News Type: Weekly Spark Research

Researchers performed a systematic review of studies published around the world between September 2005 and December 2019 to identify evidence-based, scalable suicide prevention strategies. They found the most effective strategies were training primary care physicians to identify and treat depression, educating youth on depression and suicide, reducing access to lethal means among those at risk, and following up after hospital discharge or suicidal crisis.

The review focused on randomized controlled trials (n=97) that reported suicidal thoughts or behavior as an outcome variable and epidemiological studies at the county, city, or practitioner level (n=30). The scalability of approaches was determined based on the complexity and cost of required training. Findings included the following:

Provider Training

• Primary care physicians and other non-psychiatric practitioners saw 45% of those who died by suicide in the 30 days prior to their death, and 77% in the 12 months prior.
• Training primary care providers at the state and local levels in screening and treating depression, with available assistance from psychiatrists, lowered suicide rates, nonfatal suicide attempts, and suicidal thoughts.
• Refresher sessions after the initial training reduced suicide rates progressively for years, while single-day training sessions produced no benefit for suicide deaths over 3 years.
• Depression screening and treatment referral lowered suicide rates compared to programs in similar geographic areas that did not include screening and referral.

Youth Education

• Educating youth about mental health and suicide prevention was found to be more effective in preventing suicide compared to education strategies that targeted gatekeepers such as teachers or parents.

System-Level Education

• Large-scale, system-wide interventions targeting students, mental health professionals, primary care providers, and other gatekeepers have shown promise. However, more research is needed to identify the effectiveness of specific components of interventions that incorporate multiple strategies and audiences.

Treatment Interventions

• Antidepressants reduced suicidal thoughts in 9 of 12 studies on adults.
• Studies of antidepressants in children and teens found the risk of harm to be greater compared to control groups not given antidepressants.
• Additional research is needed on the use of fast acting medications such as ketamine, which has been found to reduce suicidal thoughts, as the effect of these drugs on suicidal behavior is unclear.
• Psychotherapeutic interventions with groups at high risk, such as individuals with depression and borderline personality disorder, were found effective in reducing suicidal thoughts and reattempts.
• Follow-up contacts after a suicide attempt were found to reduce reattempts by as much as 45%.

Lethal Means Reduction

• Reducing access to the most lethal means available was shown to reduce suicide deaths.
• Gun access reduction and gun safety education programs reduced firearm suicides.

Based on these findings, the authors recommended suicide prevention efforts focus on the following:

• Training primary care physicians in depression management and evaluating the expansion of such programs to non-psychiatric medical specialists.
• Targeting education programs to high school youth about mental health and evaluating the extension of this approach to college students.
• Pre-discharge education, follow-up contacts, and outreach for psychiatric patients discharged from the emergency department or hospitals and for individuals who have previously experienced a suicidal crisis.
• Means reduction, especially gun safety education.

The authors also suggested other promising strategies include specific psychotherapies, such as cognitive behavioral therapy and dialectical behavior therapy; fast-acting medications, such as ketamine; and online screening, treatment, and continuous monitoring of risk.

The most significant limitation of this review was the heterogeneity of the populations studied and strategies employed, as well as the inconsistent quantity and quality of available data on suicide prevention. In addition, the scalability of interventions was difficult to determine due to the lack of objective criteria for determining the feasibility of scaling up from the local to the national level.

Mann, J. J., Michel, C. A., & Auerbach, R. P. (2021). Improving suicide prevention through evidence-based strategies:  A systematic review. American Journal of Psychiatry, 178(7), 611–624.

A study looked at trends in suicide mortality from 1999 to 2019, using data from the National Vital Statistics System stratified by sex, age group, and suicide method. It found that the total age-adjusted suicide rate increased 35.2% from 10.5 per 100,000 in 1999 to 14.2 in 2018, and then decreased by 2.1% to 13.9 in 2019.

Additional findings include:

• Suicide rates for females increased from 1999 to 2019 for all age groups except 75 and older. During this period, rates were highest among women ages 45 to 64, followed by women 25 to 44. 
• Suicide rates for males increased between 1999 and 2019 for all age groups except those 75 and older. However, suicide rates were highest for men ages 75 and older.
• Rates for both females and males were lowest in the 10 to 14 age group.
• Suicide rates by sex and age group remained stable or declined from 2018 through 2019
• Firearm suicide increased from 1.5 in 1999 to 1.4 in 2007, increased to 1.9 in 2016, then remained stable through 2019.
• Among females, there was a shift away from suicide by poisoning with higher rates for firearms suffocation.
• Among males, suicide rates by firearms and suffocation also increased.

