Utveckling av RESPI

Utgångspunkter för RESPI

Ambitionen är att förslagen på denna webbsida ska bygga på vetenskaplig grund. För att uppnå denna ambition genomförs systematiska litteraturöversikter årligen, för att identifiera insatser som har utvärderats vetenskapligt med suicidala beteenden som utfallsmått (fullbordat suicid och/eller suicidförsök). Det finns dock aktiviteter och strukturer som ligger utanför ramen för ”evidens”-konceptet, eller som aldrig har studerats i ett vetenskapligt sammanhang, men som bedöms vara uppenbarligen nödvändiga och därmed betraktas av RESPI:s arbetsgrupp som förutsättningar för ett lyckat suicidpreventivt arbete.

Förutsättningar är till exempel övergripande samhällsstrukturer såsom ett fungerande skolsystem och hälso- och sjukvårdssystem, eller mer specifika aktiviteter som till exