Suicide attempts: prevention of repetition

Assessment of risk factors for suicidal behavior: results from the Tehran University of Medical Sciences Employees' Cohort study

Introduction

Suicide is a major issue of concern for public health. It is estimated that suicide accounts for 700,000 deaths every year. A personal history of one or more suicide attempts is the most important determinant of suicide among the general population. This study aimed to assess the major risk factors associated with suicidal behaviors among Iranian employees in a medical setting.

Methods

In this study, 3,913 employees of Tehran University of Medical Sciences who participated in the employees' cohort study conducted by the university were recruited. Suicidal behaviors (SBs) and their associated risk factors were evaluated using the World Mental Health Composite International Diagnostic Interview (CIDI) Version 3.0. Univariate and multivariate logistic regressions were performed to identify the determinants of SBs among the participants, and crude and adjusted odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) were calculated.

Results

Overall, 49.6% of respondents (n = 1,939) reported that they were tired of life and thinking about death. The lifetime prevalence rate of suicidal ideation (SI) was 8.1% (n = 317), that of suicide planning (SP) was 7.3% (n = 287), and that of suicide attempts (SA) was 3.1% (n = 122). Being female (OR: 1.87, CI: 1.64-2.12), being divorced (OR: 3.13, CI: 1.88-5.22), having a low level of education (OR: 1.57, CI: 1.15-2.14), and working in clinical and medical services (OR: 1.25, CI: 1.09-1.43) were associated with being tired of life and thinking about death. These factors were also associated with SI, SP, and SA.

Discussion

These findings highlight the need to prioritize mental health for suicide prevention, especially for high-risk groups, in workplace mental health promotion programs and policies.

The chiropractor's role in primary, secondary, and tertiary prevention of suicide: a clinical guide

OBJECTIVE

To provide the practicing chiropractor foundational knowledge to enhance the understanding of relevant primary, secondary, and tertiary public health measures for suicide prevention.

METHODS

A descriptive literature review was performed using keywords low back pain, neck pain, psychosocial, pain, public health, suicide, suicide risk factors, and suicide prevention. English language articles pertaining to suicide prevention and the chiropractic profession were retrieved and evaluated for relevance. Additional documents from the Centers for Disease Control, Veterans Health Administration, and the World Health Organization were reviewed. Key literature from the clinical social work and clinical psychology fields were provided by authorship team subject matter experts.

CONCLUSION

No articles reported a position statement regarding suicide prevention specific to the chiropractic profession. Risk, modifiable, and protective factors associated with self-directed violence are important clinical considerations. A proactive approach to managing patients at-risk includes developing interprofessional and collaborative relationships with mental health care professionals.

Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses

BACKGROUND

The Zero Suicide framework is a system-wide approach to prevent suicides in health services. It has been implemented worldwide but has a poor evidence-base of effectiveness.

AIMS

To evaluate the effectiveness of the Zero Suicide framework, implemented in a clinical suicide prevention pathway (SPP) by a large public mental health service in Australia, in reducing repeated suicide attempts after an index attempt.

METHOD

A total of 604 persons with 737 suicide attempt presentations were identified between 1 July and 31 December 2017. Relative risk for a subsequent suicide attempt within various time periods was calculated using cross-sectional analysis. Subsequently, a 10-year suicide attempt history (2009-2018) for the cohort was used in time-to-recurrent-event analyses.

RESULTS

Placement on the SPP reduced risk for a repeated suicide attempt within 7 days (RR = 0.29; 95% CI 0.11-0.75), 14 days (RR = 0.38; 95% CI 0.18-0.78), 30 days (RR = 0.55; 95% CI 0.33-0.94) and 90 days (RR = 0.62; 95% CI 0.41-0.95). Time-to-recurrent event analysis showed that SPP placement extended time to re-presentation (HR = 0.65; 95% CI 0.57-0.67). A diagnosis of personality disorder (HR = 2.70; 95% CI 2.03-3.58), previous suicide attempt (HR = 1.78; 95% CI 1.46-2.17) and Indigenous status (HR = 1.46; 95% CI 0.98-2.25) increased the hazard for re-presentation, whereas older age decreased it (HR = 0.92; 95% CI 0.86-0.98). The effect of the SPP was similar across all groups, reducing the risk of re-presentation to about 65% of that seen in those not placed on the SPP.

