A RAPID REVIEWOF THE SUICIDEPREVENTIONLITERATURE

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TABLE OF CONTENTS

PAGEKey messages 3Background 6Methods 8Findings

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 51Appendix 1. Tables 53

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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, andii. 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.

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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).

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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.

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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, andii. 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 (includingstrategies 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?

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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.

In 2014 the age-standardised rate of suicide in New Zealand was 10.7 per 100 000, representing, provisionally, 504 suicides, and equivalent to almost 10 people dying by suicide each week.1 Rates of suicide vary by age, gender and ethnicity. The majority (75%) of suicides in New Zealand each year are men, and the rate of suicide is highest in men aged 25-44 years. The rate of suicide amongst young men (15-24 years) appears to be declining. Suicide rates for Māori are 1.4 times higher than those for non-Māori, and Māori suicide deaths are young: The majority (almost 60%) are aged less than 25 years. By contrast, approximately 20% of non- Māori deaths are aged less than 25 years. Among Pacific peoples suicide rates are also highest in young people.

Globally, there are almost one million deaths from suicide each year, and these rates are not declining. The World Health Organisation (WHO) suggests that international rates of suicide have increased by 60% during the last 45 years, and continue to rise. In the United States, age-adjusted rates and number of suicide deaths have increased steadily in recent years, from 11 deaths per 100 000 in 2005 to 13.8 in 2015, representing an average annual increase in the age-adjusted suicide rate of 2.15%. In 2015 the highest suicide rate (19.6 per 100 000) was observed in men aged 45-64 years. In Australia, the overall suicide rate increased significantly from 10.9 deaths per 100,000 in 2013 to 12 suicides per 100,000 in 2014, the highest rate since 2001. Amongst Australian deaths in 2014, suicide rates increased in adult men. In New Zealand, suicide rates appear to have remained relatively stable over the 10 years to 2104, and while they have not increased, neither have they declined, despite a 20-year focus on suicide prevention. In the past, New Zealand’s suicide rates have tended to follow, but lag, suicide trends in the United States and Australia. Given international trends for rising suicide rates, and the fact that New Zealand’s suicide rate is not declining, suicide remains a challenging problem in New Zealand.

Suicide is a difficult issue to address for many reasons. It is a problem which has multiple, complex and inter -related risk factors and causal pathways, which span individual, interpersonal, community and societal levels. These risk factors may change over time, and new factors may emerge. Some risk factors are fixed, while others are potentially modifiable, although good evidence about how they might be changed has been lacking. Less is known about the factors that are protective against suicide than is known about those that contribute to suicide. Suicide affects people across the lifespan, and disproportionately affects particular population groups. The groups which are most vulnerable to suicide may also change over time. For all these reasons, suicide prevention requires a sustained and comprehensive, but flexible, approach which incorporates a range of interventions. In the last 10 years, an increasing amount of information has been published about effective interventions, which means that a more informed and targeted approach to suicide prevention can be provided than was previously possible.

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METHODS

This rapid evidence assessment summarises evidence from systematic reviews of the international research literature published from 2006-2016, supplemented by landmark reviews or studies, and studies relevant to New Zealand or to the nominated high-risk groups and settings of interest. In the last two years there has been an exponential increase in the volume of systematic reviews about suicide prevention and related areas (e.g. treatment of depression). Given this, the review pragmatically balanced time constraints with guidelines for rapid reviews. A rapid review is a summary of findings from systematic reviews. 2-3 A systematic review is a summary of all identified studies in the international research literature that have addressed a specific issue, and which employs systematic approaches to search, select and evaluate studies for inclusion in the review, and then to summarise data. Research questions for this rapid review were identified by the Ministry of Health and covered specific populations and settings to ensure specific needs for information were addressed.

Databases searched included PubMed, CINAHL, Web of Science, PsycInfo, Medline and Embase on OVID, the Cochrane Library on Wiley (including CENTRAL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), Health Services Evidence (HSE), National Health Service Economic Evaluation Database (NHS EED), Centre for Reviews and Dissemination (CRD), Canadian Agency For Drugs And Technologies In Health (CADTH)). Bibliographies of relevant publications were searched. To identify interventions appropriate for the New Zealand context, searches for grey literature were undertaken on websites of relevant specialist organisations, both national and international. Search terms used were ‘suicid*’, “prevent*’, ‘review*’, ‘systematic‘, ‘meta-anal*’, ‘Māori’, ‘Pacific’, ‘rural’, ‘LGB*’, ‘child*’, ‘adolescen*’, ‘teen*’, older adult*’, ‘elder*’, ‘senior*’, ‘LGB*’, ‘sexual orientation’, ‘sexual minorit*’. The review was limited to publications in English, and to those available in full texts electronically.

A total of 2344 papers were reviewed and 211 were included in this review. Criteria for inclusion of systematic reviews included relevance, searches of at least two databases, use of explicit search criteria and inclusion of at least one study examining a suicide prevention approach. Landmark reviews published prior to 2005 and additional relevant papers were included to cover some areas without bias. For each paper, the focus of the review and the key findings were entered into evidence tables (see tables 1-3, Appendix 1). Information in these appendices was used to prepare the summary tables and information used in the report.

Structure of the report

Findings in this report are considered within a framework based on Gordon’s continuum of care model of prevention, treatment and maintenance activities 4-5. This model, adopted by the Institute of Medicine (IOM) to guide identification of population groups and individuals with differing prevention needs, 6 and alignment of these needs with appropriate policies and programmes, has been adapted for suicide prevention, 7-9 and is used in this report (Table 1). Using this structure, for each research question this report provides a summary of key findings from systematic reviews and relevant papers.

· Primary prevention activities are categorized for universal, selective and indicated service populations. Universal interventions target the general public or an entire population (e.g. national, regional, community, school) that has not been identified on the basis of individual risk. These programmes are designed to influence everyone within the specific population (e.g. means restriction, media guidelines).

· Selective interventions are directed at individuals or a population subgroup whose members are at risk of developing suicidal ideation or behaviours. Programmes are designed to prevent the onset of suicidal behaviours. An example of selective intervention is programmes that screen for suicide risk.

· Indicated programmes target individuals within the population who can be identified as being at risk for suicide. Programmes are delivered individually or in groups with the goal of reducing risk factors and enhancing protective factors (e.g. case management for people who have made a suicide attempt).o Treatment activities and interventions are targeted to people who have a mental disorder and/or

suicidal ideation and behaviour (e.g. psychotherapy for people with depression).o Maintenance activities refer to the range of psychoeducational, support, psychopharmacological,

psychotherapeutic and support programmes employed to provide continuing, long term care for people with chronic and serious mental illnesses or suicidal behaviours.

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Table 1. Suicide prevention interventions (adapted from Guo and Scott, 2010 7; Beautrais and Larkin, 2013 8; Hirji et al, 2014 9; WHO, 2014 10)

Type of intervention Interventions

Prevention Universal · National suicide prevention programmes· Means restriction policies· Media guidelines· Public messaging programmes· Alcohol control policies· Social welfare policies and employment policies

Selective · Suicide prevention centres· Community based suicide prevention programmes· School-based suicide prevention programmes· Tertiary education/campus-–based programmes· Child welfare/juvenile justice-based programmes· Workplace-based suicide prevention programmes· Courts/prisons-based suicide prevention programmes· Programmes for defence force personnel· Rural programmes· Alcohol/drug misuse programmes· Parenting support and Early Start programmes· Programmes to strengthen cultural identity/continuity

Indicated · Training for health and social service providers· Support to primary care providers and health service planners· Providing education and support to carers of high-risk individuals· Telephone-based (crisis) suicide prevention services· Internet- and m-health-based programmes· Postvention

Treatment Case identification

· Primary care screening programmes· Emergency Department (ED) screening programmes· Follow-up and ongoing contact after ED/hospital discharge

Standard treatment for knowndisorders

· Psychotherapy and psychosocial programmes· Pharmacotherapy· Intensive care plus outreach· Home-based therapy· General hospital admission· Neurosurgery· ECT· Multiple/combined therapies

Maintenance Adherence · Follow-up and ongoing contact· Crisis (green) cards· Caring contacts· Safety and support plans· Inpatient admission· Treatment adherence programmes· Motivational interviewing

Aftercare · Long-term therapy· Service delivery/organisation and case management models

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QUESTION 1. RISK AND PROTECTIVE FACTORS

What is current best knowledge about risk and protective factors for suicidal behaviour (including suicide and attempted suicide) with a particular focus on modifiable factors?

Table 2 summarises current knowledge about risk factors for suicide and suicide attempt for categories of individual, interpersonal and risk factors.

Table 2. Major risk factors for suicide and suicide attempt

Individual Risk FactorsFamily history There is a strong genetic contribution to suicidal behaviour. Suicidal behaviour isand genetic transmitted within families, increasing suicide risk 2-10 times depending on degree offactors relationship. Risk of suicide attempts is higher in relatives of people who die by

suicide. Risk of suicide is higher in the relatives of people with a history of suicide attempts. Adoption studies show concordance between biological, but not adoptive, relatives, suggesting that imitation of suicidal behaviour has a minor role. For example, a national registry study in Sweden found that, after a sibling suicide, the risk of suicide in remaining siblings was increased 2-fold for men and 3-fold for women. However, an unrelated spouse with a psychiatric disorder or who dies by suicide also increases the risk of suicide, illustrating the role of contextual and perhaps, imitative, effects within families.

Suicide risk can be transmitted within families by genetic predisposition for mental disorders with which suicidal behaviour is strongly associated (e.g. depression and substance abuse disorders). Transmission within families of suicide-specific behaviour seems to be mediated through a tendency for impulsive aggressive behaviour. Estimates of heritability are of the order of 30% to 50%. When the heritability of other psychiatric conditions is taken into account, the specific heritability of suicidality is estimated at 17·4% for suicide attempts and 36% for suicide ideation.

Suicidal ideation seems to be transmitted within families as part of transmission of mood disorders. Patterns of transmission of suicidal ideation and suicidal behaviours are different. Increasingly, clear distinctions are drawn between ideation and behaviours, rather than treating ideation as being part of a continuum of suicidal behaviours.

To date, candidate-gene and genome-wide association studies, and studies of gene-environment interactions, have not been conclusive.

Childhood adversity may induce long-term effects through epigenetic changes in gene pathways. Genome-wide association studies of people with depression or people who have died by suicide and who were exposed to childhood adversity have identified methylation changes in genes associated with stress, cognitive processes and neural plasticity.

Childhood adversity causes cognitive deficits, particularly in problem-solving and memory specificity, which are factors which contribute to suicidal behaviour. Individuals with a higher than average cortisol response to stress, a history of suicide ideation, or a first-degree relative who has died by suicide have impaired cognitive functions after social or emotional stressors, evident in problems with decision making, problem-solving, and executive function.

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Individual Risk Factors

Individuals with a higher than average cortisol response to stress, a history of suicide ideation, or a first-degree relative who has died by suicide have impaired cognitive functions after social or emotional stressors, evident in problems with decision making, problem-solving, and executive function.

Suicidal states are linked with various molecular changes detectable in blood, saliva, and in the brain. Neurotransmitters implicated in depression and suicide include serotonin, glutamate and γ-aminobutyric acid. Ketamine targets the glutamate pathway and offers promise for the treatment of acute suicidality and treatment Sexual orientation Risks of suicide attempts and suicide are increased in sexual minorities. National registry-based data from Denmark suggest that individuals with a history of same-sex relationships, particularly men, have a 3 to 4-fold elevated risk of suicide. New Zealand and international data suggest there is a 5 to 6-fold increased risk of suicide attempts among individuals belonging to sexual minority groups.

Age, gender and ethnicity

The risk of suicide tends to increase with increasing age, but young people attempt suicide more often than older adults. Females make twice as many suicide attempts as males, but males are three times more likely to die by suicide. Age and gender differences are explained only partially by the use of more lethal methods.Suicide rates are 1.4 times higher among Māori than non-Māori. Pacific suicide rates are lower than the national suicide rate. Māori and Pacific suicides are concentrated in young people.

Mental disorders Psychiatric illnesses are the most important predictors of suicidal behaviours and suicide. Psychological autopsies consistently find that approximately 90% of people who die by suicide have a recognisable mental or emotional disorder at the time of death. People who do not meet criteria for a psychiatric illness in these studies likely had a subthreshold disorder or a disorder which the research procedure failed to detect.

Most people with a psychiatric illness do not die by suicide. Some psychiatric illnesses have a higher risk of suicide than others. The psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcohol dependence or other substance abuse, schizophrenia, personality disorders, and anxiety disorders.

Across the lifespan, the highest risk for suicidal behaviour exists when a mood disorder that is associated with suicidal ideation co-occurs with other disorders that either increase distress (panic disorder, post-traumatic stress disorder) or decrease restraint (conduct and antisocial disorders, substance misuse).

Depression Depression is the most salient condition in suicidal behaviour. Major depressive episodes, in people with major depressive disorder or bipolar disorder, account for at least half of all suicides. In patients with depression, a history of suicide attempts is strongly correlated with feelings of worthlessness. Concurrent personality disorder is also strongly correlated with suicide attempts in depressed patients.

Among patients with bipolar disorder, mixed state episodes are strongly associated with suicide attempts, with risk increasing according to the amount of time spent in mixed depressive episodes; suicide risk is highest within the first year of illness, and amongst those with strong feelings of hopelessness.

Substance use disorders

Alcohol and drug-related disorders are common in people who die by suicide and might exacerbate underlying risk, or interact with depression to increase suicide risk. Reported rates of suicide among people with alcohol dependence range from 2% to 18%. Almost 90% of alcohol dependence suicides are men. Approximately 20 to 25%.

Individual Risk Factors

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Anxiety disorders Anxiety disorders more than double the risk of suicide attempts. Comorbid depression and anxiety increase suicide risk substantially.

Schizophrenia and other psychoticDisorders

Adults with schizophrenia and other psychotic disorders have a higher risk of suicide. In people with these disorders, suicide risk is associated with depressive symptoms, young age, male gender, education level, positive symptoms, and extent of insight into the illness. Symptoms of psychosis (delusions, command auditory hallucinations, paranoia) may increase suicide risk regardless of diagnosis.

Eating disorders Suicide is the most common cause of mortality in eating disorders.

Comorbidity Patients with multiple psychiatric comorbidities are at higher risk than those with uncomplicated depression or an anxiety disorder.

Psychiatric hospitalization

Suicide risk may be elevated following psychiatric inpatient hospitalization. In one review, 40% of those who died had been discharged from inpatient psychiatric care within the previous year.

Extent of suicide risk

Overall, people with psychiatric illness have a 10-fold higher risk of suicide than the general population. The severity of psychiatric illness is associated with risk of suicide. A meta-analysis found that lifetime risk of suicide is 8.6% in patients who had a psychiatric inpatient admission involving suicidal ideation, 4% in patients with a psychiatric admission for an affective disorder without suicidality, 2.2% in psychiatric outpatients, and <0.5% in the general population.

A general ‘psychopathology’ factor

Recent studies suggest that a general ‘psychopathology’ factor increases suicide risk, rather than any specific psychiatric illness. A prospective survey interviewed >34, 000 people at baseline and three years later, and found that current mental disorders were strongly associated with suicide attempts, but that the risk was not associated with any single disorder. Rather, the effects of mental disorders were exerted through a general psychopathology factor, representing the shared effect across all disorders. Mental disorders in remission increased the risk of current disorders, which in turn increased the risk of suicide attempts, but remitted mental disorders had no direct effect upon the risk.

Inflammatory markers

Psychiatric patients with suicidal ideation or behaviour are more likely to have aberrant levels of inflammatory markers (e.g. increased interlukin-1β and interleukin-6), compared with non-suicidal patients or healthy controls

Personality traits and psychological factors

Personality traits and cognitive styles mediate the association between risk factors and suicidal behaviour. Cluster B personality disorders (e.g. borderline, narcissistic, antisocial personality disorders), are strongly associated with suicide - all these disorders are characterised by aggressive and impulsive traits.

Hopelessness Irrespective of mental disorder, hopelessness is strongly associated with suicide, and can persist even when other symptoms of depression have remitted. Hopelessness may mediate the relationship between low self-esteem, loneliness, interpersonal losses, and suicide.

Impulsivity Impulsivity, particularly among adolescents and young adults, is associated with acting on suicidal thoughts. In combination, impulsiveness, disinhibition because of substance intoxication, and hopelessness can be especially lethal.

Suicidal ideation Individuals who express suicidal ideation have a clearly increased risk of suicide death within a year. A follow-up study found that suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients than in non-psychiatric participants.

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Individual Risk Factors

History of suicide attempts

The strongest single predictive factor for suicide is a history of suicide attempt. Patients with a history of a suicide attempt are 5 to 6 times more likely to make another attempt. Among those with prior attempts, the risk of suicide is 1% within the year following the index attempt (100 times higher than the risk in the general population). This risk endures, and is 5% in 10 years. The risk of a further attempt is highest in the first few weeks immediately after a suicide attempt. Risk of suicide after a suicide attempt, is greatest in patients with schizophrenia, or unipolar and bipolar disorder.

However, prediction of which individual patients will make further attempts, based on the presence of multiple risk factors, does not greatly exceed the association between individual suicide risk factors and suicide, and does not differ greatly from chance. A statistically strong and reliable method to usefully distinguish patients with a high-risk of suicide does not exist.

Age profiles Depression and anxiety make strong contributions to the risk of suicidal behaviour across the lifespan. However, suicide risk profiles vary with age:

· Younger suicides tend to be characterised by high morbidity, particularly cluster B personality pathology (conduct disorder and antisocial behaviour), substance misuse disorders, impulsive aggression and interpersonal conflicts.

· Middle-aged suicides tend to be characterised by major depressive disorder, and comorbid anxiety disorders and alcohol and substance misuse.

· Older people are most commonly characterised by major depressive disorder and harm avoidance.

Physical illness or injury, or chronic pain orimpairment

Some physical illnesses increase suicide risk, especially asthma, cancer, chronic obstructive pulmonary disorder, cardiovascular diseases including coronary heart disease and stroke, diabetes mellitus, degenerative diseases such as osteoporosis, spine disorders (e.g., disc disorders) and multiple sclerosis.

Chronic diseases increase risk, especially inflammatory bowel disease, migraine and epilepsy. Chronic pain, recent surgery, and terminal disease increase suicide risk.

Sleep disturbances and insomnia increase suicide risk, independently of depression. Traumatic brain injury increases suicide risk.

Marital status and living circumstances

Suicide risk varies with marital status. The highest risk is in those who have never married, followed (in order of decreasing risk) by those who are widowed, separated, or divorced; married without children; and married with children. Regardless of marital status and family composition, living alone increases suicide risk. Homelessness, especially in people with psychiatric illnesses, increases risk.

Stressful lifeevents

Social factors associated with suicide risk include perceived loneliness, adverse and traumatic events, bereavement, life stressors and interpersonal losses and conflict, financial problems and losses, legal and disciplinary crises, and high levels of introversion, hopelessness, helplessness andworthlessness, or defeat and entrapment, which may be associated with depression.

Suicide risk is increased in the bereaved, and in people who have had a relationship break-up within the previous year. Risk may also be increased in people with a history of violent behaviour in the previous year. Risk is increased at the anniversary of a suicide, or other bereavement, or a relationship loss. Amongst people whose spouse dies, risk of suicide is highest in the first week after bereavement, decreases rapidly in the following few months, but remains elevated for the whole first year.

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Individual Risk Factors

Occupation In New Zealand suicide risk is higher in those who work in unskilled occupations (e.g. trades, construction, farming, forestry, fisheries). Within an occupation, suicide risk varies with skill level, with the most skilled having lowest risk. In the most skilled workers (e.g. managerial level) suicide risk is lower than in the general working-age population. However, among highly skilled workers, physicians, dentists and vetinarians may have an increased risk of suicide. Unemployment and financial stresses may increase suicide risk.

Interpersonal Risk FactorsChildhood adversity

Exposure to childhood physical, sexual, or emotional abuse, or neglect, increases risk of suicide in young people and adults. This association is moderated by extent and frequency of abuse, and the relationship between victim and abuser. The extent of sexual abuse is related to the extent of suicidal behaviour. Other adverse childhood experiences (parental psychopathology/substance abuse/violence/ separation or divorce/imprisonment, high residential mobility, multiple family breakdowns and restructuring) increase suicide risk in young people and adults.

Family factors Family factors, including high levels of conflict, parental mental illness and a family history of suicidal behaviour can elevate suicide risk.

Older people Compared with other population groups, suicide in older people is often characterised by fewer warning signs or explicit cues, reduced history of previous attempts, greater prevalence of depression and physical illness, high levels of hopelessness, poor approaches to problem solving, and inability to open up to others including telling General Practitioners (GPs) they are suicidal.

Relatives and peers

A recent suicide or suicide attempt by a relative or peer is associated with a higher (up to 5-fold) suicide risk.

Social networks People at risk of suicide are often described as alienated from their families and having insufficient social support, and other resources necessary to cope with life stressors. Such isolation may result from adverse life circumstances and/or inability to maintain good interpersonal networks. In addition, isolated and lonely people are at higher risk of death when they engage in suicidal behaviours: their chances of being found and rescued by others are severely reduced or non-existent.

Societal Risk FactorsLethal means of suicide At an individual level, removing access to lethal means of suicide can thwart suicide

attempts. At a population level, restricting access to lethal means by imposing structural or legislative barriers can reduce suicides. Detoxifying domestic gas and vehicle exhaust gas, installing barriers at bridges, in subways and at other jumping sites, imposing legislative restrictions on access to firearms and purchasing controls on charcoal packs, are measures which have reduced suicide rates.

Where it is possible to restrict access to a widely available, commonly used, highly lethal method of suicide which lacks immediate substitutes, then a reduction in suicides by that method may be accompanied by a parallel reduction in overall suicide rates. Where access is restricted to methods which account for only a small fraction of total suicides, then suicides by that method may be reduced but no impact on overall suicide rates would be expected.

Alcohol availability Alcohol availability and hazardous drinking (e.g. binge drinking) cultures are associated with elevated suicide risks. Many forms of alcohol control are associated with reduced rates of suicide, including zero tolerance for drink-driving, higher taxation, higher minimum legal drinking ages, lower density of alcohol outlets.

Political regimes Political events or coercion, socio-political climates, and violence are associated with increased rates of suicide.

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Societal Risk Factors

Environmental settings and structures

Suicide risk is increased in particular environmental settings where vulnerable people are housed including inpatient units, prisons, police cells, and in places with structural hazards including bridges, hotspots, railways and sites which may attain iconic status as places for suicide.

Suicide clusters and contagion

Suicide risk is increased npeople exposed to suicide clusters and contagious influences, especially in institutional settings (schools, colleges and universities; Defence Forces; prisons), small towns, and small indigenous communities, which all which tend to be characterised by a homogeneous culture and a high degree of social connectedness. In this case, social connectedness, often promoted as a protective factor for suicide, is actually a risk factor.

Culture and religion

At a population level, suicide risk is associated with cultural assimilation and disruption of traditional social structures.

Lower suicide rates are reported in countries with religious sanctions against suicide, mostly Muslim and Catholic.

The protective role of religion appears to be context-specific and religion-specific.

Migration Suicide rates in migrant groups tend to reflect the suicide rates of countries of origin with a convergence toward the rates of the host country seen in some studies. Migrant status may increase suicide risk in vulnerable individuals (e.g. refugees, and/or individuals with pre-existing psychopathology) due to language barriers, stress of acculturation, and social isolation.

Economic factors Suicide risk is associated with economic crises, unemployment and loss of financial status, especially in men.

Sociological studies consistently find a correlation between high suicide rates and low socioeconomic status. However, some high-status occupations have increased risks of suicide, for example dentists, physicians and veterinarians.

In New Zealand suicide rates are higher in regions of higher, compared to lower, levels of social deprivation.

Disasters Studies of the impact of disasters have shown both increased and decreased suicide rates in the immediate aftermath of earthquakes, suggesting the impact is disaster-specific and context-specific

Media reporting Media reports or portrayals of suicide may influence vulnerable individuals to adopt particular methods and/or sites for suicide. Reporting practices which may encourage suicide include glamorizing or romanticizing suicide, normalizing suicide by presenting it as an understandable response to stress, gratuitously covering celebrity suicides, and providing details of specific methods of suicide, or details of suicide clusters. Media reporting guidelines which advocate avoiding these practices are widely available. Their application has been shown to reduce suicides.

Rural and remote areas

Suicide risk is higher in rural than urban areas, and risk increases with increasing rurality. Both personal characteristics which influence decisions to live in rural areas, and features of geographic isolation, may contribute to increased suicide risk, as well as access to lethal means of suicide including firearms.

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Factors which protect against suicide and suicide attempt

Table 3 provides a one-page overview of the major risk and protective factors for suicide and suicide attempt at the individual, social and environmental, and macrosocial and cultural levels.

While effective interventions to mitigate risk factors for suicide are essential, enhancing factors which can buffer suicidal thoughts and behaviours is an equally important component of a comprehensive suicide prevention plan. Some protective factors address specific risk factors while others protect against a number of different suicide risk factors. Protective factors have not been studied as extensively as risk factors. Table 3 lists major protective factors. Some specific high interest topics related to protective factors are discussed below.

Social connectedness is often promoted as an especially important protective factor against suicide. Caring relationships are particularly protective for adolescents, older adults, people with mental health problems and those who have made suicide attempts, all of whom have high needs for support. Close, supportive relationships with partners, family members and friends can buffer the impact of external stressors, provide help in crises and mitigate the suicide risk associated with childhood trauma.

Individual health and wellbeing, resiliency and good coping strategies are important in protecting against suicide. Some of these factors are lifestyle factors, grounded in good health habits of sleep, diet, exercise, work/life balance, good relationships and effective management of stress. Some of these well-being factors are determined, in part, by personality traits which influence responses to stress and trauma. Extraversion, optimism, emotional stability, and self-efficacy are effective buffers against the development of problems, and can mitigate the impact of stressful events, and of childhood adversity.

A number of suicide prevention programmes promote help-seeking as a protective approach. However, willingness to seek help in a crisis may be influenced by personality traits, stigmatising beliefs and personal attitudes. Men are often unwilling to ask for help, and this attitude can exacerbate mental health problems, increasing risks of suicide that may otherwise have been effectively prevented through early intervention. To supplement programmes which encourage individuals to seek help, programmes which promote help-offering, by giving people the skills to recognise those around them who are distressed, depressed and potentially at risk of suicide, and to broker assistance and early intervention, may help to protect at-risk individuals.

Addressing risk factors and enhancing protective factors with a range of early intervention programmes is an approach which holds promise for suicide prevention, as well as potentially impacting other disadvantageous outcomes such as substance misuse, violence and crime. There are a range of theoretically valid, ‘upstream approaches’ such as early childhood parenting and intervention programmes, mentoring programmes, and school based programmes to develop emotional skills. All these programmes are designed to ameliorate childhood disadvantage, to encourage the development of skills that protect against the development of mental health problems and to promote the acquisition of skills to ensure positive social and health outcomes and protect against suicide. However, while theoretically valid and promising, their impact on risk of suicide attempt and suicide remains largely unevaluated. In part, this is because of methodological and funding issues since appropriate evaluation would require large samples followed up for long periods – potentially 30 to 40 years. Nevertheless, the lack of evaluation should not prevent the adoption of promising programmes where indicated.

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Table 3. Overview of risk and protective factors for suicidal behaviours and suicideRISK FACTORS PROTECTIVE FACTORS

INDIVIDUAL SOCIAL AND ENVIRONMENTAL MACROSOCIAL AND CULTURALSocio-demographic factors (age, sex, gender, sexual orientation)

Childhood adversity

Parental psychopathology

Social disintegration, more individualism, materialism

Effective clinical and palliative care for physical illness, and for mental illness, substance abuse

Mental disorders (particularly mood & Exposure to childhood abuse and/or Globalisation, macro-economic Tailored safety and support plans, goodanxiety disorders, alcohol & substance use disorders, schizophrenia, eating disorders), personality disorders (PD)

neglect. Interpersonal violence, bullying

restructuring

Climatic events, natural disasters

discharge and follow-up care, support for chronic are conditions

(particularly borderline, narcissistic and Dysfunctional family environment, low Restricted access to lethal meansantisocial PDs) level of monitoring, Interpersonal

violenceMedia climate and reporting regulations

Stressful life events

Tendency to behave in an Relationship problems or loss Cultural factors (colonisation, extent of Strong family and community supportimpulsive/aggressive manner

Legal and disciplinary crisesalienation/integration, autonomy, language)

Community cohesion and integration; minimal economic disparities

Severe or terminal, physical illnesses Job loss, unemployment Extent of access to healthcare, mental Good health and wellness habits –

(particularly neurodevelopmentaldisorders, functional impairment) Financial problems, losses

healthcare and substance abuse treatment

sleep, diet, exercise, gratitude, optimism

Genetic, cognitive, neuroendocrine, neurobiological factors (e.g. low levels of serotonergic transmission)

Environmental hazards (bridges, hotspots, particularly those in inpatient units, prisons, police cells, colleges)

Cultural and religious beliefs about suicide

Good coping skills, and skills in problem solving, conflict resolution

Prior suicide attempts Exposure to suicide clusters and Extent of social connectedness, social Cultural and religious beliefs thatFamily history of suicidal behaviour contagious influences in institutional support and isolation proscribe against suicidePrior/current non-suicidal self-injury settings (schools, colleges /universities,

Defence Forces, prisons), small towns, small indigenous communities

Public laws/policies including means restriction, alcohol policies

Activities that promote cultural identity and continuity

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Table 4. Summary of major protective factors for suicide and suicide attempt.Individual protective factors

Skills in problem solving, conflict resolution, anger management, and nonviolent ways of handling disputes

Pregnancy

Responsibility for young children (more protective in women than men)

Participation in activities and hobbies

Personality traits of extraversion and optimism

Healthy lifestyle choices which promote mental and physical well-being and include regular exercise, adequate sleep and diet, consideration of the impact on health of alcohol and drugs, healthy relationships and social contact, and effective minimisation and management of stress.

Having religious or spiritual values that discourage suicide and support instincts for self-preservation, having a structured belief system and participating in religious activities are generally associated with a lower risk of suicide, but this effect is religion-specific and culturally specific. The protective value of religion may be derived, in part, from membership of a socially cohesive group with shared social values and activities, and from adherence to religious proscriptions against the use of alcohol and drugs.

Marriage/partnership protects against suicide in men, but for women, responsibility for children is more protective than marriage.

Community factors, including service provision

Effective clinical care for mental, physical, and substance abuse disorders

Good palliative care

Easy access to clinical interventions

Supportive responses when people seek help

Family and community support (interpersonal and community connectedness)

Support from ongoing medical and mental health care relationships (caring contacts)

Societal factors Macrosocial, macro-economic, educational and social policies that help to minimise inequalities between groups in society.

Health policies that promote ready and equitable access to health services across economic groups.

Social and cultural values that promote wellbeing and social connectedness.

Legislative controls that minimise access to means of suicide

(Legislative) controls on alcohol

Media guidelines that attempt to modify harmful reporting styles.

Factors which may protect against indigenous youth (including Māori and Pacific) suicide

Current and/or future aspirations

Personal wellness

Positive self-image

Self-efficacy

Family and community connectedness

Cultural connectedness.

Positive opportunities

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Table 4. Summary of major protective factors for suicide and suicide attempt.

Positive social norms

These factors protect against suicide attempt specifically, but also positively influence a range of related outcomes including depression; alcohol, tobacco, and substance use; delinquent and violent behaviour; resilience; and academic success. Most of the poor outcomes (depression, substance misuse, violence, crime) share risk factors with those for suicidal behaviours.

Strengths-based health promotion efforts that make use of local protective influences and work with indigenous populations to maximise protective factors are key to establishing communities in which vulnerable indigenous young people have the best chance of establishing good individual health and life skills.

Theoretically valid upstream approaches

Examples of upstream strategies include: Early childhood home visits and intervention programmes to provide

education by trained staff (e.g. nurses) to low-income expectant/new mothers, to promote good health behaviours (e.g. immunisations, depression treatment for mothers), attendance at early childhood education programmes (e.g. Early Start). These programmes can address child maltreatment, intimate partner violence, and, over time, improve parent and child mental health, parent/child relationships, and child cognitive and behavioural development.

Programmes which teach parenting skills (e.g. Triple P, Positive Parenting Programme.)

School-based programmes which teach 5-7 year olds to develop coping and social skills, promote emotional and mental health, and encourage development of caring and compassion for others (e.g. the Good Behaviour Game, Zippy’s Friends, Youth Aware of Mental Health (YAM)).

Mentoring programmes to enhance connectedness between vulnerable young people and supportive, stable and nurturing adults (e.g. Big Brother, Buddy programmes). These programmes can impact self-esteem, truancy, and drug and alcohol initiation.

Community-wide prevention systems to empower entire communities to address adolescent health and behaviour problems through a collaborative process of engagement.

School-based violence prevention, anti-bullying and skills-building programmes to engage teachers/staff, students and parents in promoting social responsibility and social-emotional skills-building (e.g. coping skills and self-efficacy, problem-solving skills, help-seeking, anger management, conflict resolution, compassion). These programmes can impact bullying, youth violence, teen dating violence, mental health and delinquency as well as suicide.

Recent findings from individual studies

While there have been are many systematic reviews of suicide interventions, there are few such reviews of risk or protective factors. Rather, new information about risk and protective factors has tended to come from individual studies, and most recent studies confirm or strengthen existing findings. As illustration, Table 5 highlights some new issues related to suicide risk from research published within the last one to two years.

Table 5. Risk and protective factors for suicide and suicide attempt from recent individual studies

Topic Findings

Economic factors In the last 10 years, there has been a focus on the contribution to suicide risk of economic factors particularly those related to the Global Financial Crisis, government austerity measures, de-industrialisation and unemployment. Studies show generally positive associations between economic recessions, poverty, unemployment and suicide.

Disasters Studies of the impact of disasters on suicide have shown both increased and decreased suicide rates in the immediate aftermath of earthquakes, suggesting the impact is disaster and context-specific.

Air pollutants Studies from three countries showed a relationship between air pollutants and suicide, prompting discussion about the impact of pollutants on cytokines, serotonin and stress hormones.

Second-hand smoke One study suggested exposure to second-hand smoke was linked to suicide, but the study could not control for the relationship between smoking and mental illness.

Lithium in water supplies

There is interest in the extent to which lithium in water supplies may be associated with lower suicide rates.

Religion While religion has generally been considered protective against suicide, a number of recent studies suggest that the effect is very culturally specific.

Parental suicide confers risk on children

One study found that maternal suicide, or parental suicide before a child reached age six, was associated with increased suicide risk.

Classroom age effects A study from Japan found that younger children within a school class had an increased risk of suicide compared to their older classmates.

