Suicide prevention strategies revisited: 10-year systematic review.
BACKGROUND
Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.


METHODS
We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.


RESULTS
We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.


CONCLUSIONS
In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.


BACKGROUND
The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.
Geha Mental Health Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, NY, USA. Electronic address: zalsman@post.tau.ac.il.
Gil
G
Zalsman
Centre for Suicide Research, University of Oxford, Oxford, UK.
Keith
K
Hawton
National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.
Danuta
D
Wasserman
Unit for Suicide Research, Ghent University, Ghent, Belgium.
Kees
K
van Heeringen
National Suicide Research Foundation, Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
Ella
E
Arensman
Department of Medicine and Health Science, University of Molise, Via De Santis Campobasso and National Institute for Health, Migration and Poverty, Roma, Italy.
Marco
M
Sarchiapone
National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.
Vladimir
V
Carli
National Institute of Mental Health, Klecany, Czech Republic.
Cyril
C
Höschl
Geha Mental Health Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Ran
R
Barzilay
Department of Developmental and Clinical Child Psychology, Institute of Psychology, Eotvos Lorand University, Budapest, Hungary.
Judit
J
Balazs
Institute of Behavioral Sciences, Semmelweis University Budapest, Budapest, Hungary.
György
G
Purebl
Université de Lorraine, Pôle de Psychiatrie et Psychologie Clinique, Centre Psychothérapique de Nancy-Laxou, Nancy-Laxou, France.
Jean Pierre
JP
Kahn
Department of Psychiatry, University of Oviedo, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM Oviedo, Spain.
Pilar Alejandra
PA
Sáiz
Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.
Cendrine Bursztein
CB
Lipsicas
Department of Psychiatry, University of Oviedo, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM Oviedo, Spain.
Julio
J
Bobes
Department of Clinical Psychology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.
Doina
D
Cozman
Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany.
Ulrich
U
Hegerl
Psychiatry Department, Sheba Health Center and Sackler School of Medicine, Tel Aviv University, Tel Avis, Israel.
Joseph
J
Zohar
D006801:Humans; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic; D000092864:Suicide Prevention