Golden Gate Bridge Suicide Net Plan Gets Boost

Joy Division wrote:

lovedust wrote:Here is the report of the Salzburg 2004 consultation between Suicide Prevention Experts from 15 different countries. It was published in the Journal of the American Medical Association in 2005.

Suicide Prevention Strategies: A Systematic Review

J. John Mann, MD; Alan Apter, MD; Jose Bertolote, MD; Annette Beautrais, PhD; Dianne Currier, PhD; Ann Haas, PhD; Ulrich Hegerl, MD; Jouko Lonnqvist, MD; Kevin Malone, MD; Andrej Marusic, MD, PhD; Lars Mehlum, MD; George Patton, MD; Michael Phillips, MD; Wolfgang Rutz, MD; Zoltan Rihmer, MD, PhD, DSc; Armin Schmidtke, MD, PhD; David Shaffer, MD; Morton Silverman, MD; Yoshitomo Takahashi, MD; Airi Varnik, MD; Danuta Wasserman, MD; Paul Yip, PhD; Herbert Hendin, MD

Author Affiliations: New York State Psychiatric Institute, Division of Neuroscience (Drs Mann and Currier) and Division of Child psychiatry (Dr Schaffer), Department of Psychiatry, Columbia University, New York; Department of Psychiatry, Schneiders Childrens Medical Center of Israel (Dr Apter); Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland (Dr Bertolote); Canterbury Suicide Project, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand (Dr Beautrais); American Foundation for Suicide Prevention, New York, NY (Drs Haas and Hendin); Department of Psychiatry, Ludwig-Maximilians-Universität, Munich, Germany (Dr Hegerl); Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland (Dr Lonnqvist); Department of Psychiatry & Mental Health Research, St Vincents University Hospital, Dublin, Ireland (Dr Malone); Institute of Public Health of the Republic of Slovenia, Ljubjana, Slovenia (Dr Marusic); Suicide Research and Prevention Unit, University of Oslo, Oslo, Norway (Dr Mehlum); Centre for Adolescent Health, University of Melbourne, Melbourne, Australia (Dr Patton); Beijing Suicide Research and Prevention Center, Beijing, China (Dr Phillips); Division of Psychiatry, Unit for Social Psychiatry and Health Promotion, Academic University Hospital, Uppsala, Sweden (Dr Rutz); National Institute for Psychiatry and Neurology, Budapest, Hungary (Dr Rihmer); Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany (Dr Schmidtke); National Suicide Prevention Technical Resource Center, Centers for Disease Prevention and Control, Newton, Mass (Dr Silverman); Division of Behavior Sciences, National Defense Medical College Research Institute, Tokyo, Japan (Dr Takahashi); Estonian-Swedish Suicidology Institute, Center Behavior and Health Science, Tallinn, Estonia (Dr Varnik); Department of Public Health Sciences at Karolinska Institute, Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health, Stockholm, Sweden (Dr Wasserman); and Hong Kong Jockey Club Center for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Dr Yip).

ABSTRACT.

Context In 2002, an estimated 877 000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.

Objectives To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.

Data Sources and Study Selection Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.

Data Extraction Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.

Data Synthesis Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.

Conclusions Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

Suicide is a significant public health issue. In 2002, an estimated 877 000 lives were lost worldwide through suicide, representing 1.5% of the global burden of disease or more than 20 million disability-adjusted life-years (years of healthy life lost through premature death or disability).1 The highest annual rates are in Eastern Europe, where 10 countries report more than 27 suicides per 100 000 persons. Latin American and Muslim countries report the lowest rates, fewer than 6.5 per 100 000.2 In the United States, in 2002, suicide accounted for 31 655 deaths, a rate of 11.0 per 100 000 per year,3 and general population surveys document a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,4 representing a huge human tragedy and an estimated $11.8 billion in lost income.5

Suicidal behavior has multiple causes that are broadly divided into proximal stressors or triggers and predisposition.6 Psychiatric illness is a major contributing factor, and more than 90% of suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric illness,7- 13 with some exceptions, such as in China.14Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.7,8,10,15,16 Other contributory factors include availability of lethal means, alcohol and drug abuse, access to psychiatric treatment, attitudes to suicide, help-seeking behavior, physical illness, marital status, age, and sex.6 To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The Figure illustrates the multiple factors involved in suicidal behavior6 and indicates where specific preventive interventions are being directed. Suicide prevention is possible because up to 83% of suicides have had contact with a primary care physician within a year of their death and up to 66% within a month.17,18 Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression. This review considers what is known about this and other prevention strategies to permit integration into a comprehensive prevention strategy.

Suicide experts from 15 countries met in Salzburg, Austria, in August 2004 to review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide.

DATA SOURCES.

An electronic literature search of all articles published between 1966 and June 2005 was conducted via MEDLINE, the Cochrane Library, and PsychINFO to identify reports evaluating suicide prevention interventions. An initial search used the MEDLINE identifier suicide (including the subheading suicide, attempted) and the subheading prevention and control, following that suicide was combined with the following identifiers: depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive agents, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media. We identified 5020 articles, which were not bound by the 5 major areas identified during the workshop. Abstracts were reviewed and full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors.

Study Selection

Studies were included if they reported on either the primary outcomes of interest, namely completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates.

We included 3 major types of studies for which the research question was clearly defined as assessment of efficacy or effectiveness of prevention programs in terms of the above primary or secondary outcomes; (1) systematic reviews and meta-analyses (n = 10) for which the search strategy was comprehensive and the methodological quality of primary studies was critically appraised; (2) quantitative studies, either randomized controlled trials (n = 18), or cohort studies (n = 24); and (3) ecological or population based studies (n = 41). Table 1 and Table 2 detail study type, study population, and preventive intervention tested and rate the studies according to the scheme proposed by the Oxford Centre for Evidence Based Medicine.112 Randomized controlled trials provide the most compelling evidence of efficacy while findings of naturalistic studies are largely correlational, indicating that their outcomes need further testing.


DATA SYNTHESIS.

Heterogeneity in study methodology and populations limited formal meta-analysis, thus we present a narrative synthesis of the results for the key domains of suicide prevention interventions.

Awareness and Education

General Public. Public education campaigns are aimed at improving recognition of suicide risk and help seeking through improved understanding of the causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious medical illness. Despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.

Studies in Germany,55 the United Kingdom,57 Australia,56 and New Zealand58 suggest modest effects of public education campaigns on attitudes regarding the causes and treatment of depression. Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.57,58,113 The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign.59 However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control region.55

Other specific education strategies are aimed at youth, including school and community-based programs.114,115 Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.114 A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support.22 A later review of studies published from 1990-2002 also found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for prevention of suicidal behavior.23 A subsequent controlled trial reported lower suicide attempt rates, greater knowledge, and more adaptive attitudes about depression and suicide in the intervention group compared with in the 3 months after the intervention, but no significant benefits for rates of suicide ideation or help-seeking.29 In adolescents, several studies found that improving problem solving, coping with stress, and increasing resilience enhance hypothesized protective factors but effects on suicidal behavior were unevaluated.43- 45

Primary Care Physicians. Depression and other psychiatric disorders are underrecognized and undertreated in the primary care setting.116,117 Prevention is possible because most suicides have had contact with a primary care physician within a month of death.17,18 Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides. Therefore, improving physician recognition of depression and suicide risk evaluation is a component of suicide prevention.

Some studies in the United Kingdom,61 Australia,60 the United States,24 and Northern Ireland,49 showed that programs aimed at educating primary care physicians improved detection and increased treatment of depression, but that was not shown in other studies in the United States,62 Brazil,63 and the United Kingdom.30 Nurse case management, collaborative care, or quality improvement initiatives can further improve the recognition and management of depression27 and has application where education alone may be insufficient.

A controlled trial comparing a treatment algorithm plus depression care management with treatment as usual for late-life depression in primary care in the United States demonstrated greater improvement in patient suicidal ideation and a more favorable course of illness in the intervention group compared with the treatment-as-usual group.31 An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians resulted in a 50% decrease in suicide attempts in the intervention group that was not statistically different from the control group (18%) due to the low base rate.42 An Australian program that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people increased identification of suicidal patients by 130% (determined by the Depressive Symptom Inventory–Suicidality Subscale score), without changes in treatment or management strategies.64 Studies examining suicidal behavior in response to primary care physician education programs, mostly targeting depression recognition and treatment, in specific regions in Sweden,66,118 Hungary,47 Japan,65 and Slovenia48 have all reported increased prescription rate for antidepressants and often substantial declines in suicide rates and represent the most striking known example of a therapeutic intervention lowering suicide rates.

Gatekeepers. Suicide prevention includes a range of interventions focused on community or organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.5Gatekeepers include clergy, first responders, pharmacists, geriatric caregivers, personnel staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy changes to encourage help-seeking, availability of resources, and efforts to reduce stigma associated with help-seeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental health and suicide and facilitated access to mental health services.

To date, systematic evaluation of impact on suicidal behavior has largely been limited to multilevel programs conducted in institutional settings, such as the military where programs in the Norwegian Army67 and the US Air Force52 have reported success in lowering suicide rates.

Screening

Screening aims to identify at-risk individuals and direct them to treatment. The focus may be on suicidal behavior directly or risk factors, such as depression or substance abuse. Screening instruments for depression, suicidal ideation, or suicidal acts administered to high school students,119 juvenile offenders,120 and youth in general121 have reliability and validity in identifying individuals at increased risk for suicidal behavior and are reported to double the number of known at-risk individuals.122 There is no evidence that screening youth for suicide induces suicidal thinking or behavior.123 Acceptance of the need for treatment by identified at-risk youth and actual treatment implementation are understudied as potential barriers to the effectiveness of screening programs.

The US Preventive Services Task Force (USPSTF) review of studies of depression screening in adults in primary health care settings found a 10% to 47% increase in rates of detection and diagnosis of depression with the use of screening tools.24 The effect on treatment was mixed, due to differences in study methodology. In contrast, a Canadian review of depression screening studies did not find routine screening in primary care to improve depression care.25 Neither report commented on effects on suicidal behavior. In contrast, screening in localized geographic areas results in more treatment of depression and lower suicide rates.50,51,66 The 2004 USPSTF26 review of evidence on screening for suicide risk, as opposed to depression, found no published studies in English evaluating the effectiveness of screening for suicide risk in primary care.

Treatment Interventions

Pharmacotherapy. Psychiatric disorders are present in at least 90% of suicides and more than 80% are untreated at time of death.124,125 Depression is untreated or undertreated in general,116,126 even after suicide attempt.127 Thus, treating mood and other psychiatric disorders is a central component of suicide prevention.5

Antidepressant medications alleviate depression and other psychiatric disorders.128 However meta-analyses of RCTs have generally not detected benefit for suicide or suicide attempts in studies of antidepressants in mood and other psychiatric disorders,19- 21 perhaps due to the low base rate of suicidal behavior and insufficient systematic screening for suicidal behavior since reliance on spontaneous reporting underestimates rates of suicidal behavior.129 Randomized controlled trials can be informative when higher-risk patients are studied and indicate an antisuicidal effect for lithium in major mood disorders34 and clozapine in schizophrenia.32,33 Few studies prospectively identified suicidal behavior as an outcome measure and systematically assessed it throughout the RCT.

