Review Paper

Suicide Attempts: Prevention of Repetition

Marc S Daigle, PhD1; Louise Pouliot, PhD2; François Chagnon, PhD3; Brian Greenfield, MD4;
Brian Mishara, PhD3

Objective: To present an overview of promising strategies to prevent repetition of suicidal

behaviours.

Method: This literature review on tertiary preventive interventions of suicide attempts was
produced using the computerized databases PubMed and PsycINFO from January 1966 to
September 2010, using French- and English-language limits and the key words: suicid* or
deliberate self-harm and treatment* or therapy or intervention* or management.

Results: Thirteen of the 35 included studies showed statistically significant effects of fewer
repeated attempts or suicides in the experimental condition. Overall, 22 studies focused
on more traditional approaches, that is, pharmacological or psychological approaches.
Only 2 of the 6 pharmacological treatments proved significantly superior to a placebo—
a study of lithium with depression and flupenthixol with personality disorders. Eight out of
16 psychological treatments proved superior to treatment as usual or another approach:
cognitive-behavioural therapy (CBT) (n = 4), (including dialectical behaviour therapy
[n = 2]); psychodynamic therapy (n = 2); mixed (CBT plus psychodynamic therapy [n = 1]);
and motivational approach and change in therapist (n = 1). Among the 8 studies using visit,
postal, or telephone contact or green-token emergency card provision, 2 were significant:
one involving telephone follow-up and the other telephone follow-up or visits. Hospitalization
was not related to fewer attempts, and 1 of the 4 outreach approaches had significant results:
a program involving individualized biweekly treatment. The rationale behind these single
or multiple approaches still needs to be clarified. There were methodological flaws in many
studies and some had very specific limited samples.

Conclusions: There is a need for more research addressing the problem in definitions
of outcomes and measurement of the dependent variables, gender-specific effects, and
inclusion of high-risk groups. There is a need for the development and evaluation of
new approaches that support collaboration with community resources and more careful
assessment and comparisons of existing treatments with different populations.

Can J Psychiatry. 2011;56(10):621–629.

Highlights
• We reviewed treatments to prevent relapse of suicidal behaviours.
• Only 2 pharmacological treatments proved significantly superior to a placebo.
• Eight out of 16 psychological treatments proved superior to treatment as usual.
• CBT and psychoanalytically oriented therapy are promising interventions.
• Two visit or phone contact approaches and 1 intensive outreach program proved
effective over treatment as usual.

Key Words: suicide, attempt, self-harm, relapse, prevention, treatment, aftercare,

