Suicide prevention: Research on successful interventions

 
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As suicide rates rise in the United States, researchers have been working to identify approaches to curb the trend. 

This roundup looks at recent publications in the field of suicide prevention research.

The findings are organized by risk group, an approach endorsed by Cheryl King, a professor in the University of Michigan Medical School’s department of psychiatry. Behind this structure is the understanding that different populations exist in different contexts with respect to access to and provision of health care.

As an example, King compared youth and veterans: youth require family permission for health care, and veterans generally have the option of seeking health care from an entirely separate system than the civilian population. This means “there are differences in the interventions, in the approaches we take,” she explained in a phone call with Journalist’s Resource.

The research below includes a sampling of successful strategies for suicide prevention for certain risk groups including men, the military, the incarcerated, youth and the elderly. Some of these studies have small sample sizes; thus journalists should seek guidance from researchers in explaining the implications of the findings and whether they can be generalized beyond these limited groups of study participants.

It’s worth noting that while individuals who are sexual and gender minorities have higher rates of suicide risk than their heteronormative peers, research on interventions targeted to this specific risk group is lacking. “Several types of suicide prevention programs have been developed for use in the general population, though none are specific to SGM [sexual and gender minority] individuals,” Alexandra Marshall, assistant professor at the University of Arkansas for Medical Sciences’ Fay W. Boozman College of Public Health, writes in a perspective article about the issue.

Men

Gun Control and Suicide: The Impact of State Firearm Regulations in the United States, 1995–2004
Andrés, Antonio Rodríguez; Hempstead, Katherine. Health Policy, June 2011.

The intervention: Gun control

“Means restriction” is a term for suicide prevention strategies that focus on reducing access to lethal means, such as firearms. For men, firearms are the most common lethal mechanism of suicide. This study looks at how suicide rates among men changed after states passed a variety of firearm regulations, including permit requirements, prohibitions on purchases by minors, prohibitions based on behavioral problems and prohibitions based on past criminal offenses, between 1995 and 2004.

The findings:

  • “General barriers to firearm access created through state regulation can have a significant effect on male suicide rates in the United States.”       
  • The most effective gun control policies with respect to suicide rates were those that reduced overall gun availability, including permit requirements and bans on sales to minors.
  • Gun control policies that tried to keep high risk individuals from possessing firearms had less of an effect on suicide rates. For instance, drug and alcohol misdemeanor conviction bans did not significantly impact suicide rates and prohibitions related to mental health concerns were only significant for men between the ages of 25 and 44.

The Effect of Public Awareness Campaigns on Suicides: Evidence from Nagoya, Japan
Matsubayashi, Tetsuya; Ueda, Michiko; Sawada, Yasuyuki. Journal of Affective Disorders, January 2014.

The intervention: Public awareness campaigns

This study looks at the relationship between suicide rates and a campaign meant to increase public awareness of depression and encourage people to seek help. The study took place over two years in Nagoya, Japan, which in 2010 had a suicide rate of 20.3 per 100,000 people.

The findings:

  • Wards of the city that had more frequent distributions of the promotional pamphlet about depression symptoms and mental health resources saw decreases in the number of suicides in the following months.
  • Suicide rates among men in particular decreased following the public awareness campaign.

Military

Effect of Crisis Response Planning vs. Contracts for Safety on Suicide Risk in U.S. Army Soldiers: A Randomized Clinical Trial
Bryan, Craig J.; et al. Journal of Affective Disorders, April 2017.

The intervention: Crisis planning

In crisis response planning, individuals develop strategies for handling personal crises. These plans identify individualized warning signs, outline coping strategies and highlight social supports and professional services. This study compared the efficacy of crisis response planning as compared with safety contracts. “The crisis response plan therefore outlines what to do during a crisis,” the authors write, “an approach that sharply contrasts with the contract for safety, which outlines what not to do during a crisis (i.e., engage in suicidal behavior).” This study compared the two approaches on 97 active duty U.S. Army soldiers receiving emergency behavioral health services. Of this group, 32 completed safety contracts while 65 created crisis response plans. Participants were then followed for 6 months after this initial intervention. The sample was 78 percent male and participants ranged from 19 to 53 years of age.

The findings:

  • In the six-month follow-up period after the initial intervention, three participants who received a crisis response plan attempted suicide (5 percent of the planning group) compared to five participants who received safety contracts (19 percent of the contract group).
  • “Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty soldiers.”

Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department
Stanley, Barbara; et al. JAMA Psychiatry, July 2018.