Higher prescription rates of antidepressants correlate with decreasing suicide rates in adults or youth in Hungary,47 Sweden,89 Australia,93 and the United States.91,92 Geographic regions or demographic groups with the highest selective serotonin reuptake inhibitor prescription rates have the lowest suicide rates in the United States91 and Australia.93 Although Iceland,94 Japan,95 and Italy96 do not show such correlations, potential reasons include lack of compliance; pre-existing low-suicide rate, resulting in a floor effect; and high rates of alcoholism that may elevate suicide rates or the effect may be confined to women because too few men seek and comply with treatment with antidepressants. Suicide rates in 27 countries fell most markedly in countries that had the greatest increase in selective serotonin reuptake inhibitor prescriptions.99 Patient population studies report lower suicide attempt rates in adults treated with antidepressant medication97 and in adolescents after 6 months of antidepressant treatment compared with less than two months of treatment.98 The risk of an ecological fallacy, that is, inferring causality from group correlations, prevents attributing decreases in suicide rates solely to antidepressant use. Nevertheless, there is a striking correlation and plausible mechanism linking antidepressant use to declining rates of untreated major depression and therefore suicide.

Concerns about higher rates of suicide-related adverse event reports in depressed children and adolescents taking selective serotonin reuptake inhibitors compared with placebo in RCTs have prompted regulatory bodies in the United States, the United Kingdom, and Europe to issue warnings urging clinicians to monitor suicide risk and adverse effects carefully when prescribing antidepressants to youth. Such concerns need to be weighed against the risk of untreated depression because suicide is the third leading cause of death in youth and more than 90% of suicides in depressed youth are untreated at the time of death.130

Psychotherapy. Promising results in reducing repetition of suicidal behavior and improving treatment adherence exist for cognitive therapy,35 problem-solving therapy,28 intensive care plus outreach,28 and interpersonal psychotherapy,36 compared with standard aftercare. Cognitive therapy halved the reattempt rate in suicide attempters compared with those receiving usual care.35 In borderline personality disorder, dialectical behavioral therapy28 and psychoanalytically oriented partial hospitalization37 improved treatment adherence and reduced suicidal behavior compared with standard after care. Intermediate outcomes such as hopelessness and depressive symptoms improve with problem solving therapy, and suicidal ideation is decreased with interpersonal psychotherapy, cognitive behavior therapy, and dialectical behavioral therapy.26

Follow-up Care After Suicide Attempts. Many psychiatric disorders, including depression, are chronic and recurrent131 and compliance with maintenance medication is often poor. Interventions for depression provided by primary care physicians are more effective when a case manager follows up with patients who miss appointments or need prescription renewals.132 Many depressed patients who survive a suicide attempt will make further suicide attempts,133 particularly in the period shortly following psychiatric hospitalization134,135 or during future major depressive episodes.136 Thus, improved acute, continuation, and maintenance care, including psychiatric hospitalization, where necessary, of those with recurrent or chronic psychiatric disorders,137- 139 particularly patients who attempt suicide with mood disorders, has potential for prevention. Reduction of the number of psychiatric inpatient beds in Norway as part of a program of deinstitutionalization of psychiatric inpatients resulted in an increased suicide rate in the year after discharge with a standardized mortality ratio of 133(95% confidence interval, 90.1-190.7) in men and 208.5 (95% confidence interval, 121.5-333.9) in women.140

The Norwegian multidisciplinary chain-of-care networks provide follow-up care after hospital care to those who attempt suicide. Regions with chain-of-care programs have lower treatment dropout rates and fewer repeat attempts.68 Intervention studies of those who attempt suicide to prevent future suicidal behavior have produced mixed results, including fewer suicides compared with a control group after regular mailings,38 and fewer suicide attempts after issuing an emergency contact green card41) or use of a suicide intervention counselor to coordinate assessment and long-term treatment.69 Other interventions for those who attempt suicide, including telephone follow-up, intensive psychosocial follow-up, and video education plus family therapy, resulted in no difference between standard aftercare and intervention groups in rate of reattempt or reemergent suicidal ideation.39,40,70

Means Restriction

Suicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in higher rates of death. Suicides by such methods have decreased after firearm control legislation,54,72- 75,100 restrictions on pesticides,76,77 detoxification of domestic gas,79- 81,101- 103 restrictions on the prescription and sale of barbiturates,82- 84,101,105- 107 changing the packaging of analgesics to blister packets,85 mandatory use of catalytic converters in motor vehicles,86- 88,108 construction of barriers at jumping sites,90 and the use of new lower toxicity antidepressants.91,109

Where the method is common, restriction of means has led to lower overall suicide rates: firearms in Canada78 and Washington, DC,54 barbiturate restriction in Australia,105 domestic gas detoxification in Switzerland80 and the United Kingdom,79 and vehicle emissions in England.87 Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republics110 and Iceland.111

Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom,81 in Germany,103 and in the United States104 and for banning the pesticide parathion in Finland.76 Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means. Gauging the extent to which declining overall suicide rates are directly attributable to restriction in access to particular means requires consideration of long-term trends and confounding factors such as increased antidepressant use.

Media

The media can help or hinder suicide prevention efforts by being an avenue for public education or by exacerbating suicide risk by glamorizing suicide or promoting it as a solution to life’s problems. The latter may encourage vulnerable individuals to attempt suicide or to be attracted to suicide hot spots portrayed in the media as discussed by Pirkis et al141,142 and Gould.143 Media blackouts on reporting suicide have coincided with decreases in suicide rates.53 A 1987 campaign to decrease media coverage of subway suicides in Austria cut subway suicides by 80%.71 The Internet is of increasing concern, particularly the effects of suicide chat rooms, the provision of instruction in methods for suicide, and the active solicitation of suicide-pact partners.

Educating journalists and establishing media guidelines for reporting suicide have had mixed results.144 The American Foundation for Suicide Prevention and Annenberg Public Policy Center,145 and The Centers for Disease Control and Prevention146 in the United States have produced guidelines for the responsible reporting of suicide; however, no published studies have evaluated their impact.

Conclusions and Future Directions
National suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. Table 3 summarizes estimates of impact of different interventions on national suicide rates showing that the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome, or there may be longer-term trends in suicide rates that are not captured by the studies.


http://jama.jamanetwork.com/article.aspx?articleid=201761

This is absolutely magnificent research LD, time consuming too.

Well done.

Baffled, he started looking for the specific ways in which studies were going wrong. And before long he discovered that the range of errors being committed was astonishing: from what questions researchers posed, to how they set up the studies, to which patients they recruited for the studies, to which measurements they took, to how they analyzed the data, to how they presented their results, to how particular studies came to be published in medical journals. [...]
“The studies were biased,” he says. “Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.” Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously.
“At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,” says Ioannidis. “There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded.”


http://psychcentral.com/blog/archives/2010/10/19/what-research-can-you-believe/

Phillipa wrote: billie joe jumped off the tallahassee bridge.

Phillipa wrote: billie joe jumped off the tallahassee bridge.

Tommy Monk wrote:Not bothered reading past first page of this thread.


Regards to op, people will just find another place or way to do themselves in so think money would be better spent on services and support to help the people before hand.

Tommy Monk wrote:Not bothered reading past first page of this thread.


Regards to op, people will just find another place or way to do themselves in so think money would be better spent on services and support to help the people before hand.

lovedust wrote:

Tommy Monk wrote:Not bothered reading past first page of this thread.


Regards to op, people will just find another place or way to do themselves in so think money would be better spent on services and support to help the people before hand.

In the thread is listed the expert opinion of

1) DR Mel Blaustein, Director of St Francis Hospital, San Francisco: "The most common myth to explode is that  people will just go elsewhere"
2) Eve Meyer, Executive Director of Suicide Prevention for San Francisco, advocate for the safety net
3) N. Kreitman, author of 'The Coal Gas Story', who after a 93 page study concluded there'd been a massive suicide rate drop following Britain' s change to safer domestic gas
4) R. Seidman, who followed up thwarted GG jumpers over 34 years and found the overwhelming majority (94%) alive decades later on average
5) "Suicide Prevention Studies", Journal of the American Medical  Association, (Oct. 2005) - found restriction of access to lethal means to be one of the most successful suicide prevention measures.

lovedust wrote:Here is the report of the Salzburg 2004 consultation between Suicide Prevention Experts from 15 different countries. It was published in the Journal of the American Medical Association in 2005.

Suicide Prevention Strategies: A Systematic Review

J. John Mann, MD; Alan Apter, MD; Jose Bertolote, MD; Annette Beautrais, PhD; Dianne Currier, PhD; Ann Haas, PhD; Ulrich Hegerl, MD; Jouko Lonnqvist, MD; Kevin Malone, MD; Andrej Marusic, MD, PhD; Lars Mehlum, MD; George Patton, MD; Michael Phillips, MD; Wolfgang Rutz, MD; Zoltan Rihmer, MD, PhD, DSc; Armin Schmidtke, MD, PhD; David Shaffer, MD; Morton Silverman, MD; Yoshitomo Takahashi, MD; Airi Varnik, MD; Danuta Wasserman, MD; Paul Yip, PhD; Herbert Hendin, MD

Author Affiliations: New York State Psychiatric Institute, Division of Neuroscience (Drs Mann and Currier) and Division of Child psychiatry (Dr Schaffer), Department of Psychiatry, Columbia University, New York; Department of Psychiatry, Schneiders Childrens Medical Center of Israel (Dr Apter); Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland (Dr Bertolote); Canterbury Suicide Project, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand (Dr Beautrais); American Foundation for Suicide Prevention, New York, NY (Drs Haas and Hendin); Department of Psychiatry, Ludwig-Maximilians-Universität, Munich, Germany (Dr Hegerl); Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland (Dr Lonnqvist); Department of Psychiatry & Mental Health Research, St Vincents University Hospital, Dublin, Ireland (Dr Malone); Institute of Public Health of the Republic of Slovenia, Ljubjana, Slovenia (Dr Marusic); Suicide Research and Prevention Unit, University of Oslo, Oslo, Norway (Dr Mehlum); Centre for Adolescent Health, University of Melbourne, Melbourne, Australia (Dr Patton); Beijing Suicide Research and Prevention Center, Beijing, China (Dr Phillips); Division of Psychiatry, Unit for Social Psychiatry and Health Promotion, Academic University Hospital, Uppsala, Sweden (Dr Rutz); National Institute for Psychiatry and Neurology, Budapest, Hungary (Dr Rihmer); Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany (Dr Schmidtke); National Suicide Prevention Technical Resource Center, Centers for Disease Prevention and Control, Newton, Mass (Dr Silverman); Division of Behavior Sciences, National Defense Medical College Research Institute, Tokyo, Japan (Dr Takahashi); Estonian-Swedish Suicidology Institute, Center Behavior and Health Science, Tallinn, Estonia (Dr Varnik); Department of Public Health Sciences at Karolinska Institute, Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health, Stockholm, Sweden (Dr Wasserman); and Hong Kong Jockey Club Center for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Dr Yip).

