Systematic Review of Suicide Prevention Strategies

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.