The intervention: The Safety Planning Intervention (SPI)

The Safety Planning Intervention is another crisis response planning tool. Five emergency departments in hospitals run by the federal Veterans Health Administration administered the trial protocol. Four control sites — also VHA emergency rooms — followed their usual care protocols, which were not standardized across sites, but which “generally consisted of an initial assessment by a nurse or social worker followed by a secondary evaluation by an [emergency department] physician.” Patients were provided with medical care and medications as needed. They did not receive a safety plan.

Over the study period, which lasted from 2010 to 2015, 1,186 patients were admitted to intervention sites for suicidal behavior, and 454 were admitted to control sites. Patients admitted from the emergency room into inpatient care were not included in the study. The researchers note that this exclusion criteria limited “the range of suicidality … to a lower-risk population.”

The SPI consisted of six steps:

  1. Identify personalized warning signs;
  2. Determine internal coping strategies;
  3. Identify family and friends who can help;
  4. Identify other individuals who can provide support;
  5. List mental health professionals to contact;
  6. Counsel patients on how they can make their environments safer.

Additionally, in the intervention group, patients were contacted at least twice through telephone follow-ups to monitor risk and go over the SPI.

The findings:

  • The SPI was associated with 45 percent fewer patients attempting suicide in the follow-up period as compared with usual care, “approximately halving the odds of suicidal behavior over six months,” the researchers write.
  • Patients in the experimental group also had over double the odds of utilizing outpatient mental health services.

A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality Versus Enhanced Care as Usual with Suicidal Soldiers
Jobes, David A.; et al. Psychiatry, 2017.

The intervention: Collaborative Assessment and Management of Suicidality (CAMS)

CAMS is described as “an empathic and collaborative assessment and treatment-planning approach to suicide risk throughout care.” It involves restricting access to lethal means and fostering coping strategies. “CAMS also targets and treats patient-defined suicidal ‘drivers’ using appropriate clinical interventions (e.g., exposure treatment for a posttraumatic stress disorder [PTSD]-related driver or couples therapy for a marriage-related driver). CAMS is concluded after three consecutive sessions when suicidal thoughts, feelings, and behaviors are successfully managed per CAMS resolution criteria.”

This study involved 148 active-duty U.S. Army soldiers experiencing significant suicidal ideation. Most of the soldiers were male (80 percent). Soldiers received either CAMS or the usual care (“typical treatment provided by on-site military clinical social workers. These clinicians had a broad range of training experiences and approaches to working with the Soldiers, who were randomized to their care.”). The soldiers were followed for a year after recruitment, which was completed in 2014. The data collection phase of the study ended in 2016.

Key findings:

  • Both treatment groups saw improvement.
  • However, soldiers receiving CAMS were less likely to have suicidal thoughts three months after baseline as compared to the usual care group.

The elderly

A Systematic Review of Interventions to Prevent Suicidal Behaviors and Reduce Suicidal Ideation in Older People
Okolie, Chukwudi; et al. International Psychogeriatrics, November 2017.

The intervention: Primary care-based depression screening

This review looks at 21 studies of interventions to prevent suicide among older adults. The most effective were two large, primary care-based trials that involved multiple hospitals. These interventions featured a collaborative care model in which “depression care managers” worked with primary care physicians to monitor symptoms, administer treatment and otherwise support the doctors.

Key findings:

  • Of all of the included interventions, the primary care-based screening and depression management programs were most effective.
  • “The primary care setting is a good opportunity for suicide prevention intervention, as most suicides are known to have had contact with a primary care physician within a month of death,” the authors write. “Primary care offers the possibility of suicide prevention through improved recognition and detection of depression along with the optimization of depression management though collaborative care.”
  • Other interventions included in the review also were effective, though to a lesser degree. These interventions included therapy, medication, telephone counseling, group activities and community-based suicide prevention programs.

Youth and teens

Association of the Youth-Nominated Support Team Intervention for Suicidal Adolescents With 11- to 14-Year Mortality Outcomes
King, Cheryl A.; et al. JAMA Psychiatry, February 2019.

The intervention: Youth-nominated support teams

Teens aged 13 to 17 who had been hospitalized for a suicide attempt or suicidal ideation were asked to select “caring adults” to support them after hospitalization. The adults were trained in suicide warning signs and treatment support strategies. The adults also received weekly phone calls from support staff for three months. The researchers were interested in the survival outcomes for the teens who had these support teams 11 to 14 years after their hospitalization as compared to those who received treatment but did not have self-appointed support teams. A total of 448 adolescents were followed through the study from 2002 through 2016. The adolescents were recruited from either a university psychiatric hospital or private psychiatric hospital in the United States.

