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Non-pharmacological interventions for preventing suicide attempts: A systematic review and network meta-analysis
A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.
Objective
Patients with severe mental illness have a high risk of suicide and frequently living eliminated from mainstream society, but the effects of social support on suicide-related behaviors among this crowd is inconclusive. The present study aimed to explore such effects among patients with severe mental illness.
Methods
We implemented a meta-analysis and a qualitative analysis of relevant studies published before February 6, 2023. Correlation coefficients (r) and 95 % CI were selected as the effect size index in meta-analysis. Studies that did not report correlation coefficients were employed for qualitative analysis.
Results
Out of 4241 identified studies, 16 were identified in this review (6 for meta-analysis, 10 for qualitative analysis). The meta-analysis presented that the pooled correlation coefficients (r) were − 0.163 (95%CI = -0.243, −0.080, P < 0.001), suggesting a negative correlation between social support and suicidal ideation. The subgroup analysis showed that this effect works in all bipolar disorder, major depression, and schizophrenia. Concerning qualitative analysis, social support presented positive effects on reducing suicidal ideation, suicide attempts, and suicide death. The effects were consistently reported in female patients. However, there existed some unaffected results in males.
Limitations
The included studies were from middle- and high-income countries and used inconsistent measurement tools, our results may have some bias.
Conclusions
The effects of social support in reducing suicide-related behaviors were positive, but it showed better effects in both female patients and adults. Males and adolescents deserve more attention. Future research needs to pay more attention to the implementation methods and effects of personalized social support.
Objective
Although excess mortality, especially suicide, is a critical trait in people living with HIV, consensus about gender differences in these areas is lacking. We conducted meta‐analyses to examine gender differences in suicidal ideation, suicide attempts, and suicide death among people living with HIV.
Methods
We systematically searched PubMed and Web of Science for studies written in English. In this review, suicide among people living with HIV includes suicide death, suicidal ideation, and suicide attempts. Studies reporting the suicide prevalence among males and females living with HIV were eligible for inclusion in our review. Odds ratios (ORs) and 95% confidence intervals (CIs) served as the effect size index. Fixed‐effects or random‐effects meta‐analyses were chosen based on the size of the heterogeneity.
Results
A total of 27 studies comprising 801 017 participants from 11 countries were included in the meta‐analysis. The overall prevalence of suicidal ideation was 18.0% (95% CI 13.3%–22.8%) in males and 20.8% (95% CI 16.4%–25.1%) in females, and there was a statistically significant higher risk of suicidal ideation in females living with HIV (OR 1.30; 95% CI 1.09–1.56; p < 0.05). The overall prevalence of suicide attempts was 16.8% (95% CI 9.0%–24.5%) in males and 24.7% (95% CI 12.4%–37.1%) in females, and there was a statistically significant higher risk of suicide attempts in females living with HIV (OR 1.34; 95% CI 1.02–1.75; p < 0.05). The pooled prevalence of suicide death was 1.2% (95% CI 0.5%–1.9%) among males and 0.2% (95% CI 0.1%–0.3%) among females, and the risk of suicide death between genders was not statistically significant (OR 0.78; 95% CI 0.50–1.24; p = 0.298).
Conclusions
There were gender differences in suicidal ideation and suicide attempts among people living with HIV. Females living with HIV were more likely to experience suicidal ideation and make suicide attempts, but there were no statistically significant gender differences in suicide death. Appropriate initiatives to optimize the recognition, treatment, and management suicide behaviours of males and females living with HIV may narrow this gender gap.
___________________________________________________________________________________________ Objective: Previous suicide interventional studies are controversial in their results. The present study compared brief intervention and contact (BIC), with treatment as usual (TAU) in their influence on the repetition of suicide attempts 6-month after the index suicide attempt. Methods: Adults who had attempted suicide were assigned two groups randomly: 311 in the TAU and 321 in the BIC. The brief intervention and contact contained a brief one-hour psycho-educational session combined with follow-up contacts by phone calls or visits after discharge. We used Mann-Whitney U test, ANOVA, and Chi-Square for analysis of variables. Results: The brief intervention and contact did not significantly reduce the repeated suicide attempts, but the patients' need to get support increased significantly (alpha value = 63.67, p<0.001) compared to the treatment as usual group. Also, the brief intervention and contact group patients tried to get support from outpatient/inpatient services, relatives, friends or by telephone contact to a significantly larger extent (alpha value = 69.2, p<0.001) compared to the treatment as usual group. Conclusion: brief intervention and contact seems to have an effect on the patients' attitude towards seeking support from outpatient/inpatient services, relatives and friends.
Background
People with serious mental illness are at great risk of suicide, but little is known about the suicide rates among this population. We aimed to quantify the suicide rates among people with serious mental illness (bipolar disorder, major depression, or schizophrenia).
Methods
PubMed and Web of Science were searched to identify studies published from 1 January 1975 to 10 December 2020. We assessed English-language studies for the suicide rates among people with serious mental illness. Random-effects meta-analysis was used. Changes in follow-up time and the suicide rates were presented by a locally weighted scatter-plot smoothing (LOESS) curve. Suicide rate ratio was estimated for assessments of difference in suicide rate by sex.
Results
Of 5014 identified studies, 41 were included in this analysis. The pooled suicide rate was 312.8 per 100 000 person-years (95% CI 230.3–406.8). Europe was reported to have the highest pooled suicide rate of 335.2 per 100 000 person-years (95% CI 261.5–417.6). Major depression had the highest suicide rate of 534.3 per 100 000 person-years (95% CI 30.4–1448.7). There is a downward trend in suicide rate estimates over follow-up time. Excess risk of suicide in males was found [1.90 (95% CI 1.60–2.25)]. The most common suicide method was poisoning [21.9 per 100 000 person-years (95% CI 3.7–50.4)].
Conclusions
The suicide rates among people with serious mental illness were high, highlighting the requirements for increasing psychological assessment and monitoring. Further study should focus on region and age differences in suicide among this population.
Background
Clinical guidelines suggest that psychological interventions specifically aimed at reducing suicidality may be beneficial. We examined the impact of two depression treatments, cognitive therapy (CT) and interpersonal psychotherapy (IPT) on suicidal ideation (SI) and explored the temporal associations between depression and SI over the course of therapy.