These findings can help guide suicide prevention strategies and assist in identifying populations at elevated risk. Increased rates of firearm suicide among both sexes indicate a need for more efforts to reduce access to guns among those at risk.

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Hedegaard, H., Curtin, S. C., & Warner, M. (2021). Suicide Mortality in the United States, 1999–2019. NCHS Data Brief, no 398. Hyattsville, MD: National Center for Health Statistics. doi: https://dx.doi.org/10.15620/cdc:101761

A study found the overall suicide rate in the U.S. declined for the first time in more than a decade. While these results may be encouraging, they should be interpreted with caution.

Researchers used data on suicide deaths among adults ages 10 and older from the 2018–2019 National Vital Statistics System. Data were analyzed by age, race/ethnicity, gender, county urbanicity, means, and state. Following are some key findings:

• From 2018 to 2019, suicide rates decreased by 2.1% overall (14.2 to 13.9/100,000), by 3.2% among females (6.2 to 6.0/100,000), and by 1.8% among males (22.8 to 22.4/100,000).
• Suicide rates declined among White people but did not change significantly among any other racial/ethnic group. Rates in 2019 were highest among American Indian/Alaska Native people.
• In 2019, suicide rates increased as the level of urbanicity decreased, with the lowest rates in large central metropolitan areas and the highest in non-metropolitan areas. 
• Firearms were used in the largest proportion of suicides in 2019 (50.4%). The rate of firearm suicide decreased by 2.9% from 2018 to 2019.

Although this study found an overall decline in suicide deaths from 2018 to 2019, changes in rates over the course of a single year should not be interpreted as a trend. Disparities in rates among racial/ethnic groups call for a better understanding of contributing factors, and for increased prevention efforts among populations at higher risk. Suicide is preventable and most effectively addressed by a comprehensive approach that reduces risk and enhances protective factors.

Learn how building a strong suicide prevention infrastructure can help states, territories, and tribes effectively prevent suicide.

Stone, D. M., Jones, C. M., & Mack, K. A. (2021). Changes in suicide rates—United States, 2018–2019.  MMWR Morbidity and Mortality Weekly Report, 70(8), 261–268.

Data from previous epidemics suggest suicide rates may initially appear to decrease during epidemics but may increase thereafter. Based on a systematic review of suicide data from 21 countries and areas within countries, this study found suicide rates did not increase during the early months of the COVID-19 pandemic.

The researchers used an interrupted time-series analysis to model the trend in monthly suicide deaths before COVID-19 (January 1, 2019 to March 31, 2020) compared to monthly suicides during the pandemic (April 1 to July 31, 2020).

The analysis found suicide rates did not increase during the study period. This finding is consistent with other studies from high-income and upper middle-income countries. While evidence suggests increased rates of depression and anxiety, this did not appear to affect suicide rates in the countries included in this study.

According to the authors, early recognition of mental health challenges during the pandemic may have helped increase support and services available. However, they also noted that financial assistance and support for mental health services is now being reduced or withdrawn, which may impact suicide rates over time.

This study had several limitations, including only using data from high- and middle-income countries. Pandemic-related disruptions in reporting and data analysis may have affected the quality and accuracy of the suicide data used. It is also important to keep in mind that the data analyzed is not complete and changes in suicide rates may not become apparent until later.

Despite limitations, this is the first study to examine suicide rates during the COVID-19 pandemic in multiple countries. Ongoing monitoring of suicide data over time can help identify emerging changes. Future research will need to examine how disease control methods (masking, social distancing, and quarantine), as well as financial and mental health supports, may influence suicide rates.

Pirkis, J., John, A., Shin, S., DelPozo-Banos, M., MRes, V. A., Analuisa-Aguilar, P., Appleby, L., Arensman, E., Bantjes, J., Baran, A., Bertolote, J. M., Borges, G., Brecic, P., Caine, E., Castelpietra, G., Chang, S-S., Colchester, D., Crompton, D., Curkovic, M., . . .  Spittal, M. J.  (2021). Suicide trends in the early months of the COVID-19 pandemic: An interrupted time-series analysis of preliminary data from 21 countries. The Lancet, 8(7), P579–588.

A recent study examined changes in U.S. emergency department (ED) visits for disaster-related mental health conditions, suicide attempts, overdoses, and violence outcomes during the COVID-19 pandemic. Using data from the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program, the study looked at nearly 190 million ED visits between December 30, 2018 and October 10, 2020.