CONCLUSIONS

This paper demonstrates a reduction in repeated suicide attempts after an index attempt and a longer time to a subsequent attempt for those receiving multilevel care based on the Zero Suicide framework.

Suicide and suicide attempts in adults: exploring suicide risk 24 months after a psychiatric emergency room visit

Objective:

Suicide risk (including attempted and completed suicide) should be measured over short periods of time after contacting health services. The objective of this study was to identify the patterns of attempted and completed suicides within 24-months of a psychiatric emergency department visit, as well as to investigate predictive risk factors, including sociodemographic and clinical variables, previous suicidal behavior, and service utilization.

Method:

A convenience sample (n=147), recruited at a general hospital’s psychiatric emergency room, included patients with suicidal ideation, suicidal plans or previous suicide attempts. These patients were followed for 24 months, focusing on two main outcomes: attempted and completed suicides.

Results:

After six months there were no completed suicides and 36 suicide attempts, while after 24 months there were seven completed suicides and 69 suicide attempts. A final logistic regression model for suicide attempts at 24 months identified somatic pathology and the number of previous psychiatric hospitalizations as predictive factors, with a good area under the receiver operating characteristic curve.

Conclusions:

The findings showed distinct patterns of attempted and completed suicides over time, indicating the importance of a systematic multidisciplinary suicide risk evaluation in psychiatric emergency rooms.

Veille sanitaire et réseau de santé mentale dans la prise en charge des suicidants. Résultats d’une étude contrôlée

Une étude prospective, contrôlée et randomisée a été réalisée sur 320 suicidants ayant regagné leur domicile après passage au SAU de Bicêtre. Elle a comparé le protocole de prise en charge habituel (groupe G1) au protocole « OSTA » (G2). Celui-ci comporte trois appels téléphoniques au patient (à j8–j15, M1 et M3) 2,3, un appel téléphonique au professionnel référent (M3) et la mise à disposition d’un numéro d’appel téléphonique pour le patient et son référent. Une évaluation téléphonique finale à un an (M12) a été effectuée dans les deux groupes.

Résultats:

Discussion et conclusion

Ces résultats sont confrontés aux données récentes de la littérature [1]. La discussion porte sur la méthodologie la plus appropriée à l’évaluation des effets de la veille sanitaire et aux moyens de contrôler les effets de l’évaluation sur les variables étudiées.

Psychiatric Hospitalization after Emergency Treatment for Deliberate Self-Harm is Associated with Repeated Deliberate Self-Harm

The objective of this study was to evaluate whether treatment at a psychiatric hospital reduces the risk of repeating parasuicide. Participants were 4,483 parasuicide patients admitted to an emergency department between July 2003 and March 2012. We analyzed the effectiveness of psychiatric hospitalization in preventing repeated parasuicide. We adjusted for background factors using multivariate logistic regression. Effects of psychiatric hospitalization upon the likelihood of repeated parasuicide within 1 year varied by age (especially those aged <35 years), indicating that hospitalization was a significant risk factor. We must be mindful of the risk of repeated parasuicide following discharge in young patients and to provide them with ongoing outpatient care and multimodal support.

The effectiveness of psychoanalytic/psychodynamic psychotherapy for reducing suicide attempts and self-harm: systematic review and meta-analysis

BACKGROUND

Preventing suicide and self-harm is a global health priority. Although there is a growing evidence base for the effectiveness of psychoanalytic and psychodynamic psychotherapies for a range of disorders, to date there has been no systematic review of its effectiveness in reducing suicidal and self-harming behaviours.AimsTo systematically review randomised controlled trials of psychoanalytic and psychodynamic psychotherapies for suicidal attempts and self-harm.

METHOD

We searched PubMed, PsycINFO, Psycharticles, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials for randomise controlled trials of psychoanalytic and psychodynamic psychotherapies for reducing suicide attempts and self-harm.

RESULTS

Twelve trials (17 articles) were included in the meta-analyses. Psychoanalytic and psychodynamic therapies were effective in reducing the number of patients attempting suicide (pooled odds ratio, 0.469; 95% CI 0.274-0.804). We found some evidence for significantly reduced repetition of self-harm at 6-month but not 12-month follow-up. Significant treatment effects were also found for improvements in psychosocial functioning and reduction in number of hospital admissions.