Methods
Ninety‐one adult (18–65) depressed outpatients from a large randomized controlled trial who were treated with CT (n = 37) and IPT (n = 54) and scored at least ≥1 on the Beck Depression Inventory II (BDI‐II) suicide item were included. Linear (two‐level) mixed effects models were used to evaluate the impact of depression treatments on SI. Mixed‐effects time‐lagged models were applied to examine temporal relations between the change in depressive symptoms and the change in SI.
Results
SI decreased significantly during treatment and there were no differential effects between the two intervention groups (B = −0.007, p = .35). Depressive symptoms at the previous session did not predict higher levels of SI at the current session (B = 0.016, p = .16). However, SI measured at the previous session significantly predicted depressive symptoms at the current session (B = 2.06, p < .001).
Conclusions
Both depression treatments seemed to have a direct association with SI. The temporal association between SI and depression was unidirectional with SI predicting future depressive symptoms during treatment. Our findings suggest that it may be most beneficial to treat SI first.
Self-injurious thoughts and behaviors (SITBs) are major public health concerns impacting a wide range of individuals and communities. Despite major efforts to develop and refine treatments to reduce SITBs, the efficacy of SITB interventions remains unclear. To provide a comprehensive summary of SITB treatment efficacy, we conducted a meta-analysis of published randomized controlled trials (RCTs) that have attempted to reduce SITBs. A total of 591 published articles from 1,125 unique RCTs with 3,458 effect sizes from the past 50 years were included. The random-effects meta-analysis yielded surprising findings: The overall intervention effects were small across all SITB outcomes; despite a nearexponential increase in the number of RCTs across five decades, intervention efficacy has not improved; all SITB interventions produced similarly small effects, and no intervention appeared significantly and consistently stronger than others; the overall small intervention effects were largely maintained at follow-up assessments; efficacy was similar across age groups, though effects were slightly weaker for child/adolescent populations and few studies focused on older adults; and major sample and study characteristics (e.g., control group type, treatment target, sample size, intervention length) did not consistently moderate treatment efficacy. This meta-analysis suggests that fundamental changes are needed to facilitate progress in SITB intervention efficacy. In particular, powerful interventions target the necessary causes of pathology, but little is known about SITB causes (vs. SITB correlates and risk factors). The field would accordingly benefit from the prioritization of research that aims to identify and target common necessary causes of SITBs.
Importance
Suicidal ideation is a widespread phenomenon. However, many individuals at risk for suicide do not seek treatment, which might be addressed by providing low-threshold, internet-based self-help interventions.
Objective
To investigate whether internet-based self-help interventions directly targeting suicidal ideation or behavior are associated with reductions in suicidal ideation.
Data Sources
A systematic search of PsycINFO, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and the Centre for Research Excellence of Suicide Prevention (CRESP) databases for trials from inception to April 6, 2019, was performed, supplemented by reference searches. Search strings consisted of various search terms related to the concepts of internet, suicide, and randomized clinical trials.
Study Selection
Two independent researchers reviewed titles, abstracts, and full texts. Randomized clinical trials evaluating the effectiveness of internet-based self-help interventions to reduce suicidal ideation were included. Interventions were eligible if they were based on psychotherapeutic elements. Trials had to report a quantitative measure of a suicide-specific outcome. Mobile-based and gatekeeper interventions were excluded; no further restrictions were placed on participant characteristics or date of publication.
Data Extraction and Synthesis
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. Standardized mean differences were calculated using a random-effects model.
Main Outcomes and Measures
Suicidal ideation was the a priori primary outcome.
Results
Six unique eligible trials (1567 unique participants; 1046 [66.8%] female; pooled mean [SD] age, 36.2 [12.5] years) were included in the systematic review and meta-analysis. All identified interventions were internet-based cognitive behavioral therapy (iCBT). Participants assigned to the iCBT condition experienced a significantly reduced suicidal ideation compared with controls following intervention in all 6 trials (standardized mean difference, −0.29; 95% CI, −0.40 to −0.19; P < .001). Heterogeneity was low (I² = 0%). The effect appeared to be maintained at follow-up in 4 trials (standardized mean difference, −0.18; 95% CI, −0.34 to −0.02; P = .03; I² = 36%). Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations.
Conclusions and Relevance
These results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions. Considering their high scalability, iCBT interventions have the potential to reduce suicide mortality. Future research should assess the effect of these digital health interventions on suicidal behavior and identify moderators and mediators to advance understanding of the mechanisms of effectiveness of these interventions.
Background
Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia.
Methods/design
Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge.
Discussion
This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense.
Trial registration and ethics approval
This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370. Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).
Objectives
To use the estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and Socio-demographic index, and to describe temporal trends between 1990 and 2016.
Design
Systematic analysis.
Main outcome measures
Crude and age standardised rates from suicide mortality and years of life lost were compared across regions and countries, and by age, sex, and Socio-demographic index (a composite measure of fertility, income, and education).
Results
The total number of deaths from suicide increased by 6.7% (95% uncertainty interval 0.4% to 15.6%) globally over the 27 year study period to 817 000 (762 000 to 884 000) deaths in 2016. However, the age standardised mortality rate for suicide decreased by 32.7% (27.2% to 36.6%) worldwide between 1990 and 2016, similar to the decline in the global age standardised mortality rate of 30.6%. Suicide was the leading cause of age standardised years of life lost in the Global Burden of Disease region of high income Asia Pacific and was among the top 10 leading causes in eastern Europe, central Europe, western Europe, central Asia, Australasia, southern Latin America, and high income North America. Rates for men were higher than for women across regions, countries, and age groups, except for the 15 to 19 age group. There was variation in the female to male ratio, with higher ratios at lower levels of Socio-demographic index. Women experienced greater decreases in mortality rates (49.0%, 95% uncertainty interval 42.6% to 54.6%) than men (23.8%, 15.6% to 32.7%).
Conclusions
Age standardised mortality rates for suicide have greatly reduced since 1990, but suicide remains an important contributor to mortality worldwide. Suicide mortality was variable across locations, between sexes, and between age groups. Suicide prevention strategies can be targeted towards vulnerable populations if they are informed by variations in mortality rates.
Background
Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.
Methods
AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.
