Peer-support groups for survivors of suicide attempt (SOSA): Systematic review.

Carolina Inostroza R., Dany Fernandez V., Yanet Quijada I., Claudio Bustos N., Francisca Rubio R., Vasily Buhring S., Belen Vargas G., Alejandro Riquelme B., Maria Paz Araya A.

ABSTRACT


Background: Suicide attempt is the main risk factor for death by suicide. The World Health Organization (WHO) suggests support groups as an intervention for this population. Objective: This study aimed to assess the efficacy of peer-support groups for survivors of suicide attempt (SOSA). Method: Systematic review (PROSPERO ID: CRD42022307581). Results: In total, 946 potential articles were identified, 81 full texts were reviewed, and one article was included. The article reported an open-label pilot study with pre- and post-intervention evaluations, without a control group, and with a high risk of bias. This is a promising intervention because the results showed decreased suicidal ideation (d=0.33) and suicide attempt (d=0.31). The small number of empirical investigations limit generalizations. Conclusion: The level of certainty of evidence is low (low certainty); therefore, the grade of recommendation corresponds to insufficient evidence (I) to recommend this strategy for public policies. The reasons for these results and possible paths to advance the field are discussed in this article.

Keywords: suicide attempt, survivals, support group.

INTRODUCTION


Suicide is a serious public health problem(1-3) and is among the top twenty causes of death worldwide, with approximately seven hundred three thousand people dying by suicide each year (3). Reducing suicide is a priority for the World Health Organization (WHO)(3). As such, suicide-prevention programs have been developed, particularly in developed countries (4-8). Chile has joined this call by establishing preventive actions in the National Suicide Prevention Program (8).

Suicidal ideation and suicide attempts are strong predictors of death by suicide and may have negative consequences, such as injuries and hospitalization (2,9). A suicide attempt is defined as a self-directed, nonfatal act in which someone harms themselves with the intent to end their life but does not die as a result of their actions (10). Thus, those who carry out this carry out this behavior represent a population with a high risk of dying by suicide and making other attempts (10). This population, also called survivors of suicide attempts (SOSA), not only share a higher risk of suicide but also deal with the stigma of having attempted suicide (11), as well as a series of compatible symptoms with post-traumatic stress disorder (12), and in some cases, the physical consequences of the act itself.

Given the high risk of SOSA, there are different clinical interventions for support, treatment, and follow-up. These include dialectical behavior therapy (DBT), cognitive therapy (CT), collaborative assessment and management of suicidality (CAMS), and enhanced usual care (EUC) (2,10,13). Likewise, and from a more community perspective, initiatives emerge in mutual support services (peer provided services) that contain duo formats (known as “peer to peer”) as well as collective such as peer support groups (14). Compared to clinical ones, the most distinctive impact of these community strategies would be in the social aspects related to stigma and the feeling of disconnection or not belonging (15).

Peer support groups are made up of people who have been affected by a problem or illness, and are led by their own members. These groups offer support opportunities in crisis situations and are an effective strategy for engaging with people not reached by health services (16). Peer-support groups are based on principles such as respect, empathy, shared responsibility, and mutual agreement(17). These programs are available for college students(18), individuals with severe mental disorders(19), veterans(20), suicide survivors(21), and other populations. Recently, the National Action Alliance for Suicide Prevention(22) has recommended the development, evaluation, and promotion of support groups for people who have experienced suicidal crises and the benefit of them being led or co-facilitated by a peer with experiences similar or expert by experience.

Systematic reviews and/ or meta-analyses have assessed the efficacy of targeted clinical or community interventions in suicide attempters(23-28). However, these studies did not include evidence on peer-support groups even though they are widely used community-based strategies(29). This systematic review aimed to investigate the efficacy of SOSA peer-support programs and narratively describe relevant aspects of this suicide prevention strategy.

METHODS


The preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) methods(30) were adopted in this study, which was conducted in two phases (PROSPERO ID: CRD42022307581).

In phase 1, articles were selected in four stages: identification, screening, eligibility, and inclusion (Figure 1). The references were processed using Buhos software (31), which manages all stages of the process in a centralized way.

The search was performed using a double strategy:

1. Descending method: search in indexed databases (PubMed, Web of Science, Scopus, and SciELO), limited to the period from 01/01/2000 to 31/12/2021.

