Jump to: Page Content, Site Navigation, Site Search,

Suicide prevention

Interventions to prevent suicide - Primary care

Read Overview

Between 10% and 40% of people who take their own lives will have visited their GP in the week before; primary care practitioners, therefore, may have an opportunity to intervene.

We found six systematic reviews 1 2 3 4 5 6 that included evidence relevant to the primary care setting. However, no RCTs relevant to this setting were found.



In this section:

Key Messages

  • Only about a quarter of those who take their own lives have been in contact with specialist mental health care services in the previous twelve months
  • About 90% of people who take their own lives have a psychiatric disorder and more than 80% are untreated at the time of death
  • Half to two thirds have visited their own doctor within a month of taking their lives, and 10% to 40% visit in the week before. Primary care practitioners may therefore have an opportunity to intervene
  • The population prevalence of suicide in the general population is low, which makes it extremely difficult to predict in a primary care setting, even with tests of high sensitivity and specificity
  • Optimal clinical care for all those consulting with mental health problems is key to suicide prevention
  • Higher prescription rates of antidepressants, especially selective serotonin reuptake inhibitors (SSRI), correlate with declining suicide rates across a large number of countries, though special care is needed in prescribing to adolescents
  • Education of GPs to recognise and treat depression in older adults may be particularly helpful.

Population Interventions

Population interventions that work

Optimal clinical care for mental illness

Increasing rates of antidepressant prescribing, particularly selective serotonin reuptake inhibitors (SSRI), correlate with declining rates of suicide across many countries. 4 More than 90% of people who take their own lives are suffering from depression or another diagnosable mental or substance misuse disorder. We know this either because they are already known to services, or from research studies which have used the technique known as “psychological autopsy”. 1

Primary care services should offer the best possible mental health care in line with the latest clinical evidence (www.clinicalevidence.com) and guidelines published by the National Institute for Health and Clinical Excellence (NICE) ( External Link ).

GP training on recognising depression in older adults

Compared with other sections of the population, older adults tend to have high consultation rates with their GP, a higher rate of suicide and a higher case fatality rate per suicide attempt. Training for GPs in recognising and treating depression in older adults can significantly reduce the rate of suicide in this age group. One review quotes a study in which the rate of suicide of older adults dropped from 25 per 100,000 to 7 per 100,000 over a three-year period. 2

Population interventions that may work

Screening tests for suicide risk

Screening tests for suicide risk in primary care populations have high sensitivity and specificity. However, the low prevalence of suicide in the general population means that the predictive value of such screening tests in a primary care setting is poor. There is insufficient evidence at present to recommend for or against screening for suicide risk in primary care. 3

If it is to be used at all, it is probably more useful to focus screening on high-risk groups such as patients with depression or a history of self-harm, but identification of high risk patients, even if reasonably reliable, is only of value if treatment then results in decreased suicide attempts or completions.

Physician education

Programmes of educating primary care physicians have shown mixed results. Some have reported improved detection of depression and increased treatment, while others have not. Some have shown increased detection but no change in treatment or management. Trials in Sweden, Hungary, Japan and Slovenia have all reported increased prescription rates for antidepressants and substantial declines in suicide rates. Benefit in Sweden was almost totally due to decreases in female suicides with major depression, while the number of male suicides remained unchanged. Three years later, the rates had returned to baseline, suggesting that the programme may need to be repeated to sustain the effect. 4 5

Antidepressant prescribing

Increasing rates of antidepressant prescribing, especially of selective serotonin reuptake inhibitors (SSRI), correlate with declining rates of suicide across many countries. 4 Primary care practitioners should follow best practice in treatment of depression and refer to Clinical Evidence (http:// External Link ).

Brief counselling for problem drinkers

Brief counselling for problem drinking reduces injuries from a range of causes combined, such as falls, motor vehicle crashes and suicide attempts, but no significant effect has been reported on mortality, and suicide has not been reported separately from the other causes of injury. 6

Population interventions that do not work

Providing guidelines on follow-up of patients who have self-harmed

Providing GPs with a letter informing them of a patient’s deliberate self-harm, a letter the GP could forward to the patient inviting him or her to make an appointment, and guidelines on managing deliberate self-harm in general practice did not work. At 12-month follow-up, analysed by intention to treat, the intervention group showed no significant difference from controls in the proportion of patients who attempted suicide (though only 58% of the intervention group GPs actually sent the letter to the patient). 3

What we don't know

We don’t know why some education programmes for primary care practitioners appear to have been effective while others have demonstrated no benefit. The background level of knowledge and expertise, the content and duration of the education programme, and the cultural factors specific to particular countries may all have played a part.

References

  1. Guo B, Harstall C. For which strategies of suicide prevention is there evidence of effectiveness? Copenhagen, WHO Regional Office for Europe Health Evidence Network report; 2004. External Link (accessed 30 Mar 2007).
  2. Klinger J. Suicide Among Seniors. Australas J Ageing 1999;18:114-118.
  3. Gaynes BN, West SL, Ford CA, Frame P, Klein J. Lohr KN. Screening for suicide risk in adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2004;140:822-835. External Link
  4. Mann J, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294:2064-2076. External Link
  5. Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2003;42:386-405. External Link
  6. Dinh-Zarr T, Goss C, Heitman E, Roberts I, DiGuiseppi C. Interventions for preventing injuries in problem drinkers. Cochrane Database Syst Rev 2004;(3):CD001857. External Link
  7. van der Sande R, Buskens E, Allart E, van der Graaf Y, van Engeland H. Psychosocial intervention following suicide attempt: a systematic review of treatment interventions. Acta Psychiatr Scand 1997;96:43-50. External Link
  8. National Institute for Mental Health in England (NIMHE). National Suicide Prevention Strategy for England Annual Report on Progress 2006. NIMHE. Department of Health; 2007. . External Link

Contributors

Dr Jenny Bywaters

Suicide Prevention

Dr Jenny Bywaters is Senior Public Mental Health Advisor for the National Institute for Mental Health in England (NIMHE) where she directs the national programmes for suicide prevention and mental health promotion/public mental health. She has been seconded to North East Public Health Observatory (NEPHO) two days a week since April 2005 as part of the Public Mental Health Observatory team. She previously worked in the mental health policy branch at the Department of Health, and before that as Senior Commissioning Manager for Mental Health and Learning Disability Services at Birmingham Health Authority. She chairs the joint Faculty of Public Health/NIMHE Working Group on Mental Health.