Suicide Prevention Strategies: A Systematic Review
J. John Mann; Alan Apter; Jose Bertolote; et al.
Online article and related content
current as of May 14, 2010. JAMA. 2005;294(16):2064-2074 (doi:10.1001/jama.294.16.2064)
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Contact me when this article is cited. Topic collections Medical Practice; Medical Education; Psychiatry; Depression; Mood Disorders;
Suicide; Review
Contact me when new articles are published in these topic areas. Related Letters Strategies to Prevent Suicide
Leonardo Tondo et al. JAMA. 2006;295(13):1515.
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http://pubs.ama-assn.org/misc/permissions.dtl reprints@ama-assn.org Downloaded from www.jama.com at Johns Hopkins University on May 14, 2010 CLINICIAN’S CORNER REVIEW Suicide Prevention Strategies
A Systematic Review
J. John Mann, MD
Alan Apter, MD
Jose Bertolote, MD
Annette Beautrais, PhD
Dianne Currier, PhD
Ann Haas, PhD
Ulrich Hegerl, MD
Jouko Lonnqvist, MD
Kevin Malone, MD
Andrej Marusic, MD, PhD
Lars Mehlum, MD
George Patton, MD
Michael Phillips, MD
Wolfgang Rutz, MD
Zoltan Rihmer, MD, PhD, DSc
Armin Schmidtke, MD, PhD
David Shaffer, MD
Morton Silverman, MD
Yoshitomo Takahashi, MD
Airi Varnik, MD
Danuta Wasserman, MD
Paul Yip, PhD
Herbert Hendin, MD S UICIDE IS A SIGNIFICANT PUBLIC health issue. In 2002, an estimated 877 000 lives were lost
worldwide through suicide, representing 1.5% of the global burden of
disease or more than 20 million disability-adjusted life-years (years of
healthy life lost through premature
death or disability).1 The highest annual rates are in Eastern Europe, where
10 countries report more than 27 suiCME available online at
www.jama.com Context In 2002, an estimated 877 000 lives were lost worldwide through suicide.
Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely
evaluated.
Objectives To examine evidence for the effectiveness of specific suicide-preventive
interventions and to make recommendations for future prevention programs and research.
Data Sources and Study Selection Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using
multiple search terms related to suicide prevention. Studies, published between 1966
and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to
lethal means; and responsible media reporting of suicide.
Data Extraction Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates,
referrals), or both. Experts from 15 countries reviewed all studies. Included articles were
those that reported on completed and attempted suicide and suicidal ideation; or, where
applicable, intermediate outcomes, including help-seeking behavior, identification of
at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined:
systematic reviews and meta-analyses (n=10); quantitative studies, either randomized controlled trials (n=18) or cohort studies (n=24); and ecological, or populationbased studies (n=41). Heterogeneity of study populations and methodology did not
permit formal meta-analysis; thus, a narrative synthesis is presented.
Data Synthesis Education of physicians and restricting access to lethal means were
found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.
Conclusions Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more
evidence of efficacy. Ascertaining which components of suicide prevention programs
are effective in reducing rates of suicide and suicide attempt is essential in order to
optimize use of limited resources.
www.jama.com JAMA. 2005;294:2064-2074 cides per 100 000 persons. Latin American and Muslim countries report the
lowest rates, fewer than 6.5 per
100 000.2 In the United States, in 2002,
suicide accounted for 31 655 deaths, a
rate of 11.0 per 100 000 per year,3 and
general population surveys document
a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,4 represent- 2064 JAMA, October 26, 2005—Vol 294, No. 16 (Reprinted) ing a huge human tragedy and an estimated $11.8 billion in lost income.5
Suicidal behavior has multiple causes
that are broadly divided into proximal
Author Affiliations are listed at the end of this article.