repetition

The Canadian Journal of Psychiatry, Vol 56, No 10, October 2011 W 621
Review Paper
I n the general population, the lifetime prevalence of
nonfatal suicidal behaviour ranges from 2% to 8%.1,2
However, intentionality, lethality, and outcomes of those
suicidal behaviours vary largely. In specific populations,
including Aboriginal people, young people living in youth
centres, inmates, alcoholics, drug abusers, and people
with mental disorders, the prevalence is much higher and
represents a substantial problem at individual high-risk and
population levels.3 Our paper presents current definitions of
suicide attempts and deliberate self-harm and data on the
risk of repetition in suicide attempters. We then critically
review the differential effectiveness of various approaches
to prevent repetition.
Definitions of Suicide Attempts and
Deliberate Self-Harm
Various nomenclature is used in scientific reports to
refer to suicidal behaviours, including: intentional self-
harm, attempted suicide, self-injury, self-mutilation, self-
poisoning, suicidal gesture, abortive suicide, simulated
suicide, pseudo- suicide, subintentional suicide, life-
threatening behaviours, and parasuicide.4,5 Silverman et
al6,7 proposed a nomenclature for the study of suicide
and suicidal behaviours that revises the version by
O’Carroll et al5 adopted by the American Psychiatric
Association8 in its practice guidelines for the assessment
and treatment of patients with suicidal behaviours.
This nomenclature establishes distinctions based on 2
elements: outcomes of the gesture (no injury, nonfatal
injury, or death) and the intent to die by suicide. According
to this new nomenclature,7 self-harm is defined as “a
self-inflicted, potentially injurious behaviour for which
there is evidence (either implicit or explicit) that the person
did not intend to kill himself/herself (i.e., had no intent to
die).”p 272 A suicide attempt is defined as “a self-inflicted,
potentially injurious behaviour with a nonfatal outcome for
which there is evidence (either explicit or implicit) of intent to
die.”p 273 The goal of these authors7 is to standardize the
common use of the terms. However, as indicated in our
paper, currently many authors do not adequately define the
terms they use. It is often impossible to understand which
behaviours are included and which are excluded from their
investigations. Namely, many authors cited in our review
use the term deliberate self-harm, adding sometimes the
idea of intentionality which is not included in the Silverman
et al6,7 definition. Researchers use various different
terminologies, sometimes reflecting regional habits rather
Abbreviations
CBT cognitive-behavioural therapy
DBT dialectical behaviour therapy
LSARS Lethality of Suicide Attempt Rating Scale
RCT randomized controlled trial
TAU treatment as usual
622
than clear ideological differences. Complications arise
between study comparisons, as different researchers often
use different criteria to determine when there is a relapse or
re-occurrence of suicidal behaviours.
Self-harm and suicide attempts can also be distinguished by
criteria other than the intent to die.9 One may instead use the
criteria of the lethality of the means employed and overall
potential lethality of the incident. For clinicians, intent to
die may appear to be the best criterion for categorizing
suicidal behaviours.10 However, as it is impossible to obtain
direct knowledge about a person’s intentions at the time an
attempt is initiated, researchers must rely on retrospective
assessments involving asking attempters to identify their
intentions at the time of the past event. We have no way of
verifying the validity of these self-reports, and it is likely
that many people may have trouble remembering what
they truly intended, particularly when they were under
the influence of alcohol or drugs at the time. People may
also deny or try to hide their true intentions to try to avoid
psychiatric hospitalization or minimize the importance of
their past behaviours once they are feeling less suicidal.11–15
Further, many people have been found to be ambivalent
or confused when questioned about their past suicide
attempts.10,16 They may reconstruct their interpretation of
the experience because of pressure to respond in a socially
desirable manner, leaving them to perhaps deny, minimize,
or exaggerate matters.
To resolve the problems involved in retrospective
assessments of intent, some researchers have sought
to specify the intent to die exclusively on the basis of
observable behaviours surrounding the event.17 These
observable behaviours correspond, incidentally, to the first
section of the Beck Suicide Intent Scale, which is based
only on the objective circumstances of the event.4
One way of trying to avoid the problems associated with
assessing the intent to die is to categorize the lethality of the
means used in the incident. The premise is that the choice
of a more lethal method indicates a more genuine intent
to die. Although this may appear to be logical, the use of
the lethality of the means as an indication of intent to die
does not stand up to careful scrutiny. Research has shown
that a wide variety of other factors are associated with the
choice of a method, including: gender, education, family
background, rural–urban residence, knowledge of specific
means, prior experiences, knowledge of examples of people
using specific means, and, in particular, availability and
ease of access.18–22 In fact, the correlation between intent to
die (measured with the Beck Suicide Intent Scale) and the
medical lethality of a gesture has been shown to be negative
for people with inaccurate expectations of this lethality
(–0.34). For the attempters with accurate knowledge and
expectations regarding the likelihood of dying by these
specific means, the correlation is positive but moderate
(0.45), accounting for only 20% of the variance.23
A third possibility is to assess the lethality of the incident.
This takes into account both the lethality of the means and
W La Revue canadienne de psychiatrie, vol 56, no 10, octobre 2011

