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Safety planning-type interventions (SPTIs) for patients at risk of suicide are often used in clinical practice, but it is unclear whether these interventions are effective.
This article reports on a meta-analysis of studies that have evaluated the effectiveness of SPTIs in reducing suicidal behaviour and ideation.
We searched Medline, EMBASE, PsycINFO, Web of Science and Scopus from their inception to 9 December 2019, for studies that compared an SPTI with a control condition and had suicidal behaviour or ideation as outcomes. Two researchers independently extracted the data. To assess suicidal behaviour, we used a random-effects model of relative risk based on a pooled measure of suicidal behaviour. For suicidal ideation, we calculated effect sizes with Hedges’ g. The study was registered at PROSPERO (registration number CRD42020129185).
Of 1816 unique abstracts screened, 6 studies with 3536 participants were eligible for analysis. The relative risk of suicidal behaviour among patients who received an SPTI compared with control was 0.570 (95% CI 0.408–0.795, P = 0.001; number needed to treat, 16). No significant effect was found for suicidal ideation.
To our knowledge, this is the first study to report a meta-analysis on SPTIs for suicide prevention. Results support the use of SPTIs to help preventing suicidal behaviour and the inclusion of SPTIs in clinical guidelines for suicide prevention. We found no evidence for an effect of SPTIs on suicidal ideation, and other interventions may be needed for this purpose.
Evidence-based theoretical models outlining the pathways to the development of suicidal ideation may inform treatment. The current research draws from the Interpersonal Theory of Suicide (IPT) and the Integrated Motivational-Volitional (IMV) Model of suicidal behaviour and aims to test the interaction between perceived burdensomeness and thwarted belongingness as proposed by the IPT model, and the defeat-entrapment pathway as proposed by the IMV model, in the prediction of suicidal ideation at 12-month follow-up.
The Scottish Wellbeing Study is a nationally representative prospective study of young people aged 18–34 years (n = 3508) from across Scotland, who completed a baseline interview and a 12-month follow-up (n = 2420). The core factors from both the IPT (perceived burdensomeness and thwarted belongingness) and the IMV model (defeat, internal and external entrapment) were measured alongside demographics, depressive symptoms and suicidal ideation at baseline. At 12-month follow-up, suicidal ideation was assessed again.
In multiple regression analysis perceived burdensomeness and internal entrapment, with baseline suicidal ideation, predicted 12-month suicidal ideation. No support for the interaction between perceived burdensomeness and thwarted belongingness in predicting 12-month suicidal ideation was found. However, there was evidence that internal, but not external, entrapment mediated the relationship between defeat and 12-month suicidal ideation, but no support was found for the moderation of burdensomeness and belongingness on the entrapment to suicidal ideation pathway.
The current findings highlight the importance of targeting perceived burdensomeness and internal entrapment to reduce the likelihood that suicidal ideation emerges in at risk individuals.
Although research has identified a wide range of risk factors for suicidal behavior in prisoners, it does not establish who is most likely to act on their suicidal thoughts while incarcerated.
Self-report data were collected from a random sample of 1,203 adult men incarcerated across 15 prisons in Belgium, who represent 12% of all male prisoners nationwide.
One-third (33%) of participants reported having suicidal thoughts during their incarceration, of whom 26% attempted suicide in prison (9% of all prisoners). Factors independently associated with suicide attempt among prisoners with suicidal ideation were violent offending (adjusted odds ratio [aOR] = 2.64, 95% confidence interval [CI] 1.33–5.23), in-prison drug use (aOR = 2.30, 95% CI 1.25–4.22), exposure to suicidal behavior (aOR = 1.96, 95% CI 1.04–3.68), and a lifetime history of nonsuicidal self-injury (aOR = 1.90, 95% CI 1.08–3.36). While related to suicidal thoughts, markers of psychiatric morbidity and aspects of the prison regime were not associated with the progression to suicide attempt.
Many prisoners who think about suicide do not attempt suicide while incarcerated. Factors associated with suicidal ideation are distinct from those that govern the transition to suicidal behavior. Our findings lend support to the hypothesis that behavioral disinhibition might act as a catalyst in the translation of suicidal thoughts into action.
The effects of coronavirus disease 2019 (COVID-19) on the population's mental health and well-being are likely to be profound and long lasting.
To investigate the trajectory of mental health and well-being during the first 6 weeks of lockdown in adults in the UK.
A quota survey design and a sampling frame that permitted recruitment of a national sample was employed. Findings for waves 1 (31 March to 9 April 2020), 2 (10 April to 27 April 2020) and 3 (28 April to 11 May 2020) are reported here. A range of mental health factors was assessed: pre-existing mental health problems, suicide attempts and self-harm, suicidal ideation, depression, anxiety, defeat, entrapment, mental well-being and loneliness.
