Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

March 2012

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, M.D., M.C.R., Director

Suicide Prevention Interventions 

and Referral/Follow-up Services:

A Systematic Review

Investigators:

Principal Investigator: 

Maya Elin O’Neil, Ph.D., M.S.

Co-Investigators and Research Associates: 

Kimberly Peterson, M.S.

Allison Low, B.A.

Susan Carson, M.P.H.

Lauren M Denneson, Ph.D.

Elizabeth Haney, M.D.

Paulo Shiroma, M.D.

Devan Kansagara, M.D., M.C.R.
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PREFACE

Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA.

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes 

and to support VA clinical practice guidelines and performance measures, 

and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: O’Neil ME, Peterson K, Low A, Carson S, Denneson LM, Haney E, 

Shiroma P and Kansagara D. Suicide Prevention Interventions and Referral/Follow-up Services: 

A Systematic Review. VA-ESP Project #05-225; 2012.

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the Portland VA Medical Center, Portland OR funded by the 

Department of Veterans Affairs, Veterans Health Administration, Office of Research and 

Development, Quality Enhancement Research Initiative. The findings and conclusions 

in this document are those of the author(s) who are responsible for its contents; the 

findings and conclusions do not necessarily represent the views of the Department 

of Veterans Affairs or the United States government. Therefore, no statement 

in this article should be construed as an official position of the Department of 

Veterans Affairs. No investigators have any affiliations or financial involvement 

(e.g., employment, consultancies, honoraria, stock ownership or options, expert 

testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report.
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TABLE OF CONTENTS

EXECUTIVE SUMMARY

Introduction ................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

INTRODUCTION............................................................................................................................................... 7

METHODS

Topic Development...................................................................................................................................... 10

Search Strategy............................................................................................................................................ 10

Study Selection............................................................................................................................................ 11

Data Abstraction .......................................................................................................................................... 13

Quality Assessment ..................................................................................................................................... 13

Data Synthesis............................................................................................................................................. 14

Rating the Body of Evidence....................................................................................................................... 14

Peer Review................................................................................................................................................. 14

RESULTS

Literature Flow ............................................................................................................................................ 15

Key Question #1. What is the effectiveness of specific interventions for reducing rates of suicidal 

self-directed violence in military and/or Veteran populations? ................................................................... 16

Key Question #2. What lessons can be learned from suicidal self-directed violence prevention 

intervention research conducted outside of Veteran or military settings that can be applied to 

Veteran and/or military populations?........................................................................................................... 16

Key Question #3. What is the effectiveness of referral and follow-up services (e.g., strategies 

designed to provide referrals, improve referral follow-through and attendance, etc.) for reducing 

rates of suicidal self-directed violence in military and/or Veteran populations?......................................... 27

Key Question #4. What lessons can be learned from research on suicidal self-directed violence 

referral and follow-up services conducted outside of Veteran or military settings that can be 

applied to Veteran and/or military populations?.......................................................................................... 27

SUMMARY AND DISCUSSION ................................................................................................................ 31

Limitations................................................................................................................................................... 33

Recommendations for Future Research....................................................................................................... 33

Conclusions ................................................................................................................................................. 34

REFERENCES ................................................................................................................................................... 36

FIGURES

Figure 1. Suicide Prevention Analytical Model................................................................................... 9

Figure 2. Literature Flow Chart......................................................................................................... 15
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APPENDIX A. Search Strategies...................................................................................................... 46

APPENDIX B. Study Selection Form.............................................................................................. 48

APPENDIX C. Criteria Used in Quality Assessment of Systematic Reviews................ 50

APPENDIX D. Criteria Used in Quality Assessment of Randomized Controlled

Trials .............................................................................................................................. 51

APPENDIX E. Criteria Used to Assess Strength of Evidence ............................................ 55

APPENDIX F. Quality Rating of Systematic Reviews Related to

Pharmacotherapy Using Oxman and Guyatt Criteria............................... 57

APPENDIX G. Data Abstraction of Primary Studies Obtained from Good

Quality Systematic Reviews Related to Pharmacotherapy .................. 60

APPENDIX H. Summary of Systematic Review Results Related to

Pharmacotherapy from Gaynes Et Al., Mann Et Al., and

NICE Reviews.............................................................................................................. 62

APPENDIX I. Description of Primary Outcomes and Intent to Treat Suicidal

Self-Directed Violence for Pharmacotherapy Studies........................... 63

APPENDIX J. Data Abstraction for Primary Studies Related to

Pharmacotherapy ...................................................................................................... 65

APPENDIX K. Risk of Bias Ratings for Primary Studies Related to

Pharmacotherapy ...................................................................................................... 68

APPENDIX L. Strength of Evidence Ratings for Primary Studies Related to

Pharmacotherapy ...................................................................................................... 73

APPENDIX M. Quality Rating of Systematic Reviews Related to Psychotherapy

Using Oxman and Guyatt Criteria ..................................................................... 77 

APPENDIX N. Data Abstraction of Primary Studies Obtained from Good Quality

Systematic Reviews Related to Psychotherapy .......................................... 80

APPENDIX O. Summary of Systematic Review Results Related to Psychotherapy

from Gaynes Et Al., Mann Et Al., and NICE Reviews ............................. 82

APPENDIX P. Description of Primary Outcomes and Intent to Treat Suicidal

Self-Directed Violence for Psychotherapy Studies ................................. 84
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APPENDIX Q. Data Abstraction for Primary Studies Related to Psychotherapy.... 89

APPENDIX R. Risk of Bias Ratings for Primary Studies Related to

Psychotherapy........................................................................................................... 103

APPENDIX S. Strength of Evidence Ratings for Primary Studies Related to

Psychotherapy........................................................................................................... 110

APPENDIX T. Quality Rating of Systematic Reviews Related to Referral/

Follow-Up Services Using Oxman and Guyatt Criteria ........................ 117

APPENDIX U. Data Abstraction of Primary Studies Obtained from Good

Quality Systematic Reviews Related to Referral/Follow-Up

Services ........................................................................................................................ 119

APPENDIX V. Summary of Systematic Review Results Related to Referral

and Follow-Up Services from Gaynes Et Al., Mann Et Al., 

and NICE Reviews ................................................................................................... 121

APPENDIX W. Description of Primary Outcomes and Intent to Treat Suicidal

Self-Directed Violence for Studies Related to Referral and

Follow-Up Services ................................................................................................ 122

APPENDIX X. Data Abstraction for Primary Studies Related to

Referral/Follow-Up Services ........................................................................... 124

APPENDIX Y. Risk of Bias Ratings for Primary Studies Related to Referral/

Follow-Up Services ................................................................................................ 129

APPENDIX Z. Strength of Evidence Ratings for Primary Studies Related to

Referral/Follow-Up Services ........................................................................... 131

APPENDIX AA. Peer Review Comments/Author Responses .................................................. 133

APPENDIX BB. Abbreviations............................................................................................................. 142

APPENDIX CC. Excluded Studies...................................................................................................... 143
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EXECUTIVE SUMMARY

INTRODUCTION

Suicide is the tenth leading cause of death in the United States (US), with nearly 100 suicides 

occurring each day and over 36,000 dying by suicide each year.1

 Among Veterans and current 

military, suicide is a national public health concern. Recent estimates suggest current or former 

military represent 20 percent of all known suicides in the US2

 and the rate of suicides among 

Veterans utilizing Veterans Health Administration (VHA) services is estimated to be higher than 

the general population.3

 The enormity of the problem has led to several major public health 

initiatives and a growth in research funding for suicide prevention.4-7

Despite recent suicide prevention efforts, the suicide rate in the US has changed relatively little 

over the past 100 years.8

 The body of research on suicide prevention approaches has been reviewed 

previously by Gaynes and colleagues,9 and Mann and colleagues,9, 10 and recent, similar work 

exists in the form of draft self-harm guidelines from the National Institute for Health and Clinical 

Excellence (NICE) in 2011.11 As requested by the Veterans Affairs (VA)/Department of Defense 

(DoD) Evidence Based Practice Working Group (EBPWG) on suicide prevention, we examined 

recent research on suicidal self-directed violence as defined by Crosby et al. 2011.12 We update the 

work of Gaynes et al. and Mann et al. by systematically reviewing relevant literature that was not 

included in either report, and was published in 2005 through November 18, 2011. Though the focus 

of the report is on suicide prevention, we include as outcomes any type of suicidal self-directed 

violence, defined as “Behavior that is self-directed and deliberately results in injury or the potential 

for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent.”12, 13

The key questions were:

Key Question #1. What is the effectiveness of specific interventions for reducing rates of suicidal 

self-directed violence in military and/or Veteran populations?

Key Question #2. What lessons can be learned from suicidal self-directed violence prevention 

intervention research conducted outside of Veteran or military settings that can be applied to 

Veteran and/or military populations?

Key Question #3. What is the effectiveness of referral and follow-up services (e.g., strategies 

designed to provide referrals, improve referral follow-through and attendance, etc.) for reducing 

rates of suicidal self-directed violence in military and/or Veteran populations?

Key Question #4. What lessons can be learned from research on suicidal self-directed violence 

referral and follow-up services conducted outside of Veteran or military settings that can be 

applied to Veteran and/or military populations?

METHODS

The VA/DoD suicide prevention Evidence Based Practice Workgroup (EBPWG) requested a 

systematic review of literature related to suicidal self-directed violence published since two 

prior reports on the topic by Mann et al. and Gaynes et al.9, 10 The workgroup requested a review 
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focused on countries and populations of interest due to their similarity to US Veteran and military 

populations. Though a previous systematic review was conducted by Shekelle and colleagues in 

2009,14 the EBPWG requested that the current review include studies of pharmacotherapy and 

psychotherapy interventions, which were largely excluded from this previous report; and, therefore, 

we used the end search date from the Mann et al. review as the starting point for the current 

search. We identified relevant systematic reviews and controlled trials by searching PubMed, 

PsycINFO, the Cochrane Database of Systematic Reviews®, and the Cochrane Central Register 

of Controlled Trials® from 2005 to November 18, 2011. We used suicide and related terminology, 

and included interventions, military, Veterans as search terms (Appendix A). We limited the 

search to peer-reviewed articles involving human subjects and published in the English language 

that were not included in the previously published systematic reviews on the topic.9, 10 We also 

report results from these two older systematic reviews, as well as results from a draft systematic 

review on self-harm,11 comparing and combining findings across the three reports to the findings 

in this current report. Additional citations were identified from reference lists, consultation with 

content experts, and web sources. Titles, abstracts, and articles were reviewed by doctoral level 

investigators and project research associates trained in the critical analysis of literature; all articles 

were reviewed in duplicate. Quality assessment of all included primary studies and systematic 

reviews was performed in duplicate by investigators and research associates. We assessed study 

quality of systematic reviews using Oxman and Guyatt criteria.15 We assessed the risk of bias of 

primary studies using the tool described in version 5.1.0 of the Cochrane Handbook for Systematic 

Reviews of Interventions.

16 Data on study characteristics, patient characteristics, and outcomes were 

extracted by trained research associates under the supervision of the Principal Investigator, a VA 

clinical psychologist. All data were narratively summarized.

DATA SYNTHESIS

We constructed evidence tables showing study, patient, and intervention characteristics; 

methodological quality; and outcomes, organized by key question, intervention type, and 

comparison group. We analyzed studies to compare their characteristics, methods, and findings. 

We graded strength of evidence based on the guidance established for the Evidence-based 

Practice Center (EPC) Program of the Agency for Healthcare Research and Quality (AHRQ).17

We compiled a summary of findings for each question based on qualitative and semi-quantitative 

synthesis of the findings. We identified and highlighted findings from VA and DoD populations.

PEER REVIEW

A draft version of this report was reviewed by eight technical experts, as well as clinical 

leadership. Reviewer comments were addressed and our responses were incorporated in the final 

report (Appendix AA).

RESULTS

We reviewed 16,518 titles and abstracts from the electronic and hand searches. Applying our 

inclusion/exclusion criteria eliminated studies published prior to 2005; studies that did not report 

suicidal self-directed violence as an outcome; studies that were not randomized controlled trials 
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(RCTs); and studies conducted in countries other than Australia, Canada, New Zealand, the 

United Kingdom, and the United States. We rejected 16,110 at the abstract level, and performed a 

more detailed full-text review on 408 articles. From these, we identified 38 RCTs (reported in 47 

publications) and 23 systematic reviews (reported in 25 publications) that addressed at least one 

of the key questions.

We classified studies as pharmacotherapy interventions, psychotherapy interventions, or referral 

and follow-up services. We defined interventions as interventions designed to treat a condition, 

symptom, or behavior. Referral and follow-up services were any services that were provided 

to patients that were primarily designed to facilitate access to interventions rather than treat a 

condition, symptom, or behavior. Because many interventions include components designed to 

increase adherence and attendance, we classified any study describing an intervention component 

as an “intervention” study rather than a “referral and follow-up services” study even if it also 

included components of referral and follow-up services. Therefore, the studies designated as 

referral and follow-up services were described by the authors as solely designed to increase 

access to, attendance at, and adherence to other interventions not included in the study design.

Key Question #1. What is the effectiveness of specific interventions for reducing 

rates of suicidal self-directed violence in military and/or Veteran populations?

We found no RCTs of self-directed violence prevention interventions in military and/or VA 

health care settings.

Key Question #2. What lessons can be learned from suicidal self-directed violence prevention intervention research conducted outside of Veteran or military 

settings that can be applied to Veteran and/or military populations?

Pharmacotherapy Results

Findings from other systematic reviews with similar key questions report that pharmacotherapy 

findings are based on few studies with limited sample sizes, some methodological quality 

concerns, and short term follow-up assessment periods;9-11 therefore, pharmacotherapy findings 

should be interpreted with caution. All three reports found that available evidence from 

antidepressant trials does not show a benefit for reducing suicide, but caution that rates of suicide 

may have been too low to detect differences. Although observational studies show a correlation 

between increasing prescription rates and decreasing suicide rates, this evidence is considered 

lower strength than evidence obtained from RCTs or meta-analyses. The three systematic reviews 

included different studies of antipsychotic medications. Overall, they report positive findings 

from trials of flupenthixol, clozapine, and fluphenazine, though caution that findings are based 

on small samples of patients in very few studies. Finally, the systematic reviews report different 

results related to mood stabilizing medications. Gaynes et al. report no reduction in suicide 

rates based on one trial of lithium, whereas Mann et al. and NICE report some non-significant 

reductions in suicide rates for patients receiving lithium.9-11

Primary studies included in the current report evaluated antidepressants, atypical antipsychotics, 

mood stabilizers, and omega-3 supplements and reported their efficacy in prevention of 

suicidal self-directed violence in civilian populations. Findings from antidepressant trials in 

civilian populations were consistent with previous reviews on the topic, and did not provide 
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sufficient evidence to make a strong conclusion about the effectiveness of antidepressants in 

reducing suicides and suicide attempts. We identified nine trials (reported in 10 publications) 

that evaluated antidepressant medications. Comparisons included various combinations 

of antidepressant medications versus placebo;18-23 one antidepressant versus another;24, 25

antidepressant therapy versus cognitive behavioral therapy (CBT);23 and antidepressant therapy 

with and without CBT.19, 21, 26, 27 Many studies had no suicides in either group. Because of the 

short duration and low participant numbers, many of these studies would not have had the 

statistical power and duration of follow-up to allow the medication to effect a change in suicide 

rates. Therefore, they are felt to be of low strength, and are insufficient for determining the 

effectiveness of various combinations of antidepressant medications for reducing suicidal selfdirected violence. 

We found three trials that reported on the effectiveness of quetiapine (1 trial)28 or adjunctive 

aripiprazole (2 trials in 3 publications)29-31 in reducing suicide deaths. These trials were six 

to eight weeks in duration and none had any suicides reported during the follow-up period. 

The quetiapine trial reported one suicide attempt in each group (treatment and intervention). 

Therefore, we concluded there was insufficient evidence to determine antisuicidal benefit. 

Notably, the previous review by Mann and colleagues reported an antisuicidal effect of 

clozapine, an atypical antipsychotic medication.10

The two trials of mood stabilizers compared lithium versus valproate (2.5 years)32 and lithium 

versus citalopram (8 weeks).33 These trials reported no instances of suicidal self-directed violence 

for the duration of either study. The previous report by Mann et al., however, found an antisuicidal 

effect for lithium compared to carbamazepine and amitriptyline.10 Thus, trials conducted since 

the Mann et al. report provided insufficient evidence to draw conclusions about the comparative 

effectiveness of mood stabilizers in preventing suicide attempts. One study conducted outside a 

country within the scope of this review was suggested for inclusion by reviewers.34 This study, had 

it been included in our results, provided insufficient evidence for the effectiveness of lithium in 

prevention of suicidal self-directed violence when compared to placebo.

Finally, one trial of omega-3 fatty acid supplementation for 12 weeks did not have any suicide 

deaths in either group.35

Psychotherapy Results

Three previously published systematic reviews on this topic all report an overall insufficient 

to low strength of evidence for the effectiveness of any psychotherapeutic interventions in 

prevention of self-directed violence.9-11 In one report (NICE 2011), the authors combined 

findings from multiple psychotherapy studies with treatment as usual comparison groups, and 

describe low strength evidence of the effectiveness of these interventions in prevention of selfdirected violence.11 Individual psychotherapy results reported in the three reports include mixed 

findings related to cognitive therapies, positive findings related to Dialectical Behavior Therapy 

(DBT) for people with Borderline Personality Disorder, positive findings for interpersonal 

psychotherapy, null findings for outpatient day hospitalization, positive findings for problemsolving therapy, positive findings for psychoanalytically oriented partial day hospitalization 

for people with Borderline Personality Disorder, and positive findings for transference-focused 

psychotherapy. Notably, these results were presented in the previous reports as coming from 
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very few studies with small sample sizes, many methodological flaws, and short-term follow-up 

assessment periods, suggesting that all findings are of insufficient to low strength and should be 

interpreted with caution.

All psychotherapy trials meeting criteria for inclusion in this review were sufficiently 

heterogeneous in terms of type of treatment, duration of treatment, and population characteristics 

to preclude combination or quantitative comparison. Therefore, psychotherapy trials are 

grouped for discussion by population: those conducted in patients with Borderline Personality 

Disorder, recent suicide attempts, a psychotic spectrum disorder, and depression or dysthymia. 

The strongest evidence (moderate strength) comes from a trial of problem-solving treatment in 

addition to usual care versus usual care alone for patients with recent suicide attempts.36 This 

trial showed no significant benefit of the intervention compared to usual care for the overall 

group of patients presenting to the hospital after engaging in self-harm behaviors; however, a 

significant benefit was noted for a sub-population of patients limited to people who had multiple 

hospitalizations for self-harm prior to the intervention. The other trials of psychotherapy 

provided insufficient or low strength evidence to draw definitive conclusions, often because of 

limitations in quality and insufficient statistical power to detect intervention effects on low baserate outcomes of suicidal self-directed violence.

Three RCTs provided insufficient evidence to draw conclusions about prevention of suicide 

deaths in populations with Borderline Personality Disorder, largely because no or very few 

suicides occurred during the trials. One trial showed a significant reduction in suicide attempts 

with Mentalization Based Treatment (MBT) compared to Structured Clinical Management 

(SCM),37 as did a trial comparing DBT with community treatment by experts.38 Three other 

studies showed no significant benefit in suicide attempt prevention for Systems Training for 

Emotional Predictability and Problem Solving (STEPPS) versus treatment as usual,39 CBT 

specific to Cluster B personality disorders versus treatment as usual,40, 41 or DBT versus general 

psychiatric management.42

Few trials reported on prevention of suicide deaths as the outcome of psychotherapy 

interventions, and of those that did, most were insufficiently powered to detect an effect of the 

intervention. One study conducted a comparison among people with recent suicide attempts, 

self-harm incidents, or imminent risk.43 This trial had several design flaws that contribute to a 

high potential for bias: non-randomization, baseline differences among the groups, non-blinding, 

and differing drop-out rates among the groups. Therefore, there was insufficient evidence to 

draw conclusions about the psychotherapy comparison. Two other studies of people presenting 

with repeat self-harm reported no suicide events in either treatment or control groups for group 

therapy,44 and for intensive case management.45 Other studies evaluated inventions in similar 

populations (prior suicide). A study of Attachment-Based Family Therapy versus Enhanced 

Usual Care showed a reduction in suicide attempts, though design flaws limit the ability to draw 

a firm conclusion about the results.46 Likewise, studies comparing Collaborative Assessment and 

Management of Suicidality (CAMS) versus Enhanced Care As Usual (E-CAU) and skills-based 

intervention versus a supportive therapy control condition did not use sufficient methodological 

rigor to enable firm conclusions about effectiveness.47, 48 Notably, a study of adolescent group 

therapy compared to routine care resulted in fewer instances of self-harm in the routine care 

group indicating the possibility of iatrogenic effects in the group treatment condition; however, 
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design flaws in this study preclude the ability to draw firm conclusions based on the results.49

Finally, one study compared three conditions, CBT, problem-solving therapy, and treatment 

as usual. This study had few patients and methodological limitations, and therefore provides 

insufficient evidence related to any of the interventions being investigated.50

One study comparing CBT versus supportive counseling in patients with a psychotic spectrum 

disorder had an unacceptably high risk of bias because therapists were not blinded and delivered 

both interventions to the participants.51 Another trial compared the Improving Mood: Promoting 

Access to Collaborative Treatment (IMPACT) intervention (including a comprehensive 

depression case management and treatment component) versus usual care in people with 

depression or dysthymia used methods resulting in an unclear risk of bias.52 Each of these trials 

provides insufficient evidence to draw definitive conclusions about the effectiveness of the 

interventions.

Key Question #3. What is the effectiveness of referral and follow-up services 

(e.g., strategies designed to provide referrals, improve referral follow-through and 

attendance, etc.) for reducing rates of suicidal self-directed violence in military 

and/or Veteran populations?

We did not find any RCTs of suicidal self-directed violence prevention referral and follow-up 

services in military and/or VA health care settings.

Key Question #4. What lessons can be learned from research on suicidal selfdirected violence referral and follow-up services conducted outside of Veteran or 

military settings that can be applied to Veteran and/or military populations?

The three previously published reports on this topic all report overall insufficient to low strength 

of evidence for the effectiveness of any referral and follow-up services in prevention of selfdirected violence.9-11 Specific findings from the three reports include positive results from studies 

on case management/care coordination and 24-hour contact with a mental health professional. 

Mixed reports of findings came from studies on emergency contact cards and postal contact. Null 

findings were reported from studies investigating intensive psychosocial follow-up, telephone 

follow-up, and video education plus family therapy. Notably, these results were presented in the 

previous reports as coming from very few studies with small sample sizes, many methodological 

flaws, and short-term follow-up assessment periods, suggesting that all findings are of 

insufficient to low strength and should be interpreted with caution.

Findings from primary studies included in this report include three studies of postcard 

interventions to decrease repeated suicidal self-directed violence, which showed mixed 

results.53-55 Two studies of Youth-Nominated Support Team (YST) interventions combined with 

usual care did not significantly reduce risk of suicide attempts or death in suicidal adolescents.56,57

One study of assertive community treatment compared with community mental health care in 

difficult-to-engage adults with serious mental illness showed no reduction in suicide deaths or 

deliberate self-harm incidents.58 Finally, one trial of a depression care management program 

resulted in no significant changes in the suicide mortality rate of older adults in primary care 

settings.59 However, all these studies were given low strength of evidence ratings and thus limit 

conclusions about the effectiveness of these interventions.
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EVIDENCE REPORT

INTRODUCTION

Suicide is the tenth leading cause of death in the United States (US), with nearly 100 suicides 

occurring each day and over 36,000 dying by suicide each year.1 The rate is higher among 25 

to 34 year-olds, for whom suicide is the second leading cause of death.60 While many die by 

suicide, each suicide represents approximately 25 suicide attempts; the lifetime risk of attempt 

for the general US population is estimated to be between 1.9 and 8.7 percent.8, 61 Among Veterans 

and current military, suicide is a national public health concern. Recent estimates suggest current 

or former military represent 20 percent of all known suicides in the US,2 and the rate of suicides 

among Veterans utilizing Veterans Health Administration (VHA) services is estimated to be 

higher than the general population.3

 The impact suicide has on family, friends, and community 

can be overwhelming.62 Furthermore, suicide attempts may leave the individual severely injured, 

requiring extensive medical treatment and rehabilitation. The lifetime cost of medical treatment 

resulting from self-inflicted injuries in 2000 was estimated to be $1 billion.63 The enormity of the 

problem has led to several major public health initiatives and a growth in research funding for 

suicide prevention.4-7

Similar to other public health concerns, two main approaches to suicide prevention have 

taken shape: 1) the identification of individual-level risk factors, with the goal of developing 

targeted interventions; and 2) the development of population-level prevention strategies. Prior 

research has identified several risk factors, most notably older age, male sex, physical and 

mental health disorders (including depression and substance use disorders [SUD]), familial 

and genetic influences, impulsivity, poor psychosocial support, and access to and knowledge 

of firearms.64-67 Unique to the Veteran population are additional risk factors, such as traumatic 

brain injury (TBI),68 habituation to violence,69 and deployment-related issues (strained 

relationships, stressful events, and post-deployment adjustment).66, 70 Several autopsy studies of 

the events leading up to suicide have suggested the majority of individuals who die by suicide 

exhibit symptoms of depression or other mental health issues prior to death.71 Additionally, 

approximately 32 percent of individuals make contact with a mental health care provider and 

77 percent make contact with a primary care provider during the year prior to suicide.72 In one 

study of Veterans who died by suicide in Oregon, 22 percent made contact with Veteran Affairs 

(VA) healthcare providers during the year prior to suicide,73 a rate similar to the estimated 

one-quarter of Veterans who access VA care annually.74 As such, targeted interventions have 

been primarily developed for use in healthcare to treat individuals who present with suicidal 

thoughts, attempts, or other risk factors, or who are otherwise identified at risk (e.g., as a 

result of a suicide risk assessment).75-77 Population-level approaches do not require prior 

identification of individuals at risk but are designed to reduce suicide using strategies such 

as providing help-seeking resources (e.g., hotlines, community health centers), environment 

modification of possible triggers or available means (e.g., media guidelines on suicide 

reporting, bridge barriers), education and awareness (e.g., public service announcements 

[PSAs] on the warning signs of suicide), or population-wide screening (e.g., screening all 

school children).
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Despite these and other suicide prevention efforts, the suicide rate in the US has changed 

relatively little over the past 100 years.8

 The methodological difficulties in studying suicide 

are similar to those inherent in studying any natural phenomenon (e.g., lack of condition 

assignment), yet is made more difficult by suicide’s relatively low base rate.60, 78 The paucity 

of high-quality studies available to offer evidence for effective intervention approaches is not 

surprising.10 Furthermore, many suicide risk factors often fail to predict suicide at the individual 

level, producing numerous false positives.78 These difficulties highlight the importance of 

increased focus on research and the continued synthesis of evidence as it is made available, 

especially with regard to individual-level intervention approaches.

The model below (Figure 1) summarizes the analytical framework used in this report for Veteran, 

military, and civilian populations. In this report, we focus on individual-level interventions and 

referral/follow-up services; that is, we focus on interventions and referral/follow-up services that 

can be implemented with individuals who are identified as being at risk for suicide rather than 

such interventions that could be implemented with a population of individuals at unknown risk 

(e.g., large-scale suicide awareness education campaigns). Though the focus of the report is on 

suicide prevention, we include as outcomes any type of suicidal self-directed violence, defined 

as, “Behavior that is self-directed and deliberately results in injury or the potential for injury 

to oneself. There is evidence, whether implicit or explicit, of suicidal intent.”12, 13 We use this 

terminology throughout this evidence report when possible; however, when describing results 

from primary studies, we use terminology as reported in the original articles in order to describe 

outcomes consistent with the primary studies. 
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tion Analytical Model

Population-level interventions

• Help seeking resources (e.g., crisis 

lines)

• Public education (e.g., PSAs on 

suicide awareness)

• Environmental modification/means 

restriction (e.g., gun safety laws, bridge barriers)

• Universal screening (e.g., standardized 

intake tools)

Distal health outcomes

• Suicide• Suicidal/undetermined selfdirected violence

Known risk factor(s)/

warning 

signs absent

Key Question 1

• Veterans and 

members of the military

Key Question 2

• Civilians

Intermediate outcomes

• Change in mental health 

symptoms

• Change in substance use• Change in suicidal ideation• Change in life stressors• Change in support system

Known risk factor(s)/

warning signs present

• Depression• Substance Use Disorder• Other mental health 

disorder

• Recent stressors• Family history of suicide• History of suicide 

attempt(s)

Provide timely and 

appropriate intervention

• Pharmacotherapy 

(e.g., anti-depressants, mood stabilizers, antipsychotics, omega-3s, other pharmacotherapy)

• Psychotherapy (e.g., 

Cognitive Behavioral Therapies, Dialectical Behavior Therapy, Psychodynamic therapies, other psychotherapy)

Key Question 3

• Veterans and 

members of the military

Key Question 4

• Civilians

Provide referral/

follow-up services

• Timely, appropriate 

intervention referrals

• Case management• Provider contact (e.g., 

postcards, phone calls)

• Support services (e.g., 

family/peer engagement)
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METHODS

TOPIC DEVELOPMENT

This project was requested by the VA/Department of Defense (DoD) Evidence Based Practice 

Working Group (EBPWG) to support the development of clinical practice guidelines for suicide 

prevention. The VA/DoD suicide prevention EBPWG requested a systematic review of literature 

related to suicidal self-directed violence as defined by Crosby et al. and Brenner et al.12, 13

published since two prior reports on the topic by Mann et al. and Gaynes et al.9, 10 The workgroup 

requested a review which was focused on countries and populations of interest due to their 

similarity to US Veteran and military populations. Though a similar report on self-harm recently 

conducted by the National Institute for Health and Clinical Excellence (NICE) was released in 

draft form during the writing of this current report,11 the EBPWG requested this current ESP 

report to examine suicidal self-directed violence, specifically, rather than self-harm in general, 

and to focus on populations most comparable to US Veterans and members of the military. A 

technical panel comprised of members of this workgroup as well as VA leaders in the field of 

suicidology provided input.

The final key questions developed a priori in conjunction with the EBPWG are: 

Key Question #1. What is the effectiveness of specific interventions for reducing rates of suicidal 

self-directed violence in military and/or Veteran populations?

Key Question #2. What lessons can be learned from suicidal self-directed violence prevention 

intervention research conducted outside of Veteran or military settings that can be applied to 

Veteran and/or military populations?

Key Question #3. What is the effectiveness of referral and follow-up services (e.g., strategies 

designed to provide referrals, improve referral follow-through and attendance, etc.) for reducing 

rates of suicidal self-directed violence in military and/or Veteran populations?

Key Question #4. What lessons can be learned from research on suicidal self-directed violence 

referral and follow-up services conducted outside of Veteran or military settings that can be 

applied to Veteran and/or military populations?

SEARCH STRATEGY

The VA/DoD suicide prevention EBPWG workgroup requested a systematic review of literature 

related to suicidal self-directed violence published since two prior reports on the topic by Mann 

et al. and Gaynes et al.9, 10 The workgroup requested a review which was focused on countries 

and populations of interest due to their similarity to US Veteran and military populations. Though 

a previous systematic review was conducted by Shekelle and colleagues in 2009,14 the EBPWG 

requested that the current review include studies of pharmacotherapy and psychotherapy 

interventions, which were largely excluded from this previous report; and, therefore, we used 

the end search date from the Mann et al. review as the starting point for the current search. To 

identify relevant systematic reviews and controlled trials, we searched PubMed, PsycINFO, the 
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Cochrane Database of Systematic Reviews®, and the Cochrane Central Register of Controlled 

Trials®. Our search focused on identifying all new studies published since the systematic reviews 

completed by Mann et al. in 2005 and Gaynes et al. in 2004,9, 10 and covered the period from 

January 2005 to November 18, 2011. Therefore, we used a similar search strategy including 

suicide and all related terms; we also included interventions and military and Veteran populations 

as search terms (Appendix A). We limited the search to peer-reviewed articles involving human 

subjects and published in the English language that were not included in previously published 

systematic reviews on the topic.9, 10

To assure that our search did not miss relevant articles on suicidal self-directed violence 

interventions, we obtained additional articles from systematic reviews, reference lists of pertinent 

studies, reviews, editorials, and consulting experts. Additionally, though the focus of the requested 

review was on interventions and services to reduce suicide, we included any intervention reporting 

on suicidal self-directed violence as an outcome to include as comprehensive a list of articles as 

possible with the potential for suicidal self-directed violence prevention efficacy.

STUDY SELECTION

Titles and abstracts were reviewed by doctoral level investigators and project research associates 

trained in the critical analysis of literature. Eligibility of full-text articles was initially carefully 

ascertained by one reviewer and the accuracy of all assessments was then checked by a second 

reviewer. All disagreements were resolved by consensus. 

To determine the evidence base for interventions and referral/follow-up services to prevent 

suicide in Veteran and military populations, we examined randomized controlled trials (RCTs) of 

interventions and referral/follow-up services that can be implemented at an individual level for 

a person identified as being at risk for suicide. Though observational studies and studies lacking 

a control or comparison condition can provide important information about the natural course 

of suicide, the focus of this report was on RCTs in an attempt to examine the highest quality 

evidence with the least potential for biased results. 

Our review was designed to detect the highest quality evidence evaluating individual-level 

interventions and study settings/populations that most closely approximate US Veteran and 

military populations. Therefore, though we used selection criteria similar to those used in the 

reviews by Mann et al. and Gaynes et al., our review differs from these reviews in: 1) excluding 

observational studies, 2) excluding trials of community-based interventions, and 3) excluding 

trials conducted in countries dissimilar to the US.

We classified studies as pharmacotherapy interventions, psychotherapy interventions, or referral 

and follow-up services. We defined interventions as treatments designed to impact a condition, 

symptom, or behavior. Referral and follow-up services were any services that were provided 

to patients that were primarily designed to facilitate access to interventions rather than treat a 

condition, symptom, or behavior. Because many interventions include components designed to 

increase adherence and attendance, we classified any study describing an intervention component 

as an “intervention” study rather than a “referral and follow-up services” study even if it also 

included components of referral and follow-up services. Therefore, the studies designated as 
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referral and follow-up services were described by the authors as solely designed to increase 

access to, attendance at, and/or adherence to other interventions not included in the study design.

Below are listed the specific inclusion criteria used to select studies for each Key Question, 

respectively: 

Key Question #1 – Primary literature review of studies published between 2005 and November 

18, 2011, with the following characteristics:

• Population: Any Veteran and/or military patient subgroup from the US, United Kingdom 

(UK), Canada, New Zealand, and Australia. 

• Intervention: Any intervention with the potential to reduce or prevent suicidal selfdirected violence including interventions related to environmental modification, 

psychotherapy, medication, somatic treatment, and monitoring. This report will include 

individual-level interventions applicable to clinical encounter settings (i.e., services that 

can be provided to individual patients). This report will exclude more broadly focused 

population-level or public health types of interventions designed to be implemented with 

large groups of people with unknown individual suicide risk levels. 

• Comparator: No intention to limit by comparator.

• Outcomes: Suicidal self-directed violence including suicide attempt and suicide, not 

including self-directed violence ideation and undetermined or non-suicidal self-directed 

violence (i.e., behavior resulting in injury for which there is unclear or no implicit or 

explicit evidence of intent to die).

• Timing: Any length of follow-up.

• Setting: US Veteran or military inpatient or outpatient settings.

Key Question #2 – Review of suicidal self-directed violence prevention intervention research 

conducted in non-Veteran and/or non-military settings with the same parameters as Key Question 

#1 other than population.

Key Question #3 – Primary literature review of studies published between 2005 and November 

18, 2011, with the following characteristics:

• Population: Any Veteran and/or military patient subgroup from the US, UK, Canada, New 

Zealand, and Australia. 

• Intervention: Any referral or follow-up service with the potential to reduce or prevent 

suicidal self-directed violence including referral/follow-up services related to care 

coordination, provider contact, and social support. This report will include individuallevel referral/follow-up services applicable to clinical encounter settings (i.e., services 

that can be provided to individual patients). This report will exclude more broadly 

focused population-level or public health types of referral/follow-up services designed to 

be implemented with large groups of people with unknown individual suicide risk levels. 

• Comparator: No intention to limit by comparator.
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• Outcomes: Suicidal self-directed violence including suicide attempt and suicide, not 

including self-directed violence ideation and undetermined or non-suicidal self-directed 

violence (i.e., behavior resulting in injury for which there is unclear or no implicit or 

explicit evidence of intent to die).

• Timing: Any length of follow-up.

• Setting: Any non-Veteran or non-military inpatient or outpatient setting.

Key Question #4 – Review of suicidal self-directed violence referral and follow-up services 

research conducted in non-Veteran and/or non-military settings with the same parameters as Key 

Question #3 other than population.

The complete study selection form including abstract and full-text codes is included in Appendix B.

DATA ABSTRACTION

For controlled trials, we abstracted information on setting, population characteristics, 

interventions, comparators, number of subjects, length of follow-up, outcome assessment 

methods, and results. For systematic reviews, we abstracted information on time period and 

databases searched and eligibility criteria used; and for all included studies that also met 

our eligibility criteria, we also abstracted information on study designs, setting, sample size, 

population characteristics, interventions and comparators, and main results.

QUALITY ASSESSMENT

We assessed the quality of systematic reviews using predefined criteria established by Oxman 

and Guyatt in 1991.15 The Oxman and Guyatt quality rating system consists of nine questions 

that involve assessing the adequacy of systematic review methods including searching, reporting 

of inclusion criteria, study selection, validity assessment, data synthesis, and conclusions. Each 

question is scored as ‘Yes,’ ‘Partially/Can’t Tell,’ or ‘No’. The overall quality is scored based on 

a scale of 1 to 7, where 1 represents the presence of extensive flaws and 7 represents the presence 

of minimal flaws (Appendix C). 

We assessed the risk of bias of controlled trials using the tool described in version 5.1.0 of the 

Cochrane Handbook for Systematic Reviews of Interventions.

16 The Cochrane Collaboration’s tool 

for assessing risk of bias involves assessing the adequacy of the following six domains: sequence 

generation, allocation concealment, blinding of participants, personnel and outcome assessors, 

handling of incomplete data, selective outcome reporting, and any other sources of bias. Adequacy 

for each domain is rated as ‘yes,’ ‘no,’ or ‘unclear’. The overall risk of bias for each controlled trial 

is then rated as ‘low,’ ‘unclear,’ or ‘high’ based on the reviewer’s judgment of the plausibility that 

the biases have seriously weakened their confidence in the results (Appendix D).

Two reviewers independently assessed the quality of each study. Reviewers then compared 

their ratings and resolved all differences through discussion or by consulting a third party when 

consensus could not be reached.
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We assessed studies for applicability to US Veterans and members of the US Armed Forces, 

and included a qualitative assessment of applicability to these populations of interest in the 

discussion section of this report. 

DATA SYNTHESIS

We constructed evidence tables showing the study characteristics and results for all included 

studies, organized by key question, intervention, or clinical condition, as appropriate. We 

critically analyzed studies to compare their characteristics, methods, and findings. We compiled 

a summary of findings for each key question or clinical topic, and drew conclusions based on 

qualitative synthesis of the findings. 

We also report findings as described in the prior systematic review by Mann et al. Because our 

review was designed to be an update to the report by Mann et al., we have not re-evaluated the 

source studies included in their report. 

RATING THE BODY OF EVIDENCE

We assessed the overall quality of evidence for outcomes based on the guidance established for the 

Evidence-based Practice Center (EPC) Program of the Agency for Healthcare Research and Quality 

(AHRQ) (Appendix E).17 The AHRQ EPC approach requires assessment of four key domains: 

risk of bias, consistency, directness, and precision. When relevant, reviewers may also consider 

the following additional optional domains: dose-response association, plausible confounding that 

would decrease the observed effect, strength of association (magnitude of effect), and publication 

bias. Ratings across the multiple domains are then combined to formulate a global assessment of 

the overall strength of the evidence. The strength of the evidence level is rated as ‘high,’ ‘moderate,’ 

‘low,’ or ‘insufficient’ based on the reviewers’ confidence that the evidence reflects the true effect 

and their judgment about the likelihood that further research will change the estimate. 

Our review was designed only to examine studies published since June, 2005, so we consider 

the findings from the Mann et al. review to assess the contributions of pre-2005 literature on the 

overall strength of evidence. However, because Mann et al. used different quality assessment 

and data synthesis methodology, the combination of results from the two reports should be 

interpreted with caution.

To provide a summary of evidence combining the results of the Mann et al. and our reviews, 

we report all positive findings from the Mann et al. review along with results from the studies 

included in our review. We did not present negative findings from the Mann et al. report because 

it was impossible to discern whether these results represented a lack of good quality evidence 

or a true negative result. Acknowledging the limitations in combining studies from two reviews 

in this way, we have clearly identified those studies from the Mann review separately from the 

newer studies included in our review. 

PEER REVIEW

A draft version of this report was reviewed by eight technical experts, as well as clinical 

leadership. Their comments and our responses are presented in Appendix AA.
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RESULTS

LITERATURE FLOW

We reviewed 16,426 titles and abstracts from the electronic search, and an additional 92 from 

reference mining for a total of 16,518 references. After applying inclusion/exclusion criteria 

at the abstract level, 16,110 references were excluded. We retrieved 408 full-text articles for 

further review and another 336 references were excluded. We identified a total of 85 references 

for inclusion in the current review, including 38 RCTs (reported in 47 publications) and 23 

systematic reviews (reported in 25 publications). We grouped the studies by key question, type 

of intervention, route of administration, and clinical condition. Figure 2 details the number of 

references related to exclusion criteria and publication type. 

Figure 2. Literature Flow Charta

336 full-text articles excluded

•	18 non-English language

•	38 ineligible country

•	56 ineligible outcome

•	11 ineligible intervention 

•	11 did not evaluate 

interventions

•	100 ineligible publication type

•	50 ineligible systematic 

review due to limitations in 

quality

•	9 ineligible nonsystematic 

regulatory agency analysis

•	43 ineligible design

61 studies reported in 72 

publications included in 

qualitative synthesis

•	38 trials reported in 47 

publications

•	23 systematic reviews 

reported in 25 publications

92 additional records identified 

through other sources

16,426 records identified from database 

searches after removal of duplicates

16,518 records screened 16,110 records excluded at 

abstract level

408 full-text articles assessed 

for eligibility

a

 Modified from the PRISMA flow diagram.79
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KEY QUESTION #1. What is the effectiveness of specific interventions 

for reducing rates of suicidal self-directed violence in military and/or 

Veteran populations?

We did not find any RCTs of suicidal self-directed violence prevention interventions in military 

and/or VA health care settings. 

KEY QUESTION #2. What lessons can be learned from self-directed 

violence prevention intervention research conducted outside of VA 

or military settings that can be applied to Veteran and/or military 

populations?

Pharmacotherapy Interventions

Summary of Findings

Antidepressants

The conclusions of three systematic reviews with similar key questions to the current report 

were consistent in relation to antidepressants.9-11 All found that available evidence from trials 

does not show a benefit for reducing suicide, but caution that rates of suicide may have been too 

low to detect differences. Although observational studies show a correlation between increasing 

prescription rates and decreasing suicide rates, this evidence is considered lower strength than 

evidence obtained from RCTs or meta-analyses. 

Findings from antidepressant trials in non-Veteran/military populations were consistent 

with previous reviews on the topic, and did not provide sufficient evidence to make a strong 

conclusion about the effectiveness of antidepressants in reducing suicidal self-directed violence. 

We identified nine trials (reported in 10 publications) that evaluated antidepressant medications. 

Comparisons included various combinations of antidepressant medications versus placebo;18-23

one antidepressant versus another;24, 25 antidepressant therapy versus cognitive behavioral therapy 

(CBT);23 and antidepressant therapy with and without CBT.19, 21, 26, 27 Many studies reported no 

suicidal self-directed violence in either group. Because of the short duration and low participant 

numbers, many of these studies would not have had the statistical power and duration of followup to allow the medication to affect a change in suicide rates. Therefore, they are felt to be of 

low strength, and are insufficient for determining the effectiveness of various combinations of 

antidepressant medications for reducing suicides.

