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