Elsevier

The Lancet Psychiatry

Volume 2, Issue 11, November 2015, Pages 994-1001
The Lancet Psychiatry

Articles
Interventions to reduce suicides at suicide hotspots: a systematic review and meta-analysis

https://doi.org/10.1016/S2215-0366(15)00266-7Get rights and content

Summary

Background

Various interventions have been introduced to try to prevent suicides at suicide hotspots, but evidence of their effectiveness needs to be strengthened.

Methods

We did a systematic search of Medline, PsycINFO, and Scopus for studies of interventions, delivered in combination with others or in isolation, to prevent suicide at suicide hotspots. We did a meta-analysis to assess the effect of interventions that restrict access to means, encourage help-seeking, or increase the likelihood of intervention by a third party.

Findings

We identified 23 articles representing 18 unique studies. After we removed one outlier, interventions that restricted access to means were associated with a reduction in the number of suicides per year (incidence rate ratio 0·09, 95% CI 0·03–0·27; p<0·0001), as were interventions that encourage help-seeking (0·49, 95% CI 0·29–0·83; p=0·0086), and interventions that increase the likelihood of intervention by a third party (0·53, 95% CI 0·31–0·89; p=0·0155). When we included only those studies that assessed a particular intervention in isolation, restricting access to means was associated with a reduction in the risk of suicide (0·07, 95% CI 0·02–0·19; p<0·0001), as was encouraging help-seeking (0·39, 95% CI 0·19–0·80; p=0·0101); no studies assessed increasing the likelihood of intervention by a third party as a lone intervention.

Interpretation

The key approaches that are currently used as interventions at suicide hotspots seem to be effective. Priority should be given to ongoing implementation and assessment of initiatives at suicide hotspots, not only to prevent so-called copycat events, but also because of the effect that suicides at these sites have on people who work at them, live near them, or frequent them for other reasons.

Funding

National Health and Medical Research Council, Commonwealth Department of Health.

Introduction

Suicide hotspots are specific, accessible, and usually public sites which are frequently used as locations for suicide and gain reputations as such.1 Some hotspots offer the means of suicide, usually by jumping. Others offer seclusion, making it unlikely that a suicide attempt will be interrupted and increasing the chance that it will be fatal. In metropolitan areas, suicide hotspots tend to be bridges, tall buildings, car parks, and railway tracks. In less built-up areas, they are more likely to take the form of cliffs and woodland areas. Word-of-mouth and media reports can perpetuate the reputations of these sites as suicide hotspots, creating a form of contagion whereby individuals are drawn to these sites because they have heard that others have gone there to attempt suicide.1

Various interventions have been introduced to try to prevent suicides at suicide hotspots. In 2013, members of our team and others2 systematically reviewed studies assessing the effectiveness of these interventions, and classified them into four general approaches: (1) restricting access to means, (2) encouraging help-seeking, (3) increasing the likelihood of intervention by a third party, and (4) encouraging responsible media reporting of suicide. Most studies concerned restricting access to means, particularly barriers on bridges and cliffs. Our team and colleagues3 pooled data from studies assessing the effectiveness of restricting access to means in a meta-analysis and concluded that there was unequivocal evidence that this approach can avert suicides at these sites.3 The evidence for other approaches was weaker.2

When strategies are implemented to prevent suicides at hotspots, several interventions are often used simultaneously. This occurred at Gap Park in Sydney, for example,4 where community and industry partners instituted a programme in the area surrounding cliffs, which involved restricting access to means (constructing a new inwardly curved fence along the cliff's edge), encouraging help-seeking (installing telephones that linked directly to Australia's largest crisis service, Lifeline; putting up signs that displayed positive messages and Lifeline's telephone number), increasing the likelihood of intervention by a third party (installing CCTV cameras; improving the amenity of the site), and encouraging responsible reporting of suicide at the site (working closely with local media to prepare stories that were consistent with Australia's media guidelines).4

These sorts of multifaceted intervention make sense given the evidence of their effectiveness.2, 3 However, if the evidence could be strengthened, and the independent contributions of these different interventions better quantified, then these approaches might be further refined. In particular, it would be useful to know the relative effectiveness of each of the interventions (delivered in isolation or in association with other interventions). To meet this need, we did a meta-analysis of the effect of interventions on suicide rates at suicide hotspots.

Section snippets

Study design and procedures

We searched Medline, PsycINFO, and Scopus from their inception to April 21, 2015 for the following terms, mapped onto MeSH headings where applicable: (suicid* OR hotspot) AND (cliff OR building OR high-rise OR multi-storey OR viaduct OR rail OR metro OR subway OR river OR lake OR sea OR public* OR secluded OR remote OR woods OR forest OR rural OR magnet OR location OR bridge OR skyscraper OR car park OR underground OR road OR motorway OR highway OR reservoir OR coast OR jump* OR leap* OR fall

Results

We initially identified 8196 articles (figure 1). Removal of duplicates and screening titles and abstracts left 93 full-text articles, 70 of which we excluded, mostly because they did not relate to suicide hotspots or did not present pre-intervention and post-intervention data on suicides. We included the remaining 23 articles in the meta-analysis.4, 5, 6, 7, 8, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 We treated articles about the same intervention at the same

Discussion

Our meta-analysis provides evidence that restricting access to means, encouraging help-seeking, and increasing the likelihood of intervention by a third party can reduce deaths by suicide at suicide hotspots. A previous systematic review and meta-analysis done by members of our team and colleagues2 and a meta-analysis3 suggested that the evidence for restricting access to means was strong, but that the evidence for the other two interventions was more equivocal. On the basis of the present

References (42)

  • P O'Carroll et al.

    Community suicide prevention: the effectiveness of bridge barriers

    Suicide Life Threat Behav

    (1994)
  • T Reisch et al.

    Securing a suicide hot spot: effects of a safety net at the Bern Muenster Terrace

    Suicide Life Threat Behav

    (2005)
  • C Law et al.

    An economic evaluation of setting up physical barriers in railway stations for preventing railway injury: evidence from Hong Kong

    J Epidemiol Community Health

    (2011)
  • W Viechtbauer

    Conducting meta-analyses in R with the Metafor pacakge

    J Stat Softw

    (2010)
  • M Spittal et al.

    Meta-analysis of incidence rate data in the presence of zero events

    BMC Med Res Methodol

    (2015)
  • J Higgins et al.

    Measuring inconsistency in meta-analyses

    BMJ

    (2003)
  • A Beautrais

    Effectiveness of barriers at suicide jumping sites: a case study

    Aust N Z J Psychiatry

    (2001)
  • A Beautrais et al.

    Removing bridge barriers stimulates suicides: an unfortunate natural experiment

    Aust N Z J Psychiatry

    (2009)
  • O Bennewith et al.

    Effect of barriers on the Clifton Suspension Bridge, England, on local patterns of suicide: Implications for prevention

    Br J Psychiatry

    (2007)
  • O Bennewith et al.

    Suicidal behaviour and suicide from the Clifton Suspension Bridge, Bristol and surrounding area in the United Kingdom: 1994–2003

    Eur J Public Health

    (2011)
  • K Glatt

    Helpline: Suicide prevention at a suicide site

    Suicide Life Threat Behav

    (1987)
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