Parents with anxiety confer risk on children

A study found that parents with generalised anxiety disorder or panic disorder appeared to confer an increased risk of suicide on their children.

Parental separation and divorce

A study showed that parental separation and divorce was associated with increased risk of suicide attempts in both males and females.

Self-harm A study of self-harm found that those who cut at a site other than wrists or arms were at higher risk of suicide than those with other types of self-harm.

Primary care visits before suicide

A study of Medicaid users found that 83% had made a medical or mental health visit to their primary care provider within a year of death, 50% made such visits within one month of death, and 27% within one week. In the year prior to suicide, the median number of visits to primary care was 16. Medicaid is the major health insurer for poor or disabled individuals in the US. Such individuals are a group at high risk of suicide. These findings highlight opportunities to screen, intervene and prevent suicide in primary care settings.

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QUESTION 2. Effective universal, selective and indicated programmes

What are effective (universal, selective and indicated strategies for preventing suicide?

Universal interventions

Table 6 summarises key findings from systematic reviews of universal Interventions for preventing suicide. These reviews identified means restriction policies, media reporting guidelines, public messaging campaigns, alcohol restriction policies, employment policies, and multi-level programmes. There was strong evidence for some interventions, but limited evidence for others.

There is good evidence from robust studies that restricting access to lethal means prevents suicides by those means, and may reduce the total suicide rate if the method restricted is highly lethal, widely available and accounts for the majority of suicides. The evidence base for means restriction has strengthened in recent years with evidence of significant reductions in suicide for barriers at iconic jumping sites, and for packaging restrictions for analgesics. Women are more deterred by means restrictions; men are more likely to substitute alternative methods. The impact of means restrictions approaches may be modified by substitution of other methods although the extent to which this occurs for a specific means is difficult to assess. There are no reviews of disposing of unused medications, an approach relevant particularly to older people. Most suicides in New Zealand are by hanging but there have been few efforts to prevent suicide by hanging.

There is good evidence that implementation of media reporting guidelines can reduce suicide and change reporting behaviours, but less evidence that these changes are sustained in the longer term. In general, journalists are neither aware nor supportive of guidelines. Ongoing investment in education, monitoring and partnership with journalists is required for effective adoption of guidelines. Australia and Austria have provided good models for the dissemination of guidelines and journalist engagement. While the internet might be used positively to engage vulnerable people, there is concern about negative effects, and a sense of powerlessness about ways to restrict access to harmful content.

There is good evidence that restrictions on access to alcohol (including higher taxes, minimum legal drinking age, zero tolerance for drink-driving, fewer regional alcohol outlets) contribute to suicide prevention on a general population level and to a reduction of alcohol involvement in suicide deaths.

There is some evidence for a short-term attitude change, but no evidence for sustained changes in attitudes, knowledge and behaviours, and no evidence of an impact on suicidal behaviours, for a range of public messaging programmes including those that focus on depression awareness, destigmatising mental illness, promoting help-seeking, or promoting health and wellbeing. Some studies have reported decreased help-seeking after exposure to programmes that promote help-seeking. Mass media campaigns focused specifically on suicide literacy and awareness appear to be most effective when they are delivered as part of a multicomponent suicide prevention strategy, while "standalone” suicide literacy campaigns appear modestly useful for increasing suicide literacy.

There is weak evidence that vocational interventions reduce depressive symptoms in the unemployed and help them get work. There are no reviews of the effectiveness of national suicide prevention strategies. No outcomes have been reported for multi-level interventions but there is indirect support for possible synergies in particular combinations within multi-level strategies. One study of a national sporting event showed no impact on suicide rates.

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Table 6. Key findings from systematic reviews of universal interventions for suicide preventionINTERVENTIONSand STRATEGIES

KEY FINDINGS

National • Systematic and comprehensive evaluations of national suicide prevention strategiesprogrammes are lacking, in part, because of poor specification of implementation.

Means restriction • There is good evidence from robust studies that restricting access to lethal meanspolicies prevents suicides by those means. Restricting access to a specific method may also

reduce the total suicide rate, particularly if the method is highly lethal, widely available and accounts for the majority of suicides. However, effects on the total suicide rate may be confounded by potential substitution of alternative means.

• Means restriction is more effective in females than males; males are more likely to substitute alternative means. Means restriction is more effective for highly lethal means and for alcohol-related suicides.

• Despite hanging being a common method of suicide, there are few efforts to prevent suicides by hanging (apart from removal of potential ligature points in institutional settings). A recent study found implementation of a safety checklist for architectural and structural hazards reduced inpatient suicides by 82%.

• One study found that educating parents about means restriction after a suicide attempt led to restrictive actions by parents.

• Campaigns for disposal of unused or unwanted medications (potentially particularly relevant for older adults) do not appear to have been evaluated.

Media reportingguidelines

· Guidelines can reduce suicides (in one study by 75%, with this effect sustained for five years) and can change reporting behaviours. Reduced suicides are associated with reporting restrictions on glorification, sensationalising, ‘suicide’ in headlines, reference to celebrity status of decedents, detailed descriptions of suicide deaths, and use of photos. However, some studies find mixed results with guidelines leading to more reports of suicide, and regression in reporting styles over time.

· In general, journalists are neither aware nor supportive of guidelines. Guidelines are most likely to be effective when accompanied by media consultation and endorsement, active dissemination strategies, ongoing training and monitoring. Internet pathways can increase suicide risk, particularly for adolescents and young people, and vulnerable, socially isolated people who may be attracted to the internet.

· Restricting internet access, and internet guidelines about suicide content, may provide some protection.

Mental healthliteracy anddestigmatisationprogrammes

· Mass media campaigns appear to be most effective when delivered as part of a multicomponent suicide prevention strategy, while "standalone campaigns" are modestly useful for increasing suicide literacy. At the population level, there is fairly consistent evidence for a short-term positive attitude change, but less evidence for knowledge improvement.

· Social contact, level of exposure, repeat exposure, and community engagement seem to be crucial to the success of these campaigns, but these constructs are rarely employed. Few evaluations have examined outcomes longer than a few weeks, or impact on suicidal behaviours.

· A large multi-site school-based study showed the only effective component was a mental health education programme.

Depression awareness campaigns

· No study has clearly demonstrated that depression awareness campaigns increase help-seeking or decrease suicidal behaviours Results from 15 programmes in 8 countries suggest that these programmes contributed to a modest improvement in public knowledge of, and attitudes toward, depression or suicide, but most programme evaluations did not assess the durability of the attitude changes.

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

Promotion of mental and physical health

· No reviews identified the impact of wellness promotion programmes on suicide risk but they have showed a small effect on reducing symptoms of depression. However, this is based on only a few small studies.

Promotion of help-seeking

· Suicide-prevention programmes using psychoeducational curricula, gatekeeper training and public service messaging directed at youths do not increase help-seeking. However, in combination, multimodal interventions plus another intervention such as screening showed an effect in some studies, but not in others. Combining psychoeducation with peer-help training had no effect

· In two studies, gatekeeper training did not show improvements in attitudes or help-seeking behaviours in high school students. In one study, help-seeking from parents and peers decreased after exposure to the programme.

· There are mixed results for public service messaging about help-seeking: onesimulation study found no effect on help seeking attitudes. One study found no change in knowledge about resources for help, but an increase in those who sought help although they did not do so specifically for a mental health problem.

Harmminimisation alcohol policies

· Both intoxication and heavy alcohol use are associated with suicide at an individual level, and per capita consumption is associated with suicide at a population level. Alcohol consumption is associated with firearm use as a means of suicide.

· There is consistent evidence that restricted alcohol polices may contribute to suicide prevention at a general population and an individual level. Restrictions include taxation, a high minimum legal drinking age, lower density of alcohol outlets, and zero tolerance for drink driving. Public polices restricting access to alcohol in both the USSR and Iceland were associated with decreased suicide rates.

Social welfare policies

· There is weak evidence that child protection laws impact suicide rates.

Employment policies

· There is clear evidence of links between a range of poverty indicators, and common mental disorders, suicidal ideation and behaviours, suggesting a potential benefit in addressing economic poverty within suicide prevention strategies, with particular attention to both chronic poverty and acute economic events.

· ‘Job-club' interventions (group-assisted programmes for obtaining employment) may be effective in reducing depressive symptoms in unemployed people, particularly those at high risk of depression. There is only weak evidence that vocational interventions for the unemployed. improve work participation and limited evidence they reduce mental distress

Adequate medical and social care

· No reviews were identified for adequate medical, mental health, palliative and social care.

Multi-component strategies

· No outcomes have been reported for multi-level interventions or for synergistic· effects of multiple interventions applied together, although indirect support is found

for possible synergies in particular combination within multi-level strategies· Best individual practices identified as effective were as follows: training general

practitioners (GPs) to recognize and treat depression and suicidality, improving accessibility of care for at-risk people, and restricting access to means of suicide

Selective interventions

Table 7 summarises key findings from systematic reviews of selective interventions for preventing suicide. These reviews identified findings related to early intervention and parenting programmes, alcohol and substance abuse programmes, and interventions based in suicide prevention centres, communities, schools, tertiary educational institutions, workplaces, child welfare and juvenile justice facilities, and defence forces.

School-based suicide prevention programmes, typically gatekeeper training, have been widely implemented but, in general, poorly evaluated, and most studies show no impact on suicide attempts or suicide rates. Outcome measures in most studies have been limited to knowledge and attitudes towards suicide. However, a few programmes have shown reduced suicidal behaviour. The Good Behaviour Game, a teacher-led classroom intervention for 6-7 year olds, reduced suicide ideation and suicidal behaviour in one of two randomised trials (one trial was underpowered), and the Signs of Suicide (SOS) programme, which educates students about the relationship between mental disorders and suicide, self-identification of depression and suicidal risk, and encourages appropriate help-seeking, also reduced the incidence of suicide attempts. An international cluster randomised trial that compared a mental health awareness programme, screening and referral, and gatekeeper training found that only the mental health awareness programme (YAM) was associated with a lower incidence of serious suicide ideation and suicide attempts.

Studies of tertiary-level suicide prevention similarly showed no effect for educational or gatekeeper interventions, but one quasi-experimental study showed that method restriction and mandatory professional assessment of students who exhibited suicidal behaviours reduced the suicide rate.

A small number of programmes have been developed for at-risk occupations (e.g. defence forces, police, the construction industry). Few have been evaluated in terms of their impact on suicidal behaviours and deaths. The best known is the US Air Force multi-component 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 disclosed suicidality. The programme reduced suicide rates by 35%, and has been replicated with similar results.

Studies of community-based programmes tend to be non-randomised, small, and under-powered to detect changes in suicidal behaviour or suicide deaths. Two reviews suggest Community Mental Health Care (a multidisciplinary community-based team) may reduce hospital admissions for suicidal behaviour (compared to treatment as usual, TAU) and is more likely than usual care to promote greater acceptance of treatment.

There is evidence that family, parenting or parental support programmes can reduce or prevent substance use in adolescents, but no evidence that they reduce suicides. The most effective programmes appear to be those that emphasise active parental involvement, and developing skills in social competence, self-regulation and parenting.

Reviews of community-based gatekeeper training for indigenous suicide prevention suggest such training may be a promising intervention in Indigenous communities but needs to be culturally tailored to the target population. In small studies, pre/post evaluations were generally positive and reported non-significant reductions in suicide and attempts and increased community protective factors. However, studies were of poor quality.

Table7. Key findings from systematic reviews of selective interventions for suicide prevention

INTERVENTIONSand STRATEGIES

KEY FINDINGS

Suicide preventioncentres

· One low quality review (2002) found limited evidence of effectiveness for 2 out of 3 programmes at suicide prevention centres: one programme reduced suicidal ideation, and one programme reduced suicidal urgency.

Community-based suicide prevention programmes

· Overall, studies of community-based programmes are non-randomised, small, and under-powered to detect changes in suicidal behaviour or suicide deaths.

· Two reviews suggest Community Mental Health Care (a multidisciplinary community-based team) may reduce hospital admissions and suicide deaths (compared to treatment as usual, TAU) and is more likely than TAU to promote greater acceptance of treatment.

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

· One review suggested Intensive Care Management (ICM), compared to TAU, for people with Serious Mental Illness (SMI), did not reduce suicide deaths nor improve mental state, but may reduce hospital admissions, improve social functioning and enhance retention in care. ICM seems to be of value to people with SMI in the sub-group of those with high hospitalisation levels.

· A non-randomized study in Norway found that a community-based suicide prevention team did not decrease the risk of a repeated suicide attempt within 6 months, 12 months, or 5 years after an attempt compared with TAU.

· Community-based intervention programmes may decrease stigma associated with mental health issues and may reduce suicide attempts but it is not clear whether these programmes significantly reduce suicide rates.

· One review of internet forums reported some positive influences (reinforcement of positive behaviours, support for efforts not to self-harm, and encouragement to seeGPs for help). While there was no evidence forums reduced or increased self-harm, there was evidence of negative influences, including normalising self-harm, concealing self-harm, sharing self-harm techniques, increases in suicidal ideation, and worsening distress.

· General internet use appears to be a source of exposure and learning about suicide and self-harm. Greater internet use or addiction was associated with increased risk for self-harm.

· Four reviews of community-based interventions in indigenous communities (in US, Australia, Canada) found pre/post evaluations were generally positive and reported reductions in suicide and attempts and increased community protective factors.However the studies were generally non-randomised, small and of poor quality andresults were not statistically significant. Most interventions employed some type ofculturally adapted gatekeeper training as a major component of the programme.Such training was generally reported to increase knowledge and intent to help, but behavioural changes were not reported. Some studies suggest that the populations at-risk do not perceive a need for help. Overall, gatekeeper training holds promise for suicide intervention in Indigenous communities but needs to be culturally tailored to the target population. Better quality, randomised trials are needed.

School-based · Most reviews of school-based suicide prevention programmes conclude that thesuicide prevention studies are methodologically poor, non-randomised, not controlled, and show noprogrammes impact on suicide attempts or suicide rates. Outcome measures in most studies have

been limited to knowledge and attitudes towards suicide.

· ‘Whole school’ or ‘ecological’ approaches (curriculum-based education programmeswhich aim to deliver interventions to whole school populations) have reported positive effects in terms of increased levels of knowledge of the risk factors and warning signs for suicide. Some studies found improved (self-reported) likelihood to seek help, and improved attitudes toward suicide-related behaviour and suicidal peers. Some studies reported reductions in self-reported risk of suicide, ideation and attempt. No studies examined potentially negative effects.

· Screening programmes have been shown to successfully identify at-risk students who would not have been identified otherwise, and who were then referred to school or community-based services. Screening raises questions, however, aboutstigmatising students who are identified in this way, about high numbers of false positives, and about how often to screen.

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

· Gatekeeper training has been shown to be effective in terms of increasing knowledge, and improving attitudes and confidence, but only some programmes have found (self-reported) improvements in practice

· Three RCTs of school-based interventions reported a reduction in suicide risk behaviour over time in both the treatment and comparison groups.

· Only two studies of poor quality have evaluated school-based postventionprogrammes. The impact of these programmes is unknown.

· With regard to specific programmes, there is evidence from one study that The Good Behaviour Game (GBG) is associated with subsequent decreased suicide attempt risk. Only one study has evaluated Yellow Ribbon (YR), and found no effect. Onlyone study has evaluated the most commonly used school programmes (YR, Signs of Suicide (SOS) and safeTALK) and found no impact for any programme on suicide, ED presentations or suicide attempts.

· A New Zealand PhD thesis reviewed the SOS programme and considered it appropriate, with cultural adaptation, for use in New Zealand schools

· School-based programmes addressing depression and anxiety have shown some small effects in reducing these outcomes.

· Overall, the most promising interventions for schools appear to be gatekeeper training and screening programmes. However, more and better quality research, is needed. Programmes need to be evaluated for their impact on help-offering and suicidal behaviours rather than proxy measures of attitude and knowledge change. No school-based programmes have been evaluated in terms of safety. It may be that programmes of multiple, combined approaches are more effective.

Tertiary education/campus- based programmes

· One review suggests there is insufficient evidence to support widespreadimplementation of any programmes or policies for primary suicide prevention in post-secondary educational settings. There is no evidence of any impact on suicide or suicide attempts rates.

· A review of internet-delivered programmes to address stress, anxiety anddepression (mostly with cognitive behavioural therapies) suggested they were promising for university students but better quality evaluations were needed.

Child welfare, Juvenile justice based programmes

· One review suggested group-based Cognitive Therapy (CBT) may help to reduce symptoms of depression in young offenders with mental health problems, but larger high quality RCTs are needed.

· New Zealand has the only national suicide assessment and monitoring programmefor young people in contact with child welfare but no evaluations were identified.

Workplace-based programmes l

. There are a small number of prevention activities developed for at-risk occupations(including the defence forces, police, the construction industry). Few have been evaluated in terms of their impact on suicidal behaviours and suicide deaths. Three programmes have reported reduced suicides (pre/post) tests.

· The best described study is the multicomponent US Air Force suicide prevention programme which reduced suicides, and other behaviours associated with suicide risk. Studies of single component programmes (typically, gatekeeper training) areneeded. Such evaluations need to assess outcome in terms of referral behaviours and suicide and suicide attempt outcomes.

Courts, prisons · No reviews were identified for courts and prison-based programmes.

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

Programmes forDefence forcepersonnel

· Reviews suggest multicomponent interventions (such as the US Air Force (USAF) programme, which was associated with a 33% reduction in suicides, are more likely to reduce suicide risks, but there are insufficient studies of interactive effects and multicomponent programmes to draw conclusions about effectiveness. However, the USAF effect was replicated in Yugoslavia, with a programme modelled on that of the USAF, increasing confidence that the effect is real.

· Psychosocial interventions after a suicide attempt have been shown to be only minimally effective. However, there is promising evidence from the Collaborative Assessment and Management of Suicidality (CAMS) programme that showed significantly more rapid resolution of suicidality (in one month) and fewer ED and primary care visits for soldiers and veterans.

· No studies have assessed the specific effectiveness of hotlines, outreachprogrammes, peer counselling, treatment, coordination programmes, or internet or phone-based programmes.

· Restriction of access to lethal means has shown a means-specific effect, but the effect on total suicides is less clear. However, individual studies since this review was published, have shown reductions in both firearm-specific and total suicides when access to firearms by army personnel was restricted.

Rural regions · No reviews were identified.

Alcohol/drug misuseprogrammes

· Family, parenting or parental support programmes can reduce or prevent substance use in adolescents. The most effective appear to be those that share an emphasis on active parental involvement and on developing skills in social competence, self-regulation and parenting. More exploration is needed of change processes involved in such interventions and their long-term effectiveness.

· School-based programmes that develop psychosocial skills have shown positive effects on drug and alcohol misuse.

· In adults, social norms interventions delivered face-to-face or via computer, or other computer based interventions, have shown some benefits in reducing alcohol use among university and college students and the general adult population. However, other studies have found no effect.

· School-based programmes that were culturally adapted to include Native American values and beliefs reported positive effects on some drug use outcomes among US First Nations youth.

· Most studies have not assessed outcome in terms of suicidal behaviours, although (non-significant) reductions in suicides have been reported for an intervention for problem drinkers which involved brief intervention, a rehabilitation programme, and motivational interviewing. One study showed a reduction in suicide attempts associated with a programme which consisted of follow up phone calls.

Parenting support and ‘Early Start” programmes

· One review identified community level, socio-emotional learning programmes in schools and parenting programmes during infancy as "best practice" for promotion of mental health, and primary prevention of mental, neurological and substance use. Early child enrichment/preschool programmes and parenting programmes for children aged 2-14 years; were identified as ‘good practice’ in this regard.

· One review of 12 studies evaluated multi-faceted interventions delivered at pre-school in disadvantaged populations, and found positive intervention effects for adult outcomes across the majority of behavioural outcomes, and a suggestion of a reduction in symptoms of depression.

Indicated Interventions

Table 8 summarises findings from reviews of indicated interventions. The most common type of training and peer education programme is some form of gatekeeper training. However, despite wide use, gatekeeper training has most often been evaluated only in terms of pre/post training knowledge and attitude change and intent to intervene. I mpacts on behavioural changes and suicidal behaviours have not been assessed. Overall, there are mixed findings with some evidence that training peers as gatekeepers to better understand suicide, recognise signs of suicide in peers and to intervene to connect people to help, can be protective for high risk individuals.

Educating physicians to better recognise, treat and manage depression can reduce suicides, with greater effects for women patients, and older adults. There is little evidence that help-seeking programmes reduce suicidal behaviours. Provision of individualised support to parents of at-risk adolescents can effectively reduce adolescent risk behaviours and lead to overall improvements in adolescent health. Crisis telephone lines have been widely implemented but rarely evaluated. They have been found to be more useful for acute rather than chronic callers, and in one study were shown to reduce suicidal intent during the call. There is promising evidence for tele-mental health services for suicide prevention, and for internet-based interventions including internet cognitive behaviour therapy (iCBT) which has been shown to reduced suicidal ideation in the general population in RCTs and in a clinical audit of depressed primary care patients. There is no evidence that postvention programmes reduce suicidal behaviour, but evidence that individual counselling for traumatic grief can be helpful. One review evaluated community, school and family postvention programmes: No protective effect of any postvention programme was found for suicide deaths or attempts. Postvention counselling for familial survivors (spouses, parents, children) of suicide generally helped reduce psychological distress in the short term.

Table 8. Key findings from systematic reviews of indicated interventions for suicide prevention

INTERVENTIONSand STRATEGIES

KEY FINDINGS

Training and peer education

· Gatekeeper training has most often been evaluated in terms of pre/post trainingknowledge and attitude change, and intent to intervene. Sustained impacts on behavioural changes and on suicidal behaviours have not been assessed. Gatekeeper training has often been part of multi-component programmes so specific effects are unclear. Overall, there are mixed findings with some evidence that training peers as gatekeepers can be protective for high risk individuals. Some reviews report no impact on suicide or suicide attempt rates.

· Two New Zealand reports evaluated specific gatekeeper training programmes (QPR, ASIST) but findings in both reports were limited by methodological shortcomings. Outcome in terms of suicidal behaviours was not assessed.

· There is little evidence that help-seeking programmes are effective but some evidence that they might be if included with screening in multicomponent programmes.

· There is evidence that psycho-educational interventions may be promising if included in multicomponent programmes.

· There are mixed results for training and peer education programmes in schools- reports suggest increased knowledge about suicide but no changes in suicide rates.

Support to primary care providers and planners

· Educating physicians to better manage depression can reduce suicides, with greater effects for women, and older adults. This training usually also includes training to counsel patients about restricting access to lethal means. Screening for suicide risk and depression in primary is only effective if supported by depression care services.

Providing support to carers of at-risk individuals

· Individual support delivered to parents of at-risk adolescents is effective in reducingadolescent risk behaviours and result in overall improvements in adolescent health.

· There are no reviews of the effectiveness of providing support to families and carers of individuals who have made suicide attempts.

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

Tele phone based (crisis) suicide prevention services

· One study in a review found fewer suicides by users of crisis lines.

· One review reported that crisis lines were considered helpful for acute (compared to chronic) callers to the service.

· A recent study reported that crisis lines helpers actively engaged callers in collaborating to keep themselves safe on 76.4% of calls and sent emergency services without the callers' collaboration on 24.6% of calls.

Tele-mental health services

· One review found promising evidence for tele-mental health services for suicide prevention, child psychiatry, depression, dementia, schizophrenia, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention

· One review of Automated Telephone Communication Systems (ATCS) suggested some small evidence of success for physical activity, weight management, and alcohol use, but little or no effect for mental health. .

Internet andmobile (m-health) devices

· Preliminary evidence suggests probable benefit for Web-based strategies: Internet based cognitive behaviour therapy (iCBT) reduced suicidal ideation in the general population in RCTs and in a clinical audit of depressed primary care patients.

· Meta-analyses of internet-guided self-help interventions in depression and anxiety find relatively large effect sizes, comparable to effect sizes for face-to-face treatments. Further research is needed to optimize the use of self-help methods.

· Reviews of use of text messages for mental health patients show improved treatment adherence, symptom surveillance, appointment attendance and satisfaction with management and health care services. One study found significant reductions in suicidal ideation, depression and hopelessness.

· One review evaluated 123 apps referring to suicide, of which 49 contained at least one interactive suicide prevention feature. Safety plan apps are the most comprehensive and evidence-informed. Potentially harmful content was also identified. No apps provide comprehensive evidence-based support. Cautious recommendation is warranted as some apps present potentially harmful content as helpful.

· One study suggested guided Internet interventions for depression, anxiety and alcohol use were cost-effective. Unguided Internet interventions for suicide prevention and depression were cost-effective compared to TAU or attention control.

· There is a lack of evidence for online and mobile interventions for suicide prevention in youth. More high quality empirical evidence is needed.

Postvention · There is no evidence that school postvention programmes reduce suicidal behaviour.· One review found that treatment interventions for complicated grief showed a positive

effect, which increased during follow up.· One review found evidence of some, but not strong, benefit from interventions for

people bereaved by suicide.· One review of community, school and family postvention programmes found no benefit

of any programme for suicides or attempts. Few positive effects of school-based postvention programmes were found; one study reported negative effects. Gatekeeper training for proactive postvention increased knowledge relating to crisis intervention among school personnel. Outreach at the scene of suicide was helpful in encouraging survivors to attend a support group at a crisis centre and seek help in dealing with their loss. Postvention counselling for familial survivors (spouses, parents, children) of suicide generally helped reduce psychological distress in the short term.

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Treatment Interventions

Table 9 summarises findings from reviews of treatment interventions, including screening, pharmacological, psychotherapeutic and psychosocial programmes.

A large fraction of people who die by suicide visit their primary care provider in the month, and final week, before suicide, but suicidal ideation is rarely detected, and mental disorders may be missed. There is good evidence for benefits of screening for suicide risk in pregnant, postpartum and general adult populations, particularly in the presence of additional treatment supports such as treatment protocols, care management, and availability of specially trained depression care providers. One review suggests screening for mental health and suicide risk in emergency departments is feasible and acceptable for adults, and another review is similarly supportive for screening in paediatric emergency departments.

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.

In addition to antidepressants, other drugs show an effect on suicidal behaviours. Meta-analyses show lithium, in people with unipolar and bipolar depression, is associated with a reduction in suicide and in self-harm incidents, with the effect perhaps achieved by lithium reducing the number of episodes of mood disorders or by decreasing impulsive and aggressive behaviour. Naturalistic studies show that lithium content in water is inversely correlated with regional suicide rates.

Clozapine, compared to olanzapine, used in people with refractory schizophrenia, is associated with decreased suicide attempts and emergency referrals for suicide ideation. Naturalistic studies show that patients treated with clozapine, versus other antipsychotics, have one-third the incidence of suicide and suicide attempts.

There is much current interest in the use of ketamine (and it’s metabolite, hydroxynorketamine (HNK)), for the treatment of acute suicidal behaviour in emergency departments. Single doses of ketamine can reduce acute suicidal ideation in patients with major depressive disorder or bipolar disorder, and ketamine is also effective in treatment resistant depression.

Electroconvulsive therapy, in depressed patients at high risk of suicide, has been shown to reduce suicidal ideation. There is current interest in the use of repetitive transcranial magnetic stimulation (rTCMS) for treatment of suicidal behaviour: high doses of rTCMS applied to the left prefrontal cortex are associated with rapid reduction of suicidal ideation.

Reviews of psychotherapeutic and psychosocial interventions find that cognitive behavioural therapies are associated with reduced suicidal behaviour, repeat suicide attempts and self-harm in adults, older adults, and patients who present to emergency departments. There are also significant improvements in the secondary outcomes of depression, hopelessness, suicidal ideation, and problem solving. Dialectic behaviour therapy is associated with reductions in the recurrence of suicidal behaviour compared with usual treatment. For adolescents, a meta-analysis of studies addressing self-harm showed an overall effect of treatment compared with usual care, with some of the most promising interventions being cognitive behavioural therapy, dialectic behaviour therapy, mentalisation, and family therapy; successful interventions were more likely to have a family component and be offered as multiple sessions.There is no clear evidence for the effectiveness of provision of an emergency card (‘green card’) for priority re-presentation at EDs or mental health outpatient clinics. There is equivocal evidence for maintaining contact after ED presentations for suicidal behaviour – some studies find a reduction in repeat attempts in women, but no reduction in hospital admissions, while some studies find no effect. One review found that a brief intervention consisting of a physician follow-up telephone call resulted in small but not significant reductions in suicide and one study showed a reduction in suicidal attempts for telephone contact intervention.

There is evidence from some studies that implementing systems changes related to features of mental health services associated with increased suicide risk is associated with decreased suicide rates. Decreases have been shown for service changes associated with extent of care, 24-hour crisis services, clear policies for the management of dual diagnosis patients, multidisciplinary reviews of suicide deaths, and safety checks of structures to remove hazards and potential ligature points.

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Table 9. Key findings from systematic reviews regarding treatment interventions

INTERVENTIONS and STRATEGIES

KEY FINDINGS

Screening programmes

• The totality of evidence supports the benefits of screening in pregnant, postpartum and general adult populations, particularly in the presence of additional treatment supports such as treatment protocols, care management, and availability of specially trained depression care providers. Benefit was not evident in screening programmes without staff assistance in depression care.

• Evidence is least supportive of screening in older adults, where direct evidence is most limited.

• Primary care-feasible screening tools are less effective in adolescents than adults. In adolescents sensitivity (ability to identify those at risk) is good at .80, but specificity (ability to identify those not at risk) is lower. Both sensitivity and specificity for adults is higher and in some cases >.95.

• For young people, there is some evidence that screening and intervention for mental health disorder or health compromising behaviours in clinical settings improves health outcomes.

Screening in Emergency Departments

One review suggests screening for mental health concerns and suicidality in the ED is feasible and acceptable to patients and providers. Several approaches seem feasible: brief screening, adaptive algorithms and therapeutic assessments.

Prediction of further suicidal behaviour

Individuals who express suicidal ideation have a clearly increased risk of suicide within a year. Suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients than in non-psychiatric participants

Prediction of repeated suicidal behaviour based on the presence of multiple risk factors does not greatly exceed the association between individual suicide risk factors and suicide, and does not differ greatly from chance. There is no statistically strong, reliable method to predict patients at high risk of suicide

Pharmacological interventions

Meta-analyses of RCTs drug treatment for depression show that antidepressant treatment decreases suicide ideation and behaviours in people ≥25 years

Some evidence suggests that selective serotonin reuptake inhibitors result in greater reduction of suicide ideation than either venlafaxine or bupropion

In participants aged ≤24 years, antidepressant treatment decreases depressive symptoms, but does not always diminish suicide ideation.

Antidepressant treatment in people <25 years is associated with a 1–2% risk difference in the incidence of new-onset or worsening suicide ideation, or suicide attempts. The US Food and Drug Administration (FDA) issued a warning in 2004 about the possibility of increased suicidality associated with antidepressants in young people; several other countries followed. After the FDA 2004 black box warning, rates of diagnosis of depression and prescriptions of antidepressants for young people declined; overdoses of psychotropic drugs and suicide increased.

Antidepressant treatment in people <25 years is associated with a 1–2% risk difference in the incidence of new-onset or worsening suicide ideation, or suicide attempts. The US Food and Drug Administration (FDA) issued a warning in 2004 about the possibility of increased suicidality associated with antidepressants in

young people; several other countries followed. After the FDA 2004 black box warning, rates of diagnosis of depression and prescriptions of antidepressants for young people declined; overdoses of psychotropic drugs and suicide increased.

Pharmacoepidemiological studies using data from 26 countries show that sales and prescriptions of selective serotonin reuptake inhibitors are inversely

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correlated with national and regional suicide rates, including in young people. Other drugs used in mood disorders have shown some efficacy for suicidal

behaviour. Clozapine, an atypical antipsychotic used for treatment-refractory schizophrenia, decreased suicide attempts and emergency referrals for suicide ideation compared with olanzapine in patients with schizophrenia or schizoaffective disorder at high risk for suicidal behaviour.

A recent review of 34 RCTs found that lithium reduces risk of suicide in people with mood disorders. Lithium may exert its anti-suicidal effects by reducing relapse of mood disorder, but additional mechanisms should also be considered because there is some evidence that lithium decreases aggression and possibly impulsivity, which might be a mechanism mediating the anti-suicidal effect.

Observational studies suggest that lithium content in water is inversely correlated with regional suicide rates.

A recent review found no significant treatment effect on repetition of self-harm for newer generation antidepressants, low-dose fluphenazine, mood stabilisers, or natural products. A significant reduction in self-harm repetition was found in a single trial of the antipsychotic flupenthixol, although quality of evidence was very low. No data on adverse effects were reported. The authors concluded that, given the low/very low quality of available evidence, and the small number of trials, it is not possible to make firm conclusions regarding pharmacological interventions in self-harm patients: More and larger trials are required.

Treating elderly adults with antidepressants rapidly reduces suicidal ideation, but ideation in other high risk groups is slower to resolve.

Long-term benefits of antidepressant medication to prevent recurrence of depression in older people are not clear and no firm treatment recommendations can be made. Continuing antidepressant medication for 12 months appears to be helpful but this is based on only three small studies with relatively few participants using differing classes of antidepressants in clinically heterogeneous populations. Comparisons at other time points were not statistically significant. Data on psychological therapies and combined treatments are too limited to draw any conclusions.

For children and adolescents early evidence suggests that combination therapy of CBT with an antidepressant may be statistically more effective in response to treatment and preventing relapse than either monotherapy alone. For efficacy, only fluoxetine was statistically significantly more effective than placebo.

Trials of low dose ketamine have shown an antidepressant response within minutes of administration in patients with major depressive disorder or bipolar disorder. Preliminary studies show that single and repeated doses of ketamine can reduce suicide ideation, making it a promising treatment for patients with suicidal behaviours in EDs.

Electroconvulsive therapy (ECT)

In an open-label study of patients with depression at high suicidal risk, more than three-quarters of patients treated with ECT had no suicidal thoughts or intent after nine sessions, consistent with previous studies.

rTCMS Preliminary evidence suggests that high doses of repetitive transcranial magnetic stimulation (rTCMS) applied to the left prefrontal cortex might rapidly decrease suicide ideation.

Psychotherapy and psychosocial approaches

CBT shows a strong effect in reducing suicidal behaviour, repeat suicide attempts and self-harm in adults, older adults, and patients who present to EDs. There are also significant improvements in the secondary outcomes of depression, hopelessness, suicidal ideation, and problem solving.

Several reviews find that Dialectical Behaviour Therapy (DBT) in patients with borderline personality disorder reduced suicides, suicidal ideation and attempts and self-harm. However, results are mixed in terms of the effect on self-harm and suicide attempts. A recent review found DBT did not reduce the proportion of patients repeating self-harm but did reduce the frequency of self-harm.