the circumstances surrounding the event. The lethality of
the incident has been assessed using the LSARS, which
ranges from 0 to 10 in even increments.14,24 There is a
moderate correlation (0.67) between LSARS scores and
intent to die as rated on a 6-point scale.25 The LSARS is
a relatively sophisticated instrument used to quantitatively
evaluate not only suicide attempts but also other suicide-
related behaviours.9,26 In the LSARS, lethality refers to the
potential fatal impact of the specific act and of the means
used. The evaluation of the lethality of the method used is
modified by an analysis of the circumstances surrounding
the gesture: how much medical intervention was required—
which is only one aspect of lethality27—but also was the
person alone, did he or she tell anyone, could he or she have
expected someone to disrupt the attempt, and so on.
Need for Prevention of Repetition
Considering only suicide attempts, which is the main focus
of our paper, repetition is common, even after hospital
presentation, with most studies reporting between 12% and
25% of patients repeating and again presenting to hospital
within a year.28 About one-half of attempters seen for the
first time by a clinician previously attempted suicide at
least once. Further, the risk of a fatal repetition of a suicide
attempt is highest in the period immediately following the
attempt.29 In prospective studies of suicide attempters, up
to 3% will die by suicide within 1 year, 9% within 5 years,
and in studies of longer duration, mortality rates are close
to 11%.29 The risk of dying by suicide is 100 times higher
in people who have made prior attempts, but most will not
die by suicide.30 In the next section, we present a review on
the efficacy of different approaches addressing the issue of
repetition in suicide attempters.
Method
Although the objective was to focus on suicide attempts, as
defined by Silverman et al,7 the research strategy was larger
to cover the variations in the nomenclature and to take into
account that many authors do not specify their definitions of
a suicide attempt or use other poorly defined terminology.
Our literature review on tertiary preventive interventions
of suicidal attempts was produced using the computerized
databases PubMed and PsycINFO from January 1966 to
September 2010, using French- and English-language
limits and the key words: suicid* or deliberate self-harm
and treatment* or therapy or intervention* or management.
In addition, other articles were identified using the reference
lists of previous literature reviews on the same topic.27,31–42
Studies were included if they met the 6 following criteria:
1. the intervention occurred following a suicide attempt;
2. recurrence of suicide attempt or completed suicide was
among the measured dependent variables;
3. participants were included in the study shortly after
their suicide attempt;
4. participants were assigned randomly to either
intervention or control intervention group (RCT);
The Canadian Journal of Psychiatry, Vol 56, No 10, October 2011 W
Suicide Attempts: Prevention of Repetition
5. the primary targets of the intervention were patients;
and
6. the design of the study was prospective.
Results
eTable 1 lists the 35 studies or series of studies43–82 meeting
the inclusion criteria, by alphabetical order of the first authors
and classified within 6 types of programs or interventions
offered to the experimental group (as compared with
a control group): pharmacological treatments (n = 6);
psychological treatments (n = 16); visit, postal, or telephone
contact (n = 5); green-token emergency card provision
(n = 3); hospitalization (n = 1); and outreach programs
(n = 4). Note that the van der Sande et al study65 is not
included in the hospitalization section although it also
tests a brief admission to a special crisis intervention unit
of a university hospital. The authors65 focus mainly on
the psychosocial (problem-solving) skills of the patient
and, consequently, are included in the psychological
treatments section. The table also indicates the duration of
the programs, the longest reported follow-up periods, the
characteristics of the samples, principal dependent variables
(using the authors’ specific terminology), the source of
the data (collection), and the percentages of repeaters for
each condition. Note that reported rates are always for the
longest follow-up period; this is a more conclusive period
but, at the same time, it may hide some better results for
shorter periods and it may be unfair when comparing with
other shorter studies.
Thirteen of these 35 studies had statistically significant results,
indicating fewer repeaters or suicides in the experimental
condition. Overall, 22 studies focused on more traditional
approaches; that is, pharmacological or psychological.43–66
Only 2 of the 6 pharmacological treatments proved
significantly superior to a placebo, a study of lithium with
depression and flupenthixol with personality disorders.45,46
Eight out of 16 psychological treatments proved superior
to TAU or another approach. The effective psychological
treatments are: CBT (n = 4), including Linehan’s
DBT (n = 2); psychodynamic therapy (n = 2); mixed
(CBT + psychodynamic) (n = 1); and, motivational
approach and change in therapist (n = 1). Within the 8
studies using visit, postal, or telephone contact67–73 or
green-token emergency card provision (after initial regular
treatment)74–77 only 2 had statistically significant effects: a
program involving telephone follow-up and a program with
telephone contacts or visits.67,68,73 Finally, hospitalization78
was not related to fewer attempts and 182 of the 4 outreach
approaches79–82 had significant results, in favour of the
experimental group, a program involving biweekly
individualized treatment.
Many of the RCTs have insufficient sample sizes, which
may explain the lack of significant differences between the
intervention treatment and the comparison intervention in
many cases. In the same vein, the TAU received by control
groups may have included some aspects of the experimental
623
Review Paper
treatment, with a confounding effect on the results of the
trials. The authors often failed to specify what the TAU
consisted of.
