TABLE OF CONTENTS
PAGEKey messages / 3
Background / 6
Methods / 8
Findings
§ Risk and protective factors / 10
§ Evidence for effective interventions / 19
§ Universal, selective and indicated interventions / 19
§ Specific population groups / 35
§ Specific settings / 40
§ Current best practice in suicide prevention / 42
§ Promising strategies / 45
§ Gaps in the evidence base / 47
References / 51
Appendix 1. Tables / 53
KEY MESSAGES
The goal of this rapid review was to provide a comprehensive synopsis of current knowledge about:
i. risk and protective factors for suicidal behaviours, and
ii. the effectiveness of interventions to prevent suicide and suicidal behaviours.
Why suicide prevention is important
Suicide is a significant public health issue in New Zealand. It is consistently one of the leading 10 causes of death across all ages and it is the leading cause of death due to injury. It is a leading cause of death in young people aged <25 years. Despite efforts, suicide rates have not fallen substantially, and international trends suggest suicide rates are increasing.
While suicides occur across the lifespan, some groups are disproportionately affected, and the groups which are most vulnerable may change over time. Most suicides (75%) are men: Men of working age (20 -65 years) account for more than half of all suicides, and men aged 20-40 account for 30% of all suicides every year. Higher suicide rates are found in people with serious mental illness and addictions (more than 90% of people who die by suicide and those who make serious suicide attempts have a major mental health problem). Suicide rates are higher in Māori than non-Māori, and Māori suicides are concentrated in the young. Similarly, Pacific youth have higher suicide rates than their elders. Suicide rates are higher in men aged 25-44 years than in youth (<25 years), and older men (>65 years) have high suicide rates. Those who identify as lesbian, gay, bisexual, transgender or intersex (LGBTI) have higher rates of suicide attempt and suicide. Suicide rates are higher in rural compared to urban areas.
A complex array of inter-related risk factors and causal pathways underlies suicidal behaviour. Risk factors may change over time, new factors may emerge, and only some are potentially modifiable. Prevention programmes must span individual, interpersonal, community and societal factors, as well as addressing particular risk factors for high-risk groups. Major risk and protective factors for suicidal behaviour are now well-established and further research tends to strengthen and refine current evidence rather than identify new factors. Research is now focused on using the findings from risk factor research to develop and evaluate interventions to reduce suicidal behaviour.
Key messages
Universal, selective and indicated interventions
There is good evidence that universal interventions (restricting access to lethal means of suicide, adoption of media reporting guidelines, and restrictions on access to alcohol) can reduce suicide rates. There is some evidence for a short-term attitude change, but no evidence of an impact on suicidal behaviours, for a range of public messaging programmes including those that focus on depression awareness, de-stigmatizing mental illness, promoting help-seeking, or promoting health and wellbeing. There are no reviews of the effectiveness of national suicide prevention strategies.
School-based suicide prevention programmes, typically gatekeeper training programmes, have been widely implemented but, in general, poorly evaluated, and most studies show no impact on suicide attempts or suicide rates. An international cluster randomized trial that compared a mental health awareness programme, screening and referral, and gatekeeper training, found that only the mental health awareness programme was associated with a lower incidence of serious suicide ideation and suicide attempts. A small number of prevention activities have been developed for at-risk occupations (e.g. defence forces, police, the construction industry). The most well-known is the US Air Force multi-component preventive intervention programme which includes leadership and gatekeeper training, increased access to mental health services, coordination of care for high-risk individuals, and a higher level of confidentiality for those who disclose suicidality. The Air Force programme reduced suicide rates by 35%, and has been replicated with similar results.
Community Mental Health Care programmes (based on a multidisciplinary community-based team) may reduce hospital admissions for suicidal behaviour (compared to treatment as usual, TAU). Family or parental support programmes can reduce or prevent substance use in adolescents, but there is no evidence that they reduce suicides. There is no clear evidence about programmes that are effective in reducing suicidal behaviours for Māori or Pacific people, rural people, or for preventing suicide in LGBTI and sexual minority populations. Community-based gatekeeper training for suicide prevention may be promising in indigenous communities but needs to be culturally tailored to the target population.
