Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review
Publication: American Journal of Psychiatry
Abstract
Objective:
The authors sought to identify scalable evidence-based suicide prevention strategies.
Methods:
A search of PubMed and Google Scholar identified 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.
Results:
Training primary care physicians in depression recognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are understudied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.
Conclusions:
Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physician settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record–derived algorithms, Internet-based screening methods, ketamine’s potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.
Suicide is the 10th leading cause of death in the United States, with 48,344 suicide deaths in 2018, and it is the second leading cause of death in the 15- to 34-year age range (1). Alarmingly, the age-adjusted suicide rate rose 36.7% between 2000 and 2018 (10.4/100,000 to 14.2/100,00) (2, 3). This situation may be even worse. The 40.7% increase in the unintentional death rate from 2000 to 2017 is almost entirely due to unspecified falls (up 86.5%) and unintentional poisonings (up 98.5%), two causes of death that include misclassified suicides. The first U.S. national suicide prevention plan was proposed in 2000 (4), but from 2000 to 2012, the U.S. slipped from the 72nd to the 31st percentile worldwide in suicide rate (5). In this review we show that the U.S. suicide rate increase relative to the rest of the world has occurred in the context of underutilized proven suicide prevention options.
A critical review of suicide prevention methods is facilitated by an exponential increase in effectiveness data. The most widely cited review of suicide prevention was published in 2005 (6). From 2005 to 2019, more than four times as many articles on suicide prevention were published compared with the previous 40 years (1966–2005). We reviewed all randomized controlled trials published between 2005 and 2019 that examined suicide, nonfatal suicide attempts, and suicidal ideation. The benefits of reducing access to the most lethal methods used for suicide and the impact of prescribing antidepressants were examined using epidemiological studies, mostly time-series studies, some with contemporaneous geographic controls, identified using the same search engines. We focused on suicidal behavior as an outcome and not suicidal ideation, because there is a closer relationship between nonfatal suicide attempts and suicide deaths than there is between suicidal ideation and suicide deaths (7).
Suicide risk can be understood in terms of a stress-diathesis model (8) (Figure 1) in which stress results from an internal stressor, usually a psychiatric illness, present in about 90% of all cases of suicide and most commonly major depression, and/or an external stressor involving life events. The diathesis is a combination of heightened perception of emotional distress, a greater propensity for emotion to influence decisions, impaired learning and problem-solving capacity, and distorted social cognition involving a hypersensitivity to negative social signals and diminished sensitivity to positive social signals (8). The diathesis moderates suicide risk, and the risk can be influenced adversely by acute alcohol or drug abuse, via mood or disinhibition (Figure 1). Prevention measures can be aligned with these model components (Figure 1). Each method was judged by two criteria: first, evidence that it prevents suicide attempts and not just suicidal ideation, and second, the possibility that it can be scaled up to city, county, state, and national levels, a requirement for broader suicide prevention.
METHODS
We conducted a literature search in PubMed and Google Scholar for the period 2005 to 2019, in accordance with PRISMA standards for systematic reviews (9). Search identifiers were suicide, suicide attempt, suicidal behavior, and suicidal ideation combined separately with each of the following identifiers: prevention, control, depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressant medications, mood stabilizers, atypical antipsychotics, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, Internet, and mass media. The search was restricted to articles in English. Randomized controlled trials in which the primary outcome of interest was suicide death, attempted suicide, or suicidal ideation were included because randomized controlled trials provide the strongest evidence of efficacy for a prevention strategy. Because evaluation of restricting access to more lethal methods of suicide, use of electronic health records for screening algorithms, and medication effects on suicide as an outcome require large population studies given the low base rate of suicide, we reviewed epidemiological studies emphasizing time-series designs and studies at the city, county, or general practitioner network level that employed a geographic control or practice control sites. Such studies, together with system-level studies, provide an indication of prevention methods that can be scaled up to a national level (10). These studies were identified using the same search terms and engines as were employed for randomized controlled trials. From the 20,234 articles identified or their bibliographies, 97 randomized controlled trials and 30 epidemiological studies with suicide, attempted suicide, or suicidal ideation as primary outcomes of interest were selected to evaluate prevention strategies (Table 1, Figure 2). Abstracts were reviewed to select studies for inclusion, and methods and results were obtained from the full text. Results are summarized in Table 1 for the main suicide prevention approaches in terms of proportion of positive outcome studies, and where there were replicated positive findings for reducing suicide attempts, we made a judgment as to whether that method is scalable, based on complexity in terms of training and delivery as well as cost in terms of time and personnel. This approach is consistent with what others have recommended (10), as it builds from individual randomized controlled trials, preferably carried out in different localities or countries, in determining whether a prevention method can potentially be deployed more widely.
| Intervention Superior to Control | Intervention Not Superior to Control | |||||
|---|---|---|---|---|---|---|
| Intervention | Studies (N) | N | % | N | % | Scalabilityb |
| General practitioner educationc | 12 | 10 | 83 | 2 | 17 | Yes |
| Education for youth suicidal behavior (targeting youths for training/education) | 3 | 3 | 100 | 0 | 0 | Yes |
| Education for youth suicidal behavior prevention (targeting adults for training/education) | 6 | 1 | 17 | 5 | 83 | Yes |
| Pharmacotherapy | 17 | 4 | 24 | 13 | 76 | Yes |
| Psychotherapy (CBT, DBT) | 18 | 9 | 50 | 9 | 50 | Yes (CBT) |
| Medication and psychotherapy | 3 | 1 | 33 | 2 | 67 | NA |
| Group psychotherapy | 2 | 1 | 50 | 1 | 50 | NA |
| Contact and/or active outreach | 10 | 7 | 70 | 3 | 30 | Yes |
| Brain stimulation | 2 | 0 | 0 | 2 | 100 | NA |
| Collaborative care | 1 | 1 | 100 | 0 | 0 | NA |
| Firearms restrictiond | 49 | 48 | 98 | 1 | 2 | Yes |
| Internet based | 3 | 0 | 0 | 3 | 100 | NA |
a
Studies were included only if suicide attempts or events or self-injury were outcome measures and not solely suicidal ideation. CBT=cognitive-behavioral therapy; DBT=dialectical behavior therapy.
b
Scalability was only assessed when findings of efficacy have been replicated.
c
Contains two randomized controlled trials and 10 quasi-experimental studies.
d
Contains quasi-experimental and ecological studies.
FIGURE 2. Selection of articles on suicidal behavior prevention for reviewa
a RCT=randomized controlled trial.
RESULTS
Education
We examined education directed at health care professionals, students, the general public, or gatekeepers (military, first responders, school staff, clergy, college campus counselors, human resource departments).
General practitioner and nonpsychiatrist physician education.
Doctors in primary care and other nonpsychiatric care settings see 45% of future suicide decedents in the 30 days prior to suicide, and 77% within 12 months of suicide (11), about double the rate of mental health professionals. Therefore, educating nonpsychiatrist physicians may prevent more suicides than further training for psychiatrists. Training primary care doctors and nurses at the local and state levels to better screen and treat depression, with supplemental help available from psychiatrists, lowered suicide rates (12 –19), nonfatal suicide attempts (20, 21), and suicidal ideation (22) (Table 2). These findings support results from earlier studies (23 –25) and studies of self-harm (26). Repeating the education sessions was found to reduce suicide rates progressively for years (12, 21). In contrast, a single-day training session was found to produce no benefit for suicide deaths over 3 years (27). Studies in areas with suicide rates 3–10 times higher than the U.S. rate have shown that screening for depression combined with referral for depression treatment by a primary care doctor or psychiatrist lowered suicide rates relative to a contemporaneous geographic control (12, 15 –17). Conversely, a study of 40 primary care medical practices in the Netherlands found that a decline in depression detection rate from 65% to 44% was associated with higher suicide attempt rates in men (28).
