This meta-analysis reviewed randomized controlled trials comparing suicide prevention interventions to usual care. It found that the WHO's Brief Intervention and Contact intervention was associated with significantly lower odds of death by suicide. Cognitive behavioral therapy and lithium also showed fewer suicide deaths among intervention groups, but results were not statistically significant. Overall, most psychosocial interventions and pharmacotherapies did not show clear evidence of reducing suicide risk. The study highlights the need for further research on effective prevention strategies.

1. Journal Presentation
Dr. Ahsan Aziz
Assistant registrar, NIMH.

2. Title
Strategies to prevent death by suicide:
meta-analysis of randomized controlled trials

3. Source and publication details
British Journal of Psychiatry
June, 2017 issue
Volume number 210
Page 396-402

4. Authors
Natalie B. V. Riblet, MD, MPH
Yinong Young Xu, MS, DSc
Bradley Watts, MD, MPH
Geisel School of Medicine at Dartmouth USA
Brian shiner, MD, MPH;
The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon

5. Funding
This work was supported by the VA (Veterans Affairs)
National Center for Patient Safety Center of Inquiry
Program.

6. Background
Suicide is a significant public health concern.
10th leading cause of death and 3rd among 15-24
years age group
Suicide death is associated with considerable
emotional toll on family members.

7. Background
Suicide prevention strategies include
• Antidepressants
• Mood stabilizers and anti-psychotics
• Behavioral intervention
• Safer packaging and distribution of drugs
• Depression recognition, gatekeeper education,
lethal mean restriction
• Brief psychological intervention etc.

8. Aim of the study
To identify interventions for preventing suicide which
will help to take clinical decisions about suicide
prevention.

9. Research question
Among adults 18 years and older, which interventions
that are designed to prevent death by suicide (or
suicidal behavior or ideation) have greater efficacy
than usual care condition, placebo or waitlist at
preventing death by suicide?

10. Study design
A meta-analysis of randomized controlled trials (RCTs)
comparing the efficacy of various interventions versus
control to prevent death by suicide in adults.

11. Inclusion criteria
• Randomized controlled trials
• Study population age is 18 or more than 18
• Interventions targeted to prevent death by suicide
• Control group received usual care, placebo or
waitlist
• Outcome reported as death by suicide
• Studies conducted in English language

12. Search strategies
Medline (via Ovid), the Cochrane Library, PsycINFO,
Excerpta Medica Database (EMBASE) and The
Cumulative Index to Nursing and Allied Health
Literature (CINAHL)
Suicide, prevention, control, treatment and RCT were
common search terms.

13. Data collection

14. Data analysis
Primary outcome is evaluated using the Peto method
and calculated as odds ratios (ORs) with 95%
confidence intervals and P-values.
Groupings for heterogeneity was assessed using
Cochrane’s Q and the I² statistic. Conventional
threshold of P<0.10 and I²>50% were used to indicate
statistical significance and meaningful heterogeneity
respectively.

15. Data analysis
Confirmatory analysis was done by Poisson regression
model with intervention effects.
A modified linear regression analysis (STATA) to
identify significant funnel plot asymmetry which
would indicate publication bias.

16. Results

17. Results (Effects of complex
psychosocial interventions)
29 RCTs.
In the three trials of the WHO brief intervention and
contact (BIC) intervention, 3 out of 1041 patients in
the intervention group and 24 out of 987 patients in
the control group died by suicide.
The difference was significant (OR = 0.20, 95% CI 0.09–
0.42, P<0.0001)

18. Results in table
Complex psychosocial interventions
Intervention domain N IRR 95% CI
Total complex psychosocial
intervention
29 0.93 0.65-1.33
Intensive follow up program 11 0.71 0.34-1.48
Comprehensive follow up
program
5 0.30 0.07-1.22
Case management after
suicidal behavior
4 0.93 0.56-1.54
Case management for
psychosis
4 1.16 0.50-2.55
Letter /Phone contact 7 1.16 0.75-1.79

19. Results (Effects of psychotherapy)
A total of 24 RCTs.
In six trials of CBT for suicide prevention, 3 out of 514
patients in the intervention group and 10 out of 526
patients in the control group died by suicide.
The results, however, were not statistically significant
(OR = 0.34, 95% CI 0.12–1.03, P = 0.06; IRR = 0.30, 95%
CI 0.08–1.11, P= 0.07)

20. Results
Psychotherapy
Intervention domain N IRR 95% CI
CBT-Suicide prevention 6 0.30 0.08-1.11
CBT-Psychosis 3 OR-1.92 P=0.43
CBT-Personality disorder 3 OR-1.23 P=0.54
CBT-Substance abuse 1 No event
DBT-Personality disorder 3 OR-6.80
Problem solving therapy 4 1.00 0.25-4.04
Non-cognitive behavior therapy 5 1.10 0.27-4.38

21. Results (Effects of pharmacotherapy)
14 RCTs on pharmacotherapy. (Lithium, Clozapine,
Anti-psychotics and Anti-depressants)
After accounting for random effects and length of
follow-up, there was no evidence among the pooled
trials that pharmacotherapy reduced the risk of
suicide (OR = 0.21, 95% CI 0.05–0.86; IRR = 0.10, 95%
CI 0.00–32.27)

22. Results
Pharmacotherapy
Intervention domain N OR 95% CI
Anti-depressant 7 0.13 0.00-6.67
Lithium 6 0.23 0.05-1.02
Omega-3-fatty acid 1 No event

23. Results (Other interventions)
Partial hospital admission (2 trials, n=432; OR=0.36,
95% CI 0.07–1.86, P>0.10).
Somatic therapies such as electroconvulsive therapy
(2 trials, n=92; OR=0.14, 95% CI 0.00–6.82, P>0.10).