CONCLUSIONS

Psychoanalytic and psychodynamic psychotherapies are indicated to be effective in reducing suicidal behaviour and to have short-term effectiveness in reducing self-harm. They can also be beneficial in improving psychosocial well-being. However, the small number of trials and moderate quality of the evidence means further high-quality trials are needed to confirm our findings and to identity which specific components of the psychotherapies are effective.Declaration of interestNone.

Impact of the New Mental Health Services on Rates of Suicide and Hospitalisations by Attempted Suicide, Psychiatric Problems, and Alcohol Problems in Brazil

A sizeable proportion of all suicides have mental health issues in the background. The association between access to mental health care in the community and decreased suicide rates is inconsistent in the literature. Brazil undertook a major psychiatric reform strengthening psychiatric community-based care. To evaluate the impact of the new Brazilian community mental health care units (CAPS-Psychosocial-Community-Centres) on municipal rates of suicide, and hospitalisations by attempted suicide, psychiatric and alcohol problems. We performed robust multivariable negative binomial regression models with fixed effect for panel data from all 5507 Brazilian municipalities. Suicide and hospitalization rates were calculated by sex and standardised by age for each municipality and year from 2008 to 2012. The main variable of interest was municipal CAPS coverage. CAPS municipal coverage was associated with lower suicide rates but this was not statistically significant (RR: 0.981; 95% CI 0.952-1.011). However, increased CAPS coverage was associated with lower hospitalizations for attempted suicide (RR: 0.887; 95% CI 0.841-0.935), psychiatric (RR: 0.841; 95% CI 0.821-0.862), and alcohol problems (RR: 0.882; 95% CI 0.860-0.904). Our results suggest that access to community mental health services seems to reduce hospitalisations due to attempted suicide, psychiatric and alcohol problems but not suicidal rates. Therefore, increased investments in community mental health services in low-middle-income countries might decrease costs associated with potentially avoidable hospitalizations.

Multicomponent Intervention for Patients Admitted to an Emergency Unit for Suicide Attempt: An Exploratory Study

Suicide is a major cause of premature deaths worldwide and belongs to the top priority public health issues. While suicide attempt is the most important risk factor for completed suicide, intervention for suicide attempters (SA) have produced mixed results. Since an important proportion of SA request medical care, emergency units (EU) are an opportune setting to implement such interventions. This exploratory study evaluated the feasibility and acceptability of a multicomponent intervention for SA admitted to an EU. The intervention consisted of coordination by a case manager of a joint crisis plan (JCP), an early meeting with relatives and the existing care network, as well as phone contacts during 3 months after suicide attempt. Among 107 SA admitted to the emergency unit during the study period, 51 could not be included for logistical reason, 22 were excluded, and intervention was offered to 34. Of these, 15 refused the intervention, which was thus piloted with 19 SA. First-time attempters most frequently declined the intervention. Feasibility and acceptability of phone contacts and case manager were good, while JCPs and meetings were difficult to implement and perceived as less acceptable. Refusal pattern questions the global acceptability and is discussed: JCPs and meetings will have to be modified in order to improve their feasibility and acceptability, especially among first-time attempters.

[Follow-up interventions after suicide attempt. What tools, what effects and how to assess them?]

After attempting suicide, 60 to 70% of patients are discharged from emergency departments and referred to outpatient treatment which entails psychosocial strategies, pharmacological strategies or a combination. The main objective of outpatient care consists in preventing recurrent suicidal behavior. Yet suicide attempters have been found to be very difficult to engage in treatment. Between 11% and 50% of attempters refuse outpatient treatment or drop out of outpatient therapy very quickly. In order to address this extremely serious issue, for the past 20 years monitoring or follow up interventions has been presented as a promising approach. Follow-up intervention is defined as a service that aims at both increased access to and engagement in care as well as to prevent suicide and related behaviors. This approach consists in "stay in contact" or "connectedness" protocols using phone calls or tele-assistance, sending letters, email or mobile phone messages and medical visits or nursing at home. From one study to another these tools have been used separately, associated to one another or reinforced by motivational interviewing or brief psychotherapy. To our knowledge, since 1993 16 controlled and randomized controlled studies assessed the effectiveness of diverse follow-up. Four studies assessing telephone follow up reported a significant decrease in suicide reattempt while one study evaluating a sending letters strategy reported positive results. Among five studies assessing engagement in healthcare, only two (one using phone follow up and the other sending letters reported significantly positive results. The refusal rate of monitoring strategies has not exceeded 11% attesting to the high applicability of these methods. Despite several positive results, we cannot draw firm conclusions on replicability of these results. This is largely due to methodological issues: lack of standardization of interventions, lack of consensus on definition of the main measured variables (recurrent suicidal behavior, engagement in healthcare) but also to the confounding effect of other care approaches frequently associated with follow up intervention services. Further studies and research should be conducted as follow-up intervention services are increasingly used in suicide prevention because of their good acceptability and usefulness.