Atypical Antipsychotics

The conclusions of three systematic reviews with similar key questions to the current report 

were consistent in relation to atypical antipsychotic medications.9-11 The three reports included 

different studies of antipsychotic medications. Overall, they report positive findings from trials 

of flupenthixol, clozapine, and fluphenazine, though caution that findings are based on small 

samples of patients in very few studies.

We found three trials that reported on the effectiveness of quetiapine (1 trial)28 or adjunctive 

aripiprazole (2 trials in 3 publications)29-31 in reducing suicide deaths. These trials were six 
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to eight weeks in duration and none had any suicides reported during the follow-up period. 

The quetiapine trial reported one suicide attempt in each group (treatment and intervention). 

Therefore, we concluded there was insufficient evidence to determine antisuicidal benefit. 

Notably, the Mann et al. review found an antisuicidal effect of clozapine, an atypical 

antipsychotic medication.10

Mood Stabilizers

The conclusions of three systematic reviews with similar key questions to the current report were 

consistent in relation to atypical mood stabilizers.9-11 The three reports included different studies 

of mood stabilizers. The systematic reviews report different results related to mood stabilizing 

medications. Gaynes et al. report no reduction in suicide rates based on one trial of lithium, 

whereas Mann et al. and NICE report some non-significant reductions in suicide rates for patients 

receiving lithium.9-11

The two trials of mood stabilizers compared lithium versus valproate (2.5 years)32 and lithium 

versus citalopram (8 weeks).33 These trials did not report any occurrences of suicidal selfdirected violence during the course of the trials. The Mann et al. review found an antisuicidal 

effect for lithium compared to carbamazepine and amitriptyline in trials published prior to 

June, 2005.10 Thus, these trials provided insufficient evidence to draw conclusions about the 

comparative effectiveness of mood stabilizers in preventing suicidal self-directed violence. 

One study conducted in a country outside the scope of this review was suggested for inclusion 

by reviewers.34 This study, had it been included in our results, provided insufficient evidence for 

the effectiveness of lithium in prevention of suicidal self-directed violence when compared to 

placebo.

Omega-3 Fatty Acid Supplementation

One trial of omega-3 fatty acid supplementation for 12 weeks did not have any suicide deaths in 

either group.35

Studies of Efficacy

Systematic Reviews

We identified 20 new relevant systematic reviews (in 22 publications) that had been published 

subsequent to Mann et al.10, 80-101 However, the utility of the conclusions from these systematic 

reviews was limited due to scope differences. Specifically, in all cases for our outcomes of 

interest (i.e., suicidal self-directed violence), conclusions from existing new reviews were based 

on groups of primary studies with a broader range of designs (i.e., observational), publication 

dates (i.e., before 2005) and from a broader range of countries than our focus of the US, United 

Kingdom, Canada, New Zealand, and Australia. Therefore, we were only able to use existing 

new reviews as an additional source of identifying new primary RCTs. Appendices F and G 

document the quality assessment of the systematic reviews found in our search, as well as data 

from the RCTs included in the reviews.

We found three systematic reviews that addressed key questions that are similar to those 

addressed in this report,9-11 and a summary of findings from these reports are included in 
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Appendix H. Overall, these three systematic reviews report that all findings are based on few 

studies with limited sample sizes, some methodological quality concerns, and short term followup assessment periods; therefore, pharmacotherapy findings should be interpreted with caution. 

The findings from the Mann et al. report, which was conducted with a similar search strategy to 

this report with non-overlapping search dates, are combined with the results from our search and 

presented in the following results section and associated tables.

Randomized Controlled Trials (RCTs)

The majority of trials focused on patients with depression, but half specifically excluded those 

who posed a suicidal risk. The majority of trials did not involve the necessary sample sizes 

(mean, 284.4 patients; standard deviation, 177.8) or follow-up durations (median, 8 weeks; 

range, 4 weeks to 2.5 years) required to adequately evaluate risk of suicide attempts or suicides. 

Therefore, these trials generally provided inadequate to low strength evidence for drawing 

conclusions about risk of suicide attempts and suicides. Data abstraction, risk of bias assessment, 

and strength of evidence rating tables are included in Appendices J through L.

We also report a summary of sample sizes, outcome definitions and results from all RCTs 

included in this review, along with a description of the purpose of the study in order to examine 

possible relationships among study intent, design and outcome. Of particular interest was 

whether studies which were designed to treat suicidal self-directed violence might be better 

powered to detect effects of such a low base rate outcome when compared to studies designed to 

treat another related but more common outcome such as depression. These results are presented 

in Appendix I for studies investigating pharmacotherapy interventions. Notably, there does not 

appear to be a strong relationship between sample size (and, by extension, statistical power) and 

whether or not the studies were reportedly designed to treat suicidal self-directed violence versus 

other outcomes.

Antidepressants

The conclusions of the Mann et al., Gaynes et al., and NICE reports were similar in relation 

to antidepressants.9-11 All found that available evidence from trials does not show a benefit for 

reducing suicide, but caution that rates of suicide may have been too low to detect differences. 

Although observational studies show a correlation between increasing prescription rates and 

decreasing suicide rates, this evidence is considered lower strength than evidence obtained from 

RCTs or meta-analyses.

Antidepressants versus Placebo. The Mann review found that antidepressants were not 

associated with a benefit over placebo for suicidal self-directed violence.10

The majority of the RCTs published subsequent to the Mann review provided insufficient 

evidence for drawing conclusions about associations between antidepressants and suicidal selfdirected violence.18-22 The strength of this evidence was limited both by trials that apparently did 

not assess suicide deaths18, 20 and those that did, in which small sample sizes and/or inadequate 

follow-up durations likely led to a lack of observed events.19, 21, 22 The only trial that reported any 

suicide deaths had low potential for bias, but still provided low strength evidence of no significant 

difference between paroxetine 38.8 mg (mean) and placebo in suicide deaths at week eight among 

180 civilian adults with moderate to severe depression (0.8% compared with 0, P not reported).23
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RCTs published subsequent to the Mann review also provided low strength evidence of no 

significant difference between escitalopram 13.2 mg (mean),20 fluoxetine 32.8 mg (mean 

maximal),19, 21 or paroxetine 10 mg18 compared with placebo in suicide attempts in depressed 

children and adolescents. 

Antidepressants versus Antidepressants. We included two RCTs that directly compared different 

antidepressant medication regimens.24, 25 These trials provided insufficient evidence to draw 

conclusions about differential effects on risk of suicide death due to insufficient statistical power 

and a lack of observed events. However, one trial with an unclear risk of bias provided low 

strength evidence that escitalopram, taken in combination with (0 events) or without bupropion 

sustained-release (0 events), significantly reduced risk of suicide attempts at seven months 

compared with venlafaxine extended release plus mirtazapine (2.3%, P=0.0162) when taken in 

civilian adults with either recurrent or chronic major depressive disorder.25

Antidepressants Alone versus Antidepressants plus CBT. We included three RCTs with unclear 

risk of bias that compared antidepressants alone versus antidepressants plus CBT in adolescents 

with major depressive disorder.19, 21, 26, 27 These trials provided insufficient evidence to draw 

conclusions about prevention of suicide deaths as only one trial reported assessment of suicide 

deaths, and there were no observed events for fluoxetine alone or fluoxetine plus CBT after 36 

weeks in 216 adolescents with major depressive disorder.19, 21 Additionally, compared to taking 

antidepressants alone, these trials provided low strength evidence that combination treatment 

with CBT plus antidepressants did not significantly improve protective effects against suicidal 

self-injury adverse events at 12 weeks,26 suicidal acts at 28 weeks,27 or suicide attempts at 36 

weeks.19, 21 In one of these trials,26 subgroup analyses found that participants with higher than 

median baseline suicidal ideation were more likely to experience a self-harm event (suicidal or 

non-suicidal) if they were treated with venlafaxine than with a Selective Serotonin Reuptake 

Inhibitor (SSRI), and participants who received a benzodiazepine in addition to an antidepressant 

were more likely to experience suicidal self-injury adverse events. 

Antidepressants versus CBT. We included one RCT with an unclear risk of bias that provided 

low-strength evidence of no significant difference between paroxetine 38.8 mg (mean) and 

cognitive therapy in suicide deaths at week eight among 180 civilian adults with moderate to 

severe depression (0.8% compared with 0, P not reported).23

Atypical Antipsychotics

The Mann et al., Gaynes et al., and NICE reports included different studies of antipsychotic 

medications.9-11 Overall, they report positive findings from trials of flupenthixol, clozapine, 

and fluphenazine, though caution that findings are based on small samples of patients in very 

few studies. The Mann review found an antisuicidal effect for clozapine in two randomized, 

controlled trials in adults with schizophrenia spectrum disorders.10 These findings are 

summarized in the strength of evidence tables provided in Appendix L and provide insufficient 

to low strength evidence for the suicidal self-directed violence preventive effect of clozapine for 

adults with schizophrenia spectrum disorders.

Trials of quetiapine28 and aripiprazole29-31 published subsequent to the Mann review did not detect 

benefit for suicide prevention in civilians with mood disorders. In fact, no suicides occurred in 
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any of the three trials. This is likely because these trials: 1) enrolled lower-risk patients who 

would be expected to have a low base rate of suicide (protocols specified exclusion of patients 

that posed a suicidal risk); 2) involved inadequate follow-up durations to detect such a low base 

rate of suicide (6-8 weeks); and 3) had relatively small treatment group sample sizes that were 

likely underpowered to detect a low base rate of suicide (range, 176 to 191 patients).

Risk of bias was low in the placebo-controlled trial of quetiapine monotherapy (300 or 600 

mg) in 542 outpatients with bipolar depression.28 During the eight-week trial, only two patients 

attempted suicide (1 in each of the quetiapine groups) and there were no suicides. Risk of bias 

was unclear in the two identically-designed, placebo-controlled trials of aripiprazole (mean dose 

range, 11.0 mg/day to 11.8 mg/day) as adjunctive treatment to standard antidepressant therapy 

in the treatment of 743 patients with major depressive disorder who have shown an incomplete 

response to the same antidepressant therapy.29-31 There were no suicides during the six-week 

treatment periods in either trial. 

Mood Stabilizers

The Mann review found an antisuicidal effect for lithium compared to carbamazepine and 

amitriptyline in a long-term (2.5 years) randomized, controlled trial of 378 German adults with 

affective disorders, providing insufficient to low strength evidence for the suicidal self-directed 

violence preventive effect of lithium for adults with affective disorders. 10

However, two RCTs of lithium published subsequent to the Mann review did not detect benefit 

for suicide prevention in civilians with mood disorders.32, 33 There was no significant difference 

between lithium 0.6–1.0 mEq/dl and valproate 45–125 μg/ml detected over 2.5 years in 98 

civilian bipolar patients in a major depressive or mixed episode who had a past suicide attempt.32

There were no suicide deaths and no significant difference between lithium and valproate in 

suicide attempts (12% compared with 16%; P-value not reported) or in time to suicide attempt 

(log-rank test). Risk of bias was unclear in this trial due to insufficient information to permit 

firm judgments for the majority of the bias domains. Our uncertainty about the impact of the 

incomplete outcome data raised the most doubt about the results of this trial. The loss to followup was 26 percent and somewhat higher in the lithium group (31% compared with 20%), and 

those lost to follow-up had more previous psychiatric hospitalizations and were more likely to 

report a history of childhood abuse. However, since neither of those potential risk factors has 

strong empirical evidence of association with suicide attempts or death and we are also uncertain 

whether the proportion of missing data is enough to induce a clinically relevant bias in effect 

size, we have fair confidence in the trial’s results. 

In an RCT with low potential for bias, there were no suicide deaths or attempts at four weeks 

with citalopram 20 mg once daily, taken with or without lithium 300 mg, in 80 severely 

depressed, civilian adults.33

Although both trials enrolled high-risk participants and the 2.5-year follow-up period used in 

one of the trials was sufficiently long to capture suicide outcomes,32 neither trial was adequately 

powered to detect differences in suicide attempts or deaths. 

Finally, one study conducted in the countries outside the scope of this review was suggested for 

inclusion by reviewers.34 This study, had it been included in our results, was judged to have a 
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high risk of bias due to having a high loss to follow-up, baseline differences between groups, and 

other factors. The trial compared lithium to placebo, resulting in a suicide death rate of 0/84 (0%) 

in the intervention group and 3/83 (3.6%) in the control group, though these differences were 

not statistically significant; the combined sample size was 167. The authors report similar results 

between the two groups in terms of suicide attempts. Overall, the results from this study provide 

insufficient evidence for the effectiveness of lithium in prevention of suicidal self-directed 

violence when compared to placebo.

Omega-3 Fatty Acid Supplementation

Evidence is insufficient to draw conclusions about the antisuicidal effects of omega-3 fatty acid 

supplementation.35 In an RCT with low potential for bias, there were no suicide deaths at 12 

weeks with eicosapentaenoic acid 1.2 mg plus docosahexaenoic acid 0.9 mg or placebo in 49 

civilian adults who presented to an academic teaching hospital in Dublin, Ireland after an act of 

repeat self-harm.

Psychotherapy Interventions

Summary of Findings

All psychotherapy trials meeting criteria for inclusion in this review were sufficiently 

heterogeneous in terms of type of treatment, duration of treatment, and population characteristics 

to preclude combination or quantitative comparison. Therefore, psychotherapy trials are grouped 

for discussions by population: those conducted in patients with Borderline Personality Disorder, 

recent suicide attempts, a psychotic spectrum disorder, and depression or dysthymia.

Three previously published systematic reviews on this topic all report overall insufficient to 

low strength of evidence for the effectiveness of any psychotherapeutic interventions in the 

prevention of self-directed violence.9-11 The authors of these reviews describe these limitations as 

being due to basing findings on very few studies with limited sample sizes, some methodological 

quality concerns, and short term follow-up assessment periods, as well as difficulties studying 

such low base-rate outcomes.

Psychotherapy Interventions for People with Borderline Personality Disorder

Psychotherapy results reported in the Mann et al. systematic review included insufficient to low 

strength evidence supporting the suicidal self-directed violence preventive effects of Dialectical 

Behavior Therapy (DBT) and psychoanalytically oriented partial day hospitalization for people 

with Borderline Personality Disorder.

Three RCTs provided insufficient evidence to draw conclusions about prevention of suicide deaths 

in populations with Borderline Personality Disorder, largely because no or very few suicides 

occurred during the trials. One trial showed a significant reduction in suicide attempts with 

Mentalization Based Treatment (MBT) compared to Structured Clinical Management (SCM),37 as 

did a trial comparing DBT with community treatment by experts.38 Three other studies showed no 

significant benefit in suicide attempt prevention for Systems Training for Emotional Predictability 

and Problem Solving (STEPPS) versus treatment as usual,39 CBT specific to Cluster B personality 

disorders versus treatment as usual,40, 41 or DBT versus general psychiatric management.42
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Psychotherapy Interventions for People with Recent Suicide Attempts, Recent Self-Harm 

Incidents, or Imminent Risk

Psychotherapy results reported in the Mann et al. systematic review included insufficient to low 

strength evidence supporting the suicidal self-directed violence preventive effects of cognitive 

therapies, cognitive therapy, interpersonal psychotherapy, and problem-solving therapy.

The strongest evidence (moderate strength) obtained from primary studies included in this 

report comes from a trial of problem-solving therapy in addition to usual care versus usual care 

alone for patients with recent suicide attempts.36 This trial showed no significant benefit of the 

intervention compared to usual care when examining a patient population of people hospitalized 

for a wide variety of self-harming behaviors; patients participating in DBT were excluded from 

the study. The authors report examination of an a priori hypothesis to see whether there were 

different treatment effects for patients whose index hospitalization was the first time they were 

hospitalized for self-harm behavior versus patients who were repeatedly hospitalized for selfharm behavior prior to the intervention. They report that the treatment showed no significant 

effect in patients who were hospitalized for the first time; however, there were significantly fewer 

re-presentations to the hospital for self-harm behaviors for both consenting and all (consenting 

and non-consenting, i.e., intention-to-treat [ITT] analysis) patients when only patients who had 

repeated hospitalizations for self-harm prior to the intervention were considered. There were 

also significantly fewer participants who self-reported engaging in self-harm behaviors from the 

group of consenting patients when only patients who had repeated hospitalizations for self-harm 

prior to the intervention were considered, though this self-report data was not able to be obtained 

from non-consenting patients for the ITT analysis. The authors report that analyses adjusting for 

treatment location and therapist nesting had no effect on the results. Finally, a similar pattern of 

statistically significant results for patient groups was reported for time to re-presentation to the 

hospital for self-harm behaviors, with patients hospitalized for repeat self-harm in the treatment 

group showing a significant improvement in time to re-presentation when compared to patients 

in the control condition; these results were significant for both consenting patients as well as the 

combined group of consenting and non-consenting patients (i.e., the ITT analysis). 

Few trials reported on prevention of suicide deaths as the outcome of psychotherapy 

interventions, and of those that did, most were insufficiently powered to detect an effect of the 

intervention. One study conducted a comparison among people with recent suicide attempts, 

self-harm incidents, or imminent risk.43 This trial had several design flaws that contribute to a 

high potential for bias: non-randomization, baseline differences among the groups, non-blinding, 

and differing drop-out rates among the groups. Therefore, there was insufficient evidence to 

draw conclusions about the psychotherapy comparison. Two other studies of people presenting 

with repeat self-harm reported no suicide events in either treatment or control groups for 

group therapy,44 and for intensive case management.45 Other studies evaluated inventions in 

similar populations (prior suicidal self-directed violence). A study of Attachment-Based Family 

Therapy versus Enhanced Usual Care showed a reduction in suicide attempts, though design 

flaws limit the ability to draw a firm conclusion about the results.46 Likewise, studies comparing 

Collaborative Assessment and Management of Suicidality (CAMS) versus Enhanced Care As 

Usual (E-CAU) and skills-based intervention versus a supportive therapy control condition 

did not use sufficient methodological rigor to enable firm conclusions about effectiveness.47,48
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Notably, a study of adolescent group therapy compared to routine care resulted in fewer 

instances of self-harm in the routine care group indicating the possibility of iatrogenic effects in 

the group treatment condition; however, design flaws in this study preclude the ability to draw 

firm conclusions based on the results.49 Finally, one study compared three conditions: CBT, 

problem-solving therapy, and treatment as usual. This study had few patients and methodological 

limitations and, therefore, provides insufficient evidence related to any of the interventions being 

investigated.50

Psychotherapy Interventions for People with a Psychotic Spectrum Disorder

One study comparing CBT versus supportive counseling in patients with a psychotic spectrum 

disorder had an unacceptably high risk of bias because therapists were not blinded and delivered 

both interventions to the participants.51 This trial provided insufficient evidence to draw definitive 

conclusions about the effectiveness of the intervention. 

Psychotherapy Interventions for People with a Depression or Dysthymia

One trial comparing the Improving Mood: Promoting Access to Collaborative Treatment 

(IMPACT) intervention (including a comprehensive depression case management and treatment 

component) versus usual care in people with depression or dysthymia had methods that 

suggested an unclear risk of bias.52 This trial provided insufficient evidence to draw definitive 

conclusions about the effectiveness of the intervention.

Studies of Efficacy

Systematic Reviews

Our search identified 24 new systematic reviews relevant to psychotherapy published in 25 

articles subsequent to Mann 2005.14, 86, 87, 89, 90, 93, 94, 96, 98, 100, 102-116 Of these, 13 were rated high 

quality according to the Oxman and Guyatt validation index15 and are included in the summary 

below.14, 87, 98, 102, 104, 106, 107, 109, 111-115 Eleven were rated lower quality and are not discussed further in 

this report.

Of the 13 high quality systematic reviews, most included only primary studies that were 

outside the scope of this review: primary studies with a broader range of study designs (i.e., 

observational studies); publication dates (i.e., before 2005); and from a broader range of 

countries than our focus on the US, United Kingdom, Canada, New Zealand, and Australia. 

Of the potentially eligible RCTs identified from the high quality systematic reviews, only one 

contributed relevant data related to psychotherapeutic interventions and is included in our review 

of primary studies.52 Appendices M and N summarize quality assessment and data abstraction 

from the included systematic reviews.

In addition to these reviews, we included and summarized findings from three other systematic 

reviews with similar key questions to this current report. These three previously published 

reports on this topic all report findings of psychotherapeutic interventions with different 

combinations of studies into categories, making comparisons across reports difficult.9-11 Results 

are reported in Appendix S, and all three reports note the overall insufficient to low strength 

of evidence for the effectiveness of any psychotherapeutic interventions in prevention of selfdirected violence. The authors of the other reviews describe these limitations as being due to 
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basing findings on very few studies with limited sample sizes, some methodological quality 

concerns, and short term follow-up assessment periods, as well as difficulties studying such 

low base-rate outcomes. Overall, combination of findings from multiple psychotherapy studies 

compared to treatment as usual resulted in low strength evidence of the effectiveness of these 

interventions in prevention of self-directed violence. Individual psychotherapy results included 

mixed findings related to cognitive therapies, positive findings related to DBT for people with 

Borderline Personality Disorder, positive findings for interpersonal psychotherapy, null findings 

for outpatient day hospitalization, positive findings for problem-solving therapy, positive findings 

for psychoanalytically oriented partial day hospitalization for people with Borderline Personality 

Disorder, and positive findings for transference-focused psychotherapy. Notably, these results 

were presented in the previous reports as coming from very few studies with small sample sizes, 

many methodological flaws, and short-term follow-up assessment periods, suggesting that all 

findings are of insufficient to low strength and should be interpreted with caution. The findings 

from the Mann et al. report, which was conducted with a similar search strategy to this report 

with non-overlapping search dates, are combined with the results from our search and presented 

in the following results section and associated tables.

Randomized Controlled Trials (RCTs)

Appendices Q through S summarize quality assessment, risk of bias, and strength of evidence 

ratings from the included primary studies.

We also report a summary of sample sizes, outcome definitions, and results from all RCTs 

included in this review along with a description of the purpose of the study in order to examine 

possible relationships among study intent and design, and outcome. Of particular interest was 

whether studies which were designed to treat suicidal self-directed violence might be better 

powered to detect effects of such a low base rate outcome when compared to studies designed to 

treat another related but more common outcome such as depression. These results are presented 

in Appendix O for studies investigating psychotherapy interventions. Notably, there does not 

appear to be a strong relationship between sample size (and, by extension, statistical power) and 

whether or not the studies were reportedly designed to treat suicidal self-directed violence versus 

other outcomes.

Psychotherapy Interventions for People with Borderline Personality Disorder

The Mann review found that both psychoanalytically-oriented partial hospitalization and DBT 

reduced suicidal self-directed violence compared with standard after care.10 Notably, these results 

were presented in the Mann et al. report as coming from very few studies with small sample 

sizes, methodological flaws, and short-term follow-up assessment periods, suggesting that these 

findings should be interpreted with caution. Overall, these studies provide insufficient to low 

strength evidence for the effectiveness of the interventions. 

Evidence published since the Mann review included six trials investigating the relative 

effectiveness of interventions for the treatment of Borderline Personality Disorder in reducing 

suicidal self-directed violence. Due to the heterogeneity of study populations and interventions, 

the evidence from each study is reported separately. Detailed descriptions of the various 

interventions are contained in the data abstraction tables (Appendix Q). 
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Two studies (Bateman et al., 2008 and Bateman et al., 2009) examined MBT, though the former 

compared this treatment to treatment as usual, and the latter used SCM as the control condition.37, 117

Compared to SCM, there is low-strength evidence that MBT significantly reduced the proportion of 

patients with life-threatening suicide attempts after 18 months (2.8% compared with 25.4%; effect 

size of d = .65) and those with severe self-harm incidents (23.9% compared with 42.9%; effect size 

of d = .62).37 However, the trial that compared MBT with SCM provided insufficient evidence to 

draw conclusions about their relative effectiveness in self-directed violence prevention due to the 

presence of an unacceptably high risk of bias, as well as imprecise data.117

Blum and colleagues (2008) conducted an RCT of STEPPS versus treatment as usual.39 This 

trial provides low-strength evidence of no significant between-group differences in time to first 

suicide attempt and time to first self-harm incidents.

Two articles (Davidson et al., 2006 and Davidson et al., 2010) describe an RCT of CBT specific 

to Cluster B personality disorders versus treatment as usual.40, 41 This trial of 106 participants 

provides low-strength evidence that there is a non-significant effect of the intervention on 

number of subjects with suicidal acts over six years (56% compared with 73%; Odds ratio [OR] 

0.37; 95% Confidence Interval [CI], 0.10 to 1.38) and number of episodes of suicidal acts (1.88 

compared with 3.03; MD 1.26; 95% CI, -0.06 to 2.58).40, 41

Linehan and colleagues (2006) investigated the effectiveness of a DBT intervention versus 

community treatment by experts in a sample of 111 adult women.38 However, as there were no 

suicide deaths in this trial, there is insufficient evidence to draw conclusions about the relative 

effectiveness of suicide death prevention. The study provides low strength evidence of a 

significantly lower suicide attempt rate for DBT (23.1% compared with 46%; Hazard ratio [HR] 

2.66, p = .005).

Another study of DBT by McMain and colleagues (2009) compared the treatment to general 

psychiatric management.42 Similar to the evidence from the Linehan et al. (2006) study, this trial 

provides insufficient evidence to draw conclusions about differential effects on risk of suicide 

death due to a lack of observed events. However, this study provides low strength evidence for a 

non-significant treatment effect on mean number of suicide attempts and self-harm at 12 months 

(4.29 compared with 12.87).

Psychotherapy Interventions for People with Recent Suicide Attempts, Recent Self-Harm Incidents, or Imminent Risk

Psychotherapy results reported in the Mann et al. systematic review included insufficient to low 

strength evidence supporting the suicidal self-directed violence preventive effects of cognitive 

therapies, interpersonal psychotherapy, and problem-solving therapy. Notably, these results were 

presented in the Mann et al. report as coming from very few studies with small sample sizes, 

methodological flaws, and short-term follow-up assessment periods, suggesting that all findings 

are of insufficient to low strength and should be interpreted with caution.

We included seven RCTs of psychotherapy interventions for people with recent suicide attempts, 

recent self-harm incidents, or imminent risk.36, 43-45, 47, 48, 50 Only three of the trials reported an 

assessment of suicide deaths, but all provided only insufficient to low strength evidence because 

of lack of statistical power and methodological flaws.43-45
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A large (N = 1094) RCT conducted by Hatcher and colleagues (2011) in New Zealand provided 

moderate strength of evidence of a non-significant effect of problem-solving treatment plus 

treatment as usual versus treatment as usual on the outcomes of re-presentation to the hospital 

for self-harm (14.2% vs 17.1%; Relative risk [RR] 0.17; 95% CI, -0.24 to 0.44) and self-reported 

self-harm (27.4% vs 32.7%; RR 0.16; 95% CI, -0.13 to 0.38).36 However, the authors also report 

examination of an a priori hypothesis to see whether there were different treatment effects for 

patients whose index hospitalization was the first time they were hospitalized for self-harm 

behavior versus patients who were repeatedly hospitalized for self-harm behavior prior to the 

intervention. They report that the treatment showed no significant effect in patients who were 

hospitalized for the first time; however, there were significantly fewer re-presentations to the 

hospital for self-harm behaviors for both consenting and all (consenting and non-consenting, 

i.e., ITT analysis) patients when only patients who had repeated hospitalizations for self-harm 

prior to the intervention were considered. There were also significantly fewer participants who 

self-reported engaging in self-harm behaviors from the group of consenting patients when 

only patients who had repeated hospitalizations for self-harm prior to the intervention were 

considered, though this self-report data was not able to be obtained from non-consenting patients 

for the ITT analysis. The authors report that analyses adjusting for treatment location and 

therapist nesting had no effect on the results. Finally, a similar pattern of statistically significant 

results for patient groups was reported for time to re-presentation to the hospital for self-harm 

behaviors, with patients hospitalized for repeat self-harm in the treatment group showing a 

significant improvement in time to re-presentation when compared to patients in the control 

condition; these results were significant for both consenting patients as well as the combined 

group of consenting and non-consenting patients (i.e., the ITT analysis).

We also included RCTs that compared CAMS versus E-CAU in a population of adults with a 

recent suicide attempt or imminent risk,47 a skills-based intervention versus a supportive therapy 

control condition,48 CBT compared to problem solving therapy compared to treatment as usual,50

and intensive case management with a therapy component,45 but all trials provided insufficient 

evidence to draw conclusions about self-directed violence prevention due to an unacceptably 

high risk of bias. 

A study of Attachment-Based Family Therapy versus Enhanced Usual Care resulted in fewer low 

lethality suicide attempts in the treatment condition (11% in the treatment and 22% in the control 

group), though a low strength evidence rating limits the ability to draw a firm conclusion about 

the results.46

Notably, a study of group therapy for adolescents between 12 and 16 years of age resulted in an 

88 percent incidence of repeated self-harm after 12 months compared to a 71 percent incidence 

of self-harm (p = .07) in the routine care condition, indicating the possibility of iatrogenic 

effects in the group treatment condition. This study provided low strength evidence, however, 

and, therefore, conclusions about the possibility of iatrogenic effects are tentative.49 Another, 

more recent study of group therapy conducted by Green and colleagues provides low strength 

evidence,44 though in spite of a relatively large sample size (N = 366), this study reported no 

suicide deaths among all participants, and only one incident of self-harm with severe injury in 

the treatment group compared to two instances in the control group.
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Psychotherapy Interventions for People with a Psychotic Spectrum Disorder

We included one RCT that compared CBT with supportive counseling in 278 participants.51

However, despite the relatively large sample size, this trial had an unacceptably high risk of bias 

and provided insufficient evidence to draw conclusions about the relative effectiveness of the two 

treatments in self-directed violence prevention. 

Psychotherapy Interventions for People with Depression or Dysthymia

An RCT of the IMPACT intervention included a comprehensive depression case management 

and treatment component compared to usual care in a population of adults age 60 and older.52

In spite of the large sample size of this trial (N=1801) with unclear risk of bias, it provides 

insufficient evidence to draw conclusions about differential effects on risk of suicide death due to 

a lack of observed events. 

KEY QUESTION #3. What is the effectiveness of referral and followup services (e.g., strategies designed to provide referrals, improve 

referral follow-through and attendance, etc.) for reducing rates of 

suicidal self-directed violence in military and/or Veteran populations?

We did not find any new RCTs on self-directed violence referral and follow-up services in 

military and/or VA health care settings. 

KEY QUESTION #4. What lessons can be learned from research on 

self-directed violence referral and follow-up services conducted 

outside of VA or military settings that can be applied to Veteran and/or 

military populations?

Summary of Findings

The three previously published reports on this topic all report overall insufficient to low strength 

of evidence for the effectiveness of any referral and follow-up services in prevention of selfdirected violence.9-11 Specific findings from the three reports include positive results from studies 

on case management/care coordination and 24-hour contact with a mental health professional. 

Mixed reports of findings came from studies on emergency contact cards and postal contact. Null 

findings were reported from studies investigating intensive psychosocial follow-up, telephone 

follow-up, and video education plus family therapy. Notably, these results were presented in the 

previous reports as coming from very few studies with small sample sizes, many methodological 

flaws, and short-term follow-up assessment periods, suggesting that all findings are of 

insufficient to low strength and should be interpreted with caution.

Of the primary studies included in this review, three studies of postcard interventions to decrease 

repeated self-harm showed mixed results.53-55 Two studies of Youth-Nominated Support Team 

(YST) interventions combined with usual care did not significantly reduce risk of suicide 

attempts or death in suicidal adolescents.56, 57 One study of assertive community treatment 

compared with community mental health care in difficult-to-engage adults with serious mental 
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illness showed no reduction in suicide deaths or deliberate self-harm incidents.58 Finally, one 

trial of a depression care management program resulted in no significant changes in the suicide 

mortality rate of older adults in primary care settings.59 However, all these studies were given 

low strength of evidence ratings and thus limit conclusions about the effectiveness of these 

interventions.

Studies of Efficacy 

Systematic Reviews

We identified nine new systematic reviews relevant to referral and follow-up services published 

in 10 articles subsequent to Mann 2005.14, 90, 96, 103, 106, 109, 112, 115, 118, 119 Of these, six were rated high 

quality according to the Oxman and Guyatt validation index15 and are included in the summary 

below.14, 106, 109, 112, 115, 118 Three were rated lower quality and are not discussed further in this report.

Of the six high quality systematic reviews, three included only primary studies that were 

outside the scope of this review: primary studies with a broader range of studies designs (i.e., 

observational studies); publication dates (i.e., before 2005); and from a broader range of 

countries than our focus on the US, United Kingdom, Canada, New Zealand, and Australia. 

The other three high quality systematic reviews included a total of three eligible RCTs.54, 55, 58

Therefore, we were only able to use existing new reviews as an additional source of identifying 

new primary RCTs. These three RCTs are included as primary studies in our review.

Appendices T and U present quality assessment of the systematic reviews and data abstraction of 

the primary studies obtained from the systematic reviews.

Three previously published reports on this topic with similar key questions to the current report 

all report findings of referral and follow-up services with different combinations of studies into 

categories, making comparisons across reports difficult.9-11 Results are reported in Appendix V, 

and all three reports note the overall insufficient to low strength of evidence for the effectiveness 

of any referral and follow-up services in prevention of self-directed violence. Specific 

findings from the three reports include positive results from studies on case management/care 

coordination and 24-hour contact with a mental health professional. Mixed reports of findings 

came from studies on emergency contact cards and postal contact. Null findings were reported 

from studies investigating intensive psychosocial follow-up, telephone follow-up, and video 

education plus family therapy. Notably, these results were presented in the three systematic 

reviews as coming from very few studies with small sample sizes, methodological flaws, and 

short-term follow-up assessment periods, suggesting that all findings are of insufficient to low 

strength and should be interpreted with caution. The findings from the Mann et al. report, which 

was conducted with a similar search strategy to this report with non-overlapping search dates, 

are combined with the results from our search and presented in the following results section and 

associated tables.

Randomized Controlled Trials (RCTs)

Appendices X through Z present data abstraction, risk of bias assessment, and strength of 

evidence grading of the primary studies included in this review.
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We also report a summary of sample sizes, outcome definitions, and results from all RCTs 

included in this review along with a description of the purpose of the study in order to examine 

possible relationships among study intent and design, and outcome. Of particular interest was 

whether studies which were designed to treat suicidal self-directed violence might be better 

powered to detect effects of such a low base rate outcome when compared to studies designed to 

treat another related but more common outcome such as depression. These results are presented 

in Appendix W for studies investigating referral and follow-up services. Notably, there does not 

appear to be a strong relationship between sample size (and, by extension, statistical power) and 

whether or not the studies were reportedly designed to treat suicidal self-directed violence versus 

other outcomes.

Postcard Interventions

The Mann review included one RCT of 843 persons which found a significantly lower suicide 

rate for at least two years in those who were contacted by letter at least four times a year 

compared to those who received no further contact after discharge following hospitalization due 

to a depressive or suicidal state.10 This trial provides insufficient to low strength evidence for the 

effectiveness of postcard interventions in preventing suicidal self-directed violence.

However, findings from two RCTs (in three publications) with unclear risk of bias provided 

low strength evidence of mixed results regarding effects of postcard interventions on repeat 

self-harm.53-55 In 772 adults discharged from a Newcastle, Australia hospital after deliberate 

self-poisoning, compared to standard treatment alone, eight postcards sent over 12 months 

significantly reduced the cumulative number of repeat episodes of deliberate self-poisoning 

both at 12 months (Incident Risk Ratio [IRR] 0.55; 95% CI, 0.35 to 0.87) and at 24 months 

(IRR 0.49; 95% CI, 0.33 to 0.73), but did not reduce the proportion of patients with repeat 

deliberate self-poisoning at either time point.54, 55 However, at both 12 months and 24 months, 

subgroup analyses found that the significant reduction in cumulative number of repeat episodes 

of deliberate self-poisoning with the postcard intervention was observed only in women and not 

in men. 

In a later trial of 327 individuals aged 16 and older who were discharged from Christchurch 

Hospital in New Zealand following self-harm of attempted suicide, compared to treatment as 

usual and after adjustment for prior self-harm, six postcards mailed over 12 months did not 

significantly reduce the total number of self-harm re-presentations (IRR 1.07; 95% CI, 0.80 to 

1.43) or total proportion of patients who re-presented for self-harm (OR 0.97; 95% CI, 0.58 to 

1.62).53

Youth-Nominated Support Team (YST)

The Mann review did not include any RCTs of YST interventions.10 However, we found two 

RCTs with unclear risk of bias that provided low-strength evidence that, compared to treatment 

as usual only, adding YST did not significantly reduce suicide deaths or attempts in suicidal, 

psychiatrically hospitalized adolescents in the US.56, 57

In general, the YST intervention supplements usual care by providing youth-nominated support 

persons who maintain regular contact with the patients following hospitalization. In the first 

trial, YST-I, adolescents had the option of including one peer in the support team and the regular 
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contact was maintained for six months, but there was a trend toward a higher proportion of 

patients with one or more suicide attempts in the YST group (17.3%) compared to the treatment 

as usual only group (11.6%, P=0.26).57 In the second trial, YST-II, the support team was limited 

to adults only and contact was only maintained for three months, which led to a slightly lower 

number of patients with at least one suicide attempt in the YST group (13% compared with 15%, 

P=0.51).56

Assertive Community Treatment

The Mann review did not include any RCTs of assertive community treatment.10 However, we 

found one RCT with unclear risk of bias that provided low-strength evidence that, compared to 

care from a community mental health team, assertive community treatment did not significantly 

reduce suicide deaths (0.8% compared with 2.5%; P not reported) or deliberate self-harm 

incidents (8% compared with 11%, P=0.40) over 18 months among 251 adults with serious 

mental illness and identified as having difficulty engaging with standard community care.58

This trial was conducted in London, and the assertive community treatment approach involved 

smaller case loads than carried by the community mental health teams and all team members 

worked with all clients, met at up to a daily frequency for discussion, used assertive contact with 

clients, followed a “no drop-out” policy, and offered extended hours of availability, and “in vivo” 

locations for appointments. 

Case Management/Care Coordination

The Mann review10 reported fewer suicide attempts compared to control participants from one 

study investigating the use of a suicide intervention counselor providing care coordination/case 

management services; however, this information was not from an RCT and is, therefore, not 

included in the findings for this current report.

However, we identified a more recent secondary analysis of suicide deaths59 from the trial of 

older primary care patients originally included in the Mann review.120 The Prevention of Suicide 

in Primary Care Elderly: Collaborative Trial (PROSPECT) had unclear risk of bias and compared 

the effect of algorithm-based depression care management to usual care practices in 599 older 

primary care patients with major depression (age ≥ 60 years). PROSPECT provided low-strength 

evidence that algorithm-based depression care management did not significantly change the 

suicide mortality rate per 1,000 person-years overall (0.7 [95% CI, 0.0 to 4.2] compared with 0.0 

[95% CI, 0.0 to 3.3]), or in subgroups with either major depressive disorder (N=396: 0.0 [95% 

CI, 0.0 to 4.1] compared with 0.0 [95% CI, 0.0 to 5.1]), or clinically significant minor depression 

(N=203: 2.2 [95% CI, 0.1 to 2.5] compared with 0.0 [95% CI, 0.0 to 9.7]).

Emergency Contact Card Interventions

The Mann review included one RCT of an emergency contact card intervention, and reported a 

reduced rate of suicide attempts.10 This trial provides insufficient to lowstrength evidence for the 

effectiveness of emergency contact interventions in preventing suicidal self-directed violence.
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SUMMARY AND DISCUSSION

Suicide is an extraordinarily complex phenomenon, associated with a range of demographic, 

biological, psycho-social, and clinical risk factors. Despite the number of risk factors, any given 

person’s individual risk for suicide or suicide attempt is low.78 The complex nature of factors 

contributing to suicide and the relatively low population rate make interventions challenging. 

The complexity of suicide is reflected in the diversity of research aimed at understanding 

and preventing suicidal behaviors. For this review, we evaluated the evidence from RCTs of 

interventions aimed at reducing suicide and suicide attempts. We found articles reporting on a 

broad range of interventions from pharmacotherapy to psychotherapy and case management 

in patient populations of all ages. However, we found very few trials specifically evaluating 

interventions in Veteran and military populations. 

Our initial searches yielded nearly 16,500 titles published on suicide treatments and risk factors 

since 2005. From these we identified 45 RCTs and 40 systematic reviews that provided evidence 

for specific treatment interventions, or referral and follow-up strategies to reduce rates of suicidal 

self-directed violence. Interventions included antidepressants, antipsychotics, mood stabilizers, 

omega-3 fatty acid supplements, CBT, and DBT, among others. Follow-up and referral strategies 

included postcard interventions, YSTs, and assertive community treatment. Overall, these 

intervention trials had methodological limitations that resulted in their providing only low strength 

and insufficient evidence to properly draw conclusions on the effectiveness of the various treatment 

interventions and follow-up/referral strategies. No interventions stood out as clearly more effective 

than others. This review did not evaluate any outcomes other than suicidal self-directed violence 

and, therefore, no additional data on potential harms and side effects was investigated.

While the gold standard for testing interventions is an RCT, the majority of the literature 

documenting efforts to reduce suicidal behaviors is observational in nature, and lacking in 

comparison or control conditions. Although information from such studies can be extremely 

valuable, it can also be misleading due to the potential for participant, provider, or researcher 

expectations about the effectiveness of the treatment under investigation to inflate positive 

results. As the goal of this report was to summarize the best evidence available, we focused on 

RCTs to minimize the risk of inflated positive results. Further, because of the noted inadequacies 

of proxy outcomes such as suicidal ideation for studying suicidal behavior,121 we limited our 

included studies to those that reported self-directed violence behaviors, specifically suicide and 

suicide attempts, as well as self-directed violence with undetermined intent. Though extensive 

observational research has been conducted on the natural course of suicide in a variety of 

populations including Veterans and members of the military, few RCTs have been conducted 

investigating the effectiveness of interventions or referral and follow-up services on reducing 

suicide or suicide attempts. Though a thorough review of unpublished and ongoing research is 

outside the scope of this report, some reviewers suggested that there is such research currently 

being conducted by VA investigators. The paucity of RCT research is likely due to the difficulty 

of studying an outcome with such low base rates, even in the highest risk populations.

As noted, we found 38 RCTs that satisfied our inclusion criteria and reported outcome data on 

suicides or suicide attempts. In spite of this relatively large number of trials, the data obtained 

provided only low strength or insufficient evidence to draw conclusions about the effectiveness 
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of the interventions and referral/follow-up services being studied. This is primarily because 

interventions provided, populations studied, and comparison conditions examined in the 45 

were so heterogeneous. This heterogeneity precluded meaningful comparisons across trials and 

quantitative combination of results from multiple trials. Therefore, each trial essentially stands 

alone for providing evidence related to the specific intervention being investigated. For example, 

though multiple studies compared psychotherapeutic interventions broadly categorized as 

either DBT or CBT, some studied a solely female population and all used different comparison 

conditions, making the combination of findings impossible.

Though large, high quality trials have the potential to stand alone as strong evidence, this 

was not the case with the 38 trials included in this systematic review. One limitation was 

inadequate blinding. Although some RCTs are more straightforward and can be easily conducted 

with adequate blinding techniques (e.g., pharmacological studies), many interventions and 

referral/follow-up services appropriate for suicide prevention are difficult if not impossible 

to blind in a study. Ideally, patients would be unaware of their treatment/control group status, 

and providers would be unaware of treatment/control group status. Also, in the case of 

psychotherapeutic interventions, providers’ belief and expertise in providing a particular type 

of intervention is paramount to its effectiveness – so blinding is even more essential than it is 

with a pharmacologic study. Despite this challenge, it is possible to compare psychotherapeutic 

interventions in adequately blinded studies. An adequately blinded study would involve 

therapists who are experts in each of the reputable and presumably effective treatments being 

compared. The evaluation of effectiveness would be conducted by someone who was unaware 

of the intervention. For example, despite other sources of bias, the Linehan (2006) study 

investigating DBT provides a good example of an intervention comparison in which both patients 

and providers could reasonably assume that the treatments being delivered are effective.38

Thus, the risk of bias due to inadequate provider confidence in the therapy (a problem when the 

provider knows that he/she is delivering the placebo intervention) was minimized. These trials 

still require independent assessment of the outcome, though from the patient-provider standpoint, 

this is an example of a reasonably well-blinded study. Most RCTs of interventions and referral/

follow-up services found in this report, however, did not utilize adequate blinding procedures 

or comparison conditions. This inadequacy undermines the validity of the study results since 

patients and/or providers were likely aware of treatment assignment.

