A Systematic Review of Elderly Suicide Prevention Programs

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Prevention of suicidal beliefs in older people: A systematic review of reviews

  • Lucie Laflamme,
  • Marjan Vaez,
  • Karima Lundin,
  • Mathilde Sengoelge

PLOS

x

  • Published: January 25, 2022
  • https://doi.org/10.1371/journal.pone.0262889

Abstruse

Older people have the highest rates of suicide, notwithstanding the bear witness base on effective suicide preventions in belatedly-life is limited. This systematic review of reviews aims to synthesize information from existing reviews on the prevention and/or reduction of suicide behavior in late-life and prove for effectiveness of interventions. A systematic database search was conducted in eight electronic databases from inception to 4/2020 for reviews targeting interventions amid adults ≥ lx to prevent and/or reduce suicide, suicide effort, self-harm and suicidal ideation. Four loftier quality reviews were included and interventions categorized equally pharmacological (antidepressant use: 239 RCTs, seven observational studies) and behavioral (concrete activity: three observational studies, and multifaceted primary-care-based collaborative intendance for depression screening and management: iv RCTs). The 2009 antidepressant use review establish significant hazard reduction for suicide effort/self-harm (OR = 0.06, 95% CI 0.01–0.58) and suicide ideation (OR = 0.39, 95% CI 0.xviii–0.78) versus placebo. The 2015 review establish an increased risk of attempts with antidepressants versus no treatment (RR = i.18, 95% CI 1.x–i.27) and no statistically significant change in suicides versus no treatment (RR = i.06, 95% CI 0.68–1.66) or ideation versus placebo (OR = 0.52, 95% CI 0.14–1.94). Protective effects were found for physical activeness on ideation in ii out of iii studies when comparison active versus inactive older people. Collaborative intendance demonstrated significantly less attempts/ideation (OR = 0.80, 95% CI 0.68–0.94) in intervention group versus usual care. The results of this review of reviews notice the evidence inconclusive towards utilize of antidepressants for the prevention of suicidal behavior in older people, thus monitoring is required prior to kickoff, dosage modify or cessation of antidepressants. Prove to date supports physical activeness and collaborative management for reduction of suicide ideation, but boosted trials are required for a meta-analysis. To build on these findings, connected high-quality research is warranted to evaluate the effectiveness of interventions in late life.

Introduction

Older persons accept the highest mortality rate due to suicide in almost all regions of the world [1]. Men'due south prevalence is higher than that of women, in part because they tend to employ more lethal suicide methods (e.g., hanging, jumping, sharp objects) [2]. Sure risk factors are comparable to those observed in other historic period segments of the population; these include psychiatric weather condition, feelings of hopelessness, depression or prior suicide attempts [3]. Yet older people face item age-related challenges such equally poorer physical and mental health, pain, cognitive deficits, co-morbid medical conditions that impair role or life expectancy, increased frailty and limited social connectedness [4]. An additional important cistron is the presence of somatic comorbidities that may agonize older people, such as neurological diseases, pain and oncological diseases, which have been establish to occur more oftentimes in older people exhibiting suicidal behaviour [5]. Neurological diseases in particular crusade biological impairments also every bit feelings of astringent hopelessness, both linked to increased vulnerability to suicidal beliefs [6]. Information technology has also been shown that older people with previous suicide attempts or who die by suicide are more than likely to accept a plan and are more determined than younger adults, resulting in higher lethality rates [seven]. They are also less probable to disembalm emotional distress, thus there also exists the problem of underreporting of the burden of suicide in the aged [8].

