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Cited by 502Suicide and Self-Harm StudiesHomicide, Infanticide, and Child AbuseGrief, Bereavement, and Mental Health

Suicide

Open access
Fazel, Seena, Runeson, Bo·2020·New England Journal of Medicine
DOI 10.1056/nejmra1902944PMC PMC7116087
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Abstract

Suicide accounts for approximately 1.5% of deaths per year worldwide. Risk factors are known for populations, and psychological models address individual risks; the models and tools for assessing suicide risk are imperfect but provide some guidance.

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Written from the paper’s full text.

TL;DR

This review summarizes global epidemiology, risk factors, assessment, and prevention of suicide, emphasizing that about 800,000 people die by suicide annually and that psychiatric disorders, prior attempts, and access to lethal means are major risks. It concludes that population means restriction and targeted clinical interventions, especially lithium for mood disorders, have evidence for reducing suicide, but risk prediction and treatment trials remain limited.

Key findings

  • Global burden: approximately 800,000 deaths by suicide occur yearly, accounting for 1.5% of all deaths; the 2016 WHO suicide rate was 10.6 per 100,000, with 80% of suicides in low- and middle-income countries, higher rates among men (15.6 per 100,000) than women (7.0 per 100,000), and an estimated 18% reduction from 2000 to 2016 except in the Americas, where U.S. rates increased by 1.5% annually since 2000 and men 45–64 years old rose from 21 to 30 per 100,000 between 1999 and 2017.
  • Self-harm continuum: for each suicide death there are about 20 suicide attempts, amounting to 16 million attempts and approximately 160 million people expressing suicidal thoughts annually; among persons who attempt suicide, 1.6% die by suicide within 12 months and 3.9% within 5 years.
  • Risk factors: psychiatric disorders including depression, bipolar disorder, schizophrenia-spectrum disorders, substance use disorders, epilepsy, and traumatic brain injury each increase the odds of completed suicide by a factor of more than 3; mental illnesses are estimated to be present in half of persons who died by suicide in high-income countries, with affective disorders involved in one third to one half of suicides; twin studies estimate the genetic contribution to suicidal behavior at 30 to 50%.
  • Prevention: hanging accounts for approximately 40% of deaths by suicide worldwide and pesticides for 14 to 20%; pesticide bans were associated with reductions in Sri Lanka, Bangladesh, and South Korea; lithium was associated with a 14% decrease in suicidal acts and completed suicide in bipolar disorder, and psychostimulants with a 19% reduction among young people with ADHD; in the United States in 2017, there were 23,854 firearm suicides and 14,542 firearm homicides.

Methods

  • Narrative review; no primary data collection or formal systematic review/meta-analysis is described.
  • Synthesizes epidemiologic estimates, risk-factor studies, psychological autopsy findings, genetic and biologic studies, assessment-tool evaluations, and intervention trials or observational studies.
  • Main analysis is qualitative synthesis; no new statistical analysis is reported.

Limitations

  • Stated: randomized trials of treatment aimed at modifiable risk factors have been underpowered to examine suicide; most pharmacologic evidence comes from observational studies; many randomized trials exclude patients with suicidal ideation or behavior; suicide risk models have poor sensitivity and specificity and weak evidence for routine use.
  • Evident: as a narrative review, it does not report a systematic search strategy, inclusion criteria, or formal quality appraisal, and it presents no primary data or meta-analysis.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1056/nejmra1902944

Cites

71 of 71 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 63 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    Familial risk is partially explained by parental mood disorder, impulsivity and aggressiveness, or neurocognitive disorders, all of which are heritable.

    “This familial risk is partially explained by parental mood disorder, traits of impulsivity and aggressiveness, or neurocognitive disorders, all of which are heritable.38”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] Brent DA Mann JJ Familial pathways to suicidal behavior — understanding and preventing suicide among adolescents N Engl J Med 2006 355 2719 21 17192535 source

      Not checked in the free run.

  • Premisenone given

    Studies have not been able to distinguish behavioral imitation of a family member's suicide from genetic propensity as explanatory factors.

    “However, studies have not been able to differentiate between behavioral imitation of a family member's suicide and a genetic propensity for suicide as explanatory factors.”
    Quote in the paperNot a substantial claim
  • Premisenone given

    Evidence for media influences on suicide is weaker for adolescents than for adults.

    “The evidence for media influences on adolescents is weaker than the evidence for media influences on adults.”
    Quote in the paperNot a substantial claim
  • Interpretationreasoning

    These assessment tools may increase clinical workload by requiring psychiatric assessment or hospitalization in false-positive cases.

    “Thus, these assessment tools may increase the clinical workload by requiring psychiatric assessment or hospitalization in cases of false positive risks of suicide.”
    Quote in the paperSubstantial claim
  • Premisecitation

    Restrictions on common means of suicide, such as detoxifying domestic gas, reducing alcoholic spirits availability, and state firearm restrictions, have been linked to changes in suicide rates.

    “Changes in suicide rates have also been attributed to restriction of common means of suicide, such as detoxification of domestic gas (i.e., the reduction and eventual elimination of the carbon monoxide content of gas owing to a switch to natural gas) in the United Kingdom, starting in the 1960s,6 decreased availability of alcoholic spirits in Russia,7 and state restrictions of firearms in the”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [6] Kreitman N The coal gas story: United Kingdom suicide rates, 1960-71 Br J Prev Soc Med 1976 30 86 93 953381 PMC478945

      Not checked in the free run.

    • cites [7] Razvodovsky YE Beverage-specific alcohol sale and suicide in Russia Crisis 2009 30 186 91 19933064 source

      Not checked in the free run.

    • cites [8] Kaufman EJ Morrison CN Branas CC Wiebe DJ State firearm laws and interstate firearm deaths from homicide and suicide in the United States: a crosssectional analysis of data by county JAMA Intern Med 2018 178 692 700 29507953 PMC5885268 source

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  • May combine two claims. 34
  • Classified as probably not a substantial claim. 6

  • May combine two claims.

    Premisenone given

    Imaging and postmortem studies show changes in serotonergic pathways correlated with suicide, but these associations have not been validated.

    “Imaging and postmortem studies have shown changes in serotonergic pathways that are correlated with suicide, but these associations have not been validated.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    Suicide risk prediction models used in clinical practice vary in content and validation and often were developed for other purposes.

    “However, models used in clinical practice vary in content and in the degree of validation and often have been developed for other purposes, such as assessing patients for depression or rating the severity of current suicidal ideation rather than predicting the future risk of suicide (Table 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Impulsivity is a component of most psychological models of suicide; it is partly familial and has disproportionate influence on suicide risk among young people.

    “Impulsivity is a component of most psychological models of suicide. This trait is partly familial32 and has a disproportionate influence on suicide risk among young people.33”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [32] McGirr A Alda M Séguin M Cabot S Lesage A Turecki G Familial aggregation of suicide explained by cluster B traits: a three-group family study of suicide controlling for major depressive disorder Am J Psychiatry 2009 166 1124 34 19755577 source

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    • cites [33] McGirr A Renaud J Bureau A Seguin M Lesage A Turecki G Impulsive-aggressive behaviours and completed suicide across the life cycle: a predisposition for younger age of suicide Psychol Med 2008 38 407 17 17803833 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Relationship difficulties, death of a partner, and death by suicide of someone close are precipitating events for suicide; for mothers, death by suicide of adult children is particularly relevant.

    “Such events include relationship difficulties (particularly separation or divorce), death of a partner, and death by suicide of someone close16 — in particular, for mothers, death by suicide of adult children.26”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] Agerbo E Midlife suicide risk, partner's psychiatric illness, spouse and child bereavement by suicide or other modes of death: a gender specific study J Epidemiol Community Health 2005 59 407 12 15831691 PMC1733072 source

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    • cites [26] Pitman A Osborn D King M Erlangsen A Effects of suicide bereavement on mental health and suicide risk Lancet Psychiatry 2014 1 86 94 26360405 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In high-income countries, mental illnesses are estimated to be present in half of people who died by suicide, with affective disorders involved in a third to half of suicides.