The findings:

  • There were two deaths in the support team group — one homicide and one suicide — out of a sample of 223. There were 13 deaths in the group without support teams, including eight that were either by suicide or were drug-related deaths with unknown intent, out of a sample of 225.
  • The control group had a 6.6-fold increased risk of death compared to the support team group.
  • The support team intervention was “shown to be a safe intervention with no associated negative outcomes.”

Cognitive-Behavioral Family Treatment for Suicide Attempt Prevention: A Randomized Controlled Trial
Asarnow, Joan R.; et al. Journal of the American Academy of Child & Adolescent Psychiatry, June 2017.

The intervention: Family treatment

The Safe Alternatives for Teens and Youth (SAFETY) study involved “a cognitive-behavioral, dialectical behavior therapy-informed family treatment designed to promote safety.”

Here’s what that means in practice: “Two therapists work with each family; one therapist focuses primarily on the youth, and the other focuses on the parents or caregivers (hereafter referred to as parents). Sessions begin with simultaneous individual youth and parent components with their respective therapists, and conclude with all participants coming together to practice skills and to address identified issues.”

The researchers compared the SAFETY intervention to “[outpatient] treatment as usual enhanced by parent education and support accessing community treatment.” The study occurred between 2011 and 2015 and the sample included 42 youths between the ages of 12 and 18 with recent suicide attempts or other self-harm.

The findings:

  • SAFETY participants had a “significantly higher probability of survival without a suicide attempt” at the 3-month follow-up compared with the participants who received the usual treatment.
  • “This is the second randomized trial to demonstrate that treatment including cognitive behavioral and family components can provide some protection from suicide attempt risk in these high-risk youths,” the authors conclude.

The SOS Suicide Prevention Program: Further Evidence of Efficacy and Effectiveness
Schilling, Elizabeth A.; Aseltine, Robert H.; James, Amy. Prevention Science, February 2016.

The intervention: A school-based prevention program

The Signs of Suicide (SOS) prevention program teaches students to identify the warning signs of suicide risk and seek help from adults if they or their friends are displaying these signs. Part of the program includes completing an optional self-administered depression screening with the goal of “rais[ing] students’ awareness of the symptoms of depression in others and of their own level of depressive symptomatology.” Students with scores above the cut-off are encouraged to seek help. In Connecticut, 17 high schools implemented the program. The researchers measured self-reported suicide attempts before and three months after the program, comparing responses between students who had participated and those who had not.

The findings:                   

  • “After controlling for the pre-test reports of suicide behaviors, exposure to the SOS program was associated with significantly fewer self-reported suicide attempts in the three months following the program. Ninth grade students in the intervention group were approximately 64 percent less likely to report a suicide attempt in the past three months compared with students in the control group.”
  • “Similarly, exposure to the SOS program resulted in greater knowledge of depression and suicide and more favorable attitudes toward (1) intervening with friends who may be exhibiting signs of suicidal intent and (2) getting help for themselves if they were depressed or suicidal.”
  • “In addition, high-risk SOS participants, defined as those with a lifetime history of suicide attempt, were significantly less likely to report planning a suicide in the three months following the program compared to lower-risk participants.”

Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide
McCauley, Elizabeth; et al. JAMA Psychiatry, August 2018.

The intervention: Dialectical behavioral therapy

Dialectical behavioral therapy (DBT) is a form of cognitive behavioral therapy that has a focus on “teaching skills for enhancing emotion regulation, distress tolerance, and building a life worth living.” This study involved 173 adolescents between the age of 12 to 18 who had at least one suicide attempt over their lifetime and elevated suicidal ideation over the past month. Participants received either six months of weekly individual and group therapy; the treatment group received dialectical behavioral therapy and the control received individual and group supportive therapy.

The findings:

  • Dialectical behavioral therapy was more effective in reducing self-harm and suicide attempts than the control treatment group. In the DBT group, 9.7 percent attempted suicide from baseline to six months, compared with 21.5 percent in the individual and group supportive therapy arm.
  • However, “because youths in both groups improved over time,” the advantages conferred by DBT decreased longitudinally – at 12 months follow up, there were no significant differences between the two groups.

The incarcerated

Cognitive–Behavioral Suicide Prevention for Male Prisoners: A Pilot Randomized Controlled Trial
Pratt, Daniel; et al. Psychological Medicine, December 2015.

The intervention: Cognitive behavioral therapy

Cognitive behavioral therapy is a type of psychotherapy that stems from the idea that thoughts and behaviors influence emotions – thus, it operates by encouraging individuals to challenge thoughts and change behaviors that are tied to their mental distress. At a male prison in England, 31 suicidal inmates received cognitive-behavioral therapy while 31 of their suicidal peers received the usual treatment, which was not standardized but could include “psychotropic medication and nursing support.” The length of treatment was 6 months. Overall, participants ranged in age from 21 to 60 years old, the average age was 35. Most of the participants were white (85 percent).

