Preventing suicide at suicide hotspots: a case study from Australia

The Effect of Explicit Suicide Language in Engagement With a Suicide Prevention Search Page Help-Seeking Prompt: Nonrandomized Trial

BACKGROUND

Given that signage, messaging, and advertisements (ads) are the gateway to many interventions in suicide prevention, it is important that we understand what type of messaging works best for whom.

OBJECTIVE

We investigated whether explicitly mentioning suicide increases engagement using internet ads by investigating engagement with campaigns with different categories of keywords searched, which may reflect different cognitive states.

METHODS

We ran a 2-arm study Australia-wide, with or without ads featuring explicit suicide wording. We analyzed whether there were differences in engagement for campaigns with explicit and nonexplicit ads for low-risk (distressed but not explicitly suicidal), high-risk (explicitly suicidal), and help-seeking for suicide keywords.

RESULTS

Our analyses revealed that having explicit wording has opposite effects, depending on the search terms used: explicit wording reduced the engagement rate for individuals searching for low-risk keywords but increased engagement for those using high-risk keywords.

CONCLUSIONS

The findings suggest that individuals who are aware of their suicidality respond better to campaigns that explicitly use the word "suicide." We found that individuals who search for low-risk keywords also respond to explicit ads, suggesting that some individuals who are experiencing suicidality search for low-risk keywords.

A Spatial Analysis of Suicide Displacement at a High-Risk Cliff-Based Location Following Installation of a Means Restriction Initiative

Means restriction interventions are recognised as highly effective for the deterrence of suicide attempts by jumping. While such interventions can lead to significant reductions in suicide, it is unclear whether these reductions represent a displacement effect, whereby individuals are instead choosing to attempt suicide at other nearby locations which offer the same means. The potential displacement of suicides as an unintended consequence of means restriction has been relatively unexplored to date. The only studies exploring displacement effects have focused on bridges, which are relatively easily contained sites; no studies have yet explored displacement effects at cliff-based high risk suicide locations (hotspots). Using Australian coronial data for the period of 2006-2019, we undertook joinpoint and kernel density analysis of suicides by jumping at a well-known cliff-based hotspot in Sydney, Australia, to determine whether there was evidence of displacement to local and broader surrounding cliffs following the installation of a multi-component harm minimization intervention (the Gap Park Masterplan). While slight decreases were noted in the immediate area subject to the structural intervention in the post-implementation period, alongside slight increases in the surrounding cliffs, there was no evidence for statistically significant changes. While kernel density analyses did not identify the emergence of any new hotspot locations in the post-implementation period, three existing hotspot sites of concern were found in our total area of interest, with greater than expected growth in the density of one of the hotspots. While we found no persuasive evidence of displacement, ongoing monitoring of the cliff-based location where the structural interventions were implemented is needed to ensure the ongoing safety of the area.

Cost-effectiveness of Installing Barriers at Bridge and Cliff Sites for Suicide Prevention in Australia

IMPORTANCE

Installation of barriers has been shown to reduce suicides. To our knowledge, no studies have evaluated the cost-effectiveness of installing barriers at multiple bridge and cliff sites where suicides are known to occur.

OBJECTIVE

To examine the cost-effectiveness of installing barriers at bridge and cliff sites throughout Australia.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used an economic model to examine the costs, costs saved, and reductions in suicides if barriers were installed across identified bridge and cliff sites over 5 and 10 years. Specific and accessible bridge and cliff sites across Australia that reported 2 or more suicides over a 5-year period were identified for analysis. A partial societal perspective (including intervention costs and monetary value associated with preventing suicide deaths) was adopted in the development of the model.

INTERVENTIONS

Barriers installed at bridge and cliff sites.

MAIN OUTCOMES AND MEASURES

Primary outcome was return on investment (ROI) comparing cost savings with intervention costs. Secondary outcomes included incremental cost-effectiveness ratio (ICER), comprising the difference in costs between installation of barriers and no installation of barriers divided by the difference in reduction of suicide cases. Uncertainty and sensitivity analyses were undertaken to examine the association of changes in suicide rates with barrier installation, adjustments to the value of statistical life, and changes in maintenance costs of barriers.

RESULTS

A total of 7 bridges and 19 cliff sites were included in the model. If barriers were installed at bridge sites, an estimated US $145 million (95% uncertainty interval [UI], $90 to $160 million) could be saved in prevented suicides over 5 years, and US $270 million (95% UI, $176 to $298 million) over 10 years. The estimated ROI ratio for building barriers over 10 years at bridges was 2.4 (95% UI, 1.5 to 2.7); the results for cliff sites were not significant (ROI, 2.0; 95% UI, -1.1 to 3.8). The ICER indicated monetary savings due to averted suicides over the intervention cost for bridges, although evidence for similar savings was not significant for cliffs. Results were robust in all sensitivity analyses except when the value of statistical life-year over 5 or 10 years only was used.