Corresponding Author: J. John Mann, MD, Department of Neuroscience, New York State Psychiatric Institute, 1051 Riverside Dr, Box 42, New York, NY
10032 (jjm@columbia.edu). ©2005 American Medical Association. All rights reserved. Downloaded from www.jama.com at Johns Hopkins University on May 14, 2010 SUICIDE PREVENTION STRATEGIES stressors or triggers and predisposition.6 Psychiatric illness is a major contributing factor, and more than 90% of
suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) psychiatric illness,7-13 with some exceptions, such as
in China.14 Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about
60% of suicides.7,8,10,15,16 Other contributory factors include availability of
lethal means, alcohol and drug abuse,
access to psychiatric treatment, attitudes to suicide, help-seeking behavior, physical illness, marital status, age,
and sex.6 To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The F IGURE
illustrates the multiple factors involved in suicidal behavior6 and indicates where specific preventive interventions are being directed. Suicide
prevention is possible because up to
83% of suicides have had contact with a primary care physician within a year
of their death and up to 66% within a
month.17,18 Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major
depression. This review considers what
is known about this and other prevention strategies to permit integration into
a comprehensive prevention strategy.
Suicide experts from 15 countries met
in Salzburg, Austria, in August 2004 to
review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the
general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media
reporting of suicide. Cochrane Library, and PsychINFO to
identify reports evaluating suicide prevention interventions. An initial search
used the MEDLINE identifier suicide (including the subheading suicide, attempted) and the subheading prevention
and control, following that suicide was
combined with the following identifiers:
depression, health education, health promotion, public opinion, mass screening,
family physicians, medical education, primary health care, antidepressive agents,
psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media. We identified
5020 articles, which were not bound by
the 5 major areas identified during the
workshop. Abstracts were reviewed and
full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors. DATA SOURCES
An electronic literature search of all articles published between 1966 and June
2005 was conducted via MEDLINE, the Study Selection Figure. Targets of Suicide Prevention Interventions
S U I C I D A L B E H AV I O R A to E
Stressful Life Event Mood or Other
Psychiatric Disorder PREVENTION INTERVENTIONS A Education and Awareness Programs
Primary Care Physicians
General Public
Community or Organizational
Gatekeepers B
Suicidal Ideation F A C T O R S I N V O LV E D
I N S U I C I D A L B E H AV I O R C D
Impulsivity
C D
Hopelessness
and/or Pessimism
F
Access to
Lethal Means B Screening for Individuals at High Risk
Treatment
C Pharmacotherapy
Antidepressants, Including Selective
Serotonin Reuptake Inhibitors
Antipsychotics
D Psychotherapy
Alcoholism Programs
Cognitive Behavioral Therapy
E Follow-up Care for Suicide Attempts G
Imitation F Restriction of Access to Lethal Means
G Media Reporting Guidelines for Suicide Suicidal Act Circled letters refer to relevant prevention interventions listed on right. ©2005 American Medical Association. All rights reserved. Studies were included if they reported on
either the primary outcomes of interest,
namely completed and attempted suicide
andsuicidalideation;or,whereapplicable,
intermediate outcomes, including helpseeking behavior, identification of at-risk
individuals, entry into treatment, and antidepressant prescription rates.
