome measures,
School-based programmes as well as absence of good standards for evidence level in
Adolescents 1b RCT129 the literature, limits conclusions about the current
Adolescents 1b RCT130 effectiveness of suicide prevention strategies. However,
Children 1b RCT131
there have clearly been major advances since the review
by Mann and colleagues in 2005.13
Young adults (students) 2a Meta-analysis132
There is now strong evidence that restricting access to
Adolescent 2a Systematic review133
lethal means is associated with a decrease in suicide and
Children and adolescents 2a Systematic review134 that substitution to other methods appears to be limited.
Adolescents 2a Systematic review135 This is clearly a major strategy to be integrated in national
Adolescents 2a Systematic review136 suicide prevention plans.
Adolescents 2b Quasi-experimental137 Data support the use of a few pharmacological
Adolescents and adults (school staff) 2b Quasi-experimental138 interventions in suicide prevention. First, antidepressant
Adolescents 2b Cohort study139 pharmacotherapy treatment in adults is associated with
Public awareness campaigns
reduced suicide risk, while initiation of pharmacotherapy
does not lead to an exacerbation of suicide risk. In people
Adult men in Austria 2c Quasi-experimental140
aged over 75 years with depression, there is a clear
General population in USA 2c Quasi-experimental141
beneficial effect of pharmacotherapy on the risk of
General population in USA 2c Ecological142 attempted and completed suicide. In children and
Gay men in Switzerland 2c Quasi-experimental143 adolescents, increased risk of suicidal thoughts has to be
General population in Japan 2c Ecological144 taken into account when starting pharmacotherapy for
Primary care physicians education depression. However, given the increased risk of suicide
Primary care physicians in Sweden 2c Quasi-experimental145 in untreated depression and the absence of an increased
Primary care physicians in Hungary 2c Quasi-experimental146 risk of suicide associated with pharmacotherapy,
currently available evidence does not support the
Primary care physicians in Slovenia 2c Quasi-experimental147
avoidance of initiation and continuation of pharmaco-
Gatekeeper training
therapy for depression in children and adolescents.
School staff 1b RCT148
Therefore, the ongoing discussion about possible
Suicidal callers (to crisis line) 1b RCT149 induction of suicidality in minors should not prevent
Mixed populations 2a Systematic review150 physicians from prescribing SSRIs.77 If a decision is
Indigenous peoples in Australia, USA, Canada, and New 2a Systematic review151 made to use medication, then fluoxetine might be
Zealand considered, given that it is recommended as first-line
Youth helpers in schools 2b Quasi-experimental152 medication in guidelines. Second, lithium is effective in
Counselling staff for veterans in USA 2b Cohort study153 reducing the risk of suicide in people with mood
Adolescents and adults with major depressive disorder 2c Cohort study154 disorders, possibly through decreasing aggression and
Native children and adolescents in Alaska 2c Ecological155 impulsivity. Valproate might have similar efficacy in
General population in Nuremberg 2c Quasi-experimental156
patients with bipolar disorder. Third, an anti-suicidal
effect of clozapine in psychosis has been demonstrated;
Media reporting
however, recent studies suggest that clozapine might not
Media reporting 2a Systematic review157
differ from risperidone or olanzapine in this respect.
Mixed populations 2a Systematic review158
Studies of ketamine suggest promising rapid beneficial
General population in Austria 2c Ecological160 effects on reducing suicidal thoughts.
Depressed outpatients in Taiwan 4 Quasi-experimental161 Case series show that electroconvulsive therapy provides
Media blackout a rapid relief of suicidal thoughts. Electroconvulsive
General population in Austria 2c Quasi-experimental159 therapy should therefore be considered earlier, rather than
Screening at its conventional last resort position for patients at risk.
Primary care patients 1a– Systematic review162
Data support the efficacy of psychotherapies such as
CBT and DBT. Psychodynamic psychotherapies have not
Adolescents 1b RCT163
been systematically studied. Understanding which
Adolescents 1b RCT164
treatment components (such as the development of a
Adolescents 1b Quasi-experimental study165 therapeutic alliance, the role of case-management and of
Helpline callers 1b Cohort study166 significant others) might be effective in treatment of
Adolescents 2a Systematic review167 suicidality is an important line for future investigation.
Adolescents 2b Cohort study (longitudinal)168 The evidence on chain of care and follow-up is scarce
(Table 3 continues on next page) and heterogeneous, leading to weak significance of the
aggregate data. Follow-up of people who attempt suicide
in elderly people, screening for depression combined Crisis line callers/internet chat and forum users 2b Cohort study174
with community follow-up is effective in reducing suicide Internet-based intervention
risk. Family interventions with suicidal adolescents show Suicidal adults 2b RCT175
a promising effect on suicide ideation. Telephone intervention
RCTs increasingly show reduced suicide attempts and Adolescent outpatients (alcohol abusers) 2b RCT176
ideation following school-based mental health and Crisis line callers 2b RCT177
suicide awareness programmes, with or without
Mobile phone intervention
combined screening. While there has been an increase
Suicide attempters 4 Cohort study178
in the evaluation of general public awareness campaigns,
a lack of RCTs remains a major limitation, indicating that Telephone intervention
no statements can be made about the effectiveness of Suicide attempters (veterans) 4 Cohort study179
these campaigns in reducing suicide. Adult crisis-line callers 4 Cohort study180
Interventions including training programmes for GPs Crisis line callers 4 Cohort study181
might be followed by increased prescription of Crisis line callers 4 Cohort study182
antidepressants, and subsequent decrease in suicides, Crisis line callers 5 Cohort study183
but a direct association between training and reduced
Combined interventions
rates is difficult to identify. Future research using RCTs
Elderly population in Japan 2b Quasi-experimental184
should examine the value of GP training and the
Elderly population in Japan 2b Quasi-experimental185
efficiency of their diagnostic capabilities.
