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Objectives: There is accumulating evidence about effectiveness of a number of suicide prevention interventions, and a multilevel systems approach seems promising in reducing suicide risk. This approach requires that components ranging from individual-level to public health interventions are implemented simultaneously in a localised region. This paper presents estimated reductive effects on suicide attempts and deaths that might be expected in Australia if active components of the systems approach were to be implemented. Method: The study estimated population preventable fractions which indicate the extent to which suicide attempts and deaths might be decreased if the each of the proposed interventions was fully implemented. The population preventable fractions were based on the best available evidence available in the literature for the risk ratio for each intervention. Prevalence estimates were assessed for each component of the proposed systems approach: reducing access to suicide means, media guidelines, public health campaigns, gatekeeper programmes, school programmes, general practitioner training, psychotherapy and co-ordinated/assertive aftercare. Results: There was insufficient evidence available for the impact of a number of strategies, including frontline staff gatekeeper training, on either suicide attempts or deaths. Taking prevalence of exposure to the intervention into consideration, the strategies likely to bring about the strongest reduction in suicide attempts were psychosocial treatments and co-ordinated/assertive aftercare. The greatest impact on reductions in suicide deaths was found for psychosocial treatment, general practitioner training, gatekeeper training and reducing access to means of suicide. Conclusion: The evidence regarding the overall efficacy of the systems approach is important in identifying what strategies should be prioritised to achieve the biggest impact. The findings of the population preventable fraction calculations indicate that the systems approach could lead to significant reduction in suicide attempts and suicide deaths in Australia. Potential synergistic effects between strategies included in the approach could further increase the impact of implemented strategies.
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Australian & New Zealand Journal of Psychiatry
1 –4
DOI: 10.1177/0004867415620024
© The Royal Australian and
New Zealand College of Psychiatrists 2015
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Australian & New Zealand Journal of Psychiatry
In 2013, 2522 people died by suicide in
Australia, and an estimated 65,000
made an attempt (Australian Bureau of
Statistics [ABS], 2015b; Johnston etal.,
2009). Australia’s suicide rate (approx-
imately 11 per 100,000) has remained
stubbornly consistent over the last
decade or more (ABS, 2015b).
Moreover, it exceeds that of some
European countries, including the
United Kingdom, the Netherlands,
Spain and Switzerland (World Health
Organization [WHO], 2014).
Recently, there have been signifi-
cant changes, globally, to suicide pre-
vention by researchers and policy
makers. First, evidence is accumulat-
ing about the effectiveness of a num-
ber of suicide prevention interventions
(Mann et al., 2005). Second, a new idea
has emerged that a multilevel, multi-
factorial systemic approach is needed
Best strategies for reducing the suicide
rate in Australia
Karolina Krysinska1, Philip J Batterham2, Michelle Tye1,
Fiona Shand1, Alison L Calear2, Nicole Cockayne1
and Helen Christensen1
Abstract
Objectives: There is accumulating evidence about effectiveness of a number of suicide prevention interventions, and a
multilevel systems approach seems promising in reducing suicide risk. This approach requires that components ranging
from individual-level to public health interventions are implemented simultaneously in a localised region. This paper pres-
ents estimated reductive effects on suicide attempts and deaths that might be expected in Australia if active components
of the systems approach were to be implemented.
Method: The study estimated population preventable fractions which indicate the extent to which suicide attempts and
deaths might be decreased if the each of the proposed interventions was fully implemented. The population preventable
fractions were based on the best available evidence available in the literature for the risk ratio for each intervention.
Prevalence estimates were assessed for each component of the proposed systems approach: reducing access to suicide
means, media guidelines, public health campaigns, gatekeeper programmes, school programmes, general practitioner
training, psychotherapy and co-ordinated/assertive aftercare.
Results: There was insufficient evidence available for the impact of a number of strategies, including frontline staff
gatekeeper training, on either suicide attempts or deaths. Taking prevalence of exposure to the intervention into con-
sideration, the strategies likely to bring about the strongest reduction in suicide attempts were psychosocial treatments
and co-ordinated/assertive aftercare. The greatest impact on reductions in suicide deaths was found for psychosocial
treatment, general practitioner training, gatekeeper training and reducing access to means of suicide.