    “In high-income countries, mental illnesses are estimated to be present in half of persons who have died by suicide, with affective disorders (depression and bipolar disorder) involved in a third to half of suicides.24”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Arsenault-Lapierre G Kim C Turecki G Psychiatric diagnoses in 3275 suicides: a meta-analysis BMC Psychiatry 2004 4 37 15527502 PMC534107 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There is a small increase in suicide rates after a celebrity suicide, and the effect is larger when press guidelines are disregarded.

    “There is a small increase in suicide rates after the suicide of a celebrity, and the effect is magnified when press guidelines for avoiding both explicit descriptions of the death and speculation about causes are disregarded.18”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Niederkrotenthaler T Fu KW Yip PSF Changes in suicide rates following media reports on celebrity suicide: a meta-analysis J Epidemiol Community Health 2012 66 1037 42 22523342 source

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  • May combine two claims.

    Premisecitation

    Risk models for suicide used in emergency departments to assess self-harm have poor balance between sensitivity and specificity and do not provide probability scores.

    “Risk models for suicide have been used in emergency departments to assess persons who have harmed themselves, but these models have a poor balance between sensitivity and specificity and do not provide probability scores.48”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [48] Chan MK Bhatti H Meader N Predicting suicide following self-harm: systematic review of risk factors and risk scales Br J Psychiatry 2016 209 277 83 27340111 source

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  • May combine two claims.

    Premisecitation

    People in unskilled professions have increased suicide risk, partly explained by psychosocial stress, while professions with access to lethal means have high suicide rates.

    “People in unskilled professions have an increased risk of suicide, which is partly explained by greater psychosocial stress; however, people in professions with access to lethal means for suicide have high rates, such as farmers, nurses, veterinarians, physicians, and police.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Milner A Spittal MJ Pirkis J LaMontagne AD Suicide by occupation: systematic review and meta-analysis Br J Psychiatry 2013 203 409 16 24297788 source

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  • May combine two claims.

    Premisecitation

    Religious affiliation of any type has been reported to be protective against suicide, but this has not been shown for minority religious groups, which may be socially isolated.

    “Religious affiliation of any type has been reported to be protective against suicide, but this has not been shown for minority religious groups, which may be socially isolated.30”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Lawrence RE Oquendo MA Stanley B Religion and suicide risk: a systematic review Arch Suicide Res 2016 20 1 21 26192968 PMC7310534 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    The interpersonal psychological model holds that a sense of burdening others and not being accepted interacts with hopelessness that these perceptions will not change.

    “This model has been augmented by an interpersonal psychological model, in which the sense of burdening others and not being accepted in social groups interacts with the feeling of hopelessness that these perceptions will not change.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Among people who attempt suicide, 1.6% die by suicide within 12 months and 3.9% within 5 years.

    “Among persons who attempt suicide, 1.6% die by suicide within the next 12 months, and 3.9% die by suicide within the next 5 years.10”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Olfson M Wall M Wang S Crystal S Gerhard T Blanco C Suicide following deliberate self-harm Am J Psychiatry 2017 174 765 74 28320225 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Depression, bipolar disorder, schizophrenia-spectrum disorders, substance use disorders, epilepsy, and traumatic brain injury each raise the odds of completed suicide by more than threefold.

    “Depression, bipolar disorder, schizophrenia-spectrum disorders, substance use disorders, epilepsy,13 and traumatic brain injury14 each increases the odds of completed suicide by a factor of more than 3.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [12] Chesney E Goodwin GM Fazel S Risks of all-cause and suicide mortality in mental disorders: a meta-review World Psychiatry 2014 13 153 60 24890068 PMC4102288 source

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    • cites [13] Fazel S Wolf A Långström N Newton CR Långström P Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study Lancet 2013 382 1646 54 23883699 PMC3899026 source

      Not checked in the free run.