The findings:

  • Cognitive behavioral therapy was more effective in reducing self-injurious behavior, suicidal ideation, and other suicidal behaviors as compared with the usual treatment.
  • Over half of the participants receiving cognitive behavioral therapy “achieved a clinically significant recovery by the end of therapy.” One-quarter of the group who received the usual treatment achieved recovery.

Children in juvenile detention

Biopsychosocial Causes of Suicide and Suicide Prevention Outcome Studies in Juvenile Detention Facilities: A Review
Joshi, Kshamta; Billick, Stephen B. Psychiatric Quarterly, March 2017.

The intervention: Suicide risk screening

One strategy for suicide prevention involves screening individuals to determine who is most at risk. This review of the research on suicide in juvenile detention facilities looks at the efficacy of screening as an intervention.

The findings:                                                      

  • “Various studies, based on their findings, have suggested that routine suicide screening protocols at the time of intake and periodically during incarceration are prudent practices,” the authors write. For example, one study included in the review found that if all youths in a facility were screened within the first 24 hours of their arrival, there was a lower incidence of suicide attempts. “Similarly, the odds of suicide attempt increase if only some portion of the facility’s population is screened within a 2–7 day time frame since their arrival.”

Other strategies

Lithium in Drinking Water and Suicide Prevention: A Review of the Evidence
Vita, Antonio; De Peri, Luca; Sacchetti, Emilio. International Clinical Psychopharmacology, January 2015.

The intervention: Lithium in the water supply

Lithium is a chemical element and a treatment for a number of mental health conditions. Research suggests that lithium is effective at reducing suicide mortality in both short- and long-term treatment. Lithium is also naturally present in drinking water in some areas. This research review assessed whether areas with higher lithium levels in the drinking water had lower suicide rates in the general population.

The findings:

  • A number of recent studies present consistent findings that higher levels of lithium in drinking water are correlated with lower suicide rates.
  • However, the potential mechanism of action underlying this relationship is not known.
  • Further, even higher levels of lithium in drinking water are much lower than the therapeutic dose for humans. “Explication of the findings that even the very low levels of lithium provided in drinking water may reduce the risk of suicide is, at present, only speculative,” the authors write.

Long Term Effect of Reduced Pack Sizes of Paracetamol on Poisoning Deaths and Liver Transplant Activity in England and Wales: Interrupted Time Series Analyses
Hawton, Keith; et al. British Medical Journal, February 2013.

The intervention: Reducing quantities of over-the-counter acetaminophen available for purchase

Acetaminophen (known by the brand name Tylenol in the U.S. and called paracetamol in the United Kingdom), is an over-the-counter pain reliever that, if consumed in large quantities, can severely damage the liver and lead to death. Because the drug is sometimes used as a method of suicide, the United Kingdom government passed legislation in September 1998 to reduce the quantity sold per package over the counter (pharmacies can sell up to 32 pills per package; non-pharmacy retailers can sell up to 16). To understand the effects of this policy, researchers looked at the number of deaths per quarter in England and Wales involving acetaminophen before and after the legislation was passed.

Key findings:

  • After the legislation passed, acetaminophen-related deaths fell by an average of 17 per quarter in England and Wales.
  • “This decrease represented a 43 percent reduction or an estimated 765 fewer deaths over the 11 ¼ years after the legislation.”

Interventions to Reduce Suicides at Suicide Hotspots: A Systematic Review and Meta-Analysis
Pirkis, Jane; et al. The Lancet, November 2015.

The intervention: Reducing access to suicide hotspots

“Suicide hotspots are specific, accessible, and usually public sites which are frequently used as locations for suicide and gain reputations as such,” the authors of this review write. Such hotspots include bridges and forests. Do interventions to prevent suicides at these hotspots work? The authors looked at the evidence from 23 articles to assess their effectiveness.

Key findings:

  • Restricting access through barriers and other means, encouraging people to seek help through signage and crisis telephones at the hotspot, and establishing a greater chance of third-party intervention through additional staffing, a police presence, or Closed Circuit TV monitoring all worked to reduce the number of suicides per year at the hotspots where these interventions were tested.

Looking for more research? We covered a study that shows how many soldiers who attempt suicide have no prior mental health diagnosis. We also collected research that looks at how the news media affects suicide trends and wrote about research that highlights recent trends in injury-related deaths. For guidelines about reporting on suicide, University of Pennsylvania’s Annenberg Public Policy Center has recommendations at ReportingonSuicide.org.

Last updated: February 25, 2019

 

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