ABSTRACT.

Context In 2002, an estimated 877 000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.

Objectives To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.

Data Sources and Study Selection Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.

Data Extraction Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.

Data Synthesis Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.

Conclusions Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

Suicide is a significant public health issue. In 2002, an estimated 877 000 lives were lost worldwide through suicide, representing 1.5% of the global burden of disease or more than 20 million disability-adjusted life-years (years of healthy life lost through premature death or disability).1 The highest annual rates are in Eastern Europe, where 10 countries report more than 27 suicides per 100 000 persons. Latin American and Muslim countries report the lowest rates, fewer than 6.5 per 100 000.2 In the United States, in 2002, suicide accounted for 31 655 deaths, a rate of 11.0 per 100 000 per year,3 and general population surveys document a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,4 representing a huge human tragedy and an estimated $11.8 billion in lost income.5

Suicidal behavior has multiple causes that are broadly divided into proximal stressors or triggers and predisposition.6 Psychiatric illness is a major contributing factor, and more than 90% of suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric illness,7- 13 with some exceptions, such as in China.14Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.7,8,10,15,16 Other contributory factors include availability of lethal means, alcohol and drug abuse, access to psychiatric treatment, attitudes to suicide, help-seeking behavior, physical illness, marital status, age, and sex.6 To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The Figure illustrates the multiple factors involved in suicidal behavior6 and indicates where specific preventive interventions are being directed. Suicide prevention is possible because up to 83% of suicides have had contact with a primary care physician within a year of their death and up to 66% within a month.17,18 Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression. This review considers what is known about this and other prevention strategies to permit integration into a comprehensive prevention strategy.

Suicide experts from 15 countries met in Salzburg, Austria, in August 2004 to review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide.

DATA SOURCES.

An electronic literature search of all articles published between 1966 and June 2005 was conducted via MEDLINE, the Cochrane Library, and PsychINFO to identify reports evaluating suicide prevention interventions. An initial search used the MEDLINE identifier suicide (including the subheading suicide, attempted) and the subheading prevention and control, following that suicide was combined with the following identifiers: depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive agents, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media. We identified 5020 articles, which were not bound by the 5 major areas identified during the workshop. Abstracts were reviewed and full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors.

Study Selection

Studies were included if they reported on either the primary outcomes of interest, namely completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates.

We included 3 major types of studies for which the research question was clearly defined as assessment of efficacy or effectiveness of prevention programs in terms of the above primary or secondary outcomes; (1) systematic reviews and meta-analyses (n = 10) for which the search strategy was comprehensive and the methodological quality of primary studies was critically appraised; (2) quantitative studies, either randomized controlled trials (n = 18), or cohort studies (n = 24); and (3) ecological or population based studies (n = 41). Table 1 and Table 2 detail study type, study population, and preventive intervention tested and rate the studies according to the scheme proposed by the Oxford Centre for Evidence Based Medicine.112 Randomized controlled trials provide the most compelling evidence of efficacy while findings of naturalistic studies are largely correlational, indicating that their outcomes need further testing.


DATA SYNTHESIS.

Heterogeneity in study methodology and populations limited formal meta-analysis, thus we present a narrative synthesis of the results for the key domains of suicide prevention interventions.

Awareness and Education

General Public. Public education campaigns are aimed at improving recognition of suicide risk and help seeking through improved understanding of the causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious medical illness. Despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.

Studies in Germany,55 the United Kingdom,57 Australia,56 and New Zealand58 suggest modest effects of public education campaigns on attitudes regarding the causes and treatment of depression. Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.57,58,113 The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign.59 However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control region.55

Other specific education strategies are aimed at youth, including school and community-based programs.114,115 Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.114 A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support.22 A later review of studies published from 1990-2002 also found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for prevention of suicidal behavior.23 A subsequent controlled trial reported lower suicide attempt rates, greater knowledge, and more adaptive attitudes about depression and suicide in the intervention group compared with in the 3 months after the intervention, but no significant benefits for rates of suicide ideation or help-seeking.29 In adolescents, several studies found that improving problem solving, coping with stress, and increasing resilience enhance hypothesized protective factors but effects on suicidal behavior were unevaluated.43- 45

Primary Care Physicians. Depression and other psychiatric disorders are underrecognized and undertreated in the primary care setting.116,117 Prevention is possible because most suicides have had contact with a primary care physician within a month of death.17,18 Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides. Therefore, improving physician recognition of depression and suicide risk evaluation is a component of suicide prevention.

Some studies in the United Kingdom,61 Australia,60 the United States,24 and Northern Ireland,49 showed that programs aimed at educating primary care physicians improved detection and increased treatment of depression, but that was not shown in other studies in the United States,62 Brazil,63 and the United Kingdom.30 Nurse case management, collaborative care, or quality improvement initiatives can further improve the recognition and management of depression27 and has application where education alone may be insufficient.

A controlled trial comparing a treatment algorithm plus depression care management with treatment as usual for late-life depression in primary care in the United States demonstrated greater improvement in patient suicidal ideation and a more favorable course of illness in the intervention group compared with the treatment-as-usual group.31 An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians resulted in a 50% decrease in suicide attempts in the intervention group that was not statistically different from the control group (18%) due to the low base rate.42 An Australian program that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people increased identification of suicidal patients by 130% (determined by the Depressive Symptom Inventory–Suicidality Subscale score), without changes in treatment or management strategies.64 Studies examining suicidal behavior in response to primary care physician education programs, mostly targeting depression recognition and treatment, in specific regions in Sweden,66,118 Hungary,47 Japan,65 and Slovenia48 have all reported increased prescription rate for antidepressants and often substantial declines in suicide rates and represent the most striking known example of a therapeutic intervention lowering suicide rates.

Gatekeepers. Suicide prevention includes a range of interventions focused on community or organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.5Gatekeepers include clergy, first responders, pharmacists, geriatric caregivers, personnel staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy changes to encourage help-seeking, availability of resources, and efforts to reduce stigma associated with help-seeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental health and suicide and facilitated access to mental health services.

To date, systematic evaluation of impact on suicidal behavior has largely been limited to multilevel programs conducted in institutional settings, such as the military where programs in the Norwegian Army67 and the US Air Force52 have reported success in lowering suicide rates.

Screening

Screening aims to identify at-risk individuals and direct them to treatment. The focus may be on suicidal behavior directly or risk factors, such as depression or substance abuse. Screening instruments for depression, suicidal ideation, or suicidal acts administered to high school students,119 juvenile offenders,120 and youth in general121 have reliability and validity in identifying individuals at increased risk for suicidal behavior and are reported to double the number of known at-risk individuals.122 There is no evidence that screening youth for suicide induces suicidal thinking or behavior.123 Acceptance of the need for treatment by identified at-risk youth and actual treatment implementation are understudied as potential barriers to the effectiveness of screening programs.

The US Preventive Services Task Force (USPSTF) review of studies of depression screening in adults in primary health care settings found a 10% to 47% increase in rates of detection and diagnosis of depression with the use of screening tools.24 The effect on treatment was mixed, due to differences in study methodology. In contrast, a Canadian review of depression screening studies did not find routine screening in primary care to improve depression care.25 Neither report commented on effects on suicidal behavior. In contrast, screening in localized geographic areas results in more treatment of depression and lower suicide rates.50,51,66 The 2004 USPSTF26 review of evidence on screening for suicide risk, as opposed to depression, found no published studies in English evaluating the effectiveness of screening for suicide risk in primary care.

Treatment Interventions

Pharmacotherapy. Psychiatric disorders are present in at least 90% of suicides and more than 80% are untreated at time of death.124,125 Depression is untreated or undertreated in general,116,126 even after suicide attempt.127 Thus, treating mood and other psychiatric disorders is a central component of suicide prevention.5

Antidepressant medications alleviate depression and other psychiatric disorders.128 However meta-analyses of RCTs have generally not detected benefit for suicide or suicide attempts in studies of antidepressants in mood and other psychiatric disorders,19- 21 perhaps due to the low base rate of suicidal behavior and insufficient systematic screening for suicidal behavior since reliance on spontaneous reporting underestimates rates of suicidal behavior.129 Randomized controlled trials can be informative when higher-risk patients are studied and indicate an antisuicidal effect for lithium in major mood disorders34 and clozapine in schizophrenia.32,33 Few studies prospectively identified suicidal behavior as an outcome measure and systematically assessed it throughout the RCT.

Higher prescription rates of antidepressants correlate with decreasing suicide rates in adults or youth in Hungary,47 Sweden,89 Australia,93 and the United States.91,92 Geographic regions or demographic groups with the highest selective serotonin reuptake inhibitor prescription rates have the lowest suicide rates in the United States91 and Australia.93 Although Iceland,94 Japan,95 and Italy96 do not show such correlations, potential reasons include lack of compliance; pre-existing low-suicide rate, resulting in a floor effect; and high rates of alcoholism that may elevate suicide rates or the effect may be confined to women because too few men seek and comply with treatment with antidepressants. Suicide rates in 27 countries fell most markedly in countries that had the greatest increase in selective serotonin reuptake inhibitor prescriptions.99 Patient population studies report lower suicide attempt rates in adults treated with antidepressant medication97 and in adolescents after 6 months of antidepressant treatment compared with less than two months of treatment.98 The risk of an ecological fallacy, that is, inferring causality from group correlations, prevents attributing decreases in suicide rates solely to antidepressant use. Nevertheless, there is a striking correlation and plausible mechanism linking antidepressant use to declining rates of untreated major depression and therefore suicide.

