Suicide Prevention: New Data

Nancy A. Melville

July 04, 2016

While collective research on suicide prevention over the past decade failed to show significant superiority of any one specific strategy over another, a new systematic review offers reassuring evidence that various individual strategies such as restricting access to lethal methods and the use of some pharmaceutical interventions are effective.

"In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others," the authors, led by Gil Zalsman, PhD, of Geha Mental Health Center and Sackler School of Medicine at Tel Aviv University, Israel, write.

"Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs," they add.

The study was published in the July issue of Lancet Psychiatry.

Restricted Access to Lethal Means

For the current analysis, researchers sought to update findings reported in a large analysis published in 2005 in JAMA on the effectiveness of suicide prevention strategies.

The authors focused on 164 relevant studies with primary outcomes of suicide, attempt, or ideation among research on seven commonly used suicide prevention interventions, including public and physical education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support.

The studies included 23 systemic reviews, 12 meta-analyses, 40 randomized controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations.

Researchers found restricting access to lethal means of suicide was effective. For example, restricting access to analgesics was linked to an overall 43% reduction in suicide. In addition, blocking access to popular suicide sites, such as bridges, by various means was associated with an 86% reduction in suicide.

"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," the authors write.

Restriction of firearm availability had mixed results. As many as 30 of the studies that examined restriction of firearms as a means of reducing suicide showed availability of firearms in households results in an increased odds ratio (OR) of 3.24 of suicide by firearm.

However, the investigators report that, overall, evidence was insufficient to determine if gun restriction laws are linked to a decrease in overall suicide rates. Some single US studies did show such restrictions help reduce suicide in certain populations, such as those with severe mental illness.

Meanwhile, research supports the use of antidepressant pharmacotherapy in reducing suicide risk in adults, and although the drugs have been linked to an increase in suicidal thoughts in children, the benefits of suicide prevention appear to outweigh those risks.

"Given the increased risk of suicide in untreated depression and the absence of an increased risk of suicide associated with pharmacotherapy, currently available evidence does not support the avoidance of initiation and continuation of pharmacotherapy for depression in children and adolescents," the authors write.

"Therefore, the ongoing discussion about possible induction of suicidality in minors should not prevent physicians from prescribing selective serotonin reuptake inhibitors."

The evidence further shows pharmacological interventions such as clozapine reduce suicide risk in patients with psychosis and lithium, benefitting those with mood disorders.

Few RCTs

Studies demonstrate efficacy of psychotherapies such as cognitive and dialectical behavioral therapies, and although the 2005 analysis showed mixed results on the efficacy of follow-up of people who attempt suicide, such as through contact interventions and collaborative care, the newer evidence supports such follow-up.

"[Follow-up] is strongly supported by data and should be included in any national suicide prevention strategy," the authors note.

"Findings that associate mental health service availability and reduced rates of suicide indicate the need for providing mental health services in national prevention initiatives."

Whereas the 2005 analysis showed school-based programs lack evidence-based approaches, the quality of those programs appears to have improved over the past decade, and such programs are linked to significant reductions in suicide attempts (OR, 0.45; P = .014) and suicidal ideation (OR, 0.5; P = .025).

Community- and family-based interventions do not show efficacy in suicide prevention among those with severe mental illness; however, such interventions help raise awareness of treatment acceptance.

The evidence further shows that depression screening in elderly people, combined with community follow-up, can be effective in reducing suicide risk.

However there was not benefit of suicide prevention screening measures in the primary care setting.

"Even in high-risk populations, evidence does not justify the cost of expensive screening procedures," the investigators write.

Future research on effective strategies should include more RTCs and evaluate the potential benefits of combinations of evidence-based strategies and specific populations, including psychiatric patients, children, the elderly, and ethnic groups, the authors assert.

"The paucity of RCTs is a major limitation in the evaluation of preventive interventions," they write.

Valuable Update

In an accompanying editorial, Gustavo Turecki, MD, PhD, of the McGill Group for Suicide Studies at the department of psychiatry, McGill University, Montreal, Quebec, Canada, notes that although it was challenged by broad differences in study designs the analysis offers a valuable update to improve understanding of the approaches that offer the best chance for suicide prevention.

"This review fulfills an important role in highlighting areas of potential discrepancy between expert opinion (eg, need for follow-up care), legislation (eg, black-box warnings on antidepressant use in youth), or public policy (eg, general public awareness campaigns), and available scientific data, identifying areas in which research must be focused to effect meaningful change on suicide," Dr Turecki writes.

The study received funding from the Expert Platform on Mental Health, Focus on Depression, and European College of Neuropsychopharmacology. Dr Turecki has received investigator-initiated grants from Pfizer Canada and honoraria from Bristol-Myers Squibb Canada and Janssen Canada.

Lancet Psychiatry. 2016;3:597-598, 646-659. Abstract Editorial

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