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Suicide Prevention Strategies

Suicide Prevention Strategies 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.Suicide is a significant public health issue. In 2002, an estimated 877 000 lives were lost worldwide through suicide, representing 1.5% of the global burden of disease or more than 20 million disability-adjusted life-years (years of healthy life lost through premature death or disability).The highest annual rates are in Eastern Europe, where 10 countries report more than 27 suicides per 100 000 persons. Latin American and Muslim countries report the lowest rates, fewer than 6.5 per 100 000.In the United States, in 2002, suicide accounted for 31 655 deaths, a rate of 11.0 per 100 000 per year,and general population surveys document a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,representing a huge human tragedy and an estimated $11.8 billion in lost income.Suicidal behavior has multiple causes that are broadly divided into proximal stressors or triggers and predisposition.Psychiatric illness is a major contributing factor, and more than 90% of suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV) psychiatric illness,with some exceptions, such as in China.Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.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.To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The Figureillustrates the multiple factors involved in suicidal behaviorand indicates where specific preventive interventions are being directed. 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.Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression. This review considers what is known about this and other prevention strategies to permit integration into a comprehensive prevention strategy.Figure.Targets of Suicide Prevention InterventionsCircled letters refer to relevant prevention interventions listed on right.Suicide experts from 15 countries met in Salzburg, Austria, in August 2004 to review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide.DATA SOURCESAn electronic literature search of all articles published between 1966 and June 2005 was conducted via MEDLINE, the Cochrane Library, and PsychINFO to identify reports evaluating suicide prevention interventions. An initial search used the MEDLINE identifier suicide(including the subheading suicide, attempted) and the subheading prevention and control, following that suicidewas combined with the following identifiers: depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive agents, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media.We identified 5020 articles, which were not bound by the 5 major areas identified during the workshop. Abstracts were reviewed and full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors.Study SelectionStudies were included if they reported on either the primary outcomes of interest, namely 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 as assessment of efficacy or effectiveness of prevention programs in terms of the above primary or secondary outcomes; (1) systematic reviews and meta-analyses (n = 10) for which the search strategy was comprehensive and the methodological quality of primary studies was critically appraised; (2) quantitative studies, either randomized controlled trials (n = 18), or cohort studies (n = 24); and (3) ecological or population based studies (n = 41). Table 1and Table 2detail study type, study population, and preventive intervention tested and rate the studies according to the scheme proposed by the Oxford Centre for Evidence Based Medicine.Randomized controlled trials provide the most compelling evidence of efficacy while findings of naturalistic studies are largely correlational, indicating that their outcomes need further testing.Table 1.Study Type, Level of Evidence, Population, and Prevention StrategySourceStudy TypeLevel*PopulationPrevention StrategyGunnell et al,2005Meta-analysis1ARCTs in UK psychiatric patientsAntidepressant useFergusson et al,2005Meta-analysis1ARCTs in psychiatric patientsAntidepressant useKhan et al,2003Meta-analysis1ARCTs in US psychiatric patientsAntidepressant usePloeg et al,1996Systematic review2AAdolescentsCurriculum-based programsGuo and Harstall,2002Systematic review2AAdolescentsCurriculum-based programPignone et al,2002Systematic review2APrimary care patientsScreening for depression in primary careFeightner,1994Systematic review2APrimary care patientsScreening for depression in primary careGaynes et al,2004Systematic review2APrimary care patientsScreening for suicide risk in primary careGilbody et al,2003Systematic review2APrimary care patientsDetecting and treating depression in primary careHawton et al,2000Systematic review2APatients who attempted suicidePsychotherapyAseltine and DeMartino,2004RCT1BAdolescentsCurriculum-based programThompson et al,2000RCT1BPrimary care patientsDetecting and treating depression in primary careBruce et al,2004RCT1BOlder primary care patientsDetecting and treating depression in primary careGlick et al,2004RCT1BAdults with schizophrenia spectrum disordersClozapineMeltzer et al,2003RCT1BAdults with schizophrenia spectrum disordersClozapineThies-Flechtner et al,1996RCT1BAdults with affective disordersLithiumBrown et al,2005RCT1BSuicide attemptersPsychotherapyGuthrie et al,2001RCT1BSuicide attemptersPsychotherapyBateman and Fonagy,2001RCT1BBorderline personality disorder patientsPsychotherapyMotto and Bostrom,2001RCT1BSuicide attemptersFollow-up care: postal contact programCedereke et al,2002RCT1BSuicide attemptersFollow-up care: telephone contact programAllard et al,1992RCT1BSuicide attemptersFollow-up careMorgan et al,1993RCT1BSuicide attemptersFollow-up care: green cardAsarnow et al,2005RCT1BAdolescentsPrimary care physician education: quality improvementOrbach and Bar-Joseph,1993RCT1BAdolescentsCurriculum-based programEggert et al,1995RCT1BAdolescentsCurriculum-based programThompson et al,2001RCT1BAdolescentsCurriculum-based programHuey et al,2004RCT1BPsychiatric crisis in adolescentsFollow-up careRihmer,2001Cohort study (quasi-experimental)2BPrimary care patients in HungaryPrimary care physician educationMarusic et al,2004Cohort study (quasi-experimental)2BPrimary care patients in SloveniaPrimary care physician educationKelly et al,1998Cohort study (quasi-experimental)2BPrimary care physiciansPrimary care physician educationOyama et al,2004Cohort study (quasi-experimental)2BPrimary care patients in JapanPrimary care physician educationMann et al,2004Cohort study (quasi-experimental)2BGeneral population in HungaryAntidepressantsKnox et al,2003Cohort study (quasi-experimental)2BUS Air Force personnelGatekeeper programsMotto,1970Quasi-experimental2BGeneral US populationMedia blackoutLoftin et al,1991Cohort study (quasi-experimental)2BGeneral US populationFirearm restrictionHegerl et al,2003Cohort study (quasi-experimental)2BGeneral population in GermanyPublic education campaignJorm et al,2005Cohort study (quasi-experimental)2BGeneral population in AustraliaPublic education campaignPaykel et al,1998Cohort study2BGeneral UK populationPublic education campaignAkroyd and Wyllie,2002Cohort study2BGeneral population in New ZealandPublic education campaignLehfeld et al,2004Cohort study2BGeneral population in GermanyPublic education campaignNaismith et al,2001Cohort study2BPrimary care physicians in AustraliaPrimary care physician educationHannaford et al,1996Cohort study2BPrimary care physicians in UKPrimary care physician educationLin et al,2001Cohort study2BPrimary care physicians in USPrimary care physician educationValentini et al,2004Cohort study2BPrimary care physicians and patients in BrazilPrimary care physician educationPfaff et al,2001Cohort study2BPrimary care physicians in AustraliaPrimary care physician educationTakahashi et al,1998Cohort study2BPrimary care patientsPrimary care physician educationRutz,1989Cohort study2BPrimary care patientsPrimary care physician educationMehlum and Schwebs,2000Cohort study2BNorwegian ArmyGatekeeper educationDieserud et al,2000Cohort study2BGeneral population in NorwayChain of careAoun,1999Cohort study4 High-risk adultsFollow-up careRotheram-Borus et al,2000Cohort study4 Suicide attemptersFollow-up careAbbreviation: RCT, randomized controlled trial.