Systematic review

An evidence summary developed by the Centre for Evidence-Based Practice identified 12 studies that looked at communication to people with suicidal ideation (Dockx et al., 2020). Evidence is of low quality and results cannot be considered precise due to the low number of events and large variability of results.

Appraisal of or having a confidant

There is limited evidence with benefit for appraisal of having a confidant (i.e. the perceived availability of someone to talk to about one’s problems.). It was shown that appraisal of or having a confidant resulted in a statistically significant decreased risk of suicidality, compared to low appraisal of or not having a confidant. 

Staying connected to and befriending

There is limited evidence in favour of staying connected to the person at risk such as through means of sending postcards. In one study, after hospital discharge, postcards were sent every few weeks or months. In these postcards, a doctor asked how the person was doing and whether they wished to drop them a note. It was shown that sending postcards resulted in a statistically significant decrease in suicidal ideation and suicide attempts, compared to not sending any postcards. A statistically significant decrease of suicidal death, when sending postcards compared to not sending postcards, could not be demonstrated.

There is limited evidence in favour of befriending. This involved using a trusting and non-judgmental approach to providing care and opportunities for people to talk about their life events in a calm, relaxing and safe environment. In the study, the people stayed in a respite centre for a time-limited four-night period. It was shown that this method resulted in a statistically significant decrease in psychological distress from pre to post and follow-up measurement. 

Psychological first aid intervention principles

Psychological first aid is a method of helping people in distress to feel calm and supported in coping with their challenges. It addresses both the emotional and social needs of individuals, with the intention of helping people use their resources, enhance their resilience and make informed decisions. There are a limited number of studies that researched the effectiveness of psychological first aid as a complete programme. Two existing systematic reviews on psychological first aid both concluded that there is a lack of controlled studies to support it (Dieltjes et al., 2014; Fox et al., 2012). However, as it is unlikely to have adequate representation of randomised controlled trials using interventions for traumatic events, interventions need to be informed by good practices and psychological first aid is supported by expert opinion. 

Non-systematic review

Guidelines for suicide developed via Delphi methodology

While randomised controlled trials provide a high quality of research evidence, it is highly infeasible and unethical to conduct such studies in developing guidelines in response to suicidality, and good-quality observational research is currently lacking. The Delphi method is a methodology of reaching expert consensus, and the following guidelines developed using Delphi methods. (Colucci et al., 2011; Kelly et al., 2008; Ross et al., 2014)

There are five basic actions when responding to suicide “ALGEE” (Mental Health First Aid Australia, 2014):

• Assess the risk of suicide and/or harm.
• Listen non-judgmentally.
• Give reassurance.
• Encourage professional support.
• Encourage other supports.

Psychological first aid intervention principles

Psychological first aid provided by trained persons is widely supported by expert opinion and rational conjecture as the tool to be provided by trained persons for people who have experienced a traumatic event (Shultz & Forbes, 2014).

Through observation and expert experience there is widespread consensus and support (IASC, 2007) for the five principles that should be used to guide and inform any psychosocial support intervention and prevention efforts at the early to mid-term stages of an emergency. These five principles facilitate survivors’ short-term adjustment and long-term adaptation to the impact of disasters (Hobfoll et al., 2007) and they involve the promotion of:

• calm
• hope
• connectedness
• a sense of safety
• a sense of self and community efficacy.

First aid for mental health problems

In 2019 the Belgian Red Cross-Flanders developed guidelines to provide first aid to people experiencing mental health problems based on a systematic review of scientific evidence (evidence summaries developed by CEBaP, as mentioned above), expert opinion and the preferences of the target population (Dockx et al., 2020). The guidelines include specific recommendations to support people exposed to shocking events. 

Signals of suicidal ideation

Many people experiencing suicidal ideation exhibit signals during the suicidal process which could be observed by others. Awareness and attentiveness by the first aid provider for signs of suicidal thoughts and warning signs of suicidal threat could contribute to the person getting the help they need in time.

Warning signs of suicidal threat include (Mental Health First Aid Australia, 2014; IFRC Reference Centre for Psychosocial Support, 2020):

• Threats of suicide or self-injury.
• Planning for suicide (e.g., searching for methods, acquiring means). The risk somebody takes their own life increases if somebody has a clear plan (how, where, when), has the means to execute the plan and or declares the intention to act.
• Talking, writing, online posting about death or suicide.
• Previous suicide attempts.

Other possible signals of suicidal ideation include (Mental Health First Aid Australia, 2014; IFRC Reference Centre for Psychosocial Support, 2020):

• Making arrangements, appearing to ‘say goodbye’, getting affairs in order.
• Affective changes such as pronounced negative feelings (e.g., hopelessness; stuck, feeling there is no way out; angry, vengeful; seeing no reason to live; inferior, feeling a burden to others; anxious) or pronounced fluctuations in mood.
• Changes in behaviour such as increased risk behaviour (e.g., recklessness, increased consumption of alcohol or other drugs), a sudden display of elation (as a plan has been finalised), sleep problems, or social withdrawal.