A total of 3077 adults in the UK completed the survey at wave 1. Suicidal ideation increased over time. Symptoms of anxiety, and levels of defeat and entrapment decreased across waves whereas levels of depressive symptoms did not change significantly. Positive well-being also increased. Levels of loneliness did not change significantly over waves. Subgroup analyses showed that women, young people (18–29 years), those from more socially disadvantaged backgrounds and those with pre-existing mental health problems have worse mental health outcomes during the pandemic across most factors.
The mental health and well-being of the UK adult population appears to have been affected in the initial phase of the COVID-19 pandemic. The increasing rates of suicidal thoughts across waves, especially among young adults, are concerning.
The effects of the COVID-19 pandemic on population mental health are unknown. We need to understand the scale of any such impact in different sections of the population, who is most affected and how best to mitigate, prevent and treat any excess morbidity. We propose a coordinated and interdisciplinary mental health science response.
Many people who consider suicide do not translate these intentions into action. Although prisoners constitute a particularly high-risk group for suicide, little is known about the factors that distinguish those who think about suicide from those who attempt suicide.
Participants were 1326 adult offenders (1203 men) randomly selected from 15 Belgian prisons, representing 14% of the national prison population. Multivariate regression analysis compared prisoners who attempted suicide (n = 277) with those who thought about suicide but never made an attempt (n = 312) on a range of established risk factors.
Among the 589 participants reporting a lifetime history of suicidal ideation (44% of the total sample), almost half (47%) had made a suicide attempt. Relative to those who only thought about suicide, participants who attempted suicide were more likely to be violent offenders (aOR 2.33, 95% CI 1.49–3.62) and have a history of non-suicidal self-injury (aOR 3.19, 95% CI 2.09–4.86). The presence of self-reported mental disorder diagnosis (aOR = 2.84, 95% CI 1.91–4.24) and illicit substance abuse (aOR = 2.01, 95% CI 1.24–3.28) also independently differentiated prisoners who attempted v. considered suicide.
This study provides preliminary evidence that behavioural and mental health factors are implicated in the transition from thoughts to acts of suicide in prisoners. Prospective studies are warranted to explore whether these risk factors predict progression from ideation to action over time.
Suicide attempts and non-suicidal self-harm (NSSH) are major public health concerns that affect millions of young people worldwide. Consequently, there is a strong need for up-to-date epidemiological data in this population.
To provide prevalence and trend estimates of suicidal thoughts and behaviours and NSSH thoughts and behaviour in university students.
Data are from a 2018 national health survey for higher education in Norway. A total of 50 054 full-time students (69.1% women) aged 18–35 years participated (response rate 31%). Suicidal ideation, suicide attempts and NSSH were assessed with three items drawn from the Adult Psychiatric Morbidity Survey, and thoughts of NSSH were assessed with one item from the Child and Adolescent Self-Harm in Europe study.
Lifetime suicidal thoughts were reported by 21.0%, and 7.2% reported having such thoughts within the past year. In total, 4.2% reported a suicide attempt, of whom 0.4% reported attempting suicide within the past year. The prevalence of lifetime NSSH behaviour and thoughts was 19.6% and 22.6%, respectively. All four suicidal behaviour and NSSH variables were more common among students who were single, living alone and with a low annual income, as well as among immigrants. There was an increase in suicidal thoughts from 2010 (7.7%) to 2018 (11.4%), which was evident in both men and women.
The observed high and increasing prevalence of suicidal thoughts and NSSH among college and university students is alarming, underscoring the need for further research, preferably registry-linked studies, to confirm whether the reported prevalence is representative of the student population as a whole.
There are few prevalence studies of suicide attempts and non-suicidal self-harm (NSSH).
We aimed to estimate the prevalence of thoughts of NSSH, suicidal thoughts, NSSH and suicide attempts among 18- to 34-year-olds in Scotland.
We interviewed a representative sample of young adults from across Scotland.
We interviewed 3508 young people; 11.3 and 16.2% reported a lifetime history of suicide attempts and NSSH, respectively. The first episode of NSSH tended to precede the first suicide attempt by about 2 years. Age at onset of NSSH and suicide attempt was younger in females. Earlier age at onset was associated with more frequent NSSH/suicide attempts. Women are significantly more likely to report NSSH and suicide attempts compared with men.
One in nine young people has attempted suicide and one in six has engaged in NSSH. Clinicians should be vigilant, as suicide attempts and NSSH are relatively common.
Suicidal behaviour is the end result of the complex relation between many factors which are biological, psychological and environmental in nature. Network analysis is a novel method that may help us better understand the complex association between different factors.
To examine the relationship between suicidal symptoms as assessed by the Beck Scale for Suicide Ideation and future suicidal behaviour in patients admitted to hospital following a suicide attempt, using network analysis.
Secondary analysis was conducted on previously collected data from a sample of 366 patients who were admitted to a Scottish hospital following a suicide attempt. Network models were estimated to visualise and test the association between baseline symptom network structure and suicidal behaviour at 15-month follow-up.
