Elsevier

The Lancet Psychiatry

Volume 3, Issue 7, July 2016, Pages 646-659
The Lancet Psychiatry

Articles
Suicide prevention strategies revisited: 10-year systematic review

https://doi.org/10.1016/S2215-0366(16)30030-XGet rights and content

Summary

Background

Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.

Methods

We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.

Findings

We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24–0·85; 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 substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.

Interpretation

In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.

Funding

The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

Introduction

Over 800 000 people worldwide die each year by suicide,1 accounting for 1·4% of deaths worldwide. Suicide can occur at any point in the lifespan, and is the second most frequent, and in some countries the leading, cause of death among young people aged 15–24 years.1 In addition, around 20–30 times as many suicide attempts occur.2

Suicide occurs because of a convergence of genetic,3 psychological,4 social, and cultural risk factors, combined with experiences of trauma and loss.5 Internal or external risk factors and the relations between them can be explained in models of suicide, such as stress–diathesis,6 gene–environment,7 and gene–environment and timing interactions.8

The complexity of this multifaceted phenomenon and low base rates, make research on suicide prevention highly challenging.9 However, the recognition of suicide prevention as a public health priority10 and national prevention programmes have encouraged research, detection, treatment, and management of people at risk for suicide in many countries.11, 12 A major review of the effectiveness of approaches to suicide prevention was done by Mann and colleagues in 2005.13 We did a systematic review using similar methodology to assess progress in suicide prevention research since that influential study.

Section snippets

Search strategy

We searched PubMed and the Cochrane library for all relevant English language studies published between Jan 1, 2005, and Dec 31, 2014. The initial search used the Medical Subject Headings identifiers for “suicide” (including the subheadings “suicide, attempted”, and “prevention and control”). “Suicide” was then combined with depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive drugs,

Results

Our literature search identified 1797 papers. Another 24 were obtained from other sources (figure). 224 papers were selected because they reported primary outcomes of interest or included applicable intermediate outcomes. These papers were assessed for eligibility, and 80 were excluded because of irrelevance or low evidence.

Heterogeneity in study methodology and in populations prevented a formal meta-analysis. We therefore present a narrative synthesis of the results in key domains of suicide

Discussion

The heterogeneity of strategies and outcome measures, as well as absence of good standards for evidence level in the literature, limits conclusions about the current effectiveness of suicide prevention strategies. However, there have clearly been major advances since the review by Mann and colleagues in 2005.13

There is now strong evidence that restricting access to lethal means is associated with a decrease in suicide and that substitution to other methods appears to be limited. This is clearly

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