We included 3 major types of studies for which the research question was
clearly defined as assessment of efficacy
or effectiveness of prevention programs
in terms of the above primary or secondary outcomes; (1) systematic reviews and
meta-analyses (n=10) for which the
search strategy was comprehensive and
the methodological quality of primary
studieswascriticallyappraised;(2)quantitative studies, either randomized controlled trials (n=18), or cohort studies
(n=24); and (3) ecological or population based studies (n=41). TABLE 1 and
TABLE 2 detail study type, study population, and preventive intervention tested
and rate the studies according to the
scheme proposed by the Oxford Centre
for Evidence Based Medicine.112 Randomized controlled trials provide the
most compelling evidence of efficacy
while findings of naturalistic studies are
largely correlational, indicating that their
outcomes need further testing. (Reprinted) JAMA, October 26, 2005—Vol 294, No. 16 2065 Downloaded from www.jama.com at Johns Hopkins University on May 14, 2010 SUICIDE PREVENTION STRATEGIES Table 1. Study Type, Level of Evidence, Population, and Prevention Strategy
Level* Population Prevention Strategy Gunnell et al,19 2005
Fergusson et al,20 2005
Khan et al,21 2003
Ploeg et al,22 1996
Guo and Harstall,23 2002
Pignone et al,24 2002
Feightner,25 1994
Gaynes et al,26 2004
Gilbody et al,27 2003
Hawton et al,28 2000
Aseltine and DeMartino,29 2004
Thompson et al,30 2000
Bruce et al,31 2004
Glick et al,32 2004 Source Meta-analysis
Meta-analysis
Meta-analysis
Systematic review
Systematic review
Systematic review
Systematic review
Systematic review
Systematic review
Systematic review
RCT
RCT
RCT
RCT Study Type 1A
1A
1A
2A
2A
2A
2A
2A
2A
2A
1B
1B
1B
1B Antidepressant use
Antidepressant use
Antidepressant use
Curriculum-based programs
Curriculum-based program
Screening for depression in primary care
Screening for depression in primary care
Screening for suicide risk in primary care
Detecting and treating depression in primary care
Psychotherapy
Curriculum-based program
Detecting and treating depression in primary care
Detecting and treating depression in primary care
Clozapine Meltzer et al,33 2003 RCT 1B Thies-Flechtner et al,34 1996
Brown et al,35 2005
Guthrie et al,36 2001
Bateman and Fonagy,37 2001 RCT
RCT
RCT
RCT 1B
1B
1B
1B Motto and Bostrom,38 2001
Cedereke et al,39 2002
Allard et al,40 1992
Morgan et al,41 1993
Asarnow et al,42 2005 RCT
RCT
RCT
RCT
RCT 1B
1B
1B
1B
1B RCTs in UK psychiatric patients
RCTs in psychiatric patients
RCTs in US psychiatric patients
Adolescents
Adolescents
Primary care patients
Primary care patients
Primary care patients
Primary care patients
Patients who attempted suicide
Adolescents
Primary care patients
Older primary care patients
Adults with schizophrenia spectrum
disorders
Adults with schizophrenia spectrum
disorders
Adults with affective disorders
Suicide attempters
Suicide attempters
Borderline personality disorder
patients
Suicide attempters
Suicide attempters
Suicide attempters
Suicide attempters
Adolescents Orbach and Bar-Joseph,43 1993
Eggert et al,44 1995
Thompson et al,45 2001
Huey et al,46 2004
Rihmer,47 2001
Marusic et al,48 2004
Kelly et al,49 1998
Oyama et al,50 2004
Mann et al,51 2004
Knox et al,52 2003
Motto,53 1970
Loftin et al,54 1991
Hegerl et al,55 2003
Jorm et al,56 2005
Paykel et al,57 1998
Akroyd and Wyllie,58 2002
Lehfeld et al,59 2004
Naismith et al,60 2001
Hannaford et al,61 1996
Lin et al,62 2001
Valentini et al,63 2004 RCT
RCT
RCT
RCT
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Quasi-experimental
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Cohort study (quasi-experimental)
Cohort study
Cohort study
Cohort study
Cohort study
Cohort study
Cohort study
Cohort study 1B
1B
1B
1B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B
2B Pfaff et al,64 2001
Takahashi et al,65 1998
Rutz,66 1989
Mehlum and Schwebs,67 2000
Dieserud et al,68 2000
Aoun,69 1999
Rotheram-Borus et al,70 2000 Cohort study
Cohort study
Cohort study
Cohort study
Cohort study
Cohort study
Cohort study 2B
2B
2B
2B
2B
4
4 Adolescents
Adolescents
Adolescents
Psychiatric crisis in adolescents
Primary care patients in Hungary
Primary care patients in Slovenia
Primary care physicians
Primary care patients in Japan
General population in Hungary
US Air Force personnel
General US population
General US population
General population in Germany
General population in Australia
General UK population
General population in New Zealand
General population in Germany
Primary care physicians in Australia
Primary care physicians in UK
Primary care physicians in US
Primary care physicians and
patients in Brazil
Primary care physicians in Australia
Primary care patients
Primary care patients
Norwegian Army
General population in Norway
High-risk adults
Suicide attempters Clozapine
Lithium
Psychotherapy
Psychotherapy
Psychotherapy
Follow-up care: postal contact program
Follow-up care: telephone contact program
Follow-up care
Follow-up care: green card
Primary care physician education: quality
improvement
Curriculum-based program
Curriculum-based program
Curriculum-based program
Follow-up care
Primary care physician education
Primary care physician education
Primary care physician education
Primary care physician education
Antidepressants
Gatekeeper programs
Media blackout
Firearm restriction
Public education campaign
Public education campaign
Public education campaign
Public education campaign
Public education campaign
Primary care physician education
Primary care physician education
Primary care physician education
Primary care physician education
Primary care physician education
Primary care physician education
Primary care physician education
Gatekeeper education
Chain of care
Follow-up care
Follow-up care Abbreviation: RCT, randomized controlled trial.