Results
1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13–14 months (RR [95% CI]: 0.46 [0.25–0.85] and 0.50 [0.31–0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13–14 months (RR [95% CI]: 0.84 [0.57–1.25] and 1.00 [0.73–1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.
Conclusions
This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.
Background
There is evidence that several intervention types, including psychotherapy, reduce repeat suicide attempts. However, these interventions are less applicable to the heterogeneous patients admitted to emergency departments (EDs). The risk of a repeat suicide attempt is especially high in the first 6 months after the initial attempt. Therefore, it is particularly important to develop effective ED interventions to prevent repeat suicide attempts during this 6-month period.
Methods
We systematically reviewed randomized controlled trials of ED-initiated interventions for suicidal patients admitted to EDs using the databases MEDLINE, PsychoINFO, CINAHL, and EMBASE up to January 2015 in accordance with an a priori published protocol (PROSPERO: CRD42013005463). Interventions were categorized into four types, including active contact and follow-up interventions (intensive care plus outreach, brief interventions and contact, letter/postcard, telephone, and composite of letter/postcard and telephone), and a meta-analysis was conducted to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of a repeat suicide attempt within 6 months.
Results
Of the 28 selected trials, 14 were active contact and follow-up interventions. Two of these trials (n = 984) reported results at 6 months (pooled RR = 0.48; 95% CI: 0.31 to 0.76). There were not enough trials of other interventions to perform meta-analysis. Some trials included in the meta-analysis were judged as showing risk of bias.
Conclusion
Active contact and follow-up interventions are recommended for suicidal patients admitted to an ED to prevent repeat suicide attempts during the highest-risk period of 6 months.
Systematic review registration
PROSPERO CRD42013005463 (27 August 2013).
Electronic supplementary material
The online version of this article (10.1186/s12888-019-2017-7) contains supplementary material, which is available to authorized users.
Objective:
Access to mental health care is regarded as a central suicide prevention strategy. This is the first systematic review and meta-analysis of the prevalence of contact with mental health services preceding suicide.
Methods:
A systematic search for articles reporting prevalence of contact with mental health services before suicide was conducted in MEDLINE and PsycINFO, restricted to studies published from January 1, 2000, to January 12, 2017. A random-effects meta-analysis with double arcsine transformations was conducted, with meta-regression used to explore heterogeneity.
Results:
Thirty-five studies were included in the systematic review, and 20 were included in the meta-analysis. Among suicide decedents in the population, 3.7% (95% confidence interval [CI]=2.6%-4.8%) were inpatients at the time of death. In the year before death, 18.3% (CI=14.6%-22.4%) of suicide decedents had contact with inpatient mental health services, 26.1% (CI=16.5%-37.0%) had contact with outpatient mental health services, and 25.7% (CI=22.7%-28.9%) had contact with inpatient or outpatient mental health services. Meta-regression showed that women had significantly higher levels of contact compared with men and that the prevalence of contact with inpatient or outpatient services increased according to the sample year.
Conclusions:
Contact with services prior to suicide was found to be common and contact with inpatient or outpatient mental health services before suicide seems to be increasing. However, the reviewed studies were mainly conducted in Western European and North American countries, and most studies focused on psychiatric hospitalization, which resulted in limited data on contact with outpatient services. Better monitoring and data on suicides that occur during and after treatment seem warranted.
Background:
Treatment for suicidality can be delivered online, but evidence for its effectiveness is needed.
Objective:
The goal of our study was to examine the effectiveness of an online self-help intervention for suicidal thinking compared to an attention-matched control program.
Methods:
A 2-arm randomized controlled trial was conducted with assessment at postintervention, 6, and, 12 months. Through media and community advertizing, 418 suicidal adults were recruited to an online portal and were delivered the intervention program (Living with Deadly Thoughts) or a control program (Living Well). The primary outcome was severity of suicidal thinking, assessed using the Columbia Suicide Severity Rating Scale.
Results:
Intention-to-treat analyses showed significant reductions in the severity of suicidal thinking at postintervention, 6, and 12 months. However, no overall group differences were found.
Conclusions:
Living with Deadly Thoughts was of no greater effectiveness than the control group. Further investigation into the conditions under which this program may be beneficial is now needed. Limitations of this trial include it being underpowered given the effect size ultimately observed, a high attrition rate, and the inability of determining suicide deaths or of verifying self-reported suicide attempts.
Trial registration:
Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595.
Background
Attempted suicide is a major public health problem, and the efficacies of current postvention protocols vary. We evaluated the effectiveness of telephone follow-up of patients referred to an emergency psychiatric unit for attempted suicide on any further attempt/s over the following year. Method
In a single-center, controlled study with intent to treat, we evaluated the efficacy of a protocol of telephone follow-up of 436 patients at 8, 30, and 60 days after they were treated for attempted suicide. As controls for comparison, we evaluated patients with similar social and demographic characteristics referred to our emergency psychiatric unit in the year prior to the study who did not receive telephone follow-up after their initial hospitalization. Data were analyzed using logistic regression. ResultsVery early telephone follow-up of our patients effectively reduced recidivism and seemed to be the only protective factor against repeated suicide attempt. Conclusions
Implementing a protocol of early telephone follow-up after attempted suicide could help prevent repeated attempt/s. More controlled studies are needed to assess optimal techniques to prevent such repetition.
Suicidal thoughts and behaviors (STBs) are major public health problems that have not declined appreciably in several decades. One of the first steps to improving the prevention and treatment of STBs is to establish risk factors (i.e., longitudinal predictors). To provide a summary of current knowledge about risk factors, we conducted a meta-analysis of studies that have attempted to longitudinally predict a specific STB-related outcome. This included 365 studies (3,428 total risk factor effect sizes) from the past 50 years. The present random-effects meta-analysis produced several unexpected findings: across odds ratio, hazard ratio, and diagnostic accuracy analyses, prediction was only slightly better than chance for all outcomes; no broad category or subcategory accurately predicted far above chance levels; predictive ability has not improved across 50 years of research; studies rarely examined the combined effect of multiple risk factors; risk factors have been homogenous over time, with 5 broad categories accounting for nearly 80% of all risk factor tests; and the average study was nearly 10 years long, but longer studies did not produce better prediction. The homogeneity of existing research means that the present meta-analysis could only speak to STB risk factor associations within very narrow methodological limits-limits that have not allowed for tests that approximate most STB theories. The present meta-analysis accordingly highlights several fundamental changes needed in future studies. In particular, these findings suggest the need for a shift in focus from risk factors to machine learning-based risk algorithms. (PsycINFO Database Record
Globally, over 800 000 people died by suicide in 2012 and there are indications that for each adult who died of suicide there were likely to be many more attempting suicide. There are many millions of people every year who are affected by suicide and suicide attempts, taking into consideration the family members, friends, work colleagues and communities, who are bereaved by suicide. In the WHO Mental Health Action Plan 2013–2020, Member States committed themselves to work towards the global target of reducing the suicide rate in countries by 10% by 2020. Hence, the first-ever WHO report on suicide prevention, Preventing suicide: a global imperative, published in September 2014, is a timely call to take action using effective evidence-based interventions. Their relevance for low- and middle-income countries is discussed in this paper, highlighting restricting access to means, responsible media reporting, introducing mental health and alcohol policies, early identification and treatment, training of health workers, and follow-up care and community support following a suicide attempt.