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Four trials each of case management and sending regular postcards did not reduce repetition of self-harm.

Psychotherapy may reduce attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. A limitation is that treatment evidence is derived from high-risk vs. screen-detected populations.

For adolescents, only mentalisation was associated with a reduction in frequency of repetition of self-harm in one trial. However the effect was only modest and the trial was small, precluding firm conclusions about effectiveness. There was no clear evidence of effectiveness for compliance enhancement, individual CBT, home-based family intervention, or provision of an emergency card, nor was there clear evidence for group therapy for adolescents with a history of multiple episodes of self-harm. Apart from group based therapy and DBT evaluations of all other psychosocial interventions were based on only one trial each.

Individual and group CBT reduce psychological harm in children and adolescents exposed to trauma.

Psychosocial interventions may reduce suicidal ideation in patients with schizophrenia spectrum disorders and psychosis, although additional benefit of these interventions above that contributed by a control condition or TAU is not clear.

A meta-analytic review of 18 studies found no evidence that additional psychosocial interventions following self-harm had a marked effect on the likelihood of subsequent suicide.

A review of psychosocial interventions for adolescents found fewer suicidal and self-harm events, but at a later period than immediately after intervention, they were slightly more likely to have suicidal and self-harm events than control group participants. Intervention (vs. control) group participants were slightly less likely to report suicidal ideation, both at post-test and at follow-up.

Some evidence suggests parenting programmes reduce self-harm in adolescents.

One review found that education in psychosocial skills in adolescents reduced suicide risk for up to nine months.

One review found support for psychoeducation only among various psychosocial interventions. Psychoeducation reduced relapse in mood disorders but only in a selected subgroup of patients at an early stage of the disease who had very good, if not complete remission, of the acute episode.

One review found no significant difference in depressive symptoms between CBT and interpersonal psychotherapy.

One review found that psychotherapy in adults found to be at high risk on screening might reduce suicide attempts.

‘Third wave’ cognitive therapies

There is promising evidence that 'third wave' cognitive and behavioural therapies (e.g. Acceptance and Commitment Therapy (ACT), compassionate mind training, functional analytic psychotherapy, DBT, Mindfulness-based Cognitive Therapy (MBCT), extended behavioural activation and metacognitive therapy) may be effective in reducing relapse in patients with depression, when used in the maintenance phase of major depression, or used during the continuation phase of treatment with patients at high risk for relapse.

There is some evidence that mindfulness can be used to treat drug and alcohol problems by suitably trained and experienced drug and alcohol professionals.

Inpatient therapies One review failed to find an effect for day hospital care compared to outpatient care for psychiatric symptoms, or for clinical or social outcomes.

Outpatient therapies There is promising evidence for interventions including collaborative, CBT,-behavioural, and motivational enhancement strategies for children and adolescents presenting to EDs. Brief therapeutic assessment approaches have demonstrated success in improving rates of follow-up care after discharge from

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the ED. Some data support clinical benefits when youths receive evidence-based outpatient follow-up care.

Collaborative care (co-located mental health and primary care) provides substantial benefits over usual care in outcomes for depression and anxiety, and improves suicide ideation in older patients with depression.

Nurse home visits to outpatients did not reduce repetition of suicidal behaviour. Combined inpatient and outpatient treatments were not effective in reducing repeated suicidal behaviour compared to outpatient care only.

Three reviews have found no clear evidence that follow up caring contacts (postcards, emails, face to face visits) reduced repetition for self-harm, although one review suggests it is a promising intervention.

One study found that suicidal ideation decreased significantly in adolescents who received psychological therapy compared to antidepressant medication, and this effect appeared to remain at six to nine months.

There was no clear evidence of effectiveness for provision of an emergency card for adolescents with a history of multiple episodes of Self-harm.

Home based therapies

Young people receiving home-based Multisystemic Therapy (MST) experienced some improved functioning in terms of externalising symptoms and spent fewer days out of school and out-of-home placement. At short term follow up the control group had a greater improvement in terms of adaptability and cohesion; this was not sustained at four months follow up.

A recent review found no clear evidence of effectiveness for home-based family intervention for adolescents with a history of multiple episodes of self-harm.

Multifaceted treatment

Combined pharmacotherapy and psychotherapy.

One review found no added benefit, in terms of suicidal ideation, reduction in depressive symptoms, or global improvement, for CBT for patients already receiving antidepressant medication. This study also found no added benefit for suicidal ideation, for pharmacotherapy added to psychotherapy, or psychotherapy with placebo, at follow-up after 12 months.

Multifaceted treatment

Combined screening and psychosocial intervention

One review found that when screening was followed by psychosocial therapy, the combination was effective in reducing risk factors for suicide and in reducing suicidal ideation in adolescents.

One review found that community screening followed by psychosocial health education was effective in reducing suicide in older adults.

One review found that screening followed by education provided by a physician was effective in reducing suicide in men (provided the follow-up was by a psychiatrist) and women (for follow-up by either a psychiatrist or a GP).

One review found that in combination, multimodal interventions and another intervention such as screening showed an effect in some studies, but not in others. Combining psychoeducation with peer-help training had no effect in increasing help-seeking behaviours in youth.

A recent international cluster randomised trial in schools that compared screening and referral, gatekeeper training, and a mental health awareness programme showed that only the mental health awareness programme was associated with a lower incidence of serious suicide ideation and attempts.

One review found that close follow-up contact maintained after hospital discharge showed a small, but not significant, reduction in suicide deaths. Maintaining contact reduced self-harm repetition in women but not in men but did not reduce readmission rates.

One review found that telephone aftercare reduced suicide attempts.

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One review found that brief physician intervention with follow-up telephone call resulted in small but not significant reductions in suicide and one study showed a reduction in suicidal attempts for telephone contact intervention. There was no clear evidence of effectiveness for compliance enhancement for adolescents with a history of multiple episodes of self-harm.

Multi-faceted treatment

Other combinations of interventions

One review found no outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, although indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies.

In military personnel, there is limited evidence that multifaceted suicide prevention programmes based on risk factor identification and educational and organizational changes reduced the rates of suicide and attempted suicide.

Maintenance treatments Adherence with long term treatment

Ongoing contact

One review found that close follow-up contact maintained after hospital discharge showed a small, but not significant, reduction in suicide deaths. Maintaining contact reduced self-harm repetition in women but not in men but did not reduce readmission rates.

One review found that telephone aftercare reduced suicide attempts.

One review found that brief physician intervention with follow-up telephone call resulted in small but not significant reductions in suicide and one study showed a reduction in suicidal attempts for telephone contact intervention.

There was no clear evidence of effectiveness for compliance enhancement for adolescents with a history of multiple episodes of self-harm.

Maintenance treatments Adherence with long term treatment Caring contacts Crisis cards

Three reviews found mixed results. One review found that five studies showed a statistically significant reduction in suicidal behaviour with ongoing caring contact (postcards, letters, emails). Four studies found mixed results with trends for a preventative effect; two studies did not find a preventative effect.

One review of caring contacts (based on three studies) found a non-significant effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person.

One review found sending regular postcards did not reduce repetition of self-harm.

There was no clear evidence of effectiveness for provision of an emergency card for adolescents with a history of multiple episodes of self-harm.

Aftercare Long-term therapy Service

restructuring

No reviews were identified.

One recent UK study found that implementing systems changes related to features of mental health services associated with increased suicide risk led to decreased regional suicide rates. Decreases were related to the extent of care, 24 hour crisis services, clear policies for the management of dual diagnosis patients, and multidisciplinary reviews of suicide deaths.

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QUESTION 3. Strategies for specific high risk populations

What are effective strategies for preventing suicide in specific high-risk populations including: Māori Pacific Children adolescents and young adults (<25 yrs) Adults(25-64 yrs) and older adults (>64 years), especially men Users of mental health services LGBTI Rural areas

Table 10 summarises evidence about effective strategies for suicide prevention in specific high-risk groups. There is no clear evidence about programmes that are effective for Māori or Pacific people. Gatekeeper training programmes, with some cultural modifications, have been commonly used, but most have not been well-evaluated. There are few suggestions for interventions that might be effective, other than gatekeeper programmes adapted for specific cultures and communities. There is no clear evidence about the most effective strategies for preventing suicide in LGBTI and sexual minority populations. There is no clear evidence about preventing suicide in rural populations. Current rural programmes have a strong focus on promoting social connectedness and tend to be initiated in response to crises, but generally lack an evidential or theoretical basis, and few have been evaluated.

For adolescents a meta-analysis of studies addressing self-harm showed an overall effect of treatment compared with usual care, with some of the most promising interventions being CBT, dialectic behaviour therapy, mentalisation, and family therapy. Successful interventions were more likely to have a family component and be offered as multiple sessions. In young people, antidepressant treatment decreases depressive symptoms, but does not always diminish suicide ideation. Antidepressant treatment in youth <25 years is associated with a 1–2% risk difference in the incidence of new-onset or worsening suicide ideation, or suicide attempts. Overall, however, the benefits of antidepressant treatment outweigh the risks of not using antidepressants.

For youth, there is evidence that community and school-based programmes consisting of multiple, combined approaches are more effective than individual programmes. However, no recommendations about which programmes might be included can be made on the basis of current evidence – apart from the Good Behaviour Game, Signs of Suicide, and the Youth Aware of Mental Health component of the SELYE study, few show impacts on suicidal behaviour. There is no evidence that gatekeeper training or postvention programmes in schools reduce suicidal behaviour. No school-based programmes, community based culturally adapted programmes or postvention programmes for schools have been evaluated in terms of safety. Tertiary education suicide prevention programmes similarly show no effect for educational or gatekeeper interventions, but one quasi-experimental study showed that method restriction and mandatory professional assessment of students who exhibit suicidal behaviours reduced suicide rates. There is some promising evidence for parenting programmes for parents, and skills building and emotional developmental programmes for children. There are promising effects for workplace-based, multi-compartmental programmes and gatekeeper and peer education programmes in all ages, and such programmes are relevant for young men.

For adults, and older adults, there is evidence that gatekeeper-based prevention activities in male-dominated workforces are associated with reductions in suicidal behaviour. In primary care and emergency departments promising programmes include physician education, and screening for suicide risk. For older adults, collaborative depression care in primary care is associated with decreased suicide risk and there is support for a range of activities which promote social connectedness.

For people with serious mental illness psychopharmacological (e.g. antidepressants, lithium, clozapine, possibly ketamine), somatic (e.g. ECT, rTCMS,) psychotherapeutic (e.g. CBT, DBT, mentalisation, third wave (mindfulness, yoga)) and psychosocial (e.g. long-term follow-up contacts, physician follow-up calls), are effective and promising approaches for suicide prevention. Systems based approaches within mental health services are associated with reduced rates of suicide attempt and suicide.

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Table 9. Key findings from systematic reviews for specific high risk populations

INTERVENTIONSand STRATEGIES

KEY FINDINGS

Māori · No reviews of interventions specifically for Māori were identified.

· Four reviews of indigenous community-based interventions (in Australia, Canada, US) found that pre/post evaluations were generally positive and reported reductions in suicide and attempts and increased community protective factors. However the studies were generally non-randomised, small, of poor quality and results were not statistically significant. Most interventions employed some type of culturally adapted gatekeeper training as a major component of the programme.

· One trial (with a high likelihood of bias) of Māori who presented to hospital with intentional self-harm found a culturally informed intervention (a package of measures which include problem solving therapy, postcards, patient support, culturalassessment, improved access to primary care and a risk management strategy) had an effect on hopelessness and re-presentation for self-harm in the short term, but not at 12 months.

· A New Zealand PhD thesis reviewed the Signs of Suicide (SOS) programme in operation in US Native American communities and considered it appropriate, with cultural adaptation, for use in New Zealand schools.

Pacific peoples · No reviews of interventions were identified.

· One study found that risk factors for suicide attempt in Pacific youth included: being female, household food insecurity, low levels of family connections and family monitoring, life dissatisfaction, having a religious affiliation, previous suicide by a family member or friend. The authors suggest the Pacific family environment (extended rather than nuclear) is a critical space for intervening.

Child, adolescents and youth populations(<25 years)

· Adolescents are less likely than adults to seek help in the last year and month before suicide. Despite high prevalence of lifetime contact for emotional or substance-related difficulties, fewer than 20% continue to use services within 1 year of onset of suicidal behaviour. More effective outreach programmes for young people are needed.

· Primary care screening tools are less effective in adolescents than adults. Inadolescents sensitivity (ability to identify those at risk) is good at .80, but specificity (ability to identify those not at risk) is lower. Both sensitivity and specificity for adults is higher and in some cases >.95.

· For adolescents, a meta-analysis of studies addressing self-harm showed an overall effect of treatment compared with TAU, with some of the most promising interventions being CBT, dialectic behaviour therapy, mentalisation, and familytherapy. Successful interventions were more likely to have a family component and be offered as multiple sessions.

· In youth <25 years, antidepressant treatment decreases depressive symptoms, but does not always diminish suicide ideation. Antidepressant treatment in youth <25 years is associated with a 1–2% risk difference in the incidence of new-onset or worsening suicide ideation, or suicide attempts.

· Recent reviews suggest only some school-based interventions reduce the incidence of suicide ideation or behaviour. The Good Behaviour Game, for 6–7 year olds, reduced suicide ideation and behaviour in one of two RCTs (one trial was underpowered). An international cluster randomised trial (SEYLE) that compared screening and referral, gatekeeper training, and a mental health awareness programme found that only the mental health awareness programme was associated with a lower incidence of serious suicide ideation and attempts

Table 9. Key findings from systematic reviews for specific high risk populations

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

· In general, reviews suggest that community and school-based programmes consisting of multiple, combined approaches are more effective. However, no recommendations about which programmes might be included can be made on the basis of current evidence – apart from the Good Behaviour Game, Signs of Suicide, and the SEYLE study, few show impacts on suicidal behaviour.

· No school-based programmes, community based culturally adapted programmes or postvention programmes for schools have been evaluated in terms of safety.

· Studies of tertiary education suicide prevention also show no effect for educational or gatekeeper interventions, but one quasi-experimental study showed that method restriction and mandatory professional assessment of students who exhibit suicidal behaviours reduced suicide rate.

· There are promising effects for workplace-based, multi-compartmental programmes and gatekeeper and peer education programmes. Such programmes are relevant for young working adults, especially men, <25 years.

Adults (25 – 64 years),particularly men.

· Despite multiple reviews addressing different levels of interventions, fewprogrammes have been targeted at men in particular. Few studies have explored gender-specific outcomes. Those that have tend to find effects that favour women.

· For adult men, there are a few examples of prevention activities developed for at-risk occupations with male-dominated workforces (e.g. police, military, the construction industry). Three programmes reported reduced suicides (pre/post tests). The best described study which also provides the most convincing evidence is a multi-component programme in the US Air Force (including training,

guidelines,surveillance, and screening) which led to a 33% decrease in suicides. An international replication of these findings in a programme based on the USAF programme strengthens the US findings.

· A substantial proportion of patients access primary care within one month of suicide, but are rarely diagnosed with a mental disorder. Education programmes for primary care doctors targeting identification and treatment of depression have been shown to decrease regional suicide rates, but particularly in women, suggesting a focus on recognition of at-risk men in primary care physician education programmes could be useful.

· There are no reviews of ED programmes for suicide prevention focused on men but one paper has identified EDs as under-utilised sites for recognising men at risk of suicide.

Older adults (≥ 65 years), especially men

· One review found most studies were centred on the reduction of risk factors (depression screening and treatment, and decreasing isolation), but when gender was considered, programmes were mostly effective for women.

· Empirical evaluations of programmes addressing needs of high-risk older adults are positive; most studies show a reduction in the level of suicidal ideation of patients or in the suicide rate of participating communities. Collaborative care programmes with depression managers in primary care are effective in decreasing depressive symptoms and suicide. Results are generally not disaggregated by gender but when they are, tend to favour women.

· Among elderly people, some evidence suggests that interventions to decrease isolation and augment social support through activity groups and telephone outreach

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

can reduce suicide. Reviewers suggest innovative strategies to improve resilience and positive aging, engage family and community gatekeepers, use telecommunications to reach vulnerable older adults, and evaluate the effects of physician education on elderly suicide are needed.

One (grey literature) review found that Men’s Sheds and other genderedinterventions provide an array of benefits for older men including: learning new skills, sharing knowledge; personal achievement; community engagement; opportunity to meet and interact with others. However, there is no robust evidence that involvement in Men’s Sheds has a significant effect on physical health, depression or suicidal behaviour of older men who attend.

Mental health · Collaborative care (care for psychiatric disorders co-located with primary care)service users provides substantial benefits over usual care in outcomes for depression and anxiety,

and improves suicide ideation in older patients with depression.

· Health systems features (24 hour crisis care, clear policies for management of dual diagnosis patients, multidisciplinary reviews of suicide deaths) were shown to be associated with reduced regional suicide rates

· Case management, outreach approaches, improved coordination between primary and secondary care, and maintaining follow-up with ED patients after a suicide attempt visit can reduce repetition of suicide attempt in the following 12 months.

· Internet applications to monitor patients post-discharge and between appointments can improve patient outcomes, but further study to show effectiveness is needed.

· Meta-analyses of RCTs of drug treatment for depression show that antidepressant treatment decreases suicide ideation in individuals ≥ 25 years.

· Other drugs used in mood disorders show some efficacy for suicidal behaviour. Meta-analyses of RCTs support lithium's protective effect against suicide.

· Trials of low dose ketamine show an antidepressant response within minutes of administration in patients with major depressive disorder or bipolar disorder. Single and repeated doses of ketamine can reduce suicide ideation, making it a promising treatment for patients with suicidal behaviours in EDs.

· Other classes of drugs also have anti-suicidal effects, including clozapine, used fortreatment-refractory schizophrenia. Clozapinedecreased suicideattemptsand emergency referrals for suicide ideation compared with olanzapine in patients withschizophrenia or schizoaffective disorder at high riskfor suicidal behaviour.

· Naturalistic studies show patients treated with clozapine have one third the incidence of suicide and attempts vs. patients treated with other antipsychotics.

· In an open-label study of patients with depression at high suicidal risk, more than three-quarters of patients treated with ECT had no suicidal thoughts or intent after nine sessions, consistent with previous studies.

· Preliminary evidence suggests that high doses of repetitive transcranial magnetic stimulation (rTCMS) applied to the left prefrontal cortex might rapidly decrease suicide ideation.

· The most efficacious psychotherapeutic interventions for recurrent suicidal behaviour share several common elements: explicit focus on suicidal behaviour, focus on emotional and cognitive precursors of the behaviour, interventions to encourage positive, and discourage negative, behaviours, having the therapist adopt an active attitude to treatment including problem-solving; planning for coping with suicidal urges.

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INTERVENTIONSand STRATEGIES

KEY FINDINGS

· Dialectic behaviour therapy (DBT. mostly studied in patients with borderlinepersonality disorder; has been shown to reduce recurrence of suicidal behaviour compared with TAU, with more modest differences compared with expert community care.

· There is good evidence CBT can reduce recurrence of suicidal behaviour, with larger effects in adults than adolescents, with individual versus group treatment, and when suicidality is an explicit focus of treatment.

· Mentalisation-based therapy, in which patients are taught how to think about their and other people's actions as the result of underlying thoughts and emotions, thereby improving their ability to understand their own and others' perceptions, is also effective in reducing suicidal behaviours according to two trials in adults with borderline personality disorder.

· Studies that have attempted to longitudinally predict suicidal behaviour find generally poor results that differ little from chance.

LGBTI · No reviews were identified.

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QUESTION 4. Strategies for different settings and contexts

What are effective strategies for suicide prevention in different settings and contexts including: Models of care in the healthcare system Primary care and community-based services Educational/school settings, including tertiary settings Regional differences in suicide risk, particularly urban vs rural differences (including those working in farm

and agricultural industries)

Table 11 outlines evidence about effective interventions for specific settings and sites. Within healthcare systems, different approaches are relevant for specific settings. For primary care and community services, physician education, depression screening and care management programmes involving staff assistance (e.g., case management or mental health specialist involvement) are recommended. Collaborative care models (care for psychiatric disorders co-located with primary care) are more beneficial than usual care for treatment of depression and anxiety, and improve suicide ideation in older patients with depression. Multiple reviews conclude that depression screening and detection are of no benefit without staff assistance in depression care. Within emergency departments, physician and provider education about suicide prevention is recommended. There are suggestions for mandated screening of all ambulatory ED patients for suicide risk with referral to mental health services, provision of safety plans and counselling about access to lethal means by ED staff as minimal interventions prior to discharge for those who screen positive. Post-discharge follow up for at least a year with some form of caring contacts (messages via phone, email, texts, letters, postcards) is regarded as optimal. Within general hospital and mental health services, recommended models of care include multi-level, multi-compartmental programmes such as Zero Suicide, or the UK approach of systematically and simultaneously implementing various features of service delivery shown to be associated with decreased suicide risk (eg, 24 hour crisis care, dual diagnosis programmes, multidisciplinary reviews of suicide deaths.). In addition, intensive care management and community mental health teams are also recommended.

In schools only a very small number of programmes have been shown to have a positive effect on suicidal behaviours. These programmes focus on skills building, emotional development and mental health awareness (e.g. The Good Behaviour Game, Youth Awareness of Mental Health). The evidence for other programmes is limited. Despite wide use, there is no evidence gatekeeper training programmes in schools reduce suicidal behaviour, and there is no evidence about the effectiveness or safety of postvention programmes in schools. Sustained, ‘whole of school’, ecological strategies (incorporating, for example, programmes such as mental health awareness, emotional development, life skills development, mentoring, anti-violence) hold appeal and promise but require evaluation.

Despite the lack of a strong evidence base about risk factors for farm-related suicides various interventions have been implemented but rarely evaluated. There is no systematic review of rural interventions for suicide prevention. However, there is a general agreement interventions should include healthcare, social and political strategies, and be culturally appropriate and acceptable. Recommendations tend to be broad and generic to rural communities and not specific to type of farming, type of farmer, or a specific region or problem. At an individual level, recommendations include suicide prevention activities focused on firearm safety measures, alcohol harm reduction measures, health promotion programmes to enhance resiliency, and interventions to reduce social isolation and address individual sources of stress. Suggestions for community interventions include measures to enhance social support, health promotion programmes to enhance resiliency, and gatekeeper training to equip rural residents with the skills and confidence to recognise people who might stressed or depressed and refer them to appropriate resources for help. Suggestions for healthcare measures include enhancing education for primary care providers about suicide risk assessment and management, and depression recognition and treatment. However, as noted, few existing programmes have been well-evaluated

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Table 11. Key findings from systematic reviews for strategies for different settings and contextsINTERVENTIONS KEY FINDINGS

Healthcare systems

Primary care andcommunity-based services

Physician education, depression screening and care management programmeswith staff assistance, such as collaborative care, case management or mentalhealth specialist involvement, can increase depression response and remission.

The US Preventive Services Task Force has recommended screening for suiciderisk for all adolescents, adults and older adults in primary care, including pregnant and post-partum women. Psychotherapy can reduce the risk for suicide attempts in high-risk populations identified by screening

EmergencyDepartments

· Maintaining follow-up with people after ED visits for suicide attempts can reduce attempt repetition in the following 12 months. Caring contacts via various media (postcards/letters/texts/emails/phone) show promising effects.

· Screening for suicide risk in paediatric EDs is feasible and acceptable, and follow-up interventions reduce suicide risk.

· Provider education for ED physicians and healthcare staff could potentially reduce suicidal behaviours in adults who present to EDs.

· ED counselling of parents and carers about restricting access to lethal means after someone has made a suicide attempt can reduce suicide risk.

Hospitals andmental health services

· Multi-level, multi-compartment programmes such as Zero Suicide.· Systems changes (e.g. 24 h crisis centres, multidisciplinary reviews of suicide

deaths) are associated with declining regional suicide rates.

· There is promising evidence for health systems approaches which focus on intensive care management and community mental health teams.

Educational settings

· Schools (primary andadolescent students)

· Sustained, ‘whole of school’, ecological approaches offer promise.· Gatekeeper training programmes are widely used but have been evaluated

only in terms of pre/post changes in knowledge, attitudes and intention to help. There is no evidence they reduce suicidal behaviour.

· A very small number of school programmes (focused on skills building, emotional development and mental health awareness) have a positive effect on suicidal behaviours (e.g. Good Behaviour Game).

· An international cluster randomised controlled trial in schools compared screening and referral, gatekeeper training and a mental health awareness programme; only the mental health awareness programme was associated with a lower incidence of serious suicide ideation and suicide attempts.

· There is no evidence about the effectiveness or safety of postvention programmes in schools.

· Tertiary educationalsettings

· Tertiary studies show no effect for educational or gatekeeper interventions, but one study found that method restriction and mandatory professional assessment of students with suicidal behaviours reduced the suicide rate.

Geographic settings.

· Rural · No reviews were identified. Most rural programmes (including a large numberthat promote social connectedness) are not empirically-based, nor evaluated.

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QUESTION 5. Current ‘best practice’ in suicide prevention

What constitutes current ‘best practice’ in suicide prevention?

There are two approaches to addressing the risk of suicide: by preventing the development of new cases and by better identifying, treating and managing existing cases. A comprehensive suicide prevention programme encompasses both approaches using a range of programmes that have good evidence of effectiveness. A wide range of additional programmes offer promise but require careful evaluation to determine their effectiveness.

Table 12 summarises the evidence for approaches with current stronger evidence of effectiveness. These include integrated , multi-component, multi-level, systems-based interventions within health and mental health services and their local communities (e.g. Perfect Depression, The US Air Force Programme, and 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 recognising, treating and managing depression and suicidal behaviour; maintaining ongoing contact with vulnerable individuals, 24-hour crisis services, minimizing access to lethal means of suicide, controls on alcohol, gatekeeper education programmes, responsible media reporting and enhancing resiliency in indigenous communities.

Effective initiatives targeted at managing individuals at risk include pharmacotherapeutic, psychotherapeutic and psychosocial interventions. In particular there is good evidence for the effectiveness of cognitive behavioural therapies and problem solving therapies delivered face to face or online, and for long-term follow-up and management of at-risk patients. The evidence for effective pharmacological treatments of depression in youth, adult, and older adults has been strengthened. Clozapine and lithium have anti-suicidal effects, and ketamine holds promise for the management of acute suicidality and for treatment resistant depression. There is promising evidence for health systems approaches which focus on intensive care management and community mental health teams. Evidence supports collaborative approaches (between patient and practitioner) to assessment and management, including, for example, the Collaborative Assessment and Management of Suicide (CAMS) programme..

At a practice level, collaborative care, in which care for psychiatric disorders is co-located with primary care, provides substantial benefits over usual care in outcomes for depression and anxiety, and improves suicide ideation in older patients with depression e.g. the Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) programme. Recent evidence suggests the value of low-cost minimal interventions such as caring contacts after ED discharge, with contact maintained for at least a year. At a regional level, systems changes directed at enhancing features of mental health services identified as being associated with suicide risk can reduce regional suicide rates. Reductions have been shown for a programme which includes clear policies for the management of dual diagnosis patients, 24-hour crisis services, and multidisciplinary reviews of suicide deaths.

While it is regarded as good practice to offer postvention services, there is no evidence to support the effectiveness or safety of these programmes. There is evidence for the effectiveness of counselling targeted for people with traumatic grief.

At an institutional level promising research includes early case finding and screening in schools, colleges, welfare and justice settings, and screening and intervention in primary care and emergency departments. School-based programmes focusing on mental health promotion and preventing substance use for children and youth that integrate behavioural changes, coping skills and social supports are regarded as more constructive and less potentially harmful than programmes that focus directly on suicide. Examples of early skills building programmes include the Good Behaviour Game, and Youth Aware of Mental Health (YAM). In the workplace, there is evidence that gatekeeper training programmes which educate staff to recognise at-risk colleagues and link them to helpful resources can reduce suicides.

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.

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Table 12. Key findings from systematic reviews regarding current best practice in suicide prevention

INTERVENTIONSand STRATEGIES

KEY FINDINGS

Generic Investments in evaluations of programme safety, effectiveness and cost-effectiveness

Training of programme implementers and evaluators in prevention science

Universal Means restrictions for all methods of suicide, wherever possible. Evidence has strengthened for package and sales restrictions of analgesics, and for barriers at iconic jumping sites.

Media reporting guidelines, provided a. that implementation is sustained, and b. that there is investment in education, monitoring and partnership with journalists to ensure awareness and uptake.

Alcohol controls (e.g. taxation, minimum legal drinking age, fewer regional alcohol outlets, zero tolerance for drink driving).

Improving accessibility of care for at-risk people.

Developing multilevel and/or multi-compartmental prevention programmes within health services, workplaces or communities with an integrated package of programmes which are effective individually and synergistically

Some support for public messaging programmes if they are part of a multifaceted strategy.

Selective Physician education and training, and support for primary care physicians including treatment guidelines, websites, liaison between physicians and psychiatric service providers, and assistance with facilitating services within their communities

Screening for suicide risk in primary care, provided depression care is available.

Training in suicide prevention for other providers working in the health and social services sectors; integration of suicide prevention education into all health professionals’ and social service providers’ curricula.

School-based programmes focusing on mental health promotion and preventing substance use for children and youth that integrate behavioural changes, coping skills and social supports. Early skills building e.g The Good Behaviour Game (at age 6) and other programmes for which there is evidence of an impact on suicidal behaviours.

Safety checks of architectural and structural hazards in institutional environments and requirements for new buildings that minimise suicide hazards

Training peers in (especially male-dominated) workplaces to better understand suicide, recognise those at risk and intervene

Culturally adapted gatekeeper training for indigenous or minority populations

Post-discharge follow-up and caring contacts after ED presentations for suicidal behaviours

Screening for suicide risk in EDs, education of emergency physicians and staff, and post-discharge follow-up with caring contacts

Indicated Pharmacological, psychotherapeutic (including cognitive behavioural therapies) for people with mental disorders, including substance abuse

Cognitive behavioural therapies for at-risk individuals, including older adults,

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Table 12. Key findings from systematic reviews regarding current best practice in suicide prevention

INTERVENTIONSand STRATEGIES

KEY FINDINGS

and people presenting to EDs with suicidal ideation and behaviours

Dialectical behavioural therapy, especially for people with borderline personality disorder

Maintaining ongoing follow-up with people at risk, including those discharged from inpatient care and ED

Safety and support plans for patients for patients discharged from ED and inpatient units, and inclusion in these plans of counselling about access to lethal means

Intensive care management and community mental health teams

Use of the Collaborative Assessment and Management for Suicidality (CAMS) approach

Systems changes within health services (including, for example, clear policies for the management of dual diagnosis patients, follow-up care, and multidisciplinary reviews of suicide deaths).

Among older adults, interventions to decrease isolation and promote social support through activity groups and telephone contact from healthcare providers

In primary care, collaborative care models (co-location of mental health and primary care) offering enhanced depression management for older adults.

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QUESTION 6. Promising strategies for suicide prevention

What are promising strategies for preventing suicide?

Table 13 summarises best evidence about promising strategies for suicide prevention. At a universal level, promising strategies include education for all health professionals, along with regular updated training programmes; continued use of lethal means restriction policies with such policies updated as necessary to reflect changes in methods and new evidence; alcohol control policies, and more support for alcohol and substance use programmes, especially for emergent problems such as methamphetamine use; and use of internet policies to minimise harmful internet use, including cyberbullying. Programmes which promote social and community connectedness, social activities and social support offer promise, especially for older people. Promising approaches include integrated multi-level community and health systems programmes such as those developed by the European Alliance against Depression.

At the selective level promising strategies include screening and support programmes in emergency departments and in primary care; integration of suicide prevention with other violence prevention programmes; support for new policies designed to engage and support at-risk men, including screening programmes in polytechs, colleges, courts and prisons, life skills training for apprentices, and support for mental health, wellbeing, and suicide prevention programmes in workplaces especially for those men who work in high risk occupations (e.g. trades and construction, farming, fisheries, forestry, and the defence forces) and for first responders , including police and ambulance and fire officers.

At the indicated level promising strategies include expansion of programmes using internet and mobile devices to deliver behavioural cognitive therapies, ‘third wave’ cognitive therapies (e.g mindfulness) and to provide follow-up support after hospital discharge, longer-term maintenance support and peer support.

At a treatment level there are promising new psychopharmacologic, psychotherapeutic and psychosocial treatments for people with suicidal ideation and behaviours, depression and mental disorders associated with suicide. Epigenetics holds most promise for personalized depression treatments. There are promising new drugs to treat depression including SNRIs (serotonin norepinephrine reuptake inhibitors) which have fewer individual side effects than SSRIs (selective serotonin reuptake inhibitors), the antiglutamatergic drug riluzole, and drugs that control cortisol. The use of ketamine or it’s metabolite HNK (hydroxynorketamine) for ED treatment of acute suicidal ideation is promising. Ketamine is also promising for treatment of treatment resistant depression. Novel drug combinations hold promise, including ketamine and riluzole, with ketamine administered first, to induce a rapid antidepressant response, followed by riluzole to sustain the response. At the psychotherapeutic level, good evidence supports the traditional cognitive behavioural therapies and ‘third wave’ cognitive therapies (eg. mindfulness).

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. A range of complementary therapies including cognitive behavioural therapies, yoga, meditation, exercise, and light therapy, used individually, and in various combinations, have been shown to reduce depression and suicidal ideation.

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 rat-risk children, parenting programmes, and programmes which encourage development of emotional skills and life skills (e.g. the Good Behaviour game, Youth Aware of Mental Health (YAM), Zippy’s Friends).

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Table 13. Promising strategies for suicide preventionINTERVENTIONS and STRATEGIES

PROMISING STRATEGIES

Universal Mandated education and training in suicide prevention for all health and relevant social service providers.

Competency standards in suicide prevention for people working in relevant health and social service positions

Alcohol control policies

Selective Screening all adolescents, adults and older adults, including pregnant and post-partum women, in primary care, provide there is a package of depression care and support available.

Screening for suicide risk all people who present to EDs, provided there is a package of provider education, intervention and follow-up after discharge.

Collaborative care models for depression management in primary care

Internet and mobile device delivery of behavioural cognitive therapies and ‘third wave’ cognitive therapies.

Integrated gatekeeper training and support packages in all workplaces, but especially male dominated workplaces

Community, health systems and institutional-level multi-compartmental programme packages (e.g. the European Alliance against Depression (EAAD), the US Air Force programme, Zero Suicide)

Gatekeeper training and education for first responders

Culturally adapted gatekeeper training and suicide prevention programmes for Māori and Pacific

Indicated Third-wave cognitive therapies including mindfulness

ED-post-discharge caring contacts with follow-up maintained for a year -

Long-term contact with at-risk individuals.

Treatment Improve treatment adherence

Develop new psychopharmacologic, psychotherapeutic and psychosocial treatments for people with suicidal ideation and behaviours, depression and mental disorders associated with suicide.