An important limitation of these studies is that, as is general
practice in RCTs, participants considered from a clinical
viewpoint to be at high risk of suicide were excluded for
ethical considerations. Although we do not have access to
the basis of exclusion of high-risk patients from the studies,
18 studies appear to have excluded patients suffering from
schizophrenia, major mood disorder, or having problems
of substance abuse or dependence.45–51,53,54,56,58–65,73,75–76,80
Owing to spatial constraints, all of these specific exclusion
criteria are not included in eTable 1, but they vary from
study to study and have certainly biased the final results. For
example, in the study by Lauterbach et al,45 all the exclusion
criteria led to retaining only 18% of the prospective sample.
In such a case, it is obvious that the conclusions only apply
to a very specific sample. It is also important to note that in
28 out of 35 studies that specified the gender of participants,
women were overrepresented in all the significant studies
(up to 100% in the Linehan et al studies59,60) and in most
of the nonsignificant ones. Gender differences in treatment
efficacy were almost never reported, possibly owing, in
part, to the low statistical power of small sample sizes.
Overall, there is limited documentation on the reliability
and validity of data on the recurrence of suicide attempts.
Regarding psychosocial interventions, there is little
information on how therapists were selected, trained, and
coached to deliver effective treatments. None of the reports
clearly describe the process used to ensure implementation
reliability for those interested in reproducing the treatment,
and there is little focus on how others can implement the
experimental interventions.
The heterogeneity in the labelling of the target outcomes
(dependent variables listed in eTable 1) is another important
aspect that has been reviewed above. These labels may refer
to different nonfatal behaviours, with different lethality and
intentionality, but this was not generally taken into account
in the 35 studies, except for 3: Slee et al,63 Wood et al,66
and Vaiva et al.73 This, again, makes comparison between
treatments difficult. However, they were all considered
suicide attempts for the purposes of our review. Only Motto
and Bostrom,72 Lauterbach et al45 and Fleischmann et al68
included suicide (fatal outcome) as a dependent variable,
although the samples were neither always large (167 to
1867 participants) nor the follow-up periods very long (12
to 120 months).
Although our classification of 6 categories of intervention
is heuristic, there are also large differences within them.
The duration of the treatments presented in eTable 1
ranged from 1 day to 18 months. Further, the follow-up
period was generally from 3 to 36 months. In Motto and
Bostrom’s study,72 the intervention of sending postcards
and the follow-up extend to 180 months. Outcomes were
generally assessed by 2 different data collection strategies:
self-reports, in which patients are asked at some point
624
during the follow-up period if they had attempted suicide,
and by reviews of patients’ clinical records.
Participants’ clinical and sociodemographic profiles vary
greatly. For example, eTable 1 shows that some programs
are for children and adolescents and others for adults; thus
the mean age of participants varies between 14 and 41 years.
Also, some interventions were for people with very specific
problems; for example, drug abuse or personality disorders.
The time of entry in the study also differs substantially
between studies. In some instances, participation began
in the hospital ward to which the patient was admitted
following the suicide attempt, while in others, participation
began days or months after discharge.
Discussion
Before presenting our general conclusions, we must discuss
some general limitations to the current state of knowledge
on the efficacy of treatments to prevent repetition of
suicide attempts. First there are important limitations
in categorizing interventions. Although interventions
may share similar therapeutic approaches, the specific
activities of the intervention, their intensity, and the
reliability of the implementation may vary considerably
between studies. Second, most studies have samples that
overrepresent women and none compare the effectiveness
of interventions by gender, except the study by Hawton
et al.56 Several recent studies suggest that men may have
the same prevalence of nonlethal suicidal behaviours in
nonclinical populations.12,83–85 It is not clear that promising
interventions are equally effective for men, who are
generally at higher risk of dying by suicide than women.86
Only one of the studies, the postcard follow-up by Motto
and Bostrom,72 who used completed suicide as the outcome,
addressed possible gender difference, and with sufficient
power. In this case, the intervention was proactive (postal
contact), as is sometimes recommended with men, and the
gender ratio was almost equal. However, the results were
not statistically significant, although differences were in the
predicted direction. Third, most samples excluded people at
high risk of attempting suicide, thus effectively eliminating
from the studies people who, one would hope, could most
benefit from the interventions. Thus our ability to generalize
about the usefulness of many interventions to prevent
recurrence in high-risk groups is limited. This reservation
about the efficacy of the interventions with high-risk groups
is supported by the fact that, in most instances, people who
have attempted suicide present an Axis I major psychiatric
disorder (that is, depression, schizophrenia, or substance
disorder), often in comorbidity with a personality disorder.
People with precisely those diagnoses were excluded from
some of the clinical trials.
Fourth, in most studies outcome assessments were based on
patients’ self-reports. Whenever self-reports are used, social
desirability can be a major issue. Suicide is a sensitive matter
that participants may be reluctant to report, and none of the trials
under review indicate that there was an attempt to validate the
W La Revue canadienne de psychiatrie, vol 56, no 10, octobre 2011