Suicidal behavior in older people is a result of numerous interactions that are dynamically changing as people historic period. This makes its detection and the evolution of effective preventive interventions to tackle this behavior challenging. Although no model to engagement is specific to late life suicide, a number of models have been developed to advance understanding of the interplay of the biological, clinical, psychological, social, cultural adventure and protective factors involved in suicidal behavior. Examples include the Interpersonal Theory of Suicide that emphasizes the function of caused capability and the simultaneous presence of thwarted belongingness and perceived burdensomeness that transact with the interpersonal environment [ix] and the Stress-Diathesis model that posits suicide is the upshot of an interaction between land-dependent (environmental) stressors and a trait-like diathesis or susceptibility to suicidal behavior [10]. These models have been applied in the suicide field for a social-ecological approach to prevention and link to efforts to identify the social determinants of mental health using a life course approach [11]. Various reviews have been conducted on suicide prevention of interventions advisable for all age groups and effective diagnosis and treatment of depression is well-nigh frequently cited as a preventive intervention because of the close association between affective illness and suicidal behavior in older people [12–14]. Yet controversy nonetheless remains as to the potential risks involved and that affective illnesses may have low detection rates [14]. A systematic review completed in 2011 by Lapierre and colleagues identified the numerous interventions utilized for prevention of suicidal behavior in older people: chief care interventions, customs-based outreach, telephone counselling, pharmacotherapy and cerebral-behavioral therapy or psychotherapy [xv]. This heterogeneity in interventions has prevented the potential for a meta-analysis. The review establish that the majority of studies used merely the presence or absence of completed suicide equally the outcome and near of the interventions targeted the reduction of risk factors [15]. While some of the interventions identified are applicative to all ages (eastward.yard. pharmacotherapy), a few are unique to late life and differ from other historic period groups. For example, older adults are less likely to utilize mental health services compared to younger adults as this aged population tend to present to master care services [xvi].

In that location is a wide range of interventions and settings utilized to reach and intervene with older adults at risk for suicide. The many individual studies and several reviews existing to date accept employed dissimilar definitions of suicide, included certain forms of interventions and excluded others (e.g., multilevel or behavioural or pharmaceutical) and used narrow effect measures, e.g., only death by suicide. As a result, there is a lack of clarity about what the evidence at hand shows and what interventions are effective from a cross-disciplinary perspective. A systematic review of original articles performed by the authors identified only four new studies that were not already included in an existing review. Noting the number of systematic reviews performed to appointment, a systematic review of reviews was selected as a tool to enable the findings of reviews to be synthesized, compared and contrasted. This allows for providing a single comprehensive overview of the published literature that includes multiple intervention types and a variety of suicide beliefs outcomes.

The objectives of this systematic review of reviews were two-fold: i) to synthesize data from existing reviews on the prevention and/or reduction of suicide behavior in older adults, including the characteristics of relevant reviews, the definition of suicide behavior used, the types of interventions included and their objectives, outcomes and effects; and ii) to clarify the testify for effectiveness. The results are to contribute to identification of knowledge gaps on what interventions are effective to guide future research.

Materials and methods

Search strategy

A systematic search strategy was adult following the Systematic Reviews and Meta-Analyses checklist (S1 Table) and applied to the following 8 electronic databases: Medline, Epub Ahead of Print, In-Procedure & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) (Ovid); Psycinfo (Ovid); Embase.com; Web of Science Core Collection; CINAHL (Ebsco); Cochrane Library (Wiley); SveMed+ and Google Scholar. The original search menstruum was Jan 2000 to Apr 2017 and a second search was repeated in April 2020 using the same search protocol. As an boosted method of review identification, we checked the reference lists of selected manufactures to observe any missed studies using the snowballing technique. Further details on the full electronic search strategy is included every bit a S2 Table. All records were imported into the electronic reference direction software, EndNote (version X8). To identify reviews, the following keywords were searched for in the EndNote library: review OR overview OR meta-analysis (each search separate).

Eligibility criteria

The PICO components (population, intervention, comparator and outcome) and exclusion criteria are depicted in Table i. We selected the age group ≥60 years in social club to maximize the potential inclusion of reviews. Furthermore, publications included whatsoever type of review (scoping, systematic, systematic review including a meta-assay) published in the peer-reviewed literature from January ane, 2000 to April 1, 2020. 1 or more suicidal behavior upshot was included in order to capture all older adults who would do good from prevention measures in the pathway ranging from suicidal ideation to completed suicide. Reviews were excluded if a more recent review existed that included all of the studies from the before review. No language restrictions were practical.

Data extraction, analysis and quality cess

Titles and abstracts of retrieved records were screened to identify reviews that met the inclusion criteria. At the get-go phase studies with relevant titles were selected for second screening past 2 reviewers evaluating independently of ane some other (MS, KL). At the second stage, only those abstracts satisfying inclusion criteria were retained for full-text review. The reviewers also examined the reference lists of all included data to identify other potentially eligible reviews. No disagreements were constitute within the review team regarding inclusion. I reviewer (MS) extracted data using a predetermined data extraction form based on the PRISMA checklist which was afterwards independently verified by the second reviewer (KL). No contact was needed with written report authors to obtain or ostend data.

