Systematic Review of Suicide Risk Assessment and Prevention
Rates of suicide increased among active duty soldiers during the wars in Afghanistan and Iraq – and between 2000 and 2010, the suicide rate among Veterans rose to exceed the rate among civilians. Despite the large public health impact of suicide in the U.S., research supporting clinical guidelines for suicide prevention has been limited. Efforts to prevent suicide generally include referrals for treatment of underlying conditions, psychotherapy, and management of imminent risk, such as hospitalization and development of safety plans. In addition to individual-level approaches, an increasing number of suicide prevention initiatives have been implemented at organizational, health system, and community levels. However, their influence on suicide prevention remains unclear because few studies demonstrating effectiveness have been published. This systematic review evaluated studies assessing the accuracy of methods to identify individuals at increased risk for suicide, and the effectiveness and adverse effects of healthcare interventions relevant to Veteran and military populations in reducing suicide and suicide attempts. Investigators reviewed the literature from January 2008 to September 2015 and identified 28 recently published studies, in addition to 9 studies from previous ESP reviews that met inclusion criteria. Of the 37 studies included in this review, six studies of risk assessment and three studies of interventions specifically included Veterans or military personnel.
- The majority of methods to identify individuals at increased risk for suicide demonstrated high sensitivity (estimates of ≥80%), but specificity varied.
- Suicide rates were reduced in 6 of 8 observational studies of various types of multiple-component population-level interventions, including two studies in Veteran and military populations. Only 2 of 10 trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care, however, most trials were inadequately designed to detect differences.
- No studies described the adverse effects of risk assessment methods or interventions for suicide prevention.
- Risk assessment methods are sensitive predictors of subsequent suicide and suicide attempts in studies, but the frequency of false positives limits their clinical utility. Future research should continue to refine these methods and examine their clinical applications.
- Studies of the effectiveness of suicide prevention interventions are inconclusive and the components necessary for successful interventions are unclear.
- Additional trials of promising individual therapies and site-randomized population-level interventions are needed.
This review focused on Veteran and military populations, potentially excluding important studies.
This study was funded through HSR&D's Quality Enhancement Research Initiative (QUERI) Evidence-based Synthesis Program (ESP). Dr. Denneson and Ms. Low are part of QUERI's ESP Program, Portland, OR.
Nelson H, Denneson L, Low A, et al. Suicide Risk Assessment and Prevention: A Systematic Review Focusing on Veterans. Psychiatric Services. June 15, 2017; Epub ahead of print.