In addition to deficiencies in study design quality, a major reason that many of the trials in this 

report were unable to provide higher strength evidence for their findings was because they were 

insufficiently powered to detect an effect of the intervention. This is not uncommon when the 

outcome being studied has a low base rate. In many of the studies reviewed here, sample sizes 

were very small (in the 40s) and it is not surprising that these trials did not show any difference 

in outcomes between the groups. Although some trials were significantly larger, even the largest 

trials included in this review with sample sizes of over 1,000 participants resulted in an underpowered study design. 

The issue of low base rate impacting sample size and overall strength of evidence also extends to 

the generalizability of the trials included in this report. For example, most of the trials included in 

this report examined populations with existing mental health diagnoses. This was necessary from 

a design standpoint in order to have a population with a reasonable likelihood of demonstrating 
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a difference in the outcome between the interventions being studied. Though members of the 

military and Veterans may have mental health diagnoses, the Veteran and military population 

in general is not solely comprised of people with mental health diagnoses and, therefore, these 

results do not necessarily represent the entire Veteran and military population. Other studies 

applied very stringent exclusion criteria in order to have a more homogeneous participant pool, 

or for safety reasons due to the outcome of interest. This practice, though necessary at times, 

can limit generalizability and also make detection of an effect even more difficult due to the 

exclusion of patients with higher rates of suicidal self-directed violence. 

There are many different paths to suicide, and there are many unique risk and protective factors 

that are difficult to study in non-Veteran/military populations. For example, we found no RCTs 

investigating the effectiveness of interventions to reduce self-directed violence in people 

diagnosed with Posttraumatic Stress Disorder or Traumatic Brain Injury, two disorders very 

common among Veterans and members of the military. Life stressors may be very different for 

this population of interest because of the duties they perform in the line of duty, the time they are 

potentially required to spend away from family and other support systems, and the potentially 

protective factors related to being a part of an organization like the military. 

LIMITATIONS

The lack of high quality trials is not a limitation of this review, per se, but rather a reflection 

of the available literature. However, in spite of finding few trials for our questions related to 

Veteran and military populations, we did not examine observational and uncontrolled studies. We 

felt that the best available evidence would come from trials conducted in non-Veteran/military 

populations rather than from observational studies conducted with our population of interest 

due to the inherent limitations in ability to ascribe causality to findings from non-experimental 

studies and studies lacking adequate control conditions. We also chose to limit the outcomes 

considered in this review to suicidal self-directed violence, which does not include suicidal 

ideation. This scoping decision could result in the exclusion of some studies related to suicidal 

self-directed violence if they did not collect and report data on that outcome. This review did not 

evaluate any outcomes other than suicidal self-directed violence, and, therefore, no additional 

data on potential harms and side effects were investigated. Potential harms and side effects 

should always be considered when evaluating the strength of evidence and considering adoption 

of an intervention or referral/follow-up service. Finally, it is likely that our search strategy, 

though based on previous systematic reviews on this topic, could have been more comprehensive 

and, therefore, some studies could have been left out of this review. For example, some reviewers 

noted that studies on other types of violent death (e.g., homicide) may have been left out of this 

search, even though the topics could be highly related.

RECOMMENDATIONS FOR FUTURE RESEARCH

Due to the low base rate of the primary outcome of interest in suicide, as well as in the 

complexity of many of the commonly implemented interventions for suicide prevention, high 

quality RCTs are difficult to implement. In spite of this difficulty, however, there remains a need 

to further test existing and new treatment methods that could be effective in preventing suicide. 
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A few high quality RCTs of promising interventions could change the strength of evidence for 

those interventions. Additionally, large-scale studies are needed to more effectively address 

unanswered questions about suicide because of its low base rates. Many studies included in 

this report cited a lack of research funding and support for the type of large-scale clinical 

trials needed to investigate an outcome with such low base-rates. Though the expense might 

be great, well-designed, very large-scale, multi-site trials with the capability to collect data 

on a sufficiently large population are needed to more adequately answer questions about the 

effectiveness of interventions designed to decrease suicide rates. Though small-scale trials may 

provide important information about intervention feasibility, resources might be best spent 

on very large-scale investigations of the most promising interventions in order to conduct 

adequately powered studies that have the ability to detect an intervention effect.

Other reviews have examined common elements of the most promising suicide prevention 

interventions, and such non-systematic reviewing of literature could be used to help guide future 

research in this area.122 This field still needs investigation of interventions and referral/follow-up 

services that are specifically targeted to be applicable to members of the military and Veteran 

populations. Additionally, when considering future research as well as intervention adoption, 

researchers and clinicians should consider intervention costs and potential harms; these two 

issues were outside the scope of this review, though the articles cited reported little information 

on these topics, suggesting that these are areas in need of further investigation. 

Given the overall limited evidence from the interventions described in this report, it is important 

to identify the relatively most promising interventions to help guide future research. One of 

the most promising interventions, Problem Solving Therapy, was reported in the Hatcher et 

al. study.36 This one study, conducted outside the US with a non-military/Veteran population, 

provides only moderate strength evidence for self-directed violence preventive effects in a 

specific sub-population of patients admitted to the hospital with repeated self-harm. Additionally, 

the findings from this current report combined with the findings from an earlier systematic 

review10 suggest that DBT has low strength evidence for effectiveness in self-directed violence 

prevention in populations with Borderline Personality Disorder. These interventions might be 

well-suited to future trials in VA and military settings to add to the overall evidence base, and to 

determine effectiveness in Veteran and military populations.

CONCLUSIONS

Examining RCTs of interventions is the gold standard for determining relative efficacy. Thouch 

there are some RCTs of suicide prevention interventions, these trials are largely plagued by 

study design flaws and insufficient power. This is likely due to: a) the complexity of conducting 

high quality trials of interventions that involve psychotherapy, and b) the very low base rates 

of suicide and suicide attempts even in the highest risk groups. In our systematic review of the 

evidence related to suicide prevention interventions, we found these two issues to be paramount 

to the lack of strong evidence for any interventions in preventing suicide and suicide attempts. 

We were most interested in RCTs related to Veteran and military populations as stated in Key 

Questions #1 and #3; however, we found no such trials meeting our inclusion criteria published 

since 2005. We, therefore, examined trials in non-Veteran/military populations in the hopes of 
35

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generalizing findings to our populations of interest. The included studies covered a broad range 

of interventions implemented with various populations in terms of gender, age, and diagnosis. 

Even the broader inclusion criteria of Key Questions #2 and #4 did not provide clear answers as 

to which interventions or referrals and follow-up services are most effective in the prevention 

of suicidal or undetermined self-directed violence. Therefore, it is likely the best available 

evidence for interventions to prevent suicide is to use a combination of the most theoretically 

sound and well researched interventions available. For example, if a Veteran or member of the 

military is identified as being at risk for suicide, making sure that this person has adequate case 

management to assist with intervention attendance as well as family or other social support 

outside of the medical setting are both likely to be good clinical practice. Additionally, assuring 

that the individual has access to relatively immediate care such as inpatient hospitalization, 

outpatient therapy, and pharmacotherapy is also warranted depending on the individual’s level 

of risk. Finally, providers should take into consideration which interventions are most likely to 

benefit the individual based on diagnosis or other relevant clinical factors (e.g., use of mood 

stabilizers if a patient meets criteria for Bipolar Disorder, or referral to an emotion regulationfocused psychotherapy intervention such as DBT if the patient meets criteria for Borderline 

Personality Disorder). Overall, the intervention and referral/follow-up service studies that were 

included in this report were quite complex and appeared very comprehensive in nature; such a 

comprehensive and multifaceted approach to suicide prevention care for Veterans and members 

of the military appears well warranted.
36

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80. Asenjo Lobos C, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical 

antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010 (11):CD006633.

81. Barbui C, Furukawa TA, Cipriani A. Effectiveness of paroxetine in the treatment of acute 

major depression in adults: a systematic re-examination of published and unpublished 

data from randomized trials. Canadian Medical Association Journal. 2008;178(3):296-

305.

82. Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of 

suicide: a systematic review of observational studies. CMAJ. 2009 Feb 3;180(3):291-7.

83. Cipriani A, Brambilla P, Furukawa T, et al. Fluoxetine versus other types of 

pharmacotherapy for depression. Cochrane Database Syst Rev. 2005 (4):CD004185.

84. Cipriani A, Pretty H, Hawton K, Geddes JR. Lithium in the prevention of suicidal 

behavior and all-cause mortality in patients with mood disorders: a systematic review of 

randomized trials. Am J Psychiatry. 2005 Oct;162(10):1805-19.

85. Cipriani A, Smith KA, Burgess SSA, Carney SM, Goodwin G, Geddes J. Lithium versus 

antidepressants in the long-term treatment of unipolar affective disorder. Cochrane 

Database of Systematic Reviews. 2009 (1).

86. Craig M, Howard L. Postnatal depression. Clin Evid (Online). 2009;2009.

87. Dubicka B, Elvins R, Roberts C, Chick G, Wilkinson P, Goodyer IM. Combined 

treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis. Br 

J Psychiatry. 2010 Dec;197:433-40.

88. Grandjean EM, Aubry JM. Lithium: updated human knowledge using an evidence-based 

approach: Part I: Clinical efficacy in bipolar disorder. CNS Drugs. 2009;23(3):225-40.

89. Hazell P. Depression in children and adolescents. Clin Evid (Online). 2011;2011.
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90. Innamorati M, Pompili M, Amore M, et al. Suicide prevention in late life: Is there 

sound evidence for practice? In: Pompili M, Tatarelli R, eds. Evidence-based practice in 

suicidology: A source book. Cambridge, MA: Hogrefe Publishing; 2011:211-32.

91. Hammerness PG, Vivas FM, Geller DA. Selective serotonin reuptake inhibitors in 

pediatric psychopharmacology: a review of the evidence. J Pediatr. 2006 Feb;148(2):158-

65.

92. McDonagh M, Peterson K, Carson S, Fu R, Thakurta S. Drug Class Review: Atypical 

Antipsychotic Drugs: Final Update 3 Report. Drug Effectiveness Review Project. 2010 

Jul:Oregon Health and Science University.

93. Robinson J, Hetrick SE, Martin C. Preventing suicide in young people: systematic 

review. Aust N Z J Psychiatry. 2011 Jan;45(1):3-26.

94. Sakinofsky I. Treating suicidality in depressive illness. Part 2: does treatment cure or 

cause suicidality? Can J Psychiatry. 2007 Jun;52(6 Suppl 1):85S-101S.

95. Sakinofsky I. Treating suicidality in depressive illness. Part 1: current controversies. Can 

J Psychiatry. 2007 Jun;52(6 Suppl 1):71S-84S.

96. Soomro GM. Deliberate self-harm (and attempted suicide). Clin Evid (Online). 

2008;12:1012.

97. Van Lieshout RJ, MacQueen GM. Efficacy and acceptability of mood stabilisers in 

the treatment of acute bipolar depression: systematic review. Br J Psychiatry. 2010 

Apr;196:266-73.

98. Williams SB, O’Connor E, Eder M, Whitlock E. Screening for Child and Adolescent 

Depression In Primary Care Settings: A Systematic Evidence Review for the U.S. 

Preventive Services Task Force. 2009 Apr.

99. Williams SB, O’Connor EA, Eder M, Whitlock EP. Screening for child and adolescent 

depression in primary care settings: a systematic evidence review for the US Preventive 

Services Task Force. Pediatrics. 2009 Apr;123(4):e716-35.

100. National Collaborating Centre for Mental Health. Depression in children and young 

people: identification and management in primary, community and secondary care. 

British Psychological Society. 2005:233.

101. Ziemba KS, O’Carroll CB, Drazkowski JF, et al. Do antiepileptic drugs increase the risk 

of suicidality in adult patients with epilepsy?: a critically appraised topic. Neurologist. 

2010 Sep;16(5):325-8.

102. Abbass AA, Hancock JT, Henderson J, Kisely SR. Short-term psychodynamic 

psychotherapies for common mental disorders. Cochrane Database of Systematic 

Reviews. 2009 (1).

103. Bagley SC, Munjas B, Shekelle P. A systematic review of suicide prevention programs 

for military or veterans. Suicide Life Threat Behav. 2010 Jun;40(3):257-65.
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104. Binks C, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Psychological therapies 

for people with borderline personality disorder. Cochrane Database of Systematic 

Reviews. 2011 (1).

105. Corcoran J, Dattalo P, Crowley M, Brown E, Grindle L. A systematic review of 

psychosocial interventions for suicidal adolescents. Children and Youth Services Review. 

2011 Nov;33(11):2112-8.

106. Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe 

mental illness. Cochrane Database Syst Rev. 2010 (10):CD007906.

107. Irving C, B., Adams CE, Rice K. Crisis intervention for people with severe mental 

illnesses. Cochrane Database of Systematic Reviews. 2010 (5).

108. Kavanagh J, Oliver S, Caird J, et al. Inequalities and the mental health of young people: 

a systematic review of secondary school-based cognitive behavioural interventions 

(Structured abstract). University of London, Institute of Education, Social Science 

Research Unit, EPPI-Centre. 2009:1-109.

109. Lapierre S, Erlangsen A, Waern M, et al. A systematic review of elderly suicide 

prevention programs. Crisis. 2011 Jan 1;32(2):88-98.

110. Leenaars AA. Evidence-based psychotherapy with suicidal people: A systematic review. 

Pompili, Maurizio [Ed]. 2011:89-123.

111. Muralidharan S, Fenton M. Containment strategies for people with serious mental illness. 

Cochrane Database of Systematic Reviews. 2009 (1).

112. Newton AS, Hamm MP, Bethell J, et al. Pediatric suicide-related presentations: a 

systematic review of mental health care in the emergency department. Ann Emerg Med. 

2010 Dec;56(6):649-59.

113. Pharoah F, Mari J, Rathbone J, Wong W. Family intervention for schizophrenia. 

Cochrane Database Syst Rev. 2010 (12):CD000088.

114. Shek E, Stein A, T., Shansis FM, Marshall M, Crowther R, Tyrer P. Day hospital versus 

outpatient care for people with schizophrenia. Cochrane Database of Systematic Reviews. 

2010 (11).

115. State of Victoria Department of Health. Suicide risk assessment and management: 

A systematic evidence review for the Clinical practice guidelines for emergency 

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Division. 2010.

116. Takada M, Shima S. Characteristics and effects of suicide prevention programs: 

comparison between workplace and other settings. Ind Health. 2010;48(4):416-26.

117. Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality 

disorder: mentalization-based treatment versus treatment as usual. The American Journal 

of Psychiatry. 2008 May;165(5):631-8.
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118. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: A 

review. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie. 2008 

Nov;53(11):769-78.

119. van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, et al. Best Practice Elements of 

Multilevel Suicide Prevention Strategies. Crisis. 2011 Sep 26:1-15.

120. Bruce M, Ten Have T, Reynolds CI, et al. Reducing suicidal ideation and depressive 

symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 

2004;291(9):1081-91.

121. Wortzel HS, Gutierrez PM, Homaifar BY, Breshears RE, Harwood JE. Surrogate 

endpoints in suicide research. Suicide Life Threat Behav. 2010 Oct;40(5):500-5.

122. Wasserman D, Wasserman C, eds. Oxford Textbook of Suicidology and Suicide 

Prevention: A Global Perspective. New York: Oxford University Press; 2009.

123. Shekelle P, Woolf S, Eccles M, Grimshaw J. Clinical guidelines: Developing guidelines. 

British Medical Journal. 1999;318(7183):593-6.

124. Vitiello B, Silva SG, Rohde P, et al. Suicidal events in the Treatment for Adolescents 

With Depression Study (TADS). J Clin Psychiatry. 2009 May;70(5):741-7.

125. March J, Silva S, Vitiello B, Team T. The Treatment for Adolescents with Depression 

Study (TADS): methods and message at 12 weeks. Journal of the American Academy of 

Child and Adolescent Psychiatry. 2006 Dec;45(12):1393-403.

126. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or 

without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the 

TORDIA randomized controlled trial. JAMA. 2008;299(8):901-13.

127. Schulberg HC, Bryce C, Chism K, et al. Managing late-life depression in primary care 

practice: a case study of the Health Specialist’s role. International Journal of Geriatric 

Psychiatry. 2001;16(6):577-84.

128. Bogner HR, Morales KH, Post EP, Bruce ML. Diabetes, depression, and death: a 

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129. Raue PJ, Morales KH, Post EP, Bogner HR, Have TT, Bruce ML. The wish to die 

and 5-year mortality in elderly primary care patients. Am J Geriatr Psychiatry. 2010 

Apr;18(4):341-50.
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APPENDIX A. SEARCH STRATEGIES

PubMed searched from 2005 – November 18, 2011

Suicide “Suicide”[Mesh] OR “Suicide, Attempted”[Mesh] OR suicid*

Risk “Risk”[Mesh] OR “Risk Assessment”[Mesh] OR “Risk Factors”[Mesh] 

OR risk[Title/Abstract]

Screening “mass screening”[Mesh] OR “Validation studies”[Publication Type] 

OR Screening[title] OR screen[title] OR assessment[title] OR 

assessments[title] OR questionnaire[title] OR questionnaires[title] OR 

instrument[title] OR instruments[title] OR tool[title] OR tools[title] OR 

scale[title] OR scales[title] OR measure[title] OR measures[title]

Prevention Prevent* OR depression OR health education OR health promotion 

OR public opinion OR mass screening OR family physicians OR 

medical Education OR primary healthcare OR antidepressive agents OR 

psychotherapy OR schools OR adolescents OR methods OR firearms OR 

overdose OR poisoning OR gas poisoning OR mass media

Suicide 

Prevention

(“Suicide/prevention and control”[Mesh] OR Suicide, Attempted/

prevention and contril”[Mesh]) NOT (case report* OR editorial* OR 

letter)

Suicide Prevention OR (Suicide AND (Risk OR Screening OR Prevention)

PsycINFO, Cochrane and HAPI Search November 18, 2011

Limited from 2005 – November 18, 2011

Search Strategy:

--------------------------------------------------------------------------------

1 exp Attempted Suicide/ or exp Suicide Prevention/ 

2 (prevent* or depression or health education or health promotion or public opinion or mass screening 

or family physicians or medical education or primary health care or antidepressive agents or 

psychotherapy or schools or adolescents or methods or firearms or overdose or poisoning or gas 

poisoning or mass media).mp. [mp=title, abstract, heading word, table of contents, key concepts, 

original title, tests & measures] 

3 suicide.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & 

measures] 

4 2 and 3

5 1 or 4 

6 exp Case Report/

7 editorial.mp. 

8 letter.mp. 
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9 6 or 7 or 8 

10 5 not 9 

11 exp Attempted Suicide/ or exp Suicide/ or suicide.mp. 

12 (suicide or suicidal or suicides or sucidality).mp. [mp=title, abstract, heading word, table of contents, 

key concepts, original title, tests & measures]

13 11 or 12 

14 exp Risk Assessment/ or risk.mp. or exp Risk Factors/ 

15 exp Screening/ 

16 exp test validity/ 

17 screening.m_titl. 

18 screen.m_titl. 

19 assessment.m_titl. 

20 assessments.m_titl. 

21 questionnaire.m_titl. 

22 questionnaires.m_titl. 

23 instrument.m_titl. 

24 instruments.m_titl. 

25 tool.m_titl. 

26 tools.m_titl. 

27 scales.m_titl. 

28 measure.m_titl. 

29 measures.m_titl. 

30 risk.mp. 

31 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 

32 13 and 31 

33 10 or 32 
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APPENDIX B. STUDY SELECTION FORM 

VA ESP Suicide Prevention Study Selection Process: Coding

Step 1: Importing citations

• Enter database name, search date, and other details into Custom 1.

Step 2: Title/Abstract level coding

• The objective of the title/abstract review phase is to eliminate obviously irrelevant publications. Abstracts that lack an explicit reference to suicidal self-directed violence (e.g., suicidality, behaviors, attempts, and suicides) will be excluded at this phase. Reviewers will provide 

decision and characteristic codes and these will be recorded in Custom 3 of the EndNote 

library. 

o Decision codes:

	R=Retrieve

	E=Exclude

	B=Retrieve for Background

o Characteristic codes: Our first priority is retrieval of systematic reviews, especially those 

focusing on Veteran/military populations. Our second priority is retrieval of primary studies in Veteran/military populations. For ease of identifying these subsets of publications in 

the ENL, reviewers should add either or both of the following codes when applicable:

	SR=systematic review

	V=Veteran and/or military population

Step 3: Full-text level coding

• Record final decision to include study in review, and any other study characteristics of 

interest.

o Characteristics of interest (recorded in Custom Fields):

	Population: Veteran/Military or Non-Veteran/Military

	Intervention Type: Psychotherapy, Pharmacotherapy, or Referral/Follow-up

	Study Design: Systematic Review, clinical trial (randomized or nonrandomized), 

 observational study, other

o Full-text exclusion codes to be entered into Custom 4:

	1=Non-English language 

	2=Ineligible country (only including US, UK, Canada, New Zealand, Australia)

	3=Ineligible outcome 

	4=Ineligible intervention (i.e., broadly focused public health interventions implemented 

among populations, etc.) 

	5=Study does not evaluate interventions

	6=Ineligible publication type (e.g., letter, editorial, publication available only as abstract, non-systematic review, etc.)

	7=Ineligible systematic review due to limitations in quality

	8=Nonsystematic regulatory agency analysis
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	9=Non-RCT study design 

•	 Full-text coding to be completed in the format of a label affixed to each publication in the 

format shown below. Reviewer 1 will circle relevant characteristics and inclusion decision, 

and list an exclusion code when applicable. Reviewer 2 will verify Reviewer 1’s decisions 

and circle Agree or Disagree. All disagreements will be resolved using a consensus process 

and consensus decisions recorded. 

Pop: Vet-Mil / Non-Vet-Mil

Intervention: Meds / Thpy / Ref-FU / NA

Design: SR / CT / Obs / Other

Rev1: Include / Exclude – Code: ____

Rev2: Agree / Disagree Consensus: _____
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ERIA USED IN QUALITY ASSESSMENT OF SYSTEMATIC REVIEWS

Criteria Operationalization of Criteria*

d?

evidence (original research) on the primary questions 

s used, date of most recent searches, and some mention of 

The purpose of this index is to evaluate the scientific quality (i.e., adherence to scientific principles) of research overviews (review articles) published in the medical literature. It is not intended to measure literary quality, importance, relevance, originality, or other attributes of overviews.The index is for assessing overviews of primary (“original”) research on pragmatic questions regarding causation, diagnosis, prognosis, therapy, or prevention. A research overview is a survey of research. The same principles that apply to epidemiological surveys apply to overviews: a question must be clearly specified, a target population identified and accessed; appropriate information obtained from that population in an unbiased fashion; and conclusions derived, sometimes with the help of formal statistical analysis, as is done in “meta-analyses”. The fundamental difference between overviews and epidemiological studies is the unit of analysis, not the scientific issues that the questions in this index address.Since most published overviews do not include a methods section, it is difficult to answer some of the questions in the index. Base your answers, as much as possible, on information provided in the overview. If the methods that were used are reported incompletely relative to a specific question, score it as “can’t tell,” unless there is information in the overview to suggest either the criterion was or was not met.

ly comprehensive?

databases and looks at other sources (such as reference 

ed?

ch studies to include in the overview reported?

oided?

udies were identified by searches, numbers excluded, and 

g them (usually because of pre-defined inclusion/exclusion 

?

e validity of the included studies reported?

ely?

ed to in the text assessed using appropriate criteria (either 

nalyzing the studies that are cited)?

sment and did some type of analysis with it (e.g., sensitivity 

atings, excluded low-quality studies, etc.)

ne studies reported?

e findings of the relevant studies (to reach a conclusion) 

alysis if there is some mention that quantitative analysis 

uld not be done, or if ‘best evidence’ or some other grading 

For Question 8, if no attempt has been made to combine findings, and no statement is made regarding the inappropriateness of combining findings, check “No” if a summary (general) estimate is given anywhere in the abstract, the discussion, or the summary section of the paper; and if it is not reported how that estimate was derived, mark “No” even if there is a statement regarding the limitations of combining the findings of the studies reviewed. If in doubt, mark “Can’t tell”.For an overview to be scored as “Yes” in Question 9, data (not just citations) must be reported that support the main conclusions regarding the primary question(s) that the overview addresses.The score for Question 10, the overall scientific quality, should be based on your answers to the first nine questions. The following guidelines can be used to assist with deriving a summary score: If the “Can’t tell” option is used one or more times on the preceding questions, a review is likely to have minor flaws at best and it is difficult to rule out major flaws (i.e., a score of 4 or lower). If the “No” option is used on Question 2, 4, 6 or 8, the review is likely to have major flaws (i.e., a score of 3 or less, depending on the number and degree of the flaws).

opriately?

es combined appropriately relative to the primary question 

eterogeneity before pooling, does appropriate subgroup 

 or other such analysis.

by the reported data?

hor(s) supported by the data and/or analysis reported in 

uality of the overview?

ty of this overview?

Each Question is scored as Yes, Partially/Can’t tell or No

Major Flaws Minor Flaws Minimal Flaws

3 4 5 6 7

Oxman & Guyatt, J Clin Epidemiol. 1991;44(11):1271-8 and Furlan, Clarke, et al., Spine. 2001 Apr 1;26(7):E155-62.
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ERIA USED IN QUALITY ASSESSMENT OF RANDOMIZED CONTROLLED 

 tool for assessing risk of bias16

Description Review authors’ judgment Describe the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups. 

Was the allocation sequence adequately generated? 

Describe the method used to conceal the allocation sequence in sufficient detail to determine whether intervention allocations could have been foreseen in advance of or during enrollment. 

Was allocation adequately concealed? 

nel 

ch 

s)

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. Provide any information relating to whether the intended blinding was effective. 

Was knowledge of the allocated intervention adequately prevented during the study? 

ch 

s)

Describe the completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, the numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by the review authors. 

Were incomplete outcome data adequately addressed? 

State how the possibility of selective outcome reporting was examined by the review authors, and what was found. 

Are reports of the study free of suggestion of selective outcome reporting? 

State any important concerns about bias not addressed in the other domains in the tool. If particular questions/entries were pre-specified in the review’s protocol, responses should be provided for each question/entry. 

Was the study apparently free of other problems that could put it at a high risk of bias? 

y assessments outcome (across domains) within and across studies

ation Within a study Across studies 

bias unlikely to seriously alter the 

Low risk of bias for all key domains. Most information is from studies at low risk of 

bias. 

bias that raises some doubt about the 

Unclear risk of bias for one or more key domains. Most information is from studies at low or 

unclear risk of bias. 

bias that seriously weakens confidence 

lts. 

High risk of bias for one or more key domains. The proportion of information from studies 

at high risk of bias is sufficient to affect the interpretation of the results. 

s in the ‘Risk of bias’ assessment tool
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dequately generated? [Short form: Adequate sequence generation?] 

The investigators describe a random component in the sequence generation process such as:	 Referring to a random number table; using a computer random number generator; coin tossing; shuffling cards or envelopes; throwing dice; 

drawing of lots; minimization.*

*Minimization may be implemented without a random element, and this is considered to be equivalent to being random.The investigators describe a non-random component in the sequence generation process. Usually, the description would involvesome systematic, non-random approach, for example:	 Sequence generated by odd or even date of birth;	 Sequence generated by some rule based on date (or day) of admission;	 Sequence generated by some rule based on hospital or clinic record number.Other non-random approaches happen much less frequently than the systematic approaches mentioned above and tend to be obvious. They usually involve judgment or some method of non-random categorization of participants, for example:	 Allocation by judgment of the clinician;	 Allocation by preference of the participant;	 Allocation based on the results of a laboratory test or a series of tests;	 Allocation by availability of the intervention.Insufficient information about the sequence generation process to permit judgment of ‘Yes’ or ‘No’.

MENT 

concealed? [Short form: Allocation concealment?]

Participants and investigators enrolling participants could not foresee assignment because one of the following, or an equivalentmethod, was used to conceal allocation:	 Central allocation (including telephone, web-based, and pharmacy-controlled randomization);	 Sequentially numbered drug containers of identical appearance;	 Sequentially numbered, opaque, sealed envelopes.Participants or investigators enrolling participants could possibly foresee assignments and thus introduce selection bias, such asallocation based on:	 Using an open random allocation schedule (e.g., a list of random numbers);	 Assignment envelopes were used without appropriate safeguards (e.g., if envelopes were unsealed or non-opaque or not sequentially 

numbered);

	 Alternation or rotation;	 Date of birth;	 Case record number;	 Any other explicitly unconcealed procedure.Insufficient information to permit judgment of ‘Yes’ or ‘No’. This is usually the case if the method of concealment is not described or not described in sufficient detail to allow a definite judgment – for example, if the use of assignment envelopes is described, but it remains unclear whether envelopes were sequentially numbered, opaque and sealed.

ANTS, PERSONNEL AND OUTCOME ASSESSORS

ated interventions adequately prevented during the study? [Short form: Blinding?]
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Any one of the following:	 No blinding, but the review authors judge that the outcome and the outcome measurement are not likely to be influenced by lack of blinding;	 Blinding of participants and key study personnel ensured, and unlikely that the blinding could have been broken;	 Either participants or some key study personnel were not blinded, but outcome assessment was blinded and the non-blinding of others 

unlikely to introduce bias.

Any one of the following:	 No blinding or incomplete blinding, and the outcome or outcome measurement is likely to be influenced by lack of blinding;	 Blinding of key study participants and personnel attempted, but likely that the blinding could have been broken;	 Either participants or some key study personnel were not blinded, and the non-blinding of others likely to introduce bias.

 

Any one of the following:	 Insufficient information to permit judgment of ‘Yes’ or ‘No’;	 The study did not address this outcome.

E DATA

data adequately addressed? [Short form: Incomplete outcome data addressed?]

Any one of the following:	 No missing outcome data;	 Reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias);	 Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups;	 For dichotomous outcome data, the proportion of missing outcomes compared with observed event risk not enough to have a clinically 

relevant impact on the intervention effect estimate;

	 For continuous outcome data, plausible effect size (difference in means or standardized difference in means) among missing outcomes not 

enough to have a clinically relevant impact on observed effect size;

	 Missing data have been imputed using appropriate methods.Any one of the following:	 Reason for missing outcome data likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across 

intervention groups;

	 For dichotomous outcome data, the proportion of missing outcomes compared with observed event risk enough to induce clinically relevant 

bias in intervention effect estimate;

	 For continuous outcome data, plausible effect size (difference in means or standardized difference in means) among missing outcomes 

enough to induce clinically relevant bias in observed effect size;

	 ‘As-treated’ analysis done with substantial departure of the intervention received from that assigned at randomization;	 Potentially inappropriate application of simple imputation.Any one of the following:	 Insufficient reporting of attrition/exclusions to permit judgment of ‘Yes’ or ‘No’ (e.g., number randomized not stated, no reasons for missing 

data provided);

	 The study did not address this outcome.

REPORTING

e of suggestion of selective outcome reporting? [Short form: Free of selective reporting?]
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Any of the following:	 The study protocol is available and all of the study’s pre-specified (primary and secondary) outcomes that are of interest in the review have 

been reported in the pre-specified way;

	 The study protocol is not available but it is clear that the published reports include all expected outcomes, including those that were prespecified (convincing text of this nature may be uncommon).

Any one of the following:	 Not all of the study’s pre-specified primary outcomes have been reported;	 One or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e.g., subscales) that were not prespecified;	 One or more reported primary outcomes were not pre-specified (unless clear justification for their reporting is provided, such as an 

unexpected adverse effect);

	 One or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta-analysis;	 The study report fails to include results for a key outcome that would be expected to have been reported for such a study.Insufficient information to permit judgment of ‘Yes’ or ‘No’. It is likely that the majority of studies will fall into this category.

REATS TO VALIDITY

ree of other problems that could put it at a risk of bias? [Short form: Free of other bias?]

The study appears to be free of other sources of bias.There is at least one important risk of bias. For example, the study:	 Had a potential source of bias related to the specific study design used; or	 Stopped early due to some data-dependent process (including a formal-stopping rule); or	 Had extreme baseline imbalance; or	 Has been claimed to have been fraudulent; or	 Had some other problem.

 

There may be a risk of bias, but there is either:	 Insufficient information to assess whether an important risk of bias exists; or	 Insufficient rationale or evidence that an identified problem will introduce bias.
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APPENDIX E. CRITERIA USED TO ASSESS STRENGTH OF 

EVIDENCE17

Definitions of the Grades of Overall Strength of Evidence

Grade Definition

High High confidence that the evidence reflects the true effect. Further research is very unlikely to change 

our confidence in the estimate of effect.

Moderate Moderate confidence that the evidence reflects the true effect. Further research may change our 

confidence in the estimate of the effect and may change the estimate.

Low Low confidence that the evidence reflects the true effect. Further research is likely to change our 

confidence in the estimate of the effect and is likely to change the estimate.

Insufficient Evidence either is unavailable or does not permit estimation of an effect.

Domains Used to Grade the Strength of Evidence

Domain Definition and Elements Score and Application

Risk of bias Risk of bias is the degree to which the included 

studies for a given outcome or comparison have a 

high likelihood of adequate protection against bias 

(i.e., good internal validity), assessed through two 

main elements:

•	 Study design (e.g., RCTs or observational studies)

•	 Aggregate quality of the studies under consideration. Information for this determination comes 

from the rating of quality (good/fair/poor) done 

for individual studies.

Use one of the three levels of aggregate 

risk of bias:

•	 Low risk of bias

•	 Medium risk of bias

•	 High risk of bias

Consistency The principle definition of consistency is the degree 

to which reported effect sizes from included studies 

appear to have the same direction of effect. This can 

be assessed through two main elements:

•	 Effect sizes have the same sign (that is, are on the 

same side of “no effect”).

•	 The range of effect sizes is narrow.

Use one of the three levels of 

consistency:

•	 Consistent (i.e., no inconsistency)

•	 Inconsistent

•	 Unknown or not applicable (e.g., 

single study)

As noted in the text, single-study 

evidence bases (even mega trials) 

cannot be judged with respect to 

consistency. In that instance, use 

“Consistency unknown (single 

study)”.
56

Suicide Prevention Interventions and Referral/Follow-up

Services: A Systematic Review Evidence-based Synthesis Program

Directness The rating of directness relates to whether the evidence 

links the interventions directly to health outcomes. 

For a comparison of two treatments, directness 

implies that head-to-head trials measure the most 

important health or ultimate outcomes.

Two types of indirectness, which can coexist, may be 

of concern.

Evidence is indirect if:

•	 It uses intermediate or surrogate outcomes instead 

of ultimate health outcomes. In this case, one body 

of evidence links the intervention to intermediate 

outcomes and another body of evidence links the 

intermediate to most important (health or ultimate) 

outcomes.

•	 It uses two or more bodies of evidence to compare 

interventions A and B – e.g., studies of A vs. 

placebo and B vs. placebo, or studies of A vs. C 

and B vs. C but not A vs. B.

Indirectness always implies that more than one 

body of evidence is required to link interventions 

to the most important health outcomes.

Directness may be contingent on the outcomes of 

interest. EPC authors are expected to make clear 

the outcomes involved when assessing this domain.

Score dichotomously as one of two 

levels directness:

•	 Direct

•	 Indirect

If indirect, specify which of the 

two types of indirectness accounts 

for the rating (or both, if that is the 

case) – namely, use of intermediate/

surrogate outcomes rather than 

health outcomes, and use of indirect 

comparisons. Comment on the 

potential weaknesses caused by, or 

inherent in, the indirect analysis. 

The EPC should note if both direct 

and indirect evidence was available, 

particularly when indirect evidence 

supports a small body of direct 

evidence.

Precision Precision is the degree of certainty surrounding an 

effect estimate with respect to a given outcome (i.e., 

for each outcome separately).

If a meta-analysis was performed, this will be the CI 

around the summary effect size.

Score dichotomously as one of two 

levels of precision:

•	 Precise

•	 Imprecise

A precise estimate is an estimate 

that would allow a clinically useful 

conclusion. An imprecise estimate is 

one for which the CI is wide enough 

to include clinically distinct conclusions. For example, results may be 

statistically compatible with both 

clinically important superiority and 

inferiority (i.e., the direction of effect 

is unknown), a circumstance that will 

preclude a valid conclusion.

Strength of 

association 

(magnitude of 

effect)

Strength of association refers to the likelihood that the 

observed effect is large enough that it cannot have 

occurred solely as a result of bias from potential 

confounding factors.

This additional domain should be 

considered if the effect size is 

particularly large. Use one of two 

levels:

•	 Strong: large effect size that is 

unlikely to have occurred in the 

absence of a true effect of the intervention.

•	 Weak: small enough effect size that it 

could have occurred solely as a result 

of bias from confounding factors.
57

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

LITY RATING OF SYSTEMATIC REVIEWS RELATED TO 

APY USING OXMAN AND GUYATT15 CRITERIA

ehensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

Yes Yes Yes Yes; excluded studies 

where sequence generation was at high risk of bias or where allocation was clearly not concealed.

Yes Yes Yes 7

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes; no variation to 

analyze.

Yes Can’t tell for 

suicide; reported no differences between fluoxetine and control AD among 4 studies but analysis of heterogeneity not reported.

Yes 6

Yes Yes; study flow 

diagram provided reasons for exclusion.

Yes No; reported allocation 

concealment, blinding and ITT analysis; no analysis based on quality, despite some variation in use of blinding.

Yes Yes Yes 6

Yes Yes Yes Yes; those rated C 

(inadequate) excluded from analysis.

Yes Yes Yes 7

mental 

Yes No; detailed 

results of study selection not reported, no reasons for exclusions described.

No Can’t tell; within 

GRADE evaluation of quality of evidence, deducted points for internal validity limitations; but, unclear as to the scope of the internal validity domains assessed. 

Yes Yes Yes 3
58

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ehensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

Yes Yes; study flow 

diagram provided reasons for exclusion.

Yes Yes; reported results 

of validity assessment; none were poor, not necessarily a need to control for variation in synthesis.

Yes Yes Yes 7

 one 

e.

No Can’t tell. No Can’t tell; validity of all 

studies not provided, but noted that only publications with the highest standards of quality were selected.

No Can’t tell; 

methods not reported.

Yes 2

 one 

e.

No Can’t tell; 

numbers and reasons for exclusions not reported.

Yes Can’t tell; validity of 

studies not referred to in text.

Can’t tell; no mention of consideration of quantitative analysis and no grading of strength of evidence.

Yes Yes 5

mental 

Yes Can’t tell; 

numbers and reasons for exclusions not reported

No Yes; validity 

assessment included in GRADE strength of evidence ratings.

Yes; used GRADE approach to rate strength of evidence.

Yes Yes 5

mental 

No; no information on PICOTS.

Can’t tell; only reported number of included studies.

No; none described; only use of Shekelle 1999123 scheme 

for classifying study design and strength of recommendation, but no quality.

No Yes; used 

Shekelle 1999123

scheme for classifying study design and strength of recommendation.

Yes Yes 3

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7
59

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ehensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

Yes Can’t tell; 

numbers of exclusions reported at each stage, but reasons not reported.

Yes No; reported results of 

validity assessment in table and paragraph, but did not appear to account for variation in synthesis.

Yes No; only 1 

comparison with >1 study and did not combine data and did not explain reasons for this.

Yes 4

veral 

es were 

Can’t tell; RCTs were the main focus but of necessity; it also considered other categories of investigations of the outcome of treatment.

No; no information related to number of articles found, included, and excluded.

No; did not describe criteria used to differentiate between good and deficiencies.

Yes; critical assessment of the quality of design, conduct and analysis of the studies was performed and reported according to authors’ constructed schema of level of evidence.

Yes Yes; report of 

findings follow simplified scheme of evidence constructed by authors.

Yes 4

hand

ng, 

e list 

ng, or 

xperts 

Yes No Yes Yes No Yes Yes 4Yes Yes; study flow 

diagram provided reasons for exclusion.

Yes Yes; only included 

studies with a Jadad score of ≥3.

Yes; used GRADE approach to rate strength of evidence.

Yes; no significant heterogeneity reported.

Yes 7

Yes Yes; study 

flow diagram in Pediatrics publication,99

reasons for exclusion for individual trials provided in Evidence Report.98

Yes Yes; excluded poor 

quality studies.

Yes Yes; did not 

conduct metaanalyses due to heterogeneity.

Yes 7

arched 

es lists 

d to 

ation 

meta

.

No No; not reported. No Can’t tell; only reported 

one study, described as the highest level of evidence they found.

No No; methods not 

reported.

Yes 2
60

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

A ABSTRACTION OF PRIMARY STUDIES OBTAINED FROM GOOD QUALITY 

EWS RELATED TO PHARMACOTHERAPY

databases 

ematic review Eligibility criteria in systematic review

Study designs of eligible studies

Countries included in eligible studies

Sample size in eligible studies

Population in eligible studies

Interventions in eligible studies

Main results of eligible studies

hrenia Group’s 

ception-June 

RCTs, single- or double-blinded, comparing clozapine with other atypical antipsychotics for treatment of psychotic mental illness

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

SE: January 

Observational and case control; completed or attempted suicide; participants any sex and age with a diagnosis of MDD

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

ration 

ty and Neurosis 

egister and 

tral Register 

s: Inception

MEDLINE: 1966-

974-2006

RCTs comparing paroxetine to placebo; participants were adults (≥18 years of age) of either sex with a diagnosis of major depression using any criteria

One RCT:DeRubeis 200523

US 240 Adult 

civilians with moderate to severe major depressive disorder

Paroxetine vs. cognitive therapy vs. placebo

Suicide deaths: Paroxetine=1/120 (0.8%); Cognitive Therapy=0/60; Placebo=0/60

ration 

ty, and Neurosis 

egisters: 

EDLINE: 1966-

974-2004

RCTs; participants any sex and age with a primary diagnosis of depression

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

ration 

ty and Neurosis 

egister, ts of searches 

6-June 2002); 

une 2002; 

rch 2001; 

e 2002; 

October 1999; 

rch 2001; 

3

RCTs comparing lithium with placebo or all other compounds used in long-term (>3 months) treatment for mood disorders (unipolar depression, bipolar disorder, schizoaffective disorder, dysthymia, and rapid cycling, diagnosed according to Diagnostic and Statistical Manual of Mental Disorders [DSM] and International Classification of Diseases criteria)

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

ration 

ty, and Neurosis 

egisters: 

y 9, 2005

Prospective RCTs in any language comparing long-term treatment with lithium to any antidepressant

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

NE, Cochrane 

ry 1980-March 

RCTs predominantly including adolescents aged 11-18 years with a DSM-IV defined episode of depression where CBT was combined with a newer generation antidepressant and compared with antidepressant treatment without CBT

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs
61

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

databases 

ematic review Eligibility criteria in systematic review

Study designs of eligible studies

Countries included in eligible studies

Sample size in eligible studies

Population in eligible studies

Interventions in eligible studies

Main results of eligible studies

er 2010; CDSR: 

MEDLINE: 

k 4 2010; 

February week 

RCTs, good quality systematic reviews, comparative observational studies; adults and adolescents with psychotic disorders; adults, children, and adolescents with bipolar disorder; adults with major depressive disorder; children and adolescents with disruptive behavior disorders; and older adults with dementia

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

SE, PsycINFO, 

Inception to 

RCTs of depressed participants aged 5-18 treated with CBT, CBT+separate parenting sessions, interpersonal psychotherapy, psychoanalytic/psychodynamic child psychotherapy, self-modeling, relaxation, social skills training, family therapy, guided self-help, or control enhancement training; and that reported remission, symptom levels, functional status or discontinuation from treatment for any reason outcomes 

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

anuary week 

 1980-week 4 

1967-January 

AHL: 1982- 

008; CCRCT, 

Published double-blind RCTs, placebocontrolled and active comparator trials (excluded crossover designs); included a mood stabilizer treatment group; adults aged 18-65 with bipolar disorder and acute major depression (excluded mixed states); Jadad scale score ≥3

One RCT: Calabrese 200528

US 542 Adult civilians 

with acute bipolar depression

Mood stabilizer vs. placebo

Attempted suicides: Quetiapine 300 mg=1/172 (0.6%); Quetiapine 600 mg=1/170 (0.6%); Placebo=0/169

DLINE, 

May 2006

Patients aged 7-18 years with MDD or depression NOS; primary care setting, school-based clinics; English language only; excluded poor quality studies

Two RCTs: Emslie 200618

Wagner 200622

US and Canada

206; 268 Child and 

adolescent civilians with a diagnosis of depression; Ages 6-17; Ages 7-17

SSRIs vs. placebo

No suicide deaths occurred in controlled trials of SSRIs
62

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

MARY OF SYSTEMATIC REVIEW RESULTS RELATED TO 

APY FROM GAYNES ET AL., MANN ET AL., AND NICE REVIEWS9-11

Gaynes 20049 Mann 200510 NICE 201111

eralizability of the studies makes the overall 

vidence fair, at best, while the results are 

gh some trends suggest incremental benefit 

nterventions, no consistent statistically 

ects have emerged for interventions for 

han one study has been done.