Conclusion: The evidence regarding the overall efficacy of the systems approach is important in identifying what strate-
gies should be prioritised to achieve the biggest impact. The findings of the population preventable fraction calculations
indicate that the systems approach could lead to significant reduction in suicide attempts and suicide deaths in Australia.
Potential synergistic effects between strategies included in the approach could further increase the impact of imple-
mented strategies.
Keywords
Population preventable fraction, risk ratio, suicide, suicide prevention
1 The University of New South Wales and
Black Dog Institute, Randwick, NSW,
Australia
2
Centre for Mental Health Research, The
Australian National University, Canberra,
ACT, Australia
Corresponding author:
Helen Christensen, The University of New
South Wales and Black Dog Institute, Hospital
Road, Randwick, NSW 2031, Australia.
Email: h.christensen@blackdog.org.au
620024ANP0010.1177/0004867415620024ANZJP ViewpointKrysinska et al.
research-article2015
Viewpoint
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2 ANZJP Perspectives
Australian & New Zealand Journal of Psychiatry
to comprehensively reduce suicide
risk (Hegerl et al., 2013; While et al.,
2012). This approach requires that
components ranging from public
health interventions to individual-
level interventions are implemented
simultaneously in a localised region.
While many of these suicide preven-
tion strategies have been individually
implemented in Australia, no attempt
has been made to simultaneously com-
bine these strategies using a systems
approach framework.
As a systems approach to suicide
prevention has not yet been imple-
mented in Australia, the present paper
attempts to estimate the reductive
effects on suicide deaths and attempts
that might be expected if active com-
ponents of a systems approach were
to be implemented. The method
involves three steps. First, nine evi-
dence-based suicide prevention strat-
egies were identified: reducing access
to lethal means, responsible media
reporting, community awareness pro-
grammes, gatekeeper training, school-
based suicide prevention programmes,
training of general practitioners and
frontline staff, psychotherapy and fol-
low-up for individuals with a recent
suicide attempts (Calear et al., 2015;
Mann et al., 2005; Van der Feltz-
Cornelis etal., 2011). Second, the size
of the effect of each of these strate-
gies were estimated using existing
risk ratio (RR) estimates for suicide
deaths and suicide attempts. Third,
the extent to which each of these
strategies will reach the communities
so that they can have impact (the
prevalence) was estimated. These two
estimates were used to calculate the
population preventable fractions
(PPFs, analogous to Population
Attributable Risk, PAR), which indi-
cate the extent to which suicide
attempts/deaths might be decreased
if the each of the proposed systems-
based interventions was fully imple-
mented. The ultimate goal of the
paper is to provide policy makers and
community organisations with evi-
dence-based information that will
help set priorities.
Method
Existing literature was used to esti-
mate PPF for each intervention. Using
the best available estimates of risk
ratio relating to either suicide deaths
or suicide attempts and proportion
exposed, the PPF was calculated
(Rockhill et al., 1998). The PPFs were
based on the best available evidence
for the risk ratio (RR) for each inter-
vention provided in the literature.
The best available evidence for the
RR estimate for each component was
chosen from a meta-analysis when
available. When no meta-analysis was
available, a multicentre randomized
controlled trial (RCT) or systematic
review was chosen as the data source.
If none of these was available, a single
study with a large sample size and
clear reporting of RR was selected.
Prevalence estimates were assessed
uniquely for each component as fol-
lows (Table 1): Reducing access to
means: the proportion of suicide
attempts/deaths attributed to self-poi-
soning, Media Guidelines the propor-
tion of the population exposed to
media, Public Health Campaigns: the
proportion of residents reached by a
flyer campaign; Gatekeeper programmes:
assumption that gatekeeper pro-
grammes could be established in 20%
of workplaces, with 52.5% of the tar-
get population in employment; School
Programmes: the proportion of resi-
dents that are school-aged combined
with an assumption that 50% of
schools would agree to participate in
such a programme; General practitioner
(GP) training: the proportion of suicidal
people who receive primary care
treatment; Psychotherapy: based on an
increase in the proportion of suicidal
people who receive mental health care
from 31.6% to 50%; and Co-ordinated
and assertive aftercare: the proportion
of people who attempt suicide that
reach an emergency department.
There was insufficient evidence for
frontline training as current studies
only examined the effect of training on
knowledge and attitudes, not on sui-
cidal deaths or attempts. This paper
rests on the requirement that data are
available on the expected size of the
effect to allow modelling, an assump-
tion that was not met for a number of
the strategies.