| Source | Prevention Strategy | Length of Intervention | Population | Study Type | Location | Outcome |
|---|---|---|---|---|---|---|
| Oyama et al., 2005 (15) | Educational intervention for nurse depression screening and GP management | 8 years, screening and depression management | Older adults | Quasi-experimentalb | Japan | Greater reduction in female suicide in intervention region compared with control region (IRR=0.35). No regional difference in male suicides. |
| Oyama et al., 2006 (17) | Educational intervention for nurse depression screening and GP management | 10 years, screening and depression management | Older adults | Quasi-experimentalb | Japan | Reduction of 64% in female suicide rate in the intervention region (IRR=0.36), but no change in the control region. No change in male suicide rate. |
| Oyama et al., 2006 (16) | Educational intervention for nurse depression screening and GP management | 10 years, screening and depression management | Older adults | Quasi-experimentalb | Japan | Greater reduction in female suicide rates in intervention region compared with control region (IRR=0.43). No regional differences in male suicides. |
| Oyama et al., 2006 (14) | Educational intervention for nurse depression screening and GP management | 5 years, screening and depression management | Older adults | Quasi-experimentalb | Japan | Reduction of 74% in female suicide rate in the intervention region (IRR=0.26), significant using a one-tailed test, and no change in the control region. No change in male suicide rate. |
| Henriksson and Isacsson, 2006 (18) | Yearly 2-day GP training sessions | 8 years, GP screening and depression treatment | Adults | Quasi-experimentalb | Sweden | Preintervention (1970–1994) suicide rate was higher in Jämtland County (Sweden) than nationwide (p<0.05), but during intervention period (1995–2002) it dropped in intervention region, so the two rates no longer differed. |
| Szanto et al., 2007 (12) | Annual educational program for GPs and their nurses | 5 years, GP supervised depression management | Adults | Quasi-experimentalb | Hungary | Decrease in suicide rate in intervention region greater than the larger county (p<0.001) and Hungary (p<0.001). |
| Alexopoulos et al., 2009 (22) | GP training and case managers | 2 years, algorithm-based treatment advice | Older adults | Randomized controlled trialc | United States | Intervention group more likely to receive antidepressants or psychotherapy (p<0.001), and those with major depression had lower rates of suicidal ideation at 4, 8, and 24 months (p=0.04). No difference in suicidal behavior. |
| Hegerl et al., 2010 (21) | Four-level intervention program including GP education | 2 years, GP depression management | Adults | Quasi-experimentalb | Germany | Intervention region had greater reduction in suicidal acts (suicides and suicide attempts) (p<0.0065) and attempts (p<0.0005) versus control from baseline to 1-year follow-up of the 2-year intervention (2000–2003). The reduction in attempts was more pronounced for high-lethality than low-lethality methods and persisted for 4 years. |
| Hübner-Liebermann et al., 2010 (19) | Four-level intervention program including GP education in depression management | 5 years, GP depression management | Adults | Quasi-experimentalb | Germany | Suicide rate declined in the intervention region (p=0.02) but not in the control region. |
| Roškar et al., 2010 (27) | One-day GP educational program | 3 years, GP depression management | Adults | Quasi-experimentald | Slovenia | Intervention group had greater increase in antidepressant prescriptions (p<0.05) compared with control group, but no group differences in suicide rate. |
| Almeida et al., 2012 (26) | GP practice audit with feedback on depression and self-harm, educational materials, and control education GP group | 2 years, GP depression management | Older adults | Randomized controlled triale | Australia | Intervention group had less self-harm behaviors (odds ratio=0.80, p<0.05) over 2 years. |
| Hegerl et al., 2019 (20) | Four-level intervention program including GP training, GP consultation hotline | 2 years, GP depression treatment | Adults | Quasi-experimentalb | Germany, Hungary, Ireland, Portugal | In Portugal, the intervention region saw a greater reduction in suicidal acts (suicides and suicide attempts) (p=0.05) and attempts (p=0.02) compared with control region. No group differences found in the other countries. |
a
GP=general practitioner; IRR=incidence rate ratio.
b
Studies used a control region as a comparison and examined time periods before and after intervention onset. For such community-level intervention studies, no inclusion or exclusion criteria were employed.
c
Patient inclusion criteria were treatment at one of the 20 primary care practices participating in the study, age at least 60 years, and meeting DSM-IV criteria for major depression or having minor depression (defined as three to four depressive symptoms, a score ≥10 on the 24-item Hamilton Depression Rating Scale, and a duration of at least 1 month); intervention group, N=320; control group, N=279.
d
The study used physicians who did not attend GP training as a control group for two regions and had one region as an additional control; pre- and postintervention time periods were examined.
e
General practitioner inclusion criteria included being on a list provided by the Australasian Medical Publishing Company, working at least 2 days per week, having at least 50 patients at least 60 years old who spoke English, and not planning to retire or move practice within the next 2 years; intervention GP group, N=188 (11,402 patients age ≥60); GP control group, N=185 (10,360 patients age ≥60).
Education for youth suicidal behavior prevention.
Four of nine prevention studies in youths reported that mental health education resulted in less suicidal behavior (see Table S1 in the online supplement ), and seven of nine studies found less ideation. A key factor appears to be the population targeted for education. Targeting high school students was found to prevent student suicide attempts (29, 30), whereas studies targeting teachers (29) and all but one parent study (see Table S1) did not find benefit. Of the two successful educational programming studies in high schools, the first (29), involving 168 high schools and 11,110 students, randomized high schools to a teacher/staff gatekeeper education program, a professional screening program with referral of identified at-risk students, student education about mental health (the Youth Aware of Mental Health program), or a control group. The Youth Aware of Mental Health program prevented suicidal behavior relative to the control condition, but the screening intervention and the teacher/staff gatekeeper education program did not. In the second study (30), 4,133 high students were randomized to a mental health and suicide education program or to a control condition. Less suicidal behavior was observed in the active intervention group relative to the control group over the following year.
There have been no controlled trials targeting gatekeeper education in adults. Depression-management education of doctors has been shown to lower adult suicide rates (Table 2), but extending the education to other gatekeepers and to the general public is not proven to further reduce nonfatal and fatal suicide attempt rates (31).
System-level education.
A system-level approach, involving the application of a combination of education, training, and screening, shows promise in lowering suicide risk. Unfortunately, when such approaches have been implemented, they have not measured the separate effect of each intervention component. One study (32), funded by the 2004 Garrett Lee Smith Memorial Act, examined the impact of interventions directed at young persons (ages 10–24) on suicide rates in 1,126 U.S. counties. The legislation funded a range of interventions, including gatekeeper training (N=125,000) and screening programs to identify at-risk youths (29,000 were screened). Of note, 73% of education recipients were students, and, as suggested by the high school study mentioned above (29), emphasizing student education may have been crucial for gatekeeper education being effective. Education also included mental health professionals and emergency department staff. The intervention counties exhibited a decline in youth suicide rates that did not extend to other causes of death in youths or to adult suicide rates, compared with 969 demographic and sociologically comparable counties where the program was not implemented. These findings indicate that the benefit for suicide was found in the intervention counties and was confined to the demographic group targeted by the intervention. Moreover, this benefit lasted for 2 years beyond the intervention and was proportional to the number of years the program ran (32). Follow-up found that the benefit faded once programming stopped, regardless of the number of years it had been operating.
System-wide health care changes have not been tested in a randomized study, but promising results have emerged from opportunistic before-and-after studies (33). One retrospective study in the United Kingdom (34) found benefit for an array of clinical service changes—including improved depression management, continuity of care from adolescent patient services to adult patient services, improved community services, and lower staff turnover—with reduced suicide rates producing incident rate ratios of 0.71–0.79. A decline in suicide rates was temporally and geographically linked to the implementation of the improvements to mental health services between 1997 and 2012. Although the study did not control for changes in the secular suicide rate and there was no randomization of the intervention, interestingly, the poorest or most underresourced districts where interventions were deployed showed the greatest declines in suicide rates (35).
Denmark formerly had one of the highest suicide rates in the world. In 1980, the annual suicide rate was 38/100,000 for persons over age 15. Since 2007, the rate has stabilized at 11.4/100,000. The Danish suicide prevention effort has many components, one of the most important of which was means restriction, but other elements included a 66% increase in psychiatric services since 2000, establishment of suicide prevention clinics, psychiatric emergency outreach teams, and a postdischarge program called Strengthening Outpatient Care After Discharge (36).
A U.S. study examined the effect of staff education and frequent screening of suicide risk in all psychiatric patients in the Henry Ford Health System, which resulted in nine consecutive quarters without a suicide, compared with a suicide rate of 80/100,000 in 2000. The program ran from 2001 to 2007, and the rate declined to zero in the period 2008–2010, inspiring the notion of zero suicide as a goal for health care systems. Implementing and sustaining such results is aspirational and is worthy of further evaluation (33).