Risk and protective factors for suicide

Suicide risk is assessed based on the risk factors, protective factors, and circumstances of the suicide attempt if the person survives after such an attempt. Examples of risk factors for suicide include the following (IFRC Reference Centre for Psychosocial Support, 2020):

• presence of depression
• presence of psychosis
• sex (the risk ratio of male: female is 2:1)
• age (the older the age, the higher the risk)
• single, separated, divorced or widowed
• presence of alcohol or substance misuse
• previous history of a suicide attempt
• presence of a suicide plan
• lack of social support
• presence of chronic illness (e.g. chronic pain).

Examples of protective factors for suicide involve (IFRC Reference Centre for Psychosocial Support, 2020):

• strong perceived social support
• close family relationship
• good coping and problem-solving skills
• having a sense of meaning and purpose in life
• ability and willingness to seek help
• access to resources.

Circumstances of an unsuccessful suicide attempt that indicate a higher risk:

• planning in advance
• precautions to avoid discovery
• no attempts to obtain help afterwards
• final acts (e.g. writing a suicide note or making a will, transferring savings to a close relative’s account, asking someone to help to take care of small children)
• dangerous method (e.g., a lethal dose of drugs was used; the use of a violent method). The person’s perception of the lethality of the method used should also be considered.

Professional help in the case of suicidal ideation should always be encouraged. A trained healthcare professional should conduct a thorough assessment of suicide risk and for the possibility of an underlying mental illness that can lead to the same.

Supporting a suicidal person can be stressful so first aid providers should guard their personal boundaries and take care of themselves. A first aid provider should do their best for the person they are helping. However, despite best efforts, some people will still die by suicide.

Systematic reviews

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders, (2018). Evidence summary Suicidal ideation – Communication.

Dockx, K., Stroobants, S., Scheers, H., Borra, V., Brier, N. D., Verlinden, S., Kaesemans, G., De Buck, E., Lauwers, K., Vandekerckhove, P. (unpublished manuscript). Providing first aid to people experiencing mental health problems: development of an evidence-based guideline. Frontiers in Public health.

Fox, J. H., Burkle, F. M., Bass, J., Pia, F.A., Epstein, J.L., & Markenson, D. (2012). The effectiveness of psychological first aid as a disaster intervention tool: research analysis of peer-reviewed literature from 1990-2010. Disaster medicine and public health preparedness, 6(3), 247-252.

Non-systematic reviews

Aerts et al. (2017). Multidisciplinary guideline for detection and treatment of suicidal behavior of the Flemish Centre of Expertise in Suicide Prevention.

Belgian Red Cross-Flanders. (2019). Luister! Eerste hulp bij psychische problemen [Listen! First aid for mental health problems]. Rode Kruis-Vlaanderen.

Colucci, E., Kelly, C.M., Minas, H., Jorm, A.F., & Suzuki, Y. (2011). Mental Health First Aid guidelines for helping a suicidal person: a Delphi consensus study in Japan, Journal of Mental Health Systems, 5(12).

Hobfoll, S.E., Watson, P.E., Ruzek, J.I., Bryant, R.A., Brymer, M.J., Pynoos, R.S., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70, 283-314.

Howarth, E. L., O’Connor, D.B., Panagioti, M., Hodkinson, A., Wilding, S., & Johnson, J. (2020). Are stressful life events prospectively associated with increased suicidal ideation and behaviour? A systematic review and meta-analysis. Journal of Affective Disorders, 266, 731-742.

IFRC Reference Centre for Psychosocial Support. (2020). Suicide prevention during COVID-19. Denmark: Copenhagen.

IFRC Reference Centre for Psychosocial Support. (2018). A Guide to Psychological First Aid for Red Cross and Red Crescent Societies. Denmark: Copenhagen.

Inter-Agency Standing Committee. (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. IASC.

Kelly, C.M., Jorm, A.F., Kitchener, B.A., & Langlands, R.L. (2008). Development of mental health first aid guidelines for suicidal ideation and behavour: A Delphi study. 8 (17).

Mental Health First Aid Australia. (2014). Mental health first aid guideline for suicidal thoughts and behaviours.

Ross, A.M., Kelly, C.M. & Jorm, A.F. (2014). Re-development of mental health first aid guidelines for suicidal ideation and behaviour: a Delphi study. BMC Psychiatry 14, 241.

Shultz, J. M., & Forbes, D. (2013). Psychological first aid: Rapid proliferation and the search for evidence. Disaster Health, 2(1), 3-12.

World Health Organization. (2019). Suicide. September 2, 2019. Retrieved from https://www.who.int/news-room/fact-sheets/detail/suicide

World Health Organization. (2011). War Trauma Foundation and World Vision International Psychological first aid: Guide for field workers. WHO.