A Review of the Literature: Suicide Prevention Interventions and Referral/Follow-up Services
Suicide is the 10th leading cause of death in the United States, with nearly 100 suicides occurring each day and more than 36,000 people dying by suicide each year. Among Veterans and current military, suicide is a national public health concern. Recent estimates suggest current or former military represent 20% of all known suicides in the U.S., and the rate of suicides among Veterans using VA healthcare is estimated to be higher than the general population. The severity of the problem has led to several major public health initiatives to address suicide and an increase in research funding for suicide prevention.
As requested by the VA/DoD Evidence-Based Practice Working Group (EBPWG) on suicide prevention, investigators at the Evidence-based Synthesis Program Center, Portland OR, examined recent research on suicidal self-directed violence. This updates previous systematic reviews (Gaynes et al. and Mann et al.) by systematically reviewing relevant literature that was not included in either report, and was published from June, 2005 through November 18, 2011. Studies were included that reported suicidal self-directed violence as an outcome, were randomized controlled trials (RCTs), and were conducted in Australia, Canada, New Zealand, the United Kingdom, and the United States. Investigators identified 38 randomized-controlled trials (reported in 47 publications) and 23 systematic reviews (reported in 25 publications) that addressed at least one of the following key questions.
What is the effectiveness of specific interventions for reducing rates of suicidal self-directed violence in military and/or Veteran populations?
- This review found no RCTs of self-directed violence prevention interventions in military and/or VA healthcare settings.
What lessons can be learned from suicidal self-directed violence prevention intervention research conducted outside of Veteran or military settings that can be applied to Veteran and/or military populations?
In three other systematic reviews with similar key questions, conclusions about the effectiveness of pharmacotherapy for preventing suicide are based on few studies with limited sample sizes, methodological limitations, and only short-term follow-up periods. Although these reviews did not report a benefit of pharmacotherapy in reducing suicide, these findings should be interpreted with caution because the trials were not designed to detect an effect on suicide. Observational studies show a correlation between increasing prescription rates for pharmacotherapy and decreasing suicide rates, but this evidence is considered lower strength than evidence obtained from RCTs or meta-analyses.
- Primary studies included in the current report evaluated antidepressants, atypical antipsychotics, mood stabilizers, and omega-3 supplements and their efficacy in preventing suicidal self-directed violence in civilian populations.
- Findings from antidepressant trials in civilian populations were consistent with previous reviews. Because of the very low number of suicides in these studies, investigators were not able to detect an effect of antidepressants on suicides and suicide attempts.
- Three systematic reviews included different studies of atypical antipsychotic medications. Overall, they report positive findings from trials of flupenthixol, clozapine, and fluphenazine, though the reviews caution that findings are based on small samples of patients in very few studies. Three trials conducted since the most recent U.S. review by Mann et al. in 1995 provide insufficient evidence for the effectiveness of quetiapine or adjunctive aripiprazole.
- Trials conducted since the Mann review provide insufficient evidence to draw conclusions about the comparative effectiveness of mood stabilizers in preventing suicide attempts. The Mann report found an antisuicidal effect for lithium compared to carbamazepine and amitriptyline in patients with major mood disorders, though this finding was based on only one trial.
- One trial of omega-3 fatty acid supplementation for 12 weeks did not have any suicide deaths in either group.
- Findings from other systematic reviews with similar key questions report overall insufficient to low strength of evidence for the effectiveness of psychotherapeutic interventions in the prevention of self-directed violence.
- Few trials reported on prevention of suicide deaths as the outcome of psychotherapy interventions, and of those that did, most were insufficiently powered to detect an effect of the intervention.
- Psychotherapy trials included in this review were sufficiently heterogeneous in terms of type and duration of treatment, and population characteristics to preclude combination or quantitative comparison. Therefore, psychotherapy trials are grouped by population: those conducted in patients with recent suicide attempts, Borderline Personality Disorder, a psychotic spectrum disorder, and depression or dysthymia.
- The strongest evidence (moderate strength) comes from a trial of Problem-Solving Therapy in addition to usual care vs usual care alone for patients hospitalized due to recent self-harm. This trial showed no significant benefit of the intervention compared to usual care for the overall group of patients presenting to the hospital after engaging in self-harm behaviors; however, a significant benefit was noted for a sub-population of patients limited to people who had multiple hospitalizations for self-harm prior to the intervention.
- Three RCTs provided insufficient evidence to draw conclusions about prevention of suicide deaths in populations with Borderline Personality Disorder, largely because no or very few suicides occurred during the trials. However, the current trials, combined with findings from the Mann et al. report suggest that the best available evidence (low strength) supports the use of Dialectical Behavior Therapy in patients with Borderline Personality Disorder.
- One study comparing CBT versus supportive counseling in patients with a psychotic spectrum disorder had an unacceptably high risk of bias because therapists were not blinded and delivered both interventions to the participants.
- One trial that compared the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (including a depression case management and treatment component) vs usual care in people with depression or dysthymia used methods resulting in an unclear risk of bias. This trial provided insufficient evidence to draw definitive conclusions about the effectiveness of the interventions.
What is the effectiveness of referral and follow-up services (e.g., strategies designed to provide referrals, improve referral follow-through and attendance, etc.) for reducing rates of suicidal self-directed violence in military and/or Veteran populations?
- Investigators found no RCTs of suicidal self-directed violence prevention referral and follow-up services in military and/or VA healthcare settings.
What lessons can be learned from research on suicidal self-directed violence referral and follow-up services conducted outside of Veteran or military settings that can be applied to Veteran and/or military populations?
- The three previously published reports on this topic all report overall insufficient to low-strength of evidence for the effectiveness of any referral and follow-up services in prevention of suicidal self-directed violence.
- Findings from primary studies in this report include:
- Three studies of postcard interventions to decrease repeated suicidal self-directed violence, which showed mixed results.
- Two studies of Youth-Nominated Support Team interventions combined with usual care did not significantly reduce risk of suicide attempts or death in suicidal adolescents.
- One study of assertive community treatment compared with community mental healthcare in difficult-to-engage adults with serious mental illness showed no reduction in suicide deaths or deliberate self-harm incidents.
- One trial of a depression care management program resulted in no significant changes in the suicide mortality rate of older adults in primary care settings.
- All of these studies were given low strength of evidence ratings, thus limiting conclusions about the effectiveness of these interventions.
Due to the low base-rate of the primary outcome of interest (suicide), as well as the complexity of many of the commonly applied interventions for suicide prevention, high quality RCTs are difficult to implement. In spite of this difficulty, there remains a need to further test existing and new treatment methods that could be effective in preventing suicide. Given the overall limited evidence from the interventions described in this report, it is important to identify the relatively most promising interventions to help guide future research. A few high-quality RCTs of promising interventions, such as Problem-Solving Therapy or Dialectical Behavior Therapy, could change the strength of evidence for those interventions. Additionally, large-scale studies are needed to more effectively address unanswered questions about suicide because of its lowbase-rates. Moreover, when considering future research, as well as intervention adoption, researchers and clinicians should consider intervention costs and potential harms; these two issues were outside the scope of this review, though the articles cited reported little information on these topics, suggesting that these are areas in need of further investigation.
A Cyberseminar session on this ESP Report will be held on June 11, 2012. To register, go to the HSR&D Cyberseminar web page.
This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.
O'Neil ME, Peterson K, Low A, Carson S, Denneson LM, Haney E, Shiroma P, and Kansagara D. Suicide Prevention Intervention and Referral/Follow-up Services: A Systematic Review. VA-ESP Project #09-009;2012.
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