Screening
Screening for suicide risk to identify otherwise undetected at-risk individuals (30, 37), if coupled with effective referral for evaluation and treatment, was found in some studies to prevent suicidal behavior (15 –17, 37, 38). However, other studies did not find screening and referral of at-risk high school students to be effective (29). Brief screening tools such as the P4, which assesses the four p’s (past suicide attempt, suicide plan, probability of completing suicide, and preventive factors), and the Columbia-Suicide Severity Rating Scale (C-SSRS), which assesses severity of previous suicidal behavior and current suicidal ideation, may improve triage (37, 39). The 2014 U.S. Preventive Services Task Force report concluded that there is insufficient evidence that screening, specifically for suicide risk in primary care, identifies new cases beyond screening for a psychiatric disorder, distress, or a past suicide attempt (40). The C-SSRS predicted suicide attempts with an odds ratio of 4.8 (95% CI=2.23, 10.32, p<0.001) in adolescents and young adults following an emergency psychiatric evaluation (41). Screening in the U.S. military (42) indicated that current ideation added predictive power to a history of a previous suicide attempt. More complex electronic health record–based screening may improve identification of higher-risk patients (43 –47).
Treatment Interventions
Pharmacotherapy.
Seventeen pharmacotherapy trials with suicidal behavior as an outcome (see Table S2A in the online supplement ), including 12 studies in adults, five pediatric studies, and seven randomized controlled trial meta-analyses (48 –54), have appeared since the U.S. Food and Drug Administration (FDA) (51) adopted black box warnings in 2004 and 2006 regarding psychotropic medication–related suicide risk in children and young adults, respectively. Medications reduced suicidal behavior in four of the 12 adult studies (55 –58), but those effective medications belonged to pharmacologically diverse classes. More promisingly, antidepressants reduced suicidal ideation in nine of 12 studies that reported effects on suicidal ideation (55, 57, 59 –65). Meta-analyses of both randomized controlled trials and pharmacoepidemiological studies often found stronger benefits than single randomized controlled trials, perhaps because they included larger samples. Pharmacoepidemiological studies often involve much larger samples, follow outcomes over a longer time frame, and apply less stringent participant exclusion criteria, resulting in the inclusion of a more clinically representative patient population, including dual-diagnosis patients and patients with more severe presentations. A meta-analysis of all FDA-registered randomized placebo-controlled studies of fluoxetine and venlafaxine found that these medications decreased suicidal ideation and behavior (49, 52). An FDA meta-analysis found that antidepressants lowered risk of suicidal behavior in older age groups, but subsequent pharmacoepidemiological studies found that selective serotonin reuptake inhibitors (SSRIs) reduced suicidal behavior more broadly, including in young adults (66, 67).
There may be advantages for specific types of antidepressants. SSRIs appeared to be more effective than noradrenergic drugs for suicidal ideation (59, 61). Contrary to earlier FDA findings, SSRIs may work without increasing risk of treatment-emergent suicidal ideation or behavior, even in youths (67 –69). Longitudinal pharmacoepidemiological studies in adolescents, young adults, and older adults have found that the greatest risk for a suicide attempt was in the month before antidepressant medication began; after the medication was initiated, the risk declined progressively over months (66, 67, 70). Ketamine, an NMDA glutamate receptor antagonist, has been found to reduce suicidal ideation within 1–4 hours in patients with major depression (71 –75) or bipolar disorder (76, 77). One randomized controlled trial found that ketamine, used adjunctively with other psychotropic medications, provided benefit for suicidal ideation that persisted for weeks (72), but its effect on suicidal behavior has never been evaluated. The FDA approved intranasal esketamine for the treatment of depression with suicidal ideation, but not for the treatment of suicidal ideation. A meta-analysis found that intravenous ketamine improved suicidal ideation but that other routes of administration lacked proof of efficacy (78). The intranasal route may be less effective because of more erratic absorption and more side effects than the more slowly administered intravenous route (78).
Two of four randomized controlled trials showed benefit for suicidal behavior with lithium compared with various other medications (55, 58, 79, 80). A meta-analysis of randomized controlled trials in bipolar disorder found no evidence of lithium preventing suicide (81); however, a meta-analysis of nonrandomized studies suggested that the risk of attempts and suicide was five times less with lithium treatment (82). Although one study found no correlation between lithium levels in drinking water and bipolar disorder and many other psychiatric disorders (83), 11 of 16 ecological studies reported that these levels were linked to lower suicide rates (84).
Three randomized controlled trials in adolescents and young adults found that antidepressants reduced suicidal ideation (62, 64, 65), one study did not (85), and none found a reduction in suicidal behavior. A systematic review of antidepressants in pediatric populations found that SSRIs were associated with increased odds of a suicide attempt (53), but most subsequent meta-analyses and epidemiological studies in both pediatric (48, 50) and adult populations (49, 52, 66, 67, 86) reported a more favorable risk-benefit ratio than the FDA analyses (51, 87), including benefits for suicidal behavior. The FDA meta-analysis of pediatric randomized controlled trials did not find a difference in suicidal behavior between placebo and active drugs (88), and even in the adolescent studies that reported more suicidal events compared with placebo, the number needed to harm (suicide-related event or ideation) was much greater than the number needed to benefit (89).
Psychotherapy.
Randomized controlled trials of psychotherapy are summarized in Table S3A in the online supplement . Cognitive-behavioral therapy (CBT) decreases suicidal behavior risk in adults and adolescents with depression and in adults with borderline personality disorder, and it halved suicide reattempt rates in patients presenting to an emergency department after a recent suicide attempt compared with treatment as usual (90). CBT for suicidal individuals is designed to help high-risk individuals apply more effective coping strategies (e.g., cognitive restructuring) in the context of stressors and problems that trigger suicidal behaviors. Therapists also are trained to identify patient-specific factors that promote suicidal behaviors (90, 91). In substance use disorders, CBT has been reported to reduce attempt frequency compared with treatment as usual in adolescents (92) but not in adults (93). CBT may work by improving negative problem orientation and emotion regulation (94), reducing impulsiveness (95), and attenuating suicidal ideation (96).
Dialectical behavior therapy (DBT) for borderline personality disorder in adolescents, college students, and adults prevents suicide attempts and hospitalization for suicidal ideation and lessens medical consequences of self-harm behaviors compared with treatment as usual (see Table S3A in the online supplement ). Treatment dose may be a factor because a single session of DBT was not found to reduce suicidal ideation (97), whereas most effective studies employed a 20-week DBT intervention (98, 99).
Psychodynamic psychotherapies for borderline personality disorder have been found to prevent suicidal or self-harm behavior in most controlled studies (see Table S3A). There are no replicated studies of other types of psychotherapeutic interventions showing prevention of suicidal behavior. Even if psychotherapies were effective, only CBT appears to be scalable (Table 2).
Comparison of pharmacotherapy and psychotherapy.
Despite efficacy evidence for pharmacotherapy and psychotherapy separately, combinations of both showed no advantage for suicidal behavior (see Table S3B in the online supplement ).
Group psychotherapy.
Group psychotherapies reduced suicidal ideation in five of 10 studies (100 –109) and suicide in one (100), but none of the studies reported reductions in nonfatal suicide attempts (see Table S3C in the online supplement ). Cost-effectiveness and potential for scaling are moot without replicated efficacy for suicidal behavior.
Contact and/or active outreach following a suicide attempt or suicidal ideation crisis.
The period of greatest risk of suicidal behavior is after discharge from the emergency department or from an inpatient hospital unit (110–112). Eighty percent of suicide deaths following a nonfatal suicide attempt happen within 1 year. Follow-up contact interventions as simple as sending postcards prevented suicide attempt in two of four studies (see Table S4 in the online supplement ), consistent with earlier studies that found a robust benefit for reducing suicidal behaviors (110). Enhancing treatment engagement and adherence after an emergency department visit or hospital stay through follow-up contact calls reduced attempts or ideation in four of five studies (see Table S4). These interventions are scalable, as shown by a multinational study reporting that psychoeducation paired with telephone or in-person contact reduced the suicide rate over 18 months among suicide attempters (113). Another study used a similar approach by sending caring text messages over 1 year to active military personnel who had reported a suicide attempt (half the sample) or suicidal ideation, but not in the context of discharge from the hospital or emergency department. The intervention lowered subsequent suicide attempts by almost half (114). A cohort comparison study of safety planning interventions, administered in the emergency department with follow-up telephone contact, produced a 45% reduction in suicidal behaviors compared with treatment as usual (115).