Epigenetics holds most promise for personalized depression treatments.

Complementary therapies including yoga, meditation, exercise, and light therapy, as well as cognitive behavioural therapies, have been shown to reduce depression and suicidal ideation.

New diagnostic tools (e.g. MRIs, specific blood tests) may predict which individuals will have poor responses and side-effects to antidepressants, and thereby help to develop individually targeted antidepressant treatments.

Low-dose ketamine, riluzole, or hydroxynorketamine (HNK) are promising drugs for acute treatment of suicidal ideation and for treatment resistant depression (TRD)

repetitive transcranial magnetic stimulation (rTCMS)

Maintenance Health systems changes (e.g. Zero Suicide, structural changes in health care delivery systems (after those found to be associated with reduced regional suicide rates in the UK, e.g. 24 hour crisis care, multidisciplinary review of suicide deaths).

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Question 7. Gaps in the evidence base

What are gaps in the evidence base for effective strategies which might have implications for policy revision and service development in New Zealand?

Table 14 summarises gaps in the evidence. Major policy, research, practice and programmatic gaps are outlined below.

In New Zealand, despite a strong policy emphasis on community-led and community-based interventions, the has been very little evaluation of the strategies and programmes that have been funded in this area. Similarly, while a high priority has been placed on addressing suicide prevention in some high-risk groups, notably Māori, Pacific and youth, few of the programmes that have been funded for these groups have been evaluated for efficacy or safety. Given lack of evidence for effectiveness, it is not surprising that there are also no evaluations of cost-effectiveness for any programmes.

For almost all the at-risk groups identified by the Ministry of Health there are clear gaps in strategies and evidence-based interventions. For example, there are no strategies to reduce suicide in men, despite the fact that they account for the majority of suicides, young men aged 20-40 years account for 30% of all suicides, and suicide rates in men aged 25-44 years are rising. There are no strategies to address suicide in older adults, despite changing demographics and the ageing of the population. There are no strategies to address rural suicide, despite increasing rural depopulation, changes in farming practices and problems in staffing rural primary health care. There is no specific suicide prevention policy direction for people with serious mental illness and others who are mental health users.

These gaps are all the more important given that there is increasing international evidence and enthusiasm for the effectiveness of integrated, multi-component, multi-level, systems based programmes such as the US Air Force programme, Zero Suicide or the community programmes initiated under the umbrella of the European Alliance Against Depression. The World Health Organization recommends comprehensive and multilevel approaches to suicide prevention that combine universal and targeted interventions. Despite a strong emphasis on community-based approaches New Zealand has produced no evidence for multi-level community interventions, and there is no clear strategic direction for such programmes.

As well as programmatic gaps, there are gaps in research and practice. Gaps in knowledge and investment exist at the policy level, at the structural 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, especially men; the impact of alcohol restrictions on suicidal behaviour, and research into social engineering strategies to address the social inequities and the social and socioeconomic determinants of suicide. More research is needed to address the growing problem of childhood adversity and the best ways to improve the life course of those children subjected to such adversity. This work includes an emphasis on programmes that address sexual abuse which is a strong and enduring risk factor for suicide throughout the life course. Research is needed about the extent and impact of current levels of substance use, particularly methamphetamine, on individuals, children, families and communities.

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 healthy lifestyle programmes and treatment adherence programmes for people with mental health problems; more knowledge about what makes people suicidal, how to interrupt a suicidal pathway and how to promote resiliency; improved risk prediction, and identification of biomarkers for suicidal behaviour. New research suggests that brief early interventions delivered in the ED and followed up for at least a year offer a useful, low-cost approach.

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; modelling to identify priorities; identification of effective interventions outside healthcare settings (e.g. communities, workplaces, sports clubs); 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).

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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; 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 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 older adults.

Within health services emergency departments and primary care are key settings for suicide prevention. Programme development should focus on developing seamless systems and training staff in detection, assessment, treatment, referral and management including long term follow-up of suicidal patients.

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.

Across all these gaps in research, policy and practice, new and promising approaches need to be carefully developed, conducted and evaluated, using a prevention science approach. Consistent, meaningful outcome measures need to be agreed upon and these need to be consistent with those used internationally to permit comparisons. The critical elements of effective programmes need to be defined and identified.

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Table 14. Summary of gaps in the evidence base for effective strategies.

FIELD GAPS in the EVIDENCE BASEStrategies, Structure, Evaluation and Evidence

Evidence Evidence that is available for inclusion in rapid reviews and systematic reviews is generally methodologically poor - almost all systematic reviews call for more research, and methodologically more robust research.

Lack of evidence about the specific and defining elements of interventions which would be key to implementing and, possibly, adapting programmes for use in New Zealand. Generally, the available evidence tends to be non-specific with regard to the critical features of a programme, the characteristics of the subjects and the key issues to secure successful implementation.

Lack of a co-ordinated programme of research, based on evidence and with strong theoretical underpinnings. Much of the research seems to reflect opportunistic or political responses or individual researcher preferences.

New Zealand A lack of evidence specific to the New Zealand culture

A lack of programmes developed and/or trialled and evaluated in New Zealand

No evaluation of the 2006-2016 national New Zealand Suicide Prevention Strategy. This is consistent with a general failure to evaluate national suicide prevention strategies worldwide.

Evaluation Lack of scientific rigour in deciding which policies and programmes to implement.

Lack of evidence for effectiveness and safety of many current programmes. A start would be to evaluate those programmes that are currently operating, especially those supported by government funding.

A lack of replicated studies.

Structure Lack of evidence about the best approach and key components needed to establish and maintain a co-ordinated, multi-disciplinary, inter-agency structure with sustained, long-term, adequate funding, and respect for evidence

Lack of national and international research and education centres to disseminate information and collate and warehouse data.

Lack of workforce capacity, both in research and in programme implementation

Cost-effectiveness

No systematic reviews address the cost-effectiveness of interventions, or (with one recent exception) of the most promising interventions. While this is a gap it is not unexpected since evidence of effectiveness is lacking for many interventions.

Translation to the New Zealand context

Insufficient information in reviews to guide or assess translation of many programmes to the New Zealand context. However, there little reason to believe that the more ‘generic’ interventions (e.g. caring contacts, telephone support) would differ in their impact on different populations.

Universal interventions

Means restriction

Lack of evidence about effective interventions to prevent hanging

Public messaging

Lack of evidence about effectiveness and safety of public messaging campaigns about suicide prevention.

High-risk groups

Males Lack of evidence about how to best screen, identify and treat adult men at risk of suicide, especially in primary care settings and in EDs.

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Māori and Pacific

Lack of evidence about effectiveness and safety of current suicide prevention programmes for, and of culturally adapted suicide prevention, including gatekeeper training, programmes.

LGBTI Lack of evidence about what type of programme best supports LGBTI, and the effectiveness of programmes in reducing suicide risk in this population

Rural sector Lack of evidence for the effectiveness of any programmes to address suicide prevention in the rural sector.

Health services

Health services

Lack of evidence about health services structural changes, programme delivery, Zero Suicide-type programmes, and specific programmes for SMI and suicidal patients.

Emergency Departments

Failure to focus on EDs as sites for suicide prevention, and to develop and evaluate screening, assessment, brief interventions, lethal means counselling, and follow-up with caring contacts programmes for ED patients.

New therapies

Lack of evidence about new drugs (e.g. ketamine, HNK, riluzole, SNRIs) for acute suicidality and treatment resistant depression

Lack of evidence to promote complementary therapies (e.g. CBT, mindfulness, yoga, exercise) for depression.

Treatment Adherence

Lack of evidence about effectiveness of treatment adherence programmes

Crisis lines Lack of evidence about the effectiveness of telephone crisis lines in reducing acute suicidality and ensuring engagement in treatment.

Postvention programmes

Lack of evidence about effectiveness and safety of postvention programmes including programmes implemented to address emergent suicide clusters.

Specific sites

Community gatekeeper training programmes

Lack of evidence about gatekeeper training programmes including whether pre/post knowledge and attitude changes translate to behavioural changes in the longer term, how to ensure and sustain behavioural changes, and how often to re-deliver training to maintain awareness.

School programmes

Lack of evidence about effectiveness and safety of school-based suicide prevention programmes and programmes delivered in schools by individual providers.

Lack of evidence about current skills building programmes in schools and their impact on suicidal behaviours. If they don’t have an effect then their presence precludes the development and implementation of programmes which might have a greater impact on suicide prevention.

Courts, prisons

Lack of evidence about effectiveness and utility of prison and court-based approaches to identify people, specially men, men at risk of suicide.

Workplace programmes

Lack of evidence about effectiveness of workplace mental health and wellbeing promotion programmes and suicide prevention programmes, both multilevel and gatekeeper-based programmes.

Internet,m-health programmes

Lack of evidence about effectiveness and cost-effectiveness of internet and mobile delivered cognitive behavioural programmes.

Systems based programmes

Lack of evidence about effective components and combinations of programmes in multilevel suicide prevention programmes.

References1.Ministry of Health. 2016. Suicide Facts: Deaths and intentional self-harm hospitalisations 2013. Wellington: Ministry of

Health

2.Varker T Forbes D, Dell L, Weston A, Merlin T, Hodson S, O'Donnell M. Rapid evidence assessment: increasing the transparency of an emerging methodology. Journal of Evaluation in Clinical Practice. 21(6):1199-204, 2015 Dec.

3.Kaltenthaler E; Cooper K; Pandor A; Martyn-St James M; Chatters R; Wong R. The use of rapid review methods in health technology assessments: 3 case studies. BMC Medical Research Methodology. 16(1):108, 2016.

4.Gordon R. An operational classification of disease prevention. Public Health Reports. 1983;98:107 –109

5.Gordon, R. (1987). An operational classification of disease prevention. In J. Steinberg & M.Silverman (Eds.), Preventing Mental Disorders: A Research Perspective (20-26). Rockville, Maryland: US Department of Health and Human Services: National Institute of Mental Health

6.Institute of Medicine. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. In: Mrazek PJ, Haggerty RJ, editors. Committee on Prevention of Mental Disorders, Division of Biobehavorial Sciences and Mental Disorders. Washington, DC: National Academy Press; 1994.

7.Guo B, Scott A, Bowker S. Suicide prevention strategies: evidence from systematic reviews. Edmonton, Canada, Alberta Heritage Foundation for Medical Research, 2003(http://www.ihe.ca/documents/suicide_prevention_strategies_evidence.pdf, accessed 1 September 2011).

8.Beautrais AL, Larkin GL. Suicide Prevention. In Knifton L, Quinn, N (Eds.,) Public Mental Health:Global Perspectives. McGraw-Hill. 2013, pp. 59-70

9.Hiji MM, Wilson MG, Yacoub K, Bhuiya A. Rapid Synthesis: Identifying Suicide-prevention Interventions. Hamilton, Canada. McMaster Health Forum, June 2014.

10. World Health Organisation. Preventing Suicide. WHO, Geneva, 2014, ISBN: 978 92 4 156477 9

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APPENDIX 1.

The tables below give details of searches made. All searches were for articles from year 2006 to 2016, supplemented by landmark reviews or studies, and studies relevant to New Zealand or to the nominated high-risk groups and settings of interest. Searches were carried out during November and December 2016. Since searches of the databases alone (see Methods, page 8), yielded 576 systematic reviews of suicide prevention and 2760 reviews of depression management and treatment, searches were refined using combinations of search terms and all were restricted to ‘English language’ with full text copy of the article available electronically. Further studies were identified through snowballing, and searches of gray literature. A total of 2344 papers were reviewed and 211 were included in this review. Tables 14-16 below, show summaries of key findings from reviews for universal, selective and indicated preventions, using the framework outlined in Table 1, page 8.

Appendix 1. Table 15. Summary of key findings for universal interventions

Intervention Focus of review(Author reference)

Key findings

Universal National suicide prevention

programmes

No systematic reviews of effectiveness were identified

Review national suicide prevention strategies in terms of content and evaluation of the strategy.

WHO, 20141

28 countries have a national suicide prevention strategy. Content is similar across countries and typically includes these elements: surveillance; means restriction; media; access to services; training and education; treatment; crisis intervention; postvention; awareness; stigma reduction; oversight and co-ordination.

Systematic and comprehensive evaluations of national strategies are limited. Where attempted, outcomes are inconsistent: Some countries show significant reductions in suicide rates for the total population (e.g. Finland, Scotland), others show limited effects. Evaluation outcomes are difficult to interpret because of poor quality information about implementation of actions.

Universal Means restriction policies

Review of effectiveness of specific suicide-preventive Interventions, including lethal means restriction.

Mann et al, 20052

Suicides by highly lethal methods have decreased after firearm control legislation, restrictions on pesticides, detoxification of domestic gas, restrictions on the prescription and sale of barbiturates, changing the packaging of analgesics to blister packets, mandatory use of catalytic converters in motor vehicles, construction of barriers at jumping sites, and the use of new lower toxicity antidepressants.

Where the method is common, restriction of means has led to lower overall suicide rates. Substitution of method may obscure a change in overall suicide rates. Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means.

Review effectiveness of Studies consistently find a reduction in completed suicide following restrictions in access to lethal

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interventions to prevent suicide and suicidal behaviour.

Leitner et al, 20083

means.

For attempted suicide, restriction of access to means is a promising intervention.

Review effective interventions for prevention of suicidal behaviour.

Van der Feltz-Cornelis et al, 2011 4

Six relevant systematic reviews were found. Best practices identified as effective included restricting access to means of suicide at a population level.

No outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, although indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies.

Review effectiveness of suicide preventive interventions.

Guo and Harstall, 2004 5

Two systematic reviews found evidence for effectiveness of restricting access to lethal means in preventing suicide at a population level. One review found a preventive effect, at the selective level, for installation of safety measures on high buildings.

Review national means restriction and intentional overdose policies/ strategies, and their effectiveness, with focus on policies/strategies relevant to children, youth, and young adults.

Guo et al, 2010 6

National suicide prevention strategies targeted restriction of means of suicide from self-poisoning, vehicle exhaust gas, use of firearms, jumping from high places, and access to railway lines.

Prevention of hanging in public settings received little attention, although hanging is the most commonly used method worldwide. Some attempts have been made to restrict means for hanging in institutional settings such as prisons and psychiatric institutions.

Strategies specific to reduce intentional drug poisoning include legislation of acetaminophen and co-proxamol, parent education about safe storage of medications, and appropriate disposal of unused, or unwanted medications.

Acetaminophen restrictions coincided with reduction in acetominophen-related deaths and admissions to liver units, although some evidence implies the association may not be causal. Data on acetaminophen sales and severity of overdoses is equivocal. One study found that restrictions on acetominophen reduced its use but led to increased use of other drugs.

In the UK, restriction of co-proxamol was associated with a reduction in its prescription as well as a significant reduction in deaths.

When barbiturates were restricted (following their substitution by antidepressants) barbiturate-related suicide deaths decreased.

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After a suicide attempt by their child, education of parents about means restriction led to parental actions to remove means.

The authors note that inconsistencies in findings of drug restriction legislations may be due to methodological differences among studies.

Review effectiveness of controlling access to means of suicide.

Sarchiapone et al, 2011 7

In many countries, restrictions of access to common means of suicide has led to lower overall suicide rates, particularly regarding suicide by firearms, detoxification of domestic and motor vehicle gas, toxic pesticides in rural areas, barriers at jumping sites and hanging, and by introducing "safe rooms" in prisons and hospitals.

Decline in prescription of barbiturates and tricyclic antidepressants (TCAs), as well as limitation of drugs pack size for paracetamol and salicylate has reduced suicides by overdose.

Increased prescription of SSRIs seems to have lowered suicidal rates.

Restriction to means of suicide may be particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods. However, since there is some risk of means substitution, restriction of access should be implemented in conjunction with other suicide prevention strategies.

Review suicide risk in military organizations, and identify opportunities for suicide prevention.

Zamorski et al, 2011 8

Suicide rates in currently serving personnel are below rates in the general population of same age and sex distribution. although the UK has reported a modest excess of suicides in younger army men, and the US Army and Marine Corps have seen a recent rise in suicide rates, bringing these rates above civilian rates. Recent UK veterans have a higher rate of suicide than their civilian counterparts, particularly in the first few years after release. Younger army males with short periods of service were at particularly elevated risk.

It is highly probable that the same broad range of risk factors, protective factors, and triggers for suicidal behaviour identified in the general population also applies to military populations.

Along with other suicide prevention initiatives, the military setting offers special opportunities for restricting access to lethal means, especially firearms, and prescriptions dispensed via military pharmacies.

Review means restriction for suicide prevention.

Yip et al, 2012 9

At the population level, means restriction is most effective when the method is common and highly lethal, accounting for a substantial percentage of deaths, and the means restriction is supported by the community and is enacted in conjunction with other suicide prevention initiatives.

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Means restriction is more effective in women than men; method substitution is more common in men than in women.

New methods might have large effects if they spread through communities rapidly via the internet.

Examine effectiveness of structural interventions at suicide hotspots.

Pirkis et al, 2013 10

Structural interventions at ‘hotspots’ avert suicide at these sites. Pooled results from 9 studies found that structural interventions at hotpots reduced suicides from 5.7 per year to 0.3 per year, a reduction of 86%. There was a 44% increase in jumping suicides per year at nearby sites, but the net gain was a 28% reduction in all jumping suicides per year.

Review effectiveness of interventions to prevent suicide at suicide hotspots.

Pirkis et al, 2015 11

Currently used interventions at hotspots seem to be effective. Interventions that restricted access to means were associated with a reduction in the number of suicides per year, as were interventions that encourage help-seeking, and interventions that increase the likelihood of intervention by a third party. When we included only those studies that assessed a particular intervention in isolation, restricting access to means was associated with a reduction in the risk of suicide, as was encouraging help-seeking. No studies assessed increasing the likelihood of intervention by a third party as a lone intervention.

Review effectiveness of measures to prevent railway suicide and trespass.

Havârneanu et al, 2015 12

Two measures show effectiveness: (a) fencing and other physical barriers and (b) appropriate reporting or broadcast of suicides to avoid a copycat effect.

Fencing has been shown to reduce fatalities at suicide hotspots between 59% and 100% and trespassing between 23% and 95% at trespass hotspots.

Studies about media guidelines suggest that guidelines might reduce suicidal behaviour between 19% in the long term (2 years after the broadcast) and about 84% in the short term (6 months after implementation).

There is limited evidence for other measures. The effectiveness of combinations of measures has not been evaluated.

Review railway suicides and measures to prevent suicides at railways.

Mishara and Bardon, 2016 13

Railway suicides resemble closely people who use other methods, although they tend to be younger. As with other suicide methods, mental health problems are likely to be present. Railway suicide attempters usually die, but most urban transportation systems attempters survive. Railway suicides are rarely impulsive. Studies of survivors suggest they chose the method because they thought they would have an immediate, certain and painless death. Media reports on railway suicides can increase their incidence.

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Better quality research is needed, both about why people use railways to kill themselves and how railway suicides can be effectively prevented, as well as more evaluations of prevention programmes. Prevention programmes should conduct a local assessment of characteristics of attempters and incidents.

There is limited evaluation of prevention measures but promising strategies include: Changing beliefs and attitudes about railway suicides, reducing media reports, offering help onsite, controlling access at hotspots and better staff training in mental health facilities near tracks. Local specificities must be considered in planning prevention strategies.

Review recent advances in suicide means safety as a suicide prevention strategy.

Jin et al, 2016 14

Means safety (vs. means restriction) is defined as reduced access to and/or increased safe storage of potentially lethal methods for suicide.

Research on means safety for jumping, firearm safety and gas inhalation has also produced unambiguously meaningful effects with respect to suicide prevention. There is a dearth of research and empirical data on hanging, intentional overdose, and alcohol. Means safety interventions seem promising for common, highly lethal methods, although cultural and practical barriers will need to be taken into consideration.

Review recent advances in suicide means safety as a suicide prevention strategy.Jin et al, 2016 14

Means safety (vs. means restriction) is defined as reduced access to and/or increased safe storage of potentially lethal methods for suicide.

Research on means safety for jumping, firearm safety and gas inhalation has also produced unambiguously meaningful effects with respect to suicide prevention. There is a dearth of research and empirical data on hanging, intentional overdose, and alcohol. Means safety interventions seem promising for common, highly lethal methods, although cultural and practical barriers will need to be taken into consideration.

Universal Media reporting/portrayal

guidelines

Review literature concerning the Internet and suicidality; examine pathways by which suicidal risks and prevention efforts are facilitated through the Internet.

Durkee et al, 2011 15

Specific Internet pathways increased the risk for suicidal behaviours, particularly in adolescents and young people. Several studies found significant correlations between pathological Internet use and suicidal ideation and non-suicidal self-injury. Pro-suicide websites and online suicide pacts were observed as high-risk factors for facilitating suicidal behaviours, particularly among isolated and susceptible individuals.

Conversely, the Internet could be an effective tool for suicide prevention, especially for socially-isolated and vulnerable individuals, who might otherwise be unreachable.

Review of evidence of the use and effectiveness of media guidelines for reporting on suicide.

Guidelines can be effective in both reducing suicide and changing reporting behaviour. Several studies suggest sharp reductions in suicide rates after introduction of media guidelines. In one study, subway suicides in Vienna decreased by 75% following introduction of media guidelines,

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Bohanna et al, 2012 16with this decrease sustained over 5 years.

One study found that reduction in suicides was limited to areas in which compliant newspapers reached more than 67% of the population, with no significant impact in areas in which <50% of the population were covered by compliant media.

Studies examining the effect of media guidelines in modifying journalists’ behaviour demonstrate mixed results. Some studies found compliance with some of the recommendations (e.g. reduction in in use of ‘suicide’ in headlines) while other studies reported increased publication of suicide articles following introduction of guidelines. One study showed a regression to original reporting styles over time.

In general, journalists were neither aware nor supportive of guidelines. Austrian and Australian examples suggest guidelines are most likely to be effective in improving reporting and reducing suicide when accompanied by media consultation and endorsement, active dissemination strategies, and ongoing training and monitoring.

To review effects of media reporting about suicidal s on actual suicidality (completed suicides, attempted suicides, suicidal ideation).

Sisask et al, 17

Most studies support the view that media reporting and suicidality are associated, although there is a risk of reporting bias. More research is available about how irresponsible media reports can provoke suicidal s (the ‘Werther effect’) and less about protective effect media can have (the ‘Papageno effect’).

The strong modelling effect of media coverage on suicide is based on age and gender.

Media reports are not representative of official suicide data and tend to exaggerate sensational suicides (e.g. dramatic and highly lethal suicide methods) which are rare in real life.

Universal Suicide prevention and

awareness public messaging campaigns

Review effectiveness of mass media campaigns targeted at suicide prevention or suicide literacy.

Torok et al, 2017 18

For behavioural outcomes, mass media campaigns appear to be most effective when delivered as part of a multicomponent suicide prevention strategy, while "standalone campaigns" were modestly useful for increasing suicide literacy. Level of exposure, repeat exposure, and community engagement appeared to be fundamental to the success of these campaigns; however, these constructs were poorly adhered to in the development and implementation of campaigns. Overall, the mixed quality of the included studies highlights a need for increased quantity, consistency, and quality of evaluations to advance the evidence base.

Universal Public messaging, includingo Mental health literacy and de-

stigmatisation programmes

Review school-based interventions, for students 18 years or younger, to prevent or eliminate mental health

Methodological limitations precluded conclusions about the value of school-based interventions.

Suggestive evidence indicates curriculum-based approaches which foster the development of empathy and, in turn, an orientation toward social inclusion and inclusiveness may be effective.

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o Depression awareness programmes

o Suicide awareness and literacy campaigns

stigmatization.

Schachter et al, 2008 19

These effects may be achieved largely by bringing especially but not exclusively the youngest children into direct, structured contact with an infant and likely only the oldest children and youth into direct contact with individuals experiencing mental health difficulties.

Meta-analysis to examine effects of anti-stigma approaches.

Corrigan et al, 2012 20

Examined anti-stigma approaches, including protest or social activism, education of the public, and contact with people with mental illness. Overall, both education and contact had positive effects on reducing stigma for adults and adolescents with a mental illness.

Contact was better than education at reducing stigma for adults. For adolescents, the opposite pattern was found: education was more effective. Overall, face-to-face contact was more effective than contact by video.

Review persistence of effects of anti-stigma programmes about mental health.

Corrigan et al, 2015 21

The effect size for overall impact was significantly different from zero for education programmes, but a similar effect size was not significantly different from zero for contact programmes because a small number of contact-intervention studies included follow-up. Effect sizes for attitudinal change were significantly different from zero for education and contact, but the effect size for contact was significantly greater.Future research designs need to include strategies for follow-up assessments.

Review effectiveness of interventions targeting the stigma of mental illness at the workplace.

Hanisch et al, 2016 22

Anti-stigma interventions at the workplace can lead to improved employee knowledge and supportive behaviour towards people with mental-health problems. Effects of interventions on employees' attitudes were mixed, but generally positive. There was some evidence that anti-stigma interventions improved workers’ knowledge of signs of mental illness and treatment options, which may lead employees to seek help earlier, and potentially impact numbers of days lost to illness. The quality of evidence varied across studies and was generally of poor quality.

Review effective interventions intended to reduce mental-illness-related stigma or discrimination

Thornicroft et al, 2016 23

At the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement.

For people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment. For specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains.

Social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. There is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress.

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Caution needs to be exercised in not overgeneralising lessons from one target group to another.Review effectiveness of mass media interventions for reducing mental health-related stigma.

Clement et al, 2013 24

Mass media interventions may have a small to medium effect in decreasing prejudice, and are equivalent to reducing the level of prejudice from that associated with schizophrenia to that associated with major depression. However, there is insufficient evidence to determine their effects on discrimination.

There are few studies in middle- and low-income countries, or with employers or health professionals as the target group, and none targeted at children or adolescents. Very little is known about costs, adverse effects or other outcomes. The findings are limited by the quality of the evidence, which was low for the primary outcomes for discrimination and prejudice, low for adverse effects and very low for costs.

Review effectiveness of interventions to reduce mental health-related stigma and discrimination in the medium and long term.

Mehta et al, 2015 25

Medium to long term follow-up was a minimum 4 weeks. There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes.

Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term.

Universal Depression awareness

programmes

Review public education campaigns about depression or suicide awareness and summarize data on the impact and effectiveness of these campaigns.

Dumesnil and Verger, 2009 26

Results from 15 programmes in 8 countries suggested that these programmes contributed to a modest improvement in public knowledge of and attitudes toward depression or suicide, but most programme evaluations did not assess the durability of the attitude changes. No study has clearly demonstrated that such campaigns help to increase care-seeking or to decrease suicidal behaviour.

Comparing programmes was difficult because of the diversity of their objectives and the methods used to deliver the programmes and to evaluate them

Review effects of universal prevention programmes on attitudes and behaviours related to help-seeking.

Klimes Dougan et al, 2013 27

Suicide-prevention programmes utilizing (1) psychoeducational curricula, (2) gatekeeper training, and (3) public service messaging directed at youths do not increase help-seeking behaviours. However, in combination, multimodal interventions and another intervention such as screening showed an effect in some studies, but not in others. Combining psychoeducation with peer-help training had no effect.In two studies, gatekeeper training did not show improvements in attitudes or help-seeking behaviours in high school students. In one study, help-seeking from parents and peers decreased. One study found that gatekeeper training improved securing resources for students in need.

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There were mixed results for public service messaging. One simulation study found no effect on help seeking attitudes. One study found no change in knowledge about resources for help, but did find reduced perceived barriers for help-seeking, and an increase in helpseeking though not specifically for a mental health problem.

UniversalPromotion of mental and physical

wellbeing

Review effectiveness of exercise in treatment of depression in adults.

Cooney et al, 2013 28

Exercise is moderately more effective than a control intervention for reducing symptoms of depression. However, analysis of methodologically robust trials only shows a smaller effect in favour of exercise.When compared to psychological or pharmacological therapies, exercise appears to be no more effective, though this conclusion is based on a few small trials.

Universal Alcohol control policies

Review effectiveness of specific suicide-preventive Interventions.

Mann et al, 2005 2

Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republics and Iceland.

Review effects of alcohol taxes and prices on alcohol-related morbidity and mortality.

Wagenaar et al, 2011 29

Public policies affecting the price of alcoholic beverages have significant effects on alcohol-related disease and injury rates. Results of this study suggest that doubling the alcohol tax would reduce alcohol-related mortality by an average of 35%, traffic crash deaths by 11%, sexually transmitted disease by 6%, violence by 2%, and crime by 1.4%. No estimate is provided for suicide deaths.

Review associations between various types of alcohol policies and suicide.

Xuan et al, 2016 30

Both intoxication and heavy alcohol use are associated with suicide. Reviewed 17 studies of alcohol policies and suicide (14 studies) or Blood Alcohol Levels (BACs) in suicide decedents (3 studies); 4 studies showed an inverse association between alcohol taxation and suicide rates (one study found a positive association).

3 studies found consistent evidence that enactment of Minimum Legal Drinking Age (i.e. MLDA raised to 21 years) in the US contributed to a reduction in youth suicide.

4 studies of outlet density tended to show higher suicide rates for young men in regions with higher number of alcohol outlets.

A study of zero tolerance driving laws found such laws were associated with reduced rates of youth suicide.

In countries outside the US, 10/13 studies showed suicide rates were positively associated with per capita consumption of alcohol.

Studies evaluating pre-post differences in response to change of a hybrid of alcohol policies, have

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tended to show that the introduction of more restrictive policies was associated with reductions in male suicides (in one study, by about 10%) but with no effect on female suicides. However, this result was not found for all studies – although it is difficult to control for potential confounding factors.

Overall, the review suggested that restrictive alcohol policies may contribute both to suicide prevention on a general population level and to a reduction of alcohol involvement among suicide deaths. This public health, population-based approach is consistent with Rose's prevention paradox which posits that the majority of cases of a health condition arise from members at low or moderate risk of the disease, while members at high risk only contribute a minority of cases. By making alcohol less available in the general population, it is possible to reduce the average risk of suicide especially those where alcohol is involved. This approach departs from approaches that narrowly target individuals deemed at “high risk” and that commonly address suicidal behaviours almost exclusively as problems of individuals, Rather, this population-based approach is likely to maximize public health benefit and to show long-lasting influence on reducing suicide.

Review effectiveness of targeting alcohol as a modifiable factor to prevent firearm violence.

Branas et al, 2016 31

One large group of studies showed that over one third of firearm violence decedents had acutely consumed alcohol and over one fourth had heavily consumed alcohol prior to their deaths.

Another large group of studies showed that alcohol was significantly associated with firearm use as a suicide means. Two controlled studies showed that gun injury after drinking, especially heavy drinking, was statistically significant among self-inflicted firearm injury victims.

Off-premise outlets selling takeout alcohol were significantly associated with firearm assault.

Overall, policies that rezone off-premise alcohol outlets, proscribe blood alcohol levels and enhance penalties for carrying or using firearms while intoxicated, and consider drunk driving convictions as a more precise criterion for disqualifying persons from the purchase or possession of firearms deserve further study

Universal Social welfare policies

No reviews were identified

Poverty Review association between poverty and common mental disorders (CMD) in low and middle income countries.

Lund et al, 2010 32

Of 115 studies reviewed, most reported positive associations between a range of poverty indicators and Common Mental Disorders (CMD). In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food

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insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal.

The relatively consistent association between CMD and a variety of poverty dimensions helps try to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association.

Review relationship between suicide and poverty in low-income and middle-income countries.

Iemmi et al, 2016 33

Over 75% of suicides occur in low-income and middle-income countries.

37 studies, published between January, 2004, and April, 2014, were included. Of 18 studies reporting the association between suicide and poverty, 31 associations were explored. The majority reported a positive association.

Universal Employment policies

Review effectiveness of vocational interventions on work participation and mental distress for unemployed adults.

Audhoe et al, 2010 34

All five interventions applied group training techniques aimed at promoting re-employment and/or improving mental health. The duration of the interventions varied from 1 week to 6 months. Interventions focused on acquiring job-search skills, maintaining paid work, personal development and preparedness against setbacks during the job-search process. Only one intervention study (randomized controlled trial) reported a significant effect on re-employment.

The authors conclude that there is weak evidence to support the use of vocational interventions to improve work participation and limited evidence to reduce mental distress for the unemployed.

Review interventions to reduce the impact of unemployment and economic hardship on mental health and suicide in the general population.

Moore et al, 2016 35

'Job club' (group-assisted programme for obtaining employment) interventions led to improvements in levels of depression up to 2 years post-intervention; effects were strongest among those at increased risk of depression (improvements of up to 0.2-0.3 s.d. in depression scores).

There was mixed evidence for effectiveness of group CBT on symptoms of depression. However the studies are old and at high risk of bias. Further trials are needed.

An RCT of debt advice found no effect but had poor uptake.Universal Access to medical and social care

No reviews were identified

Universal Other

Effectiveness of hosting a major sports event on a host city population’s health and

After controlling for potential confounders, one study examining suicide as an outcome found no effect for hosting the Olympic Games.

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determinants of health

McCartney, 2010 36

A narrative review of "best practice" and "good practice" interventions that can feasibly be delivered at population- and community-levels in low- and middle-income countries to promote mental health, primary prevention of mental, neurological and substance use (MNS) disorders, identification and case detection of MNS disorders; and to a lesser degree treatment, care and rehabilitation.

Petersen et al, 2016 37

A narrative review was conducted given the wide range of relevant interventions.

At the population-level, laws and regulations to control alcohol demand and restrict access to lethal means of suicide were considered "best practice". Child protection laws, and mass awareness campaigns were identified as "good practice".

At the community level, socio-emotional learning programmes in schools and parenting programmes during infancy were identified as "best practice".

The following were all identified as "good practice": Integrating mental health promotion strategies into workplace occupational health and safety

policies; mental health information and awareness programmes as well as detection of MNS disorders

in schools; early child enrichment/preschool educational programmes and parenting programmes for

children aged 2-14 years; gender equity and/or economic empowerment programmes for vulnerable groups; training of

gatekeepers to identify people with MNS disorders in the community; training non-specialist community members at a neighbourhood level to assist with

community-based support and rehabilitation of people with mental disorders.

Inter-sectoral engagement is important as is the need for further research on interventions at population and community levels.

Review effectiveness of suicide prevention interventions since 2005.

Zalsman et al 2016 38

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 and suicidal ideation.

The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought.

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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.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.

Review effectiveness of school, community and healthcare-based suicide prevention interventions for youth 12-25 years.

Calear et al, 2016 39

29 papers describing 28 trials (10,654 participants) were included. Of the 32 comparisons identified in the review, 10 (31 %) reported on a program delivered in a school-based setting, seven (22 %) on a program in a community (non-clinical) setting (e.g., home-based, distal) and 15 (47 %) on an intervention delivered within a healthcare (clinical) setting (e.g., in-patient hospital, health centre).