    • cites [14] Fazel S Wolf A Pillas D Lichtenstein P Långström N Suicide, fatal injuries, and other causes of premature mortality in patients with traumatic brain injury: a 41-year Swedish population study JAMA Psychiatry 2014 71 326 33 24430827 PMC4058552 source

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  • May combine two claims.

    Premisereasoning

    Suicide can occur without an identifiable psychiatric disorder, and when psychiatric disorders are present they co-occur with other predisposing and precipitating factors in people who died by suicide.

    “Suicide also occurs in the absence of an identifiable psychiatric disorder, and even when present, psychiatric disorders have co-occurred with other predisposing and precipitating risk factors in persons who have died by suicide.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The effect of parental suicide is greater on younger children than on adolescents; younger age at exposure is associated with higher lifetime suicide risk.

    “Furthermore,the effect of parental suicide is greater on younger children than on adolescents; that is, the younger children are when they experience suicidal behavior in their parents, the higher their lifetime risk of suicide.37”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] Wilcox HC Kuramoto SJ Lichtenstein P Långström N Brent DA Runeson B Psychiatric morbidity, violent crime, and suicide among children and adolescents exposed to parental death J Am Acad Child Adolesc Psychiatry 2010 49 514 23 20431471

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  • May combine two claims.

    Premisecitation

    Family history of suicide is a risk factor for suicide, with some evidence that maternal suicidal behavior has greater influence than paternal suicidal behavior.

    “A family history of suicide is a risk factor for suicide,19 with some evidence suggesting that a mother's suicidal behavior has a greater influence than a father's suicidal behavior.36”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] Qin P Agerbo E Mortensen PB Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers Lancet 2002 360 1126 30 12387960 source

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    • cites [36] Kuramoto SJ Stuart EA Runeson B Lichtenstein P Långström N Wilcox HC Maternal or paternal suicide and off-spring's psychiatric and suicide-attempt hospitalization risk Pediatrics 2010 126 5 e1026 e1032 20956422 PMC3666044 source

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  • May combine two claims.

    Premisecitation

    Suicide risk is increased among assault victims, people who have been arrested, and prisoners.

    “Suicide risk is also increased among assault victims, persons who have been arrested, and prisoners.27”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Fazel S Ramesh T Hawton K Suicide in prisons: an international study of prevalence and contributory factors Lancet Psychiatry 2017 4 946 52 29179937 PMC6066090 source

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  • May combine two claims.

    Premisecitation

    Individual vulnerability is considered to appear as suicidal ideation under stress and is magnified by impulsivity and aggression, increasing the likelihood of acting on suicidal ideas.

    “Individual vulnerability is considered to express itself in suicidal ideation under stress and is magnified by impulsivity and aggression, which increase the likelihood of acting on suicidal ideas.31”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Mann JJ Waternaux C Haas GL Malone KM Toward a clinical model of suicidal behavior in psychiatric patients Am J Psychiatry 1999 156 181 9 9989552 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A stress-diathesis psychological model explains suicide risk as a combination of stressors in vulnerable people.

    “A stress-diathesis psychological model explains suicide risk as a combination of stressors in vulnerable persons.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Mann JJ Waternaux C Haas GL Malone KM Toward a clinical model of suicidal behavior in psychiatric patients Am J Psychiatry 1999 156 181 9 9989552 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Perfectionism may be a contributory personality trait, leading to isolation and impeding psychological recovery from self-harm or suicidal ideation.

    “Perfectionism may be another contributory personality trait, leading to isolation out of fear of being stigmatized for an interpersonal crisis. A perfectionist trait also impedes psychological recovery from self-harm or suicidal ideation.34”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] O'Connor RC The relations between perfectionism and suicidality: a systematic review Suicide Life Threat Behav 2007 37 698 714 18275376 source

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    Previous suicide attempt, childhood sexual abuse, family history of suicidal behavior, and loss of a parent to suicide in early childhood are predisposing factors for suicide.