Interventions need more evidence of efficacy. The evidence base for the pharmacological treatment for 

self-harm remains very limited. The clinical efficacy of these medications remains uncertain. The variations in the treatment lengths, follow-up period, and participants’ psychiatric diagnosis in these trials made it more difficult to warrant conclusions about the clinical effects of these medications.

Scope 

r 2002 1966-June 2005 Up to January 2011

 interest was primary care patients with 

identified suicide risk. Included RCTs were 

high-risk groups as identified by a deliberate 

sode, diagnosis of borderline personality 

dmission to a psychiatric unit.

Not specified Adults, children, and young people with previous selfharm behavior

rapy, psychotherapy, referral/follow-up Pharmacotherapy, psychotherapy, referral/follow-up Pharmacotherapy, psychotherapy, referral/follow-up

letions, suicide attempts Completed and attempted suicide Primary outcome was repetition of self-harm; also 

included suicide outcomes.

ecialty care settings; no exclusions based 

Included settings not specified; no exclusions based on country.

No exclusions by country

targeting patients with chronic psychotic 

dies without adequate comparison groups.

No additional exclusion criteria specified.

Main Results: Pharmacotherapy

s showed no statistically significant effects. 

r fluoxetine vs placebo in patients without 

sion with 2 more suicide attempts.

Meta-analyses of RCTS have generally not detected benefit for suicide or suicide attempts in mood and other psychiatric disorders.

Insufficient evidence for suicide and self-harm

significantly reduced the proportion of 

berate self-harm for those with at least 2 

de attempts compared with placebo. No 

w-dose vs. ultra low-dose fluphenazine in 

 patients with a previous suicide attempt.

Benefit for clozapine in people with schizophrenia spectrum disorders in 2 RCTs.

One RCT provides limited evidence of benefit of flupenthixol on self-harm repetition prevention compared to placebo, though no recommendation was made due to study limitations and potential harms. One RCT provides insufficient evidence of benefit of fluphenazine on reducing repeated self-harm or suicide.

One RCT showed an antisuicidal effect of lithium in major mood disorders. 

One RCT resulted in no significant differences between lithium and placebo on repetition of self-harm. Though 3 cases of suicide in the placebo arm were compared to the 0 cases in the lithium arm, study limitations precluded making recommendations.

One RCT reported no significant differences for self-harm repetition.
63

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

RIPTION OF PRIMARY OUTCOMES AND INTENT TO TREAT SUICIDAL 

IOLENCE FOR PHARMACOTHERAPY STUDIES

suicide? (yes/no/unclear) N Outcome definition Results

tcomes reported in results 

362 Suicide Assessment methods NR Suicides: None

tcome was the occurrence of a 

ent.

334 Suicide-related symptoms assessed by the Beck 

Depression Inventory, Suicide Ideation QuestionnaireJr., and Side Effects Form for Children and Adolescents.

Suicidal self-injury adverse events: No statistically significant treatment effects (rates NR)

tcomes reported in results 

542 Suicide attempts, suicides: Assessment methods NR Suicide attempts: 0.5% (1/180) vs 0.5% (1/181) vs. 0, P-value 

NRSuicides: None 

tcomes reported in results 

240 Suicide Assessment methods NR Suicide deaths: A=0.8% (1/120) vs B=0 vs C=0

 this article was to report 

luding suicide-related events, 

 one of the pre-specified 

DS study.

439 Suicide behavior assessed using ColumbiaClassification Algorithm for Suicidal Assessment 

(C-CASA).

12 weeksSuicide deaths: NoneSuicide attempts: A=1.8% (2/109), B=0.9% (1/111), C=1.9% (2/107), D=0% (0/112), “rates are not significantly different” (P not reported)36 weeksSuicide deaths: NoneSuicide attempts: A=6.4% (7/109), B=3.6% (4/111), C=3.7% (4/107), D=5.4% (6/112), P not reported

es were conducted on the 

ated to suicidality.

206 Suicide Assessment methods NR Suicide behavior: A=2% (2/104) vs B=0

ssessed whether an adverse 

ve of self-harm; categorized 

suicidal ideation, self-injurious 

dal), accidental overdose, or 

316 Suicide Assessment methods NR Adverse events suggestive of self-harm, with a suicidal 

tendency: (A) 0(B) 0.6% (1/157)

harm, including attempted 

cidal self-cutting, and suicidal 

d about and recorded.

208 All acts of self-harm were asked about and recorded. 

Suicidality was rated based on suicidality items from the K-SADS-PL or the Suicidality/Self-Harm section of the K-SADS-L.

Suicide acts:Week 6: SSRI-only=9.2% (9/98) vs SSRI+CBT=5.1% (5/98)

Week 12: SSRI-only=8.0% (8/100) vs SSRI+CBT=6.9% (7/101)Week 28: SSRI-only= 6.4% (6/94) vs SSRI+CBT= 7.1% (7/98)Time–treatment interaction: OR 1.002 (95% CI, 0.93 to 1.08)

Pooled treatment effect: OR 0.995 (95% CI, 0.45 to 2.21)

m of this study was to collect 

 if an SSRI antidepressant 

e different from the NDRI, 

cing suicidal behavior, ideation, 

gical measures of impulsivity.

78 Suicidal events were assessed with the Columbia 

Suicide History Form (Oquendo 2003).

Suicide deaths: None
64

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

suicide? (yes/no/unclear) N Outcome definition Results

idality with the Overt 

49 Suicidality was measured using the Overt Aggression 

Scale.

No completed acts of suicide during the study period

ome meausure was the 

y Tracking Scale.

80 Suicidal behaviors assessed using clinicianadministered Sheehan-Suicidality Tracking Scale 

(S-STS).

Suicide deaths: NoneSuicide attempts: None

me was a composite of 

and deaths by suicide.

167 Suicidal acts assessed by participant report. Suicide deaths:

A= 0/84 (0%)B= 3/83 (3.6%)Suicide attempts:A=7/84 (8.3%)B=7/83 (8.4%)Suicide attempt or death by suicide (primary endpoint):A=7 (8.3%)B=10 (12.0%)Incidence rate per patient-year: A=12.7%B=21.7%Adjusted HR: 0.52 (0.19 to 1.44); P=0.206Death by suicide (post hoc secondary endpoint):A=0 (0%)B=3 (3.6%)Incidence rate per patient-year: A=0B=6.5%P=0.049

comes reported in results only 381 Suicide: Assessment methods NR Suicides: None

utcome measures were time to 

 time to suicide attempt, and 

nt.

98 Suicide completion: self-inflicted death for which there 

was evidence of at least some intent to end one’s lifeSuicide attempt: potentially self-injurious behavior carried out with at least some intent to end one’s life

Suicide deaths: NoneSuicide attempts: A=12% (6/49) vs B=16% (8/49); P-value not reportedTime to suicide attempt: Log-rank test showed no differences

ysis of suicide-related events 

268 Suicide Assessment methods NR No suicides

tcome was suicidal ideation; 

cify suicidal behavior as an 

665 Not reported Suicide deaths: None 

Suicide attempts: A=0 vs B=0 vs C=2.3% (4/173), P=0.0162

e country in which it was conducted; it is included in this table as a background article for comparison and discussion purposes.
65

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

 ABSTRACTION FOR PRIMARY STUDIES RELATED TO PHARMACOTHERAPY

rventions Duration N Mean age, % female, race (variance) Outcome definition Results

Adjunctive aripiprazole 11.8 mg/day (mean)Adjunctive placebo

 added to ongoing 

dard antidepressants

6 weeks 362 Age (SD): A=46.5 (10.6), B=44.2 (10.9)

Female: A=61.5%, B=64.2%Caucasian: A=87.4%, B=92.6%Black: A=8.2%, B=5.7% 

Suicide Assessment methods NR

Suicides: None

ch to another SSRI or 

afaxine:

With CBTWithout CBT

12 weeks 334 Mean age, years (SD): SSRI=16.0 (1.6), 

Venlafaxine=15.8 (1.5), No CBT=15.8 (1.6), CBT=16.0 (1.5) 70% Female82% White

Suicide-related symptoms assessed by the Beck Depression Inventory, Suicide Ideation Questionnaire-Jr., and Side Effects Form for Children and Adolescents 

Suicidal self-injury adverse events: No statistically significant treatment effects (rates NR)

Quetiapine 600 mgQuetiapine 300 mgPlacebo

8 weeks 542 Age (SD): A=37.3 (11.4), B=36.6 (11.2), 

C=38.3 (11.1)Female: A=58.2%, B=54.1%, C=62.1%Caucasian: A=84.7%, B=82.0%, C=76.3%Black: A=10.6%, B=13.4%, C=15.4%

Suicide attempts, suicides: Assessment methods NR

Suicide attempts: 0.5% (1/180) vs 0.5% (1/181) vs 0, P-value NRSuicides: None 

Paroxetine 10 mg to 50 mgPlaceboCognitive Therapy

8 weeks 240 Mean age (SD): 40 years (12)

59% Female82% White

Suicide Assessment methods NR

Suicide deaths: A=0.8% (1/120) vs B=0 vs C=0

Fluoxetine aloneCBT aloneCombination of fluoxetine and CBTPlacebo

36 weeks 439 Mean age (SD): 14.6 years (1.5)

54.4% Female73.8% White12.5% African American8.9% Hispanic

Suicide behavior assessed using Columbia-Classification Algorithm for Suicidal Assessment (C-CASA)

12 weeksSuicide deaths: NoneSuicide attempts: A=1.8% (2/109), B=0.9% (1/111), C=1.9% (2/107), D=0% (0/112), “rates are not significantly different” (P not reported)36 weeksSuicide deaths: NoneSuicide attempts: A=6.4% (7/109), B=3.6% (4/111), C=3.7% (4/107), D=5.4% (6/112), P not reported

Paroxetine 10 mgPlacebo

8 weeks 206 Mean age (SD): 12.0 (2.97)

46.8% Female79.3% White20.7% Other race

Suicide Assessment methods NR

Suicide behavior: A=2% (2/104) vs B=0

Escitalopram 10 to 20 mgPlacebo

8 weeks 316 Mean age (SD): A=14.7 (1.6) vs B=14.5 

(1.5)% Female: A=59.4% vs B=58.6%White: A=72.9% vs B=78.3%

Suicide Assessment methods NR

Adverse events suggestive of self-harm, with a suicidal tendency: (A) 0(B) 0.6% (1/157)
66

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

rventions Duration N Mean age, % female, race (variance) Outcome definition Results

SSRI alone (fluoxetine treatment of choice)SSRI plus CBT

28 weeks 208 Mean age (SD): 14.0 years (1.5)

74% Female97% were of white European origin

All acts of self-harm were asked about and recorded. Suicidality was rated based on suicidality items from the K-SADS-PL or the Suicidality/Self-Harm section of the K-SADS-L

Suicide acts:Week 6: SSRI-only=9.2% (9/98) vs SSRI+CBT=5.1% (5/98)Week 12: SSRI-only=8.0% (8/100) vs SSRI+CBT=6.9% (7/101)Week 28: SSRI-only= 6.4% (6/94) vs SSRI+CBT= 7.1% (7/98)Time–treatment interaction: OR 1.002 (95% CI, 0.93 to 1.08)Pooled treatment effect: OR 0.995 (95% CI, 0.45 to 2.21)

BupropionParoxetine

Acute=8 weeksContinuation=16 weeks

78 Mean age, years (SD): A=37.9 (11.9) vs 

B=35.2 (12.8)% Female: A=55.3% vs B=58.3%White: A=68.4% vs B=72.2%

Suicidal events were assessed with the Columbia Suicide History Form (Oquendo 2003)

Suicide deaths: None

Eicosapentaenoic acid 1.2 mg plus docosahexaenoic acid 0.9 mgPlacebo

12 weeks 49 Age, mean: A=30.5 vs B=30.7

65% Female Race NR

Suicidality was measured using the Overt Aggression Scale

No completed acts of suicide during the study period

Citalopram 20 mg plus 

ithium 300 mg

Citalopram 20 mg plus placebo

4 weeks 80 Age, mean: A=45.0 vs B=38.5

% Female: A=47.5% vs B=62.5%% Caucasian: A=72.5% vs B=62.5%

Suicidal behaviors assessed using clinician-administered Sheehan-Suicidality Tracking Scale (S-STS)

Suicide deaths: NoneSuicide attempts: None

Lithium (effective blood 

evel considered 0.6-0.8 

mmol/lPlacebo

1 year 167 A vs B:

Mean age (SD): 39.6 (3.9) vs 39.3 (13.0)61.9% vs 53.0% femaleRace NR

Attempted suicides and deaths by suicide (composite): Suicidal acts assessed by participant report.

Suicide deaths:A=0/84 (0%)B=3/83 (3.6%)Suicide attempts:A=7/84 (8.3%)B=7/83 (8.4%)Suicide attempt or death by suicide (primary endpoint):A=7 (8.3%)B=10 (12.0%)Incidence rate per patient-year: A=12.7%B=21.7%Adjusted HR: 0.52 (0.19 to 1.44); P=0.206Death by suicide (post hoc secondary endpoint):A=0 (0%)B=3 (3.6%)Incidence rate per patient-year: A=0B=6.5%P=0.049
67

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

rventions Duration N Mean age, % female, race (variance) Outcome definition Results

Adjunctive aripiprazole 11.0 mg/day (mean)Adjunctive placebo

 added to ongoing 

dard antidepressants

6 weeks 381 Age (SD): A=44.6 (11.0), B=44.4 (10.7)

Female: A=66.0%, B=67.4%Caucasian: A=89.0%, B=88.9%Black: A=7.3%, B=7.4% 

Suicide: Assessment methods NR

Suicides: None

Lithium 0.6–1.0 mEq/dlValproate 45–125 μg/ml

n-label adjunctive 

ment provided as 

ed, based on algorithm 

2.5 years 98 Age, mean (SD): A=33 (11) vs B=34 

(10)% Female: A=76% vs B=69%% White: A=67% vs B=64%

Suicide completion: selfinflicted death for which there was evidence of at least some intent to end one’s lifeSuicide attempt: potentially self-injurious behavior carried out with at least some intent to end one’s life

Suicide deaths: NoneSuicide attempts: A=12% (6/49) vs B=16% (8/49); P-value not reportedTime to suicide attempt: Log-rank test showed no differences

Escitalopram 10-20 mgPlacebo

8 weeks 268 Mean age (SD): A=12.2 (3.9) vs B=12.4 

(3.0)% female: A=51.9% vs B=51.9%White: A=71.0% vs B=71.4%Black: A=14.5% vs B=12.8%Asian: A=0.8% vs B=1.5%Other: A=13.7% vs B=14.3%

Suicide Assessment methods NR

No suicides

Escitalopram plus placeboEscitalopram plus bupropion SRVenlafaxine XR plus mirtazapine

7 months 665 Mean age (SD): 42.7 years (13.0)

68% Female67% White27.1% Black15.2% Hispanic5.9% Other

Not reported Suicide deaths: None 

Suicide attempts: A=0 vs B=0 vs C=2.3% (4/173), P=0.0162

e country in which it was conducted; it is included in this table as a background article for comparison and discussion purposes only.
68

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K OF BIAS RATINGS FOR PRIMARY STUDIES RELATED TO 

APY

ion 

alment

Blinding of participants, personnel, and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL risk of bias for study as a whole

be 

d

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated 

intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias? Yes/No/Unclear

Low/Unclear/ High

 not 

ed

Unclear Described as double-blind, but no 

information about appearance or whether outcome assessors were blinded. 

Unclear For safety analyses, Intention-to-treat 

(ITT) using Last Observation Carried Forward (LOCF) of all who received double-blind treatment (99%); overall attrition=10%; placebo=9.1% vs aripiprazole=12.1%.

Yes Protocol 

available on clinicaltrials.gov, but minimal detail about outcomes provided. 

Unclear No important 

concerns.

Yes Unclear

tion 

d

Unclear “The intent was for study 

participants, clinicians, and independent evaluators to be blinded to medication treatment assignment, and for independent evaluators to be blinded to CBT assignment.” Use of triple-dummy. “The pharmacotherapists’ accuracy in guessing medication assignment was less accurate than chance (44.2%; 2=4.57; P=.03), whereas the independent evaluators guessed CBT assignment at a rate slightly higher than chance (58.3%; 2=5.14; P=.02). In 64 cases, the blinding of the independent evaluator was compromised, most commonly because of participant disclosure of receiving CBT.” Study was designed to compare the relative efficacy of well-matched treatment alternatives and, therefore, even though patients may have been aware of the type of treatment they were receiving, all treatments were likely perceived as effective treatment methods. 

Participants=yesto meds, no for CBTPersonnel=yesfor meds, no for CBTAssessors=unclear

Missing data, attritions, and exclusions adequately reported. Rates of treatment completion were reported with respect to primary outcomes. ITT using LOCF; attrition: overall=31%, venlafaxine alone=27%, venlafaxine with CBT=36%, SSRI alone=29%, SSRI with CBT=30%.

Yes Protocol 

available on 

clinicaltrials.gov; but planned outcomes were not provided, and all expected suiciderelated outcomes were reported.

Yes Midway through the 

study, the paroxetine treatment option in the SSRI group was changed to citalopram due to safety concerns about paroxetine. Also, midway through the method for monitoring, selfharm was changed from spontaneous report to proactive assessment. No information is provided re: possible nested (e.g., therapist) effects.

Unclear Unclear
69

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ion 

alment

Blinding of participants, personnel, and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL risk of bias for study as a whole

be 

d

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated 

intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias? Yes/No/Unclear

Low/Unclear/ High

m 

as 

ed in 

en

cific 

r 

 

ive 

se 

ran

tion 

Yes Described as double-blind and use 

of identically-appearing tablets is considered sufficient for blindings of study personnel and patient, but no information about blinding of outcome assessor. Also noted that “moderate rates of sedation or somnolence were observed in both quetiapine groups, which might have compromised the integrity of the double-blind design;” but lower likelihood that suicide assessment was influenced by inadequate blinding.

Unclear No missing outcome data. Yes No omissions 

of any expected suicide-related outcomes.

Yes The study appears 

to be free of other sources of bias.

Yes Low

ed.

Unclear Outcome assessors were blinded 

to all treatment conditions. Patients and pharmacotherapists were blinded to pharmacotherapy during first 8 weeks; patients and therapists were not blinded to cognitive therapy assignment.

Outcome assessors= yes.Patients/ therapists in pharmacotherapy groups= unclear.Patients/ therapists in cognitive therapy group=no.

ITT with LOCF; attrition was reasonable (13% in first 8 weeks; 5% in second 8 weeks); numbers and reasons were balanced across groups.

Yes Protocol not 

available.

Unclear None noted. Yes Unclear

tion 

d. Unclear “Participants and all study staff remained masked in the pills-only conditions (FLX and PBO) until 

the end of stage I (week 12). Patients and treatment providers in COMB and CBT were aware of treatment assignment.” “The primary dependent measures rated blindly by an independent evaluator are the Children’s Depression Rating Scale and, for responder analysis, a dichotomized Clinical Global Impressions-Improvement score.” Notably, the study was designed to compare the relative efficacy of well-matched treatment alternatives and, therefore, even though patients may have been aware of the type of treatment they were receiving, all treatments were likely perceived as effective treatment methods. 

Unclear Well-described ITT analysis and 

pre-treatment group comparisons included in article. No missing outcome data reported. Attritions and exclusions adequately documented, and subject flowchart included in article.

Yes No omissions 

of any expected suicide-related outcomes.

Yes The study appears 

to be free of other sources of bias. Welldescribed statistical accounting for potential nested data effects through the use of random effects modeling.

Yes Unclear
70

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ion 

alment

Blinding of participants, personnel, and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL risk of bias for study as a whole

be 

d

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated 

intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias? Yes/No/Unclear

Low/Unclear/ High

tion 

d.

Unclear Described as double-blind, but no 

details provided about appearance of treatments or blinding of outcome assessors.

Unclear ITT using LOCF; overall 

attrition=18%, numbers and reasons balanced across groups.

Yes Protocol 

available on clinicaltrials.gov. Primary outcome was consistent and reported; but only one secondary outcome was listed in protocol and many others were reported in publication. 

Unclear No concerns. Yes Unclear

tion 

d.

Unclear Described as double-blind, but 

no explicit statement about who was blinded. No information about appearance of tablets. 

Unclear ITT using LOCF; safety analyses 

included all patients who received ≥ 1 dose of study medication (99%); efficacy analyses included all patients in safety analyses who had ≥ 1 post-baseline assessment. Attrition: overall=18% in 8-week study; placebo=16%, escitalopram=20%.

Yes Protocol 

available on clinicaltrials.gov, and primary and secondary outcomes match, and were reported.

Yes Free of other sources 

of bias.

Yes Unclear

 

on, 

ed 

ndent 

Yes Participants and treating clinicians: 

not blinded. Outcome assessment done by independent evaluators blind to treatment assignment. Participants, parents and treating clinicians instructed not to disclose treatment assignments. Adequacy of blinding tested by asking evaluators to guess treatment assignment, but results of testing NR.

Participants and treating clinicians=no. Outcome assessors= unclear.

ITT; overall attrition=15%, numbers balanced between groups. Reasons were not separated by group, but predictors of missing data were included as covariates in the statistical analyses.

Yes Protocol not 

available.

Unclear None noted. Yes Unclear

ce 

ed 

cist 

e 

h 

Unclear (probably yes)

Patients, psychiatrists and assessors were blinded to treatment. Pills were identically over-encapsulated so patients were blinded. After 8 weeks, the 16-week continuation phase remained blinded if patient had a satisfactory response; otherwise they were switched to open treatment.

Yes for acute phase; no for those switched to openlabel treatment in continuation phase.

Modified ITT, excluded 5% (3/78 due to ineligibility discovered after randomization, 1/78 lost to followup after randomization visit); high attrition (68%), but balanced across groups in numbers and reasons.

Unclear Protocol not 

available.

Unclear Only 27% completed 

24 weeks on assigned medication.

Yes Unclear
71

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ion 

alment

Blinding of participants, personnel, and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL risk of bias for study as a whole

be 

d

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated 

intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias? Yes/No/Unclear

Low/Unclear/ High

sed 

ndent 

ue; 

nly 

d 

ata 

on 

te.

Yes Identical capsules, ensured equality 

of “fishy breath”.

Yes ITT using LOCF; attrition: 

overall=20%, placebo=26%, omega-3 fatty acid=14%.

Yes Protocol not 

available. All expected suicide-related outcomes were reported.

Yes Free of other sources 

of bias.

Yes Low

 

on, 

ed 

ndent 

cist.

Yes Double-blind: Patients and key 

study personnel. Blinding ensured by use of “closely matching” placebo and matching prescription bottles. Not explicitly stated that clinician was blinded.

Unclear for all ITT using LOCF; Attrition=20%; 

numbers and reasons balanced across groups

Yes Protocol not 

available.

Unclear None noted. Yes Low

ed.

Unclear Double-blinded assessment was 

conducted, although in some cases this procedure could not be maintained because of emergencies in relation to suicidal acts or insufficient drug compliance.

No 56/84 (67%) lithium and 59/83 (71%) 

placebo lost to follow-up by 12 months. Did ITT analysis.Recruitment was only 36% of that estimated required for adequate power 167/468. 7 patients in treatment group and 10 in control group with suicide or suicide attempts were counted as lost to follow-up.

No; although ITT analysis was done, loss to followup was very high. 

Primary outcome was a composite of suicide and suicide attempts; suicidal acts were determined by self-report only. Did a post hoc analysis of deaths by suicides (showing 3 in placebo group vs 0 in lithium group) and this finding is highlighted even though there was no significant difference found on the primary outcome.

No Differences between 

groups at baseline on important prognostic factors: more patients in the lithium group had personality disorders (53% vs 31%; P=0.12); more in the lithium group had multiple prior suicide attempts (57% vs 31%; P=0.001); and patients in the lithium group had higher scores on the suicide intent scale at their index attempt (P=0.046).

No High
72

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ion 

alment

Blinding of participants, personnel, and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL risk of bias for study as a whole

be 

d

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated 

intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias? Yes/No/Unclear

Low/Unclear/ High

 not 

ed.

Unclear Described as double-blind, but no 

information about appearance or whether outcome assessors were blinded.

Unclear For safety analyses, ITT using 

LOCF of all who received doubleblind treatment (100%); overall attrition=15%; placebo=14.7% vs aripiprazole=15.2%.

Yes No protocol 

available.

Unclear No important 

concerns.

Yes Unclear

ed.

Unclear “Patients, study psychiatrists, and 

assessors were blind to treatment assignment.” Double-dummy approach used. Lithium levels monitored by nontreating physician. 

Yes 46/48 lithium and 48/49 valpoate 

included in analysis. Used ITT analysis, but high loss to follow-up and those lost to follow-up had more previous psychiatric hospitalizations and were more likely to report a history of childhood abuse.

Unclear Unclear if study 

protocol is available. No clinicaltrials.gov number provided, but reported all expected outcomes.

Unclear 1) 6 patients were 

eligible but not randomzed reason for not enolling notrepote 2) Power-analysis enrollment target not met. “However, the power analysis was based on an attempt rate much lower than that observed in this study.”

Unclear Unclear

tion 

d.

Unclear Described as double-blind and use 

of identically-appearing tablets. No information about blinding of outcome assessor. 

Participants/personnel: yes. Outcome assessor: unclear.

ITT using LOCF; attrition: overall=19%, numbers and reasons balanced across groups. 

Yes Protocol not 

available.

Unclear No other concerns. Yes Unclear

ed.

Unclear Participants: only blind to second 

medication. Study personnel: not blinded.

Participants: no to first medication, yes to second medication. Study personnel: no.

ITT; attrition: acute phase=23%, continuation phase=12%; reasons for attrition not reported.

Unclear Protocol 

available at clinicaltrials.gov, but explicit identification of specific scales planned to measure primary and secondary outcomes was lacking.

Unclear 2 of 4 suicide 

attempts occurred during the continuation phase; it is possible those who did not continue differed from those who did.

Unclear Unclear

e country in which it was conducted; it is included in this table as a background article for comparison and discussion purposes only.
73

Suicide Prevention Interventions and Referral/Follow-up

Services: A Systematic Review Evidence-based Synthesis Program

APPENDIX L. STRENGTH OF EVIDENCE RATINGS FOR 

PRIMARY STUDIES RELATED TO PHARMACOTHERAPYa

Table 1: Antidepressants vs placebo

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Escitalopram versus placebo (Emslie 2009, Wagner 2006)20, 22

Suicide deaths (Wagner 2006)22

1; 268 Medium

(RCT/Unclear)

N/A Indirect Imprecise No events Insufficient

Adverse events suggestive of self-harm, with a suicidal tendency (Emslie 2009)20

1; 316 Medium

(RCT/Unclear)

N/A Indirect Imprecise 0 vs 0.6% (1/157) Low

Fluoxetine versus placebo (TADS)19, 21, 124, 125

Suicide deaths at 36 weeks

1; 221 Low (RCT/Low) N/A Indirect Imprecise No events Insufficient

Suicide attempts at 36 weeks

1; 221 Low (RCT/Low) N/A Indirect Imprecise 6.4% (7/109) vs 5.4% 

(6/112), P not reported

Low

Paroxetine versus placebo (DeRubeis 2005, Emslie 2006)18, 23

Suicide deaths (DeRubeis 2005)23

1; 180 Low (RCT/Low) N/A Indirect Imprecise 0.8% (1/120) vs 0 Low

Suicide behavior (Emslie 2006)18

1; 206 Low (RCT/Low) N/A Indirect Imprecise 2% (2/104) vs 0 Low

Table 2: Antidepressants vs antidepressants

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Escitalopram plus placebo vs escitalopram plus bupropion SR vs venlafaxine XR plus mirtazapine (Zisook 

2011)25

Suicide deaths

1; 665 Medium 

(RCT/Unclear)

N/A Indirect Imprecise No events Insufficient

Suicide attempts

1; 665 Medium 

(RCT/Unclear)

N/A Indirect Imprecise 0 vs 0 vs 2.3%, 

P=0.0162

Low

Bupropion vs paroxetine (Grunebaum 2011)24

Suicide deaths

1; 78 Medium 

(RCT/Unclear)

N/A Indirect Imprecise No events Insufficient
74

Suicide Prevention Interventions and Referral/Follow-up

Services: A Systematic Review Evidence-based Synthesis Program

Table 3: Antidepressants alone vs antidepressants plus Cognitive Behavioral Therapy (CBT)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Fluoxetine alone vs fluoxetine plus CBT (TADS)19, 21, 124, 125

Suicide deaths at 36 weeks

1; 216 Medium 

(RCT/Unclear)

N/A Indirect Imprecise No events Insufficient

Suicide attempts at 36 weeks

1; 216 Medium 

(RCT/Unclear)

N/A Indirect Imprecise 6.4% vs 3.7%, P not 

reported

Low

Switch to another SSRI or venlafaxine, with or without CBT (TORDIA)26, 126

Suicidal self-injury adverse events at 12 weeks

1; 334 Medium 

(RCT/Unclear)

N/A Indirect Imprecise No statistically 

significant treatment 

effects (rates NR)

Low

SSRI alone (fluoxetine treatment of choice) vs SSRI plus CBT (ADAPT)27

Suicide acts at 28 weeks

1; 208 Medium 

(RCT/Unclear)

N/A Indirect Imprecise 6.4% vs 7.1% Low

Table 4: Antidepressants versus Cognitive Behavioral Therapy (CBT)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Antidepressants versus CBT (DeRubeis 2005)23

Suicide deaths

1; 180 Medium 

(RCT/Unclear)

N/A Indirect Imprecise 0.8% vs 0 Low
75

Suicide Prevention Interventions and Referral/Follow-up

Services: A Systematic Review Evidence-based Synthesis Program

Table 5: Atypical Antipsychotics 

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Quetiapine (Calabrese 2005)28

Suicide attempts 

1; 542 Low (RCT/Low) N/A Indirect Imprecise 0.5% (1/180) vs 0.5% 

(1/181) vs 0, P-value 

NR

Low

Suicides

1; 542 Low (RCT/Low) N/A Indirect Imprecise No events Low

Aripiprazole (Berman 2007, Marcus 2008)29, 30

Suicides

2; 743 Medium 

(RCT/Unclear)

Consistent Indirect Imprecise No events Low

Clozapine (Glick 2004 & Meltzer 2003 as cited in Mann 2005)10

Unclear outcome in Mann 200510

2; not 

reported

Medium 

(RCT/Unclear due to 

lack of report)

Consistent Indirect N/A Not reported Insufficient 

to Low

Table 6: Mood stabilizers

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Lithium versus valproate (Oquendo 2011)32

Suicide deaths

1; 98 Medium 

(RCT/Unclear)

N/A Indirect Imprecise No events Insufficient

Suicide attempts

1; 98 Medium 

(RCT/Unclear)

N/A Indirect Imprecise 12% (6/49) vs 16% 

(8/49)

Low

Time to suicide attempt

1; 98 Medium 

(RCT/Unclear)

N/A Indirect Imprecise Log-rank test showed 

no differences

Low

Citalopram plus lithium versus citalopram plus placebo (Khan 2011)33

Suicide deaths

1; 80 Low (RCT/Low) N/A Indirect Imprecise No events Insufficient

Suicide attempts

1; 98 Low (RCT/Low) N/A Indirect Imprecise No events Insufficient
76

Suicide Prevention Interventions and Referral/Follow-up

Services: A Systematic Review Evidence-based Synthesis Program

Lithium versus placebo (Lauterbach 2008)34

Suicide deaths

1; 167 High (RCT/High) N/A Indirect Imprecise 0% (0/84)

 3.6% (3/83)

Incidence rate per 

patient-year: 

0% vs 6.5% 

P=0.049

Insufficient

Suicide attempts

1; 167 High (RCT/High) N/A Indirect Imprecise 8.3% (7/84)

8.4% (7/83)

Not significant

Insufficient

Composite of suicide attempt/suicide death

1; 167 High (RCT/High) N/A Indirect Imprecise Adjusted HR: 0.52 

(0.19 to 1.44); 

P=0.206

Insufficient

Lithium (Theis-Flechtner 1996 as cited in Mann 2005)10

Unclear outcome in Mann 2005

1; not 

reported

Medium (RCT/

Unclear due to lack of 

report)

N/A Indirect N/A Not reported Insufficient to 

Low

Table 7: Omega-3 fatty acid supplementation vs placebo (Hallahan 2007)35

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias 

(Design/ Risk of 

bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Suicide deaths

1; 49 Low (RCT/Low) N/A Indirect Imprecise No events Insufficient

a

 This review did not evaluate any outcomes other than suicidal self-directed violence and, therefore, no additional 

data on potential harms and side effects was investigated. Potential harms and side effects should always be 

considered when evaluating the strength of evidence and considering adoption of an intervention or referral/followup service.
77

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

LITY RATING OF SYSTEMATIC REVIEWS RELATED TO PSYCHOTHERAPY 

D GUYATT15 CRITERIA

ehensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Can’t tell; reported that 6 

studies did not meet the quality criteria, but did not specify which studies, which criteria, and did not appear to do any type of sensitivity analysis. 

Yes Yes Yes 5

ental 

Yes No; detailed 

results of study selection not reported, no reasons for exclusions described.

No Can’t tell; within GRADE 

evaluation of quality of evidence, deducted points for internal validity limitations; but, unclear as to the scope of the internal validity domains assessed. 

Yes Yes Yes 3

y 

d one 

e, though 

base 

s multiple 

tabases.

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes; study flow 

diagram provided reasons for exclusion.

Yes Yes; reported results of 

validity assessment; none were poor, not necessarily a need to control for variation in synthesis.

Yes Yes Yes 7

ental 

Yes Can’t tell; 

numbers and reasons for exclusions not reported

No Yes, validity assessment 

included in GRADE strength of evidence ratings

Yes; used GRADE approach to rate strength of evidence

Yes Yes 5

ental 

No; no information on PICOTS.

Can’t tell; only reported number of included studies.

No; none described; only use of Shekelle 1999123 scheme for 

classifying study design and strength of recommendation, but no quality assessment

No Yes; used 

Shekelle 1999123 

scheme for classifying study design and strength of recommendation

Yes Yes 3
78

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ehensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7Yes Can’t tell; 

detailed results of study selection not reported, no reasons for exclusion described.

Yes No; reported validity 

assessment, but did not do any type of analysis with it.

Yes Yes Yes 5

Yes Can’t tell; detailed 

results of study selection not reported, no reasons for exclusions described.

No No validity assessment. No No Can’t tell; data 

not reported for all studies.

2

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7Yes Can’t tell; 

numbers of exclusions reported at each stage, but reasons not reported.

Yes No; reported results of 

validity assessment in table and paragraph, but did not appear to account for variation in synthesis.

Yes No; only 1 

comparison with >1 study; and did not combine data and did not explain reasons for this.

Yes 4
79

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ehensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

eral 

es were 

Can’t tell; RCTs were the main focus but of necessity; it also considered other categories of investigations of the outcome of treatment.

No; no information related to number of articles found, included, and excluded.

No; did not describe criteria used to differentiate between good and deficiencies.

Yes; critical assessment of the quality of design, conduct and analysis of the studies was performed and reported according to authors’ constructed schema of level of evidence.

Yes Yes; report of 

findings follow simplified scheme of evidence constructed by authors.

Yes 4

y 

d one 

e, though 

base 

s multiple 

tabases.

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7

and

g, 

e list 

g, or asking 

noted.

Yes No Yes Yes No Yes Yes 4

and

g, 

e list 

g, or asking 

noted.

Yes Yes Yes Yes Yes Can’t tell. Yes 6

and

g, 

e list 

g, or asking 

noted.

Yes Yes Yes Yes No No No 3Yes Yes; study 

flow diagram in Pediatrics publication,99

reasons for exclusion for individual trials provided in Evidence Report.98

Yes Yes; excluded poor quality 

studies.

Yes Yes; did not 

conduct metaanalyses due to heterogeneity

Yes 7
80

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

A ABSTRACTION OF PRIMARY STUDIES OBTAINED FROM GOOD QUALITY 

EWS RELATED TO PSYCHOTHERAPY

abases 

atic review Eligibility criteria in systematic review

Study designs of eligible studies

Countries included in eligible studies

Sample size in eligible studies

Population in eligible studies

Interventions in eligible studies

Main results of eligible studies

 

ces; 

, CIHAHL, 

 DARE, 

database 

All RCTs in which short-term psychodynamic psychotherapies was compared with wait-list controls, minimal treatment controls which had been designated as psychological “placebo treatments,” and treatments as usual; adult outpatients with common mental disorders (excluding psychotic disorders)

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

ry 2003; 

ember 

ober 2002; 

ary 2003; 

cialist 

Clinical RCTs with or without blinding involving psychological treatments (behavioral, cognitivebehavioral, psychodynamic, and psychoanalytic) for adults with a diagnosis of borderline personality disorder

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

nia Group 

ase 

009

Randomized clinical trials focused on people with severe mental illness ages 18-65 years; community care setting; intensive case management (ICM) compared to non-ICM or standard care

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

, Cochrane 

980-March 

RCTs predominantly including adolescents aged 11-18 years with a DSM-IV defined episode of depression where CBT was combined with a newer generation antidepressant and compared with antidepressant treatment without CBT

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

nia Group’s 

98-January 

ches in past 

w

RCTs and quasi-RCTs; patients with schizophrenia or other serious mental illness presenting to or referred to a social/psychiatric/ nursing service because they were experiencing a psychosocial crisis, however defined (excluded people in crisis with drug-induced psychosis or in a depressive crisis)

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

EMBASE, 

y, 

OCIAL 

INDEX, 

r of 

ntions 

of Public 

Reviews 

CTR, 

not reported

RCTs published from 1996 onwards in the English language that at least measured depression, anxiety, or suicidality following an intervention based on cognitive behavioral techniques delivered within secondary schools to young people aged 11-19 

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

s Register, 

 PsycINFO: 

anuary 2006

Relevant RCTs and quasi-RCTs; people with the diagnosis of serious mental illness (including “serious/chronic mental illness” or “psychotic illness”), however diagnosed

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs
81

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

abases 

atic review Eligibility criteria in systematic review

Study designs of eligible studies

Countries included in eligible studies

Sample size in eligible studies

Population in eligible studies

Interventions in eligible studies

Main results of eligible studies

 PsycINFO, 

eption to 

RCTs of depressed participants aged 5-18 treated with CBT, CBT+separate parenting sessions, interpersonal psychotherapy, psychoanalytic/psychodynamic child psychotherapy, self-modeling, relaxation, social skills training, family therapy, guided self-help, or control enhancement training, and that reported remission, symptom levels, functional status or discontinuation from treatment for any reason outcomes. 

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

 CCRCT, 

ology 

e, DARE, 

e, 

ober 2009; 

alist 

Experimental or quasi-experimental designs; mental health-based, suicide prevention-focused intervention initiated in the ED or immediately after ED discharge through direct referral/enrollment; children and adolescents (≤18 years), or their parents or ED personnel; ≥1 clinically relevant primary outcome

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

nia Group 

ptember 

Relevant RCTs or quasi-RCTs; studies where most (>75%) families included at least one member with a diagnosis of schizophrenia and/or schizoaffective disorder

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

nia Group 

y 2009

Relevant RCTs; people aged 18-65 years and suffering from illness such as schizophrenia, schizophrenia-like disorders, and bipolar disorder (excluding acutely ill patients)

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

Library, 

5-May 2008

English language; suicide or suicide attempt outcomes; no mental health interventions such as psychotherapy or pharmacotherapy unless they included Veterans

One RCT:Unutzer 2006

US 1,801 Non-Veteran/

military; no other data reported

Collaborative care model including case management in a primary care setting

No suicides in either treatment or control group

 

nuary 

English language; human; suicide related outcome; sample size ≥6; no duplication; emergency department or other acute care setting

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

INE, 

 2006

Patients aged 7-18 years with MDD or depression NOS; primary care setting, school-based clinics; English language only; excluded poor quality studies

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs
82

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

MARY OF SYSTEMATIC REVIEW RESULTS RELATED TO PSYCHOTHERAPY 

 AL., MANN ET AL., AND NICE REVIEWS9-11

Gaynes 20049 Mann 200510 NICE 201111

neralizability of the studies makes the overall 

evidence fair, at best, while the results are 

ugh some trends suggest incremental benefit 

 interventions, no consistent statistically 

ffects have emerged for interventions for 

than one study has been done.

Interventions need more evidence of efficacy. Compared with usual care, there was insufficient 

evidence to determine clinical effects between interventions and routine care in the reduction of the proportion of patients who repeated self-harm. Thus, no conclusions could be made regarding psychosocial interventions on reduction of repetitions of self-harm. For the outcome of suicide, no conclusions could be drawn due to the small evidence base.

Scope 

er 2002 1966-June 2005 Up to January 2011

of interest was primary care patients with 

nidentified suicide risk. Included RCTs were 

n high-risk groups as identified by a deliberate 

pisode, diagnosis of borderline personality 

admission to a psychiatric unit.

Not specified Adults, children, and young people with previous selfharm behavior

erapy, psychotherapy, referral/follow-up Pharmacotherapy, psychotherapy, referral/follow-up Pharmacotherapy, psychotherapy, referral/follow-up

pletions, suicide attempts Completed and attempted suicide Primary outcome was repetition of self-harm; also 

included suicide outcomes.

pecialty care settings; no exclusions based 

Included settings not specified; no exclusions based on country.

No exclusions by country

s targeting patients with chronic psychotic 

udies without adequate comparison groups.

No additional exclusion criteria specified.

Main results: Psychotherapy

10 studies were combined, though study heterogeneity suggests that results should be interpreted with caution. Repetition of self-harm (up to 6 months, 2 studies): Less people from the treatment group had a repetition of self-harm compared with the TAU group; low quality. Repetition of self-harm (6 to 12 months, 5 studies): Less people from the treatment group had a repetition of self-harm compared with the TAU group; moderate quality. Repetition of self-harm (more than 12 months, 2 studies): Less people from the treatment group had a repetition of self-harm compared with the TAU group; low quality. Repetition of self-harm (at last follow-up, 9 studies): There was a statistically significant 24% reduction in chance of repetition in the treatment group compared with TAU; low quality.

nt difference in repeated suicidal behavior in 

study.

Cognitive therapy halved the reattempt rate in suicide attempters in one RCT.