Results
Estimates of PPF are provided in
Table1, with references to the source
of the RR data. Insufficient evidence
was available for the impact of a num-
ber of strategies on either suicide
attempts or deaths (Table 1). In respect
to suicide attempts, most interven-
tions have RRs that are not dissimilar
(ranging from .397 to .680). These RRs
indicate that all strategies have demon-
strated effectiveness in reducing sui-
cide attempts. Taking prevalence of
exposure to the intervention into con-
sideration, psychosocial treatments
and coordinated/assertive/brief after-
care are the strategies likely to bring
about the strongest reduction in sui-
cide attempts. Similarly, for suicide
deaths all interventions are associated
with relatively high risk ratios (ranging
from .580 to .971). Taking into account
population exposure, however, psy-
chosocial treatment, GP training, gate-
keeper training and reducing access to
means appear to have the greatest
impact on reductions in suicide deaths.
Discussion
The findings of the PPF calculations
indicate that a systems approach could
lead to significant reduction in suicide
attempts and suicide deaths in
Australia. Two interventions with the
greatest impact on suicide attempts,
psychosocial treatments and coordi-
nated/assertive/brief aftercare, could
decrease the prevalence of attempts
by 8.0% and 19.8%, respectively. In
regards to suicide deaths, the biggest
reductions can be achieved through
GP training, psychosocial treatments,
gatekeeper training and reducing
access to means (6.3%, 5.8%, 4.9% and
4.1%, respectively). Given that, in 2013,
there were 27,112 suicide attempts
(Harrison and Henley, 2014) and 2522
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Krysinska et al. 3
Australian & New Zealand Journal of Psychiatry
suicide deaths (ABS, 2015b), these
results suggest that up to 160 lives
could be saved annually, and up to
5370 hospitalisations due to inten-
tional self-harm could be prevented. It
is possible, however, that a systems
approach may have an even greater
combined impact, due to potential
synergistic effects between strategies
(Van der Feltz-Cornelis et al., 2011).
These PPF estimates are designed
to generate further planning and dis-
cussion around the best avenues for
suicide prevention. The PPF calcula-
tions need to be considered in respect
to a number of caveats. We have used
the best available evidence for the RR
estimate for each component, such as
a meta-analysis, a multicentre RCT, a
systematic review or a single study
with a large sample size and clear
reporting of RR. Using different
sources might have resulted in differ-
ent findings. We did not include error
margins with the estimates, as many
further assumptions would be required
for these calculations. The PPFs may
vary in response to a number of fac-
tors including regional effects, imple-
mentation challenges, the context in
which the intervention is delivered and
baseline variations in terms of pre-
existing programmes that may already
be impacting on suicide attempts or
deaths. The impact of interventions
may overlap, for example, the combi-
nation of brief contact and aftercare
interventions would impact the same
population. Combined effects from
multiple interventions may be less than
the sum of their individual effects, or
synergise to create a stronger effect.
However, partial implementation of an
intervention would reduce the impact
of that intervention. In addition, the
studies from which the risk estimates
were drawn come from various
regions, where the context of the
intervention may or may not reflect
the Australian context, and do not
include the impact of social determi-
nants of health. Second, we were una-
ble to source accurate estimates for a
number of the effects of interest, as
there is insufficient research on the
effects of several of the strategies on
suicide attempts or deaths.
Conclusion
Currently, there is an absence of data
available to be able to calculate the
potential reductive effects of a number
of suicide prevention interventions on
suicide deaths and attempts. The
absence of appropriate data highlights
Table 1. Estimated population preventable fraction for each of the strategies in the systems approach.
Strategy
Suicide attempts Suicide RR sources* Prevalence
estimates*
RR Exposure PPF RR Exposure PPF
Reducing access to
suicide means
0.500 0.005 0.5% 0.720 0.110 4.1% Pirkis et al. (2013),
Skegg and Herbison
(2009)
ABS (2015b),
Harrison and
Henley (2014)
Media guidelines 0.950 0.240 1.2% Niederkrotenthaler
and Sonneck (2007)
Niederkrotenthaler
and Sonneck (2007)
Suicide public
awareness
campaign
0.971 0.109 0.3% Matsubayashi et al.
(2014)
Matsubayashi et al.
(2014)
School-based
programmes
0.546 0.037 2.9% Wasserman et al.