    “Other predisposing factors include a previous suicide attempt, childhood sexual abuse, a family history of suicidal behavior, and loss of a parent to suicide in early childhood (Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Terrorist attacks appear temporally protective against suicide in exposed populations, and greater social cohesion may explain lower suicide rates in New York after September 11, 2001.

    “Paradoxically, terrorist attacks appear to be temporally protective against suicide in exposed populations. Greater social cohesion may have explained lower suicide rates in the New York metropolitan area in the months after the September 11, 2001, attacks.28”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Claassen CA Carmody T Stewart SM Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites Br J Psychiatry 2010 196 359 64 20435960 source

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  • May combine two claims.

    Premisecitation

    One study showed that people who experienced early-life adversity have an overactive hypothalamic-pituitary-adrenal axis response to stress, which increases anxiety and mediates suicidal behavior.

    “One study showed that persons who experienced adversity in early life have an overactive hypothalamic–pituitary–adrenal axis in response to stress, which increases anxiety and acts as a mediator of suicidal behavior.41”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] Turecki G The molecular bases of the suicidal brain. Nat Rev Neurosci 2014 15 802 16 PMC5293539 25354482 source

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  • May combine two claims.

    Premisecitation

    Trials of antipsychotic medications versus placebo in schizophrenia have shown reductions in suicide rates, but results are uncertain because of small numbers of suicides.

    “Trials of antipsychotic medications as compared with placebo in patients with schizophrenia have shown reductions in suicide rates, but these results have been uncertain because of the small numbers of suicides.63”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [63] Leucht S Tardy M Komossa K Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis Lancet 2012 379 2063 71 22560607 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Mental health professionals have emphasized that developing and maintaining a therapeutic relationship is central to reducing suicide risk.

    “Mental health professionals have emphasized that developing and maintaining a therapeutic relationship is central to reducing suicide risk.75”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] Dunster-Page C Haddock G Wainwright L Berry K The relationship between therapeutic alliance and patient's suicidal thoughts, self-harming behaviours and suicide attempts: a systematic review J Affect Disord 2017 223 165 74 28755624 source

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  • May combine two claims.

    Premisenone given

    Few randomized trials of pharmacologic treatment have been underpowered to study suicide and have relied on proxy outcomes.

    “The few randomized trials of such treatment have been underpowered to study suicide and have relied on proxy outcomes (e.g., suicidal ideas or depressive symptoms).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Pesticide restrictions have been evaluated in 16 countries, and bans of highly hazardous pesticides were associated with reductions in suicides in Sri Lanka, Bangladesh, and South Korea.

    “Pesticide restrictions have been evaluated in 16 countries, and bans of the sale of highly hazardous pesticides were associated with reductions in suicides in Sri Lanka, Bangladesh, and South Korea.55”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [55] Gunnell D Knipe D Chang S-S Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidence Lancet Glob Health 2017 5 10 e1026 e1037 28807587 source

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  • May combine two claims.

    Premisecitation

    Unstructured clinical approaches may be more inaccurate and subject to cognitive biases, including overemphasis on predisposing factors and risk aversion.

    “Some studies have shown that these unstructured approaches may be more inaccurate and subject to a range of cognitive biases on the part of the assessor, including an overemphasis on predisposing factors51 and risk aversion.52”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [51] Pease JL Forster JE Davidson CL Holliman BD Genco E Brenner LA How Veterans Health Administration suicide prevention coordinators assess suicide risk Clin Psychol Psychother 2017 24 401 10 28401708 source

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    • cites [52] Berman NC Stark A Cooperman A Wilhelm S Cohen IG Effect of patient and therapist factors on suicide risk assessment Death Stud 2015 39 433 41 25674940 source

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  • May combine two claims.

    Premisecitation

    Mindfulness-based cognitive therapy has improved mood stability and problem solving in suicidal persons.

    “Mindfulness-based cognitive therapy, which combines cognitive behavioral techniques with meditation and deep breathing, has improved mood stability and problem solving in suicidal persons.70”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [70] Chesin M Interian A Kline A Benjamin-Phillips C Latorre M Stanley B Reviewing mindfulness-based interventions for suicidal behavior Arch Suicide Res 2016 20 507 27 26983364 source

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  • May combine two claims.

