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Suicide Prevention Interventions and Referral/Follow-up Services: A Systematic Review.

O'Neil ME et al. (2012)

Evidence synthesis program - n/a

Evidence Categories

  • Care setting: Healthcare Setting
  • Care setting: Other settings
  • Population group: Military/ ex military
  • Population group: Adults
  • Intervention: Selective interventions: Pharmacological interventions
  • Intervention: Selective interventions: Multicomponent (multiple selective components)
  • Intervention: Selective interventions: Psychosocial Interventions
  • Outcome: Suicide

Type of Evidence

Systematic Review

Aims

The authors state: "As requested by the Veterans Affairs (VA)/Department of Defense (DoD) Evidence Based Practice Working Group (EBPWG) on suicide prevention, we examined recent research on suicidal self-directed violence as defined by Crosby et al. 2011. We update the work of Gaynes et al. and Mann et al. by systematically reviewing relevant literature that was not included in either report, and was published in 2005 through November 18, 2011. Though the focus of the report is on suicide prevention, we include as outcomes any type of suicidal self-directed violence, defined as “Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent.”

Findings

The authors state: "As noted, we found 38 RCTs that satisfied our inclusion criteria and reported outcome data on suicides or suicide attempts. In spite of this relatively large number of trials, the data obtained provided only low strength or insufficient evidence to draw conclusions about the effectiveness of the interventions and referral/follow-up services being studied. This is primarily because interventions provided, populations studied, and comparison conditions examined in the 45 were so heterogeneous. This heterogeneity precluded meaningful comparisons across trials and quantitative combination of results from multiple trials. Therefore, each trial essentially stands alone for providing evidence related to the specific intervention being investigated. For example, though multiple studies compared psychotherapeutic interventions broadly categorized as either DBT or CBT, some studied a solely female population and all used different comparison conditions, making the combination of findings impossible."

Conclusions

The authors state: "Examining RCTs of interventions is the gold standard for determining relative efficacy. Thouch there are some RCTs of suicide prevention interventions, these trials are largely plagued by study design flaws and insufficient power. This is likely due to: a) the complexity of conducting high quality trials of interventions that involve psychotherapy, and b) the very low base rates of suicide and suicide attempts even in the highest risk groups. In our systematic review of the evidence related to suicide prevention interventions, we found these two issues to be paramount to the lack of strong evidence for any interventions in preventing suicide and suicide attempts. We were most interested in RCTs related to Veteran and military populations as stated in Key Questions #1 and #3; however, we found no such trials meeting our inclusion criteria published since 2005. We, therefore, examined trials in non-Veteran/military populations in the hopes of generalizing findings to our populations of interest. The included studies covered a broad range of interventions implemented with various populations in terms of gender, age, and diagnosis. Even the broader inclusion criteria of Key Questions #2 and #4 did not provide clear answers as to which interventions or referrals and follow-up services are most effective in the prevention of suicidal or undetermined self-directed violence. Therefore, it is likely the best available evidence for interventions to prevent suicide is to use a combination of the most theoretically sound and well researched interventions available. For example, if a Veteran or member of the military is identified as being at risk for suicide, making sure that this person has adequate case management to assist with intervention attendance as well as family or other social support outside of the medical setting are both likely to be good clinical practice. Additionally, assuring that the individual has access to relatively immediate care such as inpatient hospitalization, outpatient therapy, and pharmacotherapy is also warranted depending on the individual's level of risk. Finally, providers should take into consideration which interventions are most likely to benefit the individual based on diagnosis or other relevant clinical factors (e.g., use of mood stabilizers if a patient meets criteria for Bipolar Disorder, or referral to an emotion regulation-focused psychotherapy intervention such as DBT if the patient meets criteria for Borderline Personality Disorder). Overall, the intervention and referral/follow-up service studies that were included in this report were quite complex and appeared very comprehensive in nature; such a comprehensive and multifaceted approach to suicide prevention care for Veterans and members of the military appears well warranted."