Effective psychological and psychosocial approaches to reduce repetition of self-harm: a systematic review, meta-analysis and meta-regression

OBJECTIVE

To examine the efficacy of psychological and psychosocial interventions for reductions in repeated self-harm.

DESIGN

We conducted a systematic review, meta-analysis and meta-regression to examine the efficacy of psychological and psychosocial interventions to reduce repeat self-harm in adults. We included a sensitivity analysis of studies with a low risk of bias for the meta-analysis. For the meta-regression, we examined whether the type, intensity (primary analyses) and other components of intervention or methodology (secondary analyses) modified the overall intervention effect.

DATA SOURCES

A comprehensive search of MEDLINE, PsycInfo and EMBASE (from 1999 to June 2016) was performed.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of psychological and psychosocial interventions for adult self-harm patients.

RESULTS

Forty-five trials were included with data available from 36 (7354 participants) for the primary analysis. Meta-analysis showed a significant benefit of all psychological and psychosocial interventions combined (risk ratio 0.84; 95% CI 0.74 to 0.96; number needed to treat=33); however, sensitivity analyses showed that this benefit was non-significant when restricted to a limited number of high-quality studies. Meta-regression showed that the type of intervention did not modify the treatment effects.

CONCLUSIONS

Consideration of a psychological or psychosocial intervention over and above treatment as usual is worthwhile; with the public health benefits of ensuring that this practice is widely adopted potentially worth the investment. However, the specific type and nature of the intervention that should be delivered is not yet clear. Cognitive-behavioural therapy or interventions with an interpersonal focus and targeted on the precipitants to self-harm may be the best candidates on the current evidence. Further research is required.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

OBJECTIVES

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures.

MAIN RESULTS

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

AUTHORS' CONCLUSIONS

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.

Effectiveness of Telephone-Delivered Interventions Following Suicide Attempts: A Systematic Review

AIM

To evaluate efficacy of telephone-delivered interventions following suicide attempts.

METHODS

Systematic review, meta-analysis, and narrative synthesis.

RESULTS

Five papers evaluating telephone interventions were included. Three studies provided suicide attempters with telephone contact intervention, and two studies provided deliberate self-harm patients with crisis cards to help after discharge. Meta-analyses showed that telephone contact intervention did not significantly reduce further suicide attempts and completed suicides, and the crisis card did not significantly reduce further deliberate self-harm.

CONCLUSION

Telephone-delivered interventions have been suggested as an alternative to face-to-face psychotherapy, but their effectiveness in reducing the recurrence of suicide attempts is not supported.

OSTA program: A French follow up intervention program for suicide prevention

Attempted suicide is a strong risk factor for subsequent suicidal behavior. In recent years, a particular interest has been given to follow-up interventions as a potential effective strategy in preventing recurrent suicidal behavior. We developed a follow-up intervention program called OSTA (organization of a suitable monitoring for suicide attempters) aimed at addressing this issue and tested its effectiveness in a 1-year randomized controlled trial. Individuals who attempted suicide and were admitted to the emergency department (ED) of Bicêtre Hospital (n=320) were randomly allocated to receive either the OSTA program or a control treatment. On an intention to treat basis, the proportion of patients who reattempted suicide did not differ significantly between the interventional group (IG) 14.5% (22/152) and the control group (CG) 14% (21/150). There were also no significant differences, between the two arms, in the number of suicide attempts. Although no significant difference has been found between the OSTA program and the control treatment concerning the rate of suicide reattempts, we believe that further studies should be conducted to test the effectiveness of more standardized follow-up studies in suicide prevention.