Brain stimulation.
Repetitive transcranial magnetic stimulation and electroconvulsive therapy have been reported to reduce suicidal ideation, but the study samples were too small for evaluation of effects on suicide attempts (see Table S2B in the online supplement ). Deep brain stimulation has also not been shown to prevent suicide attempts (see Table S2B).
Collaborative care.
Collaborative care involves embedding psychiatric expertise within a primary care setting, army units, and schools to enhance mental health care. This approach was found to benefit suicidal ideation, but mostly it did not prevent suicidal behavior. The exceptions are a collaborative care program involving lay health workers in both primary and private care settings (116) and depression screening studies in which psychiatrists oversaw the antidepressant treatment, resulting in reduced suicide rates in both men and women (Table 2). By contrast, when general practitioners delivered this treatment, it was found to work in women but not in men (Table 2).
Internet-based interventions.
Internet-based interventions have not been shown to prevent suicidal behavior (see Table S5 in the online supplement ) but are highly scalable. Only three of 10 studies reported benefit for suicidal ideation (117 –123). Internet-based interventions can reach most untreated at-risk individuals and provide low-cost screening, psychoeducation, and web-based psychotherapeutic treatment interventions. A Dutch study found that adolescents disclosed comparable information about their mental health via web-based and paper-and-pencil screening forms (123). Online interventions have been found to increase suicide-prevention-related knowledge (124), but not all improved suicide literacy or reduced suicide stigma (122). Internet CBT, with or without telephone follow-up, was not more effective compared with waiting list control conditions for reducing suicidal ideation (121, 125). A game-like mobile app showed promise in reducing self-injury and suicide plans, but not suicidal ideation (126).
Means Restriction
Restricting access to the most available and lethal means for suicide, such as firearms, has been found to lower suicide rates (127 –137). Pesticide ingestion was employed in approximately one-third of suicides worldwide, mostly in rural Asia and Latin America (138). Centralized locked or guarded storage facilities combined with use of less toxic chemicals have contributed to a worldwide decline in pesticide suicides (129). Restricting access to pesticides in Sri Lanka reduced pesticide-related suicide rates without a concurrent increase in non-pesticide-related suicide deaths (139). Firearm suicide rate is closely related to firearm ownership rate (140). Firearms are used in half of all U.S. suicides (130, 131). Gun access restriction and gun safety education programs reduced firearm suicides, with only modest method substitution (127, 132 –135). Firearm buyback programs have reduced firearm-related suicides (141), but legal precedents and public opinion can undermine gun control and buyback programs and have prevented the United States from emulating the reduction in firearm suicides seen in other countries. Improved gun safety through education is more feasible than reducing gun ownership in the United States because of legal impediments to national gun control, and most guns used for suicide were purchased years before the suicide (132). Other proven means restriction approaches include better catalytic converters in automotive exhaust systems that reduce carbon monoxide content (136, 142), switching from coal gas to natural gas, which has a low carbon monoxide content (128), and barriers at suicide hot spots such as bridges and railway stations (137).
DISCUSSION
Applying the criteria of replicated efficacy for preventing suicidal behavior and scalability (Table 1) means that the best options for suicide prevention and for extending these approaches are 1) educating primary care physicians in depression management and evaluating the expansion of such programs to other nonpsychiatric medical specialists, such as internists and obstetrician-gynecologists; 2) educating high school students about mental health and evaluating extension of this approach to college students; 3) means restriction; and 4) predischarge education and follow-up contact and outreach for psychiatric patients discharged from the emergency department or hospital and for patients after a suicide crisis. Effective but less scalable options include specific psychotherapies (CBT, DBT). Finally, unproven options that are scalable and promising include fast-acting medications such as ketamine and Internet-based screening and treatment delivery and continuous passive monitoring of risk.
Educating nonpsychiatrist primary care physicians to better diagnose and treat major depression prevents suicide and nonfatal suicide attempts (Table 2). Several related observations explain why. Approximately 90% of suicide decedents had a current diagnosable psychiatric disorder, most commonly major depression, that was untreated at time of death (111, 143, 144). Suicidal ideation is common. In 2015, 9.8 million persons (4% of all persons age 18 and older) in the United States had serious thoughts about attempting suicide, and yet more than half had received no mental health services in the previous year. The result: 1.47 million persons (0.6% of all persons age 18 and older) made a suicide attempt (145). Despite a large increase in antidepressant prescription rates (49, 52, 59, 66, 86, 146), when suicide decedents seek help, they tend to go to nonpsychiatrist physicians and end up untreated for their depression.
The debate about the safety of antidepressant treatment in adolescents and young adults needs to be informed by the 17 randomized controlled trials (see Table S2A in the online supplement ) as well as meta-analytic and pharmacoepidemiological studies (48 –50, 52 –54, 66, 67, 86) published since the FDA issued black box warnings for many classes of psychotropic medications. Both pediatric and adult studies of antidepressant effects on suicidal behavior show reductions in suicidal behavior in meta-analyses, more robustly than in individual randomized controlled trials, probably because the low base rate of suicide attempts requires larger sample sizes. Ketamine reduces suicidal ideation within 1–4 hours, instead of weeks like other antidepressants, in major depression (71 –73) and bipolar disorder (76, 77). Rapid, robust reduction of suicidal ideation may dramatically increase patient safety, but ketamine’s effect on suicidal behavior is unknown and is therefore a priority for suicide prevention research. More information is needed on the relative efficacy of intranasal and intravenous ketamine.
Educating other gatekeepers about the signs of suicide risk and the need to refer patients for help raises questions about whom to focus on for the best results (see Table S1 in the online supplement ). Two studies in high schools found that pupil education prevented suicide attempts (29, 30), with one finding it more effective than teacher/gatekeeper training and that the latter was no better than the control arm of the study (29). In the absence of data from randomized controlled trials on whether training adult gatekeepers prevents adult suicidal behavior, it is unknown whether colleges, universities, military, and police should try to educate everyone in their system or just focus on their student body or workforce.
Screening for suicidal ideation in school, college, military, and medical clinic populations seeks to identify otherwise undetected at-risk individuals. Although it does not induce subsequent suicidal ideation (38, 147), screening a non-help-seeking population for suicidal ideation and nonfatal suicide attempts, beyond screening for major depression, remains a debated approach (40). Newer promising approaches may involve using smartphone technology to detect risk (148, 149) and algorithm-guided electronic health record screening (43, 44, 46, 150).
CBT, DBT, and individual psychodynamic psychotherapies prevent suicide attempts, but aside from CBT, scalability limits their value in suicide prevention. Combining medication with individual psychotherapy does not offer any measurable advantage. No brain stimulation therapies have demonstrated suicidal behavior prevention. Sleep disturbance (151) and effects on mood and decision making by acute alcohol intake (152) are risk factors for suicidal behavior that warrant further evaluation as potential prevention targets.
The period of greatest risk for repeating a suicide attempt is in the month or year following an index attempt, and particularly after discharge from a psychiatric visit to an emergency department or a stay in an inpatient hospital unit (110 –112). Predischarge education and assertive outreach after discharge or a suicide-related crisis prevent suicide attempts (Table 2; see also Table S1 in the online supplement ). Surprisingly, this approach has not been widely adopted in the United States, which may reflect gaps in continuity of care between inpatient and outpatient systems and between emergency departments and outpatient care. Calibrating suicide prevention efforts to times of greater risk as well as to patients showing higher risk clinical profiles would be more efficient and potentially effective.
The Internet has great potential for suicide prevention by screening, education, outreach, referral, and monitoring of ongoing risk and treatment, but applications are new, and testing of their efficacy is still in progress (120 –122, 153). Internet-based interventions are economical and scalable, reaching untreated at-risk individuals and offering help to anyone with a telephone and Wi-Fi access. Passive monitoring via a smartphone is an inexpensive but untested method for tracking risk.