Interventions had to be described in sufficient detail to enable classification as suicide prevention. The consequence measures were to include the bear upon of interventions on suicide, suicide attempts, self-harm without suicide intent and/or suicidal ideation. Two reviewers (MS, KL) independently completed a methodological quality assessment of the included reviews. The AMSTAR2 tool was used as it is especially designed to assess the quality of systematic reviews and meta-analyses based on 16 quality criteria and seven critical domains [17]. Reviews are rated as high if they have zero or one not-critical domain; moderate if more than than one non-critical domain, and low if 1 disquisitional flaw with or without not-critical weaknesses. A review that scored an overall rating of low was removed from the analysis. The reviewers were consequent in their decision on inclusion. In social club to analyze the reviews systematically, the following data were extracted: description of the patient or participant group/sample studied, nature of the intervention covered in the review, blazon of outcomes investigated, setting (clinical or population-based) type of review, and methodological elements such as the number of included studies, search time frame and major findings. The included reviews were and so synthesized according to the Synthesizing Without Meta-analysis (SWiM) reporting guideline to promote reporting for reviews of interventions that use alternative synthesis methods [18]. We adjusted the guideline such that findings of 'studies' were noted as findings of 'reviews'. The nine-item SWiM checklist was used to report how the reviews were grouped, the metric used for the synthesis, the synthesis method including how data were presented and limitations of the synthesis.

Results and discussion

The search generated 731 records identified as reviews. Screening of titles resulted in 221 records. Farther screening of abstract and full-text resulted in a total of vii reviews evaluating interventions to reduce or prevent suicidal behavior in older people. The flow nautical chart depicting the search strategy is presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram (Fig 1).

The main reasons for exclusion of 82 records based on full-text review were that the population was not specific to older people (i.eastward. all ages, data aggregated) and focus on risk factors for suicide, not interventions. The seven reviews were assessed for methodological quality. 3 reviews on interventions that influence help-seeking and psychiatric health care utilization amidst individuals with suicidal behavior [19], community interventions for tardily-life suicide [twenty] and multifaceted, selective and targeted interventions for tardily-life suicide prevention [21] scored an overall depression level of prove (AMSTAR2 <11) and were excluded. The review past Lapierre and colleagues [15] from 2011 was excluded and non assessed for quality as the studies in this review were included in the Okolie et al. review that met the inclusion criteria [22]. Thus, a total of four reviews were included. The reviews were categorized by intervention type, pharmacological (n = 2) and behavioral (n = ii) and the direction of effect was analyzed. Next, vote counting of the effect management was utilized to summarize the results; see the S3 Tabular array for full details of the SWiM reporting guideline.

Characteristics of included reviews

Two reviews were systematic [22, 23] and two included a systematic review and meta-analysis [24, 25]. The reviews presented findings from randomized control trials every bit well as observational, prospective and cross-sectional studies representing a range of high-income countries: Canada, Denmark, Europe, Japan, Republic of korea, kingdom of the netherlands, United Kingdom (Great britain), USA. Only 1 report on antidepressants past Barak et al. [26] was present in more than 1 review [22–24].

Two reviews were exclusively on adults ≥ lx years [22, 24] and the other ii had a broader age scope (all adults and all ages) but included older adults and provided results in a disaggregated mode [23, 25]. Table 2 summarizes the characteristics of the iv reviews categorized by blazon of intervention, pharmacological and behavioral. The table includes data on the type of review, clarification of the intervention, number of databases searched, search time frame, languages searched, countries, population under study, type of upshot measures covered, and number of studies included.

Three outs of the iv reviews restricted their search in English and a range of v to 15 databases were searched among all four reviews.

Written report quality.

The detailed quality assessment of the seven reviews having met the initial inclusion criteria are summarized in the S4 Table. The quality rating presented in Tabular array 3 indicates that the four included reviews had a high level of prove and did not have any critical weaknesses.