*Oxford Centre for Evidence Based Medicine, levels of evidence: 1A, systematic review of RCTs; 1B, individual RCT; 2A, systematic review of cohort studies; 2B, individual cohort study, low-quality RCT; 2C, ecological studies; 3A, systematic review of case-control studies; 3B, individual case-control study; 4, case series, poor-quality cohort and case-control studies.Table 2.Ecological Studies, Level of Evidence, Population, and Prevention StrategySourceStudy TypeLevel*PopulationPrevention StrategyEtzersdorfer and Sonneck,1998Ecological2CGeneral population in AustriaMedia blackoutBridges and Kunselman,2004Ecological2CGeneral population in CanadaFirearm restrictionsLester and Leenaars,1993Ecological2CGeneral population in CanadaFirearm restrictionsSnowdon and Harris,1992Ecological2CGeneral population in AustraliaFirearm restrictionsLudwig and Cook,2000Ecological2CGeneral US populationFirearm restrictionsOhberg et al,1995Ecological2CGeneral population in FinlandPesticide restrictionBowles,1995Ecological2CGeneral population in SamoaPesticide restrictionCarrington,1999Ecological2CGeneral population in CanadaFirearm restrictionKreitman,1976Ecological2CGeneral UK populationDomestic gas detoxificationLester,1990Ecological2CGeneral population in SwitzerlandDomestic gas detoxificationGunnell et al,2000Ecological2CGeneral UK populationDomestic gas detoxificationCrome,1993Ecological2CGeneral populationBarbiturate restrictionsNielsen and Nielsen,1992Ecological2CGeneral populationBarbiturate restrictionsYamasawa et al,1980Ecological2CGeneral population in JapanBarbiturate restrictionsHawton,2002Ecological2CGeneral UK populationAnalgesic packaging changesMcClure,2000Ecological2CGeneral population in England and WalesCatalytic convertersKelly and Bunting,1998Ecological2CGeneral population in England and WalesCatalytic convertersShelef,1994Ecological2CGeneral US populationCatalytic convertersCarlsten et al,2001Ecological2CGeneral population in SwedenAntidepressantsBeautrais,2001Ecological2CGeneral population in New ZealandBarriers to jumpingGibbons et al,2004Ecological2CGeneral US populationAntidepressant use plus introduction of lower-toxicity antidepressantsOlfson et al,2003Ecological2CUS adolescentsAntidepressantsHall et al,2003Ecological2CGeneral population in AustraliaAntidepressantsHelgason et al,2004Ecological2CGeneral population in IcelandAntidepressantsTakahashi,1999Ecological2CGeneral population in JapanAntidepressantsGuaiana et al,2005Ecological2CGeneral population in ItalyAntidepressantsSimon et al,2005Ecological2CGeneral US populationAntidepressantsValuck et al,2004Ecological2CUS adolescentsAntidepressantsLudwig and Marcotte,2005Ecological2CGeneral population in 27 countriesSSRIsCantor and Slater,1995Ecological2CGeneral population in AustraliaFirearm restrictionsWhitlock,1975Ecological2CGeneral population in AustraliaBarbiturate restrictionLester,1991Ecological2CGeneral population in the NetherlandsDomestic gas detoxificationWiedenmann and Weyerer,1993Ecological2CGeneral population in GermanyDomestic gas detoxificationLester,1990Ecological2CGeneral US populationDomestic gas detoxificationOliver and Hetzel,1972Ecological2CGeneral population in AustraliaBarbiturate restrictionsRetterstol,1989Ecological2CGeneral population in NorwayBarbiturate restrictionsCarlsten et al,1996Ecological2CGeneral population in SwedenBarbiturate restrictionsMott et al,2002Ecological2CGeneral US populationCatalytic convertersKapur et al,1992Ecological2CGeneral US populationIntroduction of lower-toxicity antidepressantsWasserman and Varnik,1998Ecological2CGeneral population in former USSRAlcohol restrictionLester,1999Ecological2CGeneral population in IcelandAlcohol restrictionAbbreviation: SSRIs, selective serotonin reuptake inhibitor.*For the definition of the Oxford Centre for Evidence Based Medicine, Levels of Evidence, see Table 1.DATA SYNTHESISHeterogeneity in study methodology and populations limited formal meta-analysis, thus we present a narrative synthesis of the results for the key domains of suicide prevention interventions.Awareness and EducationGeneral Public.Public education campaigns are aimed at improving recognition of suicide risk and help seeking through improved understanding of the causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious medical illness. Despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.Studies in Germany,the United Kingdom,Australia,and New Zealandsuggest modest effects of public education campaigns on attitudes regarding the causes and treatment of depression. Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign.However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control region.Other specific education strategies are aimed at youth, including school and community-based programs.Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.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.A later review of studies published from 1990-2002 also found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for prevention of suicidal behavior.A subsequent controlled trial reported lower suicide attempt rates, greater knowledge, and more adaptive attitudes about depression and suicide in the intervention group compared with in the 3 months after the intervention, but no significant benefits for rates of suicide ideation or help-seeking.In adolescents, several studies found that improving problem solving, coping with stress, and increasing resilience enhance hypothesized protective factors but effects on suicidal behavior were unevaluated.Primary Care Physicians.Depression and other psychiatric disorders are underrecognized and undertreated in the primary care setting.Prevention is possible because most suicides have had contact with a primary care physician within a month of death.Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides. Therefore, improving physician recognition of depression and suicide risk evaluation is a component of suicide prevention.Some studies in the United Kingdom,Australia,the United States,and Northern Ireland,showed that programs aimed at educating primary care physicians improved detection and increased treatment of depression, but that was not shown in other studies in the United States,Brazil,and the United Kingdom.Nurse case management, collaborative care, or quality improvement initiatives can further improve the recognition and management of depressionand has application where education alone may be insufficient.A controlled trial comparing a treatment algorithm plus depression care management with treatment as usual for late-life depression in primary care in the United States demonstrated greater improvement in patient suicidal ideation and a more favorable course of illness in the intervention group compared with the treatment-as-usual group.An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians resulted in a 50% decrease in suicide attempts in the intervention group that was not statistically different from the control group (18%) due to the low base rate.An Australian program that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people increased identification of suicidal patients by 130% (determined by the Depressive Symptom Inventory–Suicidality Subscale score), without changes in treatment or management strategies.Studies examining suicidal behavior in response to primary care physician education programs, mostly targeting depression recognition and treatment, in specific regions in Sweden,Hungary,Japan,and Sloveniahave all reported increased prescription rate for antidepressants and often substantial declines in suicide rates and represent the most striking known example of a therapeutic intervention lowering suicide rates.Gatekeepers.Suicide prevention includes a range of interventions focused on community or organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.Gatekeepersinclude clergy, first responders, pharmacists, geriatric caregivers, personnel staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy changes to encourage help-seeking, availability of resources, and efforts to reduce stigma associated with help-seeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental health and suicide and facilitated access to mental health