Disclosures: Mann reports receiving royalties from the Research Foundation for Mental Hygiene for commercial use of the Columbia-Suicide Severity Rating Scale. One study author reports being a member of the Research Grants Committee for the American Foundation for Suicide Prevention. The other author reports no relevant financial disclosures.

March 05, 2021
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Researchers identify evidence-based strategies for improving suicide prevention

Disclosures: Mann reports receiving royalties from the Research Foundation for Mental Hygiene for commercial use of the Columbia-Suicide Severity Rating Scale. One study author reports being a member of the Research Grants Committee for the American Foundation for Suicide Prevention. The other author reports no relevant financial disclosures.

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Researchers have identified multiple evidence-based strategies for improving suicide prevention, according to results of a systematic review published in American Journal of Psychiatry.

J. John Mann, MD
J. John Mann

“From 2005 to 2019, more than four times as many articles on suicide prevention were published compared with the previous 40 years,” J. John Mann, MD, of the New York State Psychiatric Institute and department of psychiatry at Columbia University, and colleagues wrote. “We reviewed all randomized controlled trials published between 2005 and 2019 that examined suicide, nonfatal suicide attempts and suicidal ideation. The benefits of reducing access to the most lethal methods used for suicide and the impact of prescribing antidepressants were examined using epidemiological studies, mostly time-series studies, some with contemporaneous geographic controls, identified using the same search engines.”

The researchers focused on suicidal behavior as an outcome instead of suicidal ideation because of the closer relationship between nonfatal suicide attempts and suicide deaths than that of suicidal ideation and suicide deaths, they noted. They searched two databases and included randomized controlled trials published between September 2005 and December 2019 that assessed suicidal behavior or ideation as primary outcomes, as well as epidemiological studies published during the same period that evaluated limiting access to lethal means, using educational approaches and the effect of antidepressant treatment.

The review, which included 97 total studies, revealed multiple strategies for mitigating risks related to suicide. These included training primary care physicians in recognizing and treating depression, which was linked to suicide prevention; educating youths on depression and suicidal behavior and fostering active outreach to psychiatric patients after discharge or a suicidal crisis, which appeared to prevent suicidal behavior; and using antidepressants to prevent suicide attempts, per results of meta-analyses, although individual randomized controlled trials appeared underpowered.

Other findings included ketamine’s role in reducing suicidal ideation in hours despite being untested for suicidal behavior prevention; cognitive behavioral therapy and dialectical behavior therapy appearing to prevent suicidal behavior; a lack of evidence for active screening for suicidal ideation or behavior being superior than just screening for depression; a lack of effectiveness regarding educating gatekeepers about youth suicidal behavior; a lack of randomized trials for gatekeeper training for adult suicidal behavior prevention; the understudied nature of algorithm-driven electronic health record screening, internet-based screening and smartphone passive monitoring for identifying high-risk patients; and the sporadic employment in the United States of means restriction, including of firearms, despite half of all U.S. suicides involving firearms.

“The biggest challenge in suicide prevention lies in improving the identification of who is at high risk and when,” Mann and colleagues wrote. “Determination of imminent risk is needed for calibration of prevention efforts to high-risk periods by employment of rapid reduction of suicidal ideation and means restriction. Fast-acting medications like ketamine may have a role during acute suicide risk but are untested for prevention of suicide attempts.

“Determination of imminent risk has evolved toward continuous monitoring via mobile devices,” they added. “Further research is needed to evaluate such approaches and how to integrate them into prevention responses.”