This study analyzed both the number of ED visits and the rates (the number of ED visits per 100,000 ED visits) associated with each outcome. The analysis found that total ED visits decreased starting March 16, 2020 after COVID-19 mitigation measures were implemented. Comparing the median number of ED visits between March 15 and October 10, 2019 to the same period in 2020, they found the number of visits was higher in 2020 for suicide attempts and all overdose-related visits, including opioid overdoses. In comparison, visit counts for intimate partner violence and suspected child abuse and neglect were significantly lower in 2020. Median rates of all outcomes studied were also higher in 2020 than in 2019, except for intimate partner violence.

The increased isolation associated with quarantines and school closures, in addition to reduced reporting and help seeking, might account for the decrease in ED visits for intimate partner violence and child abuse. The authors note several limitations of this study, namely that the sample may not be representative of the U.S. population, as not all hospitals contribute data to the surveillance program. Since the data were not stratified based on race/ethnicity or geography, potential disparities could not be determined. In addition, ED visits fluctuate throughout the year and the total number of visits were different for 2019 and 2020. The difference in rates could be influenced by characteristics of the populations served or changes in the total ED visits. However, the additional analyses of median rates allowed for a more valid comparison of the volume of ED visits for the two time periods.

Holland, K. M., Jones, C., Vivolo-Kantor, A. M., Idaikadar, N., Zwald, M., Hoots, B., Yard, E., D’Inverno, A., Swedo, E., Chen, M. S., Petrosky, E., Board, A., Martinez, P., Stone, D. M., Law, R., Coletta, M. A., Adjemian, J., Thomas, C., Puddy, R. W., . . . Houry, D.  (2021). Trends in U.S. Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic. JAMA Psychiatry, 78(4), 372–379.

A recent national retrospective study from Denmark found individuals with a diagnosed autism spectrum disorder (ASD) have an increased risk for suicide attempt and suicide death.

The study design involved secondary analysis of Danish national register data. The country’s national registries contain anonymized socio-demographic, educational, employment, morbidity, and mortality data on the entire Danish population, which offer unique opportunities for research. Participants included 6,559,266 people ages 10 and older living in Denmark from 1995 through 2016. The primary outcome variables were suicide attempt and death.

Among study participants, 35,020 had received a diagnosis of ASD. When adjustments were made for sex, age, and time period, individuals with ASD were over three times more likely to attempt suicide than those without ASD. This difference was more pronounced for females with ASD, who were more than 8 times more likely to attempt suicide than females without ASD, while males with ASD were 1.93 times more likely to attempt suicide than males without ASD. Individuals with ASD were also nearly four times more likely to die by suicide compared to individuals without ASD. Among individuals with ASD, males were over 3 times more likely to die by suicide and females 2.63 times more likely than males and females without ASD.

One of the most important findings from this study was that protective factors for suicide in the general population were not protective for individuals with ASD. In fact, being married or cohabitating and employed were less protective for those with ASD. In addition, the risk of suicide attempt increased with education level and was highest among those with a university degree. However, psychiatric comorbidity was a major risk factor for suicide in the ASD population, with more than 90% of those who attempted or died by suicide having another psychiatric diagnosis. The authors suggested social isolation and poor access to health care could explain the link between ASD and suicide risk. 

The results of this research highlight the need for tailored suicide prevention strategies for individuals with ASD whose risk and protective factors may differ from those in the general population. Study strengths include the availability of a validated national dataset with socio-demographic, medical, and educational variables. Limitations include possible underreporting of ASD and suicide attempts and deaths. While the results of this study are important, they may not generalize to populations outside Denmark.

Kolves, K., Fitzgerald, C., Nordentoft, M., Wood, S. J., & Erlangsen, A. (2021). Assessment of suicidal behaviors among individuals with autism spectrum disorder in Denmark. JAMA Network Open, 4(1), e2033565. doi:10.1001/jamanetworkopen.2020.33565

A recent study found an association between participation in the Supplemental Nutritional Assistance Program (SNAP) and suicide risk. While other studies have found that food insecurity can contribute to mental health issues and suicidal behaviors (thoughts, plans, and attempts) globally,¹ this is the first study to document the association in a nationally representative U.S. sample. 