Most suicide attempt survivors do not ultimately die by suicide, which is why means restriction, which targets the most lethal methods, saves many lives (154, 155). Surprisingly, faced with no access to their chosen method, most individuals do not turn to alternative means for suicide, as shown for coal and gas (156) and firearm restriction (127). Means restriction needs to target the main means used in a given region. Firearms are used in half of all suicides in the United States (1), yet restricting access of at-risk individuals to firearms is underutilized in this country (132). Gun buyback programs have worked in other countries (141), but safer gun storage education and state-regulated requirements may be more effective in the United States because most firearms used for suicide were purchased years earlier (157). Pesticides are highly lethal and are the leading suicide method worldwide, and the decline in suicide deaths worldwide is largely due to restriction of access to pesticides where those deaths occur most, namely, in rural China (138, 158), India (129), and Sri Lanka (159).
The major limitation of this review is the uneven quality and quantity of data available for different suicide prevention strategies. Within strategies, there is heterogeneity of study populations in terms of psychiatric illness, proportion of higher-risk patients (such as those with a history of a past suicide attempt), age, ethnicity, and proportion of males (because males have 3–4 times the suicide rate of females). Higher-risk groups (e.g., Native Americans, First Nations), demographic groups such as children and the elderly, and psychiatric disorders such as schizophrenia, eating disorders, and substance use disorders are understudied. Small sample sizes, too few studies, and lack of replication studies diminish the ability to draw firm conclusions about many approaches. Suicidal ideation is an unsatisfactory alternative outcome measure because it is not as closely related to suicide deaths as nonfatal suicide attempts. Evaluating complex interventions with multiple components makes it hard to determine the effective elements. Finally, there is a need for objective criteria for determining which interventions are capable of being scaled up from local studies to national-level deployment.
CONCLUSIONS
Education of primary care physicians, and potentially of internists and obstetrician-gynecologists, in the diagnosis and treatment of depression is a robust suicide prevention approach. Other proven scalable strategies (Table 1) are 1) follow-up of discharged and other acutely suicidal patients with active outreach, 2) treatment with CBT, and 3) implementation of means restriction. Education directed at youths prevents suicidal behavior, but education directed at teachers does not; no randomized controlled trial data are available for prevention of adult suicide by educational programming. Any prevention program requires outcome assessment that must include suicidal behavior, and preferably also mediating effects such as help-seeking behavior, treatment provision, and treatment adherence. The biggest challenge in suicide prevention lies in improving the identification of who is at high risk and when. Determination of imminent risk is needed for calibration of prevention efforts to high-risk periods by employment of rapid reduction of suicidal ideation and means restriction. Fast-acting medications like ketamine may have a role during acute suicide risk but are untested for prevention of suicide attempts. Determination of imminent risk has evolved toward continuous monitoring via mobile devices (148, 149). Further research is needed to evaluate such approaches and how to integrate them into prevention responses.
Footnote
Sadia Choudhury, Ph.D., Rahil Kamath, B.A., Grace Allison, B.A., and Kira Alqueza, B.A., helped with the literature search and supplemental tables.
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REFERENCES
1.
Centers for Disease Control and Prevention: WISQARS: Fatal injury reports, national, and regional, 1999–2018. February 20, 2020, https://webappa.cdc.gov/sasweb/ncipc/mortrate.html
2.
Xu J, Murphy S, Kochanek K, et al : Mortality in the United States, 2015. NCHS Data Brief 2016 ; 267 : 1 – 8
3.
Curtin SC, Warner M, Hedegaard H : Increase in suicide in the United States, 1999–2014. NCHS Data Brief 2016 ; 241 : 1 – 8
4.
Center for Mental Health Services and Office of the Surgeon General : National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, Md, US Public Health Service, 2001
5.
Organization for Economic Cooperation and Development: Suicide rates. https://data.oecd.org/healthstat/suicide-rates.htm
6.
Mann JJ, Apter A, Bertolote J, et al : Suicide prevention strategies: a systematic review. JAMA 2005 ; 294 : 2064 – 2074
7.
Nock MK, Borges G, Bromet EJ, et al : Cross-national prevalence and risk factors for suicidal ideation, plans, and attempts. Br J Psychiatry 2008 ; 192 : 98 – 105
8.
van Heeringen K, Mann JJ : The neurobiology of suicide. Lancet Psychiatry 2014 ; 1 : 63 – 72
9.
Moher D, Liberati A, Tetzlaff J, et al : Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009 ; 151 : 264 – 269
10.
Duflo E : Scaling up and evaluation, in Annual World Bank Conference on Development Economics 2004: Accelerating Development. Edited by Bourguignon F, Pleskovic B. Washington, DC, World Bank, and New York, Oxford University Press, 2004, pp 341 – 369
11.
Luoma JB, Martin CE, Pearson JL : Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002 ; 159 : 909 – 916
12.
Szanto K, Kalmar S, Hendin H, et al : A suicide prevention program in a region with a very high suicide rate. Arch Gen Psychiatry 2007 ; 64 : 914 – 920
13.
Rutz W : Preventing suicide and premature death by education and treatment. J Affect Disord 2001 ; 62 : 123 – 129
14.
Oyama H, Ono Y, Watanabe N, et al : Local community intervention through depression screening and group activity for elderly suicide prevention. Psychiatry Clin Neurosci 2006 ; 60 : 110 – 114
15.
Oyama H, Watanabe N, Ono Y, et al : Community-based suicide prevention through group activity for the elderly successfully reduced the high suicide rate for females. Psychiatry Clin Neurosci 2005 ; 59 : 337 – 344
16.
Oyama H, Goto M, Fujita M, et al : Preventing elderly suicide through primary care by community-based screening for depression in rural Japan. Crisis 2006 ; 27 : 58 – 65
17.
Oyama H, Fujita M, Goto M, et al : Outcomes of community-based screening for depression and suicide prevention among Japanese elders. Gerontologist 2006 ; 46 : 821 – 826
18.
Henriksson S, Isacsson G : Increased antidepressant use and fewer suicides in Jämtland County, Sweden, after a primary care educational programme on the treatment of depression. Acta Psychiatr Scand 2006 ; 114 : 159 – 167
19.
Hübner-Liebermann B, Neuner T, Hegerl U, et al : Reducing suicides through an alliance against depression? Gen Hosp Psychiatry 2010 ; 32 : 514 – 518
20.
Hegerl U, Maxwell M, Harris F, et al : Prevention of suicidal behaviour: results of a controlled community-based intervention study in four European countries. PLoS One 2019 ; 14 : e0224602
21.
Hegerl U, Mergl R, Havers I, et al : Sustainable effects on suicidality were found for the Nuremberg Alliance Against Depression. Eur Arch Psychiatry Clin Neurosci 2010 ; 260 : 401 – 406
22.
Alexopoulos GS, Reynolds CF 3rd, Bruce ML, et al : Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiatry 2009 ; 166 : 882 – 890
23.
Rutz W, von Knorring L, Wålinder J : Frequency of suicide on Gotland after systematic postgraduate education of general practitioners. Acta Psychiatr Scand 1989 ; 80 : 151 – 154
24.
Takahashi K, Naito H, Morita M, et al : [Suicide prevention for the elderly in Matsunoyama Town, Higashikubiki County, Niigata Prefecture: psychiatric care for elderly depression in the community]. Seishin Shinkeigaku Zasshi 1998 ; 100 : 469 – 485 (Japanese)
25.
Oyama H, Koida J, Sakashita T, et al : Community-based prevention for suicide in elderly by depression screening and follow-up. Community Ment Health J 2004 ; 40 : 249 – 263
26.
Almeida OP, Pirkis J, Kerse N, et al : A randomized trial to reduce the prevalence of depression and self-harm behavior in older primary care patients. Ann Fam Med 2012 ; 10 : 347 – 356
27.
Roškar S, Podlesek A, Zorko M, et al : Effects of training program on recognition and management of depression and suicide risk evaluation for Slovenian primary-care physicians: follow-up study. Croat Med J 2010 ; 51 : 237 – 242
28.
de Beurs DP, Hooiveld M, Kerkhof AJ, et al : Trends in suicidal behaviour in Dutch general practice 1983–2013: a retrospective observational study. BMJ Open 2016 ; 6 : e010868
29.
Wasserman D, Hoven CW, Wasserman C, et al : School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet 2015 ; 385 : 1536 – 1544
30.
Aseltine RH Jr, James A, Schilling EA, et al : Evaluating the SOS suicide prevention program: a replication and extension. BMC Public Health 2007 ; 7 : 161
31.