self-report data. It is possible that the lack of findings or some
of the positive findings indicating the effectiveness of some
treatments in preventing recurrence, based on self-reports,
may be related to this methodological pitfall.
The low to moderate effectiveness of some treatments in
preventing recurrence should be considered in light of the fact
that suicide is a multifaceted phenomenon.As suicidal behaviour
is related to multiple etiological factors, a monolithic approach
to prevention may have severe limitations.87 Only a handful
of trials appear to have recognized this fact by combining 2 or
more intervention approaches. However, none of these studies
offer an explicit statement of the rationale guiding the decision
to combine, or not to combine, intervention approaches in their
experimental conditions. Adding interventions without a clear
rationale is no assurance that the combination has advantages
over any specific components. Even with a clear rationale, it is
also more difficult to ascertain if the implementation of all the
components was well done. When programs that have multiple
components are compared with control conditions, if there are
significant effects, it is impossible to determine if the effects
are due to one of the components or the combination that was
studied. Also, as few studies assess less traditional intervention
methods, we have less data to determine the effectiveness of
new and innovative practices.
Pharmacological Treatments
In the past 30 years, only a handful of studies have tested the
effectiveness of pharmacological treatments in preventing
relapse of suicide attempts. In our review, only the studies
by Montgomery and Montgomery46 (on flupenthixol with
personality disorders) and by Lauterbach et al45 (on lithium
with depression) had significant findings. In the first study,46
the sample was not large but the results were very clear:
21% repetition in the experimental group compared with
75% in the control group. This study focused on a single
behavioural dependent variable, namely, a suicidal act (not
defined at all by the authors), and included only patients
with mainly borderline or histrionic personality disorders
and not suffering from schizophrenia or depression. The
study by Lauterbach et al45 has a larger sample and a
longer time of treatment and follow-up. Nevertheless, the
treatment was only effective in preventing suicides and not
suicide attempts. Also the repetition rates were very low,
both in experimental and in control conditions, as compared
with the findings in the Montgomery and Montgomery
study,46 which clearly reflects the profile of the participants:
personality disorders compared with depressive disorders.
The study with paroxetine by Verkes et al,48 which was not
significant overall with patients without major depression,
did have significant findings in 2 subgroups of the sample:
people with fewer than 5 previous attempts and people
meeting fewer than 15 criteria for cluster B personality
disorder. However, one must not forget that there is abundant
research showing the effectiveness of pharmacological
treatments for the condition most associated with suicide
attempts and completed suicides, namely, depression.88,89
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Suicide Attempts: Prevention of Repetition
Psychological Treatments
There is a growing consensus in the literature that, in the
management of suicidal behaviour, treatment interventions
should address coping deficiencies and symptoms of
psychological distress in patients who have attempted
suicide.8 In the last 3 decades, several psychotherapies
have proven to be effective in preventing the recurrence of
suicide attempts. In fact, 9 of the 16 psychotherapy studies
proved effective, if one includes the Davidson et al study.53
eTable 1 shows nonsignificant results for this study53 in its
effect on the percentage of repeaters. However, they found
that the number of repetitions (mean number of suicidal
acts per participant of CBT) was significantly less than in
the TAU.
Several studies have found that suicide attempters have
deficits in problem solving abilities.90–97 Nevertheless, none
of the studies whose interventions were specifically related
to problem solving approaches had significant effects in
decreasing repetition. The principal components of problem
solving therapies involve clarification of the problem
behind the attempt and exploration of alternative solutions.