Suicide Prevention and Follow-Up Services: A Narrative Review

Previous suicide attempt is the most important predictor of death by suicide. Thus preventive interventions after attempting to suicide is essential to prevent reattempts. This paper attempts to determine whether phone preventive interventions or other vehicles (postal cards, email and case management) are effective in reattempt prevention and health promotion after discharge by providing an overview of studies on suicide reattempts. The research investigated in this review conducted from 1995 to 2014. A total of 26 cases related to the aim of this research were derived from 36 English articles with the aforementioned keywords Research shows that providing comprehensive aids, social support, and follow-up after discharge can significantly prevent suicide reattempts. Several studies showed that follow-up support (phone calls, crisis cards, mails, postal cards.) after discharge can significantly decrease the risk of suicide. More randomized controlled trials (RCT) are required to determine what factors of follow-up are more effective than other methods.

Pharmacological interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm.

OBJECTIVES

To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013.

SELECTION CRITERIA

We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews

OBJECTIVE

We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts.

METHODS

Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings.

RESULTS

No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%.

CONCLUSIONS

Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

An observational study of the impact of service use on suicidality among adults with mental disorders

Background

It is unclear whether treatment of mental disorders reduces the probability that a) people without suicidal ideation will begin to contemplate suicide, or b) people who have thought about killing themselves (but have not attempted suicide) will go on to make an attempt.

Methods

Mental disorders, service use for emotional or substance use problems, and suicidality were assessed using the World Mental Health version of the Composite International Diagnostic Interview. Discrete-time survival analysis was used to establish the temporal priority of mental health service use and suicide-related outcomes among the 5,862 participants in the Collaborative Psychiatric Epidemiological Surveys who reported a mental disorder.

Results

Use of specialty mental health services, but not other types of services for emotional or substance use problems, was associated with an increased risk of future suicide ideation (OR = 1.27, CI = 1.01–1.60). However, respondents with a history of suicidal ideation were less likely to report a subsequent suicide attempt if they had received any type of service for emotional or substance use problems (OR = 0.62, CI = 0.46–0.83), regardless of the type of service received (i.e., it did not matter whether the service received was mental health care, general medical care, or non-health care related).

Conclusions

Among persons with frank DSM disorders and suicidal ideation, the receipt of treatment is associated with a lower rate of subsequent suicide attempts, compared with those who never received treatment, regardless of treatment provider type. Follow-up studies are a logical next step to our observational investigation.

Listening to depression and suicide risk in medical students: the Healer Education Assessment and Referral (HEAR) Program

OBJECTIVE

A growing body of literature documents high rates of burnout, depression, and suicidal ideation among physicians and medical students. Barriers to seeking mental health treatment in this group include concerns about time, stigma, confidentiality, and potential career impact. The authors describe a 4-year trial of the Healer Education Assessment and Referral (HEAR) program, designed to increase mental health services utilization (MHSU) and decrease suicide risk (SR) as assessed by an Interactive Screening Program (ISP)at one US medical school.

METHODS

Over a 4-year period, medical students were engaged in face-to-face, campus-wide, educational group programs and were invited to complete an individual, online, and anonymous survey. This survey contained the 9-item Patient Health Questionnaire (PHQ-9) scale to assess depression and items to identify suicidal thoughts and behaviors, substance use, distressing emotional states, and the use of mental health treatment. Students who engaged in this ISP by corresponding electronically with a counselor after completing the survey were assessed and when indicated, referred to further treatment.

RESULTS

The HEAR program was delivered to 1,008 medical students. Thirty-four percent (343/1,008) completed the online screening portion. Almost 8 % of respondents met the criteria for high/significant SR upon analysis of the completed screens. Ten out of 13 of the students with SR who dialogued with a counselor were not already receiving mental health treatment, indicating that this anonymous ISP identified a high proportion of an untreated, at risk, and potentially suicidal population. MHSU among medical students who completed the survey was 11.5 % in year 1 and 15.0 % by year 4. SR among medical students was 8.8 % in year 1 and 6.2 % in year 4 as assessed by the ISP.

CONCLUSIONS

This novel interventional program identified at risk, potentially suicidal medical students at one institution. Based on this single-site experience, we suggest that future multisite studies incorporate a comparison group, acquire baseline (prematriculation) data regarding MHSU and SR, and use an individualized yet anonymous identification system to measure changes in individual participants' mental health status over time.

Can early follow-up after deliberate self-harm reduce repetition? A prospective study of 325 patients

BACKGROUND

Patients who deliberately harm themselves often repeat their self-destructive acts. The objective of this study was to assess whether a follow-up visit within 10 days to a psychiatric consultant could reduce the frequency of repeated deliberate self-harm (DSH).