The PRISMA statement is a reporting guideline designed to improve the completeness of reporting of systematic reviews and meta-analyses. Authors have used this guideline worldwide to prepare their reviews for publication. In the past, these reports typically compared 2 treatment alternatives. With the evolution of systematic reviews that compare multiple treatments, some of them only indirectly, authors face novel challenges for conducting and reporting their reviews. This extension of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement was developed specifically to improve the reporting of systematic reviews incorporating network meta-analyses.
A group of experts participated in a systematic review, Delphi survey, and face-to-face discussion and consensus meeting to establish new checklist items for this extension statement. Current PRISMA items were also clarified. A modified, 32-item PRISMA extension checklist was developed to address what the group considered to be immediately relevant to the reporting of network meta-analyses.
This document presents the extension and provides examples of good reporting, as well as elaborations regarding the rationale for new checklist items and the modification of previously existing items from the PRISMA statement. It also highlights educational information related to key considerations in the practice of network meta-analysis. The target audience includes authors and readers of network meta-analyses, as well as journal editors and peer reviewers.
Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes.
To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy.
We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I.
The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol.
Frequency and severity of suicide attempts and NSSI episodes.
All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]).
A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas.
clinicaltrials.gov Identifier: NCT00183651.
This study reports the outcomes, during follow-up, of a low-cost postcard intervention in a RCT of hospital-treated self-poisoning (n = 2300). The intervention was 9 postcards over 12 months (plus usual treatment) v usual treatment. Three binary endpoints at 12-24 months (n = 2001) were; any suicidal ideation, suicide attempt or self-cutting. There was a significant reduction in any suicidal ideation (RRR 0.20 CI 95% 0.13-0.27), (NNT 8, 6-13), and any suicide attempt (RRR 0.31, 0.06-0.50), (NNT 35, 19-195), in this non-western population. However, there was no effect on self-cutting (RRR -0.01, -1.05-0.51). Sustained, brief contact by mail may reduce some forms of suicidal behaviour in self-poisoning patients during the post intervention phase.
Background:
prevention of suicide is one of priority world health. Suicide is one of the preventable causes of death. The aim of this study is evaluation of telephone follow up on suicide reattempt.
Materials and Methods:
This randomized controlled clinical trial is a prospective study which has been done in Noor Hospital of Isfahan-Iran, at 2010. 139 patients who have suicide attempt history divided in one of two groups, randomly, 70 patients in” treatment as usual (TAU)” and 69 patients in “brief interventional control (BIC). Seven telephone contact with BIC group patients have been done “during six months” and two questionnaires have been filled in each session. The data has been analyzed by descriptive and Chi-square test, under SPSS.
Results:
No significant differences of suicide reattempt has been found between two groups (P = 0.18), but significant reduction in frequency of suicidal thoughts (P = 0.007) and increase in hope at life (P = 0.001) was shown in intervention group.
Conclusion:
Telephones follow up in patients with suicide history decrease suicidal thought frequency” and increase hope in life, significantly.
Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006.
To assess the effects of psychological interventions for borderline personality disorder (BPD).
We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011.
Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects.
Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data.
Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy.
There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.
Self-harm and suicide are major public health problems in adolescents, with rates of self-harm being high in the teenage years and suicide being the second most common cause of death in young people worldwide. Important contributors to self-harm and suicide include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion are also important, with the internet having an important contemporary role. Prevention of self-harm and suicide needs both universal measures aimed at young people in general and targeted initiatives focused on high-risk groups. There is little evidence of effectiveness of either psychosocial or pharmacological treatment, with particular controversy surrounding the usefulness of antidepressants. Restriction of access to means for suicide is important. Major challenges include the development of greater understanding of the factors that contribute to self-harm and suicide in young people, especially mechanisms underlying contagion and the effect of new media. The identification of successful prevention initiatives aimed at young people and those at especially high risk, and the establishment of effective treatments for those who self-harm, are paramount needs.
Background
Mindfulness-based cognitive therapy (MBCT) can effectively prevent relapse of major depression, but there is currently insufficient evidence for efficacy against suicidal ideation during depressive episodes. We thus conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing MBCT to treatment as usual (TAU) for suppression of suicidal ideation in patients with current depression.
Methods
We systematically searched PubMed, Embase, Cochrane, CNKI, and Wan Fang databases for RCTs published in English or Chinese between January 1, 2000, and August 30, 2021. Pooled data were compared between MBCT and TAU groups using a random-effects model.
Findings
Seven RCTs with a total of 479 participants were included. Suicidal ideation and general depression scores were significantly improved following MBCT compared to TAU [Suicidal Ideation: standard mean difference (SMD) = −0.33, 95 % CI, −0.56 to −0.10; Depression: SMD = −0.96, 95%CI, −1.54 to −0.38].
Interpretation
Mindfulness-based cognitive therapy is an effective intervention for reducing depressive symptoms and suicidal ideation in depressed patients.
Trial registration
This meta-analysis was conducted in accordance with PRISMA guidelines and registered at PROSPERO https://www.crd.york.ac.uk/PROSPERO/ (CRD42021285016).
Background
Schizophrenia is a common, severe, and usually chronic disorder. Maintenance treatment with antipsychotic drugs can prevent relapse but also causes side-effects. We aimed to compare the efficacy and tolerability of antipsychotics as maintenance treatment for non-treatment resistant patients with schizophrenia.