Several CBTs had significant effects in decreasing repetition
of attempts. Four (5 including the Davidson et al study53)
of the RCTs had significant results. The 2 DBT forms of
CBT proved significant, but only with patients having a
borderline personality disorder.59,60 These 2 last studies give
no indication about the effectiveness of DBT with other
diagnoses. There was also some form of DBT in the mixed
approach of Wood et al66 with children and adolescents,66
but these findings were later contradicted in the study’s
replication by Hazell et al.57 There are fewer studies of the
effects of psychodynamic approaches. However, 2 RCTs
indicated significant effects.49–51,55 In one study, by Bateman
and Fonagy,51 the experimental group was exposed not only
to an 18 months treatment but also to another 18 months of
a maintenance program. Also, the study by Wood et al,66
which had significant effects, included both CBT and a
psychodynamic approach. Nevertheless, the findings of
our review indicate that the psychological approaches of
CBT and psychodynamic therapies are promising and may
prevent repetition of suicidal behaviour. As for the Möller
study,61 it shows the effectiveness of a short motivational
interview, but only in the context of a reference to a suicide
prevention centre where there is a change of therapist. There
is not much information in the report61 to help us understand
which conditions are associated with the success, the change
of therapist or the referral to a suicide prevention centre.
Visit, Postal, or Telephone Contact and
Green-Token Card Provision
Limited financial and human resources is an important
issue in many hospital settings. Therefore, brief, low-cost
visits, telephone, or postal contact initiatives have been
developed to address this widespread problem. Five minimal
interventions have been empirically tested in various
countries using RCTs. When we examine the percentage
of repeaters, 2 studies produced significant results. In the
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large study reported by Bertolote et al67 and Fleischmann
et al,68 participants had a 1-hour information session but the
intervention relied mainly on follow-up contacts by visits or
phone calls. The program was proven effective, but only in
reducing the number of suicides. In the Vaiva et al study,73
contacting patients by phone 1 month after discharge was
associated with significant decreases in attempts; but contact
after 3 months was not conclusive (although the results were
in a positive direction). Nevertheless, considering only the
number of readmissions for self-poisoning per person, the
Carter et al study69,70 shows a significant reduction in the
experimental group. The study by Motto and Bostrom72
also seems promising. Designed for a 10-year follow-up
(total = 15 years), this study had significant results in the first
2 years. However, although there were still differences in
suicide attempt rates in the predicted direction 5 years later,
the difference between the experimental and control groups
were not statistically significant at that time. At 15 years, the
predicted direction of the results was the opposite, although
there were nonsignificant differences between experimental
and control groups. In this study,72 patients in the contact
group were sent a personalized letter on a monthly basis for
the first 4 months, then every second month for 8 months,
and every 3 months for 4 years. Altogether, these postal
or telephone approaches are attractive, especially with
populations who may be reluctant to use available services;
for example, very high-risk groups or men.86 Here again, a
gender-specific analysis could provide further clarification
of the potential effects of these methods. It should be noted
also that, overall in our review, none of the other studies
followed their patients for more than 2 years as in the Motto
and Bostrom study, except the 5 years of the Bateman and
Fonagy study,49–51 and we do not know about their long-term
effectiveness.
Three RCTs74–77 also tested the effectiveness of providing
suicide attempters with a green card, or token, giving access
to telephone consultation with a psychiatrist and on-demand
admission to their local hospital. None of these studies
found significant differences between the experimental and
control groups in the proportion of those repeating suicide
attempts at 6- and 12-month follow-up intervals.
Hospitalization
Waterhouse and Platt78 compared the effects of general