Studies were predominantly face-to-face interventions delivered to mid-adolescent females with a history of suicidal ideation or attempts, and compared to a treatment as usual control condition. Intervention setting, content, delivery format (individual vs. family vs. group), and leaders were varied across programs. Very few distal interventions were identified in the review. Given the appeal and reach of new technologies among young people, and their ability to overcome some of the access, stigma and cost barriers associated with face-to-face services, this may be an area for further program development and evaluation.

Overall, just over half of the programs identified in the review reported significant effects on suicidal ideation, suicide attempts or deliberate self-harm. Small to large effect sizes were reported by the effective programs, with short and longer-term effects evident. Some of the programs that reported non-significant results had good sized effects. Given the small samples size of some of these studies, it is possible that these programs were effective, but that the trial was underpowered due to poor study recruitment or drop-out.

The review provides preliminary evidence for the implementation of psychosocial interventions in

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school, community and healthcare settings. Programs in all of these settings were found to be effective for suicidal ideation and attempts, with schools showing particular promise in this population. Given the reach of schools, and the captive audience they provide, this may be a good environment in which to promote and target suicide prevention and early intervention programs with young people.

In terms of program content, the current review also found a diverse range of effective interventions, with no clear stand out intervention approach.

100 % of the universal programs were effective, whereas only 50 % of the selective and indicated interventions were effective. This suggests that both universal and targeted interventions can be effective, depending on the program delivered, and that both approaches should be considered in the prevention of suicide in this population. With only two universal programs identified in this review, there is also a need to further explore universal programs in this population.

The current review also found that programs delivered to individuals alone only had effects on suicidal ideation, while group and family programs only had effects on suicide attempts. Programs that included both individual and group/family components reported effects for both suicidal ideation and attempts. This finding suggests that individual level interventions may be needed to affect change in suicidal ideation, while group interactions may facilitate changes in suicide attempts.

Those studies that found significant effects for suicidal ideation often did so at immediate post-intervention or at short-term follow-up. As such, those studies that only included longer-term follow-ups did not find effects for suicidal ideation. Similarly, those studies that just included longer-term follow-ups (16- and 18-months) tended to find effects for suicide attempts, while those without these lengthier follow-ups, or large sample sizes, did not. This finding provides support for inclusion of both short and longer-term follow-ups.

Overall, the review provides preliminary support for the implementation of universal and targeted interventions in all settings, using a diverse range of psychosocial approaches. Further quality research is needed to strengthen the evidence-base for suicide prevention programs in this population. In particular, the development of universal school-based interventions is promising given the potential reach of such an approach.

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Review evidence for suicide prevention, intervention and postvention.

Joshi et al, 2009 40

Identified six priorities for suicide prevention:

School-based programmes focusing on mental health promotion and preventing substance use for children and youth that integratebehaviouralchanges, coping skills and social supports.Key elements include:•Understanding what aspects of mental health and substance use prevention already existwithin school programmes• Building on existing programmes, or• Identifying where gaps exist and mental health programmes could be implemented• Considering elements for implementation• Engaging in a ‘whole school’ approach involving students, teachers, parents, counsellors and

principals, and engaging with the local community.

Gatekeeper training for all populations including:· Peers, health professionals, community leaders, spiritual advisors, within school and post-

secondary settings, the workplace, acute care settings, long term care facilities and justice system

· How to identify at-risk individuals and improve access to suicide intervention and mental health and substance use resources. A critical component of gatekeeper training is ensuring linkage to appropriate, evidence-informed training.

Key elements include:· Understanding what aspects of mental health care and support exist within a given setting· Identifying and recruiting key participants for gatekeeper training· Training these key persons on how to identify someone who is suicidal or in distress including· what questions to ask, and what resources they can then refer to within their communities· Consideration of persons who might access at risk populations but are not involved in the· health care sector

Physician and health professional education on early recognition, risk assessment, clinical assessment, mental health conditions and comorbidities and treatment of suicidal and/or ideation across the lifespan.

Key elements include:• Understanding the existing risk and clinical assessment practices• Identifying gaps in existing risk and clinical assessment practices to improve consistency and

comprehensiveness

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• Assessing comorbidities in mental health and substance use• Involving the caregiver, family and/or concerned others in risk assessment and treatment plans.

Culturally appropriate services, cultural safety and diversity training for service providers regarding suicide prevention, intervention and postvention including:

a) Improved translation services, expanded language capacity or improved awareness of existing services

b) Coping skills training and workshops for emotion regulation and copingc) Providing stigma reduction, mental health awareness and education messages through TV,

newspapers and radiod) Gay, lesbian, bisexual and transgendered (GLBT) resiliency training administered by GLBT

agencies and/or service providers

Coordination of services for suicide prevention, intervention and postvention in the mental health system, health care system, school/postsecondary systems and community including:a) Interdisciplinary teams and case approaches such as active case management, assertive community teams and integrated case managementb) Possible development of day programmes to address suicidality and/or concurrent disorders and crisis stabilization teams/units to address people in acute crisis or suicide states and/or provide ongoing supportc) Improved access to psychiatrists and psychiatric servicesd) Promotion of a trauma informed response to suicidal people and their familiese) Partnerships and collaborations are imperative among policy makers on the coordination of services to promote systems-level changes that would have local, regional and provincial impacts. As they exist currently, systems of care are fragmented and inconsistent, which ultimately impacts the person at risk of suicide seeking care.

Development and enhancement of postvention bereavement programmes, services andsupports for persons touched by a suicide including:a) Educational workshops, support groups, group therapy and survivor groups for those bereaved by a suicide related deathb) Postvention response protocols involving referral practices, community response teams, critical incident management and treatment.

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Appendix 1. Table 16. Summary of key findings for selective interventions

Intervention Focus of review(Author reference)

Key findings

Selective Suicide prevention centres

Review evaluated suicide programmes for Canadian youths aged 10 to 24 years.

Breton JJ et al, 2002 41

One of the three suicide prevention center programmes identified led to a reduction in suicidal urgency and another to a reduction in suicidal ideation.

Selective Community based suicide prevention

programmes

Review effectiveness of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.

Malone et al, 2007 42

Compared with standard care (non-team community care, outpatient care and admission to hospital or day hospital), CMHT (a multidisciplinary community-based team) management is not inferior in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide.

Review effectiveness of community-based depression screening (CDS) with follow-up on the completed suicide risk for residents aged 65 and over.

Oyama et al, 2008 43

Implementation of universal prevention programmes involving CDS and health education is associated with a reduced risk of completed suicide among older residents.

There are very few studies included, however, to demonstrate an association between CDS and the reduced risk, suggesting gender difference in the effectiveness of the intervention.

Review evidence on a. interventions to prevent or manage suicides following the first attempt in adolescents and adults in a community setting, and b. suicide prevention strategies in adolescents and adults in a community setting.

CANADIAN AGENCY FOR

One systematic review (Soomro et al, 2008) was identified that evaluated the effectiveness and safety of interventions for deliberate self-harm and attempted suicide, which included drug therapies, behavioural therapies, and community follow-up with the patient.

One randomized controlled trial compared the effectiveness of dialectical behaviour therapy (DBT) with community treatment by experts and found that subjects receiving DBT were half as likely to make a suicide attempt as the community treatment group.

A non-randomized study from Norway found that a community-based suicide prevention team did not significantly decrease the risk of a repeated suicide attempt within 6 months, 12 months, or 5 years after an attempt compared with treatment as usual.

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DRUGS AND TECHNOLOGIES IN HEALTH, 201144 Eight non-randomized studies were identified that described specific suicide prevention

programs in adolescents and adults in a community setting,listed as follows:

Intervention ( Author, Year) OutcomeConnectCommunity-based youth suicide prevention program (Bean et al, 2011)

Increased belief in the use of mental health careReduced stigma associated with seeking helpIncreased adult preparedness to help youth

Yellow Ribbon Suicide Prevention ProgramDenver-area high school (Freedenthal, 2010)

Staff did not report any increase in student help-seekingStudents did not report increase in help-seekingIncreased use of a crisis hotline

Regensburg Alliance Against DepressionFive-year four-level intervention program (Hubner- Liebermann et al, 2010)

Significant decrease in male suicide rate

Cultural prevention programNov 2006-Mar 2008Targeting suicide and co-occurring alcohol abuse in rural Yup’ik youth in Alaska (Allen et al, 2009)

Increased community readiness for prevention effortsIncrease in the amount of protective behaviours by adults and perceived by youth

LifeSaversThree day peer-support suicide prevention training program for high school youth in a non-metropolitan US community (Walker et al, 2009 )

Significant increase in knowledge and positive attitudes towards suicide preventionSignificant increase in self-esteemNo change in self-acceptance

Prevention of self-immolation1999-2003Aimed at young women and socio-economically deprived groups in Iran (Ahmadi et al, 2007)

Significant decrease in self-immolation rates during intervention periodSignificant decrease in suicide attempt rate during intervention period

Community-based health promotion intervention 1999-2004Raise public awareness through empowering residents and civic

Decrease in suicide rate after intervention

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participation in rural Japan (Motohashi et al. 2007 )Nuremberg Alliance against Depression2001-2002Four-level intervention program (training and supporting family doctors, public campaign on depression, cooperation with community facilitators, support for high-risk groups) in Nuremberg, Germany (Hegerl et al, 2006 )

Decrease in suicide attemptsNo significant differences in completed suicides in intervention group compared to control region

Overall, although it seems that community-based intervention programs may be effective in decreasing stigma associated with mental health issues and in decreasing suicidal attempts, it is unclear whether these programs have a significant impact on the rate of completed suicides. There is a lack of long-term follow up of subjects after completion of the intervention.

Review of effectiveness of Intensive Case Management (ICM) compared with standard community care for people with severe mental illness.

Dieterich et al, 2010 45

ICM was effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM reduced hospitalisation and increased retention in care. It also globally improved social functioning, However, there was no compelling evidence that ICM was really any better than standard care in improving mental state.

There were no differences in mortality between ICM and standard care for death or suicide.

ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years). It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.

Review of systematic reviews to identify effective interventions for the prevention of suicidal behaviour, and examine synergistic effects of multiple programmes applied together.

Van der Feltz-Cornelius et al, 2011 4

Six relevant systematic reviews were found. Best practices identified as effective included:· training general practitioners (GPs) to recognize and treat depression and suicidality· pharmacotherapy and cognitive behavioural therapy at a primary care level· gatekeeper training ( population level)· screening of high-risk groups (population-level)· hospitalization (targeted to psychiatric patients)· telephone and emotional support targeting psychiatric patients· palliative care and rural community-based support for older adults· ethnically-tailored community-wide public health programmes (including video-focused

educational interventions targeting minority ethnic groups to modify family expectations about self-harm; school-based initiatives to train staff and students how to respond to

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suicidal s).

Gatekeeper training has generally been studied as part of a multi-component programme so the specific impact of gatekeeper training is less clear.

No outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, although indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies.

Review effectiveness of collaborative care on mental and physical outcomes for people with severe mental illness living in the community)

Reilly et al, 2013 46

Collaborative care for severe mental illness (SMI) is a community-based intervention, which typically consists of a number of components. The intervention aims to improve the physical and/or mental health care of individuals with SMI.

In the one study identified in the review there were no differences in suicide deaths between the intervention and control groups.

Review evidence to determine if the internet influences the risk of self-harm or suicide in young people (<25 years)

Daine et al, 2013 47

Seven studies reported positive influences of internet forums. Evidence was found for reinforcement of positive s, support for efforts not to self-harm, and encouragement to see GPs for help. However, there was no evidence forums prevented a reduction in self-harm or that membership increased the likelihood of self-harm.

In two studies potentially positive influences of other internet media were found. In one it was suggested that youth reporting self-harm may be using the internet to connect with others and that this may alleviate psychological distress. In the other, evidence was presented that some participants viewed interactive media as a form of support.

Five studies suggested negative influences of internet forums, including normalising self-harm, concealing self-harm, sharing self-harm techniques, increases in suicidal ideation, and worsening distress. One study found these effects for internet fora but not for social networking sites.

Negative influences of other internet media were found in seven studies. General internet use appears to be a source of exposure and learning about suicide and self-harm.

Greater internet use or addiction was associated with associated with increased risk for self-harm.

Two studies suggested that cyber-bullying may have a significant influence on self-harm, and

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that it may increase rates of attempted suicide for both victims and perpetrators.Review sources of support adolescents (11-19 years) who self-harm access if they seek help, and the barriers and facilitators to help-seeking for adolescents who self-harm.

Rowe et al, 2014 48

Between a third and one half of adolescents who self-harm do not seek help. Those who seek help, primarily turn to informal sources of help - friends and family - for support.

The Internet may be more commonly used as a tool for self-disclosure rather than asking for help.

Barriers to help-seeking included fear of negative reactions from others including stigmatisation, fear of confidentiality being breached and fear of being seen as 'attention-seeking'. Few facilitators of help-seeking were identified.

Review help-seeking for suicidal thoughts or self-harm in young people up to the age of 26.

Michelmore & Hindley, 2013 49

The majority of young people do not seek professional help for suicidal thoughts and self-harm, and this includes seeking medical help after an overdose.

The majority of young people studied do, however, seek informal help from social networks that most commonly are peers.

Review systematic reviews on mental health interventions in adolescents.

Das et al, 2016 50

Of 38 identified systematic reviews, 12 related to school-based interventions, 6 were community-based interventions, 8 focussed on digital platforms, and 12 on individual-/family-based interventions.

Evidence from school-based interventions suggests that targeted group-based interventions and cognitive behavioural therapy are effective in reducing depressive symptoms and anxiety

School-based suicide prevention programmes suggest that classroom-based didactic and experiential programmes increase short-term knowledge of suicide and knowledge of suicide prevention with no evidence of an effect on suicide-related attitudes or behaviours.

Community-based creative activities have some positive effect on behavioural changes, self-confidence, self-esteem, levels of knowledge, and physical activity.

Evidence from digital platforms supports Internet-based prevention and treatment programmes for anxiety and depression; however, more extensive and rigorous research is warranted.Among individual- and family-based interventions, interventions focusing on eating attitudes and behaviours show no impact on body mass index and bulimia.

Exercise is effective in improving self-esteem and reducing depression but has no impact on

73

anxiety scores.

Cognitive behavioural therapy compared to waitlist is effective in reducing remission. Psychological therapy when compared to antidepressants has a comparable effect on remission, dropouts, and depression symptoms.

Studies were very heterogeneous, statistically, in their populations, interventions, and outcomes; future trials should also focus on standardized interventions and outcomes in order to help synthesise findings.

Review school-based strategies and non-school-based interventions designed to prevent repeat suicide attempts in youth.

Bennett et al. 2015 51

None of 7 reviews addressing school-based prevention reported decreased suicide death rates, but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported.

Included reviews addressing prevention of repeat suicide attempts (n = 14) found that a): emergency department transition programmes may reduce suicide deaths, hospitalizations, and treatment nonadherence; b). training primary care providers in depression treatment may reduce repeated attempts.

Antidepressants may increase short-term suicide risk in some patients; this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression.

Prevention with psychosocial interventions requires further evaluation.

No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness.

A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation.

Selective School-based suicide prevention

programmes

Review evaluated suicide programmes for Canadian youths aged 10 to 24 years.

Breton et al, 2002 41

Only 6 of the 9 school programmes identified resulted in improvement s in knowledge about suicide. One programme found improvements in attitudes about suicide. Only 3 led to improvements in skills required to intervene with suicidal students.

No programme had an effect on suicide or suicide attempts.

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Review the universal approach to mental health promotion, and disease prevention programmes or interventions in schools.

Wells et al, 2003 52

Identified 17 (mostly US) studies investigating 16 interventions that took a whole-school approach, those that extended beyond the classroom to all or part of the school, and those that took a classroom approach. .

Positive evidence of effectiveness was obtained for programmes that adopted a whole school ‐approach, were implemented continuously for more than a year, and were aimed at the promotion of mental health as opposed to the prevention of mental illness.

Overall, there is evidence that universal school mental health promotion programmes can be effective and that long term interventions promoting the positive mental health of all pupils and ‐involving changes to the school climate are likely to be more successful than brief class based ‐mental illness prevention programmes.

Review effectiveness of screening and early psychological intervention for depression in schools

Cuijpers et al, 2006 53

8 studies were included ; 5 studies focused on younger children (7-14 years) and three studies were aimed at adolescents (12-19 years). In total 5803 students were screened, of whom 7.2% were included in the intervention studies.

The 'numbers-needed-to-screen' was 31 (95% CI: 27-32), which means that 31 students had to be screened in order to generate one successfully treated case of depression.

Effects of the psychological treatments at post-test were compared to control conditions in the 8 studies comprising 12 contrast groups, with a total of 413 students. The mean effect size was 0.55 (95% CI: 0.35-0.76).

There were not enough studies to examine whether specific psychotherapies were superior to other psychotherapies.

Although the number of studies is small and their quality is limited, screening and early intervention at schools may be an effective strategy to reduce the burden of disease from depression in children and adolescents.

Review effectiveness of school health promotion in improving health or preventing disease.

Stewart-Brown et al, 2006 54

School health promotion is a multifactorial approach that covers teaching health knowledge and developing interpersonal skills in the classroom, changing the social and physical environment of the school, involvement of parents and creating links with the wider community.

School-based programmes that promote mental health in schools (including preventing violence and aggression) are effective.

75

Those which were most effective were of long duration and high intensity, and involved the whole school.

Programmes on preventing suicide reduced suicide potential, depression, stress and anger, but less rigorous studies suggested a potential harmful effect in young males.

Review effectiveness of school-based prevention and early intervention programs for depression

Calear and Christensen, 201055

42 trials, relating to 28 individual school-based programs, were identified. A large proportion of the programs identified were based on cognitive behavioural therapy (CBT), and delivered by a mental health professional or graduate student over 8–12 sessions.

Indicated programs, which targeted students exhibiting elevated levels of depression, were found to be the most effective, with effect sizes for all programs ranging from 0.21 to 1.40.

Teacher program leaders and the employment of attention control conditions were associated with fewer significant effects.

Review effectiveness and safety of screening for suicide to prevent suicide among adolescents.

Pena and Caine, 2006 56

Most interventions in the 17 studies took place in high schools, with a few in hospital settings or residential treatment facilities. Interventions were predominantly questionnaires to assess suicide risk.

Only two studies found reductions in suicide attempts in youth after using a programme with either a screening tool or screening instrument. However, neither study offers any conclusive evidence about the effectiveness of screening in reducing suicide or suicide attempts.

In summary, youth suicide screening programmes offer promise of improving identification for those who need treatment and help.

Review effectiveness of interventions to prevent suicide in adolescents and youth.

Pompili et al, 2010 57

Some evidence supports school-based programmes for high-risk students in reducing psychological risk factors, improving protective factors, and, perhaps, providing knowledge of appropriate resources for help.

There is little evidence that a ‘whole of school’ approach improves knowledge of or attitudes to suicide.

Skills training for high risk students has been found to improve protective factors and reduce risk factors. One study found that school-based management in children (the Good Behaviour Game) reduced suicide risk in later years.

Building coping skills in the general school population improved coping and decreased suicidal

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behaviours.

Building psychosocial skills reduced suicidal ideation and improved attitudes in adolescents and was sustained for 9 months.

Gatekeeper training has consistently been reported to improve knowledge and attitudes in educators and students, but there is no evidence about reduced suicide or attempted suicide, nor about safety. Gatekeeper training was influenced by teacher status at baseline - those with distressed students were more likely to follow-up after training by asking about suicide. There is no evidence that gatekeeper training for families, communities and others reduce suicides or suicide attempts.

Programmes which increase parenting skills have been associated with reductions in self-harm.

Screening students had low specificity and high number of false positives. When linked with psychosocial therapy screening was effective in reducing risk factors for suicide and in reducing suicidal ideation.

There is no evidence that school postvention programmes reduce suicidal behaviour.Review effectiveness of middle and high school-based suicide prevention curricula.

Cusimano and Sameem, 201158

Among 8 included studies, statistically significant improvements were noted in knowledge, attitude, and help-seeking . A decrease in self- reported ideation was reported in two studies. None reported on suicide rates.

Overall, although evidence exists that school-based programmes to prevent suicide among adolescents improve knowledge, attitudes, and help-seeking behaviours, no evidence yet exists that these prevention programmes reduce suicide rates. Further well designed, controlled research is required before such programmes are instituted broadly to populations at risk.

Effectiveness of school-based mental health programmes on secondary school students.

Kutcher and Wei, 2012 59

Limited evidence of programme effectiveness, safety and cost-effectiveness in identified programmes, mostly due to the lack of rigorous research designs, the heterogeneity of school environments, and the complexities of interventions that require multisectoral collaboration.

Four studies addressing suicide prevention reported positive outcomes, but did not assess reductions in suicide or suicide attempts.

The authors suggest mental health literacy may be an appropriate start to help to set the foundation for mental health promotion, prevention and intervention.

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The authors suggest that there is a need for better evaluations of effectiveness, cost-effectiveness and acceptability, since no programme to date has fulfilled these requirements.

Review effectiveness of interventions targeting changing the school environment (structural , relational or paedagogic elements of school life) and (2) the school environment on adolescent emotional health.

Kidger et al, 2012 60

There is only limited evidence that the school environment has a major influence on adolescent mental health, although student perceptions of teacher support and school connectedness are associated with better emotional health.

Two nonrandomized trials found some evidence that a supportive school environment improved student emotional health, but 3 randomized controlled trials did not. Six cohort papers examined school-level factors but found no effect.

There was some evidence that individual perceptions of school connectedness and teacher support predict future emotional health.

Multilevel studies showed school effects were smaller than individual-level effects.Realist review of complex school-based suicide interventions to understand which might be useful in schools, based on local needs and context.

Balaguru et al, 2013 61

Education programmes are useful for those living in rural areas, with limited or no access to metal health services, individuals with limited knowledge, and ethnic minority populations with cultural taboos about suicide

Elements of suicide prevention programmes that correlated with significant reductions in suicidal s included: recognizing and treating underlying mental illness, addressing the underlying factor of substance use improving problem solving skills, providing support and skills to manage stress, addressing cultural barriers to and taboos about suicide.

Screening can be a useful intervention in schools with well-established systems for self-harm and crisis management, or in high risk students where a case manager is available.

Process factors that increase effective ness of school-based programmes include: universal education and gatekeeper training programmes for staff; recent suicides which motivate staff to become educated, raising awareness via different methods of presenting material, tailoring interventions for target groups and for high risk individuals; using established intervention s via the support of local and regional support for resources.

Poor interventions were associated with the following programme components: clarifying myths about suicide and suicide attempters; failing to engage parents and to foster peer support; failing to address confidentiality concerns; short duration, lacking family support and resources outside

78

school, failing to address repeated suicide attempts.Review effectiveness of school-based suicide prevention programmes.

Katz et al, 2013 62

Of 16 identified programmes, only two - Signs of Suicide and the Good Game - were found to reduce suicide attempts.

Several other programmes were found to reduce suicidal ideation, improve general life skills, and change gatekeeper s.

Few programmes have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programmes' abilities to improve students' and school staffs' knowledge and attitudes toward suicide.

A combination of programmes may be optimally effective but methodological limitations restrict recommendation on basis of current evidence.

Review effectiveness of suicide postvention, prevention, and early intervention programmes in school settings.

Robinson et al, 2013 63

Universal suicide-prevention programmes (generally, curriculum-based education programmes, which aimed to deliver interventions to whole school populations) reportedpositive effects in increased levels of knowledge of the risk factors and warning signs for suicide. Some found improved self-reported likelihood to seek help, improved attitudes toward suicide-related behaviour and suicidal peers. Some reported some reduction in suicide-related outcomes, including self-reported risk of suicide, ideation and attempt. No studies examined potentially negative effects.

Selective ApproachesGatekeeper EducationOverall, gatekeeper training was shown to be effective in terms of increasing knowledge, improving attitudes, and furthering confidence among participants, and some programmes led to self-reported improvements in practice. Only a small number of the identified studies employed a controlled design, and fewer still were RCTs.

Future studies should measure changes in practice (e.g., improved risk assessment skills), student-level outcomes, and improved health and social outcomes for those who receive help from trained staff.

Screening ProgrammesOverall, screening programmes successfully identified students at risk who otherwise would not have come forward for help, with studies reporting that between 4% and 45% of students screened were identified as needing further support, many of whom were subsequently

79

successfully linked with either school or community-based services. One study identified by the current review and another subsequently published paper report that screening students for suicide risk does not appear to cause undue distress among participants. Concerns exist, however, about the potential stigma and inconvenience of identifying high rates of false positives.

Indicated InterventionsThree RCTs were included, and all reported a reduction in suicide risk behaviour over time in both the treatment and comparison groups, albeit limited effects of intervention.

PostventionOnly two studies reporting on school-based postvention programmes were identified, thus offering limited evidence to guide what models of postvention may be most effective. Because no rigorous evaluation was conducted, the potential effects of these responses,either positive or negative, remain unknown.

Overall, the most promising interventions for schools appear to be gatekeeper training and screening programmes. However, more research is needed. Overall, the evidence was limited and hampered by methodological concerns, particularly a lack of RCTs. There is limited evidence regarding indicated approaches to school-based suicide prevention, and indeed questions exist regarding the appropriateness of such interventions.

Review effectiveness of psychosocial interventions for youth suicide in school, community and healthcare settings.

Calear et al, 2016 39

Studies were predominantly face-to-face interventions delivered to mid-adolescent females with a history of suicidal ideation or attempts, and compared to a treatment as usual control condition. Intervention setting, content, delivery format (individual vs. family vs. group), and leaders were varied across programs. Very few distal interventions were identified in the review.

Overall, just over half of the programs identified in the review reported significant effects on suicidal ideation, suicide attempts or deliberate self-harm. Small to large effect sizes were reported by the effective programs, with short and longer-term effects evident. Some of the programs that reported non-significant results had good sized effects. Given the small samples size of some of these studies, it is possible that these programs were effective, but that the trial was underpowered due to poor study recruitment or drop-out.

The review provides preliminary evidence for the implementation of psychosocial interventions in school, community and healthcare settings. Programs in all of these settings were found to be effective for suicidal ideation and attempts, with schools showing particular promise in this

80

population. Given the reach of schools, and the captive audience they provide, this may be a good environment in which to promote and target suicide prevention and early intervention programs with young people.

In terms of program content, the current review also found a diverse range of effective interventions, with no clear stand out intervention approach.

100 % of the universal programs were effective, whereas only 50 % of the selective and indicated interventions were effective. This suggests that both universal and targeted interventions can be effective, depending on the program delivered, and that both approaches should be considered in the prevention of suicide in this population. With only two universal programs identified in this review, there is also a need to further explore universal programs in this population.

The current review also found that programs delivered to individuals alone only had effects on suicidal ideation, while group and family programs only had effects on suicide attempts. Programs that included both individual and group/family components reported effects for both suicidal ideation and attempts. This finding suggests that individual level interventions may be needed to affect change in suicidal ideation, while group interactions may facilitate changes in suicide attempts.

Those studies that found significant effects for suicidal ideation often did so at immediate post-intervention or at short-term follow-up. As such, those studies that only included longer-term follow-ups did not find effects for suicidal ideation. Similarly, those studies that just included longer-term follow-ups (16- and 18-months) tended to find effects for suicide attempts, while those without these lengthier follow-ups, or large sample sizes, did not. This finding provides support for inclusion of both short and longer-term follow-ups.

Review effectiveness and safety of two youth suicide prevention programmes (Signs of Suicide (SOS) and Yellow Ribbon (YR)

Wei et al, 2016 64

Reviewed 2 programmes to help determine if the quality of evidence available justifies their wide spread dissemination. Two SOS studies were ranked as "inconclusive evidence", and one was ranked as having "insufficient evidence". The YR study was ranked as "ineffective".

We cannot recommend that schools and communities implement either the SOS or YR suicide prevention programmes. Purchasers of these programmes should be aware that there is no evidence that their use prevents suicide. Academics and organizations should not overstate the positive impacts of suicide prevention interventions when the evidence is lacking.

Review effectiveness and None of the 66three programmes has demonstrated effectiveness in preventing youth suicide or

81

safety of a commonly used community (safeTALK) and 2 school suicide prevention programmes (Yellow Ribbon and Signs of Suicide (SOS)).

Kutcher et al, 2016 65

safety in application.

Only 6 studies of SafeTALK were identified. No study reported on the impact of SafeTALK on self-reported suicide attempts, emergency room visits for suicide attempts, or suicide rates. No measures of safety were reported. All 6 studies are ranked as having ‘‘insufficient evidence’’ due to the lack of rigor of study design (pre- and post-test or descriptive evaluation), external replication, and statistical significant effect.

Only 1 study of Yellow Ribbon has been published, and it was negative. Only 4 studies of SOS have been published, all by the purveyors of the programme, all with high risk of bias and none showing evidence of suicide prevention.

The authors suggest distal proxy measures (such as improved social cohesion, self-confidence in discussing suicide, or a better knowledge about suicide) that have little or no relationship to suicide rate reduction be replaced by more proximal and useful measures such as suicide rates or hospital admissions for suicide attempts to measure impact of interventions.

They also suggest that policy makers should demand good evidence for effectiveness and safety of suicide prevention before they apply or fund any suicide prevention programme in schools or in the community.

They suggest that there is insufficient evidence to continue to apply these three programmes, given that there is no evidence for any programme of effectiveness or safety.

The authors suggest that the continued funding of these programmes precludes implementation of potentially effective school and community suicide prevention programmes which include enhanced access to clinical care for youth with mental disorders and in-depth training of responsible stakeholders such as teachers and primary care providers in risk determination and appropriate interventions.

Review the population cost-effectiveness of delivering universal and indicated school-based interventions to prevent the onset of major depression among youth in Australia.

School-based psychological interventions encompass: universal interventions targeting youth in the general population; and indicated interventions targeting youth with subthreshold depression.

A literature review identified all interventions targeting youth that would be suitable for implementation in Australia and had evidence of efficacy to support analysis.

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Lee et al, 2016 67 From this review, there was evidence of effectiveness for the following intervention types: universal prevention involving group-based psychological interventions delivered to all participating school students; and indicated prevention involving group-based psychological interventions delivered to students with subthreshold depression.

The cost-effectiveness of delivering universal and indicated interventions in the population relative to a 'no intervention' comparator over a 10-year time horizon was assessed.

Universal and indicated psychological interventions delivered through face-to-face modalities had Incremental cost-effectiveness ratios (ICERs) below a threshold of $50 000 per Disability-adjusted Life Years (DALY) averted. That is, $7350 per DALY averted for universal prevention, and $19 550 per DALY averted for indicated prevention.

A sensitivity analysis found that internet-delivered prevention interventions were highly cost-effective when assuming intervention effect sizes of 100 and 50% relative to effect sizes observed for face-to-face delivered interventions.

Overall, school-based psychological interventions appear to be cost-effective. However, realising efficiency gains in the population is ultimately dependent on ensuring successful system-level implementation.

Review effectiveness of school-based psychological programmes to prevent depression and anxiety in young people.

Werner-Seidler et al, 2017 68

81 studies (31,794 school students) were included. Overall, the quality of the included studies was poor, and heterogeneity was moderate.

Small effect sizes for both depression and anxiety prevention programs immediately post-intervention were detected.

Small effects were evident after 12-month follow-up for both depression and anxiety.

Subgroup analyses suggested that universal depression prevention programs had smaller effect sizes at post-test relative to targeted programs.

For anxiety, effect sizes were comparable for universal and targeted programs.

There was some evidence that externally-delivered interventions were superior to those

83

delivered by school staff for depression, but not anxiety.

Meta-regression confirmed that targeted programs predicted larger effect sizes for the prevention of depression.

These results suggest that the refinement of school-based prevention programs has the potential to reduce mental health burden and advance public health outcomes.

Selective Tertiary education/campus-based

programmes

Review effectiveness of primary suicide prevention interventions that targeted students within the post-secondary setting.

Harrod et al, 2014 69

There is insufficient evidence to support widespread implementation of any programmes or policies for primary suicide prevention in post-secondary educational settings.

As all evaluated interventions combined primary and secondary prevention components, it was not possible to determine the independent effects of primary preventive interventions.

Classroom instruction and gatekeeper training increased short-term suicide-related knowledge. No studies tested the effects of classroom instruction on suicidal behaviour or long-term outcomes. Limited evidence suggested minimal longer-term effects of gatekeeper training on suicide-related knowledge, while no evidence was found evaluating its effect on suicidal behaviour.

A policy-based suicide intervention reduced student suicide, but findings have not been replicated.

Findings are limited by the overall low quality of the evidence and the lack of studies from middle- and low-income countries. Rigorously designed studies should test the effects of preventive interventions on important health outcomes, including suicidal ideation and behaviour, in varying post-secondary settings.

Review effectiveness of technology-based interventions for mental health for disorders (other than substance use and eating disorders) in tertiary students

Farrer et al, 2015 70

27 studies were included; Most (24/27, 89%) employed interventions targeting anxiety symptoms or disorders or stress, although almost one-third (7/24, 29%) targeted both depression and anxiety.

Overall, approximately half (24/51, 47%) of the 51 technology-based interventions employed across the 27 studies were associated with at least 1 significant positive outcome compared with the control at postintervention.However, 29% (15/51) failed to find a significant effect.

84

Internet-based technology (typically involving cognitive behavioral therapy) was the most commonly employed medium, being employed in 16 of 27 studies and approximately half of the 51 technology-based interventions (25/51, 49%).

Distal and universal preventive interventions were the most common type of intervention.

Some methodological problems were evident in the studies, with randomization methods either inadequate or inadequately described, few studies specifying a primary outcome, and most of the studies failing to undertake or report appropriate intent-to-treat analyses

Overall, the findings indicate that although technological interventions targeting certain mental health and related problems offer promise for students in university settings, more high quality trials that fully report randomization methods, outcome data, and data analysis methods are needed

Selective Child welfare/juvenile justice-based

programmes

Review effectiveness of interventions relevant for young offenders with mood disorders, anxiety disorders, or self-harm.

Townsend et al, 2010 71

Group-based Cognitive Therapy (CBT) may help to reduce symptoms of depression in young offenders with such mental health problems, but larger high quality RCTs are now needed to bolster the evidence-base.

Selective Workplace-based suicide prevention

programmes

Review effectiveness of psychosocial interventions for prevention of psychological disorders in law enforcement officers.

Peñalba et al, 2008 72

There is evidence only from individual small and low quality trials with minimal data suggesting that police officers benefit from psychosocial interventions, in terms of physical symptoms and psychological symptoms such as anxiety, depression, sleep problems, cynicism, anger, PTSD, marital problems and distress. No data on adverse effects were available.