I. Pharmacological interventions

Two reviews investigated the association between suicide and antidepressant use treatment, O'Connor et al. [23] in 2009 followed by KoKoAung et al. [24] in 2015. Both included fatal and non-fatal suicidal behavior outcomes. The O'Connor et al. review investigated the effect of 2nd-generation antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), on suicidal behavior in all ages and ii studies reported stratified results on older adults based on approximately 233 RCTs. The more than contempo KoKoAung [24] review examined the issue of SSRIs specifically compared to other antidepressant use or placebo in RCTs and observational studies (population cohort and retrospective case control studies). Two RCTs compared SSRIs versus placebo on suicidal ideation and 4 RCTs and three observational studies compared SSRIs versus other antidepressants on suicide effort. In add-on, two observational studies provided data on completed suicide and three on suicide attempt. At that place were no data available on suicidal ideation from the observational studies included in the review.

2. Behavioral interventions

Physical action.

The review by Vancampfort et al. [25] investigated physical activity in clinical and non-clinical populations comparing "active" to "inactive" as divers past the studies as well as meeting physical action guidelines compared to not coming together these guidelines, divers equally 150 minutes per week of at to the lowest degree moderate or 75 min per week of vigorous concrete activeness. Three of the studies (ii from South Korea, ane from Australia) focused specifically on older people; i a longitudinal report and the other two cross-exclusive.

Multifaceted behavioral interventions.

The review past Okolie et al. [22] encompassed multifaceted interventions in three settings: a) principal treat depression screening and management, b) clinical-based (pharmacotherapy and psychotherapy) and c) customs-based. The majority of the interventions addressed hazard predictors such as depression and in which manner the interventions varied. They included principal intendance-based depression screening and management programs in which training was provided to master care physicians on cess and direction of both low and suicidal behavior; pharmacotherapy with antidepressants; psychotherapy in the class of Problem Solving Therapy, Problem Accommodation or Supportive Therapy; telephone counseling for vulnerable older adults via a 24-hr Friendship Line or geriatric outreach via schedule telephone calls; and customs-based programs incorporating didactics, gatekeeper training, low screening, mental health/health education workshops; participating in social, voluntary and recreational activities; and exercising together.

Intervention and its furnishings

Table 3 provides the fundamental findings for each review by intervention and suicidal behavior upshot: suicide; suicide try/serious self-impairment; suicidal ideation.

Suicide.

The 2009 review on antidepressant employ included SSRIs and other 2nd generation drugs was non able to assess the association with suicide every bit no suicide deaths were reported in the approximately 233 RCTs. In contrast the 2015 review on antidepressant utilise focused exclusively on long term apply (two to xi years) of SSRIs found no statistically meaning decreased hazard for suicide (RR = 1.06, 95% CI 0.68–ane.66) based on two observational studies (n = 100,343).

Suicide attempts, self-harm, suicide ideation.

The experimental studies reviewed by O'Connor et al. revealed a significantly lower OR with antidepressants compared to placebo for both suicide attempt and serious self-impairment (OR = 0.06, 95% CI 0.01–0.58) and suicide ideation (OR = 0.39, 95% CI 0.xviii–0.78). In the studies included by KoKoAung et al. concerning long-term SSRIs compared to no handling, experimental studies establish no lower odds of suicide attempts (OR = i.00, 95% CI 0.14–vii.10; n = 592) or suicide ideation (OR = 0.52, 95% CI 0.xiv–1.94; north = 1 821). In addition, in the latter review observational studies demonstrated that those with long-term SSRIs had an increased risk of suicide attempts compared to those without treatment (RR = 1.18, 95% CI ane.10–1.27).

For its part, the review on concrete activity was based mainly on cross-exclusive studies comparison "active" versus "inactive" persons (as defined by each study) and those who met the recommended international physical activity guidelines (150 min per week of at least moderate or 75 min per calendar week of vigorous intensity physical activity) versus those who did non. Older "active" persons had significantly lower odds of suicide ideation compared to "inactive" ones in ii out of the iii studies (67%; northward = 50,745).

The Okolie et al. review on multifaceted interventions found that of the three types of interventions studied, only primary-based collaborative care was of sufficient methodological quality. This intendance refers to instance managers and physicians working together on identifying and managing depression and chance of suicide, demonstrating a reduction of self-harm (attempts and ideation) and suicide ideation at four, half-dozen and eight months. Results at 24 months were mixed with ane cluster RCT reporting no significant deviation (p = 0.12) and two other cluster RCTs showing significantly lower levels of ideation (p = 0.01; OR 0.80, 95% CI 0.68–0.94).