Methods
In this systematic review and network meta-analysis, we searched, without language restrictions, the Cochrane Schizophrenia Group's specialised register between database inception and April 27, 2020, PubMed from April 1, 2020, to Jan 15, 2021, and the lists of included studies from related systematic reviews. We included randomised controlled trials (RCTs; ≥12 weeks of follow-up) that recruited adult participants with schizophrenia or schizoaffective disorder with stable symptoms who were treated with antipsychotics (monotherapy; oral or long-acting injectable) or placebo. We excluded RCTs of participants with specific comorbidities or treatment resistance. In duplicate, two authors independently selected eligible RCTs and extracted aggregate data. The primary outcome was the number of participants who relapsed and was analysed by random-effects, Bayesian network meta-analyses. The study was registered on PROSPERO, CRD42016049022.
Findings
We identified 4157 references through our search, from which 501 references on 127 RCTs of 32 antipsychotics (comprising 18 152 participants) were included. 100 studies including 16 812 participants and 30 antipsychotics contributed to our network meta-analysis of the primary outcome. All antipsychotics had risk ratios (RRs) less than 1·00 when compared with placebo for relapse prevention and almost all had 95% credible intervals (CrIs) excluding no effect. RRs ranged from 0·20 (95% CrI 0·05–0·41) for paliperidone oral to 0·65 (0·16–1·14) for cariprazine oral (moderate-to-low confidence in estimates). Generally, we interpret that there was no clear evidence for the superiority of specific antipsychotics in terms of relapse prevention because most comparisons between antipsychotics included a probability of no difference.
Interpretation
As we found no clear differences between antipsychotics for relapse prevention, we conclude that the choice of antipsychotic for maintenance treatment should be guided mainly by their tolerability.
Funding
The German Ministry of Education and Research and Oxford Health Biomedical Research Centre.
Elder suicide is a significant public health issue in many countries. This reflects the complex underlying psychosocial, mental and physical health issues that older adults face. Increased life expectancy in developing countries has resulted in a gradual transition to an ageing population. Furthermore, in countries such as Sri Lanka the transition occurs at a lower per capita income than in developed countries. This will negatively impact the availability of resources and service delivery to at-risk individuals. Thus, addressing elder suicide and concerns of elders are timely issues. This paper looks at the underlying risk factors associated with elder suicide and strategies that can be implemented in preventing elder suicide in the South Asian context, with reference to Sri Lanka.
Importance:
People at risk of self-harm or suicidal behavior can be accurately identified, but effective prevention will require effective scalable interventions.
Objective:
To compare 2 low-intensity outreach programs with usual care for prevention of suicidal behavior among outpatients who report recent frequent suicidal thoughts.
Design, setting, and participants:
Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020.
Interventions:
Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care.
Main outcomes and measures:
The primary outcome was time to first nonfatal or fatal self-harm. Nonfatal self-harm was ascertained from health system records, and fatal self-harm was ascertained from state mortality data. Secondary outcomes included more severe self-harm (leading to death or hospitalization) and a broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm).
Results:
A total of 18 644 patients (9009 [48%] aged 45 years or older; 12 543 [67%] female; 9222 [50%] from mental health specialty clinics and the remainder from primary care) contributed at least 1 day of follow-up data and were included in analyses. Thirty-one percent of participants offered care management and 39% offered skills training actively engaged in intervention programs. A total of 540 participants had a self-harm event (including 45 deaths attributed to self-harm and 495 nonfatal self-harm events) over 18 months following randomization: 172 (3.27%) in care management, 206 (3.92%) in skills training, and 162 (3.27%) in usual care. Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07; 97.5% CI, 0.84-1.37) but was significantly higher in the skills training group than in usual care (HR, 1.29; 97.5% CI, 1.02-1.64). For severe self-harm, care management vs usual care had an HR of 1.03 (97.5% CI, 0.71-1.51); skills training vs usual care had an HR of 1.34 (97.5% CI, 0.94-1.91). For the broader self-harm definition, care management vs usual care had an HR of 1.10 (97.5% CI, 0.92-1.33); skills training vs usual care had an HR of 1.17 (97.5% CI, 0.97-1.41).
Conclusions and relevance:
Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce risk of self-harm, and offering brief dialectical behavior therapy skills training significantly increased risk of self-harm, compared with usual care. These findings do not support implementation of the programs tested in this study.
Trial registration:
ClinicalTrials.gov Identifier: NCT02326883.
Background
To address the elevated prevalence of depression, suicide, and suicidal ideation, patients require increased access to effective interventions. Mindfulness-Based Cognitive Therapy has a strong evidence base in relapse prophylaxis and can be delivered digitally through Mindful Mood Balance (MMB).
Methods
This study was a secondary analysis of the impact of MMB paired with usual depression care (UDC) compared to UDC alone on patients in a randomized clinical trial for residual depression (Segal et al., 2020) who had a history of attempted suicide or reported current suicidal ideation (N = 109).
Results
MMB relative to UDC was associated with a greater rate of reduction in SI (t(103) = 2.50, p = 0.014, d = 0.49, 95% CI [0.09-0.88]) and a greater likelihood of being in a lower severity category of SI (t(103) = 2.02, p = 0.046, odds ratio = 3.43, 95% CI [1.02-11.53]). There was also evidence that MMB reduces depression severity outcomes among this at risk group (t(105) = 2.38, p < 0.02, d = 0.46, 95% CI [0.07-0.85]).
Limitations
Reported findings are based on a subgroup of patients in a clinical trial originally designed to treat residual depressive symptoms.
Conclusions
Online interventions, such as MMB, may offer one solution to the challenge of expanding the reach of services for patients with residual depression who are at risk of suicidal ideation and behavior.
Objective
To test whether Mindfulness-Based Cognitive Therapy to Prevent Suicide (MBCT-S) is associated with improvement in attentional control, an objective marker of suicide attempt.
Method
In the context of a randomized clinical trial targeting suicide risk in Veterans, computerized Stroop and emotion Stroop (E-Stroop) tasks were administered 3 times over 6-months follow-up to 135 high suicide risk Veterans. Seventy were randomized to receive MBCT-S in addition to enhanced treatment as usual (eTAU), and 65 were randomized to eTAU only. E-Stroop word types included positively- and negatively-valenced emotion, suicide, and combat-related words. Interference scores and mixed effects linear regression analyses were used.