Concerns about higher rates of suicide-related adverse event reports in depressed children and adolescents taking selective serotonin reuptake inhibitors compared with placebo in RCTs have prompted regulatory bodies in the United States, the United Kingdom, and Europe to issue warnings urging clinicians to monitor suicide risk and adverse effects carefully when prescribing antidepressants to youth. Such concerns need to be weighed against the risk of untreated depression because suicide is the third leading cause of death in youth and more than 90% of suicides in depressed youth are untreated at the time of death.130

Psychotherapy. Promising results in reducing repetition of suicidal behavior and improving treatment adherence exist for cognitive therapy,35 problem-solving therapy,28 intensive care plus outreach,28 and interpersonal psychotherapy,36 compared with standard aftercare. Cognitive therapy halved the reattempt rate in suicide attempters compared with those receiving usual care.35 In borderline personality disorder, dialectical behavioral therapy28 and psychoanalytically oriented partial hospitalization37 improved treatment adherence and reduced suicidal behavior compared with standard after care. Intermediate outcomes such as hopelessness and depressive symptoms improve with problem solving therapy, and suicidal ideation is decreased with interpersonal psychotherapy, cognitive behavior therapy, and dialectical behavioral therapy.26

Follow-up Care After Suicide Attempts. Many psychiatric disorders, including depression, are chronic and recurrent131 and compliance with maintenance medication is often poor. Interventions for depression provided by primary care physicians are more effective when a case manager follows up with patients who miss appointments or need prescription renewals.132 Many depressed patients who survive a suicide attempt will make further suicide attempts,133 particularly in the period shortly following psychiatric hospitalization134,135 or during future major depressive episodes.136 Thus, improved acute, continuation, and maintenance care, including psychiatric hospitalization, where necessary, of those with recurrent or chronic psychiatric disorders,137- 139 particularly patients who attempt suicide with mood disorders, has potential for prevention. Reduction of the number of psychiatric inpatient beds in Norway as part of a program of deinstitutionalization of psychiatric inpatients resulted in an increased suicide rate in the year after discharge with a standardized mortality ratio of 133(95% confidence interval, 90.1-190.7) in men and 208.5 (95% confidence interval, 121.5-333.9) in women.140

The Norwegian multidisciplinary chain-of-care networks provide follow-up care after hospital care to those who attempt suicide. Regions with chain-of-care programs have lower treatment dropout rates and fewer repeat attempts.68 Intervention studies of those who attempt suicide to prevent future suicidal behavior have produced mixed results, including fewer suicides compared with a control group after regular mailings,38 and fewer suicide attempts after issuing an emergency contact green card41) or use of a suicide intervention counselor to coordinate assessment and long-term treatment.69 Other interventions for those who attempt suicide, including telephone follow-up, intensive psychosocial follow-up, and video education plus family therapy, resulted in no difference between standard aftercare and intervention groups in rate of reattempt or reemergent suicidal ideation.39,40,70

Means Restriction

Suicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in higher rates of death. Suicides by such methods have decreased after firearm control legislation,54,72- 75,100 restrictions on pesticides,76,77 detoxification of domestic gas,79- 81,101- 103 restrictions on the prescription and sale of barbiturates,82- 84,101,105- 107 changing the packaging of analgesics to blister packets,85 mandatory use of catalytic converters in motor vehicles,86- 88,108 construction of barriers at jumping sites,90 and the use of new lower toxicity antidepressants.91,109

Where the method is common, restriction of means has led to lower overall suicide rates: firearms in Canada78 and Washington, DC,54 barbiturate restriction in Australia,105 domestic gas detoxification in Switzerland80 and the United Kingdom,79 and vehicle emissions in England.87 Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republics110 and Iceland.111

Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom,81 in Germany,103 and in the United States104 and for banning the pesticide parathion in Finland.76 Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means. Gauging the extent to which declining overall suicide rates are directly attributable to restriction in access to particular means requires consideration of long-term trends and confounding factors such as increased antidepressant use.

Media

The media can help or hinder suicide prevention efforts by being an avenue for public education or by exacerbating suicide risk by glamorizing suicide or promoting it as a solution to life’s problems. The latter may encourage vulnerable individuals to attempt suicide or to be attracted to suicide hot spots portrayed in the media as discussed by Pirkis et al141,142 and Gould.143 Media blackouts on reporting suicide have coincided with decreases in suicide rates.53 A 1987 campaign to decrease media coverage of subway suicides in Austria cut subway suicides by 80%.71 The Internet is of increasing concern, particularly the effects of suicide chat rooms, the provision of instruction in methods for suicide, and the active solicitation of suicide-pact partners.

Educating journalists and establishing media guidelines for reporting suicide have had mixed results.144 The American Foundation for Suicide Prevention and Annenberg Public Policy Center,145 and The Centers for Disease Control and Prevention146 in the United States have produced guidelines for the responsible reporting of suicide; however, no published studies have evaluated their impact.

Conclusions and Future Directions
National suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. Table 3 summarizes estimates of impact of different interventions on national suicide rates showing that the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome, or there may be longer-term trends in suicide rates that are not captured by the studies.


http://jama.jamanetwork.com/article.aspx?articleid=201761

Didge wrote:There’s a fascinating article in the Nov. 2010 issue of The Atlantic by David H. Freedman that examines the world of medical research and that suggests much of our empirical, research-based knowledge may be flawed.
Anyone who reads World of Psychologyregularly already knows about the problems in a lot of industry-funded studies. But this article suggests that the problems with peer-reviewed research go far deeper than simple for-profit bias. Scientists are biased in many, many ways (not just for monetary gain). And this bias inevitably shows up in the work they perform — scientific research.
This is not a new drum to beat for me — I’ve talked aboutresearcher bias in 2007 and how researchers design studies to find specific results (this example involved researchers who found suicidal method websites when searching for — wait for it — “suicide methods” in Google). We’ve noted how virtually every study in journals such as Psychological Science rely almost exclusively on college students collected from a single campus as subjects — a significant limitation rarely mentioned in the studies themselves.

However, here’s the real troubling aspect — these kinds of biased studies appear in all sorts of journals. JAMA, NEJM and the BMJ are not immune from publishing crappy, flawed studies in medicine and psychology. We think of “respectability” of a journal as some sort of sign of a gatekeeping role — that studies appearing in the most prestigious journals must be fundamentally sound.
But that’s simply not true. The emperor is not only naked — his subjects have hidden his clothes in order to further their own careers.

The issue of biased studies being published first hit the spotlight back in 2004, when GlaxoSmithKline was sued by state attorney generals for hiding research data on Paxil. Since that time, dozens of studies have come to light and other studies have since been published showing how pharmaceutical companies appear to have regularly hid relevant research data. This data usually shows that the drug being studied was not effective, when compared to a sugar pill, in treating whatever disorder it was intended for. (Blogs likeClinical Psychology and Psychiatry: A Closer Look and the Carlat Psychiatry Blog have more details about these studies.)
But what about other kinds of bias? Are we only interested in studies where the bias is so overt, or shouldn’t we be concerned about any kind of bias that may impact the reliability of the results?
The answer is, of course, we should be interested in all forms of bias. Anything that can influence the end results of a study mean that the study’s conclusions may be in question.
John Ioannidis, a professor at the University of Ioannina, became interested in this question in medical research. So he put together an expert team of researchers and statisticians to dig deeper and see how bad the problem was. What he found didn’t surprise researchers, but will come as a surprise to most laypeople –

Baffled, he started looking for the specific ways in which studies were going wrong. And before long he discovered that the range of errors being committed was astonishing: from what questions researchers posed, to how they set up the studies, to which patients they recruited for the studies, to which measurements they took, to how they analyzed the data, to how they presented their results, to how particular studies came to be published in medical journals. [...]
“The studies were biased,” he says. “Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.” Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously.
“At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,” says Ioannidis. “There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded.”


http://psychcentral.com/blog/archives/2010/10/19/what-research-can-you-believe/

Sassy wrote:

lovedust wrote:Here is the report of the Salzburg 2004 consultation between Suicide Prevention Experts from 15 different countries. It was published in the Journal of the American Medical Association in 2005.

Suicide Prevention Strategies: A Systematic Review

J. John Mann, MD; Alan Apter, MD; Jose Bertolote, MD; Annette Beautrais, PhD; Dianne Currier, PhD; Ann Haas, PhD; Ulrich Hegerl, MD; Jouko Lonnqvist, MD; Kevin Malone, MD; Andrej Marusic, MD, PhD; Lars Mehlum, MD; George Patton, MD; Michael Phillips, MD; Wolfgang Rutz, MD; Zoltan Rihmer, MD, PhD, DSc; Armin Schmidtke, MD, PhD; David Shaffer, MD; Morton Silverman, MD; Yoshitomo Takahashi, MD; Airi Varnik, MD; Danuta Wasserman, MD; Paul Yip, PhD; Herbert Hendin, MD

Author Affiliations: New York State Psychiatric Institute, Division of Neuroscience (Drs Mann and Currier) and Division of Child psychiatry (Dr Schaffer), Department of Psychiatry, Columbia University, New York; Department of Psychiatry, Schneiders Childrens Medical Center of Israel (Dr Apter); Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland (Dr Bertolote); Canterbury Suicide Project, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand (Dr Beautrais); American Foundation for Suicide Prevention, New York, NY (Drs Haas and Hendin); Department of Psychiatry, Ludwig-Maximilians-Universität, Munich, Germany (Dr Hegerl); Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland (Dr Lonnqvist); Department of Psychiatry & Mental Health Research, St Vincents University Hospital, Dublin, Ireland (Dr Malone); Institute of Public Health of the Republic of Slovenia, Ljubjana, Slovenia (Dr Marusic); Suicide Research and Prevention Unit, University of Oslo, Oslo, Norway (Dr Mehlum); Centre for Adolescent Health, University of Melbourne, Melbourne, Australia (Dr Patton); Beijing Suicide Research and Prevention Center, Beijing, China (Dr Phillips); Division of Psychiatry, Unit for Social Psychiatry and Health Promotion, Academic University Hospital, Uppsala, Sweden (Dr Rutz); National Institute for Psychiatry and Neurology, Budapest, Hungary (Dr Rihmer); Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany (Dr Schmidtke); National Suicide Prevention Technical Resource Center, Centers for Disease Prevention and Control, Newton, Mass (Dr Silverman); Division of Behavior Sciences, National Defense Medical College Research Institute, Tokyo, Japan (Dr Takahashi); Estonian-Swedish Suicidology Institute, Center Behavior and Health Science, Tallinn, Estonia (Dr Varnik); Department of Public Health Sciences at Karolinska Institute, Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health, Stockholm, Sweden (Dr Wasserman); and Hong Kong Jockey Club Center for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Dr Yip).

ABSTRACT.

Context In 2002, an estimated 877 000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.

Objectives To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.

Data Sources and Study Selection Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.

Data Extraction Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.

Data Synthesis Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.

Conclusions Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

Suicide is a significant public health issue. In 2002, an estimated 877 000 lives were lost worldwide through suicide, representing 1.5% of the global burden of disease or more than 20 million disability-adjusted life-years (years of healthy life lost through premature death or disability).1 The highest annual rates are in Eastern Europe, where 10 countries report more than 27 suicides per 100 000 persons. Latin American and Muslim countries report the lowest rates, fewer than 6.5 per 100 000.2 In the United States, in 2002, suicide accounted for 31 655 deaths, a rate of 11.0 per 100 000 per year,3 and general population surveys document a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,4 representing a huge human tragedy and an estimated $11.8 billion in lost income.5

Suicidal behavior has multiple causes that are broadly divided into proximal stressors or triggers and predisposition.6 Psychiatric illness is a major contributing factor, and more than 90% of suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric illness,7- 13 with some exceptions, such as in China.14Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.7,8,10,15,16 Other contributory factors include availability of lethal means, alcohol and drug abuse, access to psychiatric treatment, attitudes to suicide, help-seeking behavior, physical illness, marital status, age, and sex.6 To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The Figure illustrates the multiple factors involved in suicidal behavior6 and indicates where specific preventive interventions are being directed. Suicide prevention is possible because up to 83% of suicides have had contact with a primary care physician within a year of their death and up to 66% within a month.17,18 Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression. This review considers what is known about this and other prevention strategies to permit integration into a comprehensive prevention strategy.