2. Ascending method: backward snowball search for references of articles screened from the database search and for articles selected in informal searches (quasi-gold standard).

Inclusion criteria:

1. Participants: SOSA.

2. Intervention: SOSA support group, including experience-based, expert-led support groups, with and without professional support.

3. Control: individual interventions, whether pharmacological or psychological therapy, group interventions led by professionals, and treatment as usual. Prospective observational studies may not have had controls, but they were considered, nevertheless.

Outcomes:

Primary: level of suicidal ideation/ incidence of new suicide attempts/ suicides.

Secondary: indicators of general functioning/ changes in risk/ protective factors for suicidal behavior and participation risks.

Type of study: randomized, quasi-experimental, observational, prospective cohort, case and time series, and retrospective and qualitative clinical trials.

Type of paper: research articles in English or Spanish with full-text availability.

Exclusion criteria:

Theoretical studies, letters to the editor, book reviews.

Two independent reviewers, DF and FR, applied these criteria, and discrepancies were resolved by consensus with three other researchers, CI, CB, and YQ.

In phase 2, two independent evaluators, DF and FR, analyzed the article included in this study. For this purpose, they applied the revised Cochrane risk-of-bias tool criteria for randomized trials for experimental and quasi-experimental studies (RoB-1) (32). They assessed the quality of the evidence using the criteria of the U.S. Preventive Task Force (33).

RESULTS


In total, after eliminating duplicates, 946 articles were screened. Of these, 865 were excluded through title and abstract analysis. 81 full texts were reviewed in the eligibility phase, and only one article was included for qualitative synthesis, which reported findings from a SOSA support group program (34).

Out of the 81 analyzed full-text entries, 57 corresponded to general reviews about suicide prevention (narrative reviews, systematic reviews, or meta-analyses), 20 articles corresponded to intervention studies, out of which 15 were intervention studies that did not include peer support strategy. Five articles described peer support strategies, of which four present peer-to-peer support interventions, and one is the selected article on peer support groups for SOSA (these five articles are summarized in table 1). In addition, two articles on expert recommendations, one discourse analysis, and one report without full text were not analyzed.

Systematic review main result

At the end of the systematic review, one article was included, which reported the findings of a SOSA support group program (34). According to the criteria of the US Preventive Task Force (33), peer support groups for suicide attempt survivors (SOSA) correspond to a low level of evidence (low certainty) due to the limited number of studies and their low methodological quality. The grade of recommendation corresponds to insufficient evidence (I).

SOSA support group program

The selected article of the review reported the findings of an SOSA support group program(34), developed by Didi Hirsch Mental Health Services in the United States of America (35). The corresponding Survivors of Suicide Attempts Manual for Support Groups is available from http://www.didihirsch.org/.

This was an open-label pilot study with pre- and post-intervention evaluations, without a control group, and with a high risk of bias. The objective was to assess changes in suicidal symptoms and resilience ratings after participation in the support group for people with a history of suicide attempts (n = 92), which consisted of a closed group with eight sessions led by a pair of a professional health facilitator, together with an experience-based expert.

The program significantly decreased suicidal ideation t (53) = -2.46, p = 0.017 and suicide attempts t (63) = -2.52, p = 0.014 among the participants, with small-to-medium effect sizes for ideation (d = 0.33) and for suicide attempts (d = 0.31), which indicates that the program may have a modest effect on suicidal symptoms. In addition, participation in this program was associated with significant increases in resilience rating t (53) = 2.48, p =0.016, d = 0.33. Three participants (3.8%) showed increased suicidal symptoms, and two (2.4%) attempted suicide and were hospitalized for psychiatric reasons during the study. Although the study reported positive results such as good adherence, tolerance, decreased suicidal ideation and attempt, and resilience in the treated group, these results should be taken with caution since the methodological design has a high risk of bias: It is not possible to know if the effects correspond to participation in the mutual support group or to another intervention received in parallel; the self-selection of the participants, both in the mutual support group and in the participation in the study, among others.