Further well-designed trials of psychosocial interventions are required. Research is needed on organization-based interventions to enhance psychological health among police officers.

Review content and effectiveness of suicide prevention programs conducted in the workplace and other settings, namely school, the community, medical facilities, jail, and the army.

Common contents of suicide prevention programs in the workplace and other settings are education and training of individuals, development of a support network, cooperation from internal and external resources, as well as education and training of managers and staff.

Although a reduction in undesirable attitudes and an increase in mental health knowledge and coping skills in the workplace are in agreement with findings in other settings, suicide rates, suicide-associated behavior, and depression, which were assessed in other settings, were not evaluated in the three studies targeting the workplace.

85

Takada and Shima, 2010 73

Identify workplace suicide prevention initiatives and review effectiveness.

Milner et al, 2015 74

13 relevant interventions were identified. There were a few examples of prevention activities developed for at-risk occupations (e.g. police, army, air force and the construction industry) as well as a number of general awareness programmes that could be applied across different settings.

Three programmes reported reduced suicides (pre/post tests). The best described study is by Knox and it provides the most convincing evidence: A multi-component programme in the US Air Force (including training, guidelines, surveillance, and screening) led to a 33% decrease in suicides.

Generally, however, few workplace suicide prevention initiatives had been evaluated in terms of effectiveness in reducing suicide.

Selective Courts/prisons-based suicide

prevention programmes

No reviews were identified.

Review effectiveness of treatments for deliberate self-harm in adolescents and adults

Soomro, 2008 75

19 systematic reviews, RCTs, or observational studies were included, covering the following interventions: cognitive therapy; continuity of care; dialectical behavioural therapy; emergency card; flupentixol depot injection; general practice-based guidelines; hospital admission; intensive outpatient follow-up plus outreach; mianserin; nurse-led case management; oral antipsychotics; paroxetine; problem-solving therapy; psychodynamic interpersonal therapy; and telephone contact.

No pharmaceutical treatments have been clearly shown to be of benefit in reducing recurrent self-harm. It is possible that flupentixol depot injections may reduce the recurrence of self-harm, but with associated adverse effects. Mianserin does not seem to reduce recurrence rates, but we don't know this for certain. Paroxetine has not been shown to reduce the risks of repeated deliberate self-harm and may increase suicidal ideation and congenital malformations.

The effects of psychological treatments are also unclear. Problem-solving therapy may reduce depression and anxiety, but may not be effective in preventing recurrence of self-harm. Evidence for benefit from cognitive therapy or psychodynamic interpersonal therapy compared with usual care is unclear. Intensive follow-up plus outreach, nurse-led management, emergency card, general practice-based guidelines and hospital admission have not been shown to reduce recurrent self-harm compared with usual care.

86

Selective Health system-based suicide

prevention programmes

Review specific psychological treatment (SPT) vs. treatment as usual (TAU) in achieving engagement in adolescents who have self-harmed.

Ougrin and Latif, 2011 76

Among 6 included studies, there was no difference between the number of subjects not completing four or more sessions of an SPT compared to TAU.

Engaging adolescents with psychological treatment is necessary although not sufficient to achieve treatment goals.

Review effectiveness of interventions for adolescents and young adults who present to a clinical setting with suicidal behaviours.

Robinson et al, 2011 77

The evidence regarding effective interventions for adolescents and young adults with suicide attempt, deliberate self-harm or suicidal ideation is extremely limited.

CBT shows some promise, but further investigation is required in order to determine its ability to reduce suicide risk among young people presenting to clinical services.

Review effectiveness of psychological or educational interventions, or both, in preventing onset of depressive disorder in children and adolescents.

Merry et al, 2011 78

There is some evidence that targeted and universal depression prevention programmes may prevent the onset of depressive disorders compared with no intervention. The persistence of findings suggests that this is real and not a placebo effect. Of 53 included studies, 15 reported that risk of having a depressive disorder post-intervention was reduced immediately compared with no intervention. There was no evidence for continued efficacy at 24 months but limited evidence of efficacy at 36 months. However, allocation concealment is unclear in most studies, and there is heterogeneity in the findings.

Review effectiveness of school-based healthcare (SBHC) (including sexual, reproductive, and mental healthcare services) for adolescent health and wellbeing.

Mason-Jones et al, 2012 79

Of 27 included studies, all but one were from North America. Only three measured adolescent sexual, reproductive, or mental health outcomes related to SBHC and none of the studies were randomized controlled trials. The remaining studies explored accessibility of services and clinic utilization or described pertinent contextual factors. However, there is evidence that SBHC is popular with young people, and may reduce health disparities and attendance at secondary care facilities. Clearer definitions of what constitutes SBHC and more high quality research are needed.

Review interventions to prevent and treat suicide and self- harm (SSH) in young people.

Of 38 controlled studies and 6 systematic reviews identified, 32 involved psychological interventions. Few studies involved treating young people with recognized mental disorders or substance abuse which also addressed SSH. The effectiveness of interventions within the trials was not evaluated. The evidence base for SSH interventions in young people is not well established, which hampers best-practice efforts in this area.

87

De Silva et al, 2013 80

Promising interventions that need further research include school-based prevention programmes with a skills training component, individual CBT interventions, interpersonal psychotherapy, and attachment-based family therapy.

Review effectiveness of treatments for deliberate self-harm in adolescents and adults(An update of 2008 review (above) with publications to August 2013).

Soomro and Kakhi, 2015 81

Since 2008, non-pharmacological interventions are more often used, compared with pharmacological approaches, which are either ineffective or inadequately investigated. Also, there has been more research into non-pharmacological approaches; thus, these are the focus of this review.

The quality of evidence for most interventions was not good, being either low or moderate.

Effectiveness for any of the interventions reviewed is unproven from RCTs. However, people presenting with deliberate self harm are a heterogeneous group; therefore some of the interventions may be used depending on a patient’s individual needs or previous experience with a particular patient.

Substantive changes at this update:Cognitive therapy One new RCT added Categorisation unchanged (unknown effectiveness).Continuity of care: Additional data added from already included systematic review. Categorisation unchanged (unknown effectiveness).Dialectical behavioural therapy Two RCTs added. Categorisation unchanged (unknown effectiveness).Emergency card Additional data added from already included systematic review. Categorisation changed from 'unlikely to be beneficial' to 'unknown effectiveness'.Hospital admission Additional data added from already included systematic review. Categorisation unchanged (unknown effectiveness).Problem-solving therapy One RCT added. Categorisation unchanged (unknown effectiveness).Intensive outpatient follow-up plus outreach Three RCTs added (including two separate reports of the same RCT). Categorisation changed from 'unlikely to be beneficial' to 'unknown effectiveness'.

Review effectiveness of evidence-based psychological interventions (including cognitive 82behavioural therapy (CBT), interpersonal therapy (IPT) and third wave

Of 83 included trials, 67 were carried out in school settings with eight in colleges or universities, four in clinical settings, three in the community and four in mixed settings.

Overall, results show small positive benefits of depression prevention, for both the primary outcomes of self-rated depressive symptoms post-intervention and depression diagnosis up to 12 months (but not beyond). Estimates of numbers needed to treat to benefit (NNTB = 11)

88

CBT)) in preventing onset of depressive disorder in children and adolescents.

Hetrick et al, 2016 82

compare well with other public health interventions. However, the evidence was of moderate to low quality.

Prevention programmes delivered to universal populations showed a sobering lack of effect when compared with an attention placebo control.

Interventions delivered to targeted populations, particularly those selected on the basis of depression symptoms, had larger effect sizes, but these seldom used an attention placebo comparison and there are practical difficulties inherent in the implementation of targeted programmes. The authors concluded that there is still not enough evidence to support the implementation of depression prevention programmes.

The authors suggest that, given the relative lack of evidence for universal interventions compared with attention placebo controls and the poor results from well-conducted effectiveness trials of universal interventions, future trials should test a depression prevention programme in an indicated targeted population using a credible attention placebo comparison group. Depressive disorder as the primary outcome should be measured over the longer term, as well as clinician-rated depression, and consider scalability as well as the potential for the intervention to do harm.

Selective Programmes for defence forces

personnel

Review Veteran-specific suicide prevention interventions.

Shekelle et al, 2009 83

74 studies published between 2005 and 2008 were reviewed. Findings were as follows: Multicomponent interventions are more likely to reduce the risk of suicide but there are

insufficient studies of interactive effects and multicomponent programs to draw conclusions about effectiveness;

Psychosocial interventions following a suicide attempt were only minimally effective and the quality of evidence (face validity) was moderate.

No studies assessed the specific effectiveness of any hotlines, outreach programs, peer counselling, treatment coordination programs, and new counselling programs.

Although restriction of access to lethal means likely has a cause-specific effect on suicides, its effect on total suicides is less clear.

Few studies focus on therapeutic relationships. There is a gap in randomized controlled trials and high-quality observational studies.

Review effectiveness of suicide prevention programmes in military personnel

Bagley, 2010 84

Most studies are of poor quality (observational designs).

Multicomponent programmes are consistent in reporting reductions in suicides but these declines have occurred at times of reductions in the general population.

89

The best described study is by Knox and it provides the most convincing evidence: A multi-component programme in the US Air Force (including training, guidelines, surveillance, and screening) led to a 33% decrease in suicides. This effect was replicated in Yugoslavia, with a programme modelled on that of the USAF, and this increases confidence that the effect is real.

In addition, two studies reporting results of multicomponent national suicide prevention programmes, one for Australia and one for England, both showing declines during the intervention period, add to the evidence of the benefits of multicomponent programmes.

Methodology is poor for studies based on interventions other than multicomponent programmes. One study training officers led to reduce d suicides but here were many confounding factors. In other studies training of all service members reduced suicides, but again there are confounding factors.

Psychosocial interventions for gambling reduced suicidal ideation and attempts during the treatment period.

In one study of veterans, DBT reduced self-harm by 80%. In one study treating depressed veterans with antidepressants decreased suicide rates. One study found no effect after treatment of veterans for substance abuse. All these studies were ranked as low quality.

Review suicide risk in military organizations to assess whether military personnel are at increased risk of suicide, and identify opportunities for suicide prevention in military organizations

Zamorski et al, 2011 8

Suicide rates in currently serving personnel are below rates in the general population of same age and sex distribution. although the UK has reported a modest excess of suicides in younger army men, and US Army and Marine Corps have seen a recent climb in suicide rates, bringing these rates above the civilian rates. Recent UK veterans have a higher rate of suicide than their civilian counterparts, particularly in the first few years after release. Younger army males with short periods of service were at particularly elevated risk.

It is highly probable that the same broad range of risk factors, protective factors, and triggers for suicidal identified in the general population also applies to military populations.

Along with other suicide prevention initiatives, the military setting offers special opportunities for restricting access to lethal means, especially firearms, and prescriptions dispensed via military pharmacies.

Other specific opportunities for prevention include education and awareness campaigns, selection processes; screening and assessment; media engagement; organisational initiatives to

90

mitigate work stress or strain, resiliency training; interventions to overcome barriers to care and help seeking; and modification of specific risk factors, among others.

Review effectiveness of Veteran-specific suicide prevention initiatives.

York et al, 2013 85

In several systematic reviews, researchers have suggested that multicomponent interventions are promising. The exemplar programme is the multi-component programme in the US Air Force (including training, guidelines, surveillance, and screening), described by Knox, and shown to achieve a 33% decrease in suicides.

The Collaborative Assessment and Management of Suicidality (CAMS) programme showed significantly more rapid resolution of suicidality (approximately one month) and fewer emergency department and primary care visits.

Review effectiveness of outreach strategies for suicide prevention in (assumed to be predominantly male) military personnel.

CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH, 201186

The limited evidence identified indicates that outreach programmes currently used by select national military organizations have been effective in reducing the rates of suicide amongst military personnel (assumed to be predominantly male populations).

Three non-randomized studies were identified regarding the clinical effectiveness of outreach strategies for suicide prevention in adult males. One study reported that a cohort of American soldiers who received a suicide prevention

plan consisting of education, identification, and intervention at each deployment cycle committed fewer suicides than a typical cohort of American soldiers who did not receive a suicide prevention plan.

A second study examined a cohort of soldiers from the Army of Serbia and Montenegro who received the Suicide Prevention Programme, and concluded that the incidence of suicide in this population was four times lower than the incidence of suicide in the country’s civilian population.

A third study examined the incidence of suicide in the United States Air Force for 16 years prior to, and 11 years after, the implementation of the US Air Force Suicide Prevention Programme. The authors concluded that the incidence of suicide amongst Air Force personnel was significantly lower after the implementation of the programme for every year except one, in which the programme was not being rigorously implemented.

Selective Rural-based programmes

No reviews were identified.

Selective Alcohol/drug misuse programmes

Review effectiveness of parenting programmes for preventing tobacco, alcohol or drugs misuse in children <18

Statistically significant self-reported reductions of alcohol use were found in six of 14 studies, of drugs in five of nine studies and tobacco in nine out of 13 studies. Three interventions reported increases of tobacco, drug and alcohol use.

91

Petrie et al, 2007 87The authors concluded that parenting programmes can be effective in reducing or preventing substance use. The most effective appeared to be those that shared an emphasis on active parental involvement and on developing skills in social competence, self-regulation and parenting. However, more work is needed to investigate further the change processes involved in such interventions and their long-term effectiveness.

Review effectiveness of school-based prevention for illicit drugs use

Faggiano et al, 2008 88

Skills-based interventions significantly reduce marijuana use and hard drug use, and improve decision-making skills, self-esteem, peer pressure resistance and drug knowledge.

Affective interventions improve decision-making skills and drug knowledge, and knowledge-focused programmes improve drug knowledge.

Skills-based interventions are better than affective ones in improving self-efficacy.

No differences are evident for skills vs. knowledge-focused programmes on drug knowledge.

Affective interventions improve decision-making skills and drug knowledge to a higher degree than knowledge-focused programmes.

Review effectiveness of psychosocial interventions for people with both severe mental illness and substance misuse.

Cleary et al, 2008 89

25 RCTs were included and found no compelling evidence to support any one psychosocial treatment, motivational interviewing (MI) plus cognitive behavioural therapy (CBT), CBT alone, MI alone, or skills training) over another to reduce substance use (or improve mental state) by people with serious mental illnesses.

Review effectiveness of web-based interventions designed to decrease alcohol consumption.

Bewick et al, 2008 90

There is inconsistent evidence on the effectiveness of eIectronic screening and brief intervention (eSBI) for alcohol use.

Process research suggests that web-based interventions are generally well received. However further controlled trials are needed to fully investigate their efficacy, to determine which elements are keys to outcome and to understand if different elements are required in order to engage low- and high-risk drinkers.

Review effectiveness of stand-alone computer-based interventions in reducing alcohol consumption in adults.

Computer-based interventions may reduce alcohol consumption compared with assessment-only; the conclusion remains tentative because of methodological weaknesses in the studies.

92

Khadjesari et al, 2011 91

Review effectiveness of universal alcohol misuse prevention programmes for children and adolescents

Foxcroft and Tsertsvadze, 2012 92

Certain generic psychosocial and life skills school-based programmes were effective in reducing alcohol use in youth.

Most family-based programmes were effective.

There was insufficient evidence to conclude that multiple interventions provided additional benefit over single interventions.

Review effectiveness of prevention strategies for substance misuse

CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH, 2012 93

Family or parental support programmes can be effective in reducing or preventing substance misuse in adolescents. School-based programmes that develop psychosocial skills have also shown positive effects on drug and alcohol misuse. The evidence to support mentoring and pre-school programmes for primary prevention of substance misuse are less clear.

In adults, social norms interventions delivered face-to-face or via computer, or other computer based interventions, have shown some benefits in reducing alcohol use among university and college students or the general adult population.

School-based programmes that were culturally adapted to include Native American values and beliefs reported positive effects on some drug use outcomes among US First Nations youth.

None of the studies measured death, stigma or discrimination related to substance misuse, and minimal information was available in one study on health services impact.

Review effectiveness of mentoring to prevent or reduce alcohol and drug use by adolescents.

Thomas et al, 2013 94

Only four RCTs provided evidence on mentoring and alcohol use, and the 2 that could be pooled showed less use by mentored youth.

The 6 RCTs that provided evidence on drug use could not be pooled. Two did provide some evidence that mentoring is associated with less drug use.

Review effectiveness of social norms information for alcohol misuse in university and college students.

Foxcroft et al, 2015 95

No substantive meaningful benefits are associated with social norms interventions for prevention of alcohol misuse among college/university students. Although some significant effects were found, we interpret the effect sizes as too small, given the measurement scales used in the studies included in this review, to be of relevance for policy or practice.

Review effectiveness of There are no substantive, meaningful benefits of MI interventions for preventing alcohol use,

93

motivational interviewing (MI) for the prevention of alcohol misuse in young adults.

Foxcroft et al, 2016 96

misuse or alcohol-related problems. Although we found some statistically significant effects, the effect sizes were too small to be of relevance to policy or practice.

Statistically significant effects are not consistent for all misuse measures, and the quality of evidence is not strong, implying that any effects could be inflated by risk of bias.

Selective Parenting support and Early Start

programmes

Review if attendance at preschool affects adult health.

D’Onise et al, 2010 97

The 12 eligible articles reported multi-faceted interventions and involved disadvantaged populations in all but one study. There were positive intervention effects across the majority of behavioural outcomes, and a suggestion of a reduction in symptoms of depression.

Limitations included a restricted range of health outcomes, reliance on self-report measures, small sample sizes, and a relatively young adult age at follow-up.

Selective Programmes to strengthen cultural

identity/continuity

Review suicide prevention interventions targeting Indigenous peoples in Australia, Canada, United States and New Zealand.

Clifford et al, 2013 98

Nine evaluations of suicide prevention interventions were identified: five targeting Native Americans; three targeting Aboriginal Australians; and one First Nation Canadians. None targeted New Zealand Maori.

Strategies employed included: community prevention initiatives (alcohol restriction, empowerment-building, and multiple-strategy), gatekeeper training, and education.

Only 3 of 9 evaluations measured changes in rates of suicide or suicidal behaviour. Two studies reported reduced rates of suicidal behaviour, and one reported increased rates of protective factors. A fourth study reported subjective enhancement of protective factors.

Gatekeeper training programmes found increased knowledge, confidence, and intention to help.

A one-off multimedia educational intervention improved knowledge about risk factors, at post-test.

Methodological quality of evaluations was generally poor, and included weak study designs, reliance on self-report measures, highly variable consent and follow-up rates, and the absence of economic or cost analyses.

Review protective factors and causal mechanisms that enhance the mental health of Indigenous Circumpolar youth.

MacDonald et al, 2013 99

15 studies identified more than 40 protective factors at the individual, family, and community levels which enhanced Indigenous youth mental health.

Factors included practicing and holding traditional knowledge and skills, the desire to be useful and to contribute meaningfully to one's community, having positive role models, and believing in one's self. Broadly, protective factors at the family and community levels were identified as positively creating and impacting one's social environment, which interacts with factors at the

94

individual level to enhance resilience.

Healthy communities and families foster and support youth who are resilient to mental health challenges and able to adapt and cope with multiple stressors. Creating opportunities and environments where youth can successfully navigate challenges and enhance their resilience can in turn contribute to fostering healthy communities.

Looking at the role of new social media in the way youth communicate and interact is one way of understanding how to create such opportunities. Youth perspectives of mental health programmes are crucial to developing appropriate mental health support. Meaningful engagement of youth can inform locally appropriate, culturally relevant mental health resources, programmes and community resilience strategies.

Review effectiveness of suicide prevention programmes that have been evaluated for indigenous youth in Australia, Canada, New Zealand, and the United States.

Harlow et al, 2014 100

11 articles describing nine programmes were reviewed. Two Australian programmes and seven American programmes were included. Programmes were culturally tailored, flexible, and incorporated multiple-levels of prevention.

No randomized controlled trials were found, and many programmes employed ad hoc evaluations, poor programme description, and no process evaluation.

Despite culturally appropriate content, the results of the review indicate that more controlled study designs using planned evaluations and valid outcome measures are needed in research on indigenous youth suicide prevention to generate more reliable outcomes and efficacy data.

Review effectiveness of culturally unadapted, culturally adapted and culture-based interventions for Indigenous adults with mental or substance use disorders in Australia, Canada, New Zealand or the United States.

Leske et al, 2016 101

Of eight culturally unadapted psychological/psychosocial, pharmacological and educational intervention studies, seven reported significant improvements on at least one measure of psychological well-being, mental health problem severity, or significantly reduced alcohol or illicit drug use.

Of seven culturally adapted psychological/psychosocial intervention studies, all reported significant improvement on at least one measure of symptoms of mental illness, functioning, and alcohol use.

Programme impacts on suicidal behaviours were not assessed. One culture-based psychological/psychosocial intervention study significantly reduced problem severity in medical and psychiatric domains.

Review effectiveness of current gatekeeper suicide prevention training

Six (involving five studies) met criteria for inclusion; two Australian, two from USA, and one Canadian.

95

programmes within the international Indigenous community.

Nasir et al, 2016 102

While pre and post follow up studies reported positive outcomes, this was not confirmed in the single RCT identified. However, the RCT may have been underpowered and contained participants who were at higher risk of suicide pre-training.

The authors concluded that gatekeeper training may be a promising suicide intervention in Indigenous communities but needs to be culturally tailored to the target population. Further RCT evidence is required.

Review protective factors to promote health in American Indian and Alaska Native Adolescents.

Henson et al, 2017 103

Nine categories of protective factors were positively associated with health and social outcomes, including: current and/or future aspirations, personal wellness, positive self-image, self-efficacy, non-familial connectedness, family connectedness, positive opportunities, positive social norms, and cultural connectedness.

Such factors positively influenced adolescent emotional health including depression, suicide attempt; resilience; alcohol, tobacco, and substance use; delinquent and violent behaviour; and academic success.

Protective factors spanned multiple domains of the socio-ecological model. Strengths-based health promotion efforts that leverage local, innate protective factors and work with indigenous populations to create environments rich in protective factors are key to improving the health and wellbeing in adolescents.

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Appendix 1. Table 17. Summary of key findings for indicated interventions

Intervention Focus of review(Author reference)

Key findings

Indicated Older people

Review effectiveness of Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials.

Cuijpers et al, 2006 104

25 studies were included, of which 17 compared a psychological intervention to a control condition (mainly waiting list and care-as-usual control groups).

Although the quality of many studies was not optimal, the results of this meta-analysis support the results of earlier meta-analyses, which also included non-randomized studies. Psychological treatments have moderate to large effects on depression in older adults.

No differences were found between individual, group or bibliotherapy format, or between CBT and other types of psychological treatment. The effects were comparable in studies where depression was defined according to diagnostic criteria, and those in which depression was measured with self-rating questionnaires.

Review effectiveness of Psychotherapeutic treatments for older depressed people

Wilson et al, 2008 105

A total of seven trials provided sufficient data for inclusion in the comparison between CBT and controls.

Based on five trials (153 participants), CBT was more effective than waiting list controls.

Only three small trials compared psychodynamic therapy with CBT, with no significant difference in treatment effect indicated between the two types of psychotherapeutic treatment.

Based on three trials with usable data, CBT was superior to active control interventions when using the Hamilton Depression Rating Scale, but equivalent when using the Geriatric Depression Scale.

Overall, only a small number of studies and patients were included in the meta-analysis. If taken on their own merit, the findings do not provide strong support for psychotherapeutic treatments in the management of depression in older people. However, the findings do reflect those of a larger meta-analysis that included patients with broader age ranges, suggesting that CBT may be of potential benefit.

Review effectiveness of group psychotherapy in older adults with depression

Six trials met inclusion criteria. All examined group interventions based on the cognitive behavioural therapy (CBT) model with active therapeutic interventions or waiting list controls.

Although the quality of many studies was not optimal, the results of this meta analysis support the

97

Krishna et al, 2011 106

results of earlier meta analyses. Group cognitive behavioural therapy is effective in older adults with depression. The benefits of group psychotherapy were maintained at follow-up.

Review effectiveness of elderly suicide prevention programmes.

Lapierre et al, 2011 107

Most studies were centred on the reduction of risk factors (depression screening and treatment, and decreasing isolation), but when gender was considered, programmes were mostly efficient for women.

Empirical evaluations of programmes attending to the needs of high-risk older adults seemed positive; most studies showed a reduction in the level of suicidal ideation of patients or in the suicide rate of the participating communities. However, not all studies used measures of suicidality to evaluate the outcome of the intervention, and rarely did they aim at improving protective factors.

The authors concluded that innovative strategies should aim to improve resilience and positive aging, engage family and community gatekeepers, use telecommunications to reach vulnerable older adult, and evaluate the effects of means restriction and physicians education on elderly suicide.

Review effectiveness of psychological treatment of depression in people aged 65 years and over.

Jonsson et al, 2016 108

Of 14 included trials, 6 evaluated problem-solving therapy (PST), five evaluated other forms of cognitive behavioural therapy (CBT), and three evaluated life review/reminiscence therapy.

In frail elderly with depressive symptoms, the evidence supported the efficacy of PST, with large but heterogeneous effect sizes compared with treatment as usual. The results for life-review/reminiscence therapy and CBT were also promising, but because of the limited number of trials the quality of evidence was rated as very low. Important questions about efficacy, generalizability, safety and cost-effectiveness remain.

Indicated Education and training for health and

social service providers including gatekeeper training)

No reviews were identified

Indicated Support to primary care providers

and health service planners

No reviews were identified

Indicated Providing education and support to

carers of high-risk individuals

No reviews were identified

Indicated No reviews were identified

98

Telephone-based (crisis) suicide prevention services

Indicated Internet- and m-health-based

programmes

Review effectiveness of telemental health (TMH) applications.

Hailey et al, 2008 109

72 papers that described 65 clinical studies were identified. 32 (49%) studies were of high or good quality. Quality of evidence was higher for Internet- and telephone-based interventions than for video conferencing approaches.

There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. There is a need for more good-quality studies on the use of TMH in routine care.

Review effectiveness of self-help and Internet-guided interventions in depression and anxiety disorder.

Van't Hof et al, 2009 110

13 meta-analyses reported medium to large effect sizes for self-help interventions. Studies differed in samples, type of self-help (eg, computer-aided, internet-guided), control conditions, and study design.

Self-help methods are effective in a range of different disorders, including depression and anxiety disorders. Most meta-analyses found relatively large effect sizes for self-help treatments, independent of the type of self-help, and comparable to effect sizes for face-to-face treatments. However, further research is needed to optimize the use of self-help methods.

Review efficacy of internet interventions for depression and anxiety disorders.

Griffiths et al, 2010 111

Internet interventions for depression and anxiety disorders offer promise for use as self-help applications for consumers or as an adjunct to usual care. Of 26 identified trials, 23 demonstrated some evidence of effectiveness relative to controls. Effect size differences ranged from 0.42 to 0.65 for depression interventions involving participants with clinically significant symptoms of depression, and 0.29 to 1.74 for anxiety interventions involving participants with a diagnosed anxiety disorder.

Of the five effective English-language programmes, three are available to the public without charge and two can be accessed at a small cost through health practitioner referral.

Review effectiveness of post-discharge follow-up contacts in preventing suicidal behaviour.

Luxton et al, 2013 112

Repeated follow-up contacts appear to reduce suicidal behaviour.

Eight original studies, two follow-up studies, and one secondary analysis study met inclusion criteria. Five studies showed a statistically significant reduction in suicidal behaviour. Four studies showed mixed results with trends toward a preventative effect and two studies did not show a preventative effect.

More research is needed, however, especially randomized controlled trials, to determine what specific factors might make follow-up contact modalities or methods more effective than others.

99

Review effectiveness of smartphone delivery of mental health programmes. .

Donker et al, 2013 113

8 papers describing 5 apps targeting depression, anxiety, and substance abuse met the inclusion criteria. Four apps provided support from a mental health professional. Two of the 5 evidence-based mental health apps are currently commercially available in app stores.

Results showed significant reductions in depression, stress, and substance use. Within-group and between-group intention-to-treat effect sizes ranged from 0.29-2.28 and 0.01-0.48 at post-test and follow-up, respectively.

Overall, mental health apps have the potential to be effective and may significantly improve treatment accessibility. However, the majority of apps that are currently available lack scientific evidence about their efficacy. The public needs to be educated on how to identify the few evidence-based mental health apps available in the public domain to date. Further rigorous research is required to develop and test evidence-based programmes. Given the small number of studies and participants included in this review, the high risk of bias, and unknown efficacy of long-term follow-up, current findings should be interpreted with caution, pending replication.

Review effectiveness of Web-based treatment and prevention programmes for depression, anxiety, and suicide prevention in children, adolescents, and emerging adults.

Reyes-Portillo et al, 2014 114

There is limited evidence for the effectiveness of Web-based interventions for youth depression and anxiety.

25 articles were identified, describing 9 programmes, of which 8 were Internet based and 1 was a mobile application. No Web-based interventions for suicide prevention were identified.

Of 14 randomized controlled trials and open trials (n = 3) identified, 10 reported significant post-intervention reductions in symptoms of depression and/or anxiety or improvements in diagnostic ratings, with small to large effect sizes. Many of these studies also reported significant improvements at follow-up.

The methodological quality of the studies varied. Many programmes were limited by small sample sizes and use of waitlist or no-treatment control groups.

Review effectiveness of Web-based suicide prevention strategies.

Lai et al, 2014 115

Good quality literature was surprisingly sparse, with only 15 studies fulfilling criteria for inclusion in the review, and most were rated as being medium to low quality.

Internet-based cognitive behaviour therapy (iCBT) reduced suicidal ideation in the general population in two randomized controlled trials and in a clinical audit of depressed primary care patients.

Descriptive studies reported improved accessibility and reduced barriers to treatment with

100

Internet among students.

Besides automated iCBT, preventive strategies were mainly interactive (email communication, online individual or supervised group support) or information-based (website postings).

The benefits and potential challenges of accessibility, anonymity, and text-based communication as key components for Web-based suicide prevention strategies were emphasized.

The authors concluded that there is preliminary evidence that suggests the probable benefit of Web-based strategies in suicide prevention. Future larger systematic research is needed to confirm the effectiveness and risk benefit ratio of such strategies.

Review cost-effectiveness of internet interventions for suicide prevention.

Donker et al, 2015 116

Guided Internet interventions for depression, anxiety, smoking cessation and alcohol consumption had favourable probabilities of being more cost-effective when compared to wait-list, TAU, group cognitive therapy (CBGT), attention control, telephone counselling or unguided Internet CBT.

Unguided Internet interventions for suicide prevention, depression and smoking cessation demonstrated cost-effectiveness compared to TAU or attention control.

In general, results from cost-utility analyses using more generic health outcomes (quality of life) were less favourable for unguided Internet interventions. Most studies adhered reasonably to economic guidelines.

Review studies of use of the Internet for suicide-related reasons and its influence on users.

Mok et al, 2015 117

There are significant relationships between suicide-related search trends and rates of suicide which suggest that search trends may be useful in monitoring suicide risk in a population.

Individuals use the Internet to search for suicide-related information and to discuss suicide-related problems with one another. However, the causal link between suicide-related Internet use and suicidal thoughts and behaviours is still unclear.

There is a lack of studies directly recruiting suicidal Internet users. Only case studies examined the influence of suicide-related Internet use on suicidal behaviours, while no studies assessed the influence of pro-suicide or suicide prevention websites.

Online professional services can be useful to suicide prevention and intervention efforts, but require more work in order to demonstrate their efficacy.

More research is needed, particularly involving direct contact with Internet users, in order to

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understand the impact of both informal and professionally moderated suicide-related Internet use.

Review concordance of features in publicly available apps with current scientific evidence of effective suicide prevention strategies.

Larsen et al, 2016 66

One hundred and twenty-three apps referring to suicide were identified and downloaded for full review, 49 of which were found to contain at least one interactive suicide prevention feature. Most apps focused on obtaining support from friends and family (n = 27) and safety planning (n = 14).

Of the different suicide prevention strategies contained within the apps, the strongest evidence in the literature was found for facilitating access to crisis support (n = 13).

All reviewed apps contained at least one strategy that was broadly consistent with the evidence base or best-practice guidelines.

Apps tended to focus on a single suicide prevention strategy, although safety plan apps provided the opportunity to provide a greater number of techniques.

Potentially harmful content, such as listing access to lethal means or encouraging risky behaviour in a crisis, was also identified.

No apps provide comprehensive evidence-based support. There is a need to develop useful, pragmatic, and multifaceted mobile resources.

Clinicians should be wary in recommending apps, especially as potentially harmful content can be presented as helpful. Currently safety plan apps are the most comprehensive and evidence-informed, for example, "Safety Net" and "Mood-Tools--Depression Aid".

Review use of mobile phone text messaging in mental health care.

Berrouiguet et al, 2016 118

36 studies were included in the review. Text messages have been proposed as a health care tool in a wide spectrum of psychiatric disorders including substance abuse, schizophrenia, affective disorders, and suicide prevention. Most papers described pilot studies, while some randomized clinical trials (RCTs) were also reported.

Text messaging was used in a wide range of mental health situations, notably substance abuse (31%), schizophrenia (22%), and affective disorders (17%).

Text messages were used in 4 ways: reminders (14%), information (17%), supportive messages (42%), and self-monitoring procedures (42%). Applications were sometimes combined.

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RCTs reported improved treatment adherence and symptom surveillance. Other positive points included an increase in appointment attendance and in satisfaction with management and health care services.

Review effectiveness of Automated telephone communication systems (ATCS) for preventing disease and managing long-term conditions.

Posadzki et al, 2016 119

ATCS can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

ATCS interventions can change patients' health status, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests.

ATCS (unidirectional or IVR) may improve appointment attendance, key to both preventing and managing disease.

For long-term management, multimodal ATCS had inconsistent effects on medication adherence. ATCS Plus probably improves medication adherence versus usual care. Compared with control, ATCS Plus and IVR probably slightly improve adherence, while unidirectional ATCS may have little, or slightly positive, effects.

ATCS may improve outocmes to a small degree for physical activity, weight management, and alcohol use. and diabetes. However, there is little or no effect in mental health or quitting smoking. In several areas including alcohol/substance misuse, addiction, carers' psychological stress, there is not enough evidence to tell what effects ATCS have.

Review effectiveness of online and mobile psychosocial suicide prevention interventions for young people 12-25 years.

Perry et al, 2016 120

One study met inclusion criteria, and found significant reductions in the primary outcome of suicidal ideation, as well as depression and hopelessness. Two relevant protocol papers of studies currently underway were also identified.

The authors concluded that there is a paucity of current evidence for online and mobile interventions for suicide prevention in youth. More high quality empirical evidence is required to determine the effectiveness of these novel approaches to improving suicide outcomes in young people.

Review promising approaches Advances in data science and wearable technology may provide new avenues to recognize suicidal

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for in digital suicide prevention.