Results
Veterans receiving MBCT-S showed a more favorable trajectory of attentional control over time, as indicated by performance on two E-Stroop tasks. Combat-stress interference scores improved over time among Veterans in MBCT-S. Interference processing time for negative affective words deteriorated over time among Veterans receiving eTAU only.
Conclusions
MBCT-S may effectively target attentional control, and in particular reduce processing time during affective interference, in high suicide risk Veterans. Future studies to replicate these findings are warranted.
Background
Targeting social connection to prevent suicide in later life shows promise but requires additional study to identify the most effective and acceptable interventions. This study examines acceptability, feasibility, and efficacy of Engage Psychotherapy to improve subjective disconnection (target mechanisms: low belonging and perceived burden), and improve clinical and functional outcomes (depression, suicide ideation, quality of life).
Methods
Pilot randomized trial with adults age 60 and older who reported feeling lonely and/or like a burden. Participants were randomly assigned to 10 sessions of ‘Social Engage’ (S-ENG; n=32) or care-as-usual (CAU; n=30), with follow-up assessments at 3-weeks, 6-weeks, and 10-weeks.
Results
S-ENG is feasible to deliver over 10 sessions and acceptable to older adults who report social disconnection—a population at risk for suicide. Participants were willing and able to focus each session on social engagement and demonstrated high levels of compliance. Social Engage did not show preliminary evidence of impact on belonging or perceived burden but was effective in reducing depressive symptoms and improving social-emotional quality of life.
Discussion
S-ENG holds promise for improving social-emotional quality of life and depressive symptoms. Future research is needed to identify and measure target mechanisms that account for clinical and functional improvement.
The current study aims to: 1) investigate cognitive differences among adolescents at risk for suicide versus healthy controls (HC) and 2) identify cognitive changes associated with response to psychotherapy among adolescents at high risk for suicide. Thirty-five adolescents at high risk for suicide (HR), and 14 HC adolescents were recruited. Clinical and cognitive assessments were conducted in both groups at baseline and 16 weeks later (after the patients completed psychotherapy). HR and HC adolescents were compared at baseline and at completion of the study. We also conducted further analysis by separating into two groups the HR adolescents who responded to psychotherapy (n=17) and those who did not (n=11). At baseline, the HR group had significantly lower performance on verbal memory and processing speed than the HC group. At week 16, HR adolescents performed as well as HC adolescents in all cognitive domains. Among patients, better performance on visual memory was observed in those who responded to psychotherapy compared to those who did not. We concluded that lower performance on verbal memory and processing speed may be associated with a high risk for suicide among adolescents. Improvement in visual memory might be related to a lower risk for suicide in adolescents.
Objective
This study evaluated mechanisms, mediation, and secondary/exploratory outcomes in our randomized controlled trial evaluating Dialectical Behavior Therapy (DBT) compared to Individual and Group Supportive Therapy (IGST), expanding on previously reported results indicating a DBT advantage at post-treatment on planned suicide/self-harm outcomes, and greater self-harm remission (absence of self-harm, post-hoc exploratory outcome) during active-treatment and follow-up periods.
Method
Multi-site randomized trial of 173 adolescents with prior suicide attempts, self-harm, and suicidal ideation. Randomization was to 6-months of DBT or IGST, with outcomes monitored through 12-months. Youth emotion regulation was the primary mechanistic outcome.
Results
Compared to IGST, greater improvements in youth emotion regulation were found in DBT through the treatment-period (t(498) =2.36, p=0.019) and 12-month study-period (t(498)=2.93, p=.004). Their parents reported using more DBT skills: post-treatment (t(497)=4.12, p<0.001); 12-month follow-up (t(497)=3.71, p<0.001). Mediation analyses predicted to self-harm remission during the 6-12-month follow-up, the pre-specified outcome because this was the only suicidality/self-harm variable with a significant DBT effect at follow-up: DBT 49.3%; IGST 29.7%, p=.013. Improvements in youth emotion regulation during treatment mediated the association between DBT and self-harm remission during follow-up (Months 6-12, Estimate 1.71, CI 1.01, 2.87, p= 0.045). Youth in DBT reported lower substance misuse, externalizing behavior, and total problems at post-treatment/6-months, and externalizing behavior through follow-up/12-months.
Conclusion
Results support the significance of emotion regulation as a treatment target for reducing self-harm, and indicate a DBT advantage on substance misuse, externalizing behavior, and self-harm-remission, with 49.3% of youth in DBT achieving self-harm remission during follow-up.
OBJECTIVES: To use the estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and Socio-demographic index, and to describe temporal trends between 1990 and 2016. DESIGN: Systematic analysis. MAIN OUTCOMES MEASURES: Crude and age standardised rates from suicide mortality and years of life lost were compared across regions and countries, and by age, sex, and Socio-demographic index (a composite measure of fertility, income, and education). RESULTS: The total number of deaths from suicide increased by 6.7% (95% uncertainty interval 0.4% to 15.6%) globally over the 27 year study period to 817 000 (762 000 to 884 000) deaths in 2016. However, the age standardised mortality rate for suicide decreased by 32.7% (27.2% to 36.6%) worldwide between 1990 and 2016, similar to the decline in the global age standardised mortality rate of 30.6%. Suicide was the leading cause of age standardised years of life lost in the Global Burden of Disease region of high income Asia Pacific and was among the top 10 leading causes in eastern Europe, central Europe, western Europe, central Asia, Australasia, southern Latin America, and high income North America. Rates for men were higher than for women across regions, countries, and age groups, except for the 15 to 19 age group. There was variation in the female to male ratio, with higher ratios at lower levels of Socio-demographic index. Women experienced greater decreases in mortality rates (49.0%, 95% uncertainty interval 42.6% to 54.6%) than men (23.8%, 15.6% to 32.7%). CONCLUSIONS: Age standardised mortality rates for suicide have greatly reduced since 1990, but suicide remains an important contributor to mortality worldwide. Suicide mortality was variable across locations, between sexes, and between age groups. Suicide prevention strategies can be targeted towards vulnerable populations if they are informed by variations in mortality rates.
