Evidence‐based Synthesis Pro

(ESP)

Suicide Risk Factors, Suicide R

A t ssessment, and S i id u c e P 

reve

Interventions

Systematic Reviews

Maya O Neil, ’ PhD, MS

Elizabeth Haney, MD

Portland VA Medical Center and

Oregon Health and Science University
Evidence‐based Synthesis Pro

(ESP)

Acknowledgements

Report Authors

o Maya O’Neil, PhD, MS

o Elizabeth Haney, MD

Presenters & Dis

o Maya O’Neil, Po Elizabeth Han

o Kimberly Peterson, MS

o Susan Carson, MPH

o Allison Low, BA

h

o Lisa Brenner, Po John Bradley, o Marcia Valens

o Lauren Denneson, PhD

o Chandra Oleksiewicz, MD

o Paulo Shiroma, MD

o Devan Kansagara, MD, MCR
Evidence‐based Synthesis Pro

(ESP)

Disclosure

This report is based on research research conducted conducted by the Evidence Evidence‐based 

Program (ESP) Center located at the Portland VA Medical Center fu

Department of Veterans Affairs, Veterans Health Administration, Of

Research Research and Development Development, Health Services Services Research Research and Develop

Develop

findings and conclusions in this document are those of the author(s

responsible for its contents; the findings and conclusions do not ne

represent represent the views of the Department Department of Veterans Veterans Affairs Affairs or the U

government. Therefore, no statement in this article should be cons

official position of the Department of Veterans Affairs. No investiga

affiliations affiliations or financial financial in ol ement volvement (e g. ., emplo ment y , cons ltanci

ultanci

stock ownership or options, expert testimony, grants or patents rec

pending, or royalties) that conflict with material presented in the re
Evidence‐based Synthesis Pro

(ESP)

VA Evidence‐based Synthesis (ESP)

Program Overview

• Sponsored by VA QUERI Program.• Established Established to provide provide timely and accurate accurate syntheses/reviews syntheses/reviews 

topics identified by VA clinicians, managers and policy‐maker

work to improve the health and healthcare of Veterans.

• Builds on staff and expertise already in place at the Evidence‐

Practice Centers (EPC) designated by AHRQ. Four of these EPESP Centers:

o Durham VA Medical Center; VA Greater Los Angeles Healt

System; Portland VA Medical Center; and Minneapolis VA 

Center.
Evidence‐based Synthesis Pro

(ESP)

• Provides evidence syntheses on important clinical practice to

to Veterans, and these reports help:

o d l eve op cli i l n ca poli i c es if d n ormed by evidence,

o the implementation of effective services to improve 

outcomes and to support VA clinical practice guidelin

performance measures, and

o guide the direction for future research to address gap

knowledge.

• Broad topic nomination process – e.g. VACO, VISNs, field – fa

ESP Coordinating Center (Portland) through online process:

http://www.hsrd.research.va.gov/publications/esp/TopicNomin
Evidence‐based Synthesis Pro

(ESP)

• Steering Committee representing research and operations (PC

and VISN) provides oversight and guides program direction.

• Technical Advisory Panel (TAP)

o Recruited for each topic to provide content expertise

o Guides topic develop ; ment refines the key questions

o Reviews data/draft report.

• External Peer Reviewers & Policy Partners

o Reviews Reviews and comments comments on draft report

• Final reports posted on VA HSR&D website and disseminated 

through the VA.

http://www.hsrd.research.va.gov/publications/esp/reports
Evidence‐based Synthesis Pro

(ESP)

Current Reports:

• Suicide Risk Factors and Risk Assessment To

Systematic Review (March, 2012)

• Suicide Prevention Interventions and Referr

up Services: A Systematic Review (March, 2

Full‐length reports available on ESP website:

http://www.hsrd.research.va.gov/publications/esp/reports
Evidence‐based Synthesis Pro

(ESP)

Overview of Today’s Presentation

• Background

• Why is this topic of interest, and what was the purpose of the reports?