Hegerl U, Althaus D, Schmidtke A, et al : The Alliance Against Depression: 2-year evaluation of a community-based intervention to reduce suicidality. Psychol Med 2006 ; 36 : 1225 – 1233
32.
Godoy Garraza L, Kuiper N, Goldston D, et al : Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006–2015. J Child Psychol Psychiatry 2019 ; 60 : 1142 – 1147
33.
Stanley B, Mann JJ : The need for innovation in health care systems to improve suicide prevention. JAMA Psychiatry 2019 ; 77 : 96 – 98
34.
Kapur N, Ibrahim S, While D, et al : Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. Lancet Psychiatry 2016 ; 3 : 526 – 534
35.
While D, Bickley H, Roscoe A, et al : Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. Lancet 2012 ; 379 : 1005 – 1012
36.
Nordentoft M, Erlangsen A : Suicide: turning the tide (editorial). Science 2019 ; 365:725
37.
Dube P, Kurt K, Bair MJ, et al : The P4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients. Prim Care Companion J Clin Psychiatry 2010 ; 12 :PCC.10m00978
38.
Crawford MJ, Thana L, Methuen C, et al : Impact of screening for risk of suicide: randomised controlled trial. Br J Psychiatry 2011 ; 198 : 379 – 384
39.
Posner K, Brown GK, Stanley B, et al : The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011 ; 168 : 1266 – 1277
40.
Siu AL, Bibbins-Domingo K, Grossman DC, et al : Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA 2016 ; 315 : 380 – 387
41.
Horwitz AG, Czyz EK, King CA : Predicting future suicide attempts among adolescent and emerging adult psychiatric emergency patients. J Clin Child Adolesc Psychol 2015 ; 44 : 751 – 761
42.
Kessler RC, Stein MB, Petukhova MV, et al : Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Mol Psychiatry 2017 ; 22 : 544 – 551
43.
Schoenbaum M, Kessler RC, Gilman SE, et al : Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2014 ; 71 : 493 – 503
44.
Simon GE, Rutter CM, Do Peterson MO, et al : Does response on the PHQ-9 depression questionnaires predict subsequent suicide attempt or suicide death? Psychiatr Serv 2013 ; 64 : 1195 – 1202
45.
Kessler RC, Warner CH, Ivany C, et al : Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2015 ; 72 : 49 – 57
46.
Simon GE, Shortreed SM, Johnson E, et al : Between-visit changes in suicidal ideation and risk of subsequent suicide attempt. Depress Anxiety 2017 ; 34 : 794 – 800
47.
Obeid JS, Dahne J, Christensen S, et al : Identifying and predicting intentional self-harm in electronic health record clinical notes: deep learning approach. JMIR Med Inform 2020 ; 8 : e17784
48.
Xu Y, Bai SJ, Lan XH, et al : Randomized controlled trials of serotonin-norepinephrine reuptake inhibitor in treating major depressive disorder in children and adolescents: a meta-analysis of efficacy and acceptability. Braz J Med Biol Res 2016 ; 49 : e4806
49.
Gibbons RD, Hur K, Brown CH, et al : Benefits from antidepressants: synthesis of 6-week patient-level outcomes from double-blind placebo-controlled randomized trials of fluoxetine and venlafaxine. Arch Gen Psychiatry 2012 ; 69 : 572 – 579
50.
Bridge JA, Iyengar S, Salary CB, et al : Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 2007 ; 297 : 1683 – 1696
51.
Hammad TA, Laughren T, Racoosin J : Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006 ; 63 : 332 – 339
52.
Gibbons RD, Brown CH, Hur K, et al : Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. Arch Gen Psychiatry 2012 ; 69 : 580 – 587
53.
Fergusson D, Doucette S, Glass KC, et al : Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials. BMJ 2005 ; 330 : 396
54.
Cipriani A, Zhou X, Del Giovane C, et al : Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet 2016 ; 388 : 881 – 890
55.
Khan A, Khan SR, Hobus J, et al : Differential pattern of response in mood symptoms and suicide risk measures in severely ill depressed patients assigned to citalopram with placebo or citalopram combined with lithium: role of lithium levels. J Psychiatr Res 2011 ; 45 : 1489 – 1496
56.
Thomas SH, Drici MD, Hall GC, et al : Safety of sertindole versus risperidone in schizophrenia: principal results of the Sertindole Cohort Prospective Study (SCoP). Acta Psychiatr Scand 2010 ; 122 : 345 – 355
57.
Zisook S, Lesser IM, Lebowitz B, et al : Effect of antidepressant medication treatment on suicidal ideation and behavior in a randomized trial: an exploratory report from the Combining Medications to Enhance Depression Outcomes Study. J Clin Psychiatry 2011 ; 72 : 1322 – 1332
58.
Lauterbach E, Felber W, Müller-Oerlinghausen B, et al : Adjunctive lithium treatment in the prevention of suicidal behaviour in depressive disorders: a randomised, placebo-controlled 1-year trial. Acta Psychiatr Scand 2008 ; 118 : 469 – 479
59.
Grunebaum MF, Ellis SP, Duan N, et al : Pilot randomized clinical trial of an SSRI vs bupropion: effects on suicidal behavior, ideation, and mood in major depression. Neuropsychopharmacology 2012 ; 37 : 697 – 706
60.
Weisler RH, Khan A, Trivedi MH, et al : Analysis of suicidality in pooled data from 2 double-blind, placebo-controlled aripiprazole adjunctive therapy trials in major depressive disorder. J Clin Psychiatry 2011 ; 72 : 548 – 555
61.
Perroud N, Uher R, Marusic A, et al : Suicidal ideation during treatment of depression with escitalopram and nortriptyline in Genome-Based Therapeutic Drugs for Depression (GENDEP): a clinical trial. BMC Med 2009 ; 7 : 60
62.
von Knorring A-L, Olsson GI, Thomsen PH, et al : A randomized, double-blind, placebo-controlled study of citalopram in adolescents with major depressive disorder. J Clin Psychopharmacol 2006 ; 26 : 311 – 315
63.
Canuso CM, Singh JB, Fedgchin M, et al : Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. Am J Psychiatry 2018 ; 175 : 620 – 630
64.
March JS, Silva S, Petrycki S, et al : The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry 2007 ; 64 : 1132 – 1143
65.
Brent DA, Emslie GJ, Clarke GN, et al : Predictors of spontaneous and systematically assessed suicidal adverse events in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. Am J Psychiatry 2009 ; 166 : 418 – 426
66.
Gibbons RD, Brown CH, Hur K, et al : Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets. Am J Psychiatry 2007 ; 164 : 1044 – 1049
67.
Simon GE, Savarino J, Operskalski B, et al : Suicide risk during antidepressant treatment. Am J Psychiatry 2006 ; 163 : 41 – 47
68.
Thase ME, Edwards J, Durgam S, et al : Effects of vilazodone on suicidal ideation and behavior in adults with major depressive disorder or generalized anxiety disorder: post-hoc analysis of randomized, double-blind, placebo-controlled trials. Int Clin Psychopharmacol 2017 ; 32 : 281 – 288
69.
Thase ME, Gommoll C, Chen C, et al : Measures of suicidality in phase 3 clinical trials of levomilnacipran ER in adults with major depressive disorder. CNS Spectr 2017 ; 22 : 475 – 483
70.
Valuck RJ, Libby AM, Sills MR, et al : Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder: a propensity-adjusted retrospective cohort study. CNS Drugs 2004 ; 18 : 1119 – 1132
71.
Price RB, Iosifescu DV, Murrough JW, et al : Effects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant depression. Depress Anxiety 2014 ; 31 : 335 – 343
72.
Grunebaum MF, Galfalvy HC, Choo T-H, et al : Ketamine for rapid reduction of suicidal thoughts in major depression: a midazolam-controlled randomized clinical trial. Am J Psychiatry 2018 ; 175 : 327 – 335
73.
Fan W, Yang H, Sun Y, et al : Ketamine rapidly relieves acute suicidal ideation in cancer patients: a randomized controlled clinical trial. Oncotarget 2017 ; 8 : 2356 – 2360
74.
Domany Y, Shelton RC, McCullumsmith CB : Ketamine for acute suicidal ideation: an emergency department intervention: a randomized, double-blind, placebo-controlled proof-of-concept trial. Depress Anxiety 2020 ; 37 : 224 – 233
75.