This systematic review of reviews synthesized data from existing reviews targeting the prevention or reduction of suicidal beliefs in older people. The four included reviews were assessed as existence of high methodological quality, but non all included studies were sufficiently powered to study suicide or did not include this issue due to its low incidence. This may be due to several reasons, such as the low base rate of suicidal beliefs in older (2–4 attempts for each suicide death) compared to younger ages (200 attempts for each suicide in some adolescent and young adult samples)[27]; the frailty of older adults resulting in high dropout rates in studies and the difficulty in inclusion of older adults at take a chance for suicide in outcomes research due to their isolation in society, comorbidities and functional impairments [28]. Assessing multiple reviews enabled usa to integrate data from a large number of studies and the small caste of overlap (one study) limited the risk of duplication of conclusions while ensuring the reviews were non overly selective.

Although antidepressant medication for treatment of depression in older people has been investigated over a long catamenia of time in both experimental and observational study designs [13, 28], our review suggests that information from the 2015 review of SSRIs showed no testify of a protective effect for suicide or suicidal ideation [24]. Equally SSRIs may also be prescribed for mood disorders other than low [29, xxx], at that place may exist an indication bias. One other challenge when comparison studies on antidepressants is that the population included in RCT studies may include a population at higher risk. Thus, a matter of heterogeneity may be present. Also, the high dropout rate in the studies included equally noted past KoKoAung et al. may have led to worsening of depression and therefore predispose older persons to increased run a risk of suicidal behavior [24]. Results from these types of studies examining outcomes for pharmacological treatment versus no treatment are difficult to translate due to potential confounding by indication. Physicians may have been more probable to prescribe antidepressants for older persons with more severe depression, who in plough were also more likely to thus have suicidal behaviors. As the studies were observational at that place was no control or experimental group to control for this. Equally the sale of antidepressants is rising globally [31, 32], information technology is necessary to continue scrutinizing the data in order to optimize the utilise of antidepressants. Furthermore, other drugs used in mood disorders have shown some efficacy for prevention of suicidal behavior in adults, and thus warrant further study in older populations [33].

Investigating protective factors, the Vancampfort et al. review showed that physical activity compared to beingness inactive had protective effects on suicidal ideation in two out of three studies on older people. As this outcome was based mainly on cross-sectional data, additional prospective observational studies and controlled trials are needed to ostend the findings. Furthermore, equally the majority of studies did non include a comprehensive physical activity assessment, data are defective on what blazon and dose (i.e. length, frequency, duration) of concrete activity would be optimal for older people. This information is crucial to guide prevention programs as it is not known to what extent older adults with serious physical illness and functional limitations (both associated with suicidal behavior [5]), may be physically capable of 75 minutes of rigorous exercise per week. Also, those with depression may non feel able to practice regularly due to lack of free energy and motivation. Notwithstanding, intervention strategies for older people may target the importance of physical activity for prevention of suicidal ideation based on these preliminary findings. It is fundamental that public health inquiry focuses on the bear upon of full general health promotion to optimize successful aging across the health continuum [34] and capture whether such an approach may synergistically reduce suicidal behavior [fourteen].

The review encompassing multifaceted interventions aimed at addressing take chances predictors for suicidal behavior and ideation constitute that collaborative management in master care was associated with reduced cocky-damage (composite measure of suicide attempt and suicide ideation) and for reduced suicidal ideation [22]. This finding can be explained in that older people may ofttimes accept physical and mental health symptoms or conditions that need to be addressed, which are optimally addressed and treated in a collaborative, holistic team approach. It is important to recognize that that the inclusion of self-harm with and without suicidal intent too as suicidal ideation may be problematic as although they accept overlapping behaviors, they brandish some distinct risk profiles [35]. In add-on, some older adult victims may not disclose any level of ideation [36] and ideators may never transition to suicidal behavior [37]. Yet, a history of non-suicidal self-harm and of suicidal ideation were shown past meta-analysis to confer a afterward risk of suicidal thoughts and behavior ranging from ideation to attempts and death [38]. Thus, farther research focused on improving agreement of the determination of intent and interpretation of suicidal behavior in this age group would be informative. Furthermore, no systematic effort was made in this review to place possible synergies betwixt interventions, although there is evidence that combinations of preventive interventions at several levels may have potential synergistic furnishings, east.k. training of general practitioners to accost both depression and social isolation in older patients [39]. Previous research highlights the provision of general practitioner services due to reaching out to master care prior to suicidal behavior and that services are accessible and integrated within other care elements to be effective in management and prevention [xl].