services.To date, systematic evaluation of impact on suicidal behavior has largely been limited to multilevel programs conducted in institutional settings, such as the military where programs in the Norwegian Armyand the US Air Forcehave reported success in lowering suicide rates.ScreeningScreening aims to identify at-risk individuals and direct them to treatment. The focus may be on suicidal behavior directly or risk factors, such as depression or substance abuse. Screening instruments for depression, suicidal ideation, or suicidal acts administered to high school students,juvenile offenders,and youth in generalhave reliability and validity in identifying individuals at increased risk for suicidal behavior and are reported to double the number of known at-risk individuals.There is no evidence that screening youth for suicide induces suicidal thinking or behavior.Acceptance of the need for treatment by identified at-risk youth and actual treatment implementation are understudied as potential barriers to the effectiveness of screening programs.The US Preventive Services Task Force (USPSTF) review of studies of depression screening in adults in primary health care settings found a 10% to 47% increase in rates of detection and diagnosis of depression with the use of screening tools.The effect on treatment was mixed, due to differences in study methodology. In contrast, a Canadian review of depression screening studies did not find routine screening in primary care to improve depression care.Neither report commented on effects on suicidal behavior. In contrast, screening in localized geographic areas results in more treatment of depression and lower suicide rates.The 2004 USPSTFreview of evidence on screening for suicide risk, as opposed to depression, found no published studies in English evaluating the effectiveness of screening for suicide risk in primary care.Treatment InterventionsPharmacotherapy.Psychiatric disorders are present in at least 90% of suicides and more than 80% are untreated at time of death.Depression is untreated or undertreated in general,even after suicide attempt.Thus, treating mood and other psychiatric disorders is a central component of suicide prevention.Antidepressant medications alleviate depression and other psychiatric disorders.However meta-analyses of RCTs have generally not detected benefit for suicide or suicide attempts in studies of antidepressants in mood and other psychiatric disorders,perhaps due to the low base rate of suicidal behavior and insufficient systematic screening for suicidal behavior since reliance on spontaneous reporting underestimates rates of suicidal behavior.Randomized controlled trials can be informative when higher-risk patients are studied and indicate an antisuicidal effect for lithium in major mood disordersand clozapine in schizophrenia.Few studies prospectively identified suicidal behavior as an outcome measure and systematically assessed it throughout the RCT.Higher prescription rates of antidepressants correlate with decreasing suicide rates in adults or youth in Hungary,Sweden,Australia,and the United States.Geographic regions or demographic groups with the highest selective serotonin reuptake inhibitor prescription rates have the lowest suicide rates in the United Statesand Australia.Although Iceland,Japan,and Italydo not show such correlations, potential reasons include lack of compliance; pre-existing low-suicide rate, resulting in a floor effect; and high rates of alcoholism that may elevate suicide rates or the effect may be confined to women because too few men seek and comply with treatment with antidepressants. Suicide rates in 27 countries fell most markedly in countries that had the greatest increase in selective serotonin reuptake inhibitor prescriptions.Patient population studies report lower suicide attempt rates in adults treated with antidepressant medicationand in adolescents after 6 months of antidepressant treatment compared with less than two months of treatment.The risk of an ecological fallacy, that is, inferring causality from group correlations, prevents attributing decreases in suicide rates solely to antidepressant use. Nevertheless, there is a striking correlation and plausible mechanism linking antidepressant use to declining rates of untreated major depression and therefore suicide.Concerns about higher rates of suicide-related adverse event reports in depressed children and adolescents taking selective serotonin reuptake inhibitors compared with placebo in RCTs have prompted regulatory bodies in the United States, the United Kingdom, and Europe to issue warnings urging clinicians to monitor suicide risk and adverse effects carefully when prescribing antidepressants to youth. Such concerns need to be weighed against the risk of untreated depression because suicide is the third leading cause of death in youth and more than 90% of suicides in depressed youth are untreated at the time of death.Psychotherapy.Promising results in reducing repetition of suicidal behavior and improving treatment adherence exist for cognitive therapy,problem-solving therapy,intensive care plus outreach,and interpersonal psychotherapy,compared with standard aftercare. Cognitive therapy halved the reattempt rate in suicide attempters compared with those receiving usual care.In borderline personality disorder, dialectical behavioral therapyand psychoanalytically oriented partial hospitalizationimproved treatment adherence and reduced suicidal behavior compared with standard after care. Intermediate outcomes such as hopelessness and depressive symptoms improve with problem solving therapy, and suicidal ideation is decreased with interpersonal psychotherapy, cognitive behavior therapy, and dialectical behavioral therapy.Follow-up Care After Suicide Attempts.Many psychiatric disorders, including depression, are chronic and recurrentand compliance with maintenance medication is often poor. Interventions for depression provided by primary care physicians are more effective when a case manager follows up with patients who miss appointments or need prescription renewals.Many depressed patients who survive a suicide attempt will make further suicide attempts,particularly in the period shortly following psychiatric hospitalizationor during future major depressive episodes.Thus, improved acute, continuation, and maintenance care, including psychiatric hospitalization, where necessary, of those with recurrent or chronic psychiatric disorders,particularly patients who attempt suicide with mood disorders, has potential for prevention. Reduction of the number of psychiatric inpatient beds in Norway as part of a program of deinstitutionalization of psychiatric inpatients resulted in an increased suicide rate in the year after discharge with a standardized mortality ratio of 133(95% confidence interval, 90.1-190.7) in men and 208.5 (95% confidence interval, 121.5-333.9) in women.The Norwegian multidisciplinary chain-of-care networks provide follow-up care after hospital care to those who attempt suicide. Regions with chain-of-care programs have lower treatment dropout rates and fewer repeat attempts.Intervention studies of those who attempt suicide to prevent future suicidal behavior have produced mixed results, including fewer suicides compared with a control group after regular mailings,and fewer suicide attempts after issuing an emergency contact green card) or use of a suicide intervention counselor to coordinate assessment and long-term treatment.Other interventions for those who attempt suicide, including telephone follow-up, intensive psychosocial follow-up, and video education plus family therapy, resulted in no difference between standard aftercare and intervention groups in rate of reattempt or reemergent suicidal ideation.Means RestrictionSuicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in higher rates of death. Suicides by such methods have decreased after firearm control legislation,restrictions on pesticides,detoxification of domestic gas,restrictions on the prescription and sale of barbiturates,changing the packaging of analgesics to blister packets,mandatory use of catalytic converters in motor vehicles,construction of barriers at jumping sites,and the use of new lower toxicity antidepressants.Where the method is common, restriction of means has led to lower overall suicide rates: firearms in Canadaand Washington, DC,barbiturate restriction in Australia,domestic gas detoxification in Switzerlandand the United Kingdom,and vehicle emissions in England.Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republicsand Iceland.Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom,in Germany,and in the United Statesand for banning the pesticide parathion in Finland.Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means. Gauging the extent to which declining overall suicide rates are directly attributable to restriction in access to particular means requires consideration of long-term trends and confounding factors such as increased antidepressant use.MediaThe media can help or hinder suicide prevention efforts by being an avenue for public education or by exacerbating suicide risk by glamorizing suicide or promoting it as a solution to life’s problems. The latter may encourage vulnerable individuals to attempt suicide or to be attracted to suicide hot spots portrayed in the media as discussed by Pirkis et aland Gould.Media blackouts on reporting suicide have coincided with decreases in suicide rates.A 1987 campaign to decrease media coverage of subway suicides in Austria cut subway suicides by 80%.The Internet is of increasing concern, particularly the effects of suicide chat rooms, the provision of instruction in methods for suicide, and the active solicitation of suicide-pact partners.Educating journalists and establishing media guidelines for reporting suicide have had mixed results.The American Foundation for Suicide Prevention and Annenberg Public Policy Center,and The Centers for Disease Control and Preventionin the United States have produced guidelines for the responsible reporting of suicide; however, no published studies have evaluated their impact.Conclusions and Future DirectionsNational suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. Table 3summarizes estimates of impact of different interventions on national suicide rates showing that the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome, or there may be longer-term trends in suicide rates that are not captured by the studies.Table 3.Postintervention Decrease in Total Suicide RatesInterventionSuicides, % Decline in Annual RateEducationPublicNot availablePrimary care physician22-73GatekeeperUS Air Force40Norwegian Army33Increasing antidepressant prescriptions*3.2Chain of careNot availableRestricting lethal meansGuns1.5-9.5Domestic gas19-33Barbiturates23Vehicle emissionsNot availableAnalgesicsNot availableMedia blackoutsNot available*There was a 414% increase in antidepressant prescriptions 1987-1999.Physician Education.This increases the number of diagnosed and treated depressed patients with accompanying reductions in suicide although booster programs appear necessary. Videoconferencing and other teleconferencing consulting methods are possibilities where expert help is not available locally. However, the effect on suicide rates must be measured, as well as effects on intermediate outcomes, such as primary care physician–diagnosed cases of major depression and antidepressant prescription rates.Pharmacotherapy.Randomized controlled trials are needed to prove that selective serotonin reuptake inhibitors decrease suicide rates. Their efficacy is established for major depression, the main risk factor for suicide. Education programs targeting primary care physicians should include instruction on use of antidepressants. The relationship between antidepressant use and emergent suicidal ideation and behavior in depressed children and adolescents needs further study. Because most depressed youth who attempt suicide are untreated, it is important not to prematurely discourage the use of effective antidepressants such as fluoxetine.Gatekeeper Education.Where the roles of gatekeepers are formalized and pathways to treatment are readily available, such as in the military, educating gatekeepers helps reduce suicidal behavior. Demonstration projects for other gatekeepers with intermediate outcome measures, such as referral rates and psychiatric treatment rates, should be conducted.Means Restriction.Restricting access to lethal methods decreases suicides by those methods. Priority should be given to the most commonly used methods in each country. The possibility of substitution of methods requires ongoing monitoring, as does compliance with restrictions such as firearm access.Screening.Although screening programs have reported some success in identifying individuals with known risk factors for suicide, particularly among high school and college student populations, further consideration needs to be given to determining the cost-effectiveness of screening general populations vs identified at-risk populations for reducing suicide rates, the predictive validity and reliability of specific screening instruments, and the appropriateness of standard suicide screening instruments across different cultures.Psychotherapy.Psychotherapy alone or in combination with some antidepressants can be an effective treatment for depression, for suicidal ideation, for suicide attempts in borderline personality disorder, and for preventing new attempts after a suicide attempt. More needs to be known about the combinations of psychotherapeutic and pharmacologic interventions for short-and long-term outcomes for suicidal patients.Chain of Care.After a suicide attempt, better structured collaboration between hospitals and teams providing follow-up care may improve compliance with treatment and decrease new attempts, but essential elements of postsuicide attempt interventions are yet to be identified.Media.Strategies for influencing how the media reports suicide need to be implemented and evaluated.Suicide prevention interventions should be multimodal, evidence-based, guided by specific testable hypotheses, and implemented among populations of sufficient size to yield generalizable and reliable results. Programs must include outcome measures. Finally, because most studies have been conducted in developed nations, many issues facing underresourced developing nations have not been addressed and require future studies specifically focused on suicide prevention.Corresponding Author:J. John Mann, MD, Department of Neuroscience, New York State Psychiatric Institute, 1051 Riverside Dr, Box 42, New York, NY 10032 (jjm@columbia.edu).Author Contributions:Dr Mann had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Study concept and design: Mann, Apter, Beautrais, Haas, Hegerl, Lonnqvist, Malone, Mehlum, Schmidtke, Shaffer, Varnik, Wasserman, Yip, Hendin.Acquisition of data: Mann, Apter, Bertolote, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Phillips, Silverman, Takahashi, Hendin.Analysis and interpretation of data: Mann, Bertolote, Beautrais, Currier, Haas, Hegerl, Malone, Marusic, Mehlum, Patton, Rutz, Rihmer, Silverman, Hendin.Drafting of the manuscript: Mann, Apter, Beautrais, Currier, Haas, Hegerl, Schmidtke, Shaffer.Critical revision of the manuscript for important intellectual content: Mann, Apter, Bertolote, Beautrais, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip, Hendin.Statistical analysis: Mann, Marusic.Obtained funding: Malone, Hendin.Administrative, technical, or material support: Beautrais, Currier, Haas, Hegerl, Lonnqvist, Patton, Schmidtke, Silverman, Hendin.Study supervision: Mann, Rutz, Rihmer.Financial Disclosures:Dr Mann received a grant from GlaxoSmithKline to do a positron-emission tomography study of Alzheimer disease; otherwise, no financial disclosures were reported.Funding/Support:Funding for the International Strategies Workshop was provided by an unrestricted educational grant from Pfizer Inc.Role of the Sponsor:Pfizer had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.REFERENCESWorld Health OrganizationWorld Health Report 2003: Shaping the Future.Geneva, Switzerland: World Health Organization; 2003. 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References (137)

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American Medical Association
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Copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
