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Meta-Analysis
. 2025 Jan 1;82(1):31-37.
doi: 10.1001/jamapsychiatry.2024.2854.

Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis

Wouter van Ballegooijen  1   2 , Josine Rawee  3 , Christina Palantza  4 , Clara Miguel  2 , Mathias Harrer  5 , Ioana Cristea  6 , Remco de Winter  2   7   8 , Renske Gilissen  3 , Merijn Eikelenboom  9 , Aartjan Beekman  9 , Pim Cuijpers  2
Affiliations
Meta-Analysis

Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis

Wouter van Ballegooijen et al. JAMA Psychiatry. .

Abstract

Importance: Suicidal ideation and suicide attempts are debilitating mental health problems that are often treated with indirect psychotherapy (ie, psychotherapy that focuses on other mental health problems, such as depression or personality disorders). The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts.

Objective: To investigate the effect sizes of direct and indirect psychotherapy on suicidal ideation and the incidence of suicide attempts.

Data sources: PubMed, Embase, PsycInfo, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up until April 1, 2023.

Study selection: Randomized clinical trials of psychotherapy for any mental health problem, delivered in any setting, compared with any control group, and reporting suicidal ideation or suicide attempts were included. Studies measuring suicidal ideation with 1 item were excluded.

Data extraction and synthesis: PRISMA guidelines were followed. Summary data were extracted by 2 independent researchers and pooled using 3-level meta-analyses.

Main outcomes and measures: Hedges g was pooled for suicidal ideation and relative risk (RR) was pooled for suicide attempts.

Results: Of 15 006 studies identified, 147 comprising 193 comparisons and 11 001 participants were included. Direct and indirect psychotherapy conditions were associated with reduced suicidal ideation (direct: g, -0.39; 95% CI, -0.53 to -0.24; I2, 83.2; indirect: g, -0.30; 95% CI, -0.42 to -0.18; I2, 52.2). Direct and indirect psychotherapy conditions were also associated with reduced suicide attempts (direct: RR, 0.72; 95% CI, 0.62 to 0.84; I2, 40.5; indirect: RR, 0.68; 95% CI, 0.48 to 0.95; I2, 0). Sensitivity analyses largely confirmed these results.

Conclusions and relevance: Direct and indirect interventions had similar effect sizes for reducing suicidal ideation and suicide attempts. Suicide prevention strategies could make greater use of indirect treatments to provide effective interventions for people who would not likely seek treatment for suicidal ideation or self-harm.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Rawee reported grants from the government of the Netherlands received by 113 Zelfmoordpreventie (113 Suicide Prevention) during the conduct of the study. Dr Harrer reported being a part-time employee of Get.On Institut GbmH/HelloBetter, a company that implements digital mental health interventions in routine care. Dr Gilissen reported grants from the Ministry of Health, Welfare and Sport during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. PRISMA Flow Diagram
See this image and copyright information in PMC

References

    1. Global Burden of Disease Collaborative Network . Global burden of disease study 2019 results. Accessed December 17, 2023. https://vizhub.healthdata.org/gbd-results/
    1. World Health Organization . Suicide data. 2021. Accessed December 10, 2023. https://www.who.int/teams/mental-health-and-substance-use/data-research/...
    1. De Leo D, Goodfellow B, Silverman M, et al. International study of definitions of English-language terms for suicidal behaviours: a survey exploring preferred terminology. BMJ Open. 2021;11(2):e043409. doi: 10.1136/bmjopen-2020-043409 - DOI - PMC - PubMed
    1. Goldman-Mellor SJ, Caspi A, Harrington H, et al. Suicide attempt in young people: a signal for long-term health care and social needs. JAMA Psychiatry. 2014;71(2):119-127. doi: 10.1001/jamapsychiatry.2013.2803 - DOI - PMC - PubMed
    1. Nock MK, Borges G, Bromet EJ, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192(2):98-105. doi: 10.1192/bjp.bp.107.040113 - DOI - PMC - PubMed

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