• Scope of the reviews and methods

• Synthesizing the best available and most relevant evidence

• Results

• Veteran/Military and general risk factors• Risk assessment tools• Pharmacotherapy interventions

• Psychotherapy interventions

• Referral/follow‐up services

• Limitations, Future Research

• What studies are needed to make a difference in this complex field?

• Discussion

• Process of Clinical Practice Guidelines development

• Update on current research within the VA 
Evidence‐based Synthesis Pro

(ESP)

Background

• Suicide is a major public health concern in the US, claiming o

lives each year and nearly 100 lives each day.

• Current Current or former military military represent represent 20 percent percent of all known 

the US and the rate of suicides among Veterans utilizing Vete

Administration (VHA) services is estimated to be higher than 

population.

• Veterans returning from the Iraq and Afghanistan conflicts, re

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/

may be particularly at risk. Many risk factors specific to the O

population have yet to be thoroughly evaluated and incorpor

clinical management.
Evidence‐based Synthesis Pro

(ESP)

Key Questions:

Risk Factors Factors and Assessment Assessment Tools Rep

• Key Question #1. What assessment tools are effective for ass

engaging in suicid l a self‐d d irected violence in Veteran and mil

populations?

• Key Question #2. In addition to the risk factors included by cu

assessment tools, what other risk factors predict suicidal selfviolence in Veteran and military populations?
Evidence‐based Synthesis Pro

(ESP)

Key Questions: Interventions Report

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

rates of suicidal self‐directed violence in military and/or Veteran pop

• Key Question #2. What lessons can be learned from suicidal self‐dire

prevention intervention research conducted outside of Veteran or m

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

• Key Question #3. What is the effectiveness of referral and follow‐up 

strategies di d es gned to provide ref l erra s, improve ref l erra f ll o ow‐th 

ro

attendance, etc.) for reducing rates of suicidal self‐directed violence 

and/or Veteran populations?

• Key Q estion Question #4. What lessons lessons can be learned learned from research research on s ic

uic

directed violence referral and follow‐up services conducted outside 

military settings that can be applied to Veteran and/or military popu
Evidence‐based Synthesis Pro

(ESP)

Scope of the reports:

• Previous research includes systematic reviews by Hawton et 

Gaynes et al. (2004), and Mann et al. (2005).

• Recent, similar similar work includes includes National National Institute Institute for Health an

Excellence (NICE) 2012 systematic review and clinical practic

on self‐harm.

• This report: Requested by the Veterans Affairs ( )/ VA Departm

Defense (DoD) Evidence Based Practice Working Group (EBPW

suicide prevention.

• Review of previous reviews and of recent literature published 

November 18th, 2011.
Evidence‐based Synthesis Pro

(ESP)

Scope of the reports:

• Outcomes: The definition of suicidal self‐directed violence (C

2011): “Behavior that is self‐directed and deliberately results 

the potential potential for injury to oneself oneself. There is evidence evidence, whethe

whethe

explicit, of suicidal intent."

• Risk factors and assessment tools report: Included reviews o

populations, and primary literature on Veterans and membe

military.

• Interventions report: Included reviews and primary literature 

populations due to the paucity of primary studies on Veteran

members of the military.
Evidence‐based Synthesis Pro

(ESP)

Methods

• Search: PubMed, PsycINFO, the Cochrane Database of System

Reviews®, the Cochrane Central Register of Controlled Trials, 

lists, consultation with experts, and web searches

• Search dates: 2005 to November November 18, 2011

• Inclusion/exclusion criteria: English language, country (USA, C

Britain, Australia, New Zealand)

• Reviewed 16,521 titles and abstracts from the electronic and 

searches

– 30 observational studies and 14 systematic reviews were included in th

Assessment report

– 38 RCTs and 23 systematic reviews were included in the Interventions r

• Dual, blinded q y ualit assessment of all p y rimar studies and sy

reviews
Evidence‐based Synthesis Pro

(ESP)

Key Questions:

Risk Factors Factors and Assessment Assessment Tools Rep

• Key Question #1. What assessment tools are effective for ass

engaging in suicid l a self‐d d irected violence in Veteran and mil

populations?

