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Best strategies for reducing the suicide rate in Australia

December 2015
Australian and New Zealand Journal of Psychiatry 50(2)

DOI:10.1177/0004867415620024

Authors:

Karolina Krysinska

University of Melbourne

Philip J Batterham

Australian National University

Michelle Torok

UNSW Sydney

Fiona Shand

UNSW Sydney

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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.

. Estimated population preventable fraction for each of the strategies in the systems approach.

…

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Australian & New Zealand Journal of Psychiatry

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DOI: 10.1177/0004867415620024

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

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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May 2016
EUR CHILD ADOLES PSY

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.

Preventing Suicide: A Global Imperative

Technical Report

Full-text available

Sep 2014

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.

Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: A register-based, nationwide multicentre study using propensity score matching

Article

Full-text available

Jan 2015

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.

Letters, green cards, telephone calls and postcards: Systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide

Article

Full-text available

Mar 2015
BRIT J PSYCHIAT

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.

Hospital Presenting Self-Harm and Risk of Fatal and Non-Fatal Repetition: Systematic Review and Meta-Analysis

Article

Full-text available

Feb 2014
PLOS ONE

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.

The effect of public awareness campaigns on suicides: Evidence from Nagoya, Japan

Article

Full-text available

Sep 2013

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.

Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force

Article

Full-text available

Apr 2013
ANN INTERN MED

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.

The effectiveness of structural interventions at suicide hotspots: A meta-analysis

Article

Full-text available

Mar 2013
INT J EPIDEMIOL

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.

School-based suicide prevention programmes: The SEYLE cluster-randomised, controlled trial

Article

Jan 2015
LANCET

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.

Treatment of suicidal people around the world

Article