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Systematic Review
The authors state: "To synthesise new evidence in Veterans that has emerged since the 2015 ESP suicide prevention review on diagnostic accuracy of suicide risk assessment methods and the effectiveness of healthcare service interventions in preventing suicidal self-directed violence."
The authors state: "Population-level interventions: Three population-level interventions (2 were already included in the previous report) reduced suicide rates in US military members and Veterans with acute mental health admissions in 2 before-after studies and one postintervention series. Additionally, high versus low levels of suicide intervention skills training reduced suicide attempts but not suicide death in a prospective cohort of Army Reserve members. Individual-level interventions: Review found no studies that evaluated effects of individual-focused treatments specifically in recently returned or transitioning service members or on suicide death. Compared to treatment as usual or standard safety planning, the only individual-focused treatment to statistically significantly reduce suicide attempts in active duty service members or Veterans with suicide risk irrespective of psychiatric diagnosis was outpatient cognitive behavioral therapy (CBT) (HR 0.31; 95% CI 0.13 to 0.75) after 2 years. The ESP’s Nelson 2015 review already reported this finding. Compared to standard contract for safety (CFS), Standard and Enhanced Crisis Response Plans (S-CRP, E-CRP) reduced 6-month suicide attempts in unadjusted analyses (hazard ratio = 0.24, 95% CI 0.06 to 0.96). However, after adjustment for baseline suicidal ideation, which was slightly higher in the CFS group (Beck Scale for Suicidal Ideation [BSSI]: CFS = 18.5, S-CRP = 16.1, E-CRP = 15.8), the effect was no longer significant (HR = 0.29; 95% CI 0.06 to 1.18). Dialectical behavioral therapy (DBT) did not significantly reduce 6-month suicide attempts or ideation in a randomized trial of 91 Veterans with high suicide risk irrespective of psychiatric diagnosis (~50% borderline personality disorder). Finally, in the ‘Operation Worth Living’ trial, Collaborative Assessment and Management of Suicidality (CAMS) also did not significantly reduce suicide attempts over 6 months versus enhanced usual care."
The authors state: "For suicide prevention interventions, ongoing psychotherapy-focused interventions for individuals in acute suicidal crisis continue to be the most widely studied, with outpatient CBT still being the most well-established treatment. The largest gaps in evidence that may be the highest priorities for future Veteran Health Administration research are evaluation of the adverse effects of suicide prevention efforts and evaluation of suicide prevention efforts that specifically target high-risk populations, such as those service members transitioning to civilian life and those with a history of repeat suicide attempts, and those that focus on key social determinants of health and access to lethal means."