Canadian Task Force on Preventive Health Care

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Prevention of Suicide

Prepared by Jane E. McNamee, MA, Research Associate, Department of Psychiatry, Chedoke McMaster Hospitals and David R. Offord, MD, FRCPC, Professor of Psychiatry, McMaster University, Hamilton, Ontario

MANEUVER EFFECTIVENESS LEVEL OF EVIDENCE <REF> RECOMMENDATION

Routine evaluation of suicide risk if there is evidence of membership in one or more high risk groups.* Effectiveness of routine evaluation of suicide risk by primary caregivers has not been evaluated. Expert opinion <20,24,25> (III) Poor evidence to support either inclusion or exclusion from periodic health examination: evaluation recommended for people at high risk* because of burden of suffering. (C)

Physician education in recognition and treatment of those at risk for suicide. Some evidence of increased knowledge and reduced suicide rate. Pre-post comparison studies <26,27> (II-3) Fair evidence for benefit of physician education programs on suicide prevention, and fair evidence for reduction of suicide rate in selected groups. (B)

Curriculum or school-based intervention/ prevention and postvention programs. Few comparable programs or outcome measures: Described as ineffective, inefficient and potentially deleterious. Matched cohort study <29> (II-2); descriptive survey <28> (III) Insufficient evidence to recommend referral to this intervention. (C)

Community-based suicide prevention programs, crisis centres and general help telephone lines. Few comparable programs or outcome measures. Descriptive surveys <31-33> (III) Insufficient evidence for or against referral to this service. (C)

Medical treatment for reduction of 1)suicidal ideation 2) depression. Some evidence of reduced suicidal risk, for those treated for suicidal ideation. Cohort study <34> (II-2); descriptive survey <35> (III) Fair evidence to use in the treatment of suicidal ideation, (B) and good evidence to use, where appropriate, for diagnosed depression. (A)

Good evidence of reduced suicidal risk for those treated for depression. Meta-analysis of 17 randomized clinical trials <36> (I); descriptive survey <37> (III)

For those previously attempting suicide:

Hospital admission or discharge home. No evidence of reduced risk between groups. Randomized controlled trial <39> (I) Insufficient evidence for or against referral to these interventions for those previously attempting suicide. (C)

Intensive psycho-social follow-up using the Suicidal Risk Scale as an indicator of suicidal risk. No statistically significant evidence of reduced risk. Randomized controlled trial <40> (I)

* High-risk groups include: those with a history of psychiatric illness, depression, drug & alcohol abuse especially those living in isolation, those with chronic terminal illness, Native & Aboriginal people especially young males, those with a family history of suicide, first generation immigrant women.

MANEUVER	EFFECTIVENESS	LEVEL OF EVIDENCE <REF>	RECOMMENDATION
Routine evaluation of suicide risk if there is evidence of membership in one or more high risk groups.*	Effectiveness of routine evaluation of suicide risk by primary caregivers has not been evaluated.	Expert opinion <20,24,25> (III)	Poor evidence to support either inclusion or exclusion from periodic health examination: evaluation recommended for people at high risk* because of burden of suffering. (C)
Physician education in recognition and treatment of those at risk for suicide.	Some evidence of increased knowledge and reduced suicide rate.	Pre-post comparison studies <26,27> (II-3)	Fair evidence for benefit of physician education programs on suicide prevention, and fair evidence for reduction of suicide rate in selected groups. (B)
Curriculum or school-based intervention/ prevention and postvention programs.	Few comparable programs or outcome measures: Described as ineffective, inefficient and potentially deleterious.	Matched cohort study <29> (II-2); descriptive survey <28> (III)	Insufficient evidence to recommend referral to this intervention. (C)
Community-based suicide prevention programs, crisis centres and general help telephone lines.	Few comparable programs or outcome measures.	Descriptive surveys <31-33> (III)	Insufficient evidence for or against referral to this service. (C)
Medical treatment for reduction of 1)suicidal ideation 2) depression.	Some evidence of reduced suicidal risk, for those treated for suicidal ideation.	Cohort study <34> (II-2); descriptive survey <35> (III)	Fair evidence to use in the treatment of suicidal ideation, (B) and good evidence to use, where appropriate, for diagnosed depression. (A)
	Good evidence of reduced suicidal risk for those treated for depression.	Meta-analysis of 17 randomized clinical trials <36> (I); descriptive survey <37> (III)
For those previously attempting suicide:
Hospital admission or discharge home.	No evidence of reduced risk between groups.	Randomized controlled trial <39> (I)	Insufficient evidence for or against referral to these interventions for those previously attempting suicide. (C)
Intensive psycho-social follow-up using the Suicidal Risk Scale as an indicator of suicidal risk.	No statistically significant evidence of reduced risk.	Randomized controlled trial <40> (I)