Suicide experts from 15 countries met in Salzburg, Austria, in August 2004 to review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide.

DATA SOURCES.

An electronic literature search of all articles published between 1966 and June 2005 was conducted via MEDLINE, the Cochrane Library, and PsychINFO to identify reports evaluating suicide prevention interventions. An initial search used the MEDLINE identifier suicide (including the subheading suicide, attempted) and the subheading prevention and control, following that suicide was combined with the following identifiers: depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive agents, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media. We identified 5020 articles, which were not bound by the 5 major areas identified during the workshop. Abstracts were reviewed and full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors.

Study Selection

Studies were included if they reported on either the primary outcomes of interest, namely completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates.

We included 3 major types of studies for which the research question was clearly defined as assessment of efficacy or effectiveness of prevention programs in terms of the above primary or secondary outcomes; (1) systematic reviews and meta-analyses (n = 10) for which the search strategy was comprehensive and the methodological quality of primary studies was critically appraised; (2) quantitative studies, either randomized controlled trials (n = 18), or cohort studies (n = 24); and (3) ecological or population based studies (n = 41). Table 1 and Table 2 detail study type, study population, and preventive intervention tested and rate the studies according to the scheme proposed by the Oxford Centre for Evidence Based Medicine.112 Randomized controlled trials provide the most compelling evidence of efficacy while findings of naturalistic studies are largely correlational, indicating that their outcomes need further testing.


DATA SYNTHESIS.

Heterogeneity in study methodology and populations limited formal meta-analysis, thus we present a narrative synthesis of the results for the key domains of suicide prevention interventions.

Awareness and Education

General Public. Public education campaigns are aimed at improving recognition of suicide risk and help seeking through improved understanding of the causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious medical illness. Despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.

Studies in Germany,55 the United Kingdom,57 Australia,56 and New Zealand58 suggest modest effects of public education campaigns on attitudes regarding the causes and treatment of depression. Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.57,58,113 The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign.59 However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control region.55

Other specific education strategies are aimed at youth, including school and community-based programs.114,115 Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.114 A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support.22 A later review of studies published from 1990-2002 also found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for prevention of suicidal behavior.23 A subsequent controlled trial reported lower suicide attempt rates, greater knowledge, and more adaptive attitudes about depression and suicide in the intervention group compared with in the 3 months after the intervention, but no significant benefits for rates of suicide ideation or help-seeking.29 In adolescents, several studies found that improving problem solving, coping with stress, and increasing resilience enhance hypothesized protective factors but effects on suicidal behavior were unevaluated.43- 45

Primary Care Physicians. Depression and other psychiatric disorders are underrecognized and undertreated in the primary care setting.116,117 Prevention is possible because most suicides have had contact with a primary care physician within a month of death.17,18 Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides. Therefore, improving physician recognition of depression and suicide risk evaluation is a component of suicide prevention.

Some studies in the United Kingdom,61 Australia,60 the United States,24 and Northern Ireland,49 showed that programs aimed at educating primary care physicians improved detection and increased treatment of depression, but that was not shown in other studies in the United States,62 Brazil,63 and the United Kingdom.30 Nurse case management, collaborative care, or quality improvement initiatives can further improve the recognition and management of depression27 and has application where education alone may be insufficient.

A controlled trial comparing a treatment algorithm plus depression care management with treatment as usual for late-life depression in primary care in the United States demonstrated greater improvement in patient suicidal ideation and a more favorable course of illness in the intervention group compared with the treatment-as-usual group.31 An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians resulted in a 50% decrease in suicide attempts in the intervention group that was not statistically different from the control group (18%) due to the low base rate.42 An Australian program that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people increased identification of suicidal patients by 130% (determined by the Depressive Symptom Inventory–Suicidality Subscale score), without changes in treatment or management strategies.64 Studies examining suicidal behavior in response to primary care physician education programs, mostly targeting depression recognition and treatment, in specific regions in Sweden,66,118 Hungary,47 Japan,65 and Slovenia48 have all reported increased prescription rate for antidepressants and often substantial declines in suicide rates and represent the most striking known example of a therapeutic intervention lowering suicide rates.

Gatekeepers. Suicide prevention includes a range of interventions focused on community or organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.5Gatekeepers include clergy, first responders, pharmacists, geriatric caregivers, personnel staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy changes to encourage help-seeking, availability of resources, and efforts to reduce stigma associated with help-seeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental health and suicide and facilitated access to mental health services.

To date, systematic evaluation of impact on suicidal behavior has largely been limited to multilevel programs conducted in institutional settings, such as the military where programs in the Norwegian Army67 and the US Air Force52 have reported success in lowering suicide rates.

Screening

Screening aims to identify at-risk individuals and direct them to treatment. The focus may be on suicidal behavior directly or risk factors, such as depression or substance abuse. Screening instruments for depression, suicidal ideation, or suicidal acts administered to high school students,119 juvenile offenders,120 and youth in general121 have reliability and validity in identifying individuals at increased risk for suicidal behavior and are reported to double the number of known at-risk individuals.122 There is no evidence that screening youth for suicide induces suicidal thinking or behavior.123 Acceptance of the need for treatment by identified at-risk youth and actual treatment implementation are understudied as potential barriers to the effectiveness of screening programs.

The US Preventive Services Task Force (USPSTF) review of studies of depression screening in adults in primary health care settings found a 10% to 47% increase in rates of detection and diagnosis of depression with the use of screening tools.24 The effect on treatment was mixed, due to differences in study methodology. In contrast, a Canadian review of depression screening studies did not find routine screening in primary care to improve depression care.25 Neither report commented on effects on suicidal behavior. In contrast, screening in localized geographic areas results in more treatment of depression and lower suicide rates.50,51,66 The 2004 USPSTF26 review of evidence on screening for suicide risk, as opposed to depression, found no published studies in English evaluating the effectiveness of screening for suicide risk in primary care.

Treatment Interventions

Pharmacotherapy. Psychiatric disorders are present in at least 90% of suicides and more than 80% are untreated at time of death.124,125 Depression is untreated or undertreated in general,116,126 even after suicide attempt.127 Thus, treating mood and other psychiatric disorders is a central component of suicide prevention.5

Antidepressant medications alleviate depression and other psychiatric disorders.128 However meta-analyses of RCTs have generally not detected benefit for suicide or suicide attempts in studies of antidepressants in mood and other psychiatric disorders,19- 21 perhaps due to the low base rate of suicidal behavior and insufficient systematic screening for suicidal behavior since reliance on spontaneous reporting underestimates rates of suicidal behavior.129 Randomized controlled trials can be informative when higher-risk patients are studied and indicate an antisuicidal effect for lithium in major mood disorders34 and clozapine in schizophrenia.32,33 Few studies prospectively identified suicidal behavior as an outcome measure and systematically assessed it throughout the RCT.

Higher prescription rates of antidepressants correlate with decreasing suicide rates in adults or youth in Hungary,47 Sweden,89 Australia,93 and the United States.91,92 Geographic regions or demographic groups with the highest selective serotonin reuptake inhibitor prescription rates have the lowest suicide rates in the United States91 and Australia.93 Although Iceland,94 Japan,95 and Italy96 do not show such correlations, potential reasons include lack of compliance; pre-existing low-suicide rate, resulting in a floor effect; and high rates of alcoholism that may elevate suicide rates or the effect may be confined to women because too few men seek and comply with treatment with antidepressants. Suicide rates in 27 countries fell most markedly in countries that had the greatest increase in selective serotonin reuptake inhibitor prescriptions.99 Patient population studies report lower suicide attempt rates in adults treated with antidepressant medication97 and in adolescents after 6 months of antidepressant treatment compared with less than two months of treatment.98 The risk of an ecological fallacy, that is, inferring causality from group correlations, prevents attributing decreases in suicide rates solely to antidepressant use. Nevertheless, there is a striking correlation and plausible mechanism linking antidepressant use to declining rates of untreated major depression and therefore suicide.

Concerns about higher rates of suicide-related adverse event reports in depressed children and adolescents taking selective serotonin reuptake inhibitors compared with placebo in RCTs have prompted regulatory bodies in the United States, the United Kingdom, and Europe to issue warnings urging clinicians to monitor suicide risk and adverse effects carefully when prescribing antidepressants to youth. Such concerns need to be weighed against the risk of untreated depression because suicide is the third leading cause of death in youth and more than 90% of suicides in depressed youth are untreated at the time of death.130

Psychotherapy. Promising results in reducing repetition of suicidal behavior and improving treatment adherence exist for cognitive therapy,35 problem-solving therapy,28 intensive care plus outreach,28 and interpersonal psychotherapy,36 compared with standard aftercare. Cognitive therapy halved the reattempt rate in suicide attempters compared with those receiving usual care.35 In borderline personality disorder, dialectical behavioral therapy28 and psychoanalytically oriented partial hospitalization37 improved treatment adherence and reduced suicidal behavior compared with standard after care. Intermediate outcomes such as hopelessness and depressive symptoms improve with problem solving therapy, and suicidal ideation is decreased with interpersonal psychotherapy, cognitive behavior therapy, and dialectical behavioral therapy.26

Follow-up Care After Suicide Attempts. Many psychiatric disorders, including depression, are chronic and recurrent131 and compliance with maintenance medication is often poor. Interventions for depression provided by primary care physicians are more effective when a case manager follows up with patients who miss appointments or need prescription renewals.132 Many depressed patients who survive a suicide attempt will make further suicide attempts,133 particularly in the period shortly following psychiatric hospitalization134,135 or during future major depressive episodes.136 Thus, improved acute, continuation, and maintenance care, including psychiatric hospitalization, where necessary, of those with recurrent or chronic psychiatric disorders,137- 139 particularly patients who attempt suicide with mood disorders, has potential for prevention. Reduction of the number of psychiatric inpatient beds in Norway as part of a program of deinstitutionalization of psychiatric inpatients resulted in an increased suicide rate in the year after discharge with a standardized mortality ratio of 133(95% confidence interval, 90.1-190.7) in men and 208.5 (95% confidence interval, 121.5-333.9) in women.140

The Norwegian multidisciplinary chain-of-care networks provide follow-up care after hospital care to those who attempt suicide. Regions with chain-of-care programs have lower treatment dropout rates and fewer repeat attempts.68 Intervention studies of those who attempt suicide to prevent future suicidal behavior have produced mixed results, including fewer suicides compared with a control group after regular mailings,38 and fewer suicide attempts after issuing an emergency contact green card41) or use of a suicide intervention counselor to coordinate assessment and long-term treatment.69 Other interventions for those who attempt suicide, including telephone follow-up, intensive psychosocial follow-up, and video education plus family therapy, resulted in no difference between standard aftercare and intervention groups in rate of reattempt or reemergent suicidal ideation.39,40,70

Means Restriction

Suicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in higher rates of death. Suicides by such methods have decreased after firearm control legislation,54,72- 75,100 restrictions on pesticides,76,77 detoxification of domestic gas,79- 81,101- 103 restrictions on the prescription and sale of barbiturates,82- 84,101,105- 107 changing the packaging of analgesics to blister packets,85 mandatory use of catalytic converters in motor vehicles,86- 88,108 construction of barriers at jumping sites,90 and the use of new lower toxicity antidepressants.91,109

Where the method is common, restriction of means has led to lower overall suicide rates: firearms in Canada78 and Washington, DC,54 barbiturate restriction in Australia,105 domestic gas detoxification in Switzerland80 and the United Kingdom,79 and vehicle emissions in England.87 Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republics110 and Iceland.111

Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom,81 in Germany,103 and in the United States104 and for banning the pesticide parathion in Finland.76 Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means. Gauging the extent to which declining overall suicide rates are directly attributable to restriction in access to particular means requires consideration of long-term trends and confounding factors such as increased antidepressant use.