Vahabzadeh et al, 2016 121

behavior and prevent suicide, including the use of machine learning, smartphone applications, and wearable sensor driven systems.

The authors propose a novel Sensor-driven Mental State Assessment System.

One study analyzed over 40,000 soldiers who required psychiatric hospitalization, and by using a specialized machine learning system, devised a predictive suicide risk algorithm. The algorithm succeeded in that over 50 % of the soldiers who committed suicide in the following year were in the top 5% it had predicted. This was based simply on factors like gender and listed criminal/medical records. No additional behavioral or clinical data from the subsequent year were included.

South Korean researchers used a data mining technique to identify risk factors in teenagers. In students who were very depressed, the biggest factor predicting a suicide attempt was delinquency, especially in female students. In contrast, of those students who had only a few symptoms of depression, lower levels of intimacy with their family members was the biggest risk factor. In children who were not depressed, stress, such as from falling academic performance, was the biggest risk factor for a suicide attempt.

Through the use of computerized speech analysis, researchers are able to find differences in how depressed and/or suicidal people talk. People who become suicidal may have differences in the sound frequency of their speech, either going from high frequency to low frequency or vice-versa. Research has also shown that people with depression exhibit a reduced acoustic range to their speech.

Researchers are using computerized real-time facial emotion monitoring to detect subtle changes in the facial expressions of people with suicidal thoughts. Such research could allow us to develop a rapid way to assess suicidality, especially in high risk individuals who may not verbally disclose the presence of suicidal thoughts or plans.

The authors propose the development of a digital mental state examination that assesses a patient’s presentation by utilizing a range of technologies including motion tracking, natural language processing, and speech analysis to produce quantitative, objective data that may be superior to the subjective reporting of the standard clinical MSE.

Automated cognitive behavioral therapy (CBT) can deliver a course without the involvement of a

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human therapist. While there is some evidence to suggest the utility of such approaches in affective disorders, the evidence for its use in suicide is far more limited.

A recent review of suicide-related smartphone apps showed the vast majority of apps were little more than checklists of symptoms or resources. Some apps contained information that could be potentially harmful or may worsen a person’s condition. In general, these apps did not leverage the complex inbuilt sensors and hardware capabilities of smartphones to collect behavioral data or incorporate any significant data analysis.

One study found up to 13 percent of apps contained content that could be potentially harmful, and over half having no interactive features.

Researchers have created a suicide prediction system that combines data from mood-focused smartphone apps, and also genetic blood tests (biomarkers). The system also predicts hospitalisation for suicide attempts. The smartphone apps ask participants questions about their mood and life, but did not directly ask about suicidality. This contrasts to the current standard of clinical care, where directly asking about suicidal ideation is essential. The system has been found to predict suicidality in women.

The authors propose that there is potential to detect and monitor suicidal ideation through the use of cloud computing to generate a personalized computer model of an individual’s real-time emotional state. Researchers have proposed some basic elements of this technique, such as using interconnected non-invasive sensors to monitor electro-dermal activity and electroencephalogram (EEG). A more robust model would leverage a combination of physiologic measurements from biosensors, proxy measurements of social interaction from smartphone sensors, and a patient’s baseline demographic and clinical data. Through the use of data analytics and cloud computing, a personalized real-time mental state and suicide risk model can be developed. Such a system could allow for remote monitoring, early identification of suicidal states, and beneficial changes in treatment plans. Privacy and confidentially concerns will be paramount in the development of such systems given the sensitive nature of the collected data, and users will have to carefully weigh up the risks and benefits of these systems before consenting to their use.

Mental health clinicians will continue to play a central role in suicide prevention, and early use of these technologies will augment the work of human clinicians, not replace them.

It is also imperative that people with psychiatric illness, including suicidal thoughts, are actively

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involved in the design and development of these technologies to ensure that the technology has a suitable user interface and results in high levels of user engagement.

Indicated Postvention

Review effectiveness of interventions to support people bereaved through suicide.

McDaid et al, 2008 122

Eight studies were identified. All but one study had substantial methodological limitations.

When compared with no intervention, there was evidence of some benefit from single studies of a cognitive-behavioural family intervention of four sessions with a psychiatric nurse; a psychologist-led 10-week bereavement group intervention for children; and 8-week group therapy for adults delivered by a mental health professional and volunteer.

The authors concluded that although there is evidence of some benefit from interventions for people bereaved by suicide, this is not robust. Further methodologically sound evidence is required to confirm whether interventions are helpful and, if so, for whom.

Review short-term and long-term effect of both preventive and treatment interventions on complicated grief.

Wittouck et al, 2011 123

Fourteen randomized controlled trials met the inclusion criteria. Study quality differed among the trials. Treatment interventions yielded significant pooled standardized mean differences in favour of the (specific) grief intervention at post-test and follow-up. During the follow-up period, the positive effect of treatment interventions for complicated grief even increased.

In contrast, preventive interventions, do not appear to be effective.Examine perceived needs for help by the suicide-bereaved.

Dyregrov, 2011 124

In the little research identified, the bereaved agreed about a common need for peer and social support, and that professional help must be adapted to and offered with respect for individual needs.

In societies in which the stigma about suicide has diminished, the bereaved experience very similar needs for help, whereas in other societies it is difficult to talk about their need for help because of the sanctions and taboos connected to suicide.

Review effectiveness of post-suicide intervention programmes.

Szumilas and Kutcher, 2011 125

Three target populations for postvention programmes were identified: school-based, family-focused, and community-based.

No protective effect of any postvention programme could be determined for number of suicide deaths or suicide attempts from the available studies.

Few positive effects of school-based postvention programmes were found. One study reported negative effects of a suicide postvention.

Gatekeeper training for proactive postvention was effective in increasing knowledge pertaining to crisis intervention among school personnel.

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Outreach at the scene of suicide was found to be helpful in encouraging survivors to attend a support group at a crisis centre and seek help in dealing with their loss.

Contact with a counselling postvention for familial survivors (spouses, parents, children) of suicide generally helped reduce psychological distress in the short term.

There was no statistical analysis of community-based suicide postvention programmes; however, media guidelines for reporting of suicide and suicide attempts have been adopted by mental health organizations in numerous countries.

No analyses of cost-effectiveness of suicide postvention programmes were found.Indicated –Other

Review effectiveness of group therapy for mood disorders.

CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH, 2009 126

Group psychotherapy may be beneficial in reducing depression scores in the short term relative to no-psychotherapy controls however the benefits may not persist with longer term follow up. No conclusions can be drawn on the impact on functioning, health-related quality of life (HRQL), or hospitalization.

In patients with bipolar disorder, limited data (from 5 reports for 4 studies) suggest that group psychotherapy may reduce the number of recurrences compared to non-structured group therapy. No conclusions can be drawn on the impact on HRQL.

Review effectiveness of reasons for reasons for living (RFL) as protective factors against suicidal thoughts and behaviour

Bakhiyi et al, 2016 127

RFL may protect against SI and SA and yield a predictive value. The role of two specific reasons for living (Moral Objections to Suicide and Survival and Coping Beliefs) was particularly emphasized.

No study investigating suicide death was found.

Overall, RFL may moderate suicide risk factors and correlate with resilience factors. Moreover, RFL may depend on and interact with numerous factors such as DSM-IV Axis I disorders, personality disorders and features, coping abilities and social support. Clinicians could develop therapeutic strategies aimed at enhancing RFL, like Dialectical Behaviour Therapy and Cognitive Behavioural Therapies, to prevent suicidal thoughts and behaviours and improve the care management of suicidal patients.

Review effect of psychotherapy for depression on quality of life (QoL).

A small to moderate effect size was detected for global QoL, a moderate effect size for the mental health component and a small but statistically significant effect size for the physical health component.

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Kolovos et al, 2016 128 The effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component.

Overall, results suggest that psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.

Case identification Primary care screening programmes

Review effectiveness of screening for child and adolescent depression (7 to 18 years) in primary care settings.

Williams et al, 2009 129

No controlled trials compared health outcomes in screened and unscreened paediatric populations.Although no trials of screening for paediatric MDD were identified, limited available data suggest that primary care feasible screening tools may be accurate in identifying depressed adolescents, and treatment can improve depression outcomes. Treating depressed youth with SSRIs may be associated with a small increased risk of suicidality and therefore should only be considered if judicious clinical monitoring is possible. Specific treatment should be based on the individual's needs and mental health treatment guidelines.

Review effectiveness of screening adults for depression in primary care settings.

O’Connor et al, 2009 130

Nine fair- or good-quality trials indicate that primary care depression screening and care management programmes with staff assistance, such as case management or mental health specialist involvement, can increase depression response and remission. Benefit was not evident in screening programmes without staff assistance in depression care.

Seven regulatory reviews or meta-analyses and 3 large cohort studies indicate no increased risk for completed suicide deaths with antidepressant treatment. Risk for suicidal behaviours was increased in young adults (18 to 29 years) who received antidepressants, particularly those who received paroxetine, but was reduced in older adults.

The authors concluded that depression screening programmes without substantial staff-assisted depression care supports are unlikely to improve depression outcomes. Close monitoring of all adult patients who initiate antidepressant treatment, particularly those younger than 30 years, is important both for safety and to ensure optimal treatment.

Review effectiveness of screening for suicide risk in primary care

Connor et al, 2013 131

Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents.

Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.

A limitation was that treatment evidence was derived from high-risk rather than screen-detected

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populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.

Review effectiveness of screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care in improving health outcomes.

Webb et al, 2016 132

Of 9 studies included, 7 found positive changes in substance use, diet, sexual health or risky sexual behaviour, alcohol-related risky behaviour, social stress, stress management, helmet use, sleep and exercise. Of only two studies reporting on harms, one reported a negative health outcome of increased alcohol use.

Overall, there is some evidence that the use of screening and intervention with young people for mental health disorder or health compromising behaviours in clinical settings improves health outcomes. Along with other evidence that young people value discussions of health risks with their providers, these discussions should be part of the routine primary care of young people. Further quality studies are needed to strengthen this evidence.

Provide an updated review of effectiveness of screening for depression in general and older adults.

O’Connor et al, 2016 133

Although direct evidence of the isolated health benefit of depression screening in primary care is weak, the totality of the evidence supports the benefits of screening in pregnant and postpartum and general adult populations, particularly in the presence of additional treatment supports such as treatment protocols, care management, and availability of specially trained depression care providers.

Evidence is least supportive of screening in older adults, where direct evidence is most limited.Review effectiveness of primary care screening for, and treatment of, depression in pregnant and post-partum women.

O'Connor et al, 2016 134

Screening pregnant and postpartum women for depression may reduce depressive symptoms in women with depression. Evidence for pregnant women was sparser but was consistent with the evidence for postpartum women regarding the benefits of screening, the benefits of treatment, and screening instrument accuracy.

Among pregnant and postpartum women 18 years and older, 6 trials reported 18% to 59% relative reductions with screening programmes, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (3-5 months) after participation in programmes involving depression screening, with or without additional treatment components, compared with usual care.

Based on 23 studies (n = 5398), a cut-off of 13 on the Edinburgh Postnatal Depression Scale demonstrated sensitivity ranging from 0.67 (95% CI, 0.18-0.96) to 1.00 (95% CI, 0.67-1.00) and specificity consistently 0.87 or higher.

Pooled results for the benefit of CBT for pregnant and postpartum women with screen-detected depression showed an increase in the likelihood of remission compared with usual care, with absolute increases ranging from 6.2% to 34.6%.

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Observational evidence showed that second-generation antidepressant use during pregnancy may be associated with small increases in the risks of potentially serious harms.

Provide updated review of effectiveness of screening for and treatment of depression in children and adolescents in primary care settings.

Forman-Hoffman et al, 2016135

Limited evidence from 5 studies showed that such tools as the Beck Depression Inventory and Patient Health Questionnaire for Adolescents had reasonable accuracy for identifying MDD among adolescents in primary care settings.

Six trials evaluated treatment. Several individual fair- and good-quality studies of fluoxetine, combined fluoxetine and cognitive behavioural therapy, escitalopram, and collaborative care demonstrated benefits of treatment among adolescents (but not younger children), with no associated harms.

Case identification Emergency Department screening

programmes

Review Emergency Department screening for suicide and mental health risk in the paediatric population.

Babeva et al, 2016 136

Screening for mental health concerns and suicidality in the ED is feasible and acceptable to patients and providers. Several approaches have been used, ranging from brief screening to adaptive algorithms to therapeutic assessments. When resources permit, approaches that combine a brief initial screen with more extensive evaluation and therapeutic assessment for youths screening positive are likely to prove the most feasible and effective in ED settings where there are often time and resource constraints.

While screening is an important first step for identifying patients with suicide risk or mental health needs, a critical next step is to triage patients based on need (e.g., some patients discharged home, others to more extensive evaluation, others to hospital), in order to facilitate receipt of effective care for identified needs.

Research has demonstrated that a variety of brief interventions and therapeutic assessment strategies in the ED can lead to improved linkage to outpatient follow-up care after ED visits and, when combined with guaranteed access to evidence-informed care, can lead to improved clinical outcomes. These approaches use a variety of collaborative, cognitive-behavioral, and motivational enhancement strategies and, importantly, provide patients and families with information about treatment and involve them in care decisions, a major factor related to the decision to attend outpatient care in research with adults..

Recently developed brief therapeutic assessment approaches have demonstrated success in improving rates of follow-up care after discharge from the ED. Furthermore, there is some data supporting clinical benefits when youths receive evidence-based outpatient follow-up care. ED screening combined with effective follow-up, therefore, may provide one strategy for improving mental health and reducing health disparities.

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Case identification Prediction of suicide

Review ability of the Beck Hopelessness Scale (BHS) to predict suicide and suicide attempt.

McMillan et al, 2007 137

The standard cut-off point on the BHS identifies a high-risk group for potential suicide, but the magnitude of the risk is lower than previously reported estimates.

The standard cut-off point is also capable of identifying those who are at risk of future self-harm, but the low specificity rate means it is unlikely to be of use in targeting treatment designed to lower the rate of repetition.

Review validity of screening instruments to identify risk of suicide and self-harm in offenders.

Perry et al, 2010 138

Review identified four screening instruments, including the Suicide Checklist, the Suicide Probability Scale, Suicide Concerns for Offenders in Prison Environment (SCOPE), and the Suicide Potential Scale.

Two instruments, SCOPE and Suicide Potential Scale, shared promising levels of sensitivity and specificity.Research is needed to assess the predictive validity of tools for offender populations in the identification of those at risk, particularly those in probation and community settings.

Review predictive validity of history of self-injurious thoughts and behaviours (SITB) on subsequent suicide ideation, attempts, and death.

Ribeiro et al, 2016 139

The most common outcome was suicide attempt (47.80%), followed by death (40.50%) and ideation (11.60%). Median follow-up was 52 months. Overall prediction was weak.

The authors concluded that prior SITBs confer risk for later suicidal thoughts and behaviours. However, they only provide a marginal improvement in diagnostic accuracy above chance.

Addressing gaps in study design, assessment, and underlying mechanisms may prove useful in improving prediction and prevention of suicidal thoughts and behaviours.

To review case identification in psychiatric patients

Large et al, 2016 140

The strength of suicide risk categorizations based on the presence of multiple risk factors does not greatly exceed the association between individual suicide risk factors and suicide. A statistically strong and reliable method to usefully distinguish patients with a high-risk of suicide remains elusive.

Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis.

Hubers et al, 2016 141

Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations.

81 studies were included. Meta-regression analysis was used to determine suicide risk during the first year of follow-up.

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The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43-3.87) in affective disorder populations to 8.00 (95% CI 5.46-11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74-2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10-0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting.

In conclusion, assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

Case identification Follow-up and ongoing contact

Review promising strategies to prevent repetition of suicidal behaviours.

Daigle et al, 2011 142

Thirteen of 35 included studies showed statistically significant effects of fewer repeated attempts or suicides in the experimental condition. Overall, 22 studies focused on pharmacological or psychological approaches.

Only 2 of the 6 pharmacological treatments proved significantly superior to a placebo- a study of lithium with depression and flupenthixol with personality disorders.

Eight out of 16 psychological treatments proved superior to treatment as usual or another approach: cognitive-al therapy (CBT) (n = 4), (including dialectical therapy [n = 2]); psychodynamic therapy (n = 2); mixed (CBT plus psychodynamic therapy [n = 1]); and motivational approach and change in therapist (n = 1).

Among the 8 studies using visit, postal, or telephone contact or green-token emergency card provision, 2 were significant: one involving telephone follow-up and the other telephone follow-up or visits.

Hospitalization was not related to fewer attempts.

One of the 4 outreach approaches had significant results: a programme involving individualized biweekly treatment.

The rationale behind these single or multiple approaches still needs to be clarified. There were methodological flaws in many studies and some had very specific limited samples.

Case identification No reviews were identified

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Crisis cardsCase identification In-patient care

No reviews were identified

Case identification Treatment adherence programmes

No reviews were identified

Standard treatment for known disorders

Pharmacotherapy

Review positive effects of antidepressants on suicidality

Möller, 2006 143

Overall, there seems to be reasonable evidence from different research approaches that antidepressants are able to reduce suicidal ideation and also suicidal behaviours in depressive patients. While the evidence for the beneficial effect on suicidal ideation comes from randomised control group studies, some of which used a placebo arm, the evidence for the prophylactic effect on suicidal behaviours, especially suicide, was primarily obtained from well-designed epidemiological studies.

Review evidence for negative effects of antidepressants on suicidality in depressive patients.

Möller, 2006 144

Altogether, there seems to be only a small amount of evidence from different research approaches that antidepressants, not only serotonin reuptake inhibitors (SSRIs), might induce, aggravate or increase the risk of suicidal ideation and suicide attempts. As to suicide, there are no hints in this direction.

Tricyclic Antidepressants (TCAs) have a higher risk of fatal outcome in overdose compared to SSRIs, which, in case of mono-intoxication, carry almost no risk of lethal consequences.

The ongoing discussion about suicidality-inducing effects should not prevent physicians from prescribing SSRIs and other antidepressants to their patients if they are clinically indicated. However, they should take into account potential risks and manage them by good clinical practice.

Review clinical effectiveness of second-generation antidepressants for the treatment of pediatric patients with major depressive disorder

CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH, 2015 145

The benefits and risks of prescribing second-generation antidepressants in children and adolescents vary by indication.

In patients with anxiety disorders, antidepressants have been shown to improve symptomology with no association of suicidal behaviour.

Although second-generation antidepressants are likely to benefit pediatric patients with major depressive disorder, the existing data on risk of suicidality have been conflicting so far.

Early evidence suggests that combination therapy of CBT with an antidepressant may be statistically more effective in response to treatment and preventing relapse than either monotherapy alone.

Review effectiveness of newer Overall, there was evidence that those treated with an antidepressant had lower depression

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generation antidepressants for depressive disorders in children and adolescents.

Hetrick et al, 2012 146

severity scores and higher rates of response/remission than those on placebo. However, the size of these effects was small.

Remission rates increased from 380 per 1000 to 448 per 1000 for those treated with an antidepressant.

There was evidence of an increased risk (58%) of suicide-related outcome for those on antidepressants compared with a placebo (17 trials; N = 3229). Where rates of adverse events were reported, this was higher for those prescribed an antidepressant. There was no evidence that the magnitude of intervention effects (compared with placebo) were modified by individual drug class.

The authors warned that findings should be interpreted cautiously given the methodological limitations of the included trials. However, given the risks of untreated depression in terms of completed suicide and impacts on functioning, if a decision to use medication is agreed, then fluoxetine might be the medication of first choice given guideline recommendations. Clinicians need to keep in mind that there is evidence of an increased risk of suicide-related outcomes in those treated with antidepressant medications.

Review effectiveness of ketamine as a potential treatment for suicidal ideation (SI).

Reinstatler and Youssef, 2015. 147

Nine publications (six studies and three case reports) met the search criteria for assessing SI after administration of subanesthetic ketamine. No studies examined the effect on suicide attempts or death by suicide.

Each study demonstrated a rapid and clinically significant reduction in SI, with results similar to previously described data on ketamine and treatment-resistant depression. A total of 137 patients with SI have been reported in the literature as receiving therapeutic ketamine. Seven studies delivered a dose of 0.5 mg/kg intravenously over 40 min, while one study administered a 0.2 mg/kg intravenous bolus and another study administered a liquid suspension. The earliest significant results were seen after 40 min, and the longest results were observed up to 10 days post-infusion.

While ketamine has shown early preliminary evidence of a reduction in depressive symptoms, as well as reducing SI, with minimal short-term side effects, additional studies are needed to further investigate its mechanism of action, long-term outcomes, and long-term adverse effects (including abuse) and benefits. In addition, ketamine could potentially be used as a prototype for further development of rapid-acting antisuicidal medication with a practical route of administration and the most favorable risk/benefit ratio.

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Review effectiveness of intravenous ketamine for the treatment of mental health disorders.

Canadian Agency for Drugs and Technologies in Health (CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH) 148

Major Depressive Disorder (MDD)Current evidence has consistently shown that IV ketamine may improve symptoms scored by the MADRS and HAM-D scoring tools at 24 hours in patients with MDD. However, identifying which patients are most likely to respond and the duration of response remains unknown.

Post-Traumatic Stress Disorder (PTSD)There remains a paucity of good quality evidence to fully support IV ketamine in patients experiencing PTSD as only one randomized controlled trial (RCT) was identified. This is a new area for the use of a NMDA receptor antagonist and while current evidence is optimistic, more evidence with validated outcomes is required to ascertain the clinical effectiveness of IV ketamine in PTSD.

Suicidal IdeationOverall, current evidence suggests that IV ketamine may be a benefit for components of depression scoring tools related to suicidal ideation, however identifying which patients would benefit is difficult. More trials of higher quality that investigate hard outcomes such as suicide attempts and using patients at risk of imminent suicide are required to determine clinical effectiveness of IV ketamine in suicidal ideation.

Suicidal ideation has been investigated as part of several RCTs however it appears that it has only been investigated as a primary outcome in one RCT. Current evidence is of relatively poor quality but supports the use of IV ketamine to reduce suicidal ideation. Given current evidence, IV ketamine requires further investigations looking at reducing validated and hard outcomes (i.e. suicide attempts) in patients who are at risk for imminent suicide attempts to determine clinical effectiveness.

IV ketamine for all these mental health illnesses requires further investigations to identify which patients would benefit (treatment resistant or naïve), how to best administer (IV or IM or Intranasal), in which setting (outpatient or inpatient) as well as duration of efficacy given that relapse is common in all mental health disorders.

Review effectiveness of ketamine and other glutamate receptor modulators for depression in adults.

Caddy et al, 2015 149

25 studies were identified (1242 participants) on ketamine (9 trials), memantine (3), AZD6765 (3), D-cycloserine (2), Org26576 (2), atomoxetine (1), CP-101,606 (1), MK-0657 (1), N-acetylcysteine (1), riluzole (1) and sarcosine (1). Twenty-one studies were placebo-controlled and the majority were two-arm studies (23 out of 25). Twenty-two studies defined an inclusion criteria specifying the severity of depression; 11 specified at least moderate depression; eight, severe depression; and the remaining three, mild-moderate depression. Nine studies recruited only treatment-

115

resistant patients.

Overall, there was limited evidence for ketamine's efficacy over placebo at time points up to one week in terms of the primary outcome, response rate. The effects were less certain at two weeks post-treatment. No significant results were found for the remaining ten glutamate receptor modulators, except for sarcosine being more effective than citalopram at four weeks.

In terms of adverse events, the only significant differences in favour of placebo over ketamine were in regards to confusion and emotional blunting.

Despite the promising nature of these preliminary results, confidence in the evidence was limited by risk of bias and the small number of participants. Further RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine with longer follow-up, which test the comparative efficacy of ketamine and the efficacy of repeated administrations.

Review effectiveness of psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents.

Cox et al, 2012 150

Ten studies were identified, involving 1235 participants. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results.

There was limited evidence that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention

There was limited evidence that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention.

There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention.

In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%), and this effect appeared to remain at six to nine months.

The authors concluded that there is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. The effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately

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powered RCTs are required.Review effectiveness of interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents.

Cox et al, 2012b 151

Nine trials with 882 participants were included in the review.

Overall, there is little evidence to conclude which type of treatment approach is most effective in preventing relapse or recurrence of depressive episodes in children and adolescents. Limited trials found that antidepressant medication reduces the chance of relapse-recurrence in the future: Three trials indicated participants treated with antidepressant medication had lower relapse-recurrence rates (40.9%) compared to those treated with placebo (66.6%) during a relapse prevention phase.

However, there is considerable diversity in the design of trials, making it difficult to compare outcomes across studies. Some of the research involving psychological therapies is encouraging, however at present more trials with larger sample sizes need to be conducted in order to explore this treatment approach further.

Review effectiveness of continuation and maintenance treatments for depression in older people.

Wilkinson and Izmeth, 2012 152

Seven studies met the inclusion criteria (803 participants). Six compared antidepressant medication with placebo; two involved psychological therapies. There was marked heterogeneity between the studies.

The long-term benefits of continuing antidepressant medication in the prevention of recurrence of depression in older people are not clear and no firm treatment recommendations can be made.

Continuing antidepressant medication for 12 months appears to be helpful but this is based on only three small studies with relatively few participants using differing classes of antidepressants in clinically heterogeneous populations. Comparisons at other time points did not reach statistical significance. Data on psychological therapies and combined treatments are too limited to draw any conclusions.

Review effectiveness of psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents.

Cox et al, 2014 153

11 studies, involving 1307 participants, were identified. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results.

There was limited evidence that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention.

There was limited evidence that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-

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intervention.

There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention.

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

Review effectiveness of lithium in the prevention of suicide in mood disorders

Cipriani et al, 2013 154

48 randomised controlled trials (6674 participants, 15 comparisons) were included.

Lithium was more effective than placebo in reducing the number of suicides and deaths from any cause.

No clear benefits were observed for lithium compared with placebo in preventing deliberate self harm.

In unipolar depression, lithium was associated with a reduced risk of suicide and also the number of total deaths compared with placebo.

Overall, lithium is an effective treatment for reducing the risk of suicide in people with mood disorders. Lithium may exert its antisuicidal effects by reducing relapse of mood disorder, but additional mechanisms should also be considered because there is some evidence that lithium decreases aggression and possibly impulsivity, which might be another mechanism mediating the antisuicidal effect.

Review effectiveness of ketamine in bipolar depression

Parsaik et al, 2015 155

5 studies (125 subjects with bipolar depression) were included I the review; 3 randomized controlled trials (69 subjects) were included in the meta-analysis.

The meta-analysis showed significant improvement in depression among patients receiving a single dose of intravenous ketamine compared with those who received placebo. The maximum improvement was observed 40 minutes after the ketamine infusion.

The 2 studies that were excluded from the meta-analysis also showed significant improvement in depression after ketamine therapy.

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Individual studies also reported improvement in anhedonia and suicidal ideation after ketamine therapy. None of the subjects had serious side effects, and the side effects were similar between the ketamine and placebo groups.

Overall, this review suggests that ketamine is effective in treatment-resistant bipolar depression and may reduce suicidal ideation and anhedonia.

Review effectiveness of ketamine and other glutamate receptor modulators for depression in bipolar disorder in adults.

McCloud et al, 2015 156

Five studies (329 participants) were included in this review. All included studies were placebo-controlled and two-armed, and the glutamate receptor modulators - ketamine (two trials), memantine (two trials), and cytidine (one trial) - were used as add-on drugs to mood stabilisers.

Reliable conclusions are severely limited by the small amount of data usable for analysis. The body of evidence about glutamate receptor modulators in bipolar disorder is even smaller than that which is available for unipolar depression.

Overall, there was limited evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours; ketamine did not show any better efficacy in terms of remission in bipolar depression.

Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. Ketamine's psychotomimetic effects could compromise study blinding; this is a particular issue for this review as no included study used an active comparator, and so we cannot rule out the potential bias introduced by inadequate blinding procedures.

To draw more robust conclusions, further RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine and to study different methods of sustaining antidepressant response, such as repeated administrations.

There was not enough evidence to draw meaningful conclusions for the remaining two glutamate receptor modulators (memantine and cytidine). This review is limited not only by completeness of evidence, but also by the low to very low quality of the available evidence.

Review effectiveness of low-dose and very low-dose ketamine among patients with major depression in reducing

Nine trials were identified, including 201 patients. Six trials assessed low-dose ketamine (0.5 mg/kg i.v.) and 3 tested very low-dose ketamine (one trial assessed 50 mg intra-nasal spray, another assessed 0.1-0.4 mg/kg i.v., and another assessed 0.1-0.5 mg/kg i.v., intramuscular, or s.c.).

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suicidality.

Xu et al, 2016 157At day 3, the reduction in depression severity score was less marked in the very low-dose trials and among bipolar patients. In analyses excluding the second period of crossover trials, response rates at day 7 were increased with ketamine (relative risk 3.4, 95% CI 1.6-7.1, P=.001), as were remission rates (relative risk 2.6, CI 1.2-5.7, P=.02).

The absolute benefits were large, with day 7 remission rates of 24% vs 6% (P=.02).

Seven trials provided unpublished data on suicidality item scores, which were reduced on days 1 and 3 (both P<.01) but not day 7.

The authors concluded that low-dose ketamine appears more effective than very low dose. There is substantial heterogeneity in clinical response, with remission among one-fifth of patients at 1 week but most others having benefits that are less durable. Larger, longer term parallel group trials are needed to determine if efficacy can be extended and to further assess safety.

Review comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents.

Cipriani et al, 2016 158

34 trials were eligible, including 5260 participants and 14 antidepressant treatments. The quality of evidence was rated as very low in most comparisons.

For efficacy, only fluoxetine was statistically significantly more effective than placebo.

In terms of tolerability, fluoxetine was also better than and imipramine.

Patients given imipramine, venlafaxine, and duloxetine had more discontinuations due to adverse events than did those given placebo

The authors concluded that when considering the risk-benefit profile of antidepressants in the acute treatment of major depressive disorder, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated.

Review effectiveness of pharmacological interventions in adults who self harm (SH).

Hawton et al, 2016 159

7 trials (total of 546 patients) were included.

There was no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of

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evidence).

A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although quality of evidence for this trial was very low.

No data on adverse effects, other than the planned outcomes relating to suicidal behaviours, were reported.

The authors concluded that, given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients.

More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

Standard treatment for known disorders

Psychotherapy and psychological approaches

Review effectiveness of cognitive therapy versus interpersonal psychotherapy in patients with major depressive disorder.

Jakobsen and Hansen, 2012 160

7 trials were included (741 participants). All trials had high risk of bias.

The effects of cognitive therapy and interpersonal psychotherapy do not seem to differ significantly regarding depressive symptoms.

Meta-analysis of the four trials reporting data at cessation of treatment on the Hamilton Rating Scale for Depression showed no significant difference between cognitive therapy and interpersonal psychotherapy.

Meta-analysis of the five trials reporting data at cessation of treatment on the Beck Depression Inventory showed comparable results.

Review effectiveness of meditation therapies for acute and subacute phase treatment of depressive disorders.

Jain et al, 2015 161

18 studies meeting the inclusion criteria were identified, encompassing 7 distinct techniques and 1173 patients. Mindfulness-Based Cognitive Therapy comprised the largest proportion of studies. Studies including patients having acute major depressive episodes (n = 10 studies), and those with residual subacute clinical symptoms despite initial treatment (n = 8), demonstrated moderate to large reductions in depression symptoms within the group, and relative to control groups.

Large-scale, randomized controlled trials with well-described comparator interventions and

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measures of expectation are needed to clarify the role of meditation in depression treatment.Review effectiveness of mindfulness-based interventions for substance use disorders

Chiesa and Serretti, 2014 162

24 studies were included, three of which were based on secondary analyses of previously investigated samples.

Current evidence suggests that mindfulness-based interventions (MBIs) can reduce the consumption of several substances including alcohol, cocaine, amphetamines, marijuana, cigarettes, and opiates to a significantly greater extent than waitlist controls, non-specific educational support groups, and some specific control groups.

Some preliminary evidence also suggests that MBIs are associated with a reduction in craving as well as increased mindfulness.

The findings have limited generalizability (i.e., small sample size, lack of methodological details, and the lack of consistently replicated findings). More rigorous and larger randomized controlled studies are warranted.

Review effectiveness of non-pharmacological interventions in preventing relapse in adults who have recovered from depression.

Clarke et al, 2015 163

29 trials were included (2742 participants).

At 12months cognitive-behavioural therapy (CBT), mindfulness-based cognitive therapy (MBCT), and interpersonal psychotherapy (IPT) were associated with a 22% reduction in relapse compared with controls.

The effect was maintained at 24months for CBT, but not for IPT despite ongoing sessions. There were no 24-month MBCT data.

A key area of heterogeneity differentiating these groups was prior acute treatment. Other psychological therapies and service-level programmes varied in efficacy.

The authors concluded that psychological interventions may prolong the recovery a person has achieved through use of medication or acute psychological therapy. Although there was evidence that MBCT is effective, it was largely tested following medication, so its efficacy following psychological interventions is less clear. IPT was only tested following acute IPT. Further exploration of sequencing of interventions is needed.

Review effectiveness of Mindfulness-based Interventions (MBIs) for people diagnosed with a

12 studies were included (578 participants). This is the first meta-analysis of RCTs of MBIs where all studies included only participants who were diagnosed with a current episode of a depressive or anxiety disorder.

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current episode of an anxiety or depressive disorder.

Strauss et al, 2014 164

There were significant post-intervention between-group benefits of MBIs relative to control conditions on primary symptom severity.

Effects were demonstrated for depressive symptom severity, but not for anxiety symptom severity for RCTs with an inactive control, but not where there was an active control. Effects were found for Mindfulness based Cognitive Therapy but not for Mindfulness-based Stress reduction.

Effects of MBIs on primary symptom severity were found for people with a current depressive disorder and it is recommended that MBIs might be considered as an intervention for this population.

Review effectiveness of Mindfulness-Based Interventions (MBIs) in Primary Care

Demarzo et al, 2015 165

6 trials were included (553 patients). The overall effect size of MBI compared with a control condition for improving general health was moderate.

MBIs were efficacious for improving mental health, and for improving quality of life.

Although the number of randomized controlled trials applying MBIs in primary care is still limited, these results suggest that these interventions are promising for the mental health and quality of life of primary care patients. The authors suggest innovative approaches for implementing MBIs, such as complex intervention and stepped care.

Review effectiveness of online mindfulness-based interventions in improving mental health.

Spijkerman et al, 2016 166

15 trials were included. Online MBIs have a small but significant beneficial impact on depression, anxiety, well-being and mindfulness.

The largest effect was found for stress, with a moderate effect size. For stress and mindfulness, exploratory subgroup analyses demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, meta-regression analysis showed that effect sizes for stress were significantly moderated by the number of intervention sessions.