ISSN
0098-7484
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1538-3598
DOI
10.1001/jama.294.16.2064
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16249421
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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.Suicide is a significant public health issue. In 2002, an estimated 877 000 lives were lost worldwide through suicide, representing 1.5% of the global burden of disease or more than 20 million disability-adjusted life-years (years of healthy life lost through premature death or disability).The highest annual rates are in Eastern Europe, where 10 countries report more than 27 suicides per 100 000 persons. Latin American and Muslim countries report the lowest rates, fewer than 6.5 per 100 000.In the United States, in 2002, suicide accounted for 31 655 deaths, a rate of 11.0 per 100 000 per year,and general population surveys document a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,representing a huge human tragedy and an estimated $11.8 billion in lost income.Suicidal behavior has multiple causes that are broadly divided into proximal stressors or triggers and predisposition.Psychiatric illness is a major contributing factor, and more than 90% of suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV) psychiatric illness,with some exceptions, such as in China.Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.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.To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The Figureillustrates the multiple factors involved in suicidal behaviorand indicates where specific preventive interventions are being directed. 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.Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression. This review considers what is known about this and other prevention strategies to permit integration into a comprehensive prevention strategy.Figure.Targets of Suicide Prevention InterventionsCircled letters refer to relevant prevention interventions listed on right.Suicide experts from 15 countries met in Salzburg, Austria, in August 2004 to review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide.DATA SOURCESAn electronic literature search of all articles published between 1966 and June 2005 was conducted via MEDLINE, the Cochrane Library, and PsychINFO to identify reports evaluating suicide prevention interventions. An initial search used the MEDLINE identifier suicide(including the subheading suicide, attempted) and the subheading prevention and control, following that suicidewas combined with the following identifiers: depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive agents, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media.We identified 5020 articles, which were not bound by the 5 major areas identified during the workshop. Abstracts were reviewed and full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors.Study SelectionStudies were included if they reported on either the primary outcomes of interest, namely 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 as assessment of efficacy or effectiveness of prevention programs in terms of the above primary or secondary outcomes; (1) systematic reviews and meta-analyses (n = 10) for which the search strategy was comprehensive and the methodological quality of primary studies was critically appraised; (2) quantitative studies, either randomized controlled trials (n = 18), or cohort studies (n = 24); and (3) ecological or population based studies (n = 41). Table 1and Table 2detail study type, study population, and preventive intervention tested and rate the studies according to the scheme proposed by the Oxford Centre for Evidence Based Medicine.Randomized controlled trials provide the most compelling evidence of efficacy while findings of naturalistic studies are largely correlational, indicating that their outcomes need further testing.Table 1.Study Type, Level of Evidence, Population, and Prevention StrategySourceStudy TypeLevel*PopulationPrevention StrategyGunnell et al,2005Meta-analysis1ARCTs in UK psychiatric patientsAntidepressant useFergusson et al,2005Meta-analysis1ARCTs in psychiatric patientsAntidepressant useKhan et al,2003Meta-analysis1ARCTs in US psychiatric patientsAntidepressant usePloeg et al,1996Systematic review2AAdolescentsCurriculum-based programsGuo and Harstall,2002Systematic review2AAdolescentsCurriculum-based programPignone et al,2002Systematic review2APrimary care patientsScreening for depression in primary careFeightner,1994Systematic review2APrimary care patientsScreening for depression in primary careGaynes et al,2004Systematic review2APrimary care patientsScreening for suicide risk in primary careGilbody et al,2003Systematic review2APrimary care patientsDetecting and treating depression in primary careHawton et al,2000Systematic review2APatients who attempted suicidePsychotherapyAseltine and DeMartino,2004RCT1BAdolescentsCurriculum-based programThompson et al,2000RCT1BPrimary care patientsDetecting and treating depression in primary careBruce et al,2004RCT1BOlder primary care patientsDetecting and treating depression in primary careGlick et al,2004RCT1BAdults with schizophrenia spectrum disordersClozapineMeltzer et al,2003RCT1BAdults with schizophrenia spectrum disordersClozapineThies-Flechtner et al,1996RCT1BAdults with affective disordersLithiumBrown et al,2005RCT1BSuicide attemptersPsychotherapyGuthrie et al,2001RCT1BSuicide attemptersPsychotherapyBateman and Fonagy,2001RCT1BBorderline personality disorder patientsPsychotherapyMotto and Bostrom,2001RCT1BSuicide attemptersFollow-up care: postal contact programCedereke et al,2002RCT1BSuicide attemptersFollow-up care: telephone contact programAllard et al,1992RCT1BSuicide attemptersFollow-up careMorgan et al,1993RCT1BSuicide attemptersFollow-up care: green cardAsarnow et al,2005RCT1BAdolescentsPrimary care physician education: quality improvementOrbach and Bar-Joseph,1993RCT1BAdolescentsCurriculum-based programEggert et al,1995RCT1BAdolescentsCurriculum-based programThompson et al,2001RCT1BAdolescentsCurriculum-based programHuey et al,2004RCT1BPsychiatric crisis in adolescentsFollow-up careRihmer,2001Cohort study (quasi-experimental)2BPrimary care patients in HungaryPrimary care physician educationMarusic et al,2004Cohort study (quasi-experimental)2BPrimary care patients in SloveniaPrimary care physician educationKelly et al,1998Cohort study (quasi-experimental)2BPrimary care physiciansPrimary care physician educationOyama et al,2004Cohort study (quasi-experimental)2BPrimary care patients in JapanPrimary care physician educationMann et al,2004Cohort study (quasi-experimental)2BGeneral population in HungaryAntidepressantsKnox et al,2003Cohort study (quasi-experimental)2BUS Air Force personnelGatekeeper programsMotto,1970Quasi-experimental2BGeneral US populationMedia blackoutLoftin et al,1991Cohort study (quasi-experimental)2BGeneral US populationFirearm restrictionHegerl et al,2003Cohort study (quasi-experimental)2BGeneral population in GermanyPublic education campaignJorm et al,2005Cohort study (quasi-experimental)2BGeneral population in AustraliaPublic education campaignPaykel et al,1998Cohort study2BGeneral UK populationPublic education campaignAkroyd and Wyllie,2002Cohort study2BGeneral population in New ZealandPublic education campaignLehfeld et al,2004Cohort study2BGeneral population in GermanyPublic education campaignNaismith et al,2001Cohort study2BPrimary care physicians in AustraliaPrimary care physician educationHannaford et al,1996Cohort study2BPrimary care physicians in UKPrimary care physician educationLin et al,2001Cohort study2BPrimary care physicians in USPrimary care physician educationValentini et al,2004Cohort study2BPrimary care physicians and patients in BrazilPrimary care physician educationPfaff et al,2001Cohort study2BPrimary care physicians in AustraliaPrimary care physician educationTakahashi et al,1998Cohort study2BPrimary care patientsPrimary care physician educationRutz,1989Cohort study2BPrimary care patientsPrimary care physician educationMehlum and Schwebs,2000Cohort study2BNorwegian ArmyGatekeeper educationDieserud et al,2000Cohort study2BGeneral population in NorwayChain of careAoun,1999Cohort study4 High-risk adultsFollow-up careRotheram-Borus et al,2000Cohort study4 Suicide attemptersFollow-up careAbbreviation: RCT, randomized controlled trial.