• Key Question #2. In addition to the risk factors included by cu

assessment tools, what other risk factors predict suicidal selfviolence in Veteran and military populations?
Evidence‐based Synthesis Pro

(ESP)

Review of Existing Systematic Reviews of Risk 

Civilian Populations:

• Systematic reviews by Mann et al, Gaynes et al, and NICE 2011.• Mann and Gaynes did not systematically address individual risk facto

• NICE report methodology methodology differs differs from our report in several several ways:

• Only prospective studies evaluating risk of repetition of self harm.

• Country scope broader

• Included studies that were minimally adjusted for known risk factors
Evidence‐based Synthesis Pro

(ESP)

Review of Existing Systematic Reviews of Risk 

Civilian Populations:

• Risk factors for non-fatal self 

harm:

• Risk factors for suicid

• Suicide intent/intent to 

• Prior self-harm and depression 

symptoms

• Schizophrenia and related symptoms

Al h l i

• Suicide intent/intent to • Male gender• Psychiatric history• Older age

• Alcohol misuse • Violent methods of se

• Other psychiatric history

• Unemployment and “registered sick”• female gender (mixed and poor quality 

id )

• Violent methods of se• Physical health proble• Alcohol abuse (mixed 

evidence)

• Unmarried status (not predictive in 

pooled analysis)

• Younger age
Evidence‐based Synthesis Pro

(ESP)

Systematic Review of Primary Literature on Ri

Specific Methods

• New risk factors may act through or as a result of other existing/kno• Therefore Therefore, controlling controlling for know risk factors factors is essential essential to identificati

identificati

factors.

• We included only studies that adjusted for one of the following:

• Suicidal ideation• History of suicide attempts

• Substance use disorder• History of any mental health diagnosis

• Excluded:

• Studies reporting only rates in a specific population

• Studies of genetic testing to predict suicide

• Studies of post‐mortem tissue (biochemical/pathologic) factors associated with su

• RCTs that failed to account account for treatment treatment allocation allocation.
Evidence‐based Synthesis Pro

(ESP)

Results of Systematic Review of Primary Lite

Risk Factors Factors in Veteran Veteran and Military Military Popul

Popul

• 26 studies identified, 22 with unclear or low risk of bias.• Generally Generally longitudinal longitudinal studies studies are more valid than cross‐sectional sectional st

st

prediction.

• Outcomes included suicide and suicide attempts (self‐report and ob

Suicide Attempts Suicide

Longitudinal Self‐report ‐ 2 11

Cross‐sectional Self‐report ‐ 5 0

Retrospective Objective ‐ 2 2
Evidence‐based Synthesis Pro

(ESP)

Results of Systematic Review of Primary Lite

Risk Factors Factors in Veteran Veteran and Military Military Popul

Popul

• Risk factors for suicide:

• Demographic: Demographic: male, younger younger age, white race, education, education, smoking smoking• Psych: number of conditions, PTSD (mixed), depression, anxiety, bipolar, schizoph

substance abuse, inpatient hospitalization

• Military factors: TBI

• Other: diabetes, diabetes, CV disease, disease, lower mental health functioning functioning (SF‐12), severe pain

• Risk factors for suicide attempt:

• Demographic: marital status (mixed)• Psych: presence presence of conditions conditions, PTSD, depression depression, bipolar bipolar, prior suicide suicide attempt attempt, so

abuse, substance abuse (mixed), negative life events

• Military factors: multiple specific types of trauma
Evidence‐based Synthesis Pro

(ESP)

Results: Assessment Tools

• Three systematic reviews find insufficient evidence for existin

predicting suicidal self‐directed violence

• Two broadly scoped, non‐systematic reviews highlight the Sc

Suicidal Suicidal Ideation Ideation and the Beck Hopelessness Hopelessness Scale as two me

me

have shown associations with death by suicide

• Five primary studies researched assessment tools in Veteran

populations

– Addiction Severity Index is no longer used in VA settings

– Personality Assessment Inventory is lengthy, complex to interpret and s

– Interpersonal Psychological Survey is not well researched

– Beck Depression Inventory‐II and Affective States Questionnaire are po

brief screening tools in primary care settings

– Overall very limited evidence
Evidence‐based Synthesis Pro

(ESP)

