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Special Collection - Free access to reviews

Health of Indigenous peoples: suicide prevention

Special Collection
This Special Collection is one of a series focusing on health of Indigenous peoples. See also the Special Collections on fetal alcohol spectrum disorders and diabetes and two accompanying editorials: Improving health outcomes for Indigenous peoples: what are the challenges? and Can Cochrane Reviews inform decisions to improve Indigenous people’s health?

Indigenous peoples of Australia, Canada, USA, and New Zealand experience disproportionately high rates of suicide. Prevention strategies look for a holistic view of mental, physical, cultural, and spiritual health and have an early-intervention focus that works to build strong communities through more community-focused and integrated approaches to suicide prevention.[1–3]
This Special Collection brings together systematic reviews of suicide prevention interventions with a focus on Indigenous peoples in Australia, United States, Canada, and New Zealand. There is not a great amount of evidence on suicide prevention in general, and a dearth of topical studies for Indigenous peoples in particular. The list of Cochrane Reviews is in fact disappointingly short and directed towards pharmacological treatments aimed at reducing suicidality. The reviews provide complementary information on approaches to suicide prevention in university settings and a wealth of information on the potential harms of drug therapies, especially for adolescents and young adults. Some of the reviews deal with combined pharmaco- and psychological or psychosocial therapy. None of them deal purely with non-drug-based interventions, and yet this is what Indigenous communities are saying they want. Communities are seeking ways of achieving wellness through application of Indigenous knowledge and Two-eyed Seeing (i.e. combining the best of Indigenous and Western approaches).[4] Further, only one of the studies included in the systematic reviews appears to have involved Indigenous peoples, particularly those living in Indigenous communities.[5]
Recently, Canada and a number of Nordic regions (Norway, Greenland, and USA - Alaska in particular) supported a study of best and promising practices in youth suicide prevention in circumpolar regions. Two international teams produced a synthesis report of best practices, which were presented at a conference in Iqaluit, Nunavut in March 2015.[6] Both of the teams highlighted promising practices on the basis of a number of community-based pilot studies. Some common themes emerged. All of the projects involved youth participation, in some cases with Elders, in others with local paraprofessionals. None of the six case studies highlighted had pharmacotherapy as its basis. These were community-based studies, and when community participants were involved in the study design and/or the carrying out of the intervention, the approaches did not involve the testing of pharmaceuticals.
Although drug and alcohol use are among the proximal causes of mental health conditions and contribute to suicide, they are not the root causes, certainly not in Indigenous populations. Distal causes include historical and current traumas common to Indigenous peoples worldwide – racism, displacement, cultural disconnection – that are the products of failed colonial policies in all of our countries.[7] The solutions to these problems lie in interventions with and by, not on and for, Indigenous people themselves.[8] Indigenous leadership is key to making these interventions successful.

Alcohol abuse interventions

Alcohol abuse is linked with an increase of the risk of suicide. 
Effectiveness of brief alcohol interventions in primary care populations
Early identification and secondary prevention of alcohol problems, using screening and brief interventions in primary care, have been reported to reduce the consumption of alcohol. Core features of these are that generalist health care workers deliver them, target a population of excessive (or hazardous) drinkers that tends not to be seeking help for alcohol problems and aim for reductions in consumption behaviour and related harm. This review evaluates the effectiveness of brief intervention, delivered in general practice or primary care, to reduce alcohol consumption. 

Other public health interventions

Community coalition‐driven interventions to reduce health disparities among racial and ethnic minority populations
Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models. This review assesses the effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

Harms of drug treatment

Drug therapy (particularly antidepressants) has been shown to increase the risk of suicide or suicidal ideation in adolescents and young adults.
Free Access
Tricyclic drugs for depression in children and adolescents
Depression can contribute to a variety of negative outcomes, such as poor academic functioning and difficulties in peer and family relationships. It also increases the risk for substance use, self-harm and suicide. This reviews assesses the effects of tricyclic drugs compared with placebo in children and adolescents and aims to determine differential responses between children and adolescents. Since this Cochrane Review was first published in 2000, tricyclic drugs have been replaced in most countries by newer-generation antidepressants.
Free Access
Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents
Depressive disorders are common in children and adolescents. Common symptoms of depression in children and adolescents include low mood, a loss of interest in once enjoyed activities, difficulties with concentration and motivation, changes in appetite and sleep, irritability, physical symptoms such as headaches or stomach aches and in some cases thoughts of suicide. This review evaluates psychological therapies and antidepressant medication, alone and in combination, to assess the effects of these interventions on depression in children and adolescents.
Free Access
Newer generation antidepressants for depressive disorders in children and adolescents
Depression is common in young people and can contribute to a variety of negative outcomes, such as poor academic functioning, difficulties in peer and family relationships, increases in substance use, and both attempted and completed suicide. This review aimed to determine the efficacy and adverse outcomes, including definitive suicidal behaviour and suicidal ideation, of newer generation antidepressants compared with placebo.
Free Access
Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms. This review assesses whether the combination of psychological therapy and pharmacotherapy is more effective for PTSD than either intervention delivered separately.
Pharmacological interventions for self‐harm in adults
Self-harm (intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This review focuses on pharmacological interventions in adults who self harm; it aims to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for self-harm patients.

Suicide prevention strategies targeting Indigenous populations

Open Access
A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand
The methodological quality of evaluations of suicide prevention interventions targeting Indigenous populations should be rigorously examined, in order to determine the extent to which they are effective for reducing rates of Indigenous suicide and suicidal behaviours. This systematic review aims to: 1) identify published evaluations of suicide prevention interventions targeting Indigenous peoples in Australia, Canada, United States and New Zealand; 2) critique their methodological quality; and 3) describe their main characteristics.