In all four of the reviews included, the sustainability of the interventions and evidence of long-term furnishings beyond 24 months is unknown at this time. Longitudinal, big scale studies are required to assess this, and we identified only one multicenter written report that demonstrated a reduced risk of repeated cocky-harm for persons of all ages combined receiving a psychosocial intervention in the short (one to v years) and long-term (ten to 20 years) compared to those receiving no intervention, as well equally a reduced risk of decease by suicide in the long-term; but the results were mixed when focusing on older people 50 years of age and older [41]. As the reviews identified in this report were few in number, it was not possible to stratify by gender.

Strengths and limitations

This is to our knowledge the beginning systematic review of reviews to synthesize data from existing reviews on the prevention or reduction of suicidal behavior in older people. Nosotros included wide-ranging databases employed to identify documents of relevance and a systematic arroyo to screening, reviewing, assessing, and synthesizing in line with standard guidelines. Furthermore, nosotros reported on fatal and non-fatal suicide outcomes. Yet several limitations exist. Firstly, there is limited information in the data presented regarding the frequency and elapsing of the interventions that were administered, in detail the behavioral ones. Secondly, we were unable to generate effect sizes because of the heterogeneity of the interventions or lack of meta-analyses in the original reviews. Thirdly, we limited the show to studies identified in previous systematic reviews and therefore do not capture interventions taking place that have non all the same been the subject of a systematic review. For instance, sedatives and hypnotics have been plant to be associated with increased hazard for suicide in adults ≥65 twelvemonth in a instance command study, fifty-fifty after aligning for affective and anxiety disorders [42].

Directions for future enquiry.

This systematic review of reviews indicates there is a need for additional large-calibration studies in gild to build the testify base of "what works" in suicide prevention among older people in order to arbitrate and alter the suicidal trajectories of older people [43]. This includes addressing the social and political determinants of suicidal beliefs for a whole-of-social club approach [44] given the widening gap in inequalities in suicide with higher rates among disadvantaged social groups and communities [45]. Our review identified no review addressing inequalities in late life suicide. This highlights the lack of a 'off-white opportunity of mental well-existence,' office of the World Wellness Organization Mental Health Activeness plan 2013–2020. To date, little data were found on interventions targeting high risk groups such equally older men and older people who practice not contact service providers, indicating the demand for farther investigation as to how to effectively reach these groups. Studies are also needed to examine the result for the oldest one-time (≥75 years), as well as the effect of universal, population-based suicide interventions, e.k. suicide-specific funding for interventions tailored to older people. A number of interventions with promising results in other age groups or areas of mental health crave testing in older people, such as cognitive behavioral therapy [46] or telemental wellness applications [47]. Furthermore, due to the recent meta-assay finding of a significant effect size for multilevel interventions (different healthcare settings or domains and past unlike providers) on suicide and suicide attempts in persons of all ages, large scale studies are needed to determine if this is also of added value for older persons [48]. Lastly, as older people are an increasing population, the concomitant increment in life expectancy related to this demographic change means that aging-related neurological illnesses will continue to increase, such that older people may be at increased gamble of suicidal behaviour. Interventions are needed to assess risk of suicide in older people newly diagnosed patients with neurological diseases [49].

Conclusions

The results of this review notice the bear witness inconclusive towards the use of antidepressants for the prevention of suicidal beliefs in older people and highlight that conscientious monitoring is required prior to the start, change in dose or cessation of antidepressants prescribed. Although evidence to date supports concrete activity and primary intendance collaborative management for the reduction of suicide ideation, additional trials are required for evidence from a meta-analysis. To build on these findings, continued high-quality research is warranted to evaluate the effectiveness of interventions targeting suicidal thoughts and beliefs in late life, particularly in older men and those who do not contact service providers.

Supporting information

Acknowledgments

The authors would like to thank Klas Moberg and Carl Gornitzki at the Karolinska Institutet Library for their expertise and support in the search for reviews.

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Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0262889

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