Manual Assisted Cognitive Treatment: One study showed a non-significant reduction in self-harm, another showed a significant reduction. Results should be interpreted with caution due to study limitations.
83

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

Gaynes 20049 Mann 200510 NICE 201111

howed a reduction in repetition of deliberate 

 female veterans with borderline personality 

Reduced suicidal behavior in people with borderline personality disorder.

DBT: The evidence showed some benefit in reducing rates of self-harm.

Fewer suicide attempts.

herapy group were less likely to have a 

isode of deliberate self-harm.

Fewer suicide attempts.

e between groups.

is of 5 studies showed a trend toward 

repetition of deliberate self-harm.

Fewer suicide attempts.

nts in the treatment group had attempted 

6-month follow-up.

Reduced suicidal behavior in people with borderline personality disorder.

Transference focused psychotherapy vs treatment by community psychotherapists: Significantly fewer attempted suicides in transference focused therapy group, but no difference in reduction of self-harm in either group. Results should be interpreted with caution due to study limitations.

No benefit in terms of re-attempt rate when compared to standard care.

Main results: Comparative effectiveness of different types of therapy

No significant difference in repetition of self-harm in the year following treatment entry.

e between groups. Insufficient evidence to determine clinical differences 

between groups for repetition of self-harm.Insufficient evidence to determine clinical differences between groups for repetition of self-harm. No suicides in either group.

e between groups. Insufficient evidence to determine clinical differences 

between groups for repetition of self-harm. 

or continuity of care. Limited evidence suggesting that there was a clinically 

significant difference favoring different therapist over same therapist on reducing the likelihood of repetition of self-harm.
84

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

CRIPTION OF PRIMARY OUTCOMES AND INTENT TO TREAT SUICIDAL 

IOLENCE FOR PSYCHOTHERAPY STUDIES

ear)

N Outcome definition Results

s 

ts.

41 Suicidal behavior: 1) deliberate, 2) 

life-threatening, 3) resulted in medical intervention, and 4) medical assessment consistent with a suicide attempt. Self-harm: 1) deliberate, 2) resulted in visible tissue damage, and 3) nursing or medical intervention required.

Any suicide attempt: MBT=5/22 (23%) vs TAU=14/19 (74%); χ2 (df=1)=8.7, P=0.003; effect size d=2.0 (95% CI, 1.4 to 4.9)Mean total number of suicide attempts (SD): MBT=0.05 (0.9) vs TAU=0.52 (0.48); U=73, z=3.9, P=0.00004; effect size d=1.4 (95% CI, 1.3 to 1.5)

y was 

up 

al 

3) 

134 Suicidal behavior: 1) deliberate, 2) 

life-threatening, 3) resulted in medical intervention, and 4) medical assessment consistent with a suicide attempt. Selfharm: 1) deliberate, 2) resulted in visible tissue damage, and 3) nursing or medical intervention required. Outcomes assessed at 6, 12, and 18 months

Life-threatening suicide attempts: (A) Proportion with episode=N/%; (B) Average count=Mean(SD)After 6 months: MBT=(A) 37/52.1%, (B) 0.62 (0.74) vs SCM=(A) 33/52.4%, (B) 0.70 (0.81)After 12 months: MBT=(A) 23/32.4%, (B) 0.36 (0.57) vs SCM=(A) 30/47.6%, (B) 0.60 (0.77)After 18 months: MBT=(A) 2/2.8%, (B) 0.03 (0.17) vs SCM=(A) 16/25.4%, (B) 0.32 (0.62)Proportion with episode analysis: Wald χ2 (df=3):76.21, P<0.001Change over time=OR 0.41 (95% CI, 0.30 to 0.57); Group effect over time=OR 0.37 (95% CI, 0.21 to 0.62)At 12 months=RR 0.68 (95% CI, 0.44 to 1.04)In last 6 months=RR 0.11 (95% CI, 0.02 to 0.46)End of treatment difference= d=0.65 (95% CI, 0.58 to 0.73)Average count analysis: Wald χ2 (df=3):212.56, P<0.001Change over time=IRR 0.70 (95% CI, 0.62 to 0.80)Group effect over time=IRR 0.63 (95% CI, 0.53 to 0.75)Severe self-harm incidents: (A) Proportion with episode=N/%; (B) Average count=Mean (SD)After 6 months: MBT=(A) 53/74.6%, (B) 2.61 (3.08) vs SCM=(A) 37/58.7%, (B) 1.79 (2.62)After 12 months: MBT=(A) 26/36.6%, (B) 1.30 (2.47) vs SCM=(A) 37/58.7%, (B) 1.73 (2.27)After 18 months: MBT=(A) 17/23.9%, (B) 0.38 (0.83) vs SCM=(A) 27/42.9%, (B) 1.66 (2.86)Proportion with episode analysis: Wald χ2 (df=3):62.77, P<0.001Change over time=OR 0.49(95% CI, 0.35 to 0.69); Group effect over time=OR 0.39 (95% CI, 0.23 to 0.66)First 6 months: RR 1.27 (95% CI, 0.99 to 1.63)6 to 18 months: RR NR, but “MBT showed steeper decline”In last 6 months=RR 0.55 (95% CI, 0.33 to 0.92)End of treatment difference= d=0.62 (95% CI, 0.28 to 0.97)Average count analysis: Wald χ2 (df=3):224.11, P<0.001Change over time=IRR 0.74 (95% CI, 0.65 to 0.85)Group effect over time=IRR 0.69 (95% CI, 0.59 to 0.82)
85

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ear)

N Outcome definition Results

e 

cts.

165 Data on suicide attempts and self-harm acts 

were collected at 1, 3, 6, 9 and 12 months. Outcome criteria were not defined.

Not reported separately by treatment group:Suicide attempts: 24 (22.2%), median number of attempts was 1.75 per year, and the mean 

was 2.60Self-harm acts: 56 (45.2%), the median number of acts was 9.8 per year, and the mean was 

16.6Cox proportional hazards analysis: treatment group was not associated with time to first suicide attempt (χ2<0.1, df=1, p=0.994) or first self-harm act (χ2<0.1, df=1, p=0.902)

and 

32 Suicide attempts and self-inflicted injuries 

were categorized using the Suicide Attempt and Self-Injury Count SASI-C (Linehan 1996) at all follow-up assessments conducted at 2, 4, 6 and 12 months.

2 months: mean (SD)Suicide attempts/self-inflicted injuries: CAMS=N/A vs E-CAU=5.5 (7.8)ED admissions: CAMS=N/A vs E-CAU=0.5 (0.7)Behavioral health ED admissions only: CAMS=N/A vs E-CAU=1.1 (0.6)Number of inpatient days: CAMS=N/A vs E-CAU=4.0 (5.7)4 months: mean (SD)Suicide attempts/self-inflicted injuries: CAMS=0.0 (0.0) vs E-CAU=0.8 (1.8)ED admissions: CAMS=0.4 (0.5) vs E-CAU=0.4 (0.7)Behavioral health ED admissions only: CAMS=0.1 (0.4) vs E-CAU=0.4 (0.7)Number of inpatient days: CAMS=1.4 (2.5) vs E-CAU=1.0 (2.3)6 months: mean (SD)Suicide attempts/self-inflicted injuries: CAMS=0.2 (0.4) vs E-CAU=0.0 (0.0)ED admissions: CAMS=0.4 (0.5) vs E-CAU=0.2 (0.4)Behavioral health ED admissions only: CAMS=0.2 (0.4) vs E-CAU=0.2 (0.4)Number of inpatient days: CAMS=3.5 (7.0) vs E-CAU=1.3 (4.6)12 months: mean (SD)Suicide attempts/self-inflicted injuries: CAMS=1.2 (3.9) vs E-CAU=3.3 (7.6)ED admissions: CAMS=0.4 (0.8) vs E-CAU=1.0 (2.4)Behavioral health ED admissions only: CAMS=0.2 (0.4) vs E-CAU=0.6 (1.6)Number of inpatient days: CAMS=1.4 (4.5) vs E-CAU=3.2 (8.0)

al 

me.

106 Suicidal acts over 6 years, recorded 

using the Acts of Deliberate Self-Harm Inventory, which requires fulfillment of all 3 of the following criteria: 1) deliberate, 2) life threatening, and 3) the act resulted in medical intervention or intervention would have been warranted.

0-12 months (N=101)Subjects with suicidal acts: CBT= 18 (37%) vs TAU= 21 (46%). OR= 0.77 (95% CI ; 0.29 to 2.01)Mean episodes of suicidal acts (SD): CBT= 0.61 (0.95) vs TAU= 1.02 (2.14); adjusted Mean Difference (aMD)= −0.36 (95% CI, −0.83 to 0.13)0-24 months (N=102)Subjects with suicidal acts: CBT= 23 (43% ) vs TAU= 26 (54%). OR= 0.78 (95% CI ; 0.30 to 1.98)Mean episodes of suicidal acts (SD): CBT= 0.87 (1.47) vs TAU= 1.73 (3.11); aMD= −0.91 (95% CI, −1.67 to −0.15)0-6 years (N=76)Subjects with suicidal acts: CBT= 56% (n = 24/43) vs TAU= 73% (n = 24/33); aOR = 0.37 (95% CI, 0.10 to 1.38)Mean episodes of suicidal acts (SD): CBT= 1.88 (3.19) vs TAU= 3.03 (4.16); aMD (TAU-CBT) = 1.26 (95% CI, -0.06 to 2.58)
86

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ear)

N Outcome definition Results

cale 

 

60 (22 completed 12 months of treatment)

Questions on functioning in life domains, health service use, and professional contacts determined in structured interviews with trained clinical psychologists, who performed the examinations (including selfreport scales) at 6-monthly intervals; the first being immediately following discharge.

No suicides in the 12-month follow-up period.Self-harming behaviors (ICM vs TAU)6 months: 3/14 (21.4%) vs 1/8 (12.4%)12 months: 2/14 (14.3%) vs 2/8 (25.0%)P-values not reported

ified 

66 Clinical status monitored weekly using the 

SIQ-JR and BDI-II, administered either face-to-face (ABFT) or over the phone (EUC). Definition of “low lethality suicide attempts” not reported.

Low lethality suicide attempts: ABFT=11% (4/35); EUC=22% (7/31); p not reported

nt 

ents 

rs.

39 Outcome measures were administered 3 

months (end of active treatment) and 6 months (end of maintenance).

N=31Reattempts at 6 months: SBT=26.7% (4/15) vs SRT=12.5% (2/16); χ2=1.00 The difference in rates of suicide reattempts among those taking (n = 6/6) vs not taking (n = 0/25) medication was statistically significant: χ2=7.95, P < .05

 

self

t 

366 Primary outcome was the frequency of 

episodes of self-harm (includes non-suicidal self-harm).

3 episodes of self-harm resulting in severe physical injury (2 usual care, 1 group therapy). No suicides or other deaths.
87

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ear)

N Outcome definition Results

 was 

ith 

 the 

1094 Obtained from the New Zealand Health 

Information Service details of hospital contacts throughout New Zealand in the year after the index attempt. Data obtained from the National Minimum Dataset kept by the New Zealand Health Information Service, which contains routinely collected information on all public and private hospital discharges in New Zealand.

Consenting PatientsParticipants re-presenting to hospital for self-harm; PST+TAU vs TAU:All index episodes (N=253 vs 299): 14.2% vs 17.1%; RR=0.17 (95% CI -0.24 to 0.44); P=0.43Index episode is first self-harm episode (N=137 vs 169): 13.9% vs 8.9%; RR=-0.56 (95% CI -1.96 to 0.18); P=0.23Index episode is repeat episode (N=116 vs 130): 14.7% vs 27.7%; RR=0.47 (95% CI 0.11 to 0.69); P=0.02; NNT=8Participants with self-reported self-harm; PST+TAU vs TAU:All index episodes (N=186 vs 226): 27.4% vs 32.7%; RR=0.16 (95% CI -0.13 to 0.38); P=0.29Index episode is first self-harm episode (N=98 vs 122): 25.5% vs 20.5%; RR= -0.25 (95% CI -1.03 to 0.24); P=0.47Index episode is repeat episode (N=88 vs 104): 29.5% vs 47.1%; RR=0.37 (95% CI 0.08 to 0.57); P=0.02; NNT=6Time to re-presentation to hospital, days : median; PST+TAU vs TAU:All index episodes: 56 vs 83; HR=0.81 (95% CI 0.53 to 1.25); P=0.92Index episode is first self-harm episode: 62 vs 75; HR=1.62 (95% CI 0.82 to 3.18); P=0.16Index episode is repeat episode: 45 vs 104; HR=0.47 (95% CI 0.26 to 0.85); P=0.01All PatientsParticipants re-presenting to hospital for self-harm; PST+TAU vs TAU:All index episodes (N=522 vs 572): 13.4% vs 14.1%; RR=0.05 (95% CI -0.28 to 0.30); P=0.79Index episode is first self-harm episode (N=314 vs 360): 13.4% vs 9.4%; RR=-0.42 (95% CI -1.17 to 0.08); P=0.37Index episode is repeat episode (N=208 vs 212): 13.5% vs 22.1%; RR=0.39 (95% CI 0.07 to 0.60); P=0.03; NNT=12Time to re-presentation to hospital, days : median; PST+TAU vs TAU:All index episodes: 74 vs 75; HR=0.98 (95% CI 0.71 to 1.36); P=0.92Index episode is first self-harm episode: 74 vs 61; HR=1.55 (95% CI 0.98 to 2.48); P=0.06Index episode is repeat episode: 80 vs 114; HR=0.58 (95% CI 0.36 to 0.94); P=0.03

 

f 

72 Defined as any intentional self-inflicted 

injury (including poisoning) irrespective of the apparent purpose of the behavior, based on an interview-based assessment of suicide behavior (Kerfoot 1992, Linehan 1999).

Repetition of Deliberate Self-harm by 6 months: GT = 88% (30/34); RC = 68% (23/34); p = 0.04Repetition of Deliberate Self-harm in interval of 6 to 12 months: GT = 88% (30/34); RC = 71% (24/34); p = 0.07

111 The Suicide Attempt Self-Injury Interview 

(Seligman 2006) measured the topography, suicide intent, and medical severity of each suicide attempt and nonsuicidal self-injury. Assessments completed at 4-month intervals during the 12-month treatment and 12 months of post-treatment follow-up periods by blinded, independent clinical assessors with master’s or doctoral degrees.

Median suicides (interquartile range): DBT=0 (0 to 0) vs CTBE=0 (0 to 1)Suicide attempts: DBT=23.1% vs CTBE=46%, P=0.01, HR=2.66 (95% CI not reported; P=0.005), NNT=4.24 (95% CI, 2.40 to 18.07)Nonambivalent suicide attempts: DBT=5.8% vs CTBE=13.3%, P=0.18, NNT=13.3 (95% CI, 5.28 to 25.41)Suicide attempts per period: Significantly fewer in the DBT group across the 2 years when controlling for number of suicide attempts during the pretreatment year (F1,94=3.20, P=.04, MMANOVA)Mean proportions of suicide attempters per period: DBT=6.2% (95% CI, 3.1% to 11.7%) vs CTBE=12.2% (95% CI, 7.1% to 20.3%)
88

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ear)

N Outcome definition Results

 

y 

nd 

180 Assessed every 4 months by the Suicide 

Attempt Self-Injury Interview (M.M. Linehan et al., unpublished 1983 manuscript).

Deaths by suicide: NoneMean number of suicidal and self-injurious episodes (SD): OR 0.92 (P=0.76)4 months: DBT=10.60 (20.96) vs GPM=14.02 (43.87)8 months: DBT=8.94 (19.07) vs GPM=11.44 (37.59)12 months: DBT=4.29 (9.32) vs GPM=12.87 (51.45)

 was 

pital 

32 (sample size is unclear)

Hospital chart audits recorded representation to the hospital for suicide attempts.

Average number of suicide attempts:CBT: 0.22 (SD=0.64)PST: 0.33 (SD=0.63)TAU: 0.22 (SD=0.50)No significant differences found for repetition of suicide attempts when PST group was compared to TAU (U=35, ns, r=0.13) and when CBT was compared to TAU (U=25, ns, r=0.32)

e 

ior 

s 

the 

278 Deaths for any reason identified from 

hospital and psychiatric notes. Suicides and possible suicides (where the death might have been intentional or accidental and the coroner ruled the death was accidental) were identified.Suicide ideation and behavior (combined) assessed by the non-accidental self-injury scale of the HoNOS (Health of the Nation Outcome Scales). Serious risk (score of 4) indicates suicidal attempts or deliberate self-harm. Assessed at 6 weeks, 3 months, and 18 months.

Over 18 months, there were 3 definite suicides (1.2%), 2 in the supportive counseling group and 1 in CBT group. 4 further deaths classified as accidental by the coroner (1 traffic accident, 1 fall from window, 1 in supportive counseling group, 1 in CBT group). 2 deaths by natural causes. Numbers too small for meaningful statistical analysis.On the HoNOS, there were no significant differences between the 3 treatment groups at any time point. Psychological treatment did not significantly reduce or worsen suicidal behavior compared to treatment as usual. There was a marked reduction in suicidal behavior after admission that would mask any potential treatment effect.

ified 

1801 Primary outcome was suicidal ideation. 

No information on how deaths were ascertained.

117 participants died before the 24-month follow-up; 61 of them (52%) were in the intervention group. To the authors’ knowledge, there were no suicides in either group during the 2-year study period.

s 

rds 

e also 

odes 

s 

eir 

40 Primary outcomes were measure of suicidal 

ideation and depression.For assessment of self-harm, records from the Accident and Emergency departments involved in the study were monitored for repeat episodes of self-harm in the 3 years following their initial presentation.

Repetition of deliberate self-harm, intervention vs control:At 1 year: 17% vs 36% (P=0.12)At 3 years: 35% vs 53% (P=0.18)At 5 years: 39% vs 58% (P=0.15)No repetition within 5 years: 61% vs 42% (P not reported)3 of the episodes eventuated in suicide death (1 intervention, 2 control)
89

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

A ABSTRACTION FOR PRIMARY STUDIES RELATED TO PSYCHOTHERAPY

n 2008117 (UK)

th borderline personality disorder

partial hospitalization consists of 18-month individual and group psychotherapy in a partial hospital setting offered within a structured and integrated program 

 by a supervised team. Expressive therapy using art and writing groups is included. Crises are managed within the team; medication is prescribed according to by a psychiatrist working in the therapy program. The understanding of behavior in terms of underlying mental states forms a common thread running across 

ts of treatment. The focus of therapy is on the patient’s moment-to-moment state of mind. The patient and therapist collaboratively try to generate alternative 

ives to the patient’s subjective experience of himself or herself and others by moving from validating and supportive interventions to exploring the therapy 

hip itself as it suggests alternative understanding. This psychodynamic therapy is manualized (17) and in many respects overlaps with transference-focused 

erapy. At the end of 18 months, the MBT by partial hospitalization patients were offered twice-weekly outpatient mentalizing group psychotherapy for a further 18 

nt as usual (TAU) consists of general psychiatric outpatient care with medication prescribed by the consultant psychiatrist, community support from mental health 

and periods of partial hospital and inpatient treatment as necessary but no specialist psychotherapy. After 18 months, the TAU group continued with general 

ric care with psychotherapy but not MBT if recommended by the consultant psychiatrist.

ified

ospital program

mental health professionals

hs

=22, TAU=19): MBT=30.3 years (5.86), TAU=33.3 years (6.60)

e: MBT=68%, TAU=47%

R

rted

on years (SD)

essants: MBT=1.1 (1.8) vs TAU=3.3 (2.3) F (df=1, 35)=11.6, P= 0.002; effect size 1.10 (95% CI, 0.45 to 1.70)

hotics: MBT= 0.16 (0.28) vs TAU= 3.1 (2.1); U=9.0, z=5.4, P=0.0000000005; effect size= 2.04 (95% CI, 1.60 to 2.50)

abilizers: MBT=0.11 (0.26) vs TAU=1.8(2.1); U=105.0, z=3.2, P=0.001; effect size=1.17 (95% CI, 0.73 to 1.60)

 more drugs (including hypnotics): MBT=0.02 (0.11) vs TAU=1.9 (1.9); U=58.5, z=4.6, P=0.0000009; effect size=1.45 (95% CI, 1.10 to 1.80)

of suicide attempts over the whole of the 5-year postdischarge follow-up period. Suicidal behavior: 1) deliberate, 2) life-threatening, 3) resulted in medical 

ion, and 4) medical assessment consistent with a suicide attempt. 

m: 1) deliberate, 2) resulted in visible tissue damage, and 3) nursing or medical intervention required.

de attempt: MBT=5/22 (23%) vs TAU=14/19 (74%); χ2 (df=1)=8.7, P=0.003; effect size d=2.0 (95% CI, 1.4 to 4.9)

al number of suicide attempts (SD): MBT=0.05 (0.9) vs TAU=0.52 (0.48); U=73, z=3.9, P=0.00004; effect size d=1.4 (95% CI, 1.3 to 1.5)

n 200937 (UK)

th borderline personality disorder

cused on helping patients reinstate mentalizing during a crisis via telephone contact and included: 1) once-weekly individual psychoanalytic psychotherapy; 

weekly group analytic psychotherapy (1 hour each); 3) once-a-week expressive therapy oriented toward psychodrama techniques (1 hour); and 4) a weekly 

ity meeting (1 hour), all spread over 5 days. In addition, on a once-per-month basis, subjects had: 5) a meeting with the case administrator (1 hour); and 6) 

on review by the resident psychiatrist. 

cused on support and problem solving, and included weekly combined individual and group psychotherapy and psychiatric review every 3 months. Therapy was 

n a counseling model closest to a supportive approach with case management, advocacy support, and problem-oriented psychotherapeutic interventions.

al types and doses of medication were the same for both groups, and consisted of antidepressant and antipsychotic drugs prescribed as appropriate; 

macy was discouraged.

nt context in publicly-funded specialist personality disorder treatment center
90

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ialist mental health practitioners

hs

T=71, SCM=63

rs: MBT=31.3 (SD=7.6); SCM=30.9 (SD=7.9)

e: MBT=80.3%, SCM=79.4%

itish/European: MBT=76.1%, SCM=68.3%

ican/Afro-Caribbean: MBT=15.5%, SCM=20.6%

hinese/Turkish/Pakistani: MBT=8.5%, SCM=11.1%

BT=33.8% vs SCM=17.5%

e (> 4 times/week): MBT=40.8% vs 41.3%

attempt past 6 months: MBT=74.6% vs 66.7% Axis I disorders: Major depressive disorder: MBT=57.7% vs SCM=54.0%; Depressive disorders include dysthymia: MBT=78.9% vs SCM=74.6%; Posttraumatic 

sorder: MBT=12.7% vs SCM=15.9%; any anxiety disorder: MBT=59.2% vs SCM=63.5%; Any substance use disorder: MBT=54.9% vs SCM=52.4%; Any eating 

 MBT=28.2% vs SCM=27.0%; Somatoform disorder: MBT=11.3% vs SCM=14.3%

rted

behavior: 1) deliberate, 2) life-threatening, 3) resulted in medical intervention, and 4) medical assessment consistent with a suicide attempt. 

m: 1) deliberate, 2) resulted in visible tissue damage, and 3) nursing or medical intervention required.es assessed at 6, 12, and 18 months.

atening suicide attempts: (A) Proportion with episode=N/%; (B) Average count=Mean(SD)

months: MBT=(A) 37/52.1%, (B) 0.62 (0.74) vs SCM=(A) 33/52.4%, (B) 0.70 (0.81)

months: MBT=(A) 23/32.4%, (B) 0.36 (0.57) vs SCM=(A) 30/47.6%, (B) 0.60 (0.77)months: MBT=(A) 2/2.8%, (B) 0.03 (0.17) vs SCM=(A) 16/25.4%, (B) 0.32 (0.62)

on with episode analysis: Wald χ2 (df=3):76.21, P<0.001

over time=OR 0.41 (95% CI, 0.30 to 0.57); Group effect over time=OR 0.37 (95% CI, 0.21 to 0.62)

nths=RR 0.68 (95% CI, 0.44 to 1.04)

months=RR 0.11 (95% CI, 0.02 to 0.46)eatment difference=d=0.65 (95% CI, 0.58 to 0.73)

count analysis: Wald χ2 (df=3):212.56, P<0.001

over time=IRR 0.70 (95% CI, 0.62 to 0.80)

fect over time=IRR 0.63 (95% CI, 0.53 to 0.75)

elf-harm incidents: (A) Proportion with episode=N/%; (B) Average count=Mean(SD)

months: MBT=(A) 53/74.6%, (B) 2.61(3.08) vs SCM=(A) 37/58.7%, (B) 1.79 (2.62)

months: MBT=(A) 26/36.6%, (B) 1.30 (2.47) vs SCM=(A) 37/58.7%, (B) 1.73 (2.27)months: MBT=(A) 17/23.9%, (B) 0.38 (0.83) vs SCM=(A) 27/42.9%, (B) 1.66 (2.86)

on with episode analysis: Wald χ2 (df=3):62.77, P<0.001

over time=OR 0.49(95% CI, 0.35 to 0.69); Group effect over time=OR 0.39 (95% CI, 0.23 to 0.66)

onths: RR 1.27 (95% CI, 0.99 to 1.63)

months: RR NR, but “MBT showed steeper decline”

months=RR 0.55 (95% CI, 0.33 to 0.92)eatment difference=d=0.62 (95% CI, 0.28 to 0.97)

count analysis: Wald χ2 (df=3):224.11, P<0.001

over time=IRR 0.74 (95% CI, 0.65 to 0.85)

fect over time=IRR 0.69 (95% CI, 0.59 to 0.82)

0839 (US)

ith borderline personality disorder
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ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

nt as usual (TAU): Continuation of usual care, including individual psychotherapy, medication, and case management. Subjects received no instructions or advice 

her pharmacologic or psychotherapeutic treatments.

 Training for Emotional Predictability and Problem Solving (STEPPS) plus TAU: STEPPS is a manual-based group treatment program that combines cognitive 

al elements with skills training and has the following three main components: 1) psychoeducation, 2) emotion management skills training, and 3) behavior 

ment skills training. The program involves 20 2-hour weekly sessions with 2 co-facilitators who follow a detailed lesson plan that includes homework assignments. 

 is systems-based in that family members, significant others, and health care professionals are educated about borderline personality disorder and instructed how 

nteract with their relative or friend with the disorder. 

cified

nt, group sessions with the look and feel of a seminar. Exact setting not specified. 

ered by 2 of the authors of the study (Ms. Blum and Mr. St. John)

s

EPPS=93 vs TAU=72

e, years (SD): 31.5 (9.5)

ale

ucasian

an American

rt suicide attempts

rent major depressive disorder

M-IV personality disorders

ychotropic medication use

suicide attempts and self-harm acts were collected at 1, 3, 6, 9 and 12 months. Outcome criteria were not defined. 

rted separately by treatment group:

attempts: 24 (22.2%), median number of attempts was 1.75 per year, and the mean was 2.60

m acts: 56 (45.2%), the median number of acts was 9.8 per year, and the mean was 16.6portional hazards analysis: treatment group was not associated with time to first suicide attempt (χ2<0.1, df=1, p=0.994) or first self-harm act (χ2<0.1, df=1, 

)

T Trial (Borderline Personality Disorder Study of Cognitive Therapy) (UK)

n 200640 – 1-year outcomes

n 201041 – 6-year outcomes

tween 18 and 65 years, met criteria for at least 5 items of the borderline personality disorder using the Structured Clinical Interview for DSM-IV Axis II Personality 

s, and had received either in-patient psychiatric services or an assessment at accident and emergency services or an episode of deliberate self-harm (either 

act or self-mutilation) in the previous 12 months

nt as usual (TAU): Included a wide variety of resources such as inpatient and outpatient hospital services, including A&E services, community based services such 

n centers, and primary and community care services (GP, practice nurse, Community Psychiatric Nurse, etc.).

cific to Cluster B personality disorder was delivered in up to 30 sessions of CBT over 1 year, each session lasting an hour, plus TAU. 

rted

e National Health Service in the U.K 

sts provided CBT in the trial. 4 were registered mental nurses and one, an occupational therapist. 3 of the therapists had completed a 10-month CBT training 

nd had a certificate in cognitive therapy, and 1 therapist had received CBT training in psychosis. Only 1 therapist had no previous training in CBT but had ce of managing individuals with personality disorder.

T=54 vs TAU=52
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ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

e (SD, range): 31.9 (9.1; 18-57)

ale

hite pression Inventory II Total Score, mean (SD): 42.5 (11.2)

number of years since first act of deliberate self-harm (SD): 14.8 (10.0)

rted

acts over 6 years, recorded using the Acts of Deliberate Self-Harm Inventory, which requires fulfillment of all 3 of the following criteria: 1) deliberate, 2) life 

ng, and 3) the act resulted in medical intervention or intervention would have been warranted.

nths (N=101):

 with suicidal acts: CBT= 18 (37%) vs TAU= 21 (46%). OR= 0.77 (95% CI ; 0.29 to 2.01)

sodes of suicidal acts (SD): CBT= 0.61 (0.95) vs TAU= 1.02 (2.14); adjusted Mean Difference (aMD)= −0.36 (95% CI, −0.83 to 0.13)

nths (N=102):

 with suicidal acts: CBT= 23 (43% ) vs TAU= 26 (54%). OR= 0.78 (95% CI ; 0.30 to 1.98)

isodes of suicidal acts (SD): CBT= 0.87 (1.47) vs TAU= 1.73 (3.11); aMD= −0.91 (95% CI, −1.67 to −0.15)

s (N=76):

 with suicidal acts: CBT= 56% (n = 24/43) vs TAU= 73% (n = 24/33); aOR = 0.37 (95% CI, 0.10 to 1.38)

isodes of suicidal acts (SD): CBT= 1.88 (3.19) vs TAU= 3.03 (4.16); aMD (TAU-CBT) = 1.26 (95% CI, -0.06 to 2.58)

 201147 (US)

th a recent suicide attempt or imminent risk who (a) did not have appropriate outpatient mental health

t available for an appointment in the next 2 weeks; (b) a NDA and weekly outpatient follow-up was an appropriate

on plan, and (c) the patient was sufficiently stable to be discharged home for a minimum of 24 hours prior to NDA appointment. 

ntervention developed by the second author that modifies how clinicians engage, assess, and treat suicidality. CAMS involves the use of a Suicide Status Form  guide assessment, treatment planning, on-going tracking of risk, and outcome/disposition of care. The SSF involves quantitative and qualitative assessments and 

ation of empirically-based risk factors. CAMS sessions are provided weekly, generally for 50-60 minutes. CAMS generally lasts from a minimum of 4 sessions up 

ximately 12 sessions. 

ntake with the psychiatrist or psychiatric nurse practitioner followed by 1–11 visits with a case manager and as needed medication management. Treatment ends 

onths when the ‘‘crisis is resolved’’ with referral for primary care follow-up or, when there is an appropriate diagnosis and funding is available, additional mental 

 substance abuse treatment. Care in the study was enhanced by funding equivalent clinician time in both conditions and clinicians in both conditions were asked 

ule a minimum of 4 sessions (i.e., the minimum number of sessions in CAMS).

rted

nt crisis intervention setting attached to Harborview Medical Center, a county-owned, safety net hospital focused on underserved and unfunded populations. Study 

t conditions were provided in the Crisis Intervention Service to which all Harborview next-day appointments are referred.

 clinicians (1 case manager, 2 psychologists, and 1 psychiatry resident) provided treatment after participating in a 1-day didactic training by Dr. Jobes, the CAMS 

er and reaching acceptable levels of adherence. 

Provided by case managers with average years since degree=27.5, SD53.5 

 minimum of 4 sessions

S=16 vs E-CAU-16

e (SD, range)=36.8 years (10.1, 19-62)

menucasian

s: mean (SD)

attempts/self-inflicted injuries: CAMS=3.0 (9.3) vs E-CAU=7.7 (24.5)

ssions: CAMS=1.5 (1.2) vs E-CAU=1.6 (0.8)

al health ED admissions only: CAMS=1.3 (1.1) vs E-CAU=1.1 (0.6)

of inpatient days: CAMS=5.5 (5.4) vs E-CAU=7.0 (7.0)

rted
93

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

attempts and self-inflicted injuries were categorized using the Suicide Attempt and Self-Injury Count SASI-C (Linehan 1996) at all follow-up assessments 

ed at 2, 4, 6 and 12 months. 

s: mean (SD)

attempts/self-inflicted injuries: CAMS=N/A vs E-CAU=5.5 (7.8)

ssions: CAMS=N/A vs E-CAU=0.5 (0.7)

al health ED admissions only: CAMS=N/A vs E-CAU=1.1 (0.6)

of inpatient days: CAMS=N/A vs E-CAU=4.0 (5.7)

s: mean (SD)

attempts/self-inflicted injuries: CAMS=0.0 (0.0) vs E-CAU=0.8 (1.8)

ssions: CAMS=0.4 (0.5) vs E-CAU=0.4 (0.7)

al health ED admissions only: CAMS=0.1 (0.4) vs E-CAU=0.4 (0.7)

of inpatient days: CAMS=1.4 (2.5) vs E-CAU=1.0 (2.3)

s: mean (SD)

attempts/self-inflicted injuries: CAMS=0.2 (0.4) vs E-CAU=0.0 (0.0)

ssions: CAMS=0.4 (0.5) vs E-CAU=0.2 (0.4)

al health ED admissions only: CAMS=0.2 (0.4) vs E-CAU=0.2 (0.4)

of inpatient days: CAMS=3.5 (7.0) vs E-CAU=1.3 (4.6)

hs: mean (SD)

attempts/self-inflicted injuries: CAMS=1.2 (3.9) vs E-CAU=3.3 (7.6)

ssions: CAMS=0.4 (0.8) vs E-CAU=1.0 (2.4)

al health ED admissions only: CAMS=0.2 (0.4) vs E-CAU=0.6 (1.6)

of inpatient days: CAMS=1.4 (4.5) vs E-CAU=3.2 (8.0)

200745 (Australia)

s 18 years and older with a current admission at the local psychiatric ward due to severe suicidal ideation and/or attempt as the main motive for hospitalization.

 case management (ICM): Case managers from a community mental health service had weekly face-to-face sessions with participants; intervention based on the 

ation model described by Rapp and Kisthardt. Outreach provided in a variety of settings including home visits; frequent contact, with a minimum of one contact per 

 12 months; staff available outside appointment times but within regular work hours; client-focused approach tailored to each individual; emphasis on skills-building 

lem solving, encourages client empowerment and independence; linkage to services; advocacy services; provision of individual and group psychotherapy and 

ng services; 2 telephone calls a week from counselors collaborating with case managers.

nt as usual: Individual Program Plans, pharmacotherapy, referrals to general practitioners, psychologists, psychiatrists, rehabilitation services, and/or the routine 

ase management but not telephone calls from counselors.

ity mental health service.

 mental health professionals with specialist training in mental psychotherapeutic techniques (e.g., psychologist, psychiatric nurse).

.75 weeks.

ompleted 12-month treatment: 14 ICM, 8 TAU)

AU:

age 34 years (range 24-59) vs 37 years (range 19-62)

ale

t reported

polar depression; 17% bipolar depression; 10% psychotic disorder; 8% substance abuse disorder; 2% other diagnosis; 44% comorbid diagnoses.

rted

s on functioning in life domains, health service use, and professional contacts determined in structured interviews with trained clinical psychologists, who 

d the examinations (including self-report scales) at 6-monthly intervals; the first being immediately following discharge.
94

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

des in the 12-month follow-up period.

ming behaviors (ICM vs TAU)

s: 3/14 (21.4%) vs 1/8 (12.4%)hs: 2/14 (14.3%) vs 2/8 (25.0%)

 not reported

d 201046 (US)

adolescents (Suicidal Ideation Questionnaire (SIQJR) score > 31; Beck Depression Inventory (BDI-II) > 20) between the ages of 12 and 17, identified in primary 

 emergency departments

-Based Family Therapy (ABFT): Focuses on strengthening parent-adolescent attachment bonds using a process-oriented, emotion-focused semistructured 

t protocol conceptualized as 5 specific tasks: 1) Relational Reframe Task to strengthen relationships; 2) Adolescent Alliance Task to prepare adolescent to discuss 

ily conflicts with parents; 3) Parent Alliance Task to teach emotionally focused parenting skills; 4) Reattachment Task for families to practice new skills; and 5) 

ency Task to promote adolescent autonomy. 

d Usual Care (EUC): A facilitated referral process with ongoing clinical monitoring. 

essant medication allowed if started ≥12 weeks before randomization.

ent of Psychiatry at the Children’s Hospital of Philadelphia (CHOP).

h.D.- or M.S.W.-level therapists provided ABFT under supervision of Guy and Gary Diamond

s

e, years (SD): ABFT=15.11 (1.41) vs EUC=15.29 (1.83) 

e: ABFT=91.4% vs EUC=74.2%

American: ABFT=71.4% vs EUC= 77.4%

psychiatric diagnoses, % patients

pressive episode: ABFT=37.1% vs EUC=41.9% 

ia: ABFT=8.6% vs EUC=6.52% 

ety: ABFT=60.0% vs EUC=74.2% 

zing disorder (ADHD, ODD, CD): ABFT=65% vs EUC=48% 

History, % patients

ent attempted suicide in the past: ABFT=61.3% vs EUC=62.9% 

attempts: ABFT=81.8% vs EUC=63.2% 

chiatric hospitalization: ABFT=20.0% vs EUC=24.1%

ntidepressant medicine: ABFT=8.6% vs EUC=10.3%

story of suicide attempt: ABFT=30.3% vs EUC=34.3%

ntidepressant medicine: ABFT 8.6% vs EUC=10.3% 

tatus monitored weekly using the SIQ-JR and BDI-II, administered either face-to-face (ABFT) or over the phone

Definition of “low lethality suicide attempts” not reported. 

ality suicide attempts: ABFT=11% (4/35); EUC=22% (7/31); p not reported

on 200548 (US)

ents (12–17 years old) who presented to a general pediatric emergency department or inpatient unit of an affiliated child psychiatric hospital in the Northeast after 

 attempt. Any intentional, nonfatal self-injury, regardless of medical lethality, was considered a suicide attempt if intent to die was indicated

sed Treatment (SBT): Focused on problem solving and affect management skills. Each session included an assessment of suicidality, skill education, and skill 

(both in-session and homework assignments). Participants were taught steps of effective problem solving and cognitive and behavioral strategies for affect 

ment (e.g., cognitive restructuring, relaxation) and given homework assignments to assist in skill acquisition and generalization. The SBT included active and 

ance treatment phases. The active phase included 6 individual sessions and 1 adjunct family session administered during the first 3 months of treatment. The ance phase included 3 monthly sessions. At the therapist’s discretion, 2 additional family sessions and 2 crisis sessions were available.
95

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ve Relationship Treatment (SRT): Was adapted from the Supportive Relationship Treatment Manual of Brent and Kolko (1991). This treatment was supportive 

 and focused the adolescent’s mood and behavior as well as factors that contribute to adolescent suicidal behavior. Sessions were unstructured and addressed 

 symptoms and problems. Techniques included exploratory questioning, encouraging affect, connecting affect to events, and providing feedback about changes 

 in treatment. In contrast to SBT, specific skills were not taught and homework assignments were not given during any of the SRT sessions. The session protocol 

was identify to that of SBT (described above). 

rtedrted

sts provided both treatments. 5 of the therapists held a doctorate in clinical psychology, 1 a master’s degree in psychology, and 1 a master’s degree in social work. ts received training in both approaches to allow for a crossed design

s=21 vs SRT=18

e (SD)=15.0 (1.7)

ale

te

panic

an American

ous attempt: SBT=53 (8%) vs SRT=44 (7%)

pressive disorder: SBT=27 (4%) vs SRT=31 (5%)

e behavior disorder: SBT=27 (4%) vs SRT=63 (10%)

use disorder: SBT=13 (2%) vs SRT=25 (4%)

s use disorder: SBT=40 (6%) vs SRT=50 (8%)

of diagnoses: None: SBT=53 (8%) vs SRT=25 (4%); 1: SBT=20 (3%) vs SRT=38 (6%); >2: SBT=27 (4%) vs SRT= 38 (6%)

ective serotonin reuptake inhibitor (SSRI) alone

RI plus another medication

cal antidepressant

od stabilizer

e measures were administered 3 months (end of active

t) and 6 months (end of maintenance)

pts at 6 months: SBT=26.7% (4/15) vs SRT=12.5% (2/16); χ2=1.00 

rence in rates of suicide reattempts among those taking (n = 6/6) versus not taking (n = 0/25) medication was statistically significant: χ2=7.95, P < .05

01144 (UK)

ents aged 12-17 years with at least 2 past episodes of self-harm within the previous 12 months.

mental group psychotherapy: manual-based treatment designed for self-harming adolescents. Integrated techniques including CBT, DBT, and group 

erapy. Adolescents learned strategies to deal with difficulties using group based techniques such as role play. 

ld and adolescent mental health services teams provided standard routine care according to their clinical judgment. Centers excluded any group intervention from 

are during the trial. 

d adolescent mental health service teams in the northwest of England, who served substantial geographical areas.

ts had a minimum of 3 years of relevant post-qualifying experience; had initial training in fidelity to the model and subsequent regular supervision.ntry; adolescents started attending as soon as their initial assessment and randomization were completed and attendance continued until the young person felt 

leave. Mean number of group sessions attended was 102 (SD 10.1). Minimum per protocol adherence was 4 sessions per site per year.

 group therapy, 183 usual care) 12 to 14 years at entry, 62% 15 to 17 years (mean ages not reported)

ale

k and ethnic minority
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ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

h psychosocial risk; 62% depressive disorder; 33% behavioral disorder

rted

outcome was the frequency of episodes of self-harm (includes non-suicidal self-harm). Face-to-face interview, structured interviewing techniques, additional 

telephone interview with patient and family.

es of self-harm resulting in severe physical injury (2 usual care, 1 group therapy). No suicides or other deaths.

 201136 (New Zealand)

over age 16 who presented to the hospital after self-harm between September 2005 and June 2008. Self-harm included: “intentional self-poisoning or self-injury, 

ve of motivation. Self-poisoning included the intentional ingestion of more than the prescribed amount of any drug, whether or not there was evidence that the act 

nded to result in death. This also included poisoning with non-ingestible substances (for example pesticides or carpet cleaner), overdoses of ‘recreational’ drugs 

ere alcohol intoxication where the clinical staff considered such cases to be an act of self-harm. Self-injury was defined as any injury that had been intentionally 

ted.” Patients receiving DBT or other “management plan which precluded having a short-term therapy” were excluded from the study.

nt as usual (TAU): Varied and may involve referral to multidisciplinary teams for psychiatric or psychological intervention, referral to mental health crisis teams, 

endations for engagement with alcohol and drug treatment centers or other health and non-health services.

-solving therapy plus treatment as usual (PST+TAU): Up to 9 hour-long sessions lasting up to 3 months. Conducted with individual patients in outpatient clinics. 

cluded problem orientation, problem listing and definition, brainstorming, devising an action plan and reviewing the plan. Engaged people by getting them to tell the 

heir attempt and understanding the motivation behind it. Conducted regular risk assessments and in the final sessions asked participants to apply their new skills cumstances around their original self-harm attempt.

 Health Boards (hospitals providing healthcare to about a third of the New Zealand population).