Media

The media can help or hinder suicide prevention efforts by being an avenue for public education or by exacerbating suicide risk by glamorizing suicide or promoting it as a solution to life’s problems. The latter may encourage vulnerable individuals to attempt suicide or to be attracted to suicide hot spots portrayed in the media as discussed by Pirkis et al141,142 and Gould.143 Media blackouts on reporting suicide have coincided with decreases in suicide rates.53 A 1987 campaign to decrease media coverage of subway suicides in Austria cut subway suicides by 80%.71 The Internet is of increasing concern, particularly the effects of suicide chat rooms, the provision of instruction in methods for suicide, and the active solicitation of suicide-pact partners.

Educating journalists and establishing media guidelines for reporting suicide have had mixed results.144 The American Foundation for Suicide Prevention and Annenberg Public Policy Center,145 and The Centers for Disease Control and Prevention146 in the United States have produced guidelines for the responsible reporting of suicide; however, no published studies have evaluated their impact.

Conclusions and Future Directions
National suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. Table 3 summarizes estimates of impact of different interventions on national suicide rates showing that the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome, or there may be longer-term trends in suicide rates that are not captured by the studies.


http://jama.jamanetwork.com/article.aspx?articleid=201761

People who want to ignore this only deserve emoticons as an answer as they are clearly dense and as thick as pig shit.  ::D:: 

Sassy wrote:

lovedust wrote:Here is the report of the Salzburg 2004 consultation between Suicide Prevention Experts from 15 different countries. It was published in the Journal of the American Medical Association in 2005.

Suicide Prevention Strategies: A Systematic Review

J. John Mann, MD; Alan Apter, MD; Jose Bertolote, MD; Annette Beautrais, PhD; Dianne Currier, PhD; Ann Haas, PhD; Ulrich Hegerl, MD; Jouko Lonnqvist, MD; Kevin Malone, MD; Andrej Marusic, MD, PhD; Lars Mehlum, MD; George Patton, MD; Michael Phillips, MD; Wolfgang Rutz, MD; Zoltan Rihmer, MD, PhD, DSc; Armin Schmidtke, MD, PhD; David Shaffer, MD; Morton Silverman, MD; Yoshitomo Takahashi, MD; Airi Varnik, MD; Danuta Wasserman, MD; Paul Yip, PhD; Herbert Hendin, MD

Author Affiliations: New York State Psychiatric Institute, Division of Neuroscience (Drs Mann and Currier) and Division of Child psychiatry (Dr Schaffer), Department of Psychiatry, Columbia University, New York; Department of Psychiatry, Schneiders Childrens Medical Center of Israel (Dr Apter); Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland (Dr Bertolote); Canterbury Suicide Project, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand (Dr Beautrais); American Foundation for Suicide Prevention, New York, NY (Drs Haas and Hendin); Department of Psychiatry, Ludwig-Maximilians-Universität, Munich, Germany (Dr Hegerl); Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland (Dr Lonnqvist); Department of Psychiatry & Mental Health Research, St Vincents University Hospital, Dublin, Ireland (Dr Malone); Institute of Public Health of the Republic of Slovenia, Ljubjana, Slovenia (Dr Marusic); Suicide Research and Prevention Unit, University of Oslo, Oslo, Norway (Dr Mehlum); Centre for Adolescent Health, University of Melbourne, Melbourne, Australia (Dr Patton); Beijing Suicide Research and Prevention Center, Beijing, China (Dr Phillips); Division of Psychiatry, Unit for Social Psychiatry and Health Promotion, Academic University Hospital, Uppsala, Sweden (Dr Rutz); National Institute for Psychiatry and Neurology, Budapest, Hungary (Dr Rihmer); Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany (Dr Schmidtke); National Suicide Prevention Technical Resource Center, Centers for Disease Prevention and Control, Newton, Mass (Dr Silverman); Division of Behavior Sciences, National Defense Medical College Research Institute, Tokyo, Japan (Dr Takahashi); Estonian-Swedish Suicidology Institute, Center Behavior and Health Science, Tallinn, Estonia (Dr Varnik); Department of Public Health Sciences at Karolinska Institute, Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health, Stockholm, Sweden (Dr Wasserman); and Hong Kong Jockey Club Center for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Dr Yip).

ABSTRACT.

Context In 2002, an estimated 877 000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.

Objectives To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.

Data Sources and Study Selection Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.

Data Extraction Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.

Data Synthesis Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.

Conclusions Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

Suicide is a significant public health issue. In 2002, an estimated 877 000 lives were lost worldwide through suicide, representing 1.5% of the global burden of disease or more than 20 million disability-adjusted life-years (years of healthy life lost through premature death or disability).1 The highest annual rates are in Eastern Europe, where 10 countries report more than 27 suicides per 100 000 persons. Latin American and Muslim countries report the lowest rates, fewer than 6.5 per 100 000.2 In the United States, in 2002, suicide accounted for 31 655 deaths, a rate of 11.0 per 100 000 per year,3 and general population surveys document a suicide attempt rate of 0.6% and a suicide ideation rate of 3.3%,4 representing a huge human tragedy and an estimated $11.8 billion in lost income.5

Suicidal behavior has multiple causes that are broadly divided into proximal stressors or triggers and predisposition.6 Psychiatric illness is a major contributing factor, and more than 90% of suicides have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric illness,7- 13 with some exceptions, such as in China.14Mood disorders, principally major depressive disorder and bipolar disorder, are associated with about 60% of suicides.7,8,10,15,16 Other contributory factors include availability of lethal means, alcohol and drug abuse, access to psychiatric treatment, attitudes to suicide, help-seeking behavior, physical illness, marital status, age, and sex.6 To address these causes, suicide prevention involves a multifaceted approach with particular attention to mental health. The Figure illustrates the multiple factors involved in suicidal behavior6 and indicates where specific preventive interventions are being directed. Suicide prevention is possible because up to 83% of suicides have had contact with a primary care physician within a year of their death and up to 66% within a month.17,18 Thus, a key prevention strategy is improved screening of depressed patients by primary care physicians and better treatment of major depression. This review considers what is known about this and other prevention strategies to permit integration into a comprehensive prevention strategy.

Suicide experts from 15 countries met in Salzburg, Austria, in August 2004 to review efficacy of suicide prevention interventions. The 5-day workshop identified 5 major areas of prevention: education and awareness programs for the general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide.

DATA SOURCES.

An electronic literature search of all articles published between 1966 and June 2005 was conducted via MEDLINE, the Cochrane Library, and PsychINFO to identify reports evaluating suicide prevention interventions. An initial search used the MEDLINE identifier suicide (including the subheading suicide, attempted) and the subheading prevention and control, following that suicide was combined with the following identifiers: depression, health education, health promotion, public opinion, mass screening, family physicians, medical education, primary health care, antidepressive agents, psychotherapy, schools, adolescents, methods, firearms, overdose, poisoning, gas poisoning, and mass media. We identified 5020 articles, which were not bound by the 5 major areas identified during the workshop. Abstracts were reviewed and full-text articles that met inclusion criteria were retrieved. All reports were reviewed by at least 2 authors.

Study Selection

Studies were included if they reported on either the primary outcomes of interest, namely completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates.

We included 3 major types of studies for which the research question was clearly defined as assessment of efficacy or effectiveness of prevention programs in terms of the above primary or secondary outcomes; (1) systematic reviews and meta-analyses (n = 10) for which the search strategy was comprehensive and the methodological quality of primary studies was critically appraised; (2) quantitative studies, either randomized controlled trials (n = 18), or cohort studies (n = 24); and (3) ecological or population based studies (n = 41). Table 1 and Table 2 detail study type, study population, and preventive intervention tested and rate the studies according to the scheme proposed by the Oxford Centre for Evidence Based Medicine.112 Randomized controlled trials provide the most compelling evidence of efficacy while findings of naturalistic studies are largely correlational, indicating that their outcomes need further testing.


DATA SYNTHESIS.

Heterogeneity in study methodology and populations limited formal meta-analysis, thus we present a narrative synthesis of the results for the key domains of suicide prevention interventions.

Awareness and Education

General Public. Public education campaigns are aimed at improving recognition of suicide risk and help seeking through improved understanding of the causes and risk factors for suicidal behavior, particularly mental illness. Public education also seeks to reduce stigmatization of mental illness and suicide and challenges the acceptance of suicide as inevitable, as a national character trait, or as an appropriate solution to life problems, including serious medical illness. Despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.

Studies in Germany,55 the United Kingdom,57 Australia,56 and New Zealand58 suggest modest effects of public education campaigns on attitudes regarding the causes and treatment of depression. Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.57,58,113 The German study showed an 18% decrease in suicide attempts in an intervention region after 9 months of a depression awareness campaign.59 However, the decline in suicide attempts occurred without a greater improvement in attitudes in the intervention region compared with the control region.55

Other specific education strategies are aimed at youth, including school and community-based programs.114,115 Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior.114 A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support.22 A later review of studies published from 1990-2002 also found that curriculum-based programs increase knowledge and improve attitudes to mental illness and suicide but found insufficient evidence for prevention of suicidal behavior.23 A subsequent controlled trial reported lower suicide attempt rates, greater knowledge, and more adaptive attitudes about depression and suicide in the intervention group compared with in the 3 months after the intervention, but no significant benefits for rates of suicide ideation or help-seeking.29 In adolescents, several studies found that improving problem solving, coping with stress, and increasing resilience enhance hypothesized protective factors but effects on suicidal behavior were unevaluated.43- 45

Primary Care Physicians. Depression and other psychiatric disorders are underrecognized and undertreated in the primary care setting.116,117 Prevention is possible because most suicides have had contact with a primary care physician within a month of death.17,18 Primary care physicians’ lack of knowledge about or failure to screen patients for depression may contribute to nontreatment seen in most suicides. Therefore, improving physician recognition of depression and suicide risk evaluation is a component of suicide prevention.