Other peer support programs with a “Peer to Peer” strategy

Although it does not correspond to the main result, it was decided to review the programs with a “peer to peer” strategy (see Table 1) detected in the review of full-text articles. The four interventions analyzed are characterized by involving an experienced expert alongside a person who has experienced a suicidal crisis with a suicide attempt. In this format, social support is provided to people at risk of suicide in a one-on-one and non-group interaction. The participation of peers is oriented to provide information from their lived experience, identify needs, provide information from the health system, and provide accompaniment after a hospitalization process. These studies are usually developed by health services and carried out in clinical populations or with military veterans. The reviewed articles show that peer-to-peer interventions have good results regarding implementation and acceptance of participants, and promising effects in terms of efficacy, as a reduction in the number of hospitalizations and days of hospitalization.

Discussion

Review of the Key Findings

Only one efficacy study on SOSA support groups has been published thus far (34), and the study reported positive results, such as decreased ideation and repetition of suicide attempts and increased resilience in the treatment group. However, these results should be taken cautiously because the methodological design has a high risk of bias. Some lessons are learned, such as the need to hospitalize some participants for suicide attempts, which highlights the importance of connecting these groups to the health system (22) and including a professional health facilitator who is capable of detecting and managing suicidal risk(36).

Considering the criteria of the U.S. Preventive Task Force (33), the level of evidence corresponds to low certainty due to the limited number of studies and their low methodological quality. In turn, the degree of recommendation corresponds to insufficient evidence, given the inability to determine whether participation in a support group for people who have attempted suicide generates greater benefits than risks. Notably, this aspect should be explained to potential participants so that they can make informed decisions.

Current state of peer support-based suicide prevention for Suicide Attempt Survivors (SOSA) research

According to the objectives of this study, we conducted a search guided by the terms “suicide prevention” and “peer support group”. Most research has focused on studying suicide prevention strategies that do not include peer support as an active component but present clinical or multicomponent interventions.

Only five published studies focus on the peer support strategy, in all cases being a complementary strategy to usual clinical treatment. The scarcity of studies that use the peer support strategy for suicide prevention had previously been detected in a review on lived experience with articles until 2019(29) who point out that there is a lack of research on the design, implementation, and effectiveness of programs based on lived experience for suicide prevention. The effectiveness of peer-to-peer interventions has yet to be evaluated, but they present promising implementation indicators. As in the case of peer groups, further research is required to accumulate sufficient evidence to assess the effectiveness of peer support strategies before their use can be recommended for public policy.

Several reasons may explain the lack of studies on the peer support strategy in general - and peer support groups in particular - for survivors of suicide attempts. Suicide attempt survivors are a high-risk group, which could explain why studies have prioritized clinical interventions over support groups (23-28). It should be noted that many SOSAs are diagnosed with a mental disorder, so that they may participate in support groups for mental health patients and not in SOSAs only groups (19).

Other reasons are ethical-methodological: support groups are formed in such a way that precludes compliance with clinical trial standards, such as random assignment or double-masked assessment. Likewise, it would be unethical to put people at high suicidal risk on the waiting list control group or assign a person to a peer support group for survivors as a single intervention.

Although the peer support strategy was not specified within the search criteria, this modality did appear within the mutual support services and has some favorable evidence of effectiveness and implementation for suicide prevention. This strategy may be especially effective for patients who live in a state of loneliness and who require support at critical times and are at increased risk of suicidal reattempts, such as the 6-month to one-year follow-up period after discharge from a psychiatric emergency due to self-inflicted injuries(37).

Implications and Projections

As we discussed earlier, evaluating the effectiveness of peer support interventions presents ethical and methodological difficulties. Therefore, it is a task for the scientific world to develop studies that allow us to address these challenges in order to obtain greater certainty. A possible approach to improve the evidence is the development of follow-up studies of natural cohorts that have participated in peer support groups for suicide survivors and their comparison with groups without participation, including as primary results the decrease in suicidal risk. Another viable strategy is the development of trials comparing groups that receive treatment as usual and others that receive the usual treatments supplemented by participation in a peer support group. This type of study should go hand in hand with acceptability and implementation research that makes it possible to improve the already existing promising experiences.

The need to have evidence that makes it possible to establish an adequate balance of risks and benefits that supports the recommendation of any intervention should not be forgotten. Thus arises the challenge of supporting the development of evidence for programs such as peer support groups for survivors of suicide attempts, integrating the health system, academia, and the community itself.

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