ST+TAU=522, TAU=572 

rs (SD): PST+TAU=33.2 (12.5) vs TAU=34.2 (13.2)

e: PST+TAU=68% vs TAU=69%

 (%); PST+TAU vs TAU: NZ European 62% vs 60%, Maori 14% vs 17%, Pacific Island 7% vs 5%, Asian 2% vs 4%, Other 15% vs 13%

outcome was presentation to hospital with self-harm in the year after the index attempt. Obtained from the New Zealand Health Information Service details 

al contacts throughout New Zealand in the year after the index attempt. Data obtained from the National Minimum Dataset kept by the New Zealand health 

on service, which contains routinely collected information on all public and private hospital discharges in New Zealand. 

ng Patients

nts re-presenting to hospital for self-harm; PST+TAU vs TAU:

ndex episodes (N=253 vs 299): 14.2% vs 17.1%; RR=0.17 (95% CI -0.24 to 0.44); P=0.43

x episode is first self-harm episode (N=137 vs 169): 13.9% vs 8.9%; RR=-0.56 (95% CI -1.96 to 0.18); P=0.23x episode is repeat episode (N=116 vs 130): 14.7% vs 27.7%; RR=0.47 (95% CI 0.11 to 0.69); P=0.02; NNT=8

nts with self-reported self-harm; PST+TAU vs TAU:

ndex episodes (N=186 vs 226): 27.4% vs 32.7%; RR=0.16 (95% CI -0.13 to 0.38); P=0.29

x episode is first self-harm episode (N=98 vs 122): 25.5% vs 20.5%; RR= -0.25 (95% CI -1.03 to 0.24); P=0.47x episode is repeat episode (N=88 vs 104): 29.5% vs 47.1%; RR=0.37 (95% CI 0.08 to 0.57); P=0.02; NNT=6

re-presentation to hospital, days : median; PST+TAU vs TAU:

ndex episodes: 56 vs 83; HR=0.81 (95% CI 0.53 to 1.25); P=0.92

x episode is first self-harm episode: 62 vs 75; HR=1.62 (95% CI 0.82 to 3.18); P=0.16x episode is repeat episode: 45 vs 104; HR=0.47 (95% CI 0.26 to 0.85); P=0.01

nts

nts re-presenting to hospital for self-harm; PST+TAU vs TAU:

ndex episodes (N=522 vs 572): 13.4% vs 14.1%; RR=0.05 (95% CI -0.28 to 0.30); P=0.79

x episode is first self-harm episode (N=314 vs 360): 13.4% vs 9.4%; RR=-0.42 (95% CI -1.17 to 0.08); P=0.37x episode is repeat episode (N=208 vs 212): 13.5% vs 22.1%; RR=0.39 (95% CI 0.07 to 0.60); P=0.03; NNT=12

re-presentation to hospital, days : median; PST+TAU vs TAU:

ndex episodes: 74 vs 75; HR=0.98 (95% CI 0.71 to 1.36); P=0.92

x episode is first self-harm episode: 74 vs 61; HR=1.55 (95% CI 0.98 to 2.48); P=0.06x episode is repeat episode: 80 vs 114; HR=0.58 (95% CI 0.36 to 0.94); P=0.03
97

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

00949 (Australia)

ents aged between 12 and 16 years, who had been referred to a child and adolescent mental health service in Australian sites at Newcastle, Brisbane North, or 

nd reported at least 2 episodes of self-harm in the past year, 1 of which had occurred in the past 3 months 

herapy (GT): Developed by Wood et al. (2001) and administered as described in treatment manual (Wood 2001). One-hour group sessions conducted weekly. 

essions focused on relationships, school and peer relationships, family problems, anger management, depression and self-harm, and hopelessness and feelings 

e future. After completion of the initial 6 sessions, adolescents could transition to a longer term group for up to 12 months. 

Care (RC): Generally consisted of individual counseling (using a variety of therapeutic approaches), family sessions, medication assessment and review, and 

e coordination activities

ot reported

ity-based adolescent mental health service

vered by 2 clinicians from each participating community-based adolescent mental health service, who were qualified psychologists, clinical psychologists, social 

 or nurses and were supervised by chief investigators 

 provided by community-based adolescent mental health services, but monitored via a self-report resource use surveys and the collection of information from 

c health records.

 months

e, years (SD): GT=14.57 (1.07) vs RC=14.41 (1.19)

e: GT=91% vs RC=89%

t reported

ts with: 

 incident of medication overdose: GT=71% vs RC=43% incident of deliberate self-cutting: GT=100% vs RC=97%

y serious self-harm: GT=9% vs RC=5%

probable or definite sexual abuse: GT=31% vs RC=32%

problems: GT=6% vs RC=3%

ce misuse: GT=0 vs RC=0

on: GT=49% vs RC=65%

/oppositional defiant disorder: GT=6% vs RC=8%

rted

outcome measure was repetition of self-harm, defined as any intentional self-inflicted injury (including poisoning) irrespective of the apparent purpose of the 

 based on an interview-based assessment of suicide behavior (Kerfoot 1992, Linehan 1999).

n of Deliberate Self-Harm by 6 months: GT = 88% (30/34); RC = 68% (23/34); p = 0.04n of Deliberate Self-Harm in interval of 6 to 12 months: GT = 88% (30/34); RC = 71% (24/34); p = 0.07

 200638 (US)

between the ages of 18 and 45 years who met criteria for borderline personality disorder and for current and past suicidal behavior as defined by at least 2 suicide 

 or self-injuries n the past 5 years, with at least 1 in the past 8 weeks.

ognitive behavioral treatment program developed to treat suicidal clients meeting criteria for BPD (Linehan 1993, Linehan 1993) that directly targets: 1) suicidal 

 2) behaviors that interfere with treatment delivery, and 3) other dangerous, severe, or destabilizing behaviors. Standard DBT addresses the following 5 functions: 

sing behavioral capabilities, 2) improving motivation for skillful behavior (through contingency management and reduction of interfering emotions and cognitions), 

ng generalization of gains to the natural environment, 4) structuring the treatment environment so that it reinforces functional rather than dysfunctional behaviors, 

nhancing therapist capabilities and motivation to treat patients effectively. These functions are divided among the following 4 modes of service delivery: 1) weekly 

l psychotherapy (1 h/wk), 2) group skills training (21⁄2 h/wk), 3) telephone consultation (as needed within the therapist’s limits to ensure generalization), and (4) 

herapist consultation team meetings (to enhance therapist motivation and skills and to provide therapy for the therapists).

ity Treatment By Experts (CTBE): This condition was developed specifically for this study to control for factors previously uncontrolled for in DBT studies. Similar 

 (treatment as usual) condition, the treatment provided was uncontrolled by the research team. Therapists were asked to provide the type and dose of therapy 

 believed was most suited to the patient, with a minimum of 1 scheduled individual session per week. Ancillary treatment could be prescribed as needed. CTBE 

om TAU conditions in that characteristics of CTBE therapists are controlled by the study via selection of therapists and supervisory arrangements. CTBE therapists 

 heads of inpatient psychiatric units and clinical directors of mental health agencies. 
98

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

rtedrted 

pists (16 DBT and 25 CTBE therapists).

 degree: DBT=75% vs CTBE=56%

rs’ clinical experience since terminal degree: DBT=25% vs CTBE=56%

BT=31.3% vs CTBE=36%

mber of study clients: DBT=3.6 (2.9) vs CTBE=2.5 (1.7)

 in group consultation: DBT=100% vs 57.1%

T=60 vs CTBE=51

e, years (SD): 29.3 (7.5)

omen

7%

American: 4%

merican: 2%merican or Alaskan Native: 1%

ace: 5%

psychiatric diagnoses meeting DSM-IV criteria: Major depressive disorder=72.3%, Panic Disorder=40.6%, Post-Traumatic Stress Disorder=49.5%, Any Anxiety 

=78.2%, Any Substance Use Disorder=29.7%, Any Eating Disorder=23.8%

psychiatric diagnoses meeting DSM-IV criteria: Major depressive disorder=96%, Panic Disorder=51.5%, Post-Traumatic Stress Disorder=55.4%, Any Anxiety 

=87.1%, Any Substance Use Disorder=73.3%, Any Eating Disorder=39.6%

luster A=3.0%, Cluster B other than borderline personality disorder=10.9%, Cluster C=25.7%, Paranoid=3.0, Schizoid=0.0, Schizotypal=0.0, Antisocial=10.9%, 

c=2.0%, Narcissistic=0.0%, Avoidant=20.8%, Dependent=5.9%, Obsessive Compulsive=7.9%, Psychiatric Disorder Not Otherwise Specified=89.1%

suicide attempts (interquartile range): 1.0 (0.5-4.0)nonsuicidal self-injury (interquartile range): 10.0 (2.0 to 47.0)

on of subjects taking any psychotropic medications (Estimated from Figure 2):

hs: DBT=47% vs CTBE=69%hs: DBT=54% vs CTBE=63%

ide Attempt Self-Injury Interview (Seligman 2006) measured the topography, suicide intent, and medical severity of each suicide attempt and nonsuicidal self

sessments completed at 4-month intervals during the 12-month treatment and 12 months of post-treatment follow-up periods by blinded, independent clinical 

rs with master’s or doctoral degrees. 

suicides (interquartile range): DBT=0 (0 to 0) vs CTBE=0 (0 to 1)attempts: DBT=23.1% vs CTBE=46%, P=0.01, HR=2.66 (95% CI not reported; P=0.005), NNT=4.24 (95% CI, 2.40 to 18.07)

valent suicide attempts: DBT=5.8% vs CTBE=13.3%, P=0.18, NNT=13.3 (95% CI, 5.28 to 25.41)

attempts per period: Significantly fewer in the DBT group across the 2 years when controlling for number of suicide attempts during the pretreatment year 

.20, P=.04, MMANOVA).

oportions of suicide attempters per period: DBT=6.2% (95% CI, 3.1% to 11.7%) vs CTBE=12.2% (95% CI, 7.1% to 20.3%)

200942 (Canada)

who met DSM-IV criteria for borderline personality disorder (BPD), were 18–60 years of age, and had at least two episodes of suicidal or nonsuicidal self-injurious 

 in the past 5 years, at least one of which was in the 3 months preceding enrollment
99

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ognitive behavioral treatment program developed by Linehan (Linehan 1993, Linehan 1993), which includes the following components:

cal basis: Learning theory, Zen philosophy, and dialectical philosophy. Pervasive emotion dysregulation is the primary deficit in borderline personality disorder.

nt structure: Multimodal: Individual sessions (1 hour weekly); skills group (2 hours weekly); phone coaching (2 hours weekly); consultation team for therapists 

d (2 hrs weekly); organized according to a hierarchy of targets: suicidal, treatment-interfering, and quality-of-life-interfering behaviors; explicit focus on self-harm 

dal behavior 

strategies: Psychoeducation about BPD, helping relationship, here-and-now focus, validation and empathy, emotion focus, dialectical strategies, irreverent and 

al communication style, formal skills training, behavioral strategies (e.g., exposure, contingency management, diary cards, behavioral aspects)

anagement protocols: Bias toward managing crises on an outpatient basis; phone coaching to assist in managing crises 

Psychiatric Management. (GPM): Based on the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder and included the 

 components: 

cal basis: Psychodynamic approach drawn from Gunderson 2001; emphasized the relational aspects and early attachment relationships. Disturbed attachment 

hips related to emotion dysregulation as a primary deficit.

nt structure: One mode: Individual sessions (1 hour weekly) including medication management based on structured drug algorithm; therapist supervision meeting 

d (90 minutes weekly); patient preference is given priority—no hierarchy of targets; focus is expanded away from self-harm and suicidal behaviors.

strategies: Psychoeducation about BPD, helping relationship, here-and-now focus, validation and empathy, emotion focus, active attention to signs of negative 

nce. 

anagement protocols: Hospitalization if indicated. 

ients encouraged to rely on skills over pills where appropriate (e.g., anxiolytics). Tapering from medications was a treatment goal. Psychopharmacologic 

ion was uncontrolled

atients were encouraged to use medications concurrently. Two medication algorithms, one related to mood lability and one related to impulsive-aggressiveness, 

oritized as symptom targets. Medication intervention was delivered according to the predominant symptom pattern.

nts conducted at separate University of Toronto teaching hospitals within the same health care system. DBT was conducted at the Centre for Addiction and Mental 

nd GPM at St. Michael’s Hospital. 

nts were delivered by 25 therapists, all with a minimum of 2 years of clinical experience and a minimum of 1 year of experience treatment borderline patients. 

ts included 11 psychiatrists (three and eight providing DBT and general psychiatric management, respectively), five Ph.D.-level psychologists (four and one, 

vely), six master’s-level clinicians (five and one, respectively), and three nurses (one and two, respectively). There were no between-group differences in 

ortion of clinicians with doctoral-level degrees (M.D. and Ph.D.) versus other degrees, but there were significantly more physicians in the general psychiatric 

ment condition (χ2=4.8, df=1, p=0.028).

hsT=90 vs GPM=90

e, years (SD): 30.4 (9.9)

male

t reported

DSM-IV axis I disorders, % patients: Major depressive disorder=80.0%, Panic disorder=31.7%, Post-Traumatic Stress Disorder=47.2%, any Anxiety 

=76.1%, any Substance Use Disorder=58.9%, any Eating Disorder=30.6%

DSM-IV axis I and II diagnoses: Major depressive disorder=48.9%, Panic disorder=21.7%, Post-Traumatic Stress Disorder=37.4%, any Anxiety Disorder=75%, 

stance Use Disorder=9.4%, any Eating Disorder=13.3%, Axis II cluster A disorders=7.8%, Axis II cluster B diagnosis (excluding BPD)=17.8%, Axis II cluster C 

s=40.6%

etime suicide attempts (SD): 24.7 (88.3)

rted. 

ary outcome measures were frequency and severity of suicidal and nonsuicidal self-injurious behavior episodes, as assessed every 4 months by the Suicide 

Self-Injury Interview (M.M. Linehan et al., unpublished 1983 manuscript).

y suicide: None

mber of suicidal and self-injurious episodes (SD): OR 0.92 (P=0.76)

nths: DBT=10.60 (20.96) vs GPM=14.02 (43.87)nths: DBT=8.94 (19.07) vs GPM=11.44 (37.59)onths: DBT=4.29 (9.32) vs GPM=12.87 (51.45)
100

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

200950 (Australia)

ged 18 years or older receiving inpatient treatment for a suicide attempt.

sed on a combination of Beck’s CBT and Albert Ellis’s theory of rational emotive therapy. Individual weekly sessions.

-Solving Therapy (PST): based on the 6-step D’Zurilla and Goldfried model. Individual weekly sessions.

als in Australia

nts administered by the researcher (not described)

s were one hour, with PST completed over 4 sessions and CBT over approximately 7 sessions. 

 states number of participants was 32, but also reports that 11 patients completed CBT, 12 PST, and 9 treatment as usual

ge 20-58 years (mean not reported)

ale

t reported

ported.ported.

s of psychological functioning, and repeated attempt data from hospital chart audits that recorded re-presentation to the hospital for suicide attempts. Measures 

ered when participants were initially screened, directly following treatment (for PST and CBT groups) and at 2-month follow-up (for the treatment as usual group).

number of suicide attempts:

2 (SD=0.64)

3 (SD=0.63)

2 (SD=0.50)

ficant differences found for repetition of suicide attempts when PST group was compared to TAU (U=35, ns, r=0.13) and when CBT was compared to TAU (U=25, 

2)

00651 (UK)

riteria for schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder or psychosis not otherwise specified; either first or second 

n to inpatient or daypatient unit for treatment of psychosis; positive psychotic symptoms for 4 weeks or more.

nual-based and supervised. Addressed delusions and hallucinations, generating alternative hypotheses for abnormal beliefs and hallucinations, identifying 

ting and alleviating factors and reducing associated distress, and teaching coping strategies.

ve counseling (SC). Delivered in the same 5-week format with 3 boosters, with the aim of matching the duration of total therapist contact time to that in the CBT

was manual based and supervised; the same 5 therapists administered both interventions.

nt as usual

 part of the intervention

al health units serving 3 geographically defined catchment areas.

sts trained in CBT for psychosis; 3 were clinical psychologists and 2 nurse therapists

r 15-20 hours treatment envelope within a 5-week post-admission period, plus booster sessions at a further 2 weeks, and 1, 2, and 3 months. 

lear how many in each group

rted by treatment group; reported by low self-harm score (N=242) and high self-harm score (N=36):

e, years (SD): 29.7 (10.6) and 28.6 (6.4)

e: 30.6%

inority (not specified): 12.2%

ained under MHAsubstance misuse; 13.7% daily substance misuse

mazine equivalents: mean (SD)

harm score=489.3 (374.4) mg

-harm score=537.2 (460.2) mg
101

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

or any reason identified from hospital and psychiatric notes. Suicides and possible suicides (where the death might have been intentional or accidental and the 

ruled the death as accidental) were identified.

deation and behavior (combined) assessed by the non-accidental self injury scale of the HoNOS (Health of the Nation Outcome Scales). Serious risk (score of 4) 

 suicidal attempts or deliberate self-harm. Assessed at 6 weeks, 3 months, and 18 months.

months, there were 3 definite suicides (1.2%), 2 in the supportive counseling group and 1 in CBT group. Two further deaths classified as accidental by the coroner 

accident, 1 fall from window, 1 in supportive counseling group, 1 in CBT group). 2 deaths by natural causes. Numbers too small for meaningful statistical analysis.

oNOS, there were no significant differences between the 3 treatment groups at any time point. Psychological treatment did not significantly reduce or worsen 

behavior compared to treatment as usual. There was a marked reduction in suicidal behavior after admission that would mask any potential treatment effect.

 200652 (US)

 and older, met criteria for current major depression, dysthymia, or both, and planned to use one of the participating primary care clinics over the following year.

intervention: 1-year collaborative care program that included a Depression Care manager (DCM, nurses and psychologists). DCMs completed an initial 

ent visit and provided education about treatment options, including antidepressant medications and psychotherapy. All patients were encouraged to engage in 

al activation and offered a choice of treatment with antidepressant medications, or Problem Solving Treatment in Primary Care, a brief behavioral intervention 

etween 4 and 8 sessions that non-mental health providers provide. DCMs received weekly supervision from a PCP and a psychiatrist to monitor progress and 

eatment plans according to a stepped-care treatment algorighm. The DCM followed patients in person or by telephone approximately every 2 weeks during acute

eatment and monthly during the continuation phase.

re: patients and their PCPs were told that patients met research diagnostic criteria for major depression or dysthymia. Patients could receive all treatments 

, including antidepressant medications or counseling by their PCPs, as well as referral to specialty mental health care.

ry care clinics affiliated with healthcare organizations in 5 states (Indiana, Texas, North Carolina, California, Washington)

PACT=906, Usual care=895

vs Usual care

rs (SD): 71.01 (7.35) vs 71.35 (7.6)

e: 64.1% vs 65.6%

8.2% vs 75.9%

American: 12.6% vs 12.1%

.2% vs 9.1%

ce/ethnicity: 3.0% vs 2.9%

outcome was suicidal ideation. No information on how deaths were ascertained.

cipants died before the 24-month follow-up; 61 of them (52%) were in the intervention group. To the authors’ knowledge, there were no suicides in either group 

e 2-year study period.

 prevention protocol was in place for both groups: Patients who endorsed thoughts of suicide were asked if they thought they might act on these feelings; if they 

d yes or refused to answer, the interviewer encouraged the patient to discuss these thoughts with a professional and offered telephone numbers including a 24-

ergency contact number and a suicide hotline. The protocol was activated 135 times for 108 study patients (89 times usual care vs 46 times intervention). Of the 

who triggered the risk-reduction protocol, 7.7% were in the usual care group and 4.3% in the intervention group (P<0.01)

00743 (UK)

ttending two Accident and Emergency departments following episodes of self-harm.

 construct psychotherapy. Techniques were selected on the basis of their likely impact on the client’s construing. Therapeutic techniques appropriate to particular 

 construct formulations of the client’s self-harm were set out in a brief manual. 

clinical practice: Assessment by, and possible follow-up appointments with, a mental health team. In one of the Accident and Emergency departments, a psychiatric 

m visited the client while in the department; in the other, an appointment was made for him/her to attend a psychiatric outpatient clinic.

 part of the intervention

 and Emergency departments serving a North London Borough

psychologist, supervised by an experienced personal construct psychotherapist.

on contract, commencing soon after the self-harm, which could be renewed if agreed by therapist and client. Number of sessions ranged from 2 to 22 (mean 

ssions)tervention, 40 control
102

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

ion vs control:e, years (SD)= 33.88 (7.66) vs 35.83 (10.43)

e=42% vs 60%

hnic group=100%

onal relevant information

rted

outcomes were measure of suicidal ideation and depression.

ssment of self-harm, records from the Accident and Emergency departments involved in the study were monitored for repeat episodes of self-harm in the 3 years  their initial presentation.

n of deliberate self-harm, intervention vs control

r: 17% vs 36% (P=0.12)rs: 35% vs 53% (P=0.18)rs: 39% vs 58% (P=0.15)

ition within 5 years: 61% vs 42% (P not reported)

episodes eventuated in successful suicide (1 intervention, 2 control)
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ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

K OF BIAS RATINGS FOR PRIMARY STUDIES RELATED TO 

Y

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

No information 

rovided.

Unclear Not described, does not appear 

to be blinded.

No Attritions and exclusions 

adequately documented; subject flowchart included in article. Analyzed 36/44 (82%). 3 patients in control group crossed over to treatment group after suicide attempts; 3 patients dropped out of treatment. These were not included in analysis. At 8-year follow-up: results on 41 patients.

No Methods 

published prior to results.

Yes Reports baseline 

characteristics only on those included in analysis (36 of 44 randomized). 

No High

Treatment allocation 

was made offsite via 

elephone randomiza

on.”

Yes “A study psychiatrist informed 

participants of their assignment.” “Assessors were blind to treatment group.” The study was designed to compare to a wellmatched alternative treatment provided in similar contexts by similarly trained therapists and, therefore, even though patients may have been aware of the type of treatment they were receiving, both treatments were likely perceived as effective treatment methods. 

Assessors: Yes; Participants: No

Attritions and exclusions adequately documented; subject flowchart included in article. 134/134 analyzed.

Yes No omissions 

of any expected suicide-related outcomes; authors state that primary outcomes were declared prior to beginning the study.

Yes Those who declined 

participation were more likely to have history of alcohol abuse (N=12); reported rape at baseline was more common in MBT group. No information is provided re: possible nesting (e.g., therapist effects).

Unclearmay have been other unmeasured differences at baseline.

Unclear
104

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

Coin toss occurred 

ollowing inclusion 

n study; therefore, 

llocation was unknown 

when determining 

reatment condition.

Yes No information provided. 

Because the comparison group (TAU) could likely be identified as such by participants, lack of participant blinding could introduce significant bias.

Unclear Missing data, attritions, 

and exclusions adequately reported. Those with at least one post-baseline assessment included in analysis: 124/165. 

No No omissions 

of any expected suicide-related outcomes.

Yes Reports baseline 

characteristics on 124/165 randomized (those who received the intervention); avoidant personality disorder more frequent in treatment as usual alone group (P=0.016). Because it is unclear whether or not the two treatment therapists conducted the groups together or separately, these nesting effects may not have been adequately addressed.

No High

No information 

rovided.

Unclear “Primary outcome variables...

were assessed by a licensed clinician blind to treatment condition.” No information on provider or patient blinding.

Yes for assessors, unclear for participants.

Attritions and exclusions documented; however, 12/16 (75%) of treatment and 10/16 (62.5%) of control participants did not complete study.

No No omissions 

of any expected suicide-related outcomes. 

Yes Two “severe and 

complex” patients removed from treatment condition; one control participant removed due to being court-ordered into an alternative treatment. No demographic or outcome data reported for completers vs. noncompleters.

Yes High
105

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

Blinded researcher 

ontacted trial oordinator by phone to 

nitiate a randomization.

Yes Research assistants carried out 

all assessments and were blind to treatment group allocation; they requested that patients did not mention any details of any psychological treatment they were receiving.

Yes Attritions and exclusions 

adequately documented. Follow-up data reported on 102/106 (96%).

Yes Methods 

published prior to results.

Yes The study appears to 

be free of other sources of bias.

Yes Low

Randomization 

escribed as 

maintained by 

tatistician”, but no 

nformation about 

llocation 

Unclear Study participants, personnel 

and outcome assessors were all unblinded. 

No ITT; attrition reasonable overall 

(14%) and balanced between groups, but reasons not reported 

Unclear Protocol 

available at clinicaltrials.gov and primary outcomes are consistent. No omissions of any expected suicide-related outcomes.

Yes The study appears to 

be free of other sources of bias.

Yes Unclear

Sealed envelopes Yes Patients and case managers 

not blinded; no information on blinding of outcome assessors

No High and differential attrition: 

22/60 completed 12 months of treatment; 14/30 in intervention group vs 8/30 in treatment as usual group (47% vs 27%)

No No indication 

of publication bias; outcomes described in methods are reported in results

Unclear None noted Yes High
106

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

No information 

rovided.

Unclear The same 6 therapists 

administered two types of treatments and, therefore, were not blinded. No information on assessor blinding.

No Demographic comparisons 

of completers and noncompleters; ITT analysis. 31/39 (79%) randomized completed treatment and included in analysis.

No No omissions 

of any expected suicide-related outcomes.

Yes Baseline characteristics 

reported only for 31 who completed treatment; compared those who remained to those who dropped out and found no differences, but might have been differences between groups at baseline. The same therapists provided both treatments. No statistical techniques were used to account for nested data (e.g., therapist effects).

No High

Randomization by 

emote telephone to trial 

enter

Yes Participants were not blinded 

(therapy study)Outcome assessors were blinded

Yes (for outcome assessors)

High and differential attrition: 37% in routine care group and 21% in therapy group did not receive intervention. But ITT analysis:359/366 included in ITT analysis (98%); reasons for attrition reported adequately.

Yes Results for 

stated primary outcomes are reported

Yes None noted Yes Unclear

ndependent statistician, 

ealed envelopes.

Yes Patients blinded due to Zelen 

design; no therapist blinding for PST intervention and unclear for TAU providers; no information on blinding related to health record outcomes.

Yes for patients; unclear for providers; unclear for raters.

Significant loss to follow-up in consented patients, though 100% follow-up of hospital representation outcome because this was obtained for both consenting and nonconsenting patients.

Yes Outcomes 

and subgroup analyses determined a priori.

Yes

Patients receiving DBT were excluded from the study, and this could potentially result in a biased sample of patients.

Unclear Low
107

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

Assigned by distant site 

oordinator

Yes No patient and therapist blinding. 

Outcome assessor blinding attempted, but at end of followup, raters correctly identified the treatment allocation for 54% of participants: 65% in routine care group vs. 43% in experimental treatment group; p=0.06. 

No for patient and therapist. Unclear for raters. 

Data missing for 3% in experimental group and 8% in routine care group. Reasons not reported. 

Yes Prospectivelyregistered 

protocol not available. But, no omissions of any expected suicide-related outcomes

Yes The study appears to 

be free of other sources of bias.

Yes Unclear

The participant 

oordinator, who was 

ot blinded to treatment 

ondition, executed 

he randomization 

rogram and collected ll the data related to 

reatment.”

Unclear “The participant coordinator, 

who was not blinded to treatment condition, executed the randomization program and collected all the data related to treatment.” “Assessments were conducted by blinded independent clinical assessors.” “Initial assessments were done before informing subjects of treatment assignment.” Notably, the study was designed to compare to a well-matched alternative treatment provided in similar contexts by similarly trained therapists and, therefore, even though patients may have been aware of the type of treatment they were receiving, both treatments were likely perceived as effective treatment methods. 

Assessors: yes; participants: no; providers: no.

“To assess the potential effect of missing data..., a pattern-mixture analysis was implemented using 2-tailed tests.” Found no evidence that results were biased by these differences (data not reported). Attritions and exclusions clearly documented and accounted for in analyses; subject flowchart included in article.

Yes No omissions 

of any expected suicide-related outcomes.

Yes Differences in amount 

of therapy received in the different groups (DBT received more than CTBE due to weekly group sessions and greater treatment retention). Statistical techniques adequately accounted for nested data structures.

Unclear Unclear
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Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

Scheme was held 

y statistician, who repared 45 sealed nvelopes, each 

ontaining the group 

llocations in random rder for 4 participants; ut no information bout whether nvelopes were 

equentially numbered. 

Also concerned about 

otential clinical 

mportance of ≥ 10% 

igher rates of lifetime nxiety and eating isorders, and current 

PTSD and substance 

se in DBT group.

Unclear Described as single blind. Explicit 

statements that assessors were blinded. When assessors were asked to guess treatment assignment, they were incorrect for 86% of cases, “suggesting blinding was largely maintained.” Notably, the study was designed to compare to a well-matched alternative treatment provided in similar contexts by similarly trained therapists and, therefore, even though patients may have been aware of the type of treatment they were receiving, both treatments were likely perceived as effective treatment methods. 

Assessors: yes; participants: no; providers: no.

ITT was conducted, but no information about imputation method. Attrition: 38% (DBT=39% vs. GPM=38%). Most common reasons for discontinuation of treatment were “individual sessions were not helpful (42%), scheduling problems (32%), transportation problems (32%), group sessions not helpful (29%), and that problems improved (24%)”.

Unclear No omissions 

of any expected suicide-related outcomes. 

Yes The study appears to 

be free of other sources of bias. No information is provided re: possible nested (e.g., therapist effects).

Yes Unclear

Method not described Unclear No information on blinding Unclear High and differential attrition: 

34.4%, 37.5%, and 26.1% completed CBT, PST, and TAU interventions. Number included is given as 32. Number analyzed is not clear; one outlier was eliminated before data analysis. 

No No information 

to judge; “outcome measures included...”

Unclear None noted Yes High
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Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data

Selective outcome 

reporting Other sources of bias

OVERALL 

risk of 

bias for 

study as 

a whole

Describe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed?Yes/No/Unclear

State how possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/

Unclear

State any important concerns about bias not addressed in other domains in tool. If particular questions/ entries were pre-specified in review’s protocol, responses should be provided for each question/entry.

Was study apparently free of other problems that could put it at high risk of bias?Yes/No/Unclear

Low/ Unclear/ High

The interventions 

were carried out 

ndependently of 

ssessors who were 

ept unaware of 

reatment allocation.” 

Study personnel 

ssigning treatment/

ontrol condition were 

naware of allocation.

Yes The same 5 therapists 

administered 2 types of treatments and, therefore, were not blinded. Assessors were blinded to treatment allocation; deaths determined by review of hospital records.

Assessors: yes; participants: no; providers: no.

Attritions and exclusions adequately documented and subject flowchart included in article. For suicidal behavior, 71% follow-up at 18 months (218/278); for deaths, appears to be complete information.

No No omissions 

of any expected suicide-related outcomes.

Yes The same therapists 

provided both treatments. No statistical techniques were used to account for nested data (e.g., therapist or facility effects). In addition to suicides, 2 deaths were classified as accidental by the coroner and 2 deaths by natural causes (but possible to do calculations using this information).

No High

No information 

rovided.

Unclear Telephone survey team blinded 

to intervention status (surveys measured suicidal ideation); for deaths, unclear if blinded.

Unclear Unclear if missing data for 

deaths.

Unclear No omissions 

of any expected suicide-related outcomes.

Yes Primary outcome was 

suicidal thoughts; 117 patients died during follow-up: “to the authors’ knowledge there were no suicides.” No information on how this was determined or if data are complete.

No Unclear

Not concealed. No Does not appear to be blinded 

(medical records were monitored for repeat episodes of self-harm).

No Very high and differential 

attrition: 64 allocated, 45% control and 92% intervention completed post-treatment assessment; 28% and 54% completed 6-month assessment. However, information on repetition of self-harm behavior was traced in all participants over 3 years.

No No omissions 

of any expected suicide-related outcomes.

Yes Differences at baseline 

in 2 of 10 personal construct categories of self-harm.

No High
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APPENDIX S. STRENGTH OF EVIDENCE RATINGS FOR 

PRIMARY STUDIES RELATED TO PSYCHOTHERAPYa

Table 1. Attached-Based Family Therapy

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Attached-Based Family Therapy versus Enhanced Usual Care (Diamond 2010)46

Low lethality suicide attempts

1; 66 Medium (RCT/Unclear) N/A Indirect Imprecise ABFT = 11% (4/35); 

EUC = 22% (7/31); p 

not reported

Low

Table 2. Cognitive and Cognitive Behavioral Therapies (CBT)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Cognitive Therapy for suicide attempters versus Usual Care (Brown 2005 as cited in Mann 2005)10

Suicide re-attempt rate

1; not 

reported

Medium (RCT/Unclear) N/A Indirect N/A “Halved event rate” 

reported in Mann 

2005

Insufficient to 

Low

CBT for Cluster B Personality Disorders versus treatment as usual (Davidson 2010)41

Number of subjects with suicidal acts from 0-6 years

1; 106 Low (RCT/Low) N/A Indirect Imprecise aOR = 0.37 (95% CI, 

0.10 to 1.38)

Low

Mean episodes of suicidal acts from 0-6 years

1; 106 Low (RCT/Low) N/A Indirect Imprecise aMD (TAU-CBT) = 

1.26 (95% CI, -0.06 

to 2.58)

Low

CBT versus Supportive Counseling (Tarrier 2006)51

Deaths by suicide after 18 months

1; 278 High (RCT/High) N/A Indirect Imprecise CBT = 1; SC = 2; p 

not reported

Insufficient

CBT versus Problem Solving Therapy versus Usual Care (Stewart 2009)50

Repeated in Problem Solving Therapy table below

Average number of suicide attempts

1; 32 High (RCT/High) N/A Indirect Imprecise CBT: 0.22 

PST: 0.33 

TAU: 0.22 

No significant 

differences found for 

repetition of suicide 

attempts when PST 

group was compared 

to TAU

Insufficient
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Table 3. Collaborative Assessment and Management of Suicidality (CAMS)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

CAMS versus E-CAU (Comtois 2011)47

Mean number of suicide attempts and self-inflicted injuries at 12 months

1; 32 High (RCT/High) N/A Indirect Imprecise Mean (SD): 

CAMS=1.2 (3.9) vs 

E-CAU=3.3 (7.6). P 

not reported.

Insufficient

Table 4. Dialectical Behavior Therapy (DBT)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

DBT versus Community Treatment By Experts (Linehan 2006)38

Median suicides (interquartile range)

1; 111 Medium (RCT/Unclear) N/A Indirect Imprecise DBT=0 (0 to 0) vs 

CTBE=0 (0 to 1)

Insufficient

Suicide attempts

1; 111 Medium (RCT/Unclear) N/A Indirect Imprecise DBT=23.1% vs 

CTBE=46%, P=0.01, 

HR=2.66 (95% 

CI not reported; 

P=0.005), NNT=4.24 

(95% CI, 2.40 to 

18.07)

Low

DBT versus Standard Care (Hawton 2000 as cited in Mann 2005)10

Unclear outcome reported in Mann 2005

1 systematic 

review; not 

reported

Medium (SR/Unclear) N/A Indirect N/A Not reported Insufficient to 

Low

DBT versus General Psychiatric Management (McMain 2009)42

Deaths by suicide

1; 180 Medium (RCT/Unclear) N/A Indirect Imprecise No events Insufficient

Mean number of suicidal and self-injurious episodes at 12 months

1; 180 Medium (RCT/Unclear) N/A Indirect Imprecise DBT=4.29 (9.32) vs 

GPM=12.87 (51.45); 

OR 0.92 (P=0.76)

Low
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Table 5. Group Therapy

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Group Therapy versus Routine Care (Hazell 2009)49

Repetition of Deliberate Self-Harm by 6 months

1; 72 Medium (RCT/Unclear) N/A Indirect Imprecise GT = 88% (30/34); 

RC = 68% (23/34); 

p = 0.04

Low

Repetition of Deliberate Self-Harm in interval of 6 to 12 months

1; 72 Medium (RCT/Unclear) N/A Indirect Imprecise GT = 88% (30/34); 

RC = 71% (24/34); 

p = 0.07

Low

Group Therapy versus Routine Care (Green 2011)44

Self-harm resulting in severe physical injury at 12 months

1; 366 Medium (RCT/Unclear) N/A Indirect Imprecise Group therapy: 1/183

Usual care: 2/183

P not reported

Low

Suicide death at 12 months

1; 366 Medium (RCT/Unclear) N/A Indirect Imprecise No events Low

Table 6. IMPACT intervention

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

IMPACT intervention versus Usual Care (Unutzer 2006)52

Deaths by suicide after 24 months

1; 1801 Medium (RCT/Unclear) N/A Indirect Imprecise No events Insufficient

Table 7. Intensive Care Plus Outreach

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Intensive Care Plus Outreach versus Standard Care (Hawton 2000 as cited in Mann 2005)10

Unclear outcome reported in Mann 2005

1 systematic 

review; not 

reported

Medium (SR/Unclear) N/A Indirect N/A Not reported Insufficient to 

Low
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Table 8. Intensive Case Management

Domains pertaining to strength of evidence 

Magnitude of 

effect

Strength of 

evidence

Number of 

studies;

 # of 

subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision

Summary effect 

size

(95% CI)

High,

Moderate, 

Low, 

Insufficient

Intensive Case Management versus Treatment as Usual (De Leo 2007)45

Suicide at 12 months 

1; 22 High (RCT/High) N/A Indirect Imprecise No suicides in 

either group

Insufficient

Self-harming behavior at 6 months 

1; 22 High (RCT/High) N/A Indirect Imprecise Intensive case 

management: 3/14 

(21.4%) 

Treatment as usual: 1/8 (12.4%)

12 months: 

Insufficient

Self-harming behavior at 12 months 

1; 22 High (RCT/High) N/A Indirect Imprecise Intensive case 

management: 2/14 

(14.3%) 

Treatment as usual: 2/8 (25.0%)

Insufficient

Table 9. Interpersonal Psychotherapy

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Interpersonal Psychotherapy versus Standard Care (Guthrie 2001 as cited in Mann 2005)10

Unclear outcome reported in Mann 2005

1; not 

reported

Medium (RCT/Unclear) N/A Indirect N/A Not reported Insufficient to 

Low

Table 10. Mentalization Based Treatment (MBT)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

MBT versus treatment as usual (Bateman 2008)

Any suicide attempt

1; 41 High (RCT/High) N/A Indirect Imprecise d=2.0 (95% CI, 1.4 

to 4.9)

Insufficient

Mean total suicide attempts

1; 41 High (RCT/High) N/A Indirect Imprecise d=1.4 (95% CI, 1.3 

to 1.5)

Insufficient

MBT versus Structured Clinical Management (SCM) (Bateman 2009)37

Life-threatening suicide attempts, proportion with episode at end of treatment

1; 134 Medium (RCT/Unclear) N/A Indirect Imprecise d=0.65 (95% CI, 

0.58 to 0.73)

Low

Severe self-harm incidents, proportion with episode at end of treatment

1; 134 Medium (RCT/Unclear) N/A Indirect Imprecise d=0.62 (95% CI, 

0.28 to 0.97)

Low
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Table 11. Personal Construct Psychotherapy

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Personal Construct Psychotherapy versus Normal Clinical Practice (Winter 2007)43

Deaths by suicide after 5 years

1; 40 High (RCT/High) N/A Indirect Imprecise PCP = 1; NCP = 2; p 

not reported

Insufficient

Repetition of deliberate self-harm after 5 years

1; 40 High (RCT/High) N/A Indirect Imprecise 39% vs 58% 

(P=0.15)

Insufficient

Table 12. Problem-Solving Therapy

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ Risk 

of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Problem-Solving Therapy plus treatment as usual versus treatment as usual (Hatcher 2011)36

Participants re-presenting to hospital for self-harm: All consenting patients

1; 552 Low (RCT/Low) N/A Indirect Imprecise RR= 0.17 (95% 

CI -0.24 to 0.44); 

P=0.43

Moderate

Participants with self-reported self-harm: All consenting patients

1; 412 Low (RCT/Low) N/A Indirect Imprecise RR= 0.16 (95% 

CI -0.13 to 0.38); 

P=0.29

Moderate

Time to re-presentation to hospital for self-harm: All consenting patients

1; 139 Low (RCT/Low) N/A Indirect Imprecise HR= 0.81 (95% CI 

0.53 to 1.25); P=0.92

Moderate

Participants re-presenting to hospital for self-harm: Consenting patients; first episode of self-harm 

hospitalization is index episode

1; 306 Low (RCT/Low) N/A Indirect Imprecise RR= -0.56 (95% 

CI -1.96 to 0.18); 

P=0.23

Moderate

Participants with self-reported self-harm: Consenting patients; first episode of self-harm hospitalization 

is index episode

1; 220 Low (RCT/Low) N/A Indirect Imprecise RR= -0.25 (95% 

CI -1.03 to 0.24); 

P=0.47

Moderate

Time to re-presentation to hospital for self-harm: Consenting patients; first episode of self-harm 

hospitalization is index episode

1; 137 Low (RCT/Low) N/A Indirect Imprecise HR= 1.62 (95% CI 

0.82 to 3.18); P=0.16

Moderate

Participants re-presenting to hospital for self-harm: Consenting patients; repeat episode of self-harm 

hospitalization is index episode

1; 246 Low (RCT/Low) N/A Indirect Imprecise RR= 0.47 (95% 

CI 0.11 to 0.69); 

P=0.02; NNT=8

Moderate

Participants with self-reported self-harm: Consenting patients; repeat episode of self-harm 

hospitalization is index episode

1; 192 Low (RCT/Low) N/A Indirect Imprecise RR= 0.37 (95% 

CI 0.08 to 0.57); 

P=0.02; NNT=6

Moderate
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Time to re-presentation to hospital for self-harm: Consenting patients; repeat episode of self-harm 

hospitalization is index episode

1; 149 Low (RCT/Low) N/A Indirect Imprecise HR= 0.47 (95% CI 

0.26 to 0.85); P=0.01

Moderate

Participants re-presenting to hospital for self-harm: All patients

1; 1094 Low (RCT/Low) N/A Indirect Imprecise RR= 0.05 (95% 

CI -0.28 to 0.30); 

P=0.79

Moderate

Time to re-presentation to hospital for self-harm: All patients

1; 149 Low (RCT/Low) N/A Indirect Imprecise HR= 0.98 (95% CI 

0.71 to 1.36); P=0.92

Moderate

Participants re-presenting to hospital for self-harm: All patients; first episode of self-harm 

hospitalization is index episode

1; 674 Low (RCT/Low) N/A Indirect Imprecise RR= 0.42 (95% 

CI -1.17 to 0.08); 

P=0.37

Moderate

Time to re-presentation to hospital for self-harm: All patients; first episode of self-harm hospitalization 

is index episode

1; 135 Low (RCT/Low) N/A Indirect Imprecise HR= 1.55 (95% CI 

0.98 to 2.48); P=0.06

Moderate

Participants re-presenting to hospital for self-harm: All patients; repeat episode of self-harm 

hospitalization is index episode

1; 420 Low (RCT/Low) N/A Indirect Imprecise RR= 0.39 (95% 

CI 0.07 to 0.60); 

P=0.03; NNT=12

Moderate

Time to re-presentation to hospital for self-harm: All patients; repeat episode of self-harm 

hospitalization is index episode

1; 194 Low (RCT/Low) N/A Indirect Imprecise HR= 0.58 (95% CI 

0.36 to 0.94); P=0.03

Moderate

Problem-Solving Therapy versus Standard Care (Hawton 2000 as cited in Mann 2005)10

Unclear outcome reported in Mann 2005

1 

systematic 

review; not 

reported

Medium (SR/Unclear) N/A Indirect N/A Not reported Insufficient to 

Low

CBT vs Problem Solving Therapy vs Usual Care (Stewart 2009)50

Repeated in Cognitive Therapy table above

Average number of suicide attempts

1; 32 High (RCT/High) N/A Indirect Imprecise CBT: 0.22 

PST: 0.33 

TAU: 0.22 

No significant 

differences found for 

repetition of suicide 

attempts when PST 

group was compared 

to TAU

Insufficient

Table 13. Psychoanalytically Oriented Partial Hospitalization

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Psychoanalytically Oriented Partial Hospitalization versus Standard Care in patients with Borderline 

Personality Disorder (Bateman 2001 as cited in Mann 2005)10

Unclear outcome reported in Mann 2005

1; not 

reported

Medium (RCT/Unclear) N/A Indirect N/A Not reported Insufficient to 

Low
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Table 14. Skills Based Treatment

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Skills Based Treatment versus Supportive Relationship Treatment (Donaldson 2005)48

Number of re-attempts at 6 months

1; 39 High (RCT/High) N/A Indirect Imprecise SBT=26.7% (4/15) 

vs SRT=12.5% 

(2/16); χ2=1.00 

Insufficient

Table 15. Systems Training for Emotional Predictability and Problem Solving (STEPPS)

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Risk of bias) Consistency Directness Precision Magnitude of effect

High, 

Moderate, 

Low, 

Insufficient

Systems Training for Emotional Predictability and Problem Solving versus treatment as usual (Blum 

2008)39

Time to first suicide attempt

1; 165 High (RCT/High) N/A Indirect Imprecise χ2<0.1, df=1, 

p=0.994

Low

Time to first self-harm act

1; 165 High (RCT/High) N/A Indirect Imprecise χ2<0.1, df=1, 

p=0.902

Low

a This review did not evaluate any outcomes other than suicidal self-directed violence, and therefore no additional 

data on potential harms and side effects was investigated. Potential harms and side effects should always be 

considered when evaluating the strength of evidence and considering adoption of an intervention or referral/followup service.
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LITY RATING OF SYSTEMATIC REVIEWS RELATED TO REFERRAL/

ICES USING OXMAN AND GUYATT15 CRITERIA

hensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

 searched 

ase, 

is database 

 multiple 

abases

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Can’t tell Yes 6

and

, reference 

hing, or 

perts noted

Partially; very general statement re: inclusion

No Yes Partially/Can’t 

tell; sometimes did, but often didn’t

No Yes Yes 3

Yes Can’t tell; 

detailed results of study selection not reported, no reasons for exclusions described

Yes No; reported 

validity assessment, but did not do any type of analysis with it

Yes Yes Yes 5

Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes 7

and

, reference 

hing, or 

perts noted

Yes No Yes Yes No Yes Yes 4
118

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

hensive 

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall scientific quality (higher score is better)

and

, reference 

hing, or 

perts noted

Yes Yes Yes Yes Yes Can’t tell Yes 6Yes Yes Yes Yes Yes Yes Can’t tell. 