(2015)
ABS (2015a)
Gatekeeper
training
0.670 0.105 4.9% Knox et al. (2003) ABS (2015c)
Frontline staff
gatekeeper training
GP training 0.920 0.769 6.3% Henriksson and
Isacsson (2006)
Pirkis and Burgess
(1998)
Psychosocial
treatment
0.680 0.184 8.0% 0.750 0.200 5.8% O’Connor et al.
(2013), Erlangsen
et al. (2015)
Bruffaerts et al.
(2011)
Coordinated/
assertive/brief
aftercare
0.397 0.163 19.8% 0.580 0.016 1.1% Hvid et al. (2011),
Milner et al. (2015)
Carroll et al.
(2014)
PPF: population preventable fraction; GP: general practitioner.
*Please, see supplementary file for full references.
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4 ANZJP Perspectives
Australian & New Zealand Journal of Psychiatry
the need for improved evaluation of
suicide prevention interventions, espe-
cially in the Australian context. The
available evidence regarding the overall
efficacy of the systems approach, how-
ever, is critically important in identify-
ing what strategies should be
prioritised, and where, in order to
achieve the biggest impacts.
Declaration of Conflicting
Interests
The author(s) declared no potential con-
flicts of interest with respect to the
research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial sup-
port for the research, authorship, and/or
publication of this article.
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... The prevention of suicide in old age requires multi-level strategies that, through a systemic approach (Krysinska et al., 2015), should be able to incorporate social, economic and health organizations, making them interact with the care and intervention services (RANZCP, 2020). Guidelines have been issued by the World Health Organization through the 2013-2020 Global Health Action Plan (WHO, 2013), the report, Suicide Prevention: A Global Imperative (WHO, 2014) and, more recently, the overview on national strategies for suicide prevention (WHO, 2018d). ...
... An Australian study conducted by Almeida et al. (2012) demonstrated that an educational intervention aimed at primary care physicians reduced the 2-year prevalence of depression and self-injurious behavior by 10%, compared with a control group of physicians not receiving the intervention. It is important that health professionals are aware of the impact of certain life events in older people: for example, retirement, loss of the driving license, impairments in bodily functions, or the presence of a psychiatric diagnosis (Krysinska et al., 2015;Zalsman et al., 2016). Furthermore, it is necessary to make available systematic screening tools for staff in medical and non-medical settings, and to train staff on the assessment of suicide risk in old age (De Leo and Arnautovska, 2016). ...
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Purpose: Emerging evidence indicates that systems-based suicide prevention programs can help optimise suicide prevention activities, with the National Suicide Prevention Trial using these approaches in regional and community contexts throughout Australia. The Tasmanian arm of the Trial adopted the LifeSpan systems framework to deliver suicide prevention activities across three distinct geographical areas, focusing on high-risk populations of men aged 40-64 and people 65 and over. The University of Tasmania’s Centre for Rural Health undertook a local-level evaluation of the Trial in Tasmania. Aims: To explore key stakeholder perceptions of the implementation of a systems-based suicide prevention program in regional and rural communities in Tasmania, Australia. Method: Focus groups and interviews with 46 participants, comprising Working Group members (n=25), Tasmania’s Primary Health Network employees (n=7), and other key stakeholders (n=14), with the majority (53.3%) reporting a lived experience of suicide. Thematic analysis was used to explore data and study aims. Results: Key themes centred on how the National Suicide Prevention Trial was understood and established in Tasmania; Working Group governance structures and processes; communication and engagement processes; reaching priority population groups; the LifeSpan model and activity development; and the effectiveness and sustainability of activities. Discussion: Findings showed communities were wary of suicide and wanted to engage to take action and the Trial provided the resources and coordination to do so. Perceived limitations implementing the Trial included varied involvement of key stakeholders, and lack of role clarity within Working Groups. Barriers delivering activities to the priority population groups suggested a strict adherence to the Lifespan model was challenging. Working Groups embraced a pragmatic approach, preferring activities that best utilised available capital and resources to meet perceived needs within communities. While a focus on effectiveness and sustainability of activities was seen as important, barriers at the community-level, i.e. nobody to run them, hindered these efforts. Analysis of stakeholder perceptions provides crucial insights for guiding future community-based suicide prevention efforts in regional and rural areas, and with high-risk groups.
