Elsevier

Journal of Affective Disorders

Volume 210, 1 March 2017, Pages 294-302
Journal of Affective Disorders

The effectiveness of suicide prevention delivered by GPs: A systematic review and meta-analysis

https://doi.org/10.1016/j.jad.2016.12.035Get rights and content

Highlights

  • There is interest in GPs providing suicide prevention to at-risk patients.

  • We conducted a systematic review and meta-analysis of these studies.

  • We found no evidence of reductions in suicide ideation, self harm or suicide attempt.

  • There was some evidence of reductions in death by suicide.

Abstract

Background

The aim of this review was to assess whether suicide prevention provided in the primary health care setting and delivered by GPs results in fewer suicide deaths, episodes of self-harm, attempts and lower frequency of thoughts about suicide.

Methods

We conducted a systematic review and meta-analysis using PRIMSA guidelines. Eligible studies: 1) evaluated an intervention provided by GPs; 2) assessed suicide, self-harm, attempted suicide or suicide ideation as outcomes, and; 3) used a quasi-experimental observational or trial design. Study specific effect sizes were combined using the random effects meta-analysis, with effects transformed into relative risk (RR).

Results

We extracted data from 14 studies for quantitative meta-analysis. The RR for suicide death in quasi-experimental observational studies comparing an intervention region against another region acting as a “control” was 1.26 (95% CI 0.58, 2.74). When suicide in the intervention region was compared before and after the GP program, the RR was 0.78 (95% CI 0.62, 0.97). There was no evidence of a treatment effect for GP training on rates of suicide death in one cRCT (RR 1.07, 95% CI 0.79, 1.45). There was no evidence of effect for the most other outcomes studied.

Limitations

All of the studies included in this review are likely to have a high level of bias. It is also possible that we excluded or missed relevant studies in our review process

Conclusions

Interventions have produced equivocal results, which varied by study design and outcome. Given these results, we cannot recommend the roll out of GP suicide prevention initiatives.

Introduction

Suicide and self-harm (including intentional self-injury or self-poisoning irrespective of type of motivation and/or degree of suicidal intent) represents a serious public health burden. There is now good evidence that psychotherapeutic treatments (e.g., cognitive behaviour therapy or dialectical behavioural therapy) are effective at reducing the repetition of self-harm (Hawton et al., 2016). Results also suggest a non-significant reduction in suicide when using cognitive behavioural therapy and case management (Hawton et al., 2016).

However, a large number of individuals who are at risk of suicide may never come into contact with the specialist mental health services that offer these treatments (Appleby et al., 1999, Cavanagh et al., 2003, Law et al., 2010, Schaffer et al., 2016). In contrast, many people have contact with general practitioner (GP) services prior to suicide (Andersen et al., 2000, Leavey et al., 2016, Luoma et al., 2002, Pearson et al., 2009, Power et al., 1997, Stark et al., 2012). A review of over 40 studies (Luoma et al., 2002) found that up to three of four suicide victims had contact with primary care providers in the year of their suicide. More recently, a study from Northern Ireland found that as many as 85% of people who died by suicide were in contact with general practice services in the 12 months before their death (Leavey et al., 2016). In Scotland, 18.6% of those who died by suicide during the period 2001–2004 had contact with mental health services, compared to 46.4% who had contact with general practice (Stark et al., 2012).

Given this evidence, it is unsurprising the involvement of GPs in providing suicide prevention services has been of considerable interest to researchers (Feltz-Cornelis et al., 2011, Leitner et al., 2008). There have also been several large-scale studies that feature GP training as a central component of suicide prevention initiatives (Hegerl et al., 2006, Hegerl et al., 2008, Roskar et al., 2010, Rutz et al., 1995, Rutz et al., 1989a, Rutz et al., 1992, Rutz et al., 1990, Rutz et al., 1989b, Rutz et al., 1997). However, there has been limited assessment of the effectiveness of suicide prevention interventions that involve GPs. The aim of this review was to assess whether suicide prevention provided in the primary health care setting and delivered by GPs result in fewer suicide deaths, episodes of self-harm, attempts and thoughts about suicide.

Section snippets

Methods

The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Liberati et al., 2009).

Results

A total of 14,538 records were identified following the systematic search strategy outlined in Supplementary Document SD1. A further nine records were identified following snowballing and correspondence with researchers active in the field. Following deduplication, this was reduced to 13,684. Of these, 13,249 were excluded at the first screening stage, and a further 368 were excluded following application of the inclusion and exclusion criteria at the second screening stage. A total of 16

Discussion

This meta-analytic review focused on whether GP suicide prevention interventions (delivered either as a standalone intervention or as part of a larger multicomponent intervention) influenced suicide ideation, self-harm, suicide attempts, and suicide deaths. Below we present the limitations and the main results of the meta-analysis before discussing issues related to study design. We do this in order to encourage further debate about evaluation and effectiveness in suicide prevention.

Conclusion

Interventions that target GP training for suicide prevention have produced equivocal results, which vary by study design and outcome. Considering the complexity of these interventions, we suggest that suicide prevention incorporating GP training carefully considers a multi-layered evaluation approach involving stepped wedge designs and cRCTs, as well as observational evaluation studies. Outcomes should be expanded to assess changes in exposure to risk factors for suicidal behaviours, as well as

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