    Premisecitation

    Structured tools can provide a baseline assessment, offer a checklist of risk factors, and lead to interventions for people predicted to be at high risk for suicide.

    “Nevertheless, structured tools can provide a baseline assessment during initial contact with health care providers, offer a checklist to identify risk factors, and lead to interventions for those persons who are predicted to be at high risk for suicide.49,50”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [49] Bolton JM Gunnell D Turecki G Suicide risk assessment and intervention in people with mental illness BMJ 2015 351 h4978 26552947 source

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    • cites [50] Fazel S Wolf A Suicide risk assessment tools do not perform worse than clinical judgement Br J Psychiatry 2017 211 183 PMC5734608 28864758 source

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  • May combine two claims.

    Premisecitation

    Internet-administered self-help treatments may offer approaches for hard-to-reach groups, but these findings were not replicated in a similar trial.

    “Another study showed that Internet-administered self-help treatments may offer approaches for hard-to-reach groups, such as persons who have had negative health care experiences or persons with financial or time constraints that impede access to care,73 but these findings were not replicated in a similar trial.74”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [73] van Spijker BA van Straten A Kerkhof AJ Effectiveness of online self-help for suicidal thoughts: results of a randomised controlled trial PLoS One 2014 9 2 e90118 24587233 PMC3937447 source

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    • cites [74] van Spijker BA Werner-Seidler A Batterham PJ Effectiveness of a webbased self-help program for suicidal thinking in an Australian community sample: randomized controlled trial J Med Internet Res 2018 20 2 e15 29444769 PMC5830610 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In the United States, there were 14,542 homicides and 23,854 suicides involving firearms in 2017.

    “In the United States, there were 14,542 homicides and 23,854 suicides involving firearms in 2017.4”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Centers for Disease Control and Prevention. Multiple cause of death, 1999-2017 https://wonder.cdc.gov/mcd.htmlCDC Wonder Online Database

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Trials of cognitive behavioral therapy have shown a reduction in suicidal thoughts, presumed to be mediated by reducing hopelessness.

    “Trials of cognitive behavioral therapy have shown a reduction in suicidal thoughts,69 presumed to be mediated by reducing hopelessness.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [69] Mewton L Andrews G Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes Psychol Res Behav Manag 2016 9 21 9 27042148 PMC4780394 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Treatments being investigated for suicide prevention in depression include ketamine, electroconvulsive therapy, and repetitive transcranial magnetic stimulation, but these approaches have not been sufficiently studied.

    “Treatments being investigated for suicide prevention in patients with depression include the anesthetic ketamine, electroconvulsive therapy, and repetitive transcranial magnetic stimulation, but these approaches have not been sufficiently studied.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Analyses of individual-level, area-level, and state-level data show associations between firearm ownership and suicide, and gun restrictions are associated with lower overall suicide rates and lower firearm suicide rates.

    “Analyses of individual-level data,15 area-level data in large cities,57 and state-level data58 have shown associations between firearm ownership and suicide, and gun restrictions have been associated with lower overall suicide rates as well as lower rates of suicide with firearms.8”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [15] Anglemyer A Horvath T Rutherford G The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis Ann Intern Med 2014 160 101 10 24592495 source

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    • cites [57] Miller M Warren M Hemenway D Azrael D Firearms and suicide in US cities Inj Prev 2015 21 e1 e116 e119 24302479 source

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    • cites [58] Siegel M Rothman EF Firearm ownership and suicide rates among US men and women, 1981-2013 Am J Public Health 2016 106 1316 22 27196643 PMC4984734 source

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  • May combine two claims.

    Premisecitation

    Worldwide, hanging accounts for approximately 40% of suicide deaths and pesticides for 14 to 20%.

    “Worldwide, hanging accounts for approximately 40% of deaths by suicide, and pesticides account for 14 to 20%.55”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55] Gunnell D Knipe D Chang S-S Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidence Lancet Glob Health 2017 5 10 e1026 e1037 28807587 source

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  • May combine two claims.