*Oxford Centre for Evidence Based Medicine, levels of evidence: 1A, systematic review of RCTs; 1B, individual RCT; 2A, systematic review of cohort studies; 2B, individual cohort study,
low-quality RCT; 2C, ecological studies; 3A, systematic review of case-control studies; 3B, individual case-control study; 4, case series, poor-quality cohort and case-control studies. 2066 JAMA, October 26, 2005—Vol 294, No. 16 (Reprinted) ©2005 American Medical Association. All rights reserved. Downloaded from www.jama.com at Johns Hopkins University on May 14, 2010 SUICIDE PREVENTION STRATEGIES DATA SYNTHESIS
Heterogeneity in study methodology
and populations limited formal metaanalysis, thus we present a narrative
synthesis of the results for the key domains of suicide prevention interventions.
Awareness and Education General Public. Public education campaigns are aimed at improving recognition of suicide risk and help seeking
through improved understanding of the
causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide
and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious
medical illness. Despite their popularity as a public health intervention, the
effectiveness of public awareness and
education campaigns in reducing suicidal behavior has seldom been systematically evaluated.
Studies in Germany,55 the United
Kingdom,57 Australia,56 and New Zealand58 suggest modest effects of public
education campaigns on attitudes regarding the causes and treatment of depression. Such public education and
awareness campaigns, largely about depression, have no detectable effect on
primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking
or increased antidepressant use.57,58,113
The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign. 5 9
However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control
region.55
Other specific education strategies
are aimed at youth, including school
and community-based programs.114,115
Few such programs are evidencebased, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.114 A systematic review of studies published
from 1980-1995 found that knowledge about suicide improved but there
were both beneficial and harmful effects
in terms of help-seeking, attitudes, and
peer support.22 A later review of studies published from 1990-2002 also
found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for
prevention of suicidal behavior.23 A subsequent controlled trial reported lower
suicide attempt rates, greater knowledge, and more adaptive attitudes about
depression and suicide in the intervention group compared with in the 3
months after the intervention, but no
significant benefits for rates of suicide
ideation or help-seeking.29 In adolescents, several studies found that improving problem solving, coping with
stress, and increasing resilience enhance hypothesized protective factors
but effects on suicidal behavior were unevaluated.43-45
Primary Care Physicians. Depression and other psychiatric disorders are
underrecognized and undertreated in
the primary care setting.116,117 Prevention is possible because most suicides
have had contact with a primary care
physician within a month of death.17,18
Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to
nontreatment seen in most suicides.
Therefore, improving physician recognition of depression and suicide risk
evaluation is a component of suicide
prevention.
