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O'Neil ME, Peterson K, Low A, et al. Suicide Prevention Interventions and Referral/Follow-Up Services: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2012 Mar.

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Suicide Prevention Interventions and Referral/Follow-Up Services: A Systematic Review [Internet].

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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).

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.

Figure 1. Suicide Prevention Analytical Model.

Figure 1

Suicide Prevention Analytical Model.


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