For example, awareness campaigns are categorized as actually or potentially effective in the Discussion. But, in Table 2, the Effect Sizes include “no detectable effect”, “no effect”, and “inconclusive”

5
119

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A ABSTRACTION OF PRIMARY STUDIES OBTAINED FROM GOOD QUALITY 

EWS RELATED TO REFERRAL/FOLLOW-UP SERVICES

 

ed in 

w

Eligibility criteria in systematic review

Study designs of eligible studies

Countries included in eligible studies

Sample size in eligible studies

Population in eligible studies

Interventions in eligible studies

Main results of eligible studies

oup 

n 

2009

Randomized clinical trial, focused on people with severe mental illness, ages 18-65 years, community care setting, intensive case management (ICM) compared to non-intensive case management or standard care

One RCT: Killaspy 200658

UK 251 People with severe 

mental illness, mean age was 39 years (SD 11); 58% male; 36% AfroCaribbean

ICM Assertive Community Treatment versus non-ICM Community Mental Health Treatment

One out of 127 patients assigned to ICM and three out of 124 patients assigned to non-ICM died by suicide; 10 ICM and 13 nonICM patients (p = 0.40) engaged in deliberate self-harm including suicide.

NFO, 

urnal 

RE, 

006

Clinical or administrative outcomes of Telemental Health applications; controlled studies comparing Telemental Health to a non-Telemental Health alternative; non-controlled studies with no fewer than 20 subjects

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs No eligible RCTs No eligible RCTs

ASE, 

ar, 

ment 

Elite, 

 

nd 

 

x, 

nd 

d 

n 

tober 

Experimental or quasiexperimental designs; mental health-based, suicide-preventionfocused intervention initiated in the ED or immediately after ED discharge through direct referral/enrollment; children and adolescents (aged ≤18 years), or their parents or ED personnel; at least one clinically relevant primary outcome

No eligible RCTs

No eligible RCTs

No eligible RCTs

No eligible RCTs No eligible RCTs No eligible RCTs
120

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

 

ed in 

w

Eligibility criteria in systematic review

Study designs of eligible studies

Countries included in eligible studies

Sample size in eligible studies

Population in eligible studies

Interventions in eligible studies

Main results of eligible studies

rane 

O: 

008

English language, suicide or suicide attempt outcomes, no mental health interventions such as psychotherapy or pharmacotherapy interventions unless they included Veterans

One RCT:Carter 200554

Australia 772 Non-Veteran/

Military; no other data reported

Postcards mailed every 1-2 months for a year postdischarge

57 repeated selfharm incidents in the treatment group compared to 68 incidents in the control group

ASE, 

O: 

ruary 

English language, human, suicide related outcome, sample size ≥6, no duplication, emergency department or other acute care setting

One RCT reported in 2 papers: Carter 200554

Carter 200755

Australia 772 Mean age 33 years 

for treatment group, 34 years for control; patients had an average of 2 psychiatric diagnoses

Postcards mailed every 1-2 months for a year postdischarge

RR 0.55, 95% CI 0.35-0.87 for repeat episodes of self-poisoning at 12 months followup; RR 0.49, 95% CI 0.33-0.73 for repeat episodes of self-poisoning at 24 months
121

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

MARY OF SYSTEMATIC REVIEW RESULTS RELATED TO REFERRAL AND 

ICES FROM GAYNES ET AL., MANN ET AL., AND NICE REVIEWS9-11

Gaynes 20049 Mann 200510 NICE 201111

ralizability of the studies makes the overall 

dence fair, at best, while the results are 

h some trends suggest incremental benefit 

terventions, no consistent statistically 

cts have emerged for interventions for 

an one study has been done.

Interventions need more evidence of efficacy. Compared with usual care, there was insufficient 

evidence to determine clinical effects between interventions and routine care in the reduction of the proportion of patients who repeated self-harm. Thus, no conclusions could be made regarding psychosocial interventions on reduction of repetitions of self-harm. For the outcome of suicide, no conclusions could be drawn due to the small evidence base.

Scope 

2002 1966-June 2005 Up to January 2011

nterest was primary care patients with 

dentified suicide risk. Included RCTs were 

igh-risk groups as identified by a deliberate 

ode, diagnosis of borderline personality 

mission to a psychiatric unit.

Not specified Adults, children, and young people with previous selfharm behavior

apy, psychotherapy, referral/follow-up Pharmacotherapy, psychotherapy, referral/follow-up Pharmacotherapy, psychotherapy, referral/follow-up

etions, suicide attempts Completed and attempted suicide Primary outcome was repetition of self-harm; also 

included suicide outcomes.

cialty care settings; no exclusions based on 

Included settings not specified; no exclusions based on country.

No exclusions by country

argeting patients with chronic psychotic 

es without adequate comparison groups.

No additional exclusion criteria specified.

Main Results: Referral and Follow-up Services

Fewer suicide attempts Insufficient evidence for repeat self-harm and suicide 

prevention.

of 6 studies produced a non-significant 

of decreasing repetition of deliberate self

No benefit in terms of re-attempt rate when compared to standard care.Fewer suicides Insufficient evidence for repeat self-harm; possible 

suicide prevention effect should be interpreted with caution.

No benefit in terms of re-attempt rate when compared to standard care.

Insufficient evidence for repeat self-harm and suicide prevention.

decreasing repetition of self-harm in one 
122

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

CRIPTION OF PRIMARY OUTCOMES AND INTENT TO TREAT SUICIDAL 

IOLENCE FOR STUDIES RELATED TO REFERRAL AND FOLLOW-UP 

at 

N Outcome definition Results

as 

ess 

 re

327 Re-presentations for selfharm were assessed by 

monitoring psychiatric emergency service records and hospital medical records were reviewed at the conclusion of the 12-month follow-up period. Three measures of re-presentation were calculated from these data: re-presentations to psychiatric emergency service, re-presentations to Christchurch Hospital emergency department and total re-presentations to either the psychiatric emergency service or emergency department

Unadjusted analyses:Re-presentation for self-harm, %:To psychiatric emergency service: PC=15.0 vs TAU=23.6, P<0.06, OR= 0.57 (95% CI, 0.33 to 1.01)To emergency department: PC=25.5 vs TAU=27.0, P>0.75; OR=0.92 (95% CI 0.56 to 1.52)Total (psychiatric emergency service or emergency department): PC=25.5vs TAU=28.2, P>0.58, OR=0.87 (95% CI 0.53 to 1.43)Number of self-harm re-presentations:To psychiatric emergency service: PC=23.5 vs TAU=51.1, P<0.0001, IRR= 0.46 (95% CI, 0.31 to 0.68)To emergency department: PC=53.6 vs TAU=71.8, P<0.04, IRR= 0.75 (95% CI, 0.56 to 0.99) Total (psychiatric emergency service or emergency department): PC=56.9 vs TAU=78.2, P<0.03; IRR=0.73 (95% CI, 0.56 to 0.95)Analyses adjusted for prior self-harmRe-presentation for self-harm, %To psychiatric emergency service: PC=16.2 vs TAU= 22.5; P>0.13; OR=0.64 (95% CI, 0.36 to 1.15)To emergency department: PC=26.6 vs TAU= 26.0; P>0.88; OR=1.04 (95% CI, 0.62 to 1.73)Total (psychiatric emergency service or emergency department): PC=26.6 vs TAU=27.2; P>0.91; OR=0.97 (95% CI, 0.58 to 1.62)Number of self-harm re-presentationsTo psychiatric emergency service: PC=28.7 vs TAU=44.1; P>0.04; IRR=0.65 (95% CI, 0.43 to 0.98)To emergency department: PC=67.2 vs TAU=61.0; P>0.52; IRR=1.10 (95% CI, 0.82 to 1.49) Total (psychiatric emergency service or emergency department): PC=71.1 vs TAU=66.4; P>0.64; IRR=1.07 (95% CI, 0.80 to 1.43)

ome 

772 Proportion of patients with at 

least one repeat episode of deliberate self poisoning in 24 months and the number of repeat episodes of deliberate self poisoning per individual over 24 months

12-month outcomesProportion of patients with repeat deliberate self poisoning: PC=57 (15.1%, 95% CI 11.5% to 18.7%) vs TAU=68 (17.3%, 95% CI, 13.5% to 21%); difference between groups -2% (95% CI, -7% to 3%); χ2=0.675, df = 1, P = 0.41Cumulative number of repeat episodes of deliberate self poisoning: PC=101 vs TAU=192Risk of repetition= overall incidence risk ratio (IRR) 0.55 (95% CI, 0.35 to 0.87); men only: IRR= 0.97 (95% CI, 0.48 to 1.98); women only: IRR= 0.54 (95% CI, 0.30 to 0.96)24-month outcomesProportion of patients with repeat deliberate self poisoning: PC=21.2% (80/378; 95% CI, 17.0 to 25.3) vs TAU=22.8% (90/394; 95% CI, 18.7 to 27.0); difference between groups -1.7% (95% CI, -7.5 to 4.2); χ2=0.317, df = 1, P = 0.57Cumulative number of repeat episodes of deliberate self poisoning: PC=145 vs TAU=310Risk of repetition= overall IRR 0.49 (95% CI, 0.33 to 0.73); men only: IRR= 0.97 (95% CI, 0.50 to 1.88); women only: IRR= 0.49 (95% CI, 0.30 to 0.80) 
123

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

at 

N Outcome definition Results

at 

 an 

dy 

ss 

ors for 

ut the 

in this ty, not y

599 National Center for Health 

Statistics National Death Index (NDI) Plus was used to assess vital status over a 5-year period. The underlying causes of death obtained from NDI Plus are similar to codes assigned by trained nosologists (Doody 2001, Sathiakumar 1998)

Suicide N, n/1000 person-years (95% CI)All patients (N=599): IG=1, 0.7 (0.0 to 4.2) vs UC=0, 0.0 (0.0 to 3.3)Patients with major depression disorder (N=396): IG=0, 0.0 (0.0 to 4.1) vs UC=0, 0.0 (0.0 to 5.1)Patients with clinically significant minor depression (n =203): IG=1, 2.2 (0.1 to 2.5) vs UC=0, 0.0 (0.0 to 9.7)Patients without depression (n=627): IG=0, 0.0 (0.0 to 3.0) vs UC=0, 0.0 (0.0 to 2.5)

d 

erate 

251 Serious incidents concerning 

deliberate self-harm during the 18-month study period. Outcome criteria were not reported. 

Committed suicide: ACT=0.8% (1/124) vs CMH=2.5% (3/119); between-groups comparison not reportedDeliberate self-harm: ACT=8% (10/91) vs CMH=11% (13/75); mean difference= 0.72; P=0.40

asures 

ctrum 

or 

86): a 

istory 

e, 

reat, 

ous 

236 Suicide attempts were 

measured through selfreport on the Spectrum of Suicide Behavior Scale (Pfeffer, 1986) 

No significant differences between groups in percent of adolescents with one or more suicide attempts% with 1 or more suicide attempts during the 6 month follow-up: TAU=11.7, TAU+YST-1=18.1% (fishers exact 

test, P=.22)

e or 

r more 

during 

eriod 

th an 

MH 

sorders 

346 Presence or absence of one 

or more suicide attempts during follow-up was assessed via self-report, using the question, “Have you tried to kill yourself?” from the NIMH DISC-IV Mood Disorders Module. 

No significant differences were found between groups for percent of adolescents with one or more attempts. % with one or more attempts in the 12 month follow-up period: TAU=35, TAU+YST-II=29, Chi-square (1, N=354)=0.66, p=.42One suicide death occurred in the TAU group, no suicide deaths in the TAU+YST-II group
124

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

A ABSTRACTION FOR PRIMARY STUDIES RELATED TO REFERRAL/

ICES

ais 201053 (New Zealand)

viduals aged 16 and older who presented to psychiatric emergency services at Christchurch Hospital, New Zealand, following self-harm or 

ed suicide during the period 1 August 2006 to 6 April 2007.

ent as usual (TAU) consisted of crisis assessment and referral to in-patient community-based mental health services.

us postcard intervention (PC), which consisted of a series of six ‘postcards’ sent by mail during the 12 months following the participant’s index 

ation for suicide attempt or self-harm. The postcard read: ‘It has been a short time since you were here at PES (Psych Emergency), and we hope 

re going well for you. If you wish to drop us a note we would be happy to hear from you’. Postcards were printed on A4 paper and posted in a 

aled envelope to the participant’s residential address. Postcards were posted at the following times after the index presentation: 2 and 6 weeks; 

and 12 months.

sychiatric emergency services, serving a population of approximately 500,000 people

C=153, TAU=174 

ars (variance NR): PC=33.8 vs TAU=33.9

le: PC=70.4% vs TAU=62.3%

R

entations for self-harm were assessed by monitoring psychiatric emergency service records and hospital medical records were reviewed at 

clusion of the 12-month follow-up period. Three measures of re-presentation were calculated from these data: re-presentations to psychiatric 

ncy service, re-presentations to Christchurch Hospital emergency department and total re-presentations to either the psychiatric emergency 

or emergency department.

sted analyses:

entation for self-harm, %:

psychiatric emergency service: PC=15.0 vs TAU=23.6, P<0.06, OR= 0.57 (95% CI, 0.33 to 1.01)emergency department: PC=25.5 vs TAU=27.0, P>0.75; OR=0.92 (95% CI 0.56 to 1.52)

al (psychiatric emergency service or emergency department): PC=25.5vs TAU=28.2, P>0.58, OR=0.87 (95% CI 0.53 to 1.43)

r of self-harm re-presentations:

psychiatric emergency service: PC=23.5 vs TAU=51.1, P<0.0001, IRR= 0.46 (95% CI, 0.31 to 0.68)emergency department: PC=53.6 vs TAU=71.8, P<0.04, IRR= 0.75 (95% CI, 0.56 to 0.99)

al (psychiatric emergency service or emergency department): PC=56.9 vs TAU=78.2, P<0.03; IRR=0.73 (95% CI, 0.56 to 0.95)

es adjusted for prior self-harm

entation for self-harm, %

psychiatric emergency service: PC=16.2 vs TAU= 22.5; P>0.13; OR=0.64 (95% CI, 0.36 to 1.15)emergency department: PC=26.6 vs TAU= 26.0; P>0.88; OR=1.04 (95% CI, 0.62 to 1.73)

al (psychiatric emergency service or emergency department): PC=26.6 vs TAU=27.2; P>0.91; OR=0.97 (95% CI, 0.58 to 1.62)

r of self-harm re-presentations

psychiatric emergency service: PC=28.7 vs TAU=44.1; P>0.04; IRR=0.65 (95% CI, 0.43 to 0.98)emergency department: PC=67.2 vs TAU=61.0; P>0.52; IRR=1.10 (95% CI, 0.82 to 1.49)

al (psychiatric emergency service or emergency department): PC=71.1 vs TAU=66.4; P>0.64; IRR=1.07 (95% CI, 0.80 to 1.43)
125

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

200554 – 12-month outcomes

200755 – 24-month outcomes

alia)

ged over 16 years who presented with deliberate self poisoning during April 1998 to December 2001 to the Hunter Area Toxicology Service 

ewcastle Mater Hospital, New South Wales, Australia, which serves a primary referral population of 385 000 adults and a tertiary referral 

ion of a further 170 000

ent as usual (TAU); no details provided

ard (PC) sent to participants in a sealed envelope at 1, 2, 3, 4, 6, 8, 10, and 12 months after discharge, plus TAU

cified

C=378 vs TAU=394

 age, years (interquartile range): 33 (24-44)

male

ot reported

evious admission for deliberate self-poisoning

 number of psychiatric diagnoses (interquartile range): 2 (1-2)

ion of patients with at least one repeat episode of deliberate self poisoning in 24 months and the number of repeat episodes of deliberate self 

ng per individual over 24 months

th outcomes:

ion of patients with repeat deliberate self poisoning: PC=57 (15.1%, 95% CI 11.5% to 18.7%) vs TAU=68 (17.3%, 95% CI, 13.5% to 21%); 

ce between groups -2% (95% CI, -7% to 3%); χ2=0.675, df = 1, P = 0.41

tive number of repeat episodes of deliberate self poisoning: PC=101 vs TAU=192repetition= overall incidence risk ratio (IRR) 0.55 (95% CI, 0.35 to 0.87); men only: IRR= 0.97 (95% CI, 0.48 to 1.98); women only: IRR= 

5% CI, 0.30 to 0.96)

th outcomes

ion of patients with repeat deliberate self poisoning: PC=21.2% (80/378; 95% CI, 17.0 to 25.3) vs TAU=22.8% (90/394; 95% CI, 18.7 to 27.0); 

ce between groups -1.7% (95% CI, -7.5 to 4.2); χ2=0. 317, df = 1, P = 0.57

tive number of repeat episodes of deliberate self poisoning: PC=145 vs TAU=310

repetition= overall IRR 0.49 (95% CI, 0.33 to 0.73); men only: IRR= 0.97 (95% CI, 0.50 to 1.88); women only: IRR= 0.49 (95% CI, 0.30 to 0.80) 

PECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) (US)

00759: 5-year outcomes

2004120, Schulberg 2001127: Additional detail on methods 

0 years and score greater than 20 on the Centers for Epidemiologic Studies Depression scale

Care (UC): Practices received educational sessions for primary care physicians and notification of the depression status of their patients, but no 

 recommendations were given to physicians about individual patients, except for psychiatric emergencies.

ntion Group (IG): On-site depression care manager working with primary care physicians to provide algorithm-based care. Depression 

nager’s role included (1) obtaining needed clinical information from the patient and prompting the physician with timely and targeted 

mendations about appropriate care of the patient’s depression; (2) monitoring patient’s clinical course and encouraging adherence; (3) educating 

, families and physicians on depression and suicidal ideation. 
126

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PECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) (US)

00759: 5-year outcomes

2004120, Schulberg 2001127: Additional detail on methods 

ents received citalopram, initiated at 10 mg before bedtime on the first day, 20 mg/d for the next 6 days, and 30 mg/d subsequently. After 6 

the target dosage was maintained if the patient exhibited a substantial improvement (≥ 50% reduction in the HDRS or was increased if the 

exhibited a partial improvement (30% to 50% reduction in the HDRS score). Nonresponders, for whom guidelines called for switching to 

 antidepressant, were defined as patients who did not demonstrate either minimal improvement after 6 weeks of treatment at the target dosage 

antial improvement after the dose was increased to the maximum recommended dose after 12 weeks of treatment For patients who had not 

ed at 12 weeks, the health specialist followed guidelines for switching antidepressants.

ary care practices; 16 community-based and 4 were academic practices

care managers included social workers, nurses, and psychologists

ths

=320, UC=279

ge (SD): IG=71 (7.8) vs UC=70 (8.1)

le: IG=69% vs UC=75%

minority (Hispanic, non-Hispanic Black, Asian, other non-Hispanic): IG=29% vs UC=37%

MMSE score for cognitive function (SD): IG= 27 (2.9) vs UC= 27 (2.5)

depressive disorder: IG=67% vs UC=65%

Hamilton Depression Rating Scale score for depression severity (SD): IG=19 (6.1) vs UC=18 (5.8)

Scale for Suicidal Ideation score >0): IG= 29% vs UC=20%

hs:

tion and psychotherapy: IG=5.8% vs UC=8.5%; OR 0.46 (95% CI, 0.13 to1.66)tion only : IG=57.7% vs UC=40.4%; OR 4.91 (95% CI, 2.13 to 11.33)

hs:

tion and psychotherapy: IG=9.7% vs UC=8.9%; OR 1.29 (95% CI, 0.39 to 4.30)tion only : IG=57.0% vs UC=39.4%; OR 4.20 (95% CI, 1.77 to 9.96)

ths:

tion and psychotherapy: IG=6.8% vs UC=13.6%; OR 0.25 (95% CI, 0.07 to 0.96)tion only : IG=66.3% vs UC=44.2%; OR 7.21 (95% CI, 2.86 to 18.18)

l Center for Health Statistics NDI Plus was used to assess vital status over a 5-year period. The underlying causes of death that we obtained 

DI Plus are similar to codes assigned by trained nosologists (Doody 2001, Sathiakumar 1998)

 N, n/1000 person-years (95% CI)

atients (N=599): IG=1, 0.7 (0.0 to 4.2) vs UC=0, 0.0 (0.0 to 3.3)

nts with major depression disorder (N=396): IG=0, 0.0 (0.0 to 4.1) vs UC=0, 0.0 (0.0 to 5.1)nts with clinically significant minor depression (n =203): IG=1, 2.2 (0.1 to 2.5) vs UC=0, 0.0 (0.0 to 9.7)nts without depression (n=627): IG=0, 0.0 (0.0 to 3.0) vs UC=0, 0.0 (0.0 to 2.5)
127

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

T study (Randomized Evaluation of Assertive Community Treatment) (UK)

y 200658

living in independent or low supported accommodations; under the care of the community mental health

r at least 12 months and identified as having difficulty engaging with standard community care; primary diagnosis of

mental illness (for example, schizophrenia, schizoaffective disorder, other chronic psychosis, bipolar affective disorder); and recent high use of 

nt care (at least 100 consecutive inpatient days or at least five admissions within the past two years or at least 50 consecutive inpatient days or at 

ree admissions within the past year)

ve community treatment (ACT): Total team case load=80 to 100; maximum individual case load=12; availability=extended hours (0800 to 

ery day); locations for appointments=not office based (“in vivo”): meet client at home, in cafes, parks, etc; contact with clients=assertive 

ment: multiple attempts, flexible and various approaches (for example, befriending, offering practical support, leisure activities); commitment 

=“no drop-out” policy: continue to try to engage in long term care; case work style=team approach—all team members work with all clients; 

ncy of team meetings=frequent (up to daily) to discuss clients and daily plans; source of skills=team rather than outside agencies as far as 

e

unity mental health (CMH): Total team case load=300 to 350; maximum individual case load=35; availability=office hours only (0900 to 1700 

i); locations for appointments=office based appointments and home visits; contact with clients=offer appointments at office or make home 

ommitment to care=discharge if unable to make or maintain contact; case work style=case management—little “sharing” of work with clients 

n team members; frequency of team meetings=weekly; source of skills=“brokerage”: referral to outside agencies for advice (for example, social 

 benefits, housing)

orted

cation for appointment’ information for each therapy, respectively

orted

ths

CT=127 vs CMH=124

ge, years (SD): ACT=38 (11) vs CMH=40 (11)

le: ACT=38% vs CMH=45%

e: ACT=51% vs CMH=57%

an Caribbean: ACT=41% vs CMH=31%

r Race: ACT=8% vs CMH=11%nts:

hrenia: ACT=68% vs CMH=65%

ffective: ACT=17% vs CMH=15%

 affective: ACT=6% vs CMH=4%

nal disorder: ACT=3% vs CMH=5%

depression: ACT=0 vs CMH=2%

iagnoses: ACT=6% vs CMH=8%orted

 incidents concerning deliberate self-harm during the 18-month study period. Outcome criteria were not reported. 
128

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T study (Randomized Evaluation of Assertive Community Treatment) (UK)

y 200658

tted suicide: ACT=0.8% (1/124) vs CMH=2.5% (3/119); between-groups comparison not reported

ate self-harm: ACT=8% (10/91) vs CMH=11% (13/75); mean difference= 0.72; P=0.40

00657 (US)

lescents who were psychiatrically hospitalized at a university-based or private hospital between August 1998 and December 2000.

ent as usual (TAU) varied and consisted of psychotherapy (100%), psychoactive medication (96.8%), alcohol/drug treatment (13.4%), partial 

ization (18.0%), and community services (8.5%).

us Youth-Nominated Support Team – Version 1 (YST-1) consisted of youth nominating support persons from available caring others in their 

ncluding school, neighborhood/community, and family); support persons underwent training (psychoeducation sessions approximately 1.5-2hrs 

maintained weekly supportive contact with youth, and were contacted regularly by intervention specialists (mental health professionals with 

s clinical experience with the youth). The psychoeducation included information on youth’s treatment plan, risk factors for suicidal behavior, 

lity of emergency services, and strategies for communicating with adolescents. 

cified; 6 month follow-up period post hospitalization

AU=123, TAU+YST-1=113

ge = 12.0 (SD=3.3); TAU=11.9 (SD=3.5), TAU+YST-1=12.1 (SD=3.0)

le=68.2; TAU=67.4, TAU+YST-1=68.9

e=82.4; TAU=79.6, TAU+YST-1=85.0

 attempts were measured through self-report on the Spectrum of Suicide Behavior Scale (Pfeffer, 1986) 

ificant differences between groups in percent of adolescents with one or more suicide attempts

1 or more suicide attempts during the 6 month follow-up: TAU=11.7, TAU+YST-1=18.1% (fishers exact test, P=.22)

00956 (US)

lescents (aged 13-17) psychiatrically hospitalized in either a university or private hospital between 2002 and 2005.

ent as Usual (TAU) consisted of psychotherapy (mean # sessions=22.47), psychoactive medication (mean # different medications=1.66), 

ion follow-up (mean #=8.47), alcohol/drug treatment (n=4), psychiatric hospitalization (n=13), residential treatment (n=6)

nt as Usual plus Youth Support Team-II (TAU+YST-II) consisted of youth nominating caring adults from family, school, or neighborhood/community 

 as their supportive contacts. Intervention specialists were mental health professionals, assisted with the nomination process, and conducted 

ducation sessions with the support persons. The psychoeducation included information on youth’s treatment plan, risk factors for suicidal behavior, 

lity of emergency services, and strategies for communicating with adolescents. Support persons had weekly contact with the youth.

cified; 12 month follow-up period post hospitalization

AU=171, TAU+YST-II=175 (N’s reported and included in analysis after 12 month follow-up period)

ge=15.59 (SD=1.31), TAU=15.61 (SD=1.37), TAU+YST-II=15.56 (SD=1.24)

le=71 (same in both groups)

e=83.4, TAU=84, TAU+YST-II=83

e or absence of one or more suicide attempts during follow-up was assessed via self-report, using the question, “Have you tried to kill 

f?” from the NIMH DISC-IV Mood Disorders Module. 

ificant differences were found between groups for percent of adolescents with one or more attempts. 

one or more attempts in the 12 month follow-up period: TAU=35, TAU+YST-II=29, Chi-square (1, N=354)=0.66, p=.42

cide death occurred in the TAU group, no suicide deaths in the TAU+YST-II group
129

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

 OF BIAS RATINGS FOR PRIMARY STUDIES RELATED TO REFERRAL/

ICES

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL 

risk of bias 

for the study 

as a whole

escribe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during the study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how the possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in the other domains in the tool. If particular questions/entries were pre-specified in the review’s protocol, responses should be provided for each question/entry.

Was the study apparently free of other problems that could put it at a high risk of bias? Yes/No/Unclear

Low/ Unclear/High

andomized by 

search staff who 

ere not involved 

 the recruitment 

r clinical care of articipants.

Yes Psychiatric emergency service 

clinicians masked to allocation; allocation status not conveyed to clinical or data-collection staff.

Yes 327/327 analyzed; ITT. Yes No omissions 

of any expected suicide-related outcomes.

Yes At baseline, number of 

prior attendances for self-harm was lower in the intervention group (P<0.07).

No Unclear

o maintain blinding 

 allocated group 

uring recruitment, 

ndomization was 

ot revealed until fter all information 

as entered and 

igibility had been 

etermined.

Yes Clinical and research staff were 

blinded to allocation.

Yes Well-described ITT analysis and 

pre-treatment group comparisons included in the article. Attritions and exclusions adequately documented and subject flowchart included in article. All 772 randomized were followed up. 76/378 randomized to treatment group did not consent to the intervention.

Yes No omissions 

of any expected suicide-related outcomes. 

Yes 20 participants in the 

control group received the intervention due to clerical errors but were included in the control group for the ITT analyses.

Unclear Unclear

oin flip 

ndomization 

one at the clinical ractice level, 

o no allocation oncealment related 

 patients was 

eeded.

Yes No information provided. Unclear Attritions and exclusions 

adequately documented. 12/650 (2%) excluded due to insufficient baseline data; vital statistics available on others.

Yes No omissions 

of any expected suicide-related outcomes; authors state that outcome reporting and secondary data analysis were guided by cited standards. Prespecified study hypothesis was that risk of death would be reduced by the intervention.

Yes Suicidal ideation 

higher in patients in intervention group at baseline.

Unclear Unclear
130

ns and Referral/Follow-up Services: A Systematic Review Evidence-based Synthesis Program

Allocation concealment

Blinding of participants, personnel,

and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias

OVERALL 

risk of bias 

for the study 

as a whole

escribe method

Was it adequate? Yes/No/Unclear

Describe all measures used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. Provide any information relating to whether intended blinding was effective.

Was knowledge of allocated intervention adequately prevented during the study? Yes/No/Unclear

Describe completeness of outcome data for each main outcome, including attrition and exclusions from analysis. State whether attrition and exclusions were reported, numbers in each intervention group (compared with total randomized participants), reasons for attrition/exclusions where reported, and any re-inclusions in analyses performed by review authors.

Were incomplete outcome data adequately addressed? Yes/No/Unclear

State how the possibility of selective outcome reporting was examined by review authors, and what was found.

Are reports of study free of suggestion of selective outcome reporting? Yes/No/Unclear

State any important concerns about bias not addressed in the other domains in the tool. If particular questions/entries were pre-specified in the review’s protocol, responses should be provided for each question/entry.

Was the study apparently free of other problems that could put it at a high risk of bias? Yes/No/Unclear

Low/ Unclear/High

terviewer 

ontacted 

dministrator at trial 

enter, who opened 

e appropriate 

umbered envelope 

ving details of 

e outcome of 

ndomization.

Yes No information provided. Unclear Attritions and exclusions 

adequately documented. Hospital admission data available for 243/251 at 18 months (97%); 68% response rate for interview at 18 months.

Yes No omissions 

of any expected suicide-related outcomes. 

Yes The study appears 

to be free of other sources of bias.

Yes Unclear

o allocation 

oncealment.

No “Raters were not blind to group 

status.”

No Well-described ITT analysis and 

pre-treatment group comparisons included in the article. Attritions and exclusions adequately documented and subject flowchart included in article.

Yes No omissions 

of any expected suicide-related outcomes. 

Yes Differences among 

groups who met actually treated criteria and others in age, and family income (but not prior suicide attempts).

Unclear Unclear

Group assignments 

ere unknown until 

e project manager 

enerated them at 

e randomization 

ebsite following 

e consent 

rocess (sequence nknown).”

Yes “Independent evaluators were 

blinded to group assignment.” No information on patient or provider blinding, though it would seem impossible given study design.

Assessors yes, participants unclear

Well-described ITT analysis and pre-treatment group comparisons included in the article. Attritions and exclusions adequately documented and subject flowchart included in article.

Yes No omissions 

of any expected suicide-related outcomes. 

Yes The study appears 

to be free of other sources of bias.

Yes Unclear
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APPENDIX Z. STRENGTH OF EVIDENCE RATINGS FOR 

PRIMARY STUDIES RELATED TO REFERRAL/FOLLOW-UP 

SERVICESa

Table 1: Assertive Community Treatment

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Quality) Consistency Directness Precision

Summary effect 

size

(95% CI)

High, 

Moderate, 

Low, 

Insufficient

Assertive Community Treatment versus Community Mental Healthcare (Killaspy 2006)58

Suicide deaths

1; N=251 Medium (RCT/Unclear) N/A Indirect Imprecise 0.8% vs 2.5%, P NR Low

Deliberate self-harm

1; N=251 Medium (RCT/Unclear) N/A Indirect Imprecise 8% vs 11%; P=0.40 Low

Table 2: Case Management/Care Coordination

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Quality) Consistency Directness Precision

Summary effect 

size

(95% CI)

High, 

Moderate, 

Low, 

Insufficient

Depression Care Management versus Usual Care (Gallo 2007, Bogner 2007, Raue 2010; Prevention of Suicide in Primary 

Care Elderly: Collaborative Trial [PROSPECT])59, 128, 129

Suicide deaths, n/1000 person-years (95% CI)

1; N=599 Medium (RCT/Unclear) N/A Indirect Imprecise 0.7 (0.0 to 4.2) vs 

UC=0, 0.0 (0.0 to 

3.3)

Low

Table 3: Emergency contact “green” card

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Quality) Consistency Directness Precision

Summary effect size

(95% CI)

High, 

Moderate, 

Low, 

Insufficient

Emergency contact “green” card versus Standard Care (Morgan 1993 as cited in Mann 2005)10

Suicide attempts

1; not 

reported

Medium (RCT/Unclear) N/A Indirect N/A Not reported Insufficient 

to Low
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Table 4: Postcard/Mailing Interventions

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of bias (Design/ 

Quality) Consistency Directness Precision

Summary effect size

(95% CI)

High, 

Moderate, 

Low, 

Insufficient

Postcard Intervention versus treatment as usual (Carter 2005/2007, Beautrais 2010)53-55

Proportion of patients with repeat deliberate self poisoning at 12 months and 24 months (Carter 2005/2007)54, 55

1; N=772 Medium (RCT/Unclear) N/A Indirect Imprecise 12 months: 15.1% vs 

17.3%; -2% (95% CI, 

-7% to 3%)

24 months: 21.2% vs 

22.8%; -1.7% (95% 

CI, -7.5 to 4.2

Low

Cumulative number of repeat episodes of deliberate self poisoning at 12 months and 24 months (Carter 2005/2007)54, 55

1; N=772 Medium (RCT/Unclear) N/A Indirect Imprecise 12 months: IRR 0.55 

(95% CI, 0.35 to 0.87)

24 months: 0.49 (95% 

CI, 0.33 to 0.73)

Low

Total proportions of patients re-presenting for self-harm at 12 months (Beautrais 2010)53

1; N=327 Medium (RCT/Unclear) N/A Indirect Imprecise Adjusted OR=0.97 

(95% CI, 0.58 to 1.62

Low

Total number of self-harm re-presentations at 12 months (Beautrais 2010)53

1; N=327 Medium (RCT/Unclear) N/A Indirect Imprecise Adjusted IRR=1.07 

(95% CI, 0.80 to 1.43

Low

Regular Mailings vs Standard Care (Motto 2001 as cited in Mann 2005)10

Suicide attempts

1; not 

reported

Medium (RCT/Unclear) N/A Indirect N/A Not reported Insufficient 

to Low

Table 5: Youth-Nominated Support Team (YST) plus Treatment As Usual

Domains pertaining to strength of evidence Magnitude of effect

Strength of 

evidence

Number of 

studies;

 # of subjects

Risk of rias (Design/ 

Quality) Consistency Directness Precision

Summary effect 

size

(95% CI)

High, 

Moderate, 

Low, 

Insufficient

Youth-Nominated Support Team (YST) plus Treatment As Usual versus Treatment As Usual (King 2006, King 2009)56, 57

Suicide deaths

1; N=448 Medium (RCT/Unclear) N/A Indirect Imprecise 0.4% vs 0, P NR Low

Proportion of adolescents with one or more suicide attempts

2; N=737 Medium (RCT/Unclear) Inconsistent Indirect Imprecise YST-1: 17.3% vs 

11.6%, P=0.26

YST-2: 13% vs 15%, 

P=0.51

Low

a

 This review did not evaluate any outcomes other than suicidal self-directed violence, and therefore no additional 

data on potential harms and side effects was investigated. Potential harms and side effects should always be 

considered when evaluating the strength of evidence and considering adoption of an intervention or referral/followup service.
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APPENDIX AA. PEER REVIEW COMMENTS/AUTHOR 

RESPONSES

Reviewer Comment Response

Question 1: Are the objectives, scope, and methods for this review clearly described?

1 No. There was no discussion of the methods used for evaluating 

the strength of the evidence in a publication for drawing inferences 

about suicide prevention. There was a “boiler plate” discussion of the 

methods used for rating evidence. However, the draft did not provide 

adequate information about the way that this was applied for evaluating 

the strength of a paper for drawing inferences about suicide as an 

outcome, rather than for the primary outcome. More specifically, the 

literature reviewed included a number of papers reporting on studies 

conducted to evaluate treatments for other conditions or other outcomes 

(e.g., antidepressants for depression, or other interventions for suicidal 

ideation). Apparently, these were included because the papers included 

finding on suicide or suicide attempts, even though the studies were not 

designed to test hypotheses regarding suicide-related outcomes. There 

is a clear need to separate evaluations of the quality of the research as 

designed to test the primary hypotheses from the quality of the same 

studies for drawing inferences about suicide-related outcomes. The 

draft should have included information about methods for evaluating 

the quality of the studies for contributing to the literature on suicide. The 

absence of this information is a serious drawback.

We added a table to the final report which 

now provides this information to readers. 

This table also lists sample sizes for the 

various studies so readers can see how 

sample size compares for studies with 

different primary outcomes (i.e., those 

studies designed to prevent suicide versus 

studies in which this was not a primary or 

pre-specified outcome of interest).

1 As a related issue, the draft did not include a clear discussion of 

statistical power. Based on the discussion that was provided, statistical 

power did not appear to be included in the rates of the quality of 

research and the strength of the evidence. The methods section of the 

draft should have included a discussion of sample sizes and power, 

specifically for suicide prevention.

We discuss this issue throughout many 

of the sections of the report (e.g., stating 

“The majority of trials did not involve the 

necessary sample sizes (mean, 284.4 

patients; standard deviation, 177.8) or 

follow-up durations (median, 8 weeks; 

range, 4 weeks to 2.5 years) required to 

adequately evaluate risk of suicide attempts 

or suicides. Therefore, these trials generally 

provided inadequate to low-strength 

evidence for drawing conclusions about 

risk of suicide attempts and suicides.” in 

the section on pharmacotherapy. We also 

include a specific discussion of this issue 

pertaining to the table referenced in the 

above comment.

2 Yes. The objectives and scope are clearly described. Methods are 

clearly articulated and documentation re: process is provided. The 

authors state that the goal is to update work by reviewing literature that 

was not reviewed by Gaynes et al or Mann et al. It may be helpful for the 

reader to know the main findings from these reviews. The authors may 

also want to provide more detail about further support or lack thereof for 

Gaynes et al and Mann et als’ assertions based on this review. Some of 

this is provided later in the document – but seems to be missing from the 

beginning of the review and is not consistently presented throughout.

We have updated the report to include 

more information on results from the Mann 

et al. (2005), Gaynes et al. (2004) and 

NICE (2011) systematic reviews throughout 

the report, and this information is also 

presented in tabular format.

3 Yes; no comment.

4 Yes; no comment.

5 No. Overall I think this is very well written. The objectives, scope and 

methods are fairly well described, but I do have several comments:

Thank you. Noted.

5 1. In the Key Questions 3 and 4 themselves, it needs to be made clearer 

what referral and follow-up services are. How are these approaches not subsumed under KQs 1 and 2—if they are a subset of the 

interventions covered in KQ 1 and 2, why are they being looked at 

separately? How is some change in referral or follow-up process 

not an intervention?—this needs to be clarified for Exec Summary 

and in introduction. Perhaps general access to mental health care 

may be a better/clearer construct than referral and follow-up??

We have clarified differences between 

studies cited in the “psychotherapy” versus 

“referral/follow-up services” sections of the 

report, which describes why these studies 

were discussed in two different sections 

when the treatments were similar.
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Reviewer Comment Response

5 2. There are a few places where there may be inconsistencies in the 

terminology used, and the terminology may not be consistent with 

the new VA DOD terminology for self harm behaviors. I would 

overtly acknowledge and reference this new nomenclature early on, 

include a table on it, and make sure that it is consistent throughout 

the document.

We added a description and definition of 

“suicidal self-directed violence,” the adopted 

VA/DoD nomenclature, in both the executive 

summary and the introduction section of 

the report. We have also updated the report 

with consistent terminology throughout.

5 3. Because this follows up on previous reviews, I think it would be important to include some type of summary at the end of the response to 

each KQ that incorporates or acknowledges the previous relevant 

findings from those reviews. For several of the KQs, you do not 

have findings, but perhaps that is because you are only reviewing 

what was published between 2005 and 2011. Perhaps there are 

older findings that would provide more information or context for 

your findings. The findings from the previous reviews also should 

be addressed/integrated into the Discussion/Summary section so 

the reader can see if and how (or not) things may have changed.

We have updated the report to include 

more information on results from the Mann 

et al. (2005), Gaynes et al. (2004) and 

NICE (2011) systematic reviews throughout 

the report, and this information is also 

presented in tabular format.

5 4. In the Exec Summ response to KQ2, the response is written as if suicide is the main or perhaps only outcome of interest. But you are 

also looking at other suicide behavior outcomes such as suicide 

attempts. In some places, like on page 3 and on page 15 this is not 

clear.

We have made these corrections and 

updated the report to consistently use 

the term suicidal self-directed violence in 

reference to outcomes.

5 5. doing this review again so soon—have there been a lot of new studies/what is rationale? Who was the proponent for this review—can 

that be listed?

We have updated the methods section to 

more clearly describe the rationale and 

request for the report.

5 6. In the Exec Summary it is striking to me that 16,502 papers were 

initially reviewed-these are all since 2005? Do you want to briefly 

describe your key or main inclusion criteria (I focus a lot on Exec 

Summary because this is all many readers will actually read.

We have added this brief description to the 

executive summary.

6 Yes. The questions appear sound, but an explanation of what “suicidal 

self-directed violence” means would be helpful.

We have defined and cited this terminology.

7 Yes; no comment.

8 Yes. The objectives, scope and methods are clear. I think the focus 

on RCTs is key as these studies have greater internal validity, and 

many other syntheses have made the choice to combine RCTs with 

observational studies. Keeping the focus on RCTs makes it clear how 

few high-quality data are available regarding preventative interventions 

for suicide, particularly in Veteran and military populations.

Thank you. Noted, and we agree that the 

focus on RCTs helps limit the report to 

the highest quality research available on 

suicidal self-directed violence outcomes.

8 Since this review explicitly uses the Mann review as a starting point, I 

would recommend that the synthesis build even more upon the Mann 

review. (The report already does do this, in part, in the more detailed 

sections.) Specifically I would recommend acknowledging where 

there is sufficient evidence to confirm the conclusions of this prior 

synthesis, where there is insufficient new evidence to comment on prior 

conclusions, and where there is sufficient new evidence that conflicts 

with prior conclusions. This should be done in addition to findings from 

the recent literature in new areas of intervention. At this point, there are 

several statements emphasizing contrasts to the Mann report which 

seem more a function of insufficient new evidence rather than new 

evidence that conflicts with prior conclusions. (For example, no new 

literature on clozapine was reviewed and there are insufficient data 

from studies of other antipsychotics to make a statement about other 

antipsychotic medications or the group of antipsychotic medications.) 