24. Discussion (Summary of main result )
WHO’s BIC intervention associated with significantly
lower odds of death.
Lithium and CBT showed fewer deaths by suicide
among the intervention groups than the controls. But
authors were unable to draw any definitive
conclusions, as the confidence interval for the
summary estimates spanned no difference.

25. Discussion (Comparison with other
studies)
Other reviews have suggested that CBT for suicide
prevention may prevent suicidal behaviour in high-risk
populations. This study found that CBT-based
therapies were associated with lower odds of suicide,
but the results were not significant.
Unlike prior reviews, this study found no evidence
that problem-solving therapy or dialectical behaviour
therapy reduce the risk of suicide.

26. Discussion (Comparison with other
studies)
Consistent with others, this review found that most
psychosocial interventions were ineffective.
Unlike Mann et al and Zalsman et al this study found
that there was strong evidence that the WHO BIC
programme was associated with significantly lower
odds of suicide.

27. Discussion (Comparison with other
studies)
Zalsman et al reported that antidepressants reduced
the risk of suicide in adults, this article did not
replicate this finding.
Unlike previous reviews this review did not find that
lithium significantly reduced suicide.
Mann et al and Zalsman et al concluded that clozapine
has an anti-suicidal effect, this study could not
replicate this finding.

28. Discussion (Comparison with other
studies)
Many reviews stress the role of restricting access to
lethal methods in suicide prevention (Gun control,
Storage box for pesticides). This review was unable to
systematically study this type of intervention because
only one study met the inclusion criteria.
Zalsman et al concluded that other strategies such as
screening programs and media education have some
roles. This study was unable to assess these strategies
because no studies met the inclusion criteria.

29. Discussion (Meaning and implication)
The WHO BIC intervention was associated with
significantly lower odds of suicide, but is important to
test this strategy in other populations (developed
countries).
Findings do not suggest that lithium or CBT for suicide
prevention cause harm, but they also do not provide
clear evidence of effectiveness. Findings suggest the
need for further study of these interventions.

30. Strength of the study
Rigorous search of the literature.
Focus on death by suicide rather than suicidal plan,
attempt or self-harm which can be viewed as an
strength.
RCTs are the highest quality study design and the gold
standard for evaluating the efficacy of an
intervention.
50% of the articles come from research of last 10 yrs.

31. Weakness of the study
Owing to the small sample sizes, precision around the
summary estimate of the effect size, limited the
evaluation of some interventions.
Analysis did not include patient-level data, so unable
to explore potential moderators or mediators of the
efficacy of suicide prevention interventions.
RCTs are not ideal for rare outcome like death by
suicide.

32. Critical review…selection of the article
• Suicide is a global health problem.
• Article is a new one.
• This topic wasn’t discussed before.
• It is a systemic review. Comes from a credible
source.
• Intervention strategy (BIC) is important for low
resource country like Bangladesh.
• Further research can be done in our hospital facility.

33. Critical review…Source of article
Collected from British journal of psychiatry, it has
currently an impact factor of 7.06.
Article is cited 2 times.

34. Critical review…Funding
Funded by an organization related to veterans affairs
in USA. No conflict of interest declared.

35. Critical review…Title
Title fits the objective of the article; describes what is
the problem and how it is approached.
It is not unnecessarily long; related to the content of
the article.

36. Critical review…Methodology..Design..
Population..
• Systematic review of RCT is the highest quality
research.
• RCT is difficult to design for rare outcomes;
however best for intervention strategy.
• Articles are chosen following PRISMA guideline.
• Study population don’t contain population below
18.
• Patient characteristics are not included in the study.

37. Critical review…Methodology..Design..
Population..
• Outline of the article is rational.
• Statistical analysis appears rational and sound.
• Ethical issue maintained.

38. Critical review…Biases
Publication bias was addressed and assessed by
Harbord’s modified test.
Sensitivity analysis was judged by the Cochrane Risk
of Bias Tool.

39. Critical review…Result
Result is consistent with the objective of the study
and answers research question. Result is statistically
expressed.

40. Critical review…What is missing
This article failed to point out which intervention is
good for which patient group.
Ignored child and adolescent suicide.

41. Home message
Brief Intervention and Contact (BIC) is good for low
resource countries. Government should put emphasis
on BIC training of primary health care workers.
This study contradicts some of the findings of few well
cited studies. So more research is needed in suicide
prevention strategies for the optimum clinical benefit
of patient groups.

42. Further Recommendations
• Suicide prevention strategies: a systematic review.
JAMA 2005; 294: 2064–74; Mann JJ et al.
• Suicide prevention strategies revisited: 10-year
systematic review. Lancet Psychiatry 2016; 3: 646–
59. Zalsman G et al.

43. Thank You