hospital admission with home discharge in preventing
repetition, but both conditions had a comparable number
of what they called parasuicides. However, if one only
considers the rate of rehospitalization as the outcome
variable, we know that outpatient services may be better
than hospitalization, at least with adolescents.98
Outreach Program
A large proportion of patients who have attempted
suicide discontinue their treatment and fail to attend a
follow-up appointment after their discharge from hospital
facilities.99 Visit, postal, or telephone contacts and green-
token emergency card provision may help in this regard,
626
but a number of intensive outreach programs have also
been proposed to circumvent these problems and prevent
the recurrence of suicide attempts. Our review identified
4 RCTs79–82 in this area and only 1 was not intensive.81 These
programs involved, to differing extents, a combination of
home visits, individualized treatment plans, referrals to
resources, a schedule of appointments, and compliance-
related measures. The findings from these trials failed, in
most cases, to demonstrate a decrease in the repetition of
suicidal behaviour. However, Welu’s treatment program82
appeared to be effective in reducing suicide re-attempts. It
should be noted that the follow-up period (4 months) was
shorter than in many other programs. Therefore, results
from this study82 do not provide evidence of the program’s
long-term effectiveness.
Conclusion
On the whole, more traditional approaches, especially
psychotherapies based on CBT, including DBT, as well as
psychoanalytically oriented therapies, appear to significantly
reduce repetition of suicide attempts. The minimal approach
of using regular visits, postal, or telephone contacts appears
to be a promising low-cost intervention that is worthy
of further investigation. The green or token emergency
card provision fail to have statistically significant effects.
Intensive outreach follow-up approaches often use home
visits, which are both intensive and personalized. One such
experience82 proved efficient.
One may argue that it would be best to combine all the
approaches, pharmacological, psychotherapeutic, and
follow-up, to have a maximum effect. However, adding
active ingredients does not necessarily yield better results
according to empirical findings. If interventions are
combined, a clear rationale should be elaborated. Another
concern is that each approach is costly, and the sum of
several is even more costly, with no empirical evidence, to
date, indicating greater benefits
Given that there were methodological flaws in many studies
and that some had very limited samples, there is still a need
for more sound research. Future studies should address the
problem of the definition of the dependent variables, and
the determination of the reliability and validity of measures.
There is a need to have sufficiently large samples to examine
gender-specific effects. Further, we must obtain data on
high-risk groups rather than systematically excluding them
from investigations. More thought should also be put into
approaches that support collaboration with community
resources and new technologies, such as the Internet and
text messaging,100 to explore new initiatives that may
potentially prevent repeated attempts and save lives.
Acknowledgements
Preparation of this article was supported by the team of
the Centre for Research and Intervention on Suicide and
Euthanasia. Thanks, especially, to Louise Sansoucy for her
help.
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1
Professor, Université du Québec à Trois-Rivières, Trois Rivieres,
Quebec; Researcher, Centre for Research and Intervention on Suicide
and Euthanasia (CRISE), Montreal and Philippe-Pinel Institute of
Montreal, Montreal, Quebec.
2
Associate Professor, Université du Québec à Montréal, Montreal,
Quebec; Researcher, Centre for Research and Intervention on Suicide
and Euthanasia (CRISE), Montreal, Quebec.
3
Professor, Université du Québec à Montréal, Montreal, Quebec;
Researcher, Centre for Research and Intervention on Suicide and
Euthanasia (CRISE), Montreal, Quebec.
4
Associate Professor, McGill University, Montreal, Quebec; Doctor,
Montreal Children’s Hospital, Montreal, Quebec; Researcher, Centre for
Research and Intervention on Suicide and Euthanasia (CRISE), Montreal,
Quebec.
Address for correspondence: Dr M S Daigle, Université du Québec à
Trois-Rivières, PO Box 500, Trois-Rivières, QC G9A 5H7;
marc.daigle@uqtr.ca