There is good evidence that physician education about depression recognition and management can reduce suicides, if supported by primary care depression care services, with effects greatest for women, and older adults. There is good or promising evidence for a range of internet guided self-help interventions for depression and anxiety, treatment adherence, and some support for reduced suicidal ideation. However, evidence for the effectiveness of these programmes with youth is lacking. Although crisis telephone lines are widely used, there are few evaluations of their effectiveness. There is some evidence from a small number of studies that crisis telephone services reduce suicidal ideation within the context of the crisis call, and that they are more helpful for acute compared to chronic callers.
There is no evidence that postvention programmes reduce suicidal behaviour. One review found that postvention counselling for familial survivors of suicide (spouses, parents, children) generally helped reduce psychological distress in the short term. One review found that treatment interventions for complicated grief showed a positive effect.
Meta-analyses of pharmacological treatments for depression find that antidepressant treatment decreases suicide ideation in individuals aged 25 years and older. For youth (<25 years) antidepressant treatment decreases depressive symptoms, but does not always decrease suicidal ideation, and is associated with a 1-2% risk difference in new-onset or worsening suicide ideation, or suicide attempts. For people with acute suicidal ideation and serious mental illness, including treatment resistant depression, psychopharmacological (e.g. antidepressants, lithium, clozapine, ketamine), somatic (e.g. electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTCMS)), psychotherapeutic (e.g. CBT, DBT, mentalisation, third wave (mindfulness, yoga)), psychosocial (e.g. long-term follow-up contacts, physician follow-up calls) and complementary therapies (yoga, meditation, exercise, light therapy) can be effective.
Interventions which hold promise
Within communities integrated, multi-component, multi-level, systems-based interventions are recommended, such as those developed under the umbrella of the European Alliance Against Depression. The individual programmes included as components of these approaches have good evidence of effectiveness and include: training and education for medical practitioners in recognizing, treating and managing depression and suicidal behaviour, minimizing access to lethal means of suicide, controls on alcohol, gatekeeper education programmes, responsible media reporting and enhancing resiliency in indigenous communities.
New communications technology offers an opportunity to develop cost-effective novel strategies that involve screening, intervention, caring follow-up contacts, resiliency building, therapy and mental health education, using cell phones and the internet, particularly for those who are not in contact with services. New diagnostic tools (e.g. MRIs, specific blood tests) may help to develop individually targeted antidepressant treatments. However, it will be some years before these promising drugs are available to the public so non-medicinal advances are important.
Promising strategies also include theoretically valid upstream approaches to ameliorate childhood adversity and exposure to childhood sexual abuse, encourage resiliency and life skills, and develop good emotional health. Such programmes include early intervention programmes of at-risk children, parenting programmes, and programmes which encourage development of emotional skills and life skills (e.g. the Good Behaviour Game, the Youth Aware of Mental Health (YAM) programme, Zippy’s Friends).
Gaps in the evidence base
There are multiple gaps in knowledge and research at the policy level, at the structural health systems level and in public health and mental health services. Research gaps in public health include: the need to evaluate new and existing community programmes, development of effective interventions for identified high risk groups; evaluation of the impact of alcohol restrictions on suicidal behaviour; research to address the growing problem of childhood adversity and the best ways to improve the life course of those children subjected to such adversity; and research into other social and economic inequalities that impact on suicide risk.
Research gaps in mental health include: the need to develop effective programmes to engage and treat those who have made a suicide attempt; development of effective mentally healthy lifestyle programmes, and treatment adherence programmes for people with mental health problems; more knowledge about how to promote resiliency; improved risk prediction, and identification of biomarkers for suicidal behaviour.