Phillips JL, Norris S, Talbot J, et al : Single, repeated, and maintenance ketamine infusions for treatment-resistant depression: a randomized controlled trial. Am J Psychiatry 2019 ; 176 : 401 – 409
76.
Zarate CA Jr, Brutsche NE, Ibrahim L, et al : Replication of ketamine’s antidepressant efficacy in bipolar depression: a randomized controlled add-on trial. Biol Psychiatry 2012 ; 71 : 939 – 946
77.
Grunebaum MF, Ellis SP, Keilp JG, et al : Ketamine versus midazolam in bipolar depression with suicidal thoughts: a pilot midazolam-controlled randomized clinical trial. Bipolar Disord 2017 ; 19 : 176 – 183
78.
Dadiomov D, Lee K : The effects of ketamine on suicidality across various formulations and study settings. Ment Health Clin 2019 ; 9 : 48 – 60
79.
Girlanda F, Cipriani A, Agrimi E, et al : Effectiveness of lithium in subjects with treatment-resistant depression and suicide risk: results and lessons of an underpowered randomised clinical trial. BMC Res Notes 2014 ; 7 : 731
80.
Oquendo MA, Galfalvy HC, Currier D, et al : Treatment of suicide attempters with bipolar disorder: a randomized clinical trial comparing lithium and valproate in the prevention of suicidal behavior. Am J Psychiatry 2011 ; 168 : 1050 – 1056
81.
Geddes JR, Burgess S, Hawton K, et al : Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials. Am J Psychiatry 2004 ; 161 : 217 – 222
82.
Baldessarini RJ, Tondo L, Davis P, et al : Decreased risk of suicides and attempts during long‐term lithium treatment: a meta‐analytic review. Bipolar Disord 2006 ; 8 ( 5p2 ): 625 – 639
83.
Parker WF, Gorges RJ, Gao YN, et al : Association between groundwater lithium and the diagnosis of bipolar disorder and dementia in the United States. JAMA Psychiatry 2018 ; 75 : 751 – 754
84.
Del Matto L, Muscas M, Murru A, et al : Lithium and suicide prevention in mood disorders and in the general population: a systematic review. Neurosci Biobehav Rev 2020 ; 116 : 142 – 153
85.
Emslie GJ, Findling RL, Yeung PP, et al : Venlafaxine ER for the treatment of pediatric subjects with depression: results of two placebo-controlled trials. J Am Acad Child Adolesc Psychiatry 2007 ; 46 : 479 – 488
86.
Gibbons RD, Hur K, Bhaumik DK, et al : The relationship between antidepressant medication use and rate of suicide. Arch Gen Psychiatry 2005 ; 62 : 165 – 172
87.
Hammad T : Review and evaluation of clinical trial data: relationship between psychotropic drugs and pediatric suicide. Washington, DC, US Food and Drug Administration, August 16, 2004. https://wayback.archive-it.org/7993/20171101034742/https://www.fda.gov/ohrms/dockets/ac/04/briefing/2004-4065b1-10-TAB08-Hammads-Review.pdf
88.
Stone M, Laughren T, Jones ML, et al : Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ 2009 ; 339 : b2880
89.
Mann JJ, Emslie G, Baldessarini RJ, et al : ACNP Task Force report on SSRIs and suicidal behavior in youth. Neuropsychopharmacology 2006 ; 31 : 473 – 492
90.
Brown GK, Ten Have T, Henriques GR, et al : Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA 2005 ; 294 : 563 – 570
91.
Rudd MD, Bryan CJ, Wertenberger EG, et al : Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry 2015 ; 172 : 441 – 449
92.
Esposito-Smythers C, Spirito A, Kahler CW, et al : Treatment of co-occurring substance abuse and suicidality among adolescents: a randomized trial. J Consult Clin Psychol 2011 ; 79 : 728 – 739
93.
Morley KC, Sitharthan G, Haber PS, et al : The efficacy of an opportunistic cognitive behavioral intervention package (OCB) on substance use and comorbid suicide risk: a multisite randomized controlled trial. J Consult Clin Psychol 2014 ; 82 : 130 – 140
94.
Slee N, Spinhoven P, Garnefski N, et al : Emotion regulation as mediator of treatment outcome in therapy for deliberate self-harm. Clin Psychol Psychother 2008 ; 15 : 205 – 216
95.
Ghahramanlou-Holloway M, Bhar SS, Brown GK, et al : Changes in problem-solving appraisal after cognitive therapy for the prevention of suicide. Psychol Med 2012 ; 42 : 1185 – 1193
96.
Slee N, Garnefski N, van der Leeden R, et al : Cognitive-behavioural intervention for self-harm: randomised controlled trial. Br J Psychiatry 2008 ; 192 : 202 – 211
97.
Ward-Ciesielski EF, Tidik JA, Edwards AJ, et al : Comparing brief interventions for suicidal individuals not engaged in treatment: a randomized clinical trial. J Affect Disord 2017 ; 222 : 153 – 161
98.
Linehan MM, Comtois KA, Murray AM, et al : Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006 ; 63 : 757 – 766
99.
Mehlum L, Tørmoen AJ, Ramberg M, et al : Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry 2014 ; 53 : 1082 – 1091
100.
Rabovsky K, Trombini M, Allemann D, et al : Efficacy of bifocal diagnosis-independent group psychoeducation in severe psychiatric disorders: results from a randomized controlled trial. Eur Arch Psychiatry Clin Neurosci 2012 ; 262 : 431 – 440
101.
Kaminer Y, Burleson JA, Goldston DB, et al : Suicidal ideation among adolescents with alcohol use disorders during treatment and aftercare. Am J Addict 2006 ; 15 ( suppl 1 ): 43 – 49
102.
Hsiao F-H, Lai Y-M, Chen Y-T, et al : Efficacy of psychotherapy on diurnal cortisol patterns and suicidal ideation in adjustment disorder with depressed mood. Gen Hosp Psychiatry 2014 ; 36 : 214 – 219
103.
Ebrahimi H, Kazemi AH, Fallahi Khoshknab M, et al : The effect of spiritual and religious group psychotherapy on suicidal ideation in depressed patients: a randomized clinical trial. J Caring Sci 2014 ; 3 : 131 – 140
104.
Zhang H, Neelarambam K, Schwenke TJ, et al : Mediators of a culturally-sensitive intervention for suicidal African American women. J Clin Psychol Med Settings 2013 ; 20 : 401 – 414
105.
Hazell PL, Martin G, Mcgill K, et al : Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial. J Am Acad Child Adolesc Psychiatry 2009 ; 48 : 662 – 670
106.
Green JM, Wood AJ, Kerfoot MJ, et al : Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation. BMJ 2011 ; 342 : d682
107.
Blum N, St John D, Pfohl B, et al : Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry 2008 ; 165 : 468 – 478
108.
McAuliffe C, McLeavey BC, Fitzgerald T, et al : Group problem-solving skills training for self-harm: randomised controlled trial. Br J Psychiatry 2014 ; 204 : 383 – 390
109.
Simpson GK, Tate RL, Whiting DL, et al : Suicide prevention after traumatic brain injury: a randomized controlled trial of a program for the psychological treatment of hopelessness. J Head Trauma Rehabil 2011 ; 26 : 290 – 300
110.
Motto JA, Bostrom AG : A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv 2001 ; 52 : 828 – 833
111.
Olfson M, Blanco C, Marcus SC : Treatment of adult depression in the United States. JAMA Intern Med 2016 ; 176 : 1482 – 1491
112.
Bostwick JM, Pabbati C, Geske JR, et al : Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. Am J Psychiatry 2016 ; 173 : 1094 – 1100
113.
Fleischmann A, Bertolote JM, Wasserman D, et al : Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. Bull World Health Organ 2008 ; 86 : 703 – 709
114.
Comtois KA, Kerbrat AH, DeCou CR, et al : Effect of augmenting standard care for military personnel with brief caring text messages for suicide prevention: a randomized clinical trial. JAMA Psychiatry 2019 ; 76 : 474 – 483
115.
Stanley B, Brown GK, Brenner LA, et al : Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry 2018 ; 75 : 894 – 900
116.
Patel V, Weiss HA, Chowdhary N, et al : Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet 2010 ; 376 : 2086 – 2095
117.
Wilks CR, Lungu A, Ang SY, et al : A randomized controlled trial of an Internet delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers. J Affect Disord 2018 ; 232 : 219 – 228
118.