*Oxford Centre for Evidence Based Medicine, levels of evidence: 1A, systematic review of RCTs; 1B, individual RCT; 2A, systematic review of cohort studies; 2B, individual cohort study, low-quality RCT; 2C, ecological studies; 3A, systematic review of case-control studies; 3B, individual case-control study; 4, case series, poor-quality cohort and case-control studies.Table 2.Ecological Studies, Level of Evidence, Population, and Prevention StrategySourceStudy TypeLevel*PopulationPrevention StrategyEtzersdorfer and Sonneck,1998Ecological2CGeneral population in AustriaMedia blackoutBridges and Kunselman,2004Ecological2CGeneral population in CanadaFirearm restrictionsLester and Leenaars,1993Ecological2CGeneral population in CanadaFirearm restrictionsSnowdon and Harris,1992Ecological2CGeneral population in AustraliaFirearm restrictionsLudwig and Cook,2000Ecological2CGeneral US populationFirearm restrictionsOhberg et al,1995Ecological2CGeneral population in FinlandPesticide restrictionBowles,1995Ecological2CGeneral population in SamoaPesticide restrictionCarrington,1999Ecological2CGeneral population in CanadaFirearm restrictionKreitman,1976Ecological2CGeneral UK populationDomestic gas detoxificationLester,1990Ecological2CGeneral population in SwitzerlandDomestic gas detoxificationGunnell et al,2000Ecological2CGeneral UK populationDomestic gas detoxificationCrome,1993Ecological2CGeneral populationBarbiturate restrictionsNielsen and Nielsen,1992Ecological2CGeneral populationBarbiturate restrictionsYamasawa et al,1980Ecological2CGeneral population in JapanBarbiturate restrictionsHawton,2002Ecological2CGeneral UK populationAnalgesic packaging changesMcClure,2000Ecological2CGeneral population in England and WalesCatalytic convertersKelly and Bunting,1998Ecological2CGeneral population in England and WalesCatalytic convertersShelef,1994Ecological2CGeneral US populationCatalytic convertersCarlsten et al,2001Ecological2CGeneral population in SwedenAntidepressantsBeautrais,2001Ecological2CGeneral population in New ZealandBarriers to jumpingGibbons et al,2004Ecological2CGeneral US populationAntidepressant use plus introduction of lower-toxicity antidepressantsOlfson et al,2003Ecological2CUS adolescentsAntidepressantsHall et al,2003Ecological2CGeneral population in AustraliaAntidepressantsHelgason et al,2004Ecological2CGeneral population in IcelandAntidepressantsTakahashi,1999Ecological2CGeneral population in JapanAntidepressantsGuaiana et al,2005Ecological2CGeneral population in ItalyAntidepressantsSimon et al,2005Ecological2CGeneral US populationAntidepressantsValuck et al,2004Ecological2CUS adolescentsAntidepressantsLudwig and Marcotte,2005Ecological2CGeneral population in 27 countriesSSRIsCantor and Slater,1995Ecological2CGeneral population in AustraliaFirearm restrictionsWhitlock,1975Ecological2CGeneral population in AustraliaBarbiturate restrictionLester,1991Ecological2CGeneral population in the NetherlandsDomestic gas detoxificationWiedenmann and Weyerer,1993Ecological2CGeneral population in GermanyDomestic gas detoxificationLester,1990Ecological2CGeneral US populationDomestic gas detoxificationOliver and Hetzel,1972Ecological2CGeneral population in AustraliaBarbiturate restrictionsRetterstol,1989Ecological2CGeneral population in NorwayBarbiturate restrictionsCarlsten et al,1996Ecological2CGeneral population in SwedenBarbiturate restrictionsMott et al,2002Ecological2CGeneral US populationCatalytic convertersKapur et al,1992Ecological2CGeneral US populationIntroduction of lower-toxicity antidepressantsWasserman and Varnik,1998Ecological2CGeneral population in former USSRAlcohol restrictionLester,1999Ecological2CGeneral population in IcelandAlcohol restrictionAbbreviation: SSRIs, selective serotonin reuptake inhibitor.*For the definition of the Oxford Centre for Evidence Based Medicine, Levels of Evidence, see Table 1.DATA SYNTHESISHeterogeneity in study methodology and populations limited formal meta-analysis, thus we present a narrative synthesis of the results for the key domains of suicide prevention interventions.Awareness and EducationGeneral Public.Public education campaigns are aimed at improving recognition of suicide risk and help seeking through improved understanding of the causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious medical illness. Despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.Studies in Germany,the United Kingdom,Australia,and New Zealandsuggest modest effects of public education campaigns on attitudes regarding the causes and treatment of depression. Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign.However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control region.Other specific education strategies are aimed at youth, including school and community-based programs.Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.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.A later review of studies published from 1990-2002 also found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for prevention of suicidal behavior.A subsequent controlled trial reported lower suicide attempt rates, greater knowledge, and more adaptive attitudes about depression and suicide in the intervention group compared with in the 3 months after the intervention, but no significant benefits for rates of suicide ideation or help-seeking.In adolescents, several studies found that improving problem solving, coping with stress, and increasing resilience enhance hypothesized protective factors but effects on suicidal behavior were unevaluated.Primary Care Physicians.Depression and other psychiatric disorders are underrecognized and undertreated in the primary care setting.Prevention is possible because most suicides have had contact with a primary care physician within a month of death.Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides. Therefore, improving physician recognition of depression and suicide risk evaluation is a component of suicide prevention.Some studies in the United Kingdom,Australia,the United States,and Northern Ireland,showed that programs aimed at educating primary care physicians improved detection and increased treatment of depression, but that was not shown in other studies in the United States,Brazil,and the United Kingdom.Nurse case management, collaborative care, or quality improvement initiatives can further improve the recognition and management of depressionand has application where education alone may be insufficient.A controlled trial comparing a treatment algorithm plus depression care management with treatment as usual for late-life depression in primary care in the United States demonstrated greater improvement in patient suicidal ideation and a more favorable course of illness in the intervention group compared with the treatment-as-usual group.An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians resulted in a 50% decrease in suicide attempts in the intervention group that was not statistically different from the control group (18%) due to the low base rate.An Australian program that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people increased identification of suicidal patients by 130% (determined by the Depressive Symptom Inventory–Suicidality Subscale score), without changes in treatment or management strategies.Studies examining suicidal behavior in response to primary care physician education programs, mostly targeting depression recognition and treatment, in specific regions in Sweden,Hungary,Japan,and Sloveniahave all reported increased prescription rate for antidepressants and often substantial declines in suicide rates and represent the most striking known example of a therapeutic intervention lowering suicide rates.Gatekeepers.Suicide prevention includes a range of interventions focused on community or organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.Gatekeepersinclude clergy, first responders, pharmacists, geriatric caregivers, personnel staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy changes to encourage help-seeking, availability of resources, and efforts to reduce stigma associated with