    Premisecitation

    Several studies have not confirmed the effectiveness of broad school-based suicide prevention programs, and their justification has been questioned.

    “Several studies have not confirmed the effectiveness of broad, school-based suicide prevention programs, and the justification for such initiatives has been questioned.61”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [61] Kutcher S Wei Y Behzadi P School- and community-based youth suicide prevention interventions: hot idea, hot air, or sham? Can J Psychiatry 2017 62 381 7 27407073 PMC5455865 source

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  • May combine two claims.

    Premisecitation

    A meta-analysis showed that at the end of treatment, psychological interventions directly addressing suicidal thoughts and behaviors and providing coping strategies had better outcomes than treatment for anxiety and depression, but differences diminished after 1 year.

    “A meta-analysis that included various psychological treatments showed that at the end of the treatment period, interventions that directly addressed suicidal thoughts and behaviors and provided strategies for coping with them had better outcomes than treatment for anxiety and depression, but these differences were diminished after 1 year.68”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [68] Meerwijk EL Parekh A Oquendo MA Allen IE Franck LS Lee KA Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: a systematic review and meta-analysis Lancet Psychiatry 2016 3 544 54 27017086 source

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  • May combine two claims.

    Premisenone given

    Erection of barriers at suicide spots and smaller pack sizes of certain nonprescription medications have led to reductions in suicide deaths by those means.

    “Erection of barriers at potential suicide spots, such as bridges, tall buildings, and railway tracks, and smaller pack sizes of certain nonprescription medications that are used for suicide, such as acetaminophen and preparations with dextropropoxyphene, have led to reductions in suicide deaths by these means.”
    Quote in the paperSubstantial claim
38 of 38

  • The authors state this as an assumption.

    Life-course analysis assumes that risk factors act at different stages of life and that suicide is the cumulative result of risk factors over a lifetime.

    “One approach to understanding suicide has been life-course analysis,11 which is based on the premise that risk factors come into play at different stages of life (Fig. 1) and that suicide is the cumulative result of risk factors over a lifetime.”

  • The authors state this as an assumption.

    Psychological models assume that suicidal persons have reduced fear of death and increased pain tolerance due to habituation by previous self-harm.

    “Another aspect of psychological models is the premise that suicidal persons have a reduced fear of death and increased pain tolerance as a result of habituation by previous acts of self-harm.25”

  • The paper relies on this without support.

    Predisposing factors interact with precipitating factors, and the effects of predisposing factors depend on a person's resilience.

    “Predisposing factors for suicide are thought to interact with precipitating factors, and predisposing factors may have different effects depending on the resilience of the person.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. 2012 National Strategy for Suicide Prevention: goals and objectives for action: a report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington DC: Department of Health and Human Services September 2012 (https://www.ncbi.nlm.nih.gov/books/n/surgnssp/pdf/).

Cited by

Sorted by citations

Related

Authors
Fazel, S., & Runeson, B.
Affiliations
Warneford Hospital (GB)
ORCID
Venue
New England Journal of Medicine
Publisher
Massachusetts Medical Society
Published
2020-01-16
Volume
382
Issue
3
Pages
266-274
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
DOI
10.1056/nejmra1902944
PMC
PMC7116087
OpenAlex
W4237462033
Semantic Scholar
6ec03f5291ad34d02df621542d8a5d64e1209b71
Cited by
502
References
71
Citations by year
2026: 57 · 2025: 84 · 2024: 78 · 2023: 88 · 2022: 71 · 2021: 88 · 2020: 35
FWCI
5.54
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
Wellcome Trust (202836/Z/16/Z, 202836)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Sociology and Political Science › Homicide, Infanticide, and Child Abuse
  • Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
Keywords
suicide, suicide risk factors, suicide risk assessment, suicide prevention
MeSH terms
Suicide Prevention, Female, Humans, Male, Psychotherapy, Risk Factors, Sex Factors, Suicide, Suicide, Attempted, Risk Assessment, Suicidal Ideation

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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