Insufficient new evidence would not seem to overturn prior findings, 

unless there was further synthesis of both the older and the newer 

findings.

We have updated the report to include 

more information on results from the Mann 

et al. (2005), Gaynes et al. (2004) and 

NICE (2011) systematic reviews throughout 

the report, and this information is also 

presented in tabular format.

8 I would also recommend mentioning the Bagley VA Evidence Based 

Synthesis earlier on as he and his colleagues also reviewed literature on 

psychotherapy and pharmacotherapy in addition to larger public health 

interventions.

We have included information about this 

report and scope differences in the methods 

section of both the executive summary and 

the body of the report.
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Reviewer Comment Response

8 On a minor note, this review started with studies published as of January 

2005 and the Mann review covered until June 2005. Thus there is 

some overlap in the dates covered in the two reviews. Given review 

inclusion criteria, this results in an important 2005 publication being 

included in the Mann report (Brown, JAMA 2005) and not this report. 

Knowledgeable readers will likely be looking for this paper.

We clarified that articles included in this 

report are only those not previously included 

in the Mann et al. report, and hence articles 

such as the Brown (2005) paper were 

excluded (pages 1 and 9).

2. Is there any indication of bias in our synthesis of the evidence? 

1 Possible. I used what I viewed as potentially positive findings that were 

published during the relevant period as markers for evaluating the draft. 

One was the Lauterbach study discussed in my response to question 3. 

This was a report of a study designed to determine whether adjuctive 

lithium prevented suicide reattempts in patients with depression 

or bipolar disorder who survived and initial attempt. Unfortunately, 

the investigators were unable to achieve the planned sample size. 

However, a finding based on post-hoc analyses suggested that lithium 

may have reduced deaths from suicide. I would have been interested in 

seeing how the draft evaluated this claim. However, the article was not 

included.

 Noted. As you state, this article was not 

included. This is because the study was 

conducted in Germany, a country outside 

the scope of this review, per initial scoping 

agreement with the stakeholders/CPG 

group requesting the report.

1 Another was the Hatcher article on the effect of problem-solving therapy 

for suicide prevention. The article reports that there was no significant 

effect of problem-solving therapy in the entire sample. However, 

they report that a planned subgroup analysis demonstrated that the 

intervention was effective in the subsample of the subjects who had 

survived a suicide attempt prior to the index attempt that led to study 

entry. The article was included in the review but the planned subgroup 

analysis was not mentioned.

We have updated this section, making 

specific reference to these findings.

1 The two articles I mentioned represent two of the most significant 

potential advances of the past few years. Personally, I was looking to the 

Evidence Synthesis for guidance about the evaluation of the reported 

findings. However, neither of the salient findings were addressed. It 

is possible that this reflects poor implementation. However, it is also 

possible that this may reflect a bias towards negative findings.

Noted. We have attempted to use the most 

current, objective, and stringent methods 

for preventing bias in this report, and have 

addressed the comments about these two 

studies above.

2 No; No. Noted.

3 No; no comment.

4 No; no comment.

5 No; no comment.

6 Yes; no comment.

7 No; no comment.

8 No. The study selection criteria, quality assessment criteria, and rating of 

the strength of the evidence are clearly described. I agree with the focus 

on RCTs, given the limitations of the evidence from other study designs.

Thank you. Noted, and we agree that the 

focus on RCTs helps limit the report to 

the highest quality research available on 

suicidal self-directed violence outcomes.

8 Please include a table for 317 studies and reasons for exclusion. Appendix W is a table of excluded studies, 

and contains information on reasons for 

exclusion.

3. Are there any published or unpublished studies that we may have overlooked?

1 Yes, I used what I viewed as important papers published during 

the relevant period as markers to evaluate the literature that was 

reviewed. Specifically, I searched for, “Lauterbach E. Felber W. MullerOerlinghausen B. Ahrentos B. Bronisch T, et al Adjunctive lithium 

treatment in the prevention of suicidal behaviour in depressive disorders: 

a randomised, placebo-controlled, 1-year trial. Acta Psychiatrica 

Scandinavica. 118(6):469-79, 2008”. Its absence from the literature that 

was identified raises serious questions about the process for identifying 

relevant literature.

Noted. As you state, this article was not 

included. This is because the study was 

conducted in Germany, a country outside 

the scope of this review, per initial scoping 

agreement with the stakeholders/CPG 

group requesting the report. We have, 

however, included this article in a nonsystematic addition to the review, per 

your suggestion. This information is now 

contained within the pharmacotherapy 

section of the report.
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Reviewer Comment Response

1 In addition, I have heard verbal reports that findings were available, but 

not yet published, from a second study of cognitive behavioral therapy 

for suicide prevention in attempt survivors to determine whether it 

decreased the rate of reattempts. I may be useful to contact Dr. Gregory 

Brown from the University of Pennsylvania (gregbrow@mail.med.upenn.

edu) to get more information.

Noted. Per follow-up discussions with the 

CPG and stakeholders, the decision was 

made not to include unpublished studies or 

data analysis in this report.

2 Yes.

A. In terms of intervention, several key studies seem to have been 

left out of the psychotherapy results section- perhaps because 

they were published prior or after – this makes it seem like even 

less work has been down in this area. See comment 1A above.

Noted; see responses below for each study.

2 1: Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck 

AT. Cognitive therapy for the prevention of suicide attempts: a 

randomized controlled trial. JAMA. 2005 Aug 3;294(5):563-70. 

PubMed PMID: 16077050.

Though our search did, indeed, capture this 

article, we did not include it because of its 

inclusion in the previously published Mann 

et al. (2005) report. We note this exclusion 

criterion in the report on pages 1 and 9.

2 2: Bruce ML, Ten Have TR, Reynolds CF 3rd, Katz II, Schulberg HC, 

Mulsant BH, Brown GK, McAvay GJ, Pearson JL, Alexopoulos GS. 

Reducing suicidal ideation and depressive symptoms in depressed 

older primary care patients: a randomized controlled trial. JAMA. 

2004 Mar 3;291(9):1081-91. PubMed PMID: 14996777.

This study was published prior to the 

beginning of our search dates, and was 

therefore not included in the report. 

Information published prior to June, 2005 

was addressed in the Mann et al. (2005) 

report, and so as to avoid duplication, we 

did not include any such studies in this 

current review.

2 1: Simpson GK, Tate RL, Whiting DL, Cotter RE. Suicide prevention after 

traumatic brain injury: a randomized controlled trial of a program 

for the psychological treatment of hopelessness. J Head Trauma 

Rehabil. 2011 Jul-Aug;26(4):290-300. PubMed PMID: 21734512.

This study did not include reports on 

outcomes included in this report (i.e., 

suicide and suicidal self-directed violence); 

therefore it was excluded from the review.

2 B. For TBI among veterans may want to include Brenner LA, Ignacio 

RV, Blow FC. Suicide and traumatic brain injury among individuals 

seeking Veterans Health Administration services. J Head Trauma 

Rehabil. 2011 Jul-Aug;26(4):257-64. PubMed PMID: 21734509

This study is not a RCT and was therefore 

excluded from the review; however, this 

study was considered for the companion 

review conducted by our research team on 

suicide risk and assessment.

3 No; At least none that I am aware of Noted.

4 No; no comment.

5 No; Not that I know of Noted.

6 No; no comment.

7 No; no comment.

8 I am not aware of any additional RCTs in this area during this time 

frame.

Noted.

4. Please write additional suggestions or comments below. If applicable, please indicate the page and line numbers 

from the draft report.

1 The Mann article reviewed articles through June, 2005. Please provide 

more specifics about how you ensured that there were neither gaps, nor 

overlaps with the Mann article.

We clarified that articles included in this 

report are only those not previously included 

in the Mann et al. report, and hence articles 

such as the Brown (2005) paper were 

excluded (pages 1 and 9).

1 The methods suggest that the review process did not distinguish 

articles on the basis of the goals or the aims of the research that was 

reported. This is important. Research that was conducted, for example, 

to determine whether a specific intervention led to reductions in suicidal 

ideation, may have been well designed and adequately powered to 

address that question. However, even if it reported on the number 

of subjects who attempted or died from suicide, it would probably be 

underpowered to address these outcomes. This distinction should be 

considered in evaluating the quality of the studies reviewed.

We added a table to the final report which 

now provides this information to readers. 

This table also lists sample sizes for the 

various studies so readers can see how 

sample size compares for studies with 

different primary outcomes (i.e., those 

studies designed to prevent suicide versus 

studies in which this was not a primary or 

pre-specified outcome of interest).
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Reviewer Comment Response

1 The first sentence under ”Pharmacotherapy results” states, “Studies 

evaluated antidepressants .... For their efficacy in prevention of suicide 

.... “ In fact, none of the studies were designed or intended to evaluate 

efficacy for suicide prevention. The sentence is incorrect.

We have updated the sentence to read: 

Studies evaluated antidepressants, 

atypical antipsychotics, mood stabilizers, 

and omega-3 supplements and reported 

their efficacy in prevention of suicidal selfdirected violence in non-Veteran/military 

populations.

1 The first paragraph under “Pharmacotherapy results” states that 9 

studies were reviewed, then it cites 10. This should be clarified.

We have clarified that these were 9 studies 

published in 10 publications.

1 Among the citations in the first paragraph under Pharmacology 

results,the citations numbered 15-20 and 24 were conducted to 

evaluate depression as an outcome. They were not designed or 

powered for suicide-related outcomes. This should be stated.

See above comment re: providing this 

information in tabular format.

1 The conclusions stated at the end of the first paragraph refer only to 

suicide as an outcome. This is inconsistent with the definition of the 

scope of the review that addresses “suicidal self-directed violence.” As 

written, the conclusions are confusing and misleading.

This sentence has been updated to read: 

“Therefore, they are felt to be of low 

strength, and are insufficient for determining 

the effectiveness of various combinations 

of antidepressant medications for reducing 

suicidal self-directed violence.”

1 The reports cited as 21 and 22 were written to report on outcomes 

related to suicidal ideation. This should be acknowledged.

See above comment re: providing this 

information in tabular format.

1 The report cited as 23 included suggestive, apparently post-hoc, 

analyses of greater self-harm with certain medications. It may be 

misleading to conclude only that it said nothing about deaths from 

suicide.

Added results of subgroup analyses 

showing increased risk in patients taking 

venlafaxine vs SSRIs and those taking 

benzodiazepines.

1 Studies cited as 25-27 in the second paragraph were not conducted 

to evaluate the effectiveness of antipsychotic medications in reducing 

suicide deaths. This should be acknowledged.

See above comment re: providing this 

information in tabular format.

1 The point of reference 28 was that there were no drug related 

increases in suicidal ideation as an adverse drug effect. It should be 

acknowledged that the study was not conducted to test for decreases in 

death from suicide.

See above comment re: providing this 

information in tabular format.

1 The last sentence of the second paragraph say there is a contrast 

between the cited papers and findings of an effect of clozapine. In fact, 

the findings on clozapine reflect a difference between that medication 

and another atypical antipsychotic. There is no contrast.

This sentence has been updated to read: 

“Notably, the previous review by Mann and 

colleagues reported an antisuicidal effect 

of clozapine, an atypical antipsychotic 

medication.”

1 The text in the first sentence of the third paragraph is incorrect. 

Reference 29 was a 2.5 year study. Reference 30 was an 8 week study.

This correction has been made.

1 Reference 29 found no significant differences between lithium and 

valproate, but it is not correct to say that it did not have suicide or 

suicide attempt outcomes.

This has been clarified in the report.

1 Reference 30 focused on ideation and related symptoms; this should 

be acknowledged.

We did not include ideation as an outcome 

in this report, and therefore those results 

are not reported. However, we do report 

primary outcome information from studies in 

tabular format.

1 The reference for citation 31 is incomplete. It is from the British Journal 

of Psychiatry.

This correction has been made.

1 The review should acknowledge that 31 was intended to report on 

outcomes related to ideation and related measures rather than attempts 

or deaths from suicide.

We did not include ideation as an outcome 

in this report, and therefore those results 

are not reported. However, we do report 

primary outcome information from studies in 

tabular format.

1 Reference 32 reported that problem solving was effective for 

decreasing repeated self-harm in a subsample of patients with multiple 

previous episodes. This should be acknowledged.

See above comment re: the Hatcher paper.

1 Citation 39 referred to a study evaluating 64 adults with history of self 

harm. It may have reported on deaths,but it was conducted primarily to 

look at other outcomes.

See above comment re: providing this 

information in tabular format.
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Reviewer Comment Response

1 Citation 45 reported a decreases in ideation. This should be 

acknowledged. In its critique, it is not clear what was meant by the 

phrase “had methods that suggested an unclear risk of bias.”

We did not report ideation outcomes in 

this report. The latter sentence has been 

clarified to read: “...used methods resulting 

in an unclear risk of bias.”

1 Citation 52 is a secondary analyses of a study of an intervention similar 

to that reported in 45. It should be acknowledged that the outcome of 

interest was total mortality, not suicide. The study was conducted to 

test for decreases in suicidal ideation. Moreover, it is not clear why 52 

is discussed in a section separate from 45 when the interventions were 

so similar

See above comment re: providing outcome 

information in tabular format. We have 

clarified differences between studies cited 

in the “psychotherapy” versus “referral/

follow-up services” sections of the report, 

which describes why these studies were 

discussed in two different sections when the 

treatments were similar.

2 A. Page 1 – 20% of veterans – believe this number originally came 

from the work of Kaplan et al. It is somewhat problematic in that 

Veteran was broadly defined and likely included other cohorts (e.g. 

active duty). 

This data came from NVDRS, which 

does include anyone who has served in 

the armed forces. We have modified this 

sentence to be more clear about who the 

20% represent.

2 B. Recent research has focused more on warning signs vs. risk 

factors as a prevention strategy. May want to consider including 

this. May also want to include warning signs in Analytic Model.

1: Rudd MD, Berman AL, Joiner TE Jr, Nock MK, Silverman MM, 

Mandrusiak M, Van Orden K, Witte T. Warning signs for suicide: 

theory, research, and clinical applications. Suicide Life Threat 

Behav. 2006 Jun;36(3):255-62. Review. PubMed PMID: 16805653.

Any intervention RCTs meeting inclusion 

criteria were included in this report, and a 

separate report completed by our research 

team is addressing risk factors and warning 

signs. We have included both risk factor and 

warning sign terminology in the analytical 

model.

2 C. A number of studies are currently underway in the VA – this seems 

worth mentioning – information could be found on clinical trials.gov 

or VA websites. 

We have included this information in the 

discussion.

2 D. As Analytic model 1 and 2 appear to be identical may way to 

combine.

We agree, and have combined the 

analytical models as you suggest.

3 This is an excellent review of RCTs to date and is an important followup 

to the Mann review. Essentially it states that we are a long way from 

where we would like to be in understanding what is and is not an 

effective intervention. As it pointed out, the base rate of suicide is so 

low, the phemenon itself so complex and the interventions so diverse 

that it is difficult to put together an RCT, particularly a blinded RCT, with 

sufficient power while appropriately limiting the variables being studied. 

This may account for the dearth of RCTs. In the end, it may be that 

other forms of evidence, albeit lower level evidence (e.g. aggregated 

performance improvement data), will be necessary to identify 

successful interventions.

Noted, and we agree. We have made this 

suggestion in the discussion section of the 

report.

4 None. Noted.

5 In the executive summary, on page 1 I would include the reference 

number for the Gaynes review right after you write “Gaynes and 

colleagues”, not at the end of the sentence.

We have made this change.

5 On page 3, you write about two studies on mood stabilizers that did not 

have any suicide or suicide attempt outcomes—if not, why were these 

included in the review?

We have clarified this sentence to read: 

“These trials reported no instances of 

suicidal self-directed violence for the 

duration of either study.” The trials did 

collect information on these outcomes, 

though no such events occurred.

5 Intro section on pages 6 and 7 is nicely written Noted. Dr. Denneson was responsible for 

much of this section.

5 In the inclusion criteria section you don’t include the specific dates for 

including the studies you are reviewing (ie from 2005 to 2011)

We have made this addition.

5 The limitations section should also acknowledge that your search 

strategy specifically looked for keywords and terms related to 

suicide/suicide behaviors. There may have been potentially relevant 

manuscripts published about various interventions which did not have 

those terms attached to them. There may be a bit more to say about the 

limitations of the search strategy itself in the Limitations section

We have included this information in the 

appropriate sections.
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Reviewer Comment Response

6 This is a very thorough review of suicide prevention interventions. 

The authors make a good case for focus on RCTs only and the four 

questions appear sound. I have a few suggestions for this report. 

Noted.

6 First, it might be helpful to justify why other forms of violent death/

behavior were not included. There might be public health interventions 

that are relevant to suicide prevention that address other causes of 

death such as homicide, accidents, “suicide by cop” or accidental 

overdose.

We have included comments to this effect in 

the discussion section.

6 Second, more discussion on the heterogeneity of studies is warranted. 

Many of the RCTs reported might have had stringent exclusion criteria 

(as the authors noted that patient who are suicidal are often excluded 

from trials), often leading to minimal changes in outcome. Some 

recommendations on how such criteria should be modified would help in 

the development of more generalizable studies in the future.

We have added more information on this 

topic in the results and discussion sections 

of the report.

7 Page (i) wrong header This correction has been made.

7 p. 3, p. 19 should be “usual care alone” rather than “along” This correction has been made.

7 p. 5 Bruce et al 2004 is the primary reference for the PROSPECT study. 

Gallo et al was designed to examine all-cause mortality

Agreed; however, we report as the primary 

citation the article which reports on our 

outcome of interest (i.e., suicidal selfdirected violence), and therefore we cite 

Gallo et al., whereas Bruce et al. is cited 

for inclusion as a companion article which 

was reviewed for methods information about 

the study. Similar examples are also cited 

as such in the report (e.g., the TADS trial 

papers).

7 p. 6 “suicide screen” is problematic language since suicide does not 

meet many clinical epidemiologic criteria for appropriate screening 

targets, nor is there an evidence base to commend a particular 

technique to assess suicidality

Noted. We have removed this terminology 

from the sentence.

7 p. 14 change from number of articles to number of publications is 

confusing

We agree that the paragraph can be 

confusing due to the fact that some studies 

are published in more than one paper. We 

hope the Literature Flow Chart can provide 

clarification.

8 For clarity in the narrative, it may help to group studies (e.g. those 

assessing psychotherapy) into those with sufficient sample size and 

duration to actually have a chance of addressing the outcomes of 

suicides and suicide attempts and those that do not. Currently the 

narrative is organized primarily around the specific psychotherapeutic 

intervention which often have been examined in only a single study with 

quality issues.

Though we did not group studies in this 

manner, we have added this information 

in tabular format to address this point, 

comparing sample size and commenting on 

statistical power in the studies.

8 Would recommend a short discussion section in the executive summary.

5. Are there any clinical performance measures, programs, quality improvement measures, patient care services, or 

conferences that will be directly affected by this report? If so, please provide detail.

1 I am concerned that the quality of the draft report as it is currently 

written could represent a barrier to implementation of new advances. I 

do not think the report should be released in its current form.

Noted. The report was revised per reviewer 

feedback, and is released to the public after 

suggested changes have been made.

2 The lack of evidence-based treatments would be expected to impact 

care for suicidal veterans.

Yes, it could. It is our hope that future 

research will continue to inform 

evidence-based treatment research and 

implementation so that Veterans and 

members of the military may have access to 

effective, evidence-based care.

3 This report will be viewed with interest by many in Patient Care 

Services, particularly those involved in suicide prevention. I think that 

the report validates what many believe – that suicidal behavior is 

complex, difficult to predict and can be difficult to prevent.

Noted.

4 Not that I am aware of Noted.

6 Office of Mental Health Operations, Canandaigua COE, National Center 

on Homelessness among Veterans, VA Cooperative Studies Program, 

local police

Noted.
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Reviewer Comment Response

7 Suicide prevention coordinator programs Noted.

8 In my reading of this summary, there were no RCTs at all for 

interventions for military populations or Veterans. There was insufficient 

evidence for specific pharmacotherapies or psychotherapies in general 

English speaking populations in eligible countries. The strongest 

evidence for psychotherapies was moderate evidence for no benefit of 

problem solving therapy for patients with suicide attempts. Therefore, 

this review suggests no evidence to support changes in or new clinical 

performance measures or mandated programs that emphasize these 

interventions for suicide prevention. The synthesis does outline an 

important research agenda for the VA.

Noted, and we agree that, in the case of 

an absence of evidence, particularly for the 

populations of interest, this report provides 

information related to areas of research in 

need of further investigation.

6. Please provide any recommendations on how this report can be revised to more directly address or assist 

implementation needs.

1 The organization of the report is generic, and as such, it does 

not appear to have been designed specifically to address suicide 

prevention. It may have been better to organize the report around the 

clinical ecology of suicide, where low numbers demand larger studies, 

and where information about surrogate endpoints (e.g., suicidal 

ideation) may be important, but where they may not translate directly 

into the prevention of suicide-related behaviors.

Though we did not group studies in this 

manner, we have added a table to address 

this point, comparing sample size and 

statistical power in the studies.

1 The evaluation and discussion should, perhaps, focus on studies 

that had adequate power to detect effects, and those where claims of 

effects were made. It should acknowledge that there may be promising 

findings regarding suicide ideation as an outcome, but that these were 

outside of the scope of the review. It should also be acknowledged that 

there were promising interventions, some that have been the subject of 

recent research, but where adequately powered clinical trials have not 

yet been conducted.

We have added a section on this topic, and 

included a table to present information on 

statistical power and primary outcomes in 

the trials. We have acknowledged that there 

may be promising findings regarding suicide 

ideation as an outcome, but that these were 

outside of the scope of the review as part of 

the discussion section.

2 A. Are there common elements of the most promising interventions 

that could be incorporated into current practice? May be helpful to 

review: 

Oxford Text of Suicidology and Suicide Prevention, DOI: 

10.1093/med/9780198570059.003.0058, 

Chapter 58 The psychological and behavioural treatment of 

suicidal behaviour

What are the common elements of treatments that work? 

M David Rudd, Ben Williams and David RM Trotter 

This chapter provides a review of all currently available clinical trials 

targeting suicidal behaviour. In contrast to some previous available 

reviews, the focus of the current chapter is on identifying common

elements of treatments that work. More specifically, we attempted 

to answer the question, what do treatments that work have in common? A number of psychological treatments have emerged as 

effective or potentially effective at reducing suicidal behaviour (i.e. 

suicide attempts). There now appear to be a number of identifiable 

core elements for treatments that have proven effective at reducing 

suicide attempts, all with direct and meaningful implications for day 

to day clinical practice. We also point out limitations in current science, including problematic follow-up periods and questions about 

the high-risk nature of some study samples.

We have reviewed this chapter, and agree 

that this non-systematic review could 

contain guidance for future research 

directions in the area of suicidal selfdirected violence prevention interventions. 

We have added this citation to the 

discussion section.

2 B. A trial of the PST (Hatcher et al. 2011) among Veterans may be 

indicated – wonder if this recommendation should be made.

We have included a more in depth 

discussion of this trial in the results section, 

and have highlighted this trial in the 

discussion section.
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Reviewer Comment Response

3 Related to the comments in #4. Suicide prevention efforts have been 

under way in VHA and DoD for a number of years. Many interventions 

have a great deal of face validity, and, for reasons already cited, it may 

be difficult to generate RCT data to test them in traditional ways. The 

report could be enlarged to include a section summarizing the efforts to 

date, along with population data spanning the last X number of years. It 

need not make any statements about any particular intervention, since 

doing so would not be consistent with the approach taken in this review.

We have now included more such 

information on earlier trials found in other 

systematic reviews such as Mann et al. 

(2005) and Gaynes et al. (2004) to provide 

a more comprehensive discussion of this 

point. Population data was included in the 

background sections, and will be covered 

in additional detail in a companion report 

by our research team on Suicide Risk and 

Assessment.

4 Given the findings, there is little to implement. Noted.

5 As per above, would flesh out Exec Summary a bit more since this is 

what most people will read

We have expanded this section per your 

recommendations.

6 It would be helpful to shorten the executive summary into a one-page 

synopsis of the available evidence, what more needs to be researched, 

and from the available research, what is actionable for VA leaders 

to implement as public health, practice-based, or provider level 

interventions. For example, the Office of Mental Health Services uses a 

reporting tool in which key findings and progress updates are presented 

in tabular form.

We agree that a brief summary format is 

beneficial for some readers. In addition to 

the executive summary, we report findings 

in a “management brief” single page 

format which is electronically disseminated 

following the final report publication.

7 Less mechanical and repetitive approach to organizing the manuscript. We have attempted to organize the report 

in a clear manner, consistent with standard 

systematic review reporting criteria.

8 Please see above. The evidence does not support immediate 

implementation of any suicide prevention program per se.

Noted.

7. Please provide us with contact details of any additional individuals/stakeholders who should be made aware of this 

report.

1 The report should be revised extensively before it is disseminated. Noted. We have made revisions as 

recommended by the peer reviewers.

5 Jan Kemp, Ira Katz, Toni Zeiss from VA Office of Mental Health 

Services should just have a bit of a heads up

Thank you for these recommendations.

6 Jan Kemp and Rob Bossarte, Canandaigua COE/VACO; Ira Katz, MD, 

Office of Mental Health Operations/VACO. DOD

Thank you for these recommendations.

7 Jan Kemp Thank you for these recommendations.

8 Drs. Zeiss, Kemp, Katz, Schohn in Central Office. VISN 19 MIRECC, 

VISN 2 Center of Excellence for Suicide Prevention, Defense Centers 

of Excellence for Psychological Health.

Thank you for these recommendations.
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APPENDIX BB. ABBREVIATIONS

Abbreviation Term

AHRQ Agency for Healthcare Research and Quality

CAMS Collaborative Assessment and Management of Suicidality

CBT Cognitive Behavioral Therapy

CI Confidence interval

DBT Dialectical Behavior Therapy

DoD Department of Defense

DSM Diagnostic and Statistical Manual of Mental Disorders

EBPWG Evidence Based Practice Working Group

E-CAU Enhanced Care As Usual

EPC Evidence-based Practice Center

GRADE Grading of Recommendations Assessment, Development, and Evaluation

HR Hazard ratio

IMPACT Improving Mood: Promoting Access to Collaborative Treatment

IRR Incident Risk Ratio

ITT Intention-to-treat

LOCF Last Observation Carried Forward

MBT Mentalization Based Treatment

N Sample size

N/A Not applicable

NDI National Death Index

NICE National Institute for Health and Clinical Excellence

OR Odds ratio

PROSPECT Prevention of Suicide in Primary Care Elderly: Collaborative Trial

PSA Public Service Announcement

RCT Randomized controlled trial

REACT Randomized Evaluation of Assertive Community Treatment

RR Relative risk

SCM Structured Clinical Management

SD Standard deviation

SSRI Selective Serotonin Reuptake Inhibitor

STEPPS Systems Training for Emotional Predictability and Problem Solving

SUD Substance Use Disorder

TADS Treatment for Adolescents With Depression Study

TBI Traumatic Brain Injury

TORDIA Treatment of SSRI-Resistant Depression in Adolescents

UK United Kingdom

US United States

VA Veterans Affairs

VHA Veterans Health Administration

YST Youth-Nominated Support Team
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APPENDIX CC. EXCLUDED STUDIES

The following full-text publications were considered for inclusion but failed to meet the criteria 

for this report. 

Exclusion codes: 

1 = non-English language

2 = ineligible country

3 = ineligible outcome

4 = ineligible intervention

5 = did not evaluate interventions

6 = ineligible publication type

7 = ineligible systematic review due to limitations in quality

8 = ineligible nonsystematic regulatory agency analysis

9 = ineligible design

Excluded Trials Exclusion 

Code

1 Agius M, Gardner J, Liu K, Zaman R. An audit to compare discharge rates and suicidality 

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3

2 Agius M, Shah S, Ramkisson R, Murphy S, Zaman R. Three year outcomes of an early 

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Sep;19(3):130-8.

9

3 Agomelatine: new drug. Adverse effects and no proven efficacy. Prescrire Int. 2009 

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6

4 Aksoy-Poyraz C, Ozdemir A, Ozmen M, Arikan K, Ozkara C. Electroconvulsive therapy for 

bipolar depressive and mixed episode with high suicide risk after epilepsy surgery. Epilepsy 

& Behavior. 2008 Nov;13(4):707-9.

2

5 Alexander MJ, Haugland G, Ashenden P, Knight E, Brown I. Coping with thoughts of 

suicide: techniques used by consumers of mental health services. Psychiatr Serv. 2009 

Sep;60(9):1214-21.

5

6 Alexopoulos GS, Katz IR, Bruce ML, et al. Remission in Depressed Geriatric Primary Care 

Patients: A Report From the PROSPECT Study. The American Journal of Psychiatry. 2005 

Apr;162(4):718-24.

3

7 Andersson N, Ledogar RJ. The CIET Aboriginal Youth Resilience Studies: 14 Years 

of Capacity Building and Methods Development in Canada. Pimatisiwin. 2008 

Summer;6(2):65-88.

6

8 Andrade C, Bhakta SG, Singh NM. Controversy revisited: Selective serotonin reuptake 

inhibitors in paediatric depression. World J Biol Psychiatry. 2006;7(4):251-60.

6

9 Angst J, Angst F, Gerber-Werder R, Gamma A. Suicide in 406 Mood-Disorder Patients With 

and Without Long-Term Medication: A 40 to 44 Years’ Follow-Up. Archives of Suicide 

Research. 2005 Sep;9(3):279-300.

2

10 Apter A, Lipschitz A, Fong R, et al. Evaluation of suicidal thoughts and behaviors in 

children and adolescents taking paroxetine. J Child Adolesc Psychopharmacol. 2006 FebApr;16(1-2):77-90.

6

11 Arkov K, Rosenbaum B, Christiansen L, Jonsson H, Munchow M. [Treatment of suicidal 

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2008 Jan 14;170(3):149-53.

1
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Code

12 Army Suicide Prevention Task Force. Army Health Promotion, Risk Reduction and Suicide 

Prevention: Report 2010. Washington, D.C.: Department of Defense; 2010.

6

13 Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for 

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2

14 Asarnow JR, Porta G, Spirito A, et al. Suicide attempts and nonsuicidal self-injury in the 

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6

15 Aseltine RH, Jr., James A, Schilling EA, Glanovsky J. Evaluating the SOS suicide 

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9

16 Baber K, Bean G. Frameworks: A community-based approach to preventing youth suicide. 

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3

17 Bajbouj M, Merkl A, Schlaepfer TE, et al. Two-year outcome of vagus nerve stimulation in 

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2

18 Bakim B, Karamustafalioglu K, Akpinar A. Suicides and attempted suicides in alcohol and 

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1

19 Bakim B, Karamustafalioglu K, Ogutcen O, Yumrukcal H. Alcohol-Substance Use Disorders 

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1

20 Baldessarini RJ, Pompili M, Tondo L. Suicidal risk in antidepressant drug trials. Arch Gen 

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6

21 Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FK, Hennen J. Decreased risk of 

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7

22 Baldwin DS, Reines EH, Guiton C, Weiller E. Escitalopram therapy for major depression 

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6

23 Balis T, Postolache TT. Ethnic differences in adolescent suicide in the United States. 

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6

24 Ballard ED, Pao M, Horowitz L, Lee LM, Henderson DK, Rosenstein DL. Aftermath of 

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6

25 Banerjee S, Hellier J, Dewey M, et al. Sertraline or mirtazapine for depression in dementia 

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3

26 Bangs ME, Tauscher-Wisniewski S, Polzer J, et al. Meta-analysis of suicide-related behavior 

events in patients treated with atomoxetine. Journal of the American Academy of Child & 

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6

27 Barak A. Emotional support and suicide prevention through the Internet: A field project 

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2

28 Barak Y, Olmer A, Aizenberg D. Antidepressants reduce the risk of suicide among elderly 

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9

29 Barbe RP, Rubovszky G, Venturini-Andreoli A, Andreoli A. The treatment of borderline 

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6

30 Bartlett ML. The efficacy of no-suicide contracts with clients in counseling on an outpatient 

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3

31 Basham C, Denneson LM, Millet L, Shen X, Duckart J, Dobscha SK. Characteristics and VA 

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9
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Code

32 Bauer MS, Wisniewski SR, Kogan JN, Marangell LB, Thase ME, Sachs G. Brief report: 

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2006;39(1):31-7.

3

33 Beasley CM, Jr., Ball SG, Nilsson ME, et al. Fluoxetine and adult suicidality revisited: an 

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8

34 Beautrais A, Fergusson D, Coggan C, et al. Effective strategies for suicide prevention in 

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6

35 Beautrais AL, Fergusson DM, Horwood LJ. Firearms legislation and reductions in firearmrelated suicide deaths in New Zealand. Aust N Z J Psychiatry. 2006 Mar;40(3):253-9.4

36 Beautrais AL, Gibb SJ, Fergusson DM, Horwood LJ, Larkin GL. Removing bridge barriers 

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4

37 Bennewith O, Nowers M, Gunnell D. Effect of barriers on the Clifton suspension bridge, 

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4

38 Berard R, Fong R, Carpenter DJ, Thomason C, Wilkinson C. An international, multicenter, 

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2

39 Bergen H, Hawton K, Murphy E, et al. Trends in prescribing and self-poisoning in relation 

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9

40 Bergman J, Miodownik C, Palatnik A, Lerner V. Efficacy of bupropion XR in 

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9

41 Bergmans Y, Links PS. Reducing potential risk factors for suicide-related behavior with a 

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3

42 Bessant M, King EA, Peveler R. Characteristics of suicides in recent contact with NHS 

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43 Borschmann, Rohan, Henderson, et al. Crisis interventions for people with borderline 

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6

44 Bridge JA, Barbe RP, Birmaher B, Kolko DJ, Brent DA. Emergent suicidality in a clinical 

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9

45 Bronisch T. Depression and Suicide: Antidepressive Therapies in the Acute and Chronic 

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1

46 Brown C, Wyman PA, Brinales JM, Gibbons RD. The role of randomized trials in testing 

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5

47 Burns J, Dudley M, Hazell P, Patton G. Clinical management of deliberate self-harm in 

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48 Cardish RJ. Psychopharmacologic management of suicidality in personality disorders. Can J 

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49 Carr A. Depression in young people: description, assessment and evidence-based treatment. 

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50 Catanese AA, John MS, Di Battista J, Clarke DM. Acute cognitive therapy in reducing 

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51 Chiesa M, Fonagy P, Gordon J. Community-based psychodynamic treatment program for 

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52 Chisholm D, van Ommeren M, Ayuso-Mateos JL, Saxena S. Cost-effectiveness of clinical 

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53 Cipriani A, Barbui C, Geddes JR. Suicide, depression, and antidepressants. BMJ. 

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54 Cipriani A, Geddes JR, Furukawa TA, Barbui C. Metareview on short-term effectiveness 

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55 Cipriani A, Rendell JM, Geddes JR. Haloperidol alone or in combination for acute mania. 

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56 Coffey CE. Building a system of perfect depression care in behavioral health. Jt Comm J 

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57 Cohen A, Houck PR, Szanto K, Dew MA, Gilman SE, Reynolds CF, III. Social inequalities 

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58 Cohen D. Should the use of selective serotonin reuptake inhibitors in child and adolescent 

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59 Cohen VK. Keeping students alive: mandating on-campus counseling saves suicidal college 

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60 Combalbert N, Bourdet-Loubere S. Suicide by jumping and strategies to prevent it. 

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61 Combs H, Romm S. Psychiatric inpatient suicide: A literature review. Primary Psychiatry. 

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62 Comtois KA, Linehan MM. Psychosocial treatments of suicidal behaviors: a practicefriendly review. J Clin Psychol. 2006 Feb;62(2):161-70.6

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67 Craig M, Howard L. Postnatal depression. Clin Evid (Online). 2009;2009. 7

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77 Daviss W. A review of co-morbid depression in pediatric ADHD: Etiologies, 

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78 De Leo D. The world health organization: Approach to evidence-based suicide prevention. 

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80 Department of Defense Task Force on the Prevention of Suicide by Members of the Armed 

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81 Dixon L, Goldberg R, Iannone V, et al. Use of a critical time intervention to promote 

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82 Doering S, Horz S, Rentrop M, et al. Transference-focused psychotherapy v. treatment by 

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83 Doggrell SA. Fluoxetine--do the benefits outweigh the risks in adolescent major depression? 

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84 Dombrovski AY, Mulsant BH. The evidence for electroconvulsive therapy (ECT) in the 

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85 Dube P, Kurt K, Bair MJ, Theobald D, Williams LS. The p4 screener: evaluation of a brief 

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87 Dubicka B, Wilkinson P. Evidence-based treatment of adolescent major depression. Evid 

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89 Dudley M, Hadzi-Pavlovic D, Andrews D, Perich T. New-generation antidepressants, 

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92 Eskin M, Ertekin K, Demir H. Efficacy of a problem-solving therapy for depression and 

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93 Esposito-Smythers C, Spirito A, Uth R, LaChance H. Cognitive behavioral treatment for 

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94 Everly GS, Jr., Flynn BW. Principles and practical procedures for acute psychological first 

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95 Fergusson D, Doucette S, Glass KC, et al. Association between suicide attempts and 

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96 Fleischhaker C, Bohme R, Sixt B, Bruck C, Schneider C, Schulz E. Dialectical Behavioral 

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99 Fountoulakis KN, Gonda X, Siamouli M, Rihmer Z. Psychotherapeutic intervention and 

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100 Fountoulakis KN, Grunze H, Panagiotidis P, Kaprinis G. Treatment of bipolar depression: 

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102 Freeman SA. Suicide risk and psychopharmacology: assessment and management of acute 

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103 Fu Y-X, Shen J-L, Dang W. Effects of psychological intervention on the young people of 

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104 Gardner W, Klima J, Chisolm D, et al. Screening, triage, and referral of patients who report 

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105 Garvey KA, Penn JV, Campbell AL, Esposito-Smythers C, Spirito A. Contracting for safety 

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109 Goldney RD. Suicide Prevention: A Pragmatic Review of Recent Studies. Crisis: The 

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110 Goldstein BI, Bukstein OG. Comorbid substance use disorders among youth with bipolar 

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111 Gottman JM, Gottman JS, Atkins CL. The Comprehensive Soldier Fitness Program: Family 

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114 Grawe R, Falloon I, Widen J, Skogvoll E. Two years of continued early treatment for recentonset schizophrenia: A randomised controlled study. Acta Psychiatrica Scandinavica. 2006 

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115 Greden JF, Valenstein M, Spinner J, et al. Buddy-to-Buddy, a citizen soldier peer support 

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116 Gutierrez PM, Brenner LA, Olson-Madden JH, et al. Consultation as a means of veteran 

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119 Haffner WH. Veteran suicide. Mil Med. 2010 Oct;175(10):i. 6

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121 Hamilton SM, Rolf KA. Suicide in adolescent American Indians: Preventative social work 

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122 Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with 

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123 Hammad TA, Laughren TP, Racoosin JA. Suicide rates in short-term randomized controlled 

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124 Hammerness PG, Vivas FM, Geller DA. Selective serotonin reuptake inhibitors in pediatric 

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125 Hampton T. Depression care effort brings dramatic drop in large HMO population’s suicide 

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127 Han D, Wang EC. Remission from depression: A review of venlafaxine clinical and 

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129 Harrison-Woolrych M. Varenicline and suicide. Safety data from New Zealand. BMJ. 

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130 Harrod, Curtis S, Goss, et al. Interventions for primary prevention of suicide in the postsecondary educational setting [Protocol]. Cochrane Database of Systematic Reviews. 2011 

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135 Hawgood J, De Leo D. Anxiety disorders and suicidal behaviour: an update. Curr Opin 

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136 Hays JT, Ebbert JO. Adverse effects and tolerability of medications for the treatment of 

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137 Hazell P. Depression in children and adolescents. Clin Evid (Online). 2009;2009. 3

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140 Hennen J, Baldessarini RJ. Suicidal risk during treatment with clozapine: A meta-analysis. 

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141 Hesdorffer DC, Berg AT, Kanner AM. An update on antiepileptic drugs and suicide: are 

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143 Hough D, Lewis P. A suicide prevention advisory group at an academic medical center. Mil 

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149 Irons J. Fluvoxamine in the treatment of anxiety disorders. Neuropsychiatr Dis Treat. 2005 

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150 Isaac M, Elias B, Katz LY, et al. Gatekeeper training as a preventative intervention for 

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151 Jacono J, Jacono B. The use of puppetry for health promotion and suicide prevention among 

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152 Jakupcak M, Varra EM. Treating Iraq and Afghanistan war veterans with PTSD who are at 

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153 Jones G, Gavrilovic JJ, McCabe R, Becktas C, Priebe S. Treating suicidal patients in an 

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154 Jorm AF, Kelly CM, Morgan AJ. Participant distress in psychiatric research: a systematic 

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155 Juurlink DN, Mamdani MM, Kopp A, Redelmeier DA. The risk of suicide with selective 

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156 Kaizar EE, Greenhouse JB, Seltman H, Kelleher K. Do antidepressants cause suicidality in 

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157 Kanner AM. Depression and epilepsy: A review of multiple facets of their close relation. 

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158 Karayal ON, Anway SD, Batzar E, Vanderburg DG. Assessments of suicidality in doubleblind, placebo-controlled trials of ziprasidone. J Clin Psychiatry. 2011 Mar;72(3):367-75.6

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160 Kasper S, Montgomery SA, Moller HJ, et al. Longitudinal analysis of the suicidal behaviour 

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162 Kennedy CH, Cook JH, Poole DR, Brunson CL, Jones DE. Review of the first year of an 

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163 Kennedy SH, Giacobbe P, Rizvi SJ, et al. Deep brain stimulation for treatment-resistant 

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164 Keshtkar M, Ghanizadeh A, Firoozabadi A. Repetitive Transcranial Magnetic Stimulation 

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166 Kim HM, Eisenberg D, Ganoczy D, et al. Examining the relationship between clinical 

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170 Kolla NJ, Eisenberg H, Links PS. Epidemiology, risk factors, and psychopharmacological 

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175 Kutcher S, Gardner DM. Use of selective serotonin reuptake inhibitors and youth suicide: 

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176 Lapierre S, Dube M, Bouffard L, Alain M. Addressing suicidal ideations through the 

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177 Lapierre S, Erlangsen A, Waern M, et al. A systematic review of elderly suicide prevention 

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178 Lauterbach E, Felber W, Muller-Oerlinghausen B, et al. Adjunctive lithium treatment in the 

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180 Leenaars AA. Psychotherapy with Suicidal People: The Commonalities. Archives of Suicide 

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181 Leon AC, Solomon DA, Li C, et al. Antidepressants and risks of suicide and suicide 

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182 Lester D. Resources and Tactics for Preventing Suicide. Clinical Neuropsychiatry: Journal of 

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183 Lester D. The use of the Internet for counseling the suicidal individual: possibilities and 

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185 Lewis LM. No-harm contracts: A review of what we know. Suicide and Life Threatening 

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186 Licinio J, Wong M-L. Depression, antidepressants and suicidality: a critical appraisal. Nat 

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187 Links PS, Hoffman B. Preventing suicidal behaviour in a general hospital psychiatric 

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188 Lizardi D, Stanley B. Treatment engagement: A neglected aspect in the psychiatric care of 

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189 Long CG, Fulton B, Dolley O, Hollin CR. Dealing with Feelings: the effectiveness 

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191 Lorillard S, Schmitt L, Andreoli A. How to treat suicide attempt? Part 2: A review of 

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193 Ludwig J, Marcotte DE, Norberg K. Anti-depressants and suicide. J Health Econ. 2009 

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194 Lynch MA, Howard PB, El-Mallakh P, Matthews JM. Assessment and management of 

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195 Malmberg, Lena, Fenton, Mark, Rathbone, John. Individual psychodynamic psychotherapy 

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196 Malone D, Newron-Howes G, Simmonds S, Marriot S, Tyrer P. Community mental 

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197 Mamo DC. Managing suicidality in schizophrenia. Can J Psychiatry. 2007 Jun;52(6 Suppl 

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