... Indeed, youth suicide attempts decreased over the 2 years after the implementation of the Garrett Lee Smith Memorial Suicide Prevention Program (Garraza et al., 2015), and training phone line crisis counselors in the ASIST gatekeeper training program was associated with caller self-reported decreases in suicidal ideation (Gould et al., 2013). Support for GKT programs also arises in reviews of the literature, which suggest that GKT programs are effective at decreasing suicide attempts and mitigating suicide risk and suicidal ideation, but the studies investigating these outcomes were of variable quality or only comprised a small part of the reviewed sample (Krysinska et al., 2016;Schwartz-Lifshitz et al., 2012). Despite this, these 'real world' measures of the effect of GKT programs on suicidality remain greatly under-investigated in the GKT program literature. ...
Article
Aims Gatekeeper training (GKT) is an important suicide prevention strategy. Studies have evaluated the effectiveness of GKT in different populations, often neglecting family and friends who play a vital role in caring for people with suicide risk. This review evaluated GKT programs targeting family and friends to determine their effectiveness in this specific population. Methods Academic databases were searched for studies on GKT programs. Programs involving family and friends caring for people with suicide risk were assessed for any impact on knowledge, self-efficacy, attitudes, and suicide prevention skills. Results Seventeen studies were reviewed. GKT showed significant gains on outcomes of interest. Three studies targeted family and friends, with one involving them in program creation and conduction and another adjusting the program after their input. Conclusions GKT programs have potentially positive effects on family and friends caring for people with suicide risk. Few programs address the specific needs of this group, and programs adapted specifically for them are scarce. Future program development recommendations are discussed.
... Suicide has reached global epidemic proportions and is a leading cause of death in many countries (Jones & Cipriani, 2016;World Health Organisation, 2019b). Contemporary research suggests a nine-level system is necessary to reduce suicide including: reducing access to lethal means, responsible media reporting, community awareness programs (e.g., training workshops, flyers, media awareness campaigns), gatekeeper training, school-based suicide prevention programs, training of general practitioners (GPs), training of frontline staff, effective psychotherapy and follow-up for individuals with a recent suicide attempt (Hegerl & Wittenburg, 2015;Hickie et al., 2014;Krysinska et al., 2015;Werner-Seidler et al., 2016). Despite public health efforts in each of these areas, significant headway in reducing suicide rates seems lacking. ...
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Suicide is a global epidemic. This review assessed the scope and effectiveness of suicide prevention programs. Systematic literature searches were conducted using PsycINFO, ERIC and MEDLINE to retrieve articles published between January 2007 and March 2017 and fulfilled inclusion criteria (studies evaluating the efficacy of theory/model-informed suicide prevention programs in increasing participant knowledge or skills when presented with a peer at risk of suicide). The review is informed by PRISMA guidelines. Of 1398 studies identified, 25 were reviewed and most: targeted professionals; were 1–4-day workshops; were underpinned by 21 different theories; taught less detail to the community than professionals; and improved target outcomes. Current programs, although effective, are limited by their inaccessibility, narrow content for the community and substantial variability in theory base. Future suicide prevention programs will benefit from being informed by a more specific theory, delivered through technology, targeting more of the community and improving methodological rigour.
... A growing body of evidence in the last couple of decades points to a clear link between detailed and imbalanced media portrayal of suicide and the likelihood of imitative suicidal behaviour by vulnerable sub-groups (Hawton and Williams, 2002;Menon et al., 2018;Niederkrotenthaler et al., 2020;Zalsman et al., 2016). As per estimates, adherence to media reporting guidelines can reduce annual suicide deaths by more than 1 % Krysinska et al., 2016); for a country like India, this figure may equate to prevention of nearly 1400 deaths per year. ...
Article
Background Mounting evidence points to a substantial link between detailed media portrayals of suicide and imitative suicidal behaviour. We assessed the quality of media reporting of suicide in Kerala, a high suicide burden state in India against the World Health Organization (WHO) reporting guidelines. Methods We conducted a year-round content analysis of all suicide-related news articles in four (two local language and two English) of the most widely read daily newspapers in Kerala. We used a data extraction form, prepared a priori in accordance with the WHO reporting checklist, and coded each item based on the guidelines. Results A total of 377 suicide news articles were retrieved. Harmful reporting practices such as reporting the name (93.9%) and age (93.6%) of the deceased, method of suicide (93.1%), location of suicide (88.9%), monocausal explanations (48.8%), and including photograph of the deceased (37.7%) were commonly noted. On the other hand, less than a fifth of articles complied with helpful practices such as including details of suicide support helpline (19.1%) or a link with mental health issues (14.9%). Local language newspapers displayed more numerous violations in reporting compared to English newspapers. Conclusion Media reporting of suicide in Kerala, India is poorly adherent to international reporting guidelines, with very little focus on educating the public. These findings point to the need for framing comprehensive media reporting guidelines for India and a collaborative approach to highlight the primary role of the media in suicide prevention efforts.
