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A Systematic Review

J. John Mann, MD; Alan Apter, MD; Jose Bertolote, MD; Annette Beautrais, PhD; Dianne Currier, PhD; Ann Haas, PhD; Ulrich Hegerl, MD; Jouko Lonnqvist, MD; Kevin Malone, MD; Andrej Marusic, MD, PhD; Lars Mehlum, MD; George Patton, MD; Michael Phillips, MD; Wolfgang Rutz, MD; Zoltan Rihmer, MD, PhD, DSc; Armin Schmidtke, MD, PhD; David Shaffer, MD; Morton Silverman, MD; Yoshitomo Takahashi, MD; Airi Varnik, MD; Danuta Wasserman, MD; Paul Yip, PhD; Herbert Hendin, MD

JAMA. 2005;294:2064-2074.

Context  In 2002, an estimated 877 000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.

Objectives  To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.

Data Sources and Study Selection  Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.

Data Extraction  Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.

Data Synthesis  Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.

Conclusions  Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

Author Affiliations: New York State Psychiatric Institute, Division of Neuroscience (Drs Mann and Currier) and Division of Child psychiatry (Dr Schaffer), Department of Psychiatry, Columbia University, New York; Department of Psychiatry, Schneiders Childrens Medical Center of Israel (Dr Apter); Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland (Dr Bertolote); Canterbury Suicide Project, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand (Dr Beautrais); American Foundation for Suicide Prevention, New York, NY (Drs Haas and Hendin); Department of Psychiatry, Ludwig-Maximilians-Universität, Munich, Germany (Dr Hegerl); Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland (Dr Lonnqvist); Department of Psychiatry & Mental Health Research, St Vincents University Hospital, Dublin, Ireland (Dr Malone); Institute of Public Health of the Republic of Slovenia, Ljubjana, Slovenia (Dr Marusic); Suicide Research and Prevention Unit, University of Oslo, Oslo, Norway (Dr Mehlum); Centre for Adolescent Health, University of Melbourne, Melbourne, Australia (Dr Patton); Beijing Suicide Research and Prevention Center, Beijing, China (Dr Phillips); Division of Psychiatry, Unit for Social Psychiatry and Health Promotion, Academic University Hospital, Uppsala, Sweden (Dr Rutz); National Institute for Psychiatry and Neurology, Budapest, Hungary (Dr Rihmer); Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany (Dr Schmidtke); National Suicide Prevention Technical Resource Center, Centers for Disease Prevention and Control, Newton, Mass (Dr Silverman); Division of Behavior Sciences, National Defense Medical College Research Institute, Tokyo, Japan (Dr Takahashi); Estonian-Swedish Suicidology Institute, Center Behavior and Health Science, Tallinn, Estonia (Dr Varnik); Department of Public Health Sciences at Karolinska Institute, Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health, Stockholm, Sweden (Dr Wasserman); and Hong Kong Jockey Club Center for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Dr Yip).

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