Association of Suicide Prevention Interventions With Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systematic Review and Meta-analysis

Abstract

Importance: To prevent suicide deaths, acute care settings need tools to ensure individuals at risk of suicide access mental health care and remain safe until they do so.

Objective: To examine the association of brief acute care suicide prevention interventions with patients' subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up.

Data sources: Ovid MEDLINE, Scopus, CINAHL, PsychINFO, Embase, and references of included studies using concepts of suicide, prevention, and clinical trial to identify relevant articles published January 2000 to May 2019.

Study selection: Studies describing clinical trials of single-encounter suicide prevention interventions were included. Two reviewers independently reviewed all articles to determine eligibility for study inclusion.

Data extraction and synthesis: Two reviewers independently abstracted data according to PRISMA guidelines and assessed studies' risk of bias using the Cochrane Risk of Bias tool. Data were pooled for each outcome using random-effects models. Small study effects including publication bias were assessed using Peter and Egger regression tests.

Main outcomes and measures: Three primary outcomes were examined: subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up. Suicide attempts and linkage to follow-up care were measured using validated patient self-report measures and medical record review; odds ratios and Hedges g standardized mean differences were pooled to estimate effect sizes. Depression symptoms were measured 2 to 3 months after the encounter using validated self-report measures, and pooled Hedges g standardized mean differences were used to estimate effect sizes.

Results: A total of 14 studies, representing outcomes for 4270 patients, were included. Pooled-effect estimates showed that brief suicide prevention interventions were associated with reduced subsequent suicide attempts (pooled odds ratio, 0.69; 95% CI, 0.53-0.89), increased linkage to follow-up (pooled odds ratio, 3.04; 95% CI, 1.79-5.17) but were not associated with reduced depression symptoms (Hedges g = 0.28 [95% CI, -0.02 to 0.59).

Conclusions and relevance: In this meta-analysis, breif suicide prevention interventions were associated with reduced subsequent suicide attempts. Suicide prevention interventions delivered in a single in-person encounter may be effective at reducing subsequent suicide attempts and ensuring that patients engage in follow-up mental health care.

Figure 1.. PRISMA Flow Diagram

Figure 2.. Forest Plots for 3 Study Outcomes: Depression, Linkage to Follow-up Care, and Subsequent Suicide Attempts

Studies were weighted according to sample size using random effects models. The vertical line shows the pooled odds ratio across all 3 outcomes. The boxes vary in size according to the weight of each study (proportional to the study’s sample size), and horizontal black lines represent the confidence intervals for each study. The diamond at the bottom of each outcome plot represents the pooled odds ratio and CI for the individual outcome.

Figure 3.. Contour-Enhanced Funnel Plots for 3 Study Outcomes: Depression, Linkage to Follow-up Care, and Subsequent Suicide Attempts

The vertical axis shows the standard error of the natural logarithm of the effect size for each study, and the horizontal axis shows the natural logarithm of the effect size of each study. If no publication bias is present, dots are expected to be distributed symmetrically.