Article
Aim: The effects of a bystander intervention model (BIM)-informed intervention (video) for the general community on participant risk of suicide assessment ability (ROSAA) and protective intervention ability (PIA) were compared with an active control (non-BIM-informed video). Method: Video interventions with 628 participants ( M age = 47.99, SD age = 17.34, range = 18–85 years) were conducted online. ROSAA and PIA were assessed immediately preintervention, postintervention, and at 2 months follow-up ( n = 126). Results: Linear mixed model analyses indicated that the experimental and control conditions improved on both outcome variables postintervention/Time 2 (T2); however, the former yielded better outcomes than the latter (moderate ESs in both variables). Follow-up/Time 3 (T3) experimental ROSAA scores were higher than Time 1 (T1) and lower than T2 scores. Follow-up experimental PIA scores were higher than T1 and lower than T2 scores. Follow-up control ROSAA scores were higher than those of T1 and similar to T2. Follow-up control PIA scores were similar to T1 and T2 scores. Limitations: Limitations of the study include: sample homogeneity, small n at follow-up, self-report data only (no observable behavior was tested), fair inter-rater reliability, and a brief follow-up time frame. Conclusion: Current community information increased ROSAA and PIA. A BIM-informed intervention significantly enhanced these effects, which seemed to wane somewhat over time with the effect being lower at follow-up compared with postintervention. The BIM should be explored further as a basis for community suicide prevention interventions.
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Youth suicide is a significant public health problem. A systematic review was conducted to examine the effectiveness of school, community and healthcare-based interventions in reducing and preventing suicidal ideation, suicide attempts and deliberate self-harm in young people aged 12-25 years. PsycInfo, PubMed and Cochrane databases were searched to the end of December 2014 to identify randomised controlled trials evaluating the effectiveness of psychosocial interventions for youth suicide. In total, 13,747 abstracts were identified and screened for inclusion in a larger database. Of these, 29 papers describing 28 trials fulfilled the inclusion criteria for the current review. The results of the review indicated that just over half of the programs identified had a significant effect on suicidal ideation (Cohen's d = 0.16-3.01), suicide attempts (phi = 0.04-0.38) or deliberate self-harm (phi = 0.29-0.33; d = 0.42). The current review provides preliminary support for the implementation of universal and targeted interventions in all settings, using a diverse range of psychosocial approaches. Further quality research is needed to strengthen the evidence-base for suicide prevention programs in this population. In particular, the development of universal school-based interventions is promising given the potential reach of such an approach.
Technical Report
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This report is the first WHO publication of its kind and brings together what is known in a convenient form so that immediate actions can be taken. The report aims to increase the awareness of the public health significance of suicide and suicide attempts and to make suicide prevention a higher priority on the global public health agenda. It aims to encourage and support countries to develop or strengthen comprehensive suicide prevention strategies in a multisectoral public health approach. This report proposes practical guidance on strategic actions that governments can take on the basis of their resources and existing suicide prevention activities. In particular, there are evidence-based and low-cost interventions that are effective, even in resource-poor settings.