Résumé : Tentatives de suicide : prévention de la répétition

Objectif : Présenter un aperçu de stratégies prometteuses pour prévenir la répétition de comportements
suicidaires.

Méthode : Cette revue de la littérature sur les interventions préventives tertiaires des tentatives de suicide a été
produite au moyen des bases de données informatiques PubMed et PsycINFO, de janvier 1966 à septembre
2010, à l’aide des restrictions de langue du français et de l’anglais et des mots clés : suicid* ou autodestruction et
traitement* ou thérapie ou intervention* ou prise en charge.

Résultats : Treize des 35 études incluses révélaient des effets statistiquement significatifs des tentatives répétées
ou des suicides en moins grand nombre dans la condition expérimentale. Globalement, 22 études portaient sur des
approches plus traditionnelles, c’est-à-dire, des approches pharmacologiques ou psychologiques. Seulement 2 des
6 traitements pharmacologiques se sont avérés significativement supérieurs à un placebo — une étude du lithium
pour la dépression et du flupentixol pour les troubles de la personnalité. Huit des 16 traitements psychologiques
se sont révélés supérieurs au traitement habituel ou une autre approche : la thérapie cognitivo-comportementale
(TCC) (n = 4), (y compris la thérapie comportementale dialectique [n = 2]); la thérapie psychodynamique (n = 2);
la thérapie mixte (TCC plus thérapie psychodynamique [n = 1]); et l’approche motivationnelle et le changement
de thérapeute (n = 1). Parmi les 8 études où le contact se faisait par une visite, la poste ou le téléphone, ou la
fourniture d’une carte d’urgence verte, 2 étaient significatives : l’une comportait un suivi par téléphone et l’autre,
un suivi par téléphone ou des visites. L’hospitalisation n’était pas liée à un moins grand nombre de tentatives, et
1 service d’approche sur 4 a eu des résultats significatifs : un programme comportant un traitement individualisé
toutes les 2 semaines. La raison d’être de ces approches simples ou multiples demeure à clarifier. Il y avait des
défauts méthodologiques dans bien des études et certaines avaient des échantillons limités très spécifiques.

Conclusions : Il faut plus de recherche pour aborder le problème des définitions des résultats et de la mesure des
variables dépendantes, les effets sexospécifiques, et l’inclusion de groupes à risque élevé. Il faut aussi élaborer et
évaluer de nouvelles approches qui soutiennent la collaboration avec les ressources communautaires ainsi qu’une
évaluation et des comparaisons plus précises des traitements existants pour différentes populations.

The Canadian Journal of Psychiatry, Vol 56, No 10, October 2011 W 629