No RCT showed that gatekeeper training alone affected General population in Hungary 2c Ecological186
suicide rates. Gatekeeper training is usually implemented General population in Germany 2c Quasi-experimental187
along with other initiatives, making it difficult to identify General population in Germany 2c Quasi-experimental188
the effect of this specific intervention on suicide rates.
Oxford criteria from the Oxford Centre for Evidence-based Medicine (March 2009).14 RCT=randomised controlled trial.
Intermediate outcome measures, such as referral rates
and psychiatric treatment rates, should also be used.13 Table 3: Level of evidence (Oxford criteria) of suicide prevention using population-level prevention strategies
Future research should review elements of training, such
as who is best to lead it, to whom it should be delivered, more effective, provided that the chain of care is
and with which specific content. Evaluation of the uptake continuous and useful. Even in high-risk populations,
of training in different specific contexts or populations is evidence does not justify the cost of expensive screening
especially needed. procedures.
Although no controlled studies were done on the effect Combinations of evidence-based strategies should be
of media on suicidal behaviour over the last decade, a assessed on the individual and population levels using
clear bidirectional effect can be established. Media RCTs with sufficient power and similar methodologies.
should be used in collaboration with journalists as a Future research on the efficacy of combined
channel for appropriate public education. Further evidenced-based prevention strategies should focus on
investigation is needed on the effect of the internet and specific targeted populations (psychiatric patients,
social media on suicidal behaviour. children and adolescents, older people, and ethnic
Thus far, the evidence of telephone and internet minorities), as well as on cost-effectiveness and effect
intervention effectiveness is rather scarce and of low size. Data suggest that each specific risk group might
quality. Rapidly increasing utilisation of information and need a tailored preventive approach. Priority should be
communication technologies in suicide prevention given to reaching out to those who fail to seek medical or
requires research assessing their efficacy. psychological help, with particular attention paid to
There is insufficient evidence of the benefits of older subjects.
screening in primary care populations for reducing risk The main limitation of this study is that the final
of suicide. If referral to treatment is the outcome decisions on the level of evidence rely on the
measure and not suicidal behaviour, screening might be investigators’ judgments and therefore reproducibility of
the findings might be more difficult than in a formal 11 Lapierre S, Erlangsen A, Waern M, et al. A systematic review of
meta-analysis. However, 18 investigators participated in elderly suicide prevention programs. Crisis 2011; 32: 88–98.
12 van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, et al.
this process, and decisions on disagreements were made Best practice elements of multilevel suicide prevention strategies:
based on consensus. There is also an inherent risk of a review of systematic reviews. Crisis 2011; 32: 319–33.
bias at review (eg, incomplete retrieval of identified 13 Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies:
a systematic review. JAMA 2005; 294: 2064–74.
research, reporting bias). Finally, the literature review
14 Oxford Centre for Evidence-based Medicine. Levels of evidence
goes only to the end of 2014. (March 2009). 2009. http://www.cebm.net/oxford-centre-evidence-
To conclude, sufficient evidence supports effective based-medicine-levels-evidence-march-2009/ (accessed Feb 1, 2016).
methods of prevention of suicidal behaviour. Potential 15 Hahn RA, Bilukha O, Crosby A, et al. Firearms laws and the
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It is difficult to standardise methods for evaluation of
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substitution where access to a common method of 19 Klieve H, Barnes M, De Leo D. Controlling firearms use in
Australia: has the 1996 gun law reform produced the decrease in
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access to adequate funding to encourage and permit the 20 Rosengart M, Cummings P, Nathens A, Heagerty P, Maier R,
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death and disability, the implementation of proven, 21 Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R.
evidence-based, and cost-effective strategies are the duty Firearm legislation and firearm-related fatalities in the
United States. JAMA Intern Med 2013; 173: 732–40.
and responsibility of public health policy makers and
22 Gjertsen F, Leenaars A, Vollrath ME. Mixed impact of firearms
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Contributors observational study. Int J Environ Res Public Health 2014; 11: 487–506.
GZ and JZ conceived the idea and designed the study. GZ drafted the 23 Reisch T, Steffen T, Habenstein A, Tschacher W. Change in suicide
first version. All authors participated in data analysis, review process, rates in Switzerland before and after firearm restriction resulting
from the 2003 “Army XXI” reform. Am J Psychiatry 2013;
and preparation of the final version.
170: 977–84.
Declaration of interests 24 Lubin G, Werbeloff N, Halperin D, Shmushkevitch M, Weiser M,
KH is a National Institute for Health Research (NIHR) Senior Investigator Knobler HY. Decrease in suicide rates after a change of policy
and used personal funding from NIHR to support his involvement in this reducing access to firearms in adolescents: a naturalistic
work. The other authors declare no competing interests. epidemiological study. Suicide Life Threat Behav 2010; 40: 421–24.
25 Beautrais AL, Fergusson DM, Horwood LJ. Firearms legislation and
Acknowledgments reductions in firearm-related suicide deaths in New Zealand.
We thank Michaella Gerchak for editorial services. Aust N Z J Psychiatry 2006; 40: 253–59.
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