Key Questions: Interventions Report

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

rates of suicidal self‐directed violence in military and/or Veteran pop

• Key Question #2. What lessons can be learned from suicidal self‐dire

prevention intervention research conducted outside of Veteran or m

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

• Key Question #3. What is the effectiveness of referral and follow‐up 

strategies di d es gned to provide ref l erra s, improve ref l erra f ll o ow‐th 

ro

attendance, etc.) for reducing rates of suicidal self‐directed violence 

and/or Veteran populations?

• Key Q estion Question #4. What lessons lessons can be learned learned from research research on s ic

uic

directed violence referral and follow‐up services conducted outside 

military settings that can be applied to Veteran and/or military popu
Evidence‐based Synthesis Pro

(ESP)

Results from the Interventions Repor

Pharmacotherapy in Previous Previous Review

Review

• Findings based on few studies with small sample sizes, short 

up assessment periods, and methodological quality concerns

– Antidepressant trials do not show a benefit for suicide reduction, but ra

may have been too low to detect an effect. Observational studies show 

between increasing prescription rates and decreasing suicide rates, but 

considered considered lower strength strength than evidence evidence obtained obtained from RCTs or meta‐a

a

– Positive findings from trials of the antipsychotic medications flupenthix

fluphenazine, though findings are based on small samples of patients in 

– Mixed results results related related to mood stabilizing stabilizing medications. medications. Gaynes et al. rep

in suicide rates based on one trial of lithium, whereas Mann et al. and N

non‐significant reductions in suicide rates for patients receiving lithium
Evidence‐based Synthesis Pro

(ESP)

Results from the Interventions Repor

Pharmacotherapy in Primary Primary Studies Studies

• Antidepressant medications: Insufficient evidence to make a 

conclusion about the effectiveness of antidepressants in red

and suicide attempts from 9 trials

• Antipsychotic medications: Three trials provided insufficient 

the effectiveness of q p uetia ine (1 trial) or adjunctive arip pi ra

in reducing suicidal self‐directed violence

• Mood stabilizers: One trial of lithium versus valproate and on

lithium lithium versus citalopram citalopram provided provided insufficient insufficient evidence evidence

• Omega‐3 supplements: One trial provided insufficient eviden
Evidence‐based Synthesis Pro

(ESP)

Results from the Interventions Repor

Psychotherapy in Previous Previous Reviews Reviews

• Previously published systematic reviews all report an overall 

low strength of evidence for the effectiveness of any psychot

interventions

– Cognitive therapies: Mixed results

– Dialectical Behavior Therapy: Positive results for patients with Borderlin

Disorder

– Interpersonal Psychotherapy: Positive findings

– Outpatient Day Hospitalization: Null findings

– Problem‐Solving Therapy: Positive findings

– Psychoanalytically oriented partial day hospitalization: Positive results f

Borderline Personality Disorder

– Transference‐focused Psychotherapy: Positive findings
Evidence‐based Synthesis Pro

(ESP)

Results from the Interventions Repor

Psychotherapy in Primary Primary Studies Studies

• Moderate strength evidence for problem‐solving treatment i

usual care compared to usual care alone for patients with rec

suicide attempts.

– No significant benefit of the intervention compared to usual care for th

patients. Significant benefit noted for a sub‐population of patients who 

hospitalizations for self‐harm prior to the intervention.