Review effectiveness of 'Third wave' cognitive and behavioural therapies (Acceptance and Commitment Therapy (ACT), compassionate mind training, functional analytic psychotherapy, dialectical therapy, Mindfulness-based Cognitive Therapy (MBCT)), extended

4 small studies (224 participants) were included in the review. Little information was provided about the process of allocating participants to groups. None of the studies used independent outcome assessors, and evidence suggested researcher allegiance towards the active treatments. The four studies examined a diversity of third wave CBT approaches (extended behavioural activation, acceptance and commitment therapy and competitive memory training) and control conditions. None of the studies conducted follow-up assessments.

Very low quality evidence suggests that third wave CBT approaches appear to be more effective than treatment as usual in the treatment of acute depression. The very small number of available studies and the diverse types of interventions and control comparators, together with

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behaviouralactivation and metacognitive therapy)versus treatment as usual for depression

Churchill et al, 2013 167

methodological limitations, limit the ability to draw any conclusions on their effect in the short term or over a longer term. The increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies of third wave CBT approaches in the treatment of acute depression, on a short- and long-term basis, to provide evidence of their effectiveness to policy-makers, clinicians and users of services.

Review effectiveness of mindfulness interventions for the treatment of post-traumatic stress disorder, generalized anxiety disorder, depression, and substance use disorders.

CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH 168

There is evidence to suggest that mindfulness may be beneficial as a monotherapy or adjunctive therapy for treating depression.

The effectiveness of mindfulness for treating PTSD, and GAD is unclear. One RCT of low methodological quality suggested that mindfulness intervention is more effective than treatment as usual in lowering risk of relapse to substance use and heavy drinking.

Six evidence based guideline documents considered the use of mindfulness in clinical practice. Four guidelines for depression suggested that mindfulness may be useful in reducing relapse in patients with depression, to be used in the maintenance phase of major depression, or used during the continuation phase of treatment with patients at high risk for relapse. One guideline suggested that mindfulness may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques. Another guideline suggested that mindfulness can be used to treat problematic drug and alcohol use problems by suitably trained and experienced drug and alcohol professionals.

Review effectiveness of self help technologies for emotional problems in adolescents

Ahmead and Bower, 2008 169

Self help technology refers to delivery of psychological help through information technology or paper based formats. 14 studies were identified. Studies were generally of poor quality.

Meta analysis showed small, non-significant effect size for attitude towards self, a medium, non-significant effect size for social cognition, and a medium, non-significant effect size for emotional symptoms (i.e. depression and anxiety symptoms).

At present, the adoption of self help technology for adolescents with emotional problems in routine clinical practice cannot be recommended. There is a need to conduct high quality randomised trials in clearly defined populations to further develop the evidence base before implementation.

Review effectiveness of 'Third wave' cognitive and behavioural therapies

3 studies involving 144 participants were included in the review. 'Third wave' cognitive and behavioural therapies versus included ACT, compassionate mind training, functional analytic psychotherapy, extended behavioural activation and metacognitive therapy. All other

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compared with all other psychological therapies (psychodynamic, behavioural, humanistic, integrative, cognitive-behavioural) for acute depression.

Hunot et al, 2013 170

psychological therapies included psychodynamic, behavioural, humanistic, integrative, cognitive-behavioural therapies.

Very low quality evidence suggests that third wave CBT and CBT approaches are equally effective and acceptable in the treatment of acute depression. Evidence is limited in quantity, quality and breadth of available studies, precluding conclusions as to their short- or longer-term equivalence.

The authors suggest that the increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies to compare various third wave CBT approaches with other psychological therapy approaches to inform clinicians and policymakers on the most effective forms of psychological therapy in treating depression.

Review effectiveness of internet-based interventions for children, youth, and young adults with anxiety and/or depression

Ye et al, 2014 171

7 studies (569 participants aged between 7 and 25 years) were included.

Compared to waitlist control, internet-based interventions were able to reduce anxiety symptom severity and increase remission rate, but were not effective in reducing depression symptom severity. Due to the small number of higher quality studies, more attention to this area of research is encouraged.

Review effectiveness of non-pharmacological interventions in older adults with depressive disorders.

Apóstolo et al, 2015 172

6 studies (520 participants) were included in this review. The interventions included in this systematic review were: cognitive behaviour therapy, competitive memory training, reminiscence group therapy, problem-adaptation therapy, and problem-solving therapy in home care.

Evidence suggests that all of these interventions reduce depressive symptoms and, therefore, may be useful in practice. However, due to the diversity of interventions and the low number of studies per intervention included in this systematic review, evidence is not strong enough to produce a best practice guideline.

Review effectiveness of Dialectical Therapy for suicide prevention in adolescents (18 years of age or younger).

Canadian Agency for Drugs and Technologies in Health, 2010 173

Two systematic reviews meeting the inclusion criteria were identified. One RCT and four observational studies that were not included in the two systematic reviews were also identified.

All the included studies reported some clinical effectiveness from the use of DBT in reducing suicidality, including a reduction in self-harm s and suicide ideation. No statistically significant differences were reported in completed suicides among DBT-treated participants. However, completed suicides may not be the most reliable outcome measure, because the frequency is low.

This review did not focus solely on studies of individuals at high-risk, such as those who had previously harmed themselves deliberately, and the targeted recruitment of such individuals may

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offer insight into the effectiveness of DBT in this patient population. In addition, studies assessing DBT in a high-risk population may reveal changes that are not observed in a mixed or low-risk population.

Overall, evidence on the use of DBT in adolescents is sparse. DBT may be effective in the treatment of suicidality in adolescents with or who are suspected to have BPD or bipolar disorder. However, more evidence is needed from higher quality studies to confirm these findings.

Review effectiveness of psychosocial interventions for suicidal adolescents

Corcoran et al, 2011 174

Both quasi-experimental and experimental designs in the published and unpublished literature were included, and a total of 17 studies were located.

According to meta-analysis, intervention group participants were slightly less likely to have suicidal and self-harm events than control group participants. However, when studies assessed outcome at a later period than immediately after intervention, experimental group participants were slightly more likely to have suicidal and self-harm events than control group participants. For studies that measured suicidal ideation at post-test, intervention group participants were slightly less likely to report suicidal ideation than control group participants, both at post-test and at follow-up.

Review effectiveness of adding psychodynamic therapy to antidepressants in patients with major depressive disorder

Jakobsen et al, 2012 175

5 trials (365 participants) were included. Four trials assessed ‘interpersonal psychotherapy’ and one trial ‘short psychodynamic supportive psychotherapy’.

Meta-analysis showed that adding psychodynamic therapy to antidepressants significantly reduced depressive symptoms on the 17-item Hamilton Rating Scale for Depression, but the possible treatment effect is small.

Review effectiveness of specific psychosocial interventions with comparison types of treatment (e.g., treatment as usual (TAU), placebo, or alternative pharmacological treatment) for children and adolescents who self-harm.

Hawton et al, 2015 176

11 trials (1,126 participants) were included. The majority of participants were female (mean = 80.6% in 10 trials reporting gender). All trials were of psychosocial interventions. With the exception of dialectical therapy for adolescents (DBT-A) and group-based therapy, assessments of specific interventions were based on single trials.

Only one therapeutic approach - mentalisation - was associated with a reduction in frequency of repetition of SH. However this effect was only modest and the trial was small, which precludes firm conclusions about the effectiveness of this treatment.

There was no clear evidence of effectiveness for compliance enhancement, individual cognitive behavioural therapy (CBT)-based psychotherapy, home-based family intervention, or provision of an emergency card, nor was there clear evidence for group therapy for adolescents with a history of multiple episodes of SH.

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Results for therapeutic assessment, mentalisation, and dialectical therapy indicated that these approaches warrant further evaluation.

Despite the scale of the problem of SH in children and adolescents there is a paucity of evidence of effective interventions. Further large-scale trials, with a range of outcome measures including adverse events, and investigation of therapeutic mechanisms underpinning these interventions, are required.

It is increasingly apparent that development of new interventions should be done in collaboration with patients to ensure that these are likely to meet their needs.

Use of an agreed set of outcome measures would assist evaluation and both comparison and meta-analysis of trials.

Review effectiveness of psychological therapies for people with borderline personality disorder

Binks et al, 2006 177

7 studies (262 people) were included.

Comparing dialectical therapy (DBT) with treatment as usual studies found no difference for the outcome of still meeting SCID-II criteria for the diagnosis of BPD by six months or admission to hospital in previous three months. Self harm or parasuicide may decrease at 6 to 12 months.

One study detected statistical difference in favour of people receiving DBT compared with those allocated to treatment as usual for average scores of suicidal ideation at 6 months.

For the outcome of interviewer-assessed alcohol free days, skewed data are reported and tend to favour DBT. When a substance abuse focused DBT was compared with comprehensive validation therapy plus 12-step substance misuse programme no clear differences were found for service outcomes.

When DBT-oriented treatment is compared with client centred therapy no differences were found for service outcomes, but fewer people in the DBT group displayed indicators of parasuicidal behaviour. There were no differences for outcomes of anxiety and depression, but people who received DBT had less general psychiatric severity than those in the control group. One study reported skewed data for suicidal ideation with considerably lower scores for people allocated to DBT.

People who received treatment in a psychoanalytic orientated day hospital were less likely to be admitted into inpatient or daypatient care when measured at different time points, and anxiety

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and depression scores were generally lower, while improvement in social adjustment was better.

Overall, this review suggests that some of the problems frequently encountered by people with borderline personality disorder may be amenable to talking/behavioural treatments but all therapies remain experimental and the studies are too few and small to inspire full confidence in their results. These findings require replication in larger 'real-world' studies.

Review impact of treatment intensity on suicidal behaviour and depression in borderline personality disorder

Davidson and Tran, 2013 178

6 trials were included (CBT for personality disorder, mentalization-based therapy, dialectical behaviour therapy). Seven measures of suicidal acts and two measures of depression were used in studies.

Both less and more intensive therapies report significant decreases in suicidal behaviours. Two follow-up studies showed that reductions in suicidal behaviour and depression are maintained over time.

Apart from one small trial, both less and more intensive therapies report decreases in depression with no differences between therapies and control conditions.

The authors conclude that both less and more intensive therapies are effective in treating depression and suicidal behaviours in patients with BPD. Clinicians should deliver the least intensive interventions that will provide these significant health gains.

Review effectiveness of psychological interventions aimed to prevent and/or treat depression in adolescents in also reducing suicidality.

Devenish et al, 2016 179

35 articles pertaining to 12 treatment trials, two selective prevention trials and two universal prevention trials met inclusion criteria.

There is evidence to suggest that CBT interventions produce pre-post reductions in suicidality with moderate effect sizes and are at least as efficacious as pharmacotherapy in reducing suicidality; however, it is unclear whether these effects are sustained.

There are several trials showing promising evidence for family-based and interpersonal therapies, with large pre-post effect sizes, and further evaluation with improved methodology is required.

Depression prevention studies demonstrated small but statistically significant reductions in suicidality.

The authors concluded that it is unclear whether psychological treatments are more effective than no treatment since no study has used a no-treatment control group. Depression prevention interventions show promising short-term effects in reducing suicidality..

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Review effectiveness of psychosocial interventions following self-harm in reducing the likelihood of subsequent suicide.

Crawford et al, 2007 180

18 studies (3918 participants) were included. Eighteen suicides occurred among people offered active treatment and 19 among those offered standard care. The overall rate of suicide among people participating in trials was similar to that reported in observational studies of people who self-harm.

Results of this meta-analysis do not provide evidence that additional psychosocial interventions following self-harm have a marked effect on the likelihood of subsequent suicide.

Review effectiveness of group cognitive therapy (GCBT) for unipolar depressive disorders.

Oei and Dingle 2008 181

4 trials were included. Effect sizes for GCBT over the control conditions range from small (0.1) to large (2.87) with the mean effect size of 1.10. The pre-post treatment effect sizes for GCBT range from 0.30 to 3.72 with a mean of 1.30. Convergent evidence was demonstrated across different outcome measures of GCBT.

Overall, findings indicated that GCBT yielded outcomes better than no-treatment controls and was comparable with other treatments (including both bona fide and non-bona fide comparison treatments). It was concluded that GCBT was effective for the treatment of Unipolar depression and thus can be used with confidence.

Review effectiveness of Cognitive-behavioural therapies (CBTs) in reducing suicide behaviour

Tarrier et al, 2008 182

28 studies were included. Overall, there was a highly significant effect for CBT in reducing suicide behaviour. Subgroup analysis indicates a significant treatment effect for adult samples (but not adolescent), for individual treatments (but not group), and for CBT when compared to minimal treatment or treatment as usual (but not when compared to another active treatment). There was evidence for treatment effects, albeit reduced, over the medium term.

The authors warned that although these results appear optimistic in advocating the use of CBT in ameliorating suicidal thoughts, plans, and behaviours, evidence of a publication bias tempers such optimism.

Review effectiveness of alternatives to inpatient mental health care for children and young people.

Shepperd et al, 2009 183

7 trials (799 participants) were included, evaluating four distinct models of care: multi-systemic therapy (MST) at home, specialist outpatient service, intensive home treatment and intensive home-based crisis intervention ('Homebuilders' model for crisis intervention).

Young people receiving home-based MST experienced some improved functioning in terms of externalising symptoms and they spent fewer days out of school and out-of-home placement. At short term follow up the control group had a greater improvement in terms of adaptability and cohesion; this was not sustained at four months follow up.

There were small, significant patient improvements reported in both groups in the trial evaluating the intensive home-based crisis intervention using the 'Homebuilders' model.

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No differences at follow up were reported in the two trials evaluating intensive home treatment, or in the trials evaluating specialist outpatient services.

The authors concluded that the quality of the evidence base currently provides very little guidance for the development of services.

Review effectiveness of psychosocial interventions for bipolar disorder.

Lolich et al, 2012 184

Cognitive-behavioural, psychoeducational, systematic care models, interpersonal and family therapy interventions were found to be empirically validated. All of them reported significant improvements in therapeutic adherence and in the patients' functionality.

Although these interventions are currently validated, their efficacy needs to be specified in relation to more precise variables such as clinical type, comorbid disorders, stages or duration of the disease. Taking into account these clinical features would enable a proper selection of the most adequate intervention according to the patient's specific characteristics.

Review effectiveness of addition of cognitive-behavioural therapy to antidepressant treatment in adolescents with unipolar depression in terms of depressive symptoms, suicidality, impairment and global improvement.

Dubicka et al, 2010 185

There was no evidence of a statistically significant benefit of combined treatment over antidepressants for depressive symptoms, suicidality and global improvement after acute treatment or at follow-up.

There was a statistically significant advantage of combined treatment for impairment in the short-term (at 12 weeks) only.

Overall, adding CBT to antidepressants confers limited advantage for the treatment of an episode of depression in adolescents. The variation in sampling and methodology between studies, as well as the small number of trials, limits the generalisability of the findings and any conclusions that can be drawn. Future studies should examine predictors of response to treatment as well as clinical components that may affect outcome.

Review effectiveness of psychotherapy for adult depression on suicidality and hopelessness.

Cuijpers et al, 2013 186

Thirteen studies (616 patients) were included, three of which examined the effects of psychotherapy for depression on suicidal ideation and suicide risk, and eleven on hopelessness. No studies were found with suicide attempts or completed suicides as the outcome variables.

The effects on suicidal ideation and suicide risk were small and not statistically significant.

The effects on hopelessness were large and significant, although heterogeneity was very high. Furthermore, significant publication bias was found. After adjustment of publication bias the effect size was reduced to g=0.60.

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Overall, there is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression. Although psychotherapy of depression may have small positive effects on suicidality, available data suggest that psychotherapy for depression cannot be considered to be a sufficient treatment. The effects on hopelessness are probably higher.

Review effectiveness of psychological therapies for people with borderline personality disorder.

Stoffers et al, 2012 187

28 studies (1804 participants) were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not. Among comprehensive psychotherapies, dialectical therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitivebehaviouraltherapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition.

There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger, parasuicidality and mental health.

There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment.

Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD.

IPT was only indicated as being effective in the treatment of associated depression.

For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.

Overall, there are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role

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for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.

Review effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents

Wethington et al, 2008 188

Meta-analyses were conducted, stratifying by traumatic exposures. Evaluated interventions were conducted in high-income economies, published up to March 2007. Subjects in studies were <or=21 years of age, exposed to individual/mass, intentional/unintentional, or manmade/natural traumatic events.

The seven evaluated interventions were individual cognitive-behavioural therapy, group cognitive behavioural therapy, play therapy, art therapy, psychodynamic therapy, and pharmacologic therapy for symptomatic children and adolescents, and psychological debriefing, regardless of symptoms.

The main outcome measures were indices of depressive disorders, anxiety and posttraumatic stress disorder, internalizing and externalizing disorders, and suicidal behaviour.

The review suggested that individual and group cognitive-behavioural therapy can decrease psychological harm among symptomatic children and adolescents exposed to trauma.

Evidence was insufficient to determine the effectiveness of play therapy, art therapy, pharmacologic therapy, psychodynamic therapy, or psychological debriefing in reducing psychological harm.

The authors concluded that personnel treating children and adolescents exposed to traumatic events should use interventions for which evidence of effectiveness is available, such as individual and group cognitive-behaviour therapy. Interventions should be adapted for use in diverse populations and settings. Research should be pursued on the effectiveness of interventions for which evidence is currently insufficient.

Review effectiveness of psychosocial treatment and interventions for bipolar disorder.

Miziou et al, 2015189

78 papers were included for the analysis. The literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and only in a selected subgroup of patients at an early stage of the disease who have very good, if not complete remission, of the acute episode.

CBT and interpersonal and social rhythms therapy could have some beneficial effect during the acute phase, but more data are needed.

Mindfulness interventions could only decrease anxiety.

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Interventions to improve neurocognition seem to be rather ineffective.

Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes.

Review effectiveness specific pharmacological, social, or psychological therapeutic interventions (TIs) in reducing both suicidal and nonsuicidal self-harm in adolescents (to age 18).

Ougrin et al, 2015 190

Therapeutic interventions (TI) to prevent self-harm appear to be effective. 19 RCTs (2,176 youth) were analyzed. TIs included psychological and social interventions but no pharmacological interventions.

The fraction of adolescents who self-harmed over the follow-up period was lower in the intervention groups vs. controls.

TIs with the largest effect sizes were dialectical behaviour therapy (DBT), cognitive-behavioural therapy (CBT), and mentalization-based therapy (MBT).

There were no independent replications of efficacy of any TI.Review and meta-analysis psychosocial and behavioural interventions aimed at preventing suicide and suicide attempts.

Meerwijk et al, 2016 191

31 studies provided post-treatment data with 6658 intervention group participants and 6711 control group participants at baseline, and 29 studies provided follow-up data.

Psychosocial and behavioural interventions that directly address suicidal thoughts and behaviours are effective immediately post-treatment and long term, whereas treatments indirectly addressing these components are only effective long term.

Moreover, although the differences shown between direct and indirect strategies were non-significant, the difference in favour of direct interventions represented a large post-treatment improvement and medium improvement at longer-term follow-up.

On the basis of these findings, clinicians working with patients at risk of suicide should address suicidal thoughts and behaviours with the patient directly. Although direct interventions are effective, they are not sufficient, and additional efforts are needed to further reduce death by suicide and suicide attempts. Continued patient contact might be necessary to retain long-term effectiveness.

Review effectiveness of psychosocial interventions in reducing suicidal behaviours among patients with

10 papers describing 11 trials targeting psychosocial interventions for reducing suicidal in patients with schizophrenia spectrum disorders and psychotic symptoms or disorders were included.

All psychosocial interventions were associated with significant decreases in their primary outcome

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schizophrenia spectrum disorders and psychosis.

Donker et al, 2013 192

measures of psychotic symptoms, insight into the illness, depression, hopelessness, substance use or overall symptomatology (e.g. mood disorders, anxiety disorders, somatoform disorders) compared to treatment as usual or over time.

Self-harm One study targeting self-harm found no significant differences (P>.05) in self-harm between the control group and intervention group for patients with schizophrenia, schizophreniform disorder or schizoaffective disorder and dependence on drug or alcohol, or alcohol misuse.. Self-harm was measured with participant psychiatric case notes on admission to hospital for a reason related to psychosis or death from any cause.

Suicidal ideation Four of the nine studies that measured suicidal ideation found significant reductions (P < .05) on at least one measurement occasion in patients with psychotic disorders. Of the remaining studies, one reported significantly increased suicidal ideation in the psychosocial intervention compared to the control group found no significant difference (P>.05) in suicidal ideation between the intervention and treatment as usual groups. In two studies, a non-significant increase was found in suicidal thoughts.

Suicide attempts The three studies examining suicidal attempts found no significant differences between the intervention group and treatment as usual on this measure.

Completed suicide There were no significant differences in completed suicides between psychosocial interventions and control groups in the eight studies which measured completed suicides as an outcome

The authors concluded that psychosocial interventions may be effective in reducing suicidal in patients with schizophrenia spectrum disorders and psychosis, although the additional benefit of these interventions above that contributed by a control condition or treatment-as-usual is not clear.

Standard treatment for known disorders

Out-patient based therapies

Review effectiveness of Problem-Solving Therapy (PST) for depression

Bell and D’Zurilla et al, 2009 193

Based on results involving 21 independent samples, PST was found to be equally effective as other psychosocial therapies and medication treatments and significantly more effective than no treatment and support/attention control groups.

Moreover, component analyses indicated that PST is more effective when the treatment program includes (a) training in a positive problem orientation (vs. problem-solving skills only), (b) training in all four major problem-solving skills (i.e., problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification), and (c) training in the

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complete PST package (problem orientation plus the four problem-solving skills).Review effectiveness of family psychosocial interventions in community settings for schizophrenia.

Pharoah et al, 2010 194

53 trials were included. The researchers did not find data to suggest that family intervention either prevents or promotes suicide.

Family intervention may reduce the number of relapse events and hospitalisations, and seems to improve general social impairment and the levels of expressed emotion within the family. However, the treatment effects of these trials may be overestimated due to the poor methodological quality.

Review clinical effectiveness of compulsory community and involuntary outpatient treatment for people with severe mental disorders.

Kisely et al, 2011 195

Two trials (416 participants) of court-ordered 'Outpatient Commitment' (OPC) were identified, from the USA.

Compulsory community treatment (CCT) results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.

Review clinical effectiveness of compulsory community and involuntary outpatient treatment for people with severe mental disorders.(Update 2011 review, above)

Kisely and Campbell, 2014 196

3 studies involved patients in community settings who were followed up over 12 months (n = 752 participants).

CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. People receiving CCT were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non-effective) as formal compulsory treatment in the community.

Review effectiveness of Motivational interviewing for alcohol misuse in young adults.

Foxcroft et al, 2014 197

66 randomised trials (17,901 participants) were included. Studies with longer-term follow-up (four plus months) were of more interest when considering the sustainability of intervention effects.

The results of this review indicate that there are no substantive, meaningful benefits of MI interventions for the prevention of alcohol misuse. Although some significant effects were found, we interpret the effect sizes as being too small, given the measurement scales used in the studies included in the review, to be of relevance to policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, heterogeneity was a problem in some analyses and bias cannot be discounted as a potential cause of these findings.

Review effectiveness of Nine studies with a total of 569 participants (290 PST, 279 control) met inclusion criteria. Most

135

problem solving therapy (PST) for the treatment of major depressive disorder in older adults.

Kirkham et al, 2016 198

studies administered PST in person and were between 6 and 12 weeks in duration.

Meta-analysis of six studies evaluating the effect of PST on depression using the Hamilton Rating Scale for Depression identified a significant reduction in depression associated with PST.. PST was also effective in reducing disability in studies reporting this outcome.

Overall, this review supports the existing research literature on PST suggesting that it is an effective treatment for older people with MDD. Further study is required to understand long-term outcomes associated with PST and its efficacy when compared to other treatments.

Review effectiveness of alcohol brief interventions (ABIs) in reducing alcohol consumption, and asses if the setting, practitioner group and content matter.

Platt et al, 2016 199

52 trials were included contributing data on 29 891 individuals.

ABIs reduced the quantity of alcohol consumed by 0.15 SDs.

While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity, but not frequency of alcohol consumption.

All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed. Effects were maintained in the stratified sensitivity analysis at the first and last assessment time.

Overall, ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.

Review effectiveness of patient-centered care (PCC) interventions for the management of alcohol use disorders.

Barrio and Gual, 2016 200

40 studies (16,020 patients) were included, involving two main categories of study: psychosocial (n=35 based on motivational interviewing) and pharmacological (n=5 based on an as needed dosing regimen).

Results from single sessions of motivational interviewing showed no clear benefit on alcohol consumption outcomes, with few studies indicating benefit of PCC versus control.

Although the results for studies of multiple sessions of counseling were also mixed, many did show a significant benefit of the PCC intervention.

By contrast, studies consistently demonstrated a benefit of pharmacologically supported PCC interventions, with most of the differences reaching statistical significance.

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Overall, evidence suggests PCC-based interventions may be beneficial for reducing alcohol consumption in people with alcohol use disorders.

Standard treatment for known disorders

Neurosurgery

No reviews were identified

Standard treatment for known disorders

ECT

No reviews were identified

Standard treatment for known disorders

Repetitive Transcranial Magnetic Stimulation (rTMS)

Review effectiveness of Repetitive Transcranial Magnetic Stimulation (rTMS) for Treatment Resistant Depression (TRD).

The Health Technology Assessment Unit, University of Calgary, 2015 201

rTMS is a non-invasive procedure in which cerebral electrical activity is influenced by a rapidly changing magnetic field. The magnetic field is created by a plastic-encased coil which is placed over the patient’s scalp.

Adults with TRD: 70 trials were included. rTMS is twice as likely to result in response and remission than a sham procedure.

Youth and young adults with TRD: 26 abstracts were reviewed in full-text and 3 cohort studies were included. The studies suggest that rTMS may be effective; however, further high quality studies are required.

Overall, in adults with TRD, rTMS is more effective than no treatment but the optimal protocol remains unclear. No statistically significant differences were found between rTMS and ECT; it is unclear which is most efficacious. The cost per QALY gained with rTMS compared to sham is $CAD 13,084 for response and $20,203 for remission. rTMS is more effective and less costly than ECT the majority of the time. The effectiveness in youth and young adult populations is uncertain.

Adherence Follow-up after discharge, and

ongoing contact

Review effectiveness of brief contact interventions for reducing self-harm, suicide attempt and suicide.

Milner et al, 2015 202

12 studies were included in the meta-analyses.

A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation.

Review effectiveness of early intervention strategies available to counsellors working with clients ‘at imminent risk’ of suicide.

It was possible to describe emergent themes and practice guidelines to assist counselors working with clients with suicidal ideation but not at imminent risk.While the review articles provided counsellors with guidelines on working with clients with suicidal ideation, they were wide-ranging principles and often applied to counseling practice in general.

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Monaghan and Harris, 2015 203A number of general themes emerged from the literature applicable to early intervention with clients who are suicidal, albeit not at imminent risk:

The value of a strong therapeutic relationship Collaborating with the client Regular risk assessments Involve social support Specific intervention styles: Three specific intervention styles (i.e., solution-focused

therapy, cognitive behavioural therapy, and dialectical behaviour therapy) were identified as appropriate for clients who have suicidal ideation but are not at imminent risk.

Future research is needed to investigate and develop techniques to be used with clients during an early stage of suicidal ideation and with clients who have a stronger trajectory of risk for suicide but have not begun to experience suicidal ideation. These tools could help to bridge the current gap between suicide prevention and crisis management.

Review effectiveness of interventions for paediatric patients with suicide-related emergency department (ED) visits

Newton et al, 2010 204

7 trials and 3 quasi experimental studies were included, grouped according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3).

An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions.

Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge.

The 3 ED transition intervention studies reported reduced risk of subsequent suicide after brief ED intervention and postdischarge contact, reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care and) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent.

Overall, transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence.

Review patient outcomes following discharge from secure psychiatric hospitals

A systematic review and meta-analysis of adverse outcomes after discharge along with a comparison with rates in other clinical and forensic groups in order to inform public health and policy.

138

Fazel et al, 2016 205 35 studies from 10 countries were included, involving 12 056 patients out of which 53% were violent offenders.

The crude death rate for all-cause mortality was 1538 per 100 000 person-years (95% CI 1175-1901). For suicide, the crude death rate was 325 per 100 000 person-years (95% CI 235-415). The readmission rate was 7208 per 100 000 person-years (95% CI 5916-8500). Crude reoffending rates were 4484 per 100 000 person-years (95% CI 3679-5287), with lower rates in more recent studies.CONCLUSIONS:There is some evidence that patients discharged from forensic psychiatric services have lower offending outcomes than many comparative groups. Services could consider improving interventions aimed at reducing premature mortality, particularly suicide, in discharged patients.

Review effectiveness of interventions to prevent repeat suicidal behaviour in patients admitted to an emergency department for a suicide attempt

Inagaki et al, 2015 206

24 trials were included and classified into four groups (11 trials in the Active contact and follow-up, nine in the Psychotherapy, one in the Pharmacotherapy, and three in the Miscellaneous).

Active contact and follow-up type interventions were effective in preventing a repeat suicide within 12 months (n=5319; pooled RR=0.83; 95% CI: 0.71 to 0.97). However, the effect at 24 months was not confirmed (n=925; pooled RR=0.98; 95% CI: 0.76-1.22). The effects of the other interventions on preventing a repetition of suicidal behaviour remain unclear.

Overall, interventions of active contact and follow-up are recommended to reduce the risk of a repeat suicide attempt at 12 months in patients admitted to EDs with a suicide attempt. However, the long-term effect was not confirmed.

Review effectiveness of psychosocial treatments for self-injurious thoughts and behaviors in youth.

Glenn et al, 2015 207

No interventions currently meet the Journal of Clinical Child and Adolescent Psychology standards for Level 1: well-established treatments.

Six treatment categories were classified as Level 2: probably efficacious or Level 3: possibly efficacious for reducing SITBs in youth. These treatments came from a variety of theoretical orientations, including cognitive-behavioral, family, interpersonal, and psychodynamic theories.

Common elements across efficacious treatments included family skills training (e.g., family communication and problem solving), parent education and training (e.g., monitoring and contingency management), and individual skills training (e.g., emotion regulation and problem solving).

Several treatments have shown potential promise for reducing SITBs in children and adolescents.

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However, the probably/possibly efficacious treatments identified each have evidence from only a single randomized controlled trial. Future research should focus on replicating studies of promising treatments, identifying active treatment ingredients, examining mediators and moderators of treatment effects, and developing brief interventions for high-risk periods (e.g., following hospital discharge).

Examine the efficacy of psychological and psychosocial interventions for reductions in repeated self-harm in adults.

Hetrick et al, 2016 208

45 trials of psychological and psychosocial interventions to prevent repeat self-harm in adults were included.

There were three main results from 36 trials: There is evidence that any kind of psychological or psychosocial intervention (when

combined) aimed at reducing a repeated episode self-harm had a protective effect that represents an important public health impact and is potentially clinically relevant at an individual level compared to any comparator condition;

There currently is no strong evidence that the type of intervention modifies overall efficacy;

There was strong evidence of benefits of any kind of psychological or psychosocial interventions on the severity of suicidal ideation, depression symptoms and hopelessness scores. The effects appear to be small, but may be clinically important.

Overall, consideration of a psychological or psychosocial intervention over and above treatment as usual is worthwhile; with the public health benefits of ensuring that this practice is widely adopted potentially worth the investment. However, the specific type and nature of the intervention that should be delivered is not yet clear. Cognitive-behavioural therapy or interventions with an interpersonal focus and targeted on the precipitants to self-harm may be the best candidates on the current evidence. Further research is required.

Review effectiveness of therapist-supported internet cognitive behavioural therapy for anxiety disorders in adults.

Olthius et al, 2016 145

38 studies (3214 participants) were included. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (5 trials), post-traumatic stress disorder (2 trials), obsessive compulsive disorder (2 trials), and specific phobia (2 trials). Eight remaining studies included a range of anxiety disorder diagnoses.

Low quality evidence from 11 studies (866 participants) showed clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only.

140

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults.

These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety.

Review efficacy and cost-effectiveness of stepped care prevention and treatment for depressive and/or anxiety disorders

Ho et al, 2016 209

Stepped care is an increasingly popular treatment model for common mental health disorders, given the large discrepancy between the demand and supply of healthcare service available.

Efficacy and cost-effectiveness of stepped care prevention and treatment was compared with care-as-usual (CAU) or waiting-list control for depressive and/or anxiety disorders.

10 randomized controlled trials were included, of which 6 examined stepped care prevention and 4 examined stepped care treatment, specifically including ones regarding depressive and/or anxiety disorders. Only trials with self-help as a treatment component were included.

Stepped care treatment revealed a significantly better performance than CAU in reducing anxiety symptoms, and the treatment response rate of anxiety disorders was significantly higher in stepped care treatment than in CAU.

No significant difference was found between stepped care prevention/treatment and CAU in preventing anxiety and/or depressive disorders and improving depressive symptoms.

In conclusion, the stepped care model appeared to be better than CAU in treating anxiety disorders. The model has the potential to reduce the burden on existing resources in mental health and increase the reach and availability of services.

AftercareService delivery/organisation and

case management

Review nurses' responses to suicide and suicidal patients.

Talseth and Gilie, 2011 210

Conceptually, four key concepts (critical reflection, attitudes, complex knowledge/professional role responsibilities, desire for support services/resources) can serve as a useful guide for nurses to understand their own and other nurses' responses to caring for suicidal patients in various settings.

Other relevant Research strategies

Identify and describe data systems that can be linked to

A systematic review, an environmental scan, and a targeted search were conducted to identify prevention studies and potentially linkable external data systems with suicide outcomes from

141

data from prevention studies to advance youth suicide prevention research.

Wilcox et al, 2016 211

January 1990 through December 2015. Studies and data systems had to be U.S.-based and include persons aged 25 years or younger. Data systems also had to include data on suicide, suicide attempt, or suicidal ideation.

Of 47 studies (described in 59 articles) identified in the systematic review, only 6 were already linked to data systems. A total of 153 unique and potentially linkable data systems were identified, but only 66 were classified as "fairly accessible" and had data dictionaries available. Of the data systems identified, 19% were established primarily for research, 11% for clinical care or operations, 29% for administrative services (such as billing), and 52% for surveillance. About one third (37%) provided national data, 12% provided regional data, 63% provided state data, and 41% provided data below the state level (some provided coverage for >1 geographic unit).

The authors concluded that there is untapped potential to evaluate and enhance suicide prevention efforts by linking suicide prevention data with existing data systems. However, sparse availability of data dictionaries and lack of adherence to standard data elements limit this potential.

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