Research gaps in policy include: development of a clear national suicide prevention research agenda; the impact of interventions on high-risk communities; evidence-based and culturally acceptable interventions for Māori, Pacific, Asian and immigrant New Zealanders; strategies to reduce older adult suicide; statistical modelling to identify priorities and assess the impact of interventions; identification of effective interventions outside healthcare settings (e.g. communities, workplaces), and improved infrastructure to support suicide prevention and research (e.g. more timely and more comprehensive data, registers, surveillance, databanks), and education (e.g. a central resource library, a national research and education centre).
Practice gaps in public health practice include: a lack of strategies to reduce harm related to alcohol; exploration of the extent to which new digital technologies (apps, SMS, internet) can be used for health and mental health promotion, treatment and support; and the development of early intervention programmes to support at-risk children and families.
Gaps in mental health practice include the need to implement and evaluate models of systems-based mental health care such as the Zero Suicide initiative; development and promotion of brief, intensive treatments that can be widely disseminated (e.g. online therapies); more use of ‘green ‘ prescriptions promoting, for example, exercise, sleep, nutrition, yoga, mindfulness, and stress management to minimise suicide risk; development of better service provision for comorbid disorders, especially comorbid alcohol, depression, substance abuse and antisocial behaviours; standards for screening for depression and suicide risk; development of follow-up programmes for people discharged from emergency departments and inpatient psychiatric care; and the provision of a rural mental health strategy including efforts to address, especially, substance misuse in rural regions, and the mental health problems of rural older adults.
Practice gaps in policy include the need to provide a structure that can support national suicide prevention activities, and the need to integrate crisis, police and first response services, especially in rural areas. There is a need to build workforce capacity for suicide prevention including research capacity, and a cadre of people trained and experienced in programme implementation and evaluation. There is a need for an academic unit which can provide leadership in suicide research and education, provide undergraduate and postgraduate education, deliver suicide education to health, educational and social service providers, and be a resource which can disseminate information.
BACKGROUND
Introduction
The goal of this rapid review was to provide a comprehensive synopsis of current knowledge about:
i. risk and protective factors for suicidal behaviours, and
ii. the effectiveness of interventions to prevent suicide and suicidal behaviours.
This review was commissioned by the New Zealand Ministry of Health as preparation for the development of a new national suicide prevention strategy. The review focusses on what the current evidence means in a New Zealand context, with particular emphasis on key risk groups identified by the Ministry of Health. The time period spanned in the review was from 2006 (when the previous 10-year national suicide prevention strategy was implemented) to 2016. The review was undertaken as a pragmatic rapid review, prepared over four weeks, summarising international research evidence drawn from systematic reviews of the research literature, and supplemented by studies in areas relevant to New Zealand or to the nominated high-risk groups of interest.
Specific objectives
The specific objectives of the review were as follows:
· Summarise current best knowledge about risk and protective factors for suicidal behaviour (including suicide and attempted suicide) with a particular focus on modifiable factors.
· Identify effective (universal, selective and targeted) strategies for preventing suicide.
· Identify effective strategies for preventing suicide in specific high-risk populations including:
o Indigenous (Māori) people? o Pacific peoples
o Child, adolescent and youth (<25 years) populations
o Adults (25 - 64 years) and older adults (>65 years), particularly men
o Mental health service users o LGBTIQ
· Identify effective strategies for suicide prevention in different settings and contexts including:
o Models of care in the healthcare system
o Primary care and community-based services
o Educational/school settings, including tertiary settings
o Regional differences in suicide risk, particularly urban versus rural differences (including
strategies relevant for people working in farm and agricultural industries)
· Describe what constitutes current best practice in suicide prevention.
· Identify promising strategies for preventing suicide for which there might not yet be good evidence but which might be funded and evaluated within the time frame of the new national strategy for suicide prevention.
· Specify gaps in the evidence base for effective strategies which might have implications for policy revision and service development in New Zealand?
Why suicide prevention is important
Suicide is a significant public health issue. It is one of the leading 10 causes of death in New Zealand and it is the leading cause of death due to injury. Each year there are almost twice as many suicides as deaths from motor vehicle crashes, and 10 times more suicides than workplace fatalities.