• The other trials provided insufficient or low strength evidenc

– Limitations in quality

– Insufficient statistical power to detect intervention effects on low base

– Other promising promising results: results: DBT and CBT targeting targeting suicidal suicidal behavior behavior
Evidence‐based Synthesis Pro

(ESP)

Results from the Interventions Report:

Referral & Follow‐up Services

• Previous reviews have highlighted postcard interventions as 

promise, though results are mixed and provide low strength 

• Findings from primary studies:

– Three studies of postcard interventions showed mixed results.– Two studies studies of Youth‐Nominated Nominated Support Support Team interventions, interventions, o

assertive community treatment, and one trial of a depression cmanagement program yielded non‐significant results

– All these studies studies provided provided low strength strength evidence evidence
Evidence‐based Synthesis Pro

(ESP)

Overview of Results

• Risk Factors:

– Suicide predicted by demographics, military factors, psych and 

– Suicide attempts predicted by psych and trauma experiences

• Assessment tools:

– Overall limited evidence– Scale for Suicidal Suicidal Ideation, Ideation, Beck Hopelessness Hopelessness Scale, Affective Affective S

Questionnaire, Beck Depression Inventory‐II, and Patient Healt

Questionnaire‐9 need investigation in Veteran/military populat

• Interventions:

– Best available evidence for Problem‐Solving Therapy

– Promising interventions: Dialectical Behavioral Therapy and Co

Behavioral Therapies targeting suicidal self‐directed violence
Evidence‐based Synthesis Pro

(ESP)

Limitations and Future Research Priorit

• Low base‐rates present the largest challenge• Risk factors:

– Evaluate new risk factors with accounting for known risk fa

– Additional studies in Veteran and military populations

• Assessment tools:

– Reclassification analysis is the gold standard

– Examine brief, easy to administer assessment tools in Vete

populations

• Interventions:

– Instead of small‐scale trials of multiple new and slightly dif

i i nterventions, fewer, meth d l i ll hodologically sound, very large‐sc

most promising interventions 
Evidence‐based Synthesis Pro

(ESP)

Discussants:

John Bradley, Lisa Brenner, and Marcia Valenstein

• Describe the process of creating Clinical Pract

Guidelines

• Why are clinical practice guidelines important?• How is the process unique for the t i op c of sui idc e • How does the CPG writing group use the evidence 

guidelines?

• What is the status of the clinical practice guideline

development process currently?
Evidence‐based Synthesis Pro

(ESP)

Discussants:

John Bradley, Lisa Brenner, and Marcia Valenstein

• How do we take current, limited research and implem

in policy, research, and practi ? ce

• How should we design and disseminate research t

gaps in our knowledge knowledge (risk factors, factors, risk assessmen

assessmen

interventions)?

• What does VA leadership need to do to encourage 

builds the evidence base?

• What research in this area is ongoing in VA/militar

f t ac ors, ri ks assessment t l oo s, and i t ti )? interventions)?
Evidence‐based Synthesis Pro

(ESP)

Questions?

If you have further questions,

feel free to contact:

Maya O’Neil, PhD, MS

maya oneil@VA gov maya.oneil@VA.gov

Elizabeth Haney, MD

h @h d aneye@ohsu.edu

The full report and cyberseminar presentation is available on the E

http://www.hsrd.research.va.gov/publications/esp/
6/11/2012 1:00pm Suicide Prevention Interventions and Suicide Risk 

Factors and Risk Assessment Tools

 Spotlight on Evidence-based 

Synthesis Program 

Bradley, John

Brenner, Lisa

Haney, Elizabeth

O'Neil, Maya

Valenstein, Marcia

Questions Submitted:

Can you tell us more about problem-solving therapy, such as a reference? 

Response: Of course—see the Hatcher et al. article available at 

http://bjp.rcpsych.org/content/early/2011/07/30/bjp.bp.110.090126. 

Just a note that caution should be taken with using the BDI-II to predict suicidal behavior: scores on 

question 9 (suicide) to NOT increase monotonically with total score. If you rely on that question, you 

could be easily misled. 

Response: Yes, this is a great point, and one that we hope primary authors are considering. In our 

report, we described the measures as they were reported in the primary studies. For future research, we 

agree that this BDI-II total scores should be evaluated in addition to only the BDI-II item related to 

suicidal ideation.

What is a postcard intervention? 

Response: There have been a few studies investigating the effectiveness of postcards (or other caring 

mailings) mailed to patients following psychiatric hospitalization. On recent example can be found at 

http://www.ncbi.nlm.nih.gov/pubmed/20592434.