Suicide contributes to 1–4 % of deaths worldwide every year. We conducted a systematic review aimed at summarizing evidence on the use of lithium for the prevention of suicide risk both in mood disorders and in the general population.
We followed the PRISMA methodology (keywords: “lithium”, “suicide” AND “suicidal” on Pubmed, Cochrane CENTRAL, Clinicaltrial.gov, other databases). Inclusion criteria: lithium therapy in mood disorder or found in drinking water or scalp in the general population. Exclusion criteria: no lithium administration.
From 918 screened references, 18 prospective (number of participants: 153786), 10 retrospective (number of participants: 61088) and 16 ecological studies (total sample: 2062) were included. Most of the observational studies reported a reduction in suicide in patients with mood disorders. All studies about lithium treatment’s duration reported that long-term lithium give more benefits than short-term lithium in suicide risk
The evidence seems to attribute an intrinsic anti-suicidal property of lithium, independent of its proven efficacy as a mood stabilizer.
Assessment of risk of bias is regarded as an essential component of a systematic review on the effects of an intervention. The most commonly used tool for randomised trials is the Cochrane risk-of-bias tool. We updated the tool to respond to developments in understanding how bias arises in randomised trials, and to address user feedback on and limitations of the original tool.
Suicide is a major public health issue, and treatment of suicidal thoughts may contribute to its prevention. Provision of online treatment of suicidal ideation may reduce barriers that suicidal individuals experience in face-to-face treatment. We therefore aimed at evaluating the effectiveness of a web-based intervention targeting a reduction of suicidal ideation. We carried out a two-arm, parallel-design, randomised controlled trial in the general population in Flanders (Belgium) (registered as NCT03209544). Participants who were 18 years or older and experienced suicidal ideation were included. The intervention group (n = 365) received access to the unguided web-based intervention, and the control group (n = 359) was placed on a waitlist. Assessments were carried out at baseline and at 6 and 12 weeks. Participants reported high levels of suicidal ideation, depression, hopelessness, worrying, and anxiety at baseline. Compared to the control group, participants in the intervention group experienced a significant decline in suicidal ideation, depression, hopelessness, worrying, and anxiety both at post-test and at follow-up. An important limitation of the study was a high dropout rate, in particular in the intervention group. Our findings suggest that the online self-help intervention was more effective in reducing suicidal ideation and suicide-related symptoms than a waitlist control in a severely affected population. It can help in filling the gap between crisis help and face-to-face treatment.
Background
Suicide attempt (SA), which is one of the strongest predictors of completed suicide, is common in major depressive disorder (MDD) but its prevalence across epidemiological studies has been mixed. The aim of this comprehensive meta-analysis was to examine the pooled prevalence of SA in individuals with MDD.
Methods
A systematic literature search was conducted in PubMed, Embase, PsycINFO, Web of Science and Cochrane Library from their commencement date until 27 December 2017. Original studies containing data on prevalence of SA in individuals with MDD were analyzed.
Results
In all, 65 studies with a total of 27 340 individuals with MDD were included. Using the random effects model, the pooled lifetime prevalence of SA was 31% [95% confidence interval (CI) 27–34%], 1-year prevalence was 8% (95% CI 3–14%) and 1-month prevalence was 24% (95% CI 15–34%). Subgroup analyses revealed that the lifetime prevalence of SA was significantly associated with the patient setting, study region and income level, while the 1-month prevalence of SA was associated with only the patient setting.
Conclusion
This meta-analysis confirmed that SA was common in individuals with MDD across the world. Careful screening and appropriate interventions should be implemented for SA in the MDD population.
Despite high rates of suicide ideation (SI) and behavior in youth with pediatric bipolar disorder (PBD), little work has examined how psychosocial interventions impact suicidality among this high-risk group. The current study examined SI outcomes in a randomized clinical trial comparing Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT) for PBD versus psychotherapy treatment-as-usual (TAU). Although not designed for suicide prevention, CFF-CBT addresses child and family factors related to suicide risk and thus was hypothesized to generalize to the treatment of suicidality. Participants included 71 youth aged 7–13 years (M = 9.17, SD = 1.60) with DSM-IV-TR bipolar I, II, or not otherwise specified randomly assigned, with parent(s), to receive CFF-CBT or TAU. Both treatments consisted of 12 weekly and 6 monthly booster sessions. Suicide ideation was assessed via clinician interview at baseline, posttreatment, and 6-month follow-up. Results indicated that SI was prevalent pretreatment: 39% of youth reported current suicidal thoughts. All youth significantly improved in the likelihood and intensity of ideation across treatment, but group differences were not significant. Thus, findings suggest that early intervention for these high-risk youth may reduce SI, and at this stage of suicidality, youth may be responsive to even nonspecialized treatment.
Background:
Suicide-related behaviours are common in young people and associated with a range of negative outcomes. There are few evidence-based interventions; however, cognitive behavioural therapy (CBT) shows promise. Internet delivery of CBT is popular, with potential to increase reach and accessibility.
Objective:
To test the effectiveness of an internet-based CBT program (Reframe-IT) in reducing suicide-related behaviours, depression, anxiety, hopelessness and improving problem solving and cognitive and behavioural skills in school students with suicide-related behaviours.
Methods:
A parallel randomised controlled trial testing the effectiveness of Reframe-IT plus treatment as usual (TAU) compared with TAU alone in reducing suicidal ideation, suicide attempts, depression, hopelessness, symptoms of anxiety, negative problem orientation and cognitive and behavioural skill acquisition was undertaken. We recruited students experiencing suicidal ideation from 18 schools in Melbourne, Australia, between August 2013 and December 2016. The intervention comprised eight modules of CBT delivered online over 10 weeks with assessments conducted at baseline, 10 weeks and 22 weeks.
Findings:
Only 50 of the planned 169 participants were recruited. There were larger improvements in the Reframe-IT group compared with the TAU group for the primary outcome of suicidal ideation (intervention -61.6, SD 41.6; control -47.1, SD 42.3, from baseline to 22-week follow-up intervention); however, differences were non-significant (p=0.593). There were no increases in distress in the majority of participants (91.1%) after completion of each module. Changes in depression and hopelessness partly mediated the effect of acquisition of CBT skills on suicidal ideation.
