Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research.

  • Type :#article
  • Date read: 2023-05-23
  • Bibtex: @fox2020
  • Bibliography: Fox, K. R., Huang, X., Guzmán, E. M., Funsch, K. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research. Psychological Bulletin, 146(12), 1117–1145.

Example citation

Intervention efficacy for suicidal thoughts and behaviors has not improved over the last 50 years

Most interventions for suicidal thoughts and behaviors are not linked to common suicidality theories

My notes

  • 591 articles from 1,125 RCTs and 3,458 effect sizes
  • DBT did not significantly reduce suicide ideation, suicide attempts, or NSSI
  • CT/CBT did not significantly reduce suicide attempts or suicide death

The overall intervention effects were small across all SITB outcomes; despite a near-exponential increase in the number of RCTs across five decades, intervention efficacy has not improved…

  • The first organized suicide prevention effort is thought to be Harry Warren’s Save-A-Life League, founded in New York in 1906. Warren was a baptist minister and hosted group conselling sessions.
  • We don’t really know why national suicide rates decline or increase, and calls for reductions in suicide are not very helpful.

The most commonly tested interventions are modified versions of interventions originally intended for something else and are largely disconnected from the most popular SITB theories.

Because a large number of intervention targets play small causal roles in a small proportion of SITB instances, many interventions produce small SITB reductions, but none produce moderate or large reductions

Notable interventions

  • Social outreach and large-scale outreach (1906 – today. e.g., helplines and online efforts)
  • Psychodynamic therapy (1910s – today)
  • Prefrontal lobotomy (1930s - 1950s)
  • ECT (1940s – today)
    • DBS, rTMS
  • Gatekeeper training, peer support, and institutional programs (1950s – today)
  • Pharmacotherapy (1950s – today)
  • Acute psychiatric hospitalization (1960s – today)
  • Checking-in programs (1960s – today)
  • Cognitive and behavioral approaches (1960s – today)
  • Means safety and restriction (1970s – today)
  • Multilevel eclectic approaches (2000s – today)

Future directions

  • Test commonly utilized SITB intervention within RCT designs
    • Means safety, helplines, acute hospitaliaztion
  • Conduct studies that are sufficiently powered to reliably estimate intervention effects on suicide attempt and suicide death
  • Increase research on adolescent and elderly populations
  • Demonstrate intervention target engagement (mechanism)
  • Prioritize research that can shed light on common necessary causes of SITBs
    • One candidate is means restriction like firearm access
    • The second is “disrupting SITB concepts”, so for example consolidation disruption of common SITB concepts
    • Third: focusing on the consequences rather than antedecents of suicidal behavior. ”… interventions that cause individuals to conceptualize the consequences of suicidal behavior as less appealing may be effective”.

For now, what should clinicians do?

The present meta-analysis indicates that many existing interventions produce small reductions in SITBs. As noted above, this broad finding should prompt many new research directions. But where does this leave clinicians who are tasked with managing patients with SITBs today? Based on our read of the evidence, we have three interrelated recommendations for clinicians. First, recognize the limits of existing interventions. There is no robust evidence for highly efficacious intervention for SITBs and there is no consistent evidence that particular interventions work much better for certain SITB phenomena or for certain populations. Second, understand that there are many different interventions that can produce small group-level reductions in SITBs. It is important to connect at-risk individuals to one of these interventions. Third, consider applying the most scalable of these interventions to reach the most people in the most cost-effective manner. Nearly all existing interventions tested within RCT studies produce similar effects, meaning that short, cheap, and easily accessible interventions appear to be just as efficacious as long, expensive, and difficult-to-access interventions. To maximize SITB reductions, we accordingly recommend that—for now— clinicians disseminate the most scalable existing interventions.


PDF: fox_2020_interventions_for_suicide_and_self-injury_-_a_meta-analysis_of_randomized.pdf