Some studies in the United Kingdom,61 Australia,60 the United States,24 and Northern Ireland,49 showed that programs aimed at educating primary care physicians improved detection and increased treatment of depression, but that was not shown in other studies in the United States,62 Brazil,63 and the United Kingdom.30 Nurse case management, collaborative care, or quality improvement initiatives can further improve the recognition and management of depression27 and has application where education alone may be insufficient.

A controlled trial comparing a treatment algorithm plus depression care management with treatment as usual for late-life depression in primary care in the United States demonstrated greater improvement in patient suicidal ideation and a more favorable course of illness in the intervention group compared with the treatment-as-usual group.31 An adolescent depression treatment quality improvement intervention with care managers supporting primary care physicians resulted in a 50% decrease in suicide attempts in the intervention group that was not statistically different from the control group (18%) due to the low base rate.42 An Australian program that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people increased identification of suicidal patients by 130% (determined by the Depressive Symptom Inventory–Suicidality Subscale score), without changes in treatment or management strategies.64 Studies examining suicidal behavior in response to primary care physician education programs, mostly targeting depression recognition and treatment, in specific regions in Sweden,66,118 Hungary,47 Japan,65 and Slovenia48 have all reported increased prescription rate for antidepressants and often substantial declines in suicide rates and represent the most striking known example of a therapeutic intervention lowering suicide rates.

Gatekeepers. Suicide prevention includes a range of interventions focused on community or organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment.5Gatekeepers include clergy, first responders, pharmacists, geriatric caregivers, personnel staff, and those employed in institutional settings, such as schools, prisons, and the military. Education covered awareness of risk factors, policy changes to encourage help-seeking, availability of resources, and efforts to reduce stigma associated with help-seeking. In addition to gatekeeper training, these programs also promoted organization-wide awareness of mental health and suicide and facilitated access to mental health services.

To date, systematic evaluation of impact on suicidal behavior has largely been limited to multilevel programs conducted in institutional settings, such as the military where programs in the Norwegian Army67 and the US Air Force52 have reported success in lowering suicide rates.

Screening

Screening aims to identify at-risk individuals and direct them to treatment. The focus may be on suicidal behavior directly or risk factors, such as depression or substance abuse. Screening instruments for depression, suicidal ideation, or suicidal acts administered to high school students,119 juvenile offenders,120 and youth in general121 have reliability and validity in identifying individuals at increased risk for suicidal behavior and are reported to double the number of known at-risk individuals.122 There is no evidence that screening youth for suicide induces suicidal thinking or behavior.123 Acceptance of the need for treatment by identified at-risk youth and actual treatment implementation are understudied as potential barriers to the effectiveness of screening programs.

The US Preventive Services Task Force (USPSTF) review of studies of depression screening in adults in primary health care settings found a 10% to 47% increase in rates of detection and diagnosis of depression with the use of screening tools.24 The effect on treatment was mixed, due to differences in study methodology. In contrast, a Canadian review of depression screening studies did not find routine screening in primary care to improve depression care.25 Neither report commented on effects on suicidal behavior. In contrast, screening in localized geographic areas results in more treatment of depression and lower suicide rates.50,51,66 The 2004 USPSTF26 review of evidence on screening for suicide risk, as opposed to depression, found no published studies in English evaluating the effectiveness of screening for suicide risk in primary care.

Treatment Interventions

Pharmacotherapy. Psychiatric disorders are present in at least 90% of suicides and more than 80% are untreated at time of death.124,125 Depression is untreated or undertreated in general,116,126 even after suicide attempt.127 Thus, treating mood and other psychiatric disorders is a central component of suicide prevention.5

Antidepressant medications alleviate depression and other psychiatric disorders.128 However meta-analyses of RCTs have generally not detected benefit for suicide or suicide attempts in studies of antidepressants in mood and other psychiatric disorders,19- 21 perhaps due to the low base rate of suicidal behavior and insufficient systematic screening for suicidal behavior since reliance on spontaneous reporting underestimates rates of suicidal behavior.129 Randomized controlled trials can be informative when higher-risk patients are studied and indicate an antisuicidal effect for lithium in major mood disorders34 and clozapine in schizophrenia.32,33 Few studies prospectively identified suicidal behavior as an outcome measure and systematically assessed it throughout the RCT.

Higher prescription rates of antidepressants correlate with decreasing suicide rates in adults or youth in Hungary,47 Sweden,89 Australia,93 and the United States.91,92 Geographic regions or demographic groups with the highest selective serotonin reuptake inhibitor prescription rates have the lowest suicide rates in the United States91 and Australia.93 Although Iceland,94 Japan,95 and Italy96 do not show such correlations, potential reasons include lack of compliance; pre-existing low-suicide rate, resulting in a floor effect; and high rates of alcoholism that may elevate suicide rates or the effect may be confined to women because too few men seek and comply with treatment with antidepressants. Suicide rates in 27 countries fell most markedly in countries that had the greatest increase in selective serotonin reuptake inhibitor prescriptions.99 Patient population studies report lower suicide attempt rates in adults treated with antidepressant medication97 and in adolescents after 6 months of antidepressant treatment compared with less than two months of treatment.98 The risk of an ecological fallacy, that is, inferring causality from group correlations, prevents attributing decreases in suicide rates solely to antidepressant use. Nevertheless, there is a striking correlation and plausible mechanism linking antidepressant use to declining rates of untreated major depression and therefore suicide.

Concerns about higher rates of suicide-related adverse event reports in depressed children and adolescents taking selective serotonin reuptake inhibitors compared with placebo in RCTs have prompted regulatory bodies in the United States, the United Kingdom, and Europe to issue warnings urging clinicians to monitor suicide risk and adverse effects carefully when prescribing antidepressants to youth. Such concerns need to be weighed against the risk of untreated depression because suicide is the third leading cause of death in youth and more than 90% of suicides in depressed youth are untreated at the time of death.130

Psychotherapy. Promising results in reducing repetition of suicidal behavior and improving treatment adherence exist for cognitive therapy,35 problem-solving therapy,28 intensive care plus outreach,28 and interpersonal psychotherapy,36 compared with standard aftercare. Cognitive therapy halved the reattempt rate in suicide attempters compared with those receiving usual care.35 In borderline personality disorder, dialectical behavioral therapy28 and psychoanalytically oriented partial hospitalization37 improved treatment adherence and reduced suicidal behavior compared with standard after care. Intermediate outcomes such as hopelessness and depressive symptoms improve with problem solving therapy, and suicidal ideation is decreased with interpersonal psychotherapy, cognitive behavior therapy, and dialectical behavioral therapy.26

Follow-up Care After Suicide Attempts. Many psychiatric disorders, including depression, are chronic and recurrent131 and compliance with maintenance medication is often poor. Interventions for depression provided by primary care physicians are more effective when a case manager follows up with patients who miss appointments or need prescription renewals.132 Many depressed patients who survive a suicide attempt will make further suicide attempts,133 particularly in the period shortly following psychiatric hospitalization134,135 or during future major depressive episodes.136 Thus, improved acute, continuation, and maintenance care, including psychiatric hospitalization, where necessary, of those with recurrent or chronic psychiatric disorders,137- 139 particularly patients who attempt suicide with mood disorders, has potential for prevention. Reduction of the number of psychiatric inpatient beds in Norway as part of a program of deinstitutionalization of psychiatric inpatients resulted in an increased suicide rate in the year after discharge with a standardized mortality ratio of 133(95% confidence interval, 90.1-190.7) in men and 208.5 (95% confidence interval, 121.5-333.9) in women.140

The Norwegian multidisciplinary chain-of-care networks provide follow-up care after hospital care to those who attempt suicide. Regions with chain-of-care programs have lower treatment dropout rates and fewer repeat attempts.68 Intervention studies of those who attempt suicide to prevent future suicidal behavior have produced mixed results, including fewer suicides compared with a control group after regular mailings,38 and fewer suicide attempts after issuing an emergency contact green card41) or use of a suicide intervention counselor to coordinate assessment and long-term treatment.69 Other interventions for those who attempt suicide, including telephone follow-up, intensive psychosocial follow-up, and video education plus family therapy, resulted in no difference between standard aftercare and intervention groups in rate of reattempt or reemergent suicidal ideation.39,40,70

Means Restriction

Suicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in higher rates of death. Suicides by such methods have decreased after firearm control legislation,54,72- 75,100 restrictions on pesticides,76,77 detoxification of domestic gas,79- 81,101- 103 restrictions on the prescription and sale of barbiturates,82- 84,101,105- 107 changing the packaging of analgesics to blister packets,85 mandatory use of catalytic converters in motor vehicles,86- 88,108 construction of barriers at jumping sites,90 and the use of new lower toxicity antidepressants.91,109

Where the method is common, restriction of means has led to lower overall suicide rates: firearms in Canada78 and Washington, DC,54 barbiturate restriction in Australia,105 domestic gas detoxification in Switzerland80 and the United Kingdom,79 and vehicle emissions in England.87 Restrictions on access to alcohol have coincided with decreases in overall suicide rates in the former Union of Soviet Socialists Republics110 and Iceland.111

Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom,81 in Germany,103 and in the United States104 and for banning the pesticide parathion in Finland.76 Despite unresolved questions about method substitution, these studies demonstrate the life-saving potential of restricting lethal means. Gauging the extent to which declining overall suicide rates are directly attributable to restriction in access to particular means requires consideration of long-term trends and confounding factors such as increased antidepressant use.

Media

The media can help or hinder suicide prevention efforts by being an avenue for public education or by exacerbating suicide risk by glamorizing suicide or promoting it as a solution to life’s problems. The latter may encourage vulnerable individuals to attempt suicide or to be attracted to suicide hot spots portrayed in the media as discussed by Pirkis et al141,142 and Gould.143 Media blackouts on reporting suicide have coincided with decreases in suicide rates.53 A 1987 campaign to decrease media coverage of subway suicides in Austria cut subway suicides by 80%.71 The Internet is of increasing concern, particularly the effects of suicide chat rooms, the provision of instruction in methods for suicide, and the active solicitation of suicide-pact partners.

Educating journalists and establishing media guidelines for reporting suicide have had mixed results.144 The American Foundation for Suicide Prevention and Annenberg Public Policy Center,145 and The Centers for Disease Control and Prevention146 in the United States have produced guidelines for the responsible reporting of suicide; however, no published studies have evaluated their impact.