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Background: Although deliberate self-harm is a strong predictor of suicide, evidence for effective interventions is missing. The aim of this study was to examine whether psychosocial therapy after self-harm was linked to lower risks of repeated self-harm, suicide, and general mortality. Methods: In this matched cohort study all people who, after deliberate self-harm, received a psychosocial therapy intervention at suicide prevention clinics in Denmark during 1992-2010 were compared with people who did not receive the psychosocial therapy intervention after deliberate self-harm. We applied propensity score matching with a 1:3 ratio and 31 matching factors, and calculated odds ratios for 1, 5, 10, and 20 years of follow-up. The primary endpoints were repeated self-harm, death by suicide, and death by any cause. Findings: 5678 recipients of psychosocial therapy (followed up for 42·828 person-years) were matched with 17,034 individuals with no psychosocial therapy in a 1:8 ratio. During 20 year follow-up, 937 (16·5%) recipients of psychosocial therapy repeated the act of self-harm, and 391 (6·9%) died, 93 (16%) by suicide. The psychosocial therapy intervention was linked to lower risks of self-harm than was no psychosocial therapy (odds ratio [OR] 0·73, 95% CI 0·65-0·82) and death by any cause (0·62, 0·47-0·82) within a year. Long-term effects were identified for repeated self-harm (0·84, 0·77-0·91; absolute risk reduction [ARR] 2·6%, 1·5-3·7; numbers needed to treat [NNT] 39, 95% CI 27-69), deaths by suicide (OR 0·75, 0·60-0·94; ARR 0·5%, 0·1-0·9; NNT 188, 108-725), and death by any cause (OR 0·69, 0·62-0·78; ARR 2·7%, 2·0-3·5; NNT 37, 29-52), implying that 145 self-harm episodes and 153 deaths, including 30 deaths by suicide, were prevented. Interpretation: Our findings show a lower risk of repeated deliberate self-harm and general mortality in recipients of psychosocial therapy after short-term and long-term follow-up, and a protective effect for suicide after long-term follow-up, which favour the use of psychosocial therapy interventions after deliberate self-harm. Funding: Danish Health Insurance Foundation; the Research Council of Psychiatry, Region of Southern Denmark; the Research Council of Psychiatry, Capital Region of Denmark; and the Strategic Research Grant from Health Sciences, Capital Region of Denmark.
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Background There is growing interest in brief contact interventions for self-harm and suicide attempt. Aims To synthesise the evidence regarding the effectiveness of brief contact interventions for reducing self-harm, suicide attempt and suicide. Method A systematic review and random-effects meta-analyses were conducted of randomised controlled trials using brief contact interventions (telephone contacts; emergency or crisis cards; and postcard or letter contacts). Several sensitivity analyses were conducted to examine study quality and subgroup effects. Results We found 14 eligible studies overall, of which 12 were amenable to meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio (OR) of 0.87 (95% CI 0.74-1.04, P = 0119) for intervention compared with control. The number of repetitions per person was significantly reduced in intervention v. control (incidence rate ratio IRR = 066, 95% CI 0.54-0.80, P<0001). There was no significant reduction in the odds of suicide in intervention compared with control (OR = 0.58, 95% CI 0.24-1.38). Conclusions A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation. We recommend further assessment of possible benefits in well-designed trials in clinical populations. Royal College of Psychiatrists.
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Background Suicidal behaviours in adolescents are a major public health problem and evidence-based prevention programmes are greatly needed. We aimed to investigate the efficacy of school-based preventive interventions of suicidal behaviours. Methods The Saving and Empowering Young Lives in Europe (SEYLE) study is a multicentre, cluster-randomised controlled trial. The SEYLE sample consisted of 11 110 adolescent pupils, median age 15 years (IQR 14–15), recruited from 168 schools in ten European Union countries. We randomly assigned the schools to one of three interventions or a control group. The interventions were: (1) Question, Persuade, and Refer (QPR), a gatekeeper training module targeting teachers and other school personnel, (2) the Youth Aware of Mental Health Programme (YAM) targeting pupils, and (3) screening by professionals (ProfScreen) with referral of at-risk pupils. Each school was randomly assigned by random number generator to participate in one intervention (or control) group only and was unaware of the interventions undertaken in the other three trial groups. The primary outcome measure was the number of suicide attempt(s) made by 3 month and 12 month follow-up. Analysis included all pupils with data available at each timepoint, excluding those who had ever attempted suicide or who had shown severe suicidal ideation during the 2 weeks before baseline. This study is registered with the German Clinical Trials Registry, number DRKS00000214. Findings Between Nov 1, 2009, and Dec 14, 2010, 168 schools (11 110 pupils) were randomly assigned to interventions (40 schools [2692 pupils] to QPR, 45 [2721] YAM, 43 [2764] ProfScreen, and 40 [2933] control). No significant differences between intervention groups and the control group were recorded at the 3 month follow-up. At the 12 month follow-up, YAM was associated with a significant reduction of incident suicide attempts (odds ratios [OR] 0·45, 95% CI 0·24–0·85; p=0·014) and severe suicidal ideation (0·50, 0·27–0·92; p=0·025), compared with the control group. 14 pupils (0·70%) reported incident suicide attempts at the 12 month follow-up in the YAM versus 34 (1·51%) in the control group, and 15 pupils (0·75%) reported incident severe suicidal ideation in the YAM group versus 31 (1·37%) in the control group. No participants completed suicide during the study period. Interpretation YAM was effective in reducing the number of suicide attempts and severe suicidal ideation in school-based adolescents. These findings underline the benefit of this universal suicide preventive intervention in schools. Funding Coordination Theme 1 (Health) of the European Union Seventh Framework Programme.