CONCLUSIONS AND RELEVANCE

In an economic analysis, barriers were a cost-effective suicide prevention intervention at bridge sites. Further research is required for cliff sites.

An analysis of the impact of suicide prevention messages and memorials on motorway bridges

Recently, there has been activity at public locations where people have died by suicide, including the erection of suicide prevention messages and memorials (decorations). This research looks at the impact of these decorations and associated media coverage of the decorations on suicidal behaviour at bridges. Incidents (n = 160) of suicidal behaviour on 26 bridges across motorways in England were analysed. Overall, there was no significant difference in the proportion of incidents pre-decoration versus post-decoration (p-value = .55). The incident rates were not significantly different pre- and post-decoration (p = .46). Only one bridge had statistically significantly more incidents post-decoration and media reporting (p = .03). However, following correction for multiple testing there was no significant difference in pre- and post-incident rates at any of the bridges. In total, 58% of bridges had a greater frequency of incidents when decorations were absent; however, this proportion was not statistically significant (p = .41). Further research is required to establish how suicide prevention messages are perceived. There does not appear to be any benefit, but it often generates media coverage which has been shown to increase risk.

Intervento. La prevenzione del suicidio e l'accesso a metodi letali

La ricerca mostra che i tassi di suicidio sono collegati alla disponibilità di mezzi letali. Ad esem-pio, è stato dimostrato che l'installazione di barriere di sicurezza sui ponti notoriamente usati dai suicidi ha un effetto preventivo senza che vi sia ricorso ad altre modalità suicidarie, e che la rimo-zione di queste barriere porta a un aumento di suicidi. Allo stesso modo, limitazioni della vendita di pesticidi e dell'accesso ai pesticidi utilizzando contenitori chiusi a chiave sono correlate con la diminuzione dei tassi di suicidio per ingestione di pesticidi. Inoltre, dato che è più facile ingerire una quantità significativa di pillole direttamente dal flacone che estraendole una per una dal blister, la diffusione di confezioni di pillole in blister ha ridotto i tentativi di suicidio con questo metodo. Questi sono solo alcuni esempi. Si ritiene che altri approcci simili contribuiscano in modo signifi-cativo alla prevenzione del suicidio.

The Use of Closed-Circuit Television and Video in Suicide Prevention: Narrative Review and Future Directions

BACKGROUND

Suicide is a recognized public health issue, with approximately 800,000 people dying by suicide each year. Among the different technologies used in suicide research, closed-circuit television (CCTV) and video have been used for a wide array of applications, including assessing crisis behaviors at metro stations, and using computer vision to identify a suicide attempt in progress. However, there has been no review of suicide research and interventions using CCTV and video.

OBJECTIVE

The objective of this study was to review the literature to understand how CCTV and video data have been used in understanding and preventing suicide. Furthermore, to more fully capture progress in the field, we report on an ongoing study to respond to an identified gap in the narrative review, by using a computer vision-based system to identify behaviors prior to a suicide attempt.

METHODS

We conducted a search using the keywords "suicide," "cctv," and "video" on PubMed, Inspec, and Web of Science. We included any studies which used CCTV or video footage to understand or prevent suicide. If a study fell into our area of interest, we included it regardless of the quality as our goal was to understand the scope of how CCTV and video had been used rather than quantify any specific effect size, but we noted the shortcomings in their design and analyses when discussing the studies.

RESULTS

The review found that CCTV and video have primarily been used in 3 ways: (1) to identify risk factors for suicide (eg, inferring depression from facial expressions), (2) understanding suicide after an attempt (eg, forensic applications), and (3) as part of an intervention (eg, using computer vision and automated systems to identify if a suicide attempt is in progress). Furthermore, work in progress demonstrates how we can identify behaviors prior to an attempt at a hotspot, an important gap identified by papers in the literature.

CONCLUSIONS

Thus far, CCTV and video have been used in a wide array of applications, most notably in designing automated detection systems, with the field heading toward an automated detection system for early intervention. Despite many challenges, we show promising progress in developing an automated detection system for preattempt behaviors, which may allow for early intervention.

Geospatial suicide clusters and emergency responses: An analysis of text messages to a crisis service

Suicide is a leading cause of death globally, and certain locations experience clusters of increased frequencies of suicidal behaviours. Prevention efforts are warranted in these locations to prevent contagion effects, and there is increasing interest in technology-supported suicide prevention interventions. Crisis support services are also implementing online and mobile health support. This study investigated the relationship between geospatial suicide clusters in the US and service use, and emergency responses initiated by, a text message-based crisis support service. 103,570 conversations involving 64,391 unique users over a two-year period were de-identified, analysed, and mapped to the state and county level. Moderate correlations were observed between service user rate and suicide mortality (ρ=0.53), and active rescues and suicide mortality (ρ=0.46). Suicide clusters were associated with a non-significant increase in service use (p=0.06) and active rescues (p=0.48). While it was not possible to observe significant cluster effects within this dataset, future analysis involving data collected through mobile health platforms may lead to better identification of risk at an individual level.