Conclusions and Future Directions
National suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. Table 3 summarizes estimates of impact of different interventions on national suicide rates showing that the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome, or there may be longer-term trends in suicide rates that are not captured by the studies.


http://jama.jamanetwork.com/article.aspx?articleid=201761

People who want to ignore this only deserve emoticons as an answer as they are clearly dense and as thick as pig shit.  ::D:: 

Didge wrote:There’s a fascinating article in the Nov. 2010 issue of The Atlantic by David H. Freedman that examines the world of medical research and that suggests much of our empirical, research-based knowledge may be flawed.
Anyone who reads World of Psychologyregularly already knows about the problems in a lot of industry-funded studies. But this article suggests that the problems with peer-reviewed research go far deeper than simple for-profit bias. Scientists are biased in many, many ways (not just for monetary gain). And this bias inevitably shows up in the work they perform — scientific research.
This is not a new drum to beat for me — I’ve talked aboutresearcher bias in 2007 and how researchers design studies to find specific results (this example involved researchers who found suicidal method websites when searching for — wait for it — “suicide methods” in Google). We’ve noted how virtually every study in journals such as Psychological Science rely almost exclusively on college students collected from a single campus as subjects — a significant limitation rarely mentioned in the studies themselves.

However, here’s the real troubling aspect — these kinds of biased studies appear in all sorts of journals. JAMA, NEJM and the BMJ are not immune from publishing crappy, flawed studies in medicine and psychology. We think of “respectability” of a journal as some sort of sign of a gatekeeping role — that studies appearing in the most prestigious journals must be fundamentally sound.
But that’s simply not true. The emperor is not only naked — his subjects have hidden his clothes in order to further their own careers.

The issue of biased studies being published first hit the spotlight back in 2004, when GlaxoSmithKline was sued by state attorney generals for hiding research data on Paxil. Since that time, dozens of studies have come to light and other studies have since been published showing how pharmaceutical companies appear to have regularly hid relevant research data. This data usually shows that the drug being studied was not effective, when compared to a sugar pill, in treating whatever disorder it was intended for. (Blogs likeClinical Psychology and Psychiatry: A Closer Look and the Carlat Psychiatry Blog have more details about these studies.)
But what about other kinds of bias? Are we only interested in studies where the bias is so overt, or shouldn’t we be concerned about any kind of bias that may impact the reliability of the results?
The answer is, of course, we should be interested in all forms of bias. Anything that can influence the end results of a study mean that the study’s conclusions may be in question.
John Ioannidis, a professor at the University of Ioannina, became interested in this question in medical research. So he put together an expert team of researchers and statisticians to dig deeper and see how bad the problem was. What he found didn’t surprise researchers, but will come as a surprise to most laypeople –

Baffled, he started looking for the specific ways in which studies were going wrong. And before long he discovered that the range of errors being committed was astonishing: from what questions researchers posed, to how they set up the studies, to which patients they recruited for the studies, to which measurements they took, to how they analyzed the data, to how they presented their results, to how particular studies came to be published in medical journals. [...]
“The studies were biased,” he says. “Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.” Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously.
“At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,” says Ioannidis. “There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded.”


http://psychcentral.com/blog/archives/2010/10/19/what-research-can-you-believe/

Didge wrote:Simple Irn, they are pointing out flaws and not making recommendations themselves, it is a critical review just like this one:



Abstract
OBJECTIVE:
Risk of suicide attempt, suicidal ideation and deliberate self-harm is high among young people, yet limited evidence exists regarding effective interventions, particularly from randomized controlled trials. The aim of this study was to conduct a systematic review and meta-analysis of all randomized controlled trials testing interventions for adolescents and young adults who have presented to a clinical setting with any of these behaviours.

METHODS:
The Cochrane Central Register of Controlled Trials, Medline, EMBASE and PsycINFO were searched for articles published from 1980 to June 2010. The following keywords formed the basis of the search strategy: 'self-injurious behaviour', 'attempted suicide', 'suicide', 'suicidal behaviour', 'self-inflicted wounds', 'self-mutilation', 'self-harm'. We also hand searched conference abstracts from two major suicide prevention conferences and the reference lists of all retrieved articles and previous reviews.

RESULTS:
There were 15 trials included in the review, with six ongoing trials also identified. In general, the reporting of the conduct of trials was poor, making it difficult to assess the risk of bias. The reporting of outcome data was inconsistent. No differences were found between treatment and control groups except in one study that found a difference between individual cognitive behavioural therapy and treatment as usual.

CONCLUSION:
The evidence regarding effective interventions for adolescents and young adults with suicide attempt, deliberate self-harm or suicidal ideation is extremely limited. Many more methodologically rigorous trials are required. However, in the meantime CBT shows some promise, but further investigation is required in order to determine its ability to reduce suicide risk among young people presenting to clinical services.


http://www.ncbi.nlm.nih.gov/pubmed/21174502

Didge wrote:Qualifications?
So you need qualifications to recognise flaws in something, invent something or be a mathematical genius for example? If qualifications is all you have to go on, look up the people, it matters little if within the industry bias has been found and admitted by themselves also and also their own failings in reports

Behave, that is a poor counter to say the least.







I have pointed out the many flaws which many do not seem to have a response to  



Again these studies actively look with bias for a link.

They fail to prove the link is what they claim, they see a decrease in suicides then claim a connection whilst failing to explain when it rises again 

They fail to account for the levels of other factors like methods which thus does not show a correlation.

It does not take into account levels of the risk factor problems that can create people being vulnerable., when levels increase and decrease with suicides .

The point about the jumpers is very flawed, it was human intervention that helped these people an afterwards, no net is going to accomplish the same achievements as what the patrolman did, again showing the failings of such reports again, where they fail to understand this

Again many of these studies even admit bias and failings within their reports.

Didge wrote:The author of the article:


 JOHN M. GROHOL, PSY.D. 

Didge wrote:First of all that is complete rubbish when this is about problems with studies, you do not even have to be an expert in that field to show flaws and bias, so that really is poor Irn. You just need to understand methodology 

His name is on the article, look him up, not hard ist it?


John M. Grohol, Psy.D. is an expert in online psychology and behavior, researcher, author, and CEO & founder of the leading mental health and psychology network,Psych Central.com. Since receiving his doctorate in clinical psychology from Nova Southeastern University in 1995, Dr. Grohol has worked tirelessly as an online patient advocate and publisher of independent, objective mental health information designed to reduce the stigma associated with these concerns.

He founded Psych Central in 1995 as one of the first mental health and psychology sites that offered information about the symptoms and treatments of mental disorders, including interactive screening quizzes and self-help tools. It now is the home to over 170 support groups, over 200,000 members, and was recognized byTIME.com as one of the 50 Best Websites of 2008.

Dr. Grohol has also worked for a number of e-Health firms, including drkoop.com; the Internet's first online clinic, HelpHorizons.com; and Steve Case's Revolution Health, helping them with their own mental health centers and understanding the power of online self-help support groups.

As one of the pioneering leaders in psychology online, Dr. Grohol sits on the editorial board for the journal CyberPsychology, Social Networking & Behavior and is a founding member of the Society for Participatory Medicine. He is also the author ofThe Insider's Guide to Mental Health Resources Online (Guilford) and blogs regularly at e-Patients.net as well as on PsychCentral.com.
Show full bio

http://www.huffingtonpost.com/dr-john-grohol/



http://psychcentral.com/news/author/grohol


Not only that you are also failing to see the reports themselves own up to bias and flaws themselves, and I have pointed out more, so basically you are being pedantic on a non-entity


Right have to go.

Irn Bru wrote:

Didge wrote:The author of the article:


 JOHN M. GROHOL, PSY.D. 

You're right, Didge. You posted that in between my last post and I've read up on him now. His qualifications are impeccable and I should never have questioned his research.

He is actually an active campaigner and a supporter to have the suicide prevention system installed on the Golden Gate Bridge and has been calling for it for years and complaining about the delay in it happening.

You can read what he says here...

http://psychcentral.com/blog/archives/2006/10/22/should-bridges-be-suicideproof/

Game over.

Didge wrote:PMSL, so now because he campaigns for something does not mean the studies are not flawed as he points out, talk about desperate IRn, he use is on their flaws, not whether he supports a motion, man alive you clutch at straws, so you now do not dispute the studies are flawed.

Try again

Irn Bru wrote:

Didge wrote:PMSL, so now because he campaigns for something does not mean the studies are not flawed as he points out, talk about desperate IRn, he use is on their flaws, not whether he supports a motion, man alive you clutch at straws, so you now do not dispute the studies are flawed.

Try again

Well now that you have given me the information on his qualifications I'm not disputing his studies are flawed. In fact he is well qualified in his field and his views on the suicide barrier reflect that.

Night Didge.

Didge wrote:

Irn Bru wrote:

Didge wrote:PMSL, so now because he campaigns for something does not mean the studies are not flawed as he points out, talk about desperate IRn, he use is on their flaws, not whether he supports a motion, man alive you clutch at straws, so you now do not dispute the studies are flawed.

Try again

Well now that you have given me the information on his qualifications I'm not disputing his studies are flawed. In fact he is well qualified in his field and his views on the suicide barrier reflect that.

Night Didge.

Yes Irn he states they save lives which they do with accidents, he points out also such studies are flawed, so you need to make your mind up and not run away from these flaws, whether he agree with a project or not.

So if you do not dispute the flaws, my points still stand then which have not been countered

Thanks

Irn Bru wrote:

Didge wrote:


Yes Irn he states they save lives which they do with accidents, he points out also such studies are flawed, so you need to make your mind up and not run away from these flaws, whether he agree with a project or not.

So if you do not dispute the flaws, my points still stand then which have not been countered

Thanks

Didge, I doubt very much that he would doubt his own studies or his own views.

It's the end of the line for you and your arguments have well and truly hit the buffers.

Night Didge.

Didge wrote:

Irn Bru wrote:

Didge wrote:


Yes Irn he states they save lives which they do with accidents, he points out also such studies are flawed, so you need to make your mind up and not run away from these flaws, whether he agree with a project or not.

So if you do not dispute the flaws, my points still stand then which have not been countered

Thanks

Didge, I doubt very much that he would doubt his own studies or his own views.

It's the end of the line for you and your arguments have well and truly hit the buffers.

Night Didge.

No its you running away again, you stated there is flaws, I have pointed out flaws and questions on these flaws which you now want to duck out of answering, it shows your desperation.
So you are doing what you always do being a complete copout, that is the sassy gang for you!

Try again

Irn Bru wrote:

Didge wrote:


No its you running away again, you stated there is flaws, I have pointed out flaws and questions on these flaws which you now want to duck out of answering, it shows your desperation.
So you are doing what you always do being a complete copout, that is the sassy gang for you!

Try again

No Didge, you said goodnight about 10 minutes ago but you're still here but don't let me keep you out of your bed.

He said there are flaws and I accept that. And you were so keen to give me information about all his qualifications and that he is an expert in his field of work and I accept that as well just as I accept his qualifications to give his views that the suicide barrier on the Golden Gate Bridge is the right thing to do.

End of line for you Didge, I'm afraid. It's over, it's the end.