METHODS

A cohort of 325 consecutive DSH patients attending two large emergency departments in Stockholm, Sweden, were included and followed for 6 months. Any visit to a psychiatric consultant within 10 days was registered as an early follow-up. Repeated DSH episode within 6 months among the 325 patients was detected via nationwide registers.

MAIN OUTCOME MEASURE

Repeated DSH within 6 months.

RESULTS

At 6 months follow-up 22 (24%) of 92 patients with an early follow-up had repeated their DSH acts compared to 58 (25%) of 233 patients without an early follow-up (OR 1.06 (95% CI: 0.60-1.85) p-value 0.85). After adjustment for possible confounders, multivariable analysis showed an OR of 1.22 (95% CI: 0.62-2.38, p-value 0.56).

LIMITATIONS

Early follow-up was registered as any visit to a psychiatric consultant and no information regarding actions taken at the visit were obtained.

CONCLUSION

After adjusting for other factors associated with repetition there was an association of patients who were offered and thereafter attended an early follow-up visit and a decreased risk of repeated DSH.

Suicide reattempters: a systematic review

The aim of this study is to identify the characteristic features of suicide reattempters. The recognition of the suicide reattempters population as a distinct clinical population may encourage future preventive and clinical work with this high-risk subgroup and thus reduce deaths. A systematic literature review was carried out in order to identify the key demographic, psychological, and clinical variables associated with the repetition of suicide attempts. In addition, we wished to analyze the operational definitions of the repetition of suicide attempts proposed in the scientific literature. Studies published from 2000 to 2012 were identified in PubMed, PsycINFO, and Web of Science databases and were selected according to predetermined criteria. We examined a total of 1480 articles and selected 86 that matched our search criteria. The literature is heterogeneous, with no consensus regarding the operational definitions of suicide reattempters. Comparison groups in the literature have also been inconsistent and include subjects making a single lifetime attempt and subjects who did not reattempt during a defined study period. Suicide reattempters were associated with higher rates of the following characteristics: unemployment, unmarried status, diagnosis of mental disorders, suicidal ideation, stressful life events, and family history of suicidal behavior. Additional research is needed to establish adequate differentiation and effective treatment plans for this population.

Attempted and completed suicide: not what we expected?

BACKGROUND

Suicide attempters and suicide completers are two overlapping but distinct suicide populations. This study aims to present a more accurate characterization by comparing populations of suicide attempters and completers from the same geographical area.

METHODS

Samples and procedure: All cases of attempted suicide treated at the emergency room of the Corporacio Sanitària i Universitària Tauli Parc de Sabadell in 2008 (n=312) were compared with all completed suicides recorded in the same geographical area from 2008 to 2011 (n=86). Hospital and primary care records were reviewed for sociodemographic and clinical variables.

STATISTICAL ANALYSIS

Chi-square, ANOVA, and Mann-Whitney U tests were used to identify characteristics related to suicide completion.

RESULTS

Compared to suicide attempters, suicide completers were more likely to be male (73.3% vs. 37.8%; p<0.001), pensioners (73.7% vs. 23.4%; p<0.001), and people living alone (31.8% vs. 11.4%; p=0.006). Suicide completers more frequently presented somatic problems (71.7 vs. 15.7; p<0.001), Major Depressive Disorder (54.7% vs. 27.9%; p<0.001), and made use of more lethal methods (74.1 vs. 1.9; p<0.001). Suicide completers were more likely to have been followed by a primary care provider (50.0% vs. 16.0%; p<0.001). 92.3% of the suicides committed were completed during the first or second attempt.

LIMITATIONS

Suicide completers were not evaluated using the psychological autopsy method.

CONCLUSIONS

Despite presenting a profile of greater social and clinical severity, suicide completers are less likely to be followed by Mental Health Services than suicide attempters. Current prevention programs should be tailored to the specific profile of suicide completers.

Suicide prevention in schizophrenia spectrum disorders and psychosis: a systematic review

BACKGROUND

The incidence of suicide is high among patients with schizophrenia spectrum disorders and psychosis. A systematic review was performed to investigate the effectiveness of psychosocial interventions in reducing suicidal behaviour among patients with schizophrenia spectrum disorders and psychosis.