Some studies in the United Kingdom,61 Australia,60 the United States,24
and Northern Ireland,49 showed that
programs aimed at educating primary
care physicians improved detection and
increased treatment of depression, but
that was not shown in other studies in
the United States,62 Brazil,63 and the
United Kingdom.30 Nurse case management, collaborative care, or quality
improvement initiatives can further improve the recognition and management of depression27 and has applica- ©2005 American Medical Association. All rights reserved. tion where education alone may be
insufficient.
A controlled trial comparing a treatment algorithm plus depression care
management with treatment as usual for
late-life depression in primary care in the
United States demonstrated greater improvement in patient suicidal ideation
and a more favorable course of illness
in the intervention group compared with
the treatment-as-usual group.31 An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians
resulted in a 50% decrease in suicide attempts in the intervention group that
was not statistically different from the
control group (18%) due to the low base
rate. 42 An Australian program that
trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young
people increased identification of suicidal patients by 130% (determined by
the Depressive Symptom Inventory–
Suicidality Subscale score), without
changes in treatment or management
strategies.64 Studies examining suicidal
behavior in response to primary care
physician education programs, mostly
targeting depression recognition and
treatment, in specific regions in Sweden,66,118 Hungary,47 Japan,65 and Slovenia48 have all reported increased prescription rate for antidepressants and
often substantial declines in suicide rates
and represent the most striking known
example of a therapeutic intervention
lowering suicide rates.
Gatekeepers. Suicide prevention includes a range of interventions focused
on community or organizational gatekeepers whose contact with potentially
vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.5 Gatekeepers
include clergy, first responders, pharmacists, geriatric caregivers, personnel
staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy
changes to encourage help-seeking,
availability of resources, and efforts to (Reprinted) JAMA, October 26, 2005—Vol 294, No. 16 2067 Downloaded from www.jama.com at Johns Hopkins University on May 14, 2010 SUICIDE PREVENTION STRATEGIES reduce stigma associated with helpseeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental
health and suicide and facilitated access to mental health services. To date, systematic evaluation of impact on suicidal behavior has largely
been limited to multilevel programs
conducted in institutional settings, such
as the military where programs in the
Norwegian Army 67 and the US Air Force52 have reported success in lowering suicide rates.
Screening Screening aims to identify at-risk individuals and direct them to treatment. Table 2. Ecological Studies, Level of Evidence, Population, and Prevention Strategy
Source
Etzersdorfer and Sonneck,71 1998 Study Type Level* Ecological
Ecological
Ecological 2C
2C
2C General population in Austria
General population in Canada
General population in Canada Media blackout
Firearm restrictions
Firearm restrictions Ecological
Ecological
Ecological 2C
2C
2C General population in Australia
General US population
General population in Finland Firearm restrictions
Firearm restrictions
Pesticide restriction Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological 2C
2C
2C
2C
2C
2C
2C
2C
2C
2C
2C
2C
2C
2C
2C General population in Samoa
General population in Canada
General UK population
General population in Switzerland
General UK population
General population
General population
General population in Japan
General UK population
General population in England and Wales
General population in England and Wales
General US population
General population in Sweden
General population in New Zealand
General US population Ecological
Ecological
Ecological 2C
2C
2C US adolescents
General population in Australia
General population in Iceland Pesticide restriction
Firearm restriction
Domestic gas detoxification
Domestic gas detoxification
Domestic gas detoxification
Barbiturate restrictions
Barbiturate restrictions
Barbiturate restrictions
Analgesic packaging changes
Catalytic converters
Catalytic converters
Catalytic converters
Antidepressants
Barriers to jumping
Antidepressant use plus
introduction of
lower-toxicity
antidepressants
Antidepressants
Antidepressants
Antidepressants Ludwig and Marcotte,99 2005
Cantor and Slater,100 1995
Whitlock,101 1975
Lester,102 1991
Wiedenmann and Weyerer,103 1993
Lester,104 1990
Oliver and Hetzel,105 1972
Retterstol,106 1989
Carlsten et al,107 1996
Mott et al,108 2002
Kapur et al,109 1992 Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecological
Ecologica...

 

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