O’Toole MS, Arendt MB, Pedersen CM : Testing an app-assisted treatment for suicide prevention in a randomized controlled trial: effects on suicide risk and depression. Behav Ther 2019 ; 50 : 421 – 429
119.
Tighe J, Shand F, Ridani R, et al : Ibobbly mobile health intervention for suicide prevention in Australian Indigenous youth: a pilot randomised controlled trial. BMJ Open 2017 ; 7 : e013518
120.
van Spijker BA, van Straten A, Kerkhof AJ : Effectiveness of online self-help for suicidal thoughts: results of a randomised controlled trial. PLoS One 2014 ; 9 : e90118
121.
Christensen H, Farrer L, Batterham PJ, et al : The effect of a web-based depression intervention on suicide ideation: secondary outcome from a randomised controlled trial in a helpline. BMJ Open 2013 ; 3 : e002886
122.
Taylor-Rodgers E, Batterham PJ : Evaluation of an online psychoeducation intervention to promote mental health help seeking attitudes and intentions among young adults: randomised controlled trial. J Affect Disord 2014 ; 168 : 65 – 71
123.
Van De Looij‐Jansen PM, De Wilde EJ : Comparison of web‐based versus paper‐and‐pencil self‐administered questionnaire: effects on health indicators in Dutch adolescents. Health Serv Res 2008 ; 43 ( 5p1 ): 1708 – 1721
124.
Till B, Tran US, Voracek M, et al : Beneficial and harmful effects of educative suicide prevention websites: randomised controlled trial exploring Papageno v Werther effects. Br J Psychiatry 2017 ; 211 : 109 – 115
125.
Hetrick SE, Yuen HP, Bailey E, et al : Internet-based cognitive behavioural therapy for young people with suicide-related behaviour (Reframe-IT): a randomised controlled trial. Evid Based Ment Health 2017 ; 20 : 76 – 82
126.
Franklin JC, Fox KR, Franklin CR, et al : A brief mobile app reduces nonsuicidal and suicidal self-injury: evidence from three randomized controlled trials. J Consult Clin Psychol 2016 ; 84 : 544 – 557
127.
Reisch T, Steffen T, Habenstein A, et al : Change in suicide rates in Switzerland before and after firearm restriction resulting from the 2003 “Army XXI” reform. Am J Psychiatry 2013 ; 170 : 977 – 984
128.
Sarchiapone M, Mandelli L, Iosue M, et al : Controlling access to suicide means. Int J Environ Res Public Health 2011 ; 8 : 4550 – 4562
129.
Vijayakumar L, Jeyaseelan L, Kumar S, et al : A central storage facility to reduce pesticide suicides: a feasibility study from India. BMC Public Health 2013 ; 13 : 850
130.
Thompson AJ : Gun violence in the United States: a public health epidemic, in Public Health: Social and Behavioral Health. Edited by Maddock J. London, Intech, 2012, pp 501 – 522
131.
Anglemyer A, Horvath T, Rutherford G : The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med 2014 ; 160 : 101 – 110
132.
Mann JJ, Michel CA : Prevention of firearm suicide in the United States: what works and what is possible. Am J Psychiatry 2016 ; 173 : 969 – 979
133.
Andrés AR, Hempstead K : Gun control and suicide: the impact of state firearm regulations in the United States, 1995–2004. Health Policy 2011 ; 101 : 95 – 103
134.
McGinty EE, Webster DW, Barry CL : Gun policy and serious mental illness: priorities for future research and policy. Psychiatr Serv 2014 ; 65 : 50 – 58
135.
McPhedran S, Baker J : Suicide prevention and method restriction: evaluating the impact of limiting access to lethal means among young Australians. Arch Suicide Res 2012 ; 16 : 135 – 146
136.
Thomsen AH, Gregersen M : Suicide by carbon monoxide from car exhaust gas in Denmark 1995–1999. Forensic Sci Int 2006 ; 161 : 41 – 46
137.
Pirkis J, Spittal MJ, Cox G, et al : The effectiveness of structural interventions at suicide hotspots: a meta-analysis. Int J Epidemiol 2013 ; 42 : 541 – 548
138.
Gunnell D, Eddleston M, Phillips MR, et al : The global distribution of fatal pesticide self-poisoning: systematic review. BMC Public Health 2007 ; 7 : 357
139.
Knipe DW, Chang S-S, Dawson A, et al : Suicide prevention through means restriction: impact of the 2008–2011 pesticide restrictions on suicide in Sri Lanka. PLoS One 2017 ; 12 : e0172893
140.
Anestis MD, Houtsma C : The association between gun ownership and statewide overall suicide rates. Suicide Life Threat Behav 2018 ; 48 : 204 – 217
141.
Chapman S, Alpers P, Agho K, et al : Australia’s 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev 2006 ; 12 : 365 – 372
142.
Routley V : Motor vehicle exhaust gas suicide: review of countermeasures. Crisis 2007 ; 28 ( suppl 1 ): 28 – 35
143.
Cavanagh JT, Carson AJ, Sharpe M, et al : Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003 ; 33 : 395 – 405
144.
Niederkrotenthaler T, Logan JE, Karch DL, et al : Characteristics of US suicide decedents in 2005–2010 who had received mental health treatment. Psychiatr Serv 2014 ; 65 : 387 – 390
145.
Piscopo K, Lipari R, Cooney J, et al : Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review, September 2016 ( https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm)
146.
Gibbons RD, Hur K, Brown CH, et al : Gabapentin and suicide attempts. Pharmacoepidemiol Drug Saf 2010 ; 19 : 1241 – 1247
147.
Gould MS, Marrocco FA, Kleinman M, et al : Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA 2005 ; 293 : 1635 – 1643
148.
Allen NB, Nelson BW, Brent D, et al : Short-term prediction of suicidal thoughts and behaviors in adolescents: can recent developments in technology and computational science provide a breakthrough? J Affect Disord 2019 ; 250 : 163 – 169
149.
Torous J, Larsen ME, Depp C, et al : Smartphones, sensors, and machine learning to advance real-time prediction and interventions for suicide prevention: a review of current progress and next steps. Curr Psychiatry Rep 2018 ; 20 : 51
150.
Barak-Corren Y, Castro VM, Javitt S, et al : Predicting suicidal behavior from longitudinal electronic health records. Am J Psychiatry 2017 ; 174 : 154 – 162
151.
Malik S, Kanwar A, Sim LA, et al : The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev 2014 ; 3 : 18
152.
Borges G, Cherpitel CJ, Orozco R, et al : A dose-response estimate for acute alcohol use and risk of suicide attempt. Addict Biol 2017 ; 22 : 1554 – 1561
153.
van Spijker BA, Majo MC, Smit F, et al : Reducing suicidal ideation: cost-effectiveness analysis of a randomized controlled trial of unguided web-based self-help. J Med Internet Res 2012 ; 14 : e141
154.
Daigle MS : Suicide prevention through means restriction: assessing the risk of substitution: a critical review and synthesis. Accid Anal Prev 2005 ; 37 : 625 – 632
155.
Yip PS, Caine E, Yousuf S, et al : Means restriction for suicide prevention. Lancet 2012 ; 379 : 2393 – 2399
156.
Kreitman N : The coal gas story: United Kingdom suicide rates, 1960–71. Br J Prev Soc Med 1976 ; 30 : 86 – 93
157.
Miller M, Hemenway D : The relationship between firearms and suicide: a review of the literature. Aggress Violent Behav 1999 ; 4 : 59 – 75
158.
Gunnell D, Eddleston M : Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. Int J Epidemiol 2003 ; 32 : 902 – 909
159.
Gunnell D, Fernando R, Hewagama M, et al : The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol 2007 ; 36 : 1235 – 1242
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Received: 16 June 2020
Revision received: 8 September 2020
Accepted: 2 November 2020
Published online: 18 February 2021
Published in print: July 2021
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Dr. Mann receives royalties from the Research Foundation for Mental Hygiene for commercial use of the Columbia-Suicide Severity Rating Scale. Dr. Auerbach is a member of the Research Grants Committee for the American Foundation for Suicide Prevention. Ms. Michel reports no financial relationships with commercial interests.Funding from NIMH provided partial support for Dr. Mann (grant 5P50MH090964) and Dr. Auerbach (grant U01MH108168) in the preparation of this manuscript.
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