Means restriction for the prevention of suicide by jumping

BACKGROUND

Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established.

OBJECTIVES

To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures.

SEARCH METHODS

We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions.

SELECTION CRITERIA

Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach.

MAIN RESULTS

We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I2 = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I2 = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I2 = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I2 = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I2 = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality.

AUTHORS' CONCLUSIONS

The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

A suicide prevention initiative at a jumping site: A mixed-methods evaluation

BACKGROUND

Gap Park in Sydney, Australia has historically been recognised as a suicide jumping site. In 2010-2011 the Gap Park Masterplan initiative implemented a series of suicide prevention measures. This study applied a mixed-methods design to evaluate the effectiveness of the Masterplan in reducing suicides.

METHODS

Data from the Australian National Coronial Information System (NCIS) was examined to compare suicides at Gap Park before and after the Masterplan was implemented. This was complemented with qualitative data from interviews with police officers who respond to suicidal behaviours at Gap Park.

FINDINGS

Joinpoint analysis of NCIS data showed a non-significant upward trend in jumping suicides during the study period. A significant upward trend in suicides was seen for females before the implementation of the Masterplan (2000-2010), followed by a significant downward trend from the implementation period onwards (2010-2016) for females: however, a non-significant upward trend for males was observed. Qualitative analysis of police interviews identified six key themes: romanticism and attraction at hotspots, profiles and behavioural patterns of suicidal individuals, responding to a person in a suicidal crisis, repeat attempts, means restriction, and personal impacts on police officers.

INTERPRETATION

The mixed-method study provided important insights, suggesting the Gap Park Masterplan has contributed to a reduction in female, but not in male jumping suicides. Further qualitative information from police officers suggested that the safety barriers were not difficult to climb, and may be more of a visual or psychological barrier. However, the effectiveness of CCTV and alarms in the detection and location of suicide attempters was highlighted.

FUNDING

Lifeline Research Foundation.

Trends in suicide-related research in Australia

Background

Despite continuous research over the past 20 years in Australia there is still limited understanding of what works and what does not work in suicide prevention and where to invest research efforts that will help to expand this knowledge base. There is a recursive relationship between research activities, knowledge gain and the development of strategy and action plans as these in turn guide future decisions on research funding. In this context, the first step to continuous improvement in knowledge is to better understand where research has been invested in the past until now and where it has not.

Methods

We conducted a study that collected data over two periods. The first data collection was done in 2006 for the period of 1999 to 2006 and the second data collection was in 2017 for the period from 2010 to 2017. This allowed us to examine changes in published suicide-related journal articles, and grants/fellowships funded between the two periods. Published articles and grants/fellowships were classified according to a pre-determined framework.

Results

The number of suicide-related articles and grants/fellowships increased over the two periods. We noted shifts in the types of research that were funded and published, and in the emphasis that was given to different types of suicidal behavior, suicide methods, and settings. Research target groups showed a trend towards increasing diversification.

Conclusions

Our findings help to identify current research priorities and inform where future priorities for suicide-related research in Australia lie by linking findings to other external data sources (population risk data, stakeholder consultations, national strategies and action plan documents).

Interventions to reduce suicides at suicide hotspots: a systematic review and meta-analysis

BACKGROUND

Various interventions have been introduced to try to prevent suicides at suicide hotspots, but evidence of their effectiveness needs to be strengthened.

METHODS

We did a systematic search of Medline, PsycINFO, and Scopus for studies of interventions, delivered in combination with others or in isolation, to prevent suicide at suicide hotspots. We did a meta-analysis to assess the effect of interventions that restrict access to means, encourage help-seeking, or increase the likelihood of intervention by a third party.

FINDINGS

We identified 23 articles representing 18 unique studies. After we removed one outlier, interventions that restricted access to means were associated with a reduction in the number of suicides per year (incidence rate ratio 0.09, 95% CI 0.03-0.27; p<0.0001), as were interventions that encourage help-seeking (0.49, 95% CI 0.29-0.83; p=0.0086), and interventions that increase the likelihood of intervention by a third party (0.53, 95% CI 0.31-0.89; p=0.0155). When we included only those studies that assessed a particular intervention in isolation, restricting access to means was associated with a reduction in the risk of suicide (0.07, 95% CI 0.02-0.19; p<0.0001), as was encouraging help-seeking (0.39, 95% CI 0.19-0.80; p=0.0101); no studies assessed increasing the likelihood of intervention by a third party as a lone intervention.

INTERPRETATION

The key approaches that are currently used as interventions at suicide hotspots seem to be effective. Priority should be given to ongoing implementation and assessment of initiatives at suicide hotspots, not only to prevent so-called copycat events, but also because of the effect that suicides at these sites have on people who work at them, live near them, or frequent them for other reasons.

FUNDING

National Health and Medical Research Council, Commonwealth Department of Health.