Conclusions:
The trial was underpowered due to difficulties recruiting participants as a result of the complex recruitment procedures that were used to ensure safety of participants. Although there were no significant differences between groups, young people were safely and generally well engaged in Reframe-IT and experienced decreases in suicidal ideation and other symptoms as well as improvements in CBT skills. The study is the first online intervention trial internationally to include young people demonstrating all levels of suicide risk.
Clinical implications:
Integration of internet-delivered interventions for young people with suicide-related behaviour may result in reductions in these behaviours. Further research is needed, but researchers should feel more confident about being able to safely undertake research with young people who experience these behaviours.
Trial registration number:
ACTRN12613000864729.
Aim:
Conformity to traditional masculine gender norms may deter men's help-seeking and/or impact the services men engage. Despite proliferating research, current evidence has not been evaluated systematically. This review summarises findings related to the role of masculinity on men's help-seeking for depression.
Method:
Six electronic databases were searched using terms related to masculinity, depression and help-seeking. Titles and abstracts were reviewed and data systematically extracted and examined for methodological quality.
Results:
Of 1927 citations identified, 37 met inclusion criteria. Seventeen (46%) studies reported qualitative research; eighteen (49%) employed quantitative methods, and two (5%) mixed methods. Findings suggest conformity to traditional masculine norms has a threefold effect on men experiencing depression, impacting: i) their symptoms and expression of symptoms; ii) their attitudes to, intention, and, actual help-seeking behaviour; and, iii) their symptom management.
Conclusion:
Results demonstrate the problematic impact of conformity to traditional masculine norms on the way men experience and seek help for depression. Tailoring and targeting clinical interventions may increase men's service uptake and the efficacy of treatments. Future research examining factors associated with men's access to, and engagement with depression care will be critical to increasing help-seeking, treatment uptake, and effectual self-management among men experiencing depression.
Objective:
Emergency departments (EDs) are often the primary contact point for suicidal individuals. The post-ED visit period is a high suicide risk time. To address the need for support during this time, a novel intervention was implemented in five Department of Veterans Affairs medical center EDs. The intervention combined the Safety Planning Intervention (SPI) with structured follow-up and monitoring (SFU) by telephone for suicidal individuals who did not require hospitalization. This study assessed the intervention's acceptability and perceived usefulness.
Methods:
A selected sample of 100 intervention participants completed a semistructured interview consisting of open-ended questions about the intervention's acceptability, usefulness, and helpfulness. Satisfaction with the SPI and SFU was separately evaluated.
Results:
Nearly all participants found the SAFE VET intervention to be acceptable, reporting that it was helpful in preventing further suicidal behavior and fostering treatment engagement.
Conclusions:
The SAFE VET intervention showed promise as an ED intervention for suicidal patients.
Suicide is a complex public health problem of global importance. Suicidal behaviour differs between sexes, age groups, geographic regions, and sociopolitical settings, and variably associates with different risk factors, suggesting aetiological heterogeneity. Although there is no effective algorithm to predict suicide in clinical practice, improved recognition and understanding of clinical, psychological, sociological, and biological factors might help the detection of high-risk individuals and assist in treatment selection. Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent suicidal behaviour; additionally, regular follow-up of people who attempt suicide by mental health services is key to prevent future suicidal behaviour.
Objective:
The authors evaluated the effectiveness of brief cognitive-behavioral therapy (CBT) for the prevention of suicide attempts in military personnel.
Method:
In a randomized controlled trial, active-duty Army soldiers at Fort Carson, Colo., who either attempted suicide or experienced suicidal ideation with intent, were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76). Assessment of incidence of suicide attempts during the follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation with intent to die during the past week and/or a suicide attempt within the past month. Soldiers were excluded if they had a medical or psychiatric condition that would prevent informed consent or participation in outpatient treatment, such as active psychosis or mania. To determine treatment efficacy with regard to incidence and time to suicide attempt, survival curve analyses were conducted. Differences in psychiatric symptoms were evaluated using longitudinal random-effects models.
Results:
From baseline to the 24-month follow-up assessment, eight participants in brief CBT (13.8%) and 18 participants in treatment as usual (40.2%) made at least one suicide attempt (hazard ratio=0.38, 95% CI=0.16-0.87, number needed to treat=3.88), suggesting that soldiers in brief CBT were approximately 60% less likely to make a suicide attempt during follow-up than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms.
Conclusions:
Brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt.
Background:
Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments.
Methods:
In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444).
Findings:
Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698).
Interpretation:
Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research.
Funding:
The Ministry of Health, Labour, and Welfare of Japan.
Objective:
Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs.
Method:
Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion.
Results:
Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors.
Conclusions:
There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.
The relation of hopelessness to levels of depression and suicidal intent was explored both psychometrically and clinically. The results of an investigation of 384 suicide attempters support previous reports that hopelessness is the key variable linking depression to suicidal behavior. This finding has direct implications for the therapy of suicidal individuals. By focusing on reducing the sources of a patient's hopelessness, the professional may be able to alleviate suicidal crises more effectively than in the past.
(JAMA 234:1146-1149, 1975)
Studied the relation of hopelessness to levels of depression and suicidal intent in 384 17-63 yr old suicide attempters using the Beck Depression Inventory and the Beck Helplessness Scale. Results support previous reports that hopelessness is the key variable linking depression to suicidal behavior. This finding has direct implications for the therapy of suicidal individuals. By focusing on reducing the sources of a patient's hopelessness, the professional may be able to alleviate suicidal crises more effectively than in the past. (30 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To present some simple graphical and quantitative ways to assist interpretation and improve presentation of results from multiple-treatment meta-analysis (MTM).
We reanalyze a published network of trials comparing various antiplatelet interventions regarding the incidence of serious vascular events using Bayesian approaches for random effects MTM, and we explore the advantages and drawbacks of various traditional and new forms of quantitative displays and graphical presentations of results.
We present the results under various forms, conventionally based on the mean of the distribution of the effect sizes; based on predictions; based on ranking probabilities; and finally, based on probabilities to be within an acceptable range from a reference. We show how to obtain and present results on ranking of all treatments and how to appraise the overall ranks.
Bayesian methodology offers a multitude of ways to present results from MTM models, as it enables a natural and easy estimation of all measures based on probabilities, ranks, or predictions.