METHODS

Cochrane, PubMed and PsycINFO databases were searched to January 2012. Additional materials were obtained from reference lists. Randomised Controlled Trials describing psychosocial interventions for psychotic disorders with attention placebo, treatment as usual (TAU), no intervention or waitlist control groups were included.

RESULTS

In total, 11,521 abstracts were identified. Of those, 10 papers describing 11 trials targeting psychosocial interventions for reducing suicidal behaviour in patients with schizophrenia spectrum disorders and psychosic symptoms or disorders met the inclusion criteria. Odds Ratios describing the likelihood of a reduction in suicidal behaviour or ideation ranged from 0.09 to 1.72 at post-test and 0.13 to 1.48 at follow-up.

CONCLUSIONS

Psychosocial interventions may be effective in reducing suicidal behaviour in patients with schizophrenia spectrum disorders and psychosis, although the additional benefit of these interventions above that contributed by a control condition or treatment-as-usual is not clear.

Evaluation of attempted suicide in emergency departments in Sanliurfa province, southeastern Turkey

AIM

Attempted suicide is one of the most important public health problems among preventable causes of mortality in the general population. Identifying risk factors for the prevention of suicide is a major public health goal. The aim of this study was to determine the annual rate of attempted suicide, related risk factors, and interventions, among referrals to emergency departments in the Sanliurfa province of southeastern Turkey.

SUBJECTS AND METHODS

Data were obtained from all emergency departments in the province based on the 'Suicide Attempt Registry' standardized records for the calendar year 2010. Sociodemographic characteristics, aetiology, psychiatric history, psychiatric consultations, and interventions were examined. The groups were analysed with the chi-square test; the significance level was set at p<0.05.

RESULTS

The annual rate of suicide attempts was 55.39 in 100,000 for the calendar year 2010. The rate was 3.47 times higher among women than men, and in particular 4.15 times higher for the 15-24 year age group among women than in men with the highest incidence of suicide attempts. The majority of cases were referred in April and May. Medication or toxic agent ingestions comprised 90.3 % of cases. The main reason for attempts was family problems or domestic violence among women, and economic hardships among men, and rates of physical and mental problems were similar for both sexes. Only 8.8 % of cases were subsequently referred for psychiatric consultation. Among cases with a prior suicide attempt history, 44.6 % had a reported psychiatric disorder.

CONCLUSION

The results of this investigation show that strengthening of surveillance and emergency healthcare systems, enhancement of mental health literacy, and inter-sector collaboration for development of community empowerment programmes are of vital importance for prevention of attempted suicide. The low rate of psychiatric referrals for subsequent intervention represented a major gap in urgent mental health services in the region.

Rapid improvement of depressive symptoms in suicide attempters following treatment with milnacipran and tricyclic antidepressants - a case series

Suicide is a serious social problem in many countries, including Japan. The majority of people who commit suicide suffer from depression. Suicide attempt patients suffering from serious physical injuries are initially treated in hospital emergency departments. The present post hoc analysis examined data from patients admitted to an emergency hospital for treatment of physical injuries, resulting from a suicide attempt, and initial psychiatric treatment for depression and prevention of future suicide attempts. The effects on depressive symptoms were studied in two groups of patients using the 17-item Hamilton depression scale (HAMD). One group (n = 6) had received intravenous tricyclic antidepressants (TCA) (amitriptyline or clomipramine) while the other group (n = 7) had been treated orally with milnacipran, a serotonin and norepinephrine reuptake inhibitor antidepressant. Prior to treatment the four highest scoring items on the HAMD scale were the same in both groups namely, item 1 (depressed mood), item 3 (suicidality), item 7 (interest in work and activities), and item 10 (psychic anxiety). After 1 week of treatment, mean global HAMD scores were significantly reduced in both groups. Treatment resulted in a significant reduction of five HAMD items in the TCA group, whereas in the milnacipran group 12 HAMD items were significantly reduced. Suicidality (item 3) was significantly improved by 1 week treatment with milnacipran, but not by TCAs. Milnacipran rapidly improved a wide range of depressive symptoms, including suicidality within the first week. The improvement with milnacipran would appear to be, at least, equivalent to that achieved with TCAs, possibly affecting a wider range of symptoms. Since milnacipran has been shown in comparative studies to be better tolerated than TCAs, this antidepressant offers an interesting option for the treatment of suicidal patients in an emergency setting.