Primary prevention

Primary care physician training

  • People who die by suicide often see primary healthcare professionals within 1 month before death.[86] Effective early treatment of depression in primary care is associated with decreased suicide rates and a reduced incidence of self-harm episodes.​[87][88][89][90] Knowledge and confidence in assessing and managing individuals who may be at risk of suicide is variable among primary care providers.[91][92] One potential approach to suicide prevention is the training of general practitioners (primary care physicians) to recognise, treat, and, if necessary, refer patients with mental illness, especially depression.[93][94][95][96] Further training and delivery of appropriate resources may improve confidence and skills in suicide prevention. However, uncertainty remains about the effectiveness of suicide prevention strategies provided by general practitioners.[97][98]

Gatekeeper training

  • 'Gatekeepers’ are people in contact with people or populations at high risk of suicide and include clergy, first responders, pharmacists, geriatric carers, personnel staff, and people employed in school, military, and prison settings. Gatekeeper training to facilitate recognition of suicide risk, mental illness, or high levels of distress, and to improve links between the person in distress and mental health services, has been successful in improving knowledge, attitudes, and skills of trainees; programmes implemented in the Norwegian army and the US Air Force, as well as the Garrett Lee Smith Memorial Youth Suicide Prevention programme have been successful in lowering suicide rates.​[95][99][100][101][102]

School-based suicide-prevention programmes

  • Suicide awareness curricula are employed widely in schools in many countries despite little evidence to support their implementation.[81][103]​​[104][105][106][107][108] However, one large meta-analysis from 2016 concluded that school-based awareness programmes reduced suicide attempts (odds ratio [OR] 0.45, 95% CI 0.24 to 0.85; P=0.014) and suicidal ideation (OR 0.5, 95% CI 0.27 to 0.92; P=0.025).[108] One European school-based study also demonstrates promise, using a curriculum-based intervention linked to gatekeeper-type training with additional access to mental health care for those determined to be at risk.[109]

Community-based prevention programmes

  • Many community-based suicide-prevention programmes, such as those built on the ideology of enhancing protective factors or strengthening community cohesion, have not been shown to decrease suicide rates. Often, neither the potential risks (e.g., a rise in suicide after the implementation of a programme) nor the cost-effectiveness of these approaches has been evaluated adequately.[106][110] 

  • Media education to report suicide responsibly has been shown to reduce suicide rates in Austria, but study quality limited conclusions of a meta-analysis.[111][112] 

  • Although crisis hotlines are widely available, there is little evidence of their effectiveness in suicide prevention.​[103]​​[113]​

  • The benefits and risks of public service announcements regarding suicidal ideation, suicide attempt, or death by suicide are unclear.[114]

Restricting access to lethal methods of self-harm

  • Access to methods for self-harm is a modifiable risk factor. Constructing bridge safety barriers, detoxifying cooking gas and car exhausts, limiting access to paracetamol, restricting access to hazardous pesticides, and restricting firearms have all been cited as possible effective suicide-prevention strategies.​[81][103][115][116]

Secondary prevention

Evidence suggests a possible reduction in the number of suicide attempts for those receiving initial contact within 3 days of discharge, compared with those receiving initial contact within 7 days of discharge. Therefore try to arrange follow-up within 3 days of discharge, ideally face-to-face but if not, by telephone.[5]

In patients who have already attempted suicide, informed consent should be obtained from patients to allow clinicians and family members to contact each other if suicide risk is a concern. Family members should be asked to contact the patient's clinician if they suspect adherence to treatments has been compromised, if the patient begins to discuss suicide ideas or plans, or if the patient's clinical condition worsens.

Lethal means such as firearms should be removed from the home. Fostering family alliance and increasing the availability of external supports may be important in reducing the risk of a suicide attempt in adolescents who self-harm.[206]

Enhanced care services

  • Follow-up mental health interventions for young people assessed for suicide risk and discharged from the accident and emergency department leads to a reduction in suicide-related outcomes and improvement in post-discharge treatment adherence.

  • One randomised clinical trial of young people aged 13 to 17 years who had been admitted after a suicide attempt, with suicidal thoughts, or both, showed that the psychoeducational social support intervention Youth-Nominated Support Team Intervention for Suicidal Adolescents-Version II reduced suicide rates.[207] 

  • In older patients, several studies have shown enhanced interventions to be of benefit. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) showed that a care management intervention (including pharmacological and/or psychological therapies) reduced suicidal ideation in primary care patients who were ≥60 years old.[208] A similar finding was reported in one Australian study.[209] Enhanced A&E department interventions paired with ongoing follow-up during the waiting interval prior to outpatient mental health appointments showed a decreased risk of suicide in patients who did not have baseline symptoms of depression.[210]

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