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Shekelle P, Bagley S, Munjas B. Strategies for Suicide Prevention in Veterans [Internet]. Washington (DC): Department of Veterans Affairs (US); 2009 Jan.

Cover of Strategies for Suicide Prevention in Veterans

Strategies for Suicide Prevention in Veterans [Internet].

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STUDY SELECTION

In consultation with the ESP Advisory Committee and VA policymakers in mental health, we developed the following criteria to guide study selection. Our focus was on veterans and active military duty persons, consequently studies of children and adolescents were excluded. All studies of veterans and military personnel (from any country) were included. In addition to this, we included studies of the non-veteran population from the US and countries sufficiently similar to the US in terms of culture (Canada, United Kingdom, Ireland, Australia, New Zealand). Only studies that reported outcomes as suicides or suicide attempts were included; studies reporting only other proxy outcomes were excluded. Studies of strictly mental health interventions (psychotherapy, pharmacotherapy) have been reviewed by others and were therefore excluded unless they included military or veterans.

DATA ABSTRACTION

Data were abstracted by a psychiatrist with prior experience in systematic reviews. The following data were abstracted from included trials: population, mean and median age, setting, country, interventions, outcomes, and study design. Data abstraction forms are provided in Appendix A.

QUALITY ASSESSMENT OF INDIVIDUAL ARTICLES

To assess the quality of the RCT and CCTs we used was a modification of the Delphi List.11 We abstracted data on whether or not the study was described as randomized; treatment allocation; was the method of randomization performed and was the treatment allocation concealed; were the groups similar at baseline regarding the most important prognostic indicators; were the eligibility criteria specified; was the outcome assessor blinded; was the care provider blinded; was the patient blinded; were point estimates and measures of variability presented for the primary outcome measures; were all randomized participants analyzed in the group to which they were allocated; were co-interventions avoided or similar; was compliance in all groups acceptable; was the timing of the outcome assessment in all groups similar.

RATING THE BODY OF EVIDENCE

We assessed the overall quality of evidence for outcomes using a method developed by the Grade Working Group, which classified the grade of evidence across outcomes according to the following criteria:12

  • High = Further research is very unlikely to change our confidence on the estimate of effect.
  • Moderate = Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
  • Low = Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
  • Very Low = Any estimate of effect is very uncertain.

GRADE also suggests using the following scheme for assigning the “grade” or strength of evidence:

Criteria for assigning grade of evidence

Type of evidence

Randomized trial = high

Observational study = low

Any other evidence = very low

Decrease grade if:

  • Serious (−1) or very serious (−2) limitation to study quality
  • Important inconsistency (−1)
  • Some (−1) or major (−2) uncertainty about directness
  • Imprecise or sparse data (−1)
  • High probability of reporting bias (−1)

Increase grade if:

  • Strong evidence of association-significant relative risk of > 2 (< 0.5) based on consistent evidence from two or more observational studies, with no plausible confounders (+1)
  • Very strong evidence of association-significant relative risk of > 5 (< 0.2) based on direct evidence with no major threats to validity (+2)
  • Evidence of a dose response gradient (+1)
  • All plausible confounders would have reduced the effect (+1)

For this report, we used both this explicit scoring scheme and the global implicit judgment about “confidence” in the result. Where the two disagreed, we went with the lower of the two classifications

DATA SYNTHESIS

The studies included in this review were too heterogeneous to statistically pool, and we therefore summarized these narratively, in the following categories multifaceted interventions for military personnel; other multifaceted programs (national suicide prevention programs); interventions for veterans; psychosocial interventions post-suicide attempt; postal or telephone follow up post-suicide attempt; hospital admission for attempted suicide; and restriction of access to lethal means.

PEER REVIEW

This report was reviewed by 6 experts selected by the VA ESP Advisory Committee for their expertise in this area and their knowledge of VA. Peer review comments received, and the changes we made to the report as a result, are presented in Appendix D.

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