Network analysis showed that the desire for an active attempt was found to be the most central, strongly related suicide symptom. Of the 19 suicide symptoms that were assessed at baseline, 10 symptoms were directly related to repeat suicidal behaviour. When comparing baseline network structure of repeaters (n=94) with the network of non-repeaters (n=272), no significant differences were found.
Network analysis can help us better understand suicidal behaviour by visualising the complex relation between relevant symptoms and by indicating which symptoms are most central within the network. These insights have theoretical implications as well as informing the assessment and treatment of suicidal behaviour.
People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex.
To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm.
We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable.
Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the metaanalysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38–2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91–3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16–3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70–2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%.
The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.
Implementation intentions link triggers for self-harm with coping skills
and appear to create an automatic tendency to invoke coping responses
when faced with a triggering situation.
To test the effectiveness of implementation intentions in reducing
suicidal ideation and behaviour in a high-risk group.
Two hundred and twenty-six patients who had self-harmed were randomised
to: (a) forming implementation intentions with a ‘volitional help sheet’;
(b) self-generating implementation intentions without help; or (c)
thinking about triggers and coping, but not forming implementation
intentions. We measured self-reported suicidal ideation and behaviour,
threats of suicide and likelihood of future suicide attempt at baseline
and then again at the 3-month follow-up.
All suicide-related outcome measures were significantly lower at
follow-up among patients forming implementation intentions compared with
those in the control condition (ds>0.35). The
volitional help sheet resulted in fewer suicide threats
(d = 0.59) and lowered the likelihood of future
suicide attempts (d = 0.29) compared with patients who
self-generated implementation intentions.
Implementation intention-based interventions, particularly when supported
by a volitional help sheet, show promise in reducing future suicidal
ideation and behaviour.
Although self-harm and sleep problems are major public health problems in
adolescence, detailed epidemiological assessment is essential to
understand the nature of this relationship.
To conduct a detailed assessment of the relationship between sleep and
self-harm in adolescence.
A large population-based study in Norway surveyed 10 220 adolescents aged
16–19 years on mental health, including a comprehensive assessment of
sleep and self-harm.
Adolescents with sleep problems were significantly more likely to report
self-harm than those without sleep problems. Insomnia, short sleep
duration, long sleep onset latency, wake after sleep on set as well as
large differences between weekdays versus weekends, yielded higher odds
of self-harm consistent with a dose–response relationship. Depressive
symptoms accounted for some, but not all, of this association.
The findings highlight a strong relationship between sleep problems and
self-harm. Interventions to reduce adolescent self-harm ought to
incorporate sleep problems as a treatment target.
Non-suicidal self-injury (NSSI) is a term that is becoming popular
especially in North America and it has been proposed as a new diagnosis in
DSM-5. In this paper we consider what self-harm research can tell us about
the concept of NSSI and examine the potential pitfalls of introducing NSSI
into clinical practice.
Adolescent self-harm is a major public health concern, yet little is known about the factors that distinguish adolescents who think about self-harm but do not act on these thoughts from those who act on such thoughts.
Within a new theoretical model, the integrated motivational–volitional model, we investigated factors associated with adolescents having thoughts of self-harm (ideators) v. those associated with self-harm enaction (enactors).
Observational study of school pupils employing an anonymous self-report survey to compare three groups of adolescents: self-harm enactors (n = 628) v. self-harm ideators (n = 675) v. those without any self-harm history (n = 4219).
Enactors differed from ideators on all of the volitional factors. Relative to ideators, enactors were more likely to have a family member/close friend who had self-harmed, more likely to think that their peers engaged in self-harm and they were more impulsive than the ideators. Enactors also reported more life stress than ideators. Conversely, the two self-harm groups did not differ on any of the variables associated with the development of self-harm thoughts.
As more adolescents think about self-harm than engage in it, a better understanding of the factors that govern behavioural enaction is crucial in the effective assessment of the risk of self-harm.
The suicide rate in Scotland is twice as high as that in England. However, the prevalence of self-harm is unknown.
To determine the prevalence of self-harm in adolescents in Scotland and the factors associated with it.
A total of 2008 pupils aged 15–16 years completed an anonymous lifestyle and coping survey. Information was obtained on demographic characteristics, lifestyle, life events and problems, social influences, psychological variables and self-harm.
Self-harm was reported by 13.8% of the respondents. The majority (71%) of those who had self-harmed had done so in the past 12 months and girls were approximately 3.4 times more likely to report self-harm than boys. In multivariate analyses, smoking, bullying, worries about sexual orientation, self-harm by family and anxiety were associated with self-harm in both genders. In addition, drug use, physical abuse, serious boy/girlfriend problems, self-harm by friends and low levels of optimism were also associated with self-harm in girls.
Despite markedly different national suicide rates, the prevalence of self-harm in Scotland is similar to that in England with girls at least three times more likely to report self-harm than boys. The findings suggest a role for emotional literacy programmes in schools and highlight the importance of promoting positive mental health among adolescents.
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