Article summary of Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis by Meerwijk a.o. - 2016

What is this article about?

This article focuses on comparing the effectiveness of direct treatments which directly address suicidal thoughts and behaviors versus indirect treatments which address only the associated symptoms, like hopelessness, depression, anxiety, quality of life.

In the USA prevalence of suicide have been steadily rising. Efforts to prevent suicide have often fallen short, necessitating a reevaluation of intervention strategies. Most individuals who die by suicide have underlying mental health disorders, offering an opportunity to address suicidal thoughts and behaviors during treatment. However, existing meta-analyses often combine outcomes such as suicide attempts with proxy measures like suicidal ideation, reducing their reliability. To address this gap, this study conducted a systematic review and meta-analysis of psychosocial and behavioral interventions specifically targeting suicide or mental illness associated with suicide.

What methods are used?

For this systematic review and meta-analysis a search on various databases and sources was conducted without language or publication year restrictions up to 2015. Eligible studies were screened for inclusion and data extraction and verification were conducted independently to ensure accuracy. The search focused on randomized controlled trials reporting suicides or suicide attempts as outcomes, excluding certain treatments and trials with zero reported suicides or attempts.

Random-effects meta-analyses were performed, comparing direct and indirect treatments separately, with post-hoc subgroup analyses conducted to assess specific intervention effects.

What are the results?

44 studies with a total of 12.349 participants across immediate post-treatment and longer-term follow-up assessments were included in this study. The majority of studies focused on individuals at risk of suicide due to suicidal behavior or mental illness associated with increased suicide risk.

What type of treatments were used?

Most direct treatments were based on cognitive or dialectical behavior therapy. Of the indirect treatments four types could be identified:

1. Skill development, like problem solving and social skills
2. Active outreach, like home visits and phone calls for support
3. Psychotherapy, like cognitive behavior therapy
4. Case management services

Control groups mostly received some form of usual care, while a few received alternative interventions.

Which treatments are effective in reducing suicide?

Results show direct treatments significantly decrease suicide compared to control groups both post-treatment and at follow-up. For indirect treatments results showed no significant differences compared to controls at post-treatment, but did show significant decreases compared to controls at follow-up. Of all indirect treatments only active outreach showed a significant effectiveness to reduce suicide. Furthermore, when comparing direct treatments to indirect treatments results showed no significant differences in effectiveness both at post-treatment and at follow-up.

Incomplete data both post-treatment and at follow-up are the most common potential bias sources in this study. For studies examing direct interventions at post-treatment publication bias could be present. 

Wat is the conclusion?

Direct treatments, like dialectical or cognitive behavior therapy, are significantly effective in reducing (the likelihood of) suicide both immediately post-treatment as well as long term. However, indirect treatments, like active outreach and skill development, are mainly effective in the long term. Active outreach in particular seems to be effective both immediately post-treatment as well as long term.

Although differences between direct and indirect strategies were not statistically significant, direct interventions showed substantial improvement post-treatment and moderate improvement at longer-term follow-up.

What are limitations of this article?

The following limitations of this article are identified:

1. The analysis primarily focused on preventing suicide and suicide attempts, potentially overlooking interventions that could have beneficial effects on associated clinical symptoms beyond the scope of this study.
2. Various diagnostic groups were included, but intervention effectiveness might vary across different disorders.
3. No significant differences in medication status between direct and indirect treatments was found, but the potential influence of medication on suicidal behavior in studies lacking medication data cannot be ruled out. This could lead to biases, as psychosocial and behavioral interventions might influence medication use differently between control and intervention groups.
4. Variability in control group interventions across studies could have influenced results, especially considering that some studies used alternative interventions for comparison rather than usual care.
5. Approximately half of the studies reported over 10% incomplete data due to attrition, which might result in bias in the results.

What should future research focus on?

Future research should focus on standardizing the report of the number of suicide attempts besides the number of suicides during a treatment to more accurately examine the effectiveness of a treatment.

What is the take-home message?

Prioritizing psychosocial and behavioral treatments that directly address suicidal thoughts and behaviors is crucial. Complementary efforts, such as active outreach, may further strengthen prevention initiatives, ultimately advancing the goal of reducing suicide and suicide attempts within the communities.