help-seeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental health and suicide and facilitated access to mental health services.To date, systematic evaluation of impact on suicidal behavior has largely been limited to multilevel programs conducted in institutional settings, such as the military where programs in the Norwegian Armyand the US Air Forcehave reported success in lowering suicide rates.ScreeningScreening aims to identify at-risk individuals and direct them to treatment. The focus may be on suicidal behavior directly or risk factors, such as depression or substance abuse. Screening instruments for depression, suicidal ideation, or suicidal acts administered to high school students,juvenile offenders,and youth in generalhave reliability and validity in identifying individuals at increased risk for suicidal behavior and are reported to double the number of known at-risk individuals.There is no evidence that screening youth for suicide induces suicidal thinking or behavior.Acceptance of the need for treatment by identified at-risk youth and actual treatment implementation are understudied as potential barriers to the effectiveness of screening programs.The US Preventive Services Task Force (USPSTF) review of studies of depression screening in adults in primary health care settings found a 10% to 47% increase in rates of detection and diagnosis of depression with the use of screening tools.The effect on treatment was mixed, due to differences in study methodology. In contrast, a Canadian review of depression screening studies did not find routine screening in primary care to improve depression care.Neither report commented on effects on suicidal behavior. In contrast, screening in localized geographic areas results in more treatment of depression and lower suicide rates.The 2004 USPSTFreview of evidence on screening for suicide risk, as opposed to depression, found no published studies in English evaluating the effectiveness of screening for suicide risk in primary care.Treatment InterventionsPharmacotherapy.Psychiatric disorders are present in at least 90% of suicides and more than 80% are untreated at time of death.Depression is untreated or undertreated in general,even after suicide attempt.Thus, treating mood and other psychiatric disorders is a central component of suicide prevention.Antidepressant medications alleviate depression and other psychiatric disorders.However meta-analyses of RCTs have generally not detected benefit for suicide or suicide attempts in studies of antidepressants in mood and other psychiatric disorders,perhaps due to the low base rate of suicidal behavior and insufficient systematic screening for suicidal behavior since reliance on spontaneous reporting underestimates rates of suicidal behavior.Randomized controlled trials can be informative when higher-risk patients are studied and indicate an antisuicidal effect for lithium in major mood disordersand clozapine in schizophrenia.Few studies prospectively identified suicidal behavior as an outcome measure and systematically assessed it throughout the RCT.Higher prescription rates of antidepressants correlate with decreasing suicide rates in adults or youth in Hungary,Sweden,Australia,and the United States.Geographic regions or demographic groups with the highest selective serotonin reuptake inhibitor prescription rates have the lowest suicide rates in the United Statesand Australia.Although Iceland,Japan,and Italydo not show such correlations, potential reasons include lack of compliance; pre-existing low-suicide rate, resulting in a floor effect; and high rates of alcoholism that may elevate suicide rates or the effect may be confined to women because too few men seek and comply with treatment with antidepressants. Suicide rates in 27 countries fell most markedly in countries that had the greatest increase in selective serotonin reuptake inhibitor prescriptions.Patient population studies report lower suicide attempt rates in adults treated with antidepressant medicationand in adolescents after 6 months of antidepressant treatment compared with less than two months of treatment.The risk of an ecological fallacy, that is, inferring causality from group correlations, prevents attributing decreases in suicide rates solely to antidepressant use. Nevertheless, there is a striking correlation and plausible mechanism linking antidepressant use to declining rates of untreated major depression and therefore suicide.Concerns about higher rates of suicide-related adverse event reports in depressed children and adolescents taking selective serotonin reuptake inhibitors compared with placebo in RCTs have prompted regulatory bodies in the United States, the United Kingdom, and Europe to issue warnings urging clinicians to monitor suicide risk and adverse effects carefully when prescribing antidepressants to youth. Such concerns need to be weighed against the risk of untreated depression because suicide is the third leading cause of death in youth and more than 90% of suicides in depressed youth are untreated at the time of death.Psychotherapy.Promising results in reducing repetition of suicidal behavior and improving treatment adherence exist for cognitive therapy,problem-solving therapy,intensive care plus outreach,and interpersonal psychotherapy,compared with standard aftercare. Cognitive therapy halved the reattempt rate in suicide attempters compared with those receiving usual care.In borderline personality disorder, dialectical behavioral therapyand psychoanalytically oriented partial hospitalizationimproved treatment adherence and reduced suicidal behavior compared with standard after care. Intermediate outcomes such as hopelessness and depressive symptoms improve with problem solving therapy, and suicidal ideation is decreased with interpersonal psychotherapy, cognitive behavior therapy, and dialectical behavioral therapy.Follow-up Care After Suicide Attempts.Many psychiatric disorders, including depression, are chronic and recurrentand compliance with maintenance medication is often poor. Interventions for depression provided by primary care physicians are more effective when a case manager follows up with patients who miss appointments or need prescription renewals.Many depressed patients who survive a suicide attempt will make further suicide attempts,particularly in the period shortly following psychiatric hospitalizationor during future major depressive episodes.Thus, improved acute, continuation, and maintenance care, including psychiatric hospitalization, where necessary, of those with recurrent or chronic psychiatric disorders,particularly patients who attempt suicide with mood disorders, has potential for prevention. Reduction of the number of psychiatric inpatient beds in Norway as part of a program of deinstitutionalization of psychiatric inpatients resulted in an increased suicide rate in the year after discharge with a standardized mortality ratio of 133(95% confidence interval, 90.1-190.7) in men and 208.5 (95% confidence interval, 121.5-333.9) in women.The Norwegian multidisciplinary chain-of-care networks provide follow-up care after hospital care to those who attempt suicide. Regions with chain-of-care programs have lower treatment dropout rates and fewer repeat attempts.Intervention studies of those who attempt suicide to prevent future suicidal behavior have produced mixed results, including fewer suicides compared with a control group after regular mailings,and fewer suicide attempts after issuing an emergency contact green card) or use of a suicide intervention counselor to coordinate assessment and long-term treatment.Other interventions for those who attempt suicide, including telephone follow-up, intensive psychosocial follow-up, and video education plus family therapy, resulted in no difference between standard aftercare and intervention groups in rate of reattempt or reemergent suicidal ideation.Means RestrictionSuicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in higher rates of death. Suicides by such methods have decreased after firearm control legislation,restrictions on pesticides,detoxification of domestic gas,restrictions on the prescription and sale of barbiturates,changing the packaging of analgesics to blister packets,mandatory use of catalytic converters in motor vehicles,construction of barriers at jumping sites,and the use of new lower toxicity antidepressants.Where the method is common, restriction of means has led to lower overall suicide rates: firearms in Canadaand Washington, DC,barbiturate restriction in Australia,domestic gas detoxification in Switzerlandand the United Kingdom,and vehicle emissions in England.Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republicsand Iceland.Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom,in Germany,and in the United Statesand for banning the pesticide parathion in Finland.Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means. Gauging the extent to which declining overall suicide rates are directly attributable to restriction in access to particular means requires consideration of long-term trends and confounding factors such as increased antidepressant use.MediaThe media can help or hinder suicide prevention efforts by being an avenue for public education or by exacerbating suicide risk by glamorizing suicide or promoting it as a solution to life’s problems. The latter may encourage vulnerable individuals to attempt suicide or to be attracted to suicide hot spots portrayed in the media as discussed by Pirkis et aland Gould.Media blackouts on reporting suicide have coincided with decreases in suicide rates.A 1987 campaign to decrease media coverage of subway suicides in Austria cut subway suicides by 80%.The Internet is of increasing concern, particularly the effects of suicide chat rooms, the provision of instruction in methods for suicide, and the active solicitation of suicide-pact partners.Educating journalists and establishing media guidelines for reporting suicide have had mixed results.The American Foundation for Suicide Prevention and Annenberg Public Policy Center,and The Centers for Disease Control and Preventionin the United States have produced guidelines for the responsible reporting of suicide; however, no published studies have evaluated their impact.Conclusions and Future DirectionsNational suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. Table 3summarizes estimates of impact of different interventions on national suicide rates showing that the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome, or there may be longer-term trends in suicide rates that are not captured by the studies.Table 3.Postintervention Decrease in Total Suicide RatesInterventionSuicides, % Decline in Annual RateEducationPublicNot availablePrimary care physician22-73GatekeeperUS Air Force40Norwegian Army33Increasing antidepressant prescriptions*3.2Chain of careNot availableRestricting lethal meansGuns1.5-9.5Domestic gas19-33Barbiturates23Vehicle emissionsNot availableAnalgesicsNot availableMedia blackoutsNot available*There was a 414% increase in antidepressant prescriptions 1987-1999.Physician Education.This increases the number of diagnosed and treated depressed patients with accompanying reductions in suicide although booster programs appear necessary. Videoconferencing and other teleconferencing consulting methods are possibilities where expert help is not available locally. However, the effect on suicide rates must be measured, as well as effects on intermediate outcomes, such as primary care physician–diagnosed cases of major depression and antidepressant prescription rates.Pharmacotherapy.Randomized controlled trials are needed to prove that selective serotonin reuptake inhibitors decrease suicide rates. Their efficacy is established for major depression, the main risk factor for suicide. Education programs targeting primary care physicians should include instruction on use of antidepressants. The relationship between antidepressant use and emergent suicidal ideation and behavior in depressed children and adolescents needs further study. Because most depressed youth who attempt suicide are untreated, it is important not to prematurely discourage the use of effective antidepressants such as fluoxetine.Gatekeeper Education.Where the roles of gatekeepers are formalized and pathways to treatment are readily available, such as in the military, educating gatekeepers helps reduce suicidal behavior. Demonstration projects for other gatekeepers with intermediate outcome measures, such as referral rates and psychiatric treatment rates, should be conducted.Means Restriction.Restricting access to lethal methods decreases suicides by those methods. Priority should be given to the most commonly used methods in each country. The possibility of substitution of methods requires ongoing monitoring, as does compliance with restrictions such as firearm access.Screening.Although screening programs have reported some success in identifying individuals with known risk factors for suicide, particularly among high school and college student populations, further consideration needs to be given to determining the cost-effectiveness of screening general populations vs identified at-risk populations for reducing suicide rates, the predictive validity and reliability of specific screening instruments, and the appropriateness of standard suicide screening instruments across different cultures.Psychotherapy.Psychotherapy alone or in combination with some antidepressants can be an effective treatment for depression, for suicidal ideation, for suicide attempts in borderline personality disorder, and for preventing new attempts after a suicide attempt. More needs to be known about the combinations of psychotherapeutic and pharmacologic interventions for short-and long-term outcomes for suicidal patients.Chain of Care.After a suicide attempt, better structured collaboration between hospitals and teams providing follow-up care may improve compliance with treatment and decrease new attempts, but essential elements of postsuicide attempt interventions are yet to be identified.Media.Strategies for influencing how the media reports suicide need to be implemented and evaluated.Suicide prevention interventions should be multimodal, evidence-based, guided by specific testable hypotheses, and implemented among populations of sufficient size to yield generalizable and reliable results. Programs must include outcome measures. Finally, because most studies have been conducted in developed nations, many issues facing underresourced developing nations have not been addressed and require future studies specifically focused on suicide prevention.Corresponding Author:J. John Mann, MD, Department of Neuroscience, New York State Psychiatric Institute, 1051 Riverside Dr, Box 42, New York, NY 10032 (jjm@columbia.edu).Author Contributions:Dr Mann had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Study concept and design: Mann, Apter, Beautrais, Haas, Hegerl, Lonnqvist, Malone, Mehlum, Schmidtke, Shaffer, Varnik, Wasserman, Yip, Hendin.Acquisition of data: Mann, Apter, Bertolote, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Phillips, Silverman, Takahashi, Hendin.Analysis and interpretation of data: Mann, Bertolote, Beautrais, Currier, Haas, Hegerl, Malone, Marusic, Mehlum, Patton, Rutz, Rihmer, Silverman, Hendin.Drafting of the manuscript: Mann, Apter, Beautrais, Currier, Haas, Hegerl, Schmidtke, Shaffer.Critical revision of the manuscript for important intellectual content: Mann, Apter, Bertolote, Beautrais, Haas, Hegerl, Lonnqvist, Malone, Marusic, Mehlum, Patton, Phillips, Rutz, Rihmer, Schmidtke, Shaffer, Silverman, Takahashi, Varnik, Wasserman, Yip, Hendin.Statistical analysis: Mann, Marusic.Obtained funding: Malone, Hendin.Administrative, technical, or material support: Beautrais, Currier, Haas, Hegerl, Lonnqvist, Patton, Schmidtke, Silverman, Hendin.Study supervision: Mann, Rutz, Rihmer.Financial Disclosures:Dr Mann received a grant from GlaxoSmithKline to do a positron-emission tomography study of Alzheimer disease; otherwise, no financial disclosures were reported.Funding/Support:Funding for the International Strategies Workshop was provided by an unrestricted educational grant from Pfizer Inc.Role of the Sponsor:Pfizer had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.REFERENCESWorld Health OrganizationWorld Health Report 2003: Shaping the Future.Geneva, Switzerland: World Health Organization; 2003. 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