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Non-fatal self-harm is one of the most frequent reasons for emergency hospital admission and the strongest risk factor for subsequent suicide. Repeat self-harm and suicide are key clinical outcomes of the hospital management of self-harm. We have undertaken a comprehensive review of the international literature on the incidence of fatal and non-fatal repeat self-harm and investigated factors influencing variation in these estimates as well as changes in the incidence of repeat self-harm and suicide over the last 30 years. Medline, EMBASE, PsycINFO, Google Scholar, article reference lists and personal paper collections of the authors were searched for studies describing rates of fatal and non-fatal self-harm amongst people who presented to health care services for deliberate self-harm. Heterogeneity in pooled estimates of repeat self-harm incidence was investigated using stratified meta-analysis and meta-regression. The search identified 177 relevant papers. The risk of suicide in the 12 months after an index attempt was 1.6% (CI 1.2-2.4) and 3.9% (CI 3.2-4.8) after 5 years. The estimated 1 year rate of non-fatal repeat self-harm was 16.3% (CI 15.1-17.7). This proportion was considerably lower in Asian countries (10.0%, CI 7.3-13.6%) and varies between studies identifying repeat episodes using hospital admission data (13.7%, CI 12.3-15.3) and studies using patient report (21.9%, CI 14.3-32.2). There was no evidence that the incidence of repeat self-harm was lower in more recent (post 2000) studies compared to those from the 1980s and 1990s. One in 25 patients presenting to hospital for self-harm will kill themselves in the next 5 years. The incidence of repeat self-harm and suicide in this population has not changed in over 10 years. Different methods of identifying repeat episodes of self-harm produce varying estimates of incidence and this heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeat self-harm.
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Public awareness campaigns about depression and suicide have been viewed as highly effective strategies in preventing suicide, yet their effectiveness has not been established in previous studies. This study evaluates the effectiveness of a public-awareness campaign by comparing suicide counts before and after a city-wide campaign in Nagoya, Japan, where the city government distributed promotional materials that were aimed to stimulate public awareness of depression and promote care-seeking behavior during the period of 2010-2012. In each of the sixteen wards of the city of Nagoya, we count the number of times that the promotional materials were distributed per month and then examine the association between the suicide counts and the frequency of distributions in the months following such distributions. We run a Poisson regression model that controls for the effects of ward-specific observed and unobserved heterogeneities and temporal shocks. Our analysis indicates that more frequent distribution of the campaign material is associated with a decrease in the number of suicides in the subsequent months. The campaign was estimated to have been especially effective for the male residents of the city. The underlying mechanism of how the campaign reduced suicides remains to be unclear. Public awareness campaigns can be an effective strategy in preventing suicide.
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BACKGROUND: In 2009, suicide accounted for 36 897 deaths in the United States. PURPOSE: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care. DATA SOURCES: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012). STUDY SELECTION: Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings. DATA EXTRACTION: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality. DATA SYNTHESIS: Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths. LIMITATION: Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited. CONCLUSION: Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
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Background: Certain sites have gained notoriety as 'hotspots' for suicide by jumping. Structural interventions (e.g. barriers and safety nets) have been installed at some of these sites. Individual studies examining the effectiveness of these interventions have been underpowered. Method: We conducted a meta-analysis, pooling data from nine studies. Results: Following the interventions, there was an 86% reduction in jumping suicides per year at the sites in question (95% CI 79% to 91%). There was a 44% increase in jumping suicides per year at nearby sites (95% CI 15% to 81%), but the net gain was a 28% reduction in all jumping suicides per year in the study cities (95% CI 13% to 40%). Conclusions: Structural interventions at 'hotspots' avert suicide at these sites. Some increases in suicide are evident at neighbouring sites, but there is an overall gain in terms of a reduction in all suicides by jumping.