To determine whether SNAP is an appropriate setting for suicide prevention, researchers analyzed 2012-2018 data on adults ages 18 and older from the National Survey on Drug Use and Health. In the survey, SNAP participation was measured by asking whether the respondent or a member of their household had received benefits in the past year. Suicide-related outcomes were also measured with yes-no questions about having suicidal thoughts, planning a suicide attempt, or attempting suicide in the past year. The analyses controlled for demographic variables such as race/ethnicity, gender, marital status, age, education, employment status, and household income and size. Adjusted models were stratified by demographic factors, socioeconomic status, self-perceived physical health status, mental health service use, and age.

The results of the analyses indicated that SNAP participants were 1.89 times more likely to have suicidal thoughts, 2.35 times more likely to have planned suicide, and 2.89 times more likely to have attempted suicide in the past year than non-SNAP participants. When these results were adjusted to account for survey year, demographics, socioeconomic status, health status, and mental health service use, the association between SNAP participation and suicidal thoughts remained significant, with slight significance for planning and attempts.

These findings suggest systematically screening SNAP participants for mental health and suicidal behaviors may allow early identification of those at risk and offer an opportunity for prevention and intervention, particularly for those who may not be reached through other social services. This study is especially relevant given the increased prevalence of food insecurity resulting from the COVID-19 pandemic. It is important to note that this is a cross-sectional study (i.e., it reflects data collected at one point in time) and does not reflect current or ongoing conditions. The study measured SNAP participation by household rather than individual, and therefore may have implications for engaging the person at risk in suicide screening and intervention.

Bergmans, R. S., Jannausch, M., & Ilgen M. A. (2020). Prevalence of suicide ideation, planning and attempts among Supplemental Nutrition Assistance Program participants in the United States. Journal of Affective Disorders, 277, 99–103.

1. Koyanagi, A., Stubbs, B., Oh, H., Veronese, N., Smith, L., Haro, J. M., & Vancampfort, D,. (2019). Food insecurity (hunger) and suicide attempts among 179,771 adolescents attending school from 9 high-income, 31 middle income and 4 low-income countries: A cross-sectional study. Journal of Affective Disorders, 248, 91–98.

Suicide Attempts and Eating Disorders | Suicide Prevention Resource Center

Suicide Rates by Industry and Occupation—Morbidity and Mortality Weekly Report

Suicide Resilience among African American Women—Journal of Family Violence

Postvention Effectiveness—BMC Psychiatry

More Research from 2020

Suicide bereavement support (i.e., postvention) may be an important prevention strategy for people who have experienced a suicide loss. However, there is limited information on its effectiveness. This study sought to identify the impact of postvention strategies on grief, mental health, and suicide-related outcomes through a systematic literature review.

Researchers identified 12 peer-reviewed, controlled research studies on postvention interventions that had outcomes in the targeted areas of grief, mental health, or suicide. They found that interventions using trained facilitators and engaging family and community supports were more likely to have positive outcomes.

The identified studies examined a wide range of interventions, study populations, and outcome measures, and they had limited replicability. These considerations make it difficult to draw conclusions about the implications of current research for postvention practice.

To better understand the role of postvention in suicide prevention efforts, the researchers concluded more methodologically rigorous studies on the effectiveness of postvention interventions are needed.

Andriessen, K., Krysinska, K., Hill, N. T. M., Reifels, L., Robinson, J., Reavley, N., & Pirkis, J. (2019). The effectiveness of interventions for people bereaved through suicide: A systematic review of controlled studies of grief, psychosocial, and suicide-related outcomes. BMC Psychiatry, 19(1), 49.

Formal training in suicide postvention through ongoing professional development and graduate training may improve the perceived knowledge and competence of school psychologists in providing a postvention response.

Seventeen percent of school psychologists employed by a public school system in North Carolina during the 2016–2017 academic year responded to a survey on postvention experience, training, and perceived knowledge and competency. Forty percent of participants reported having formal training in postvention response, and just over 40 percent reported having at least one experience conducting a postvention response. Only 5.4% reported feeling “very knowledgeable” about postvention and only 1.8 percent reported feeling “very knowledgeable” about suicide contagion effects. Few participants (9.9%) reported feeling “very prepared” to provide a postvention response. Formal training in postvention significantly impacted providers’ knowledge and competency in employing a postvention response. The presence of a postvention protocol did not improve providers’ perceived knowledge or competency.

For school psychologists to feel confident and knowledgeable about postvention, additional early-career and ongoing professional development training opportunities are needed.

O’Neill, J. C., Marraccini, M. E., Bledsoe, S. E., Knotek, S. E., & Tabori, A. V. (2020). Suicide postvention practices in schools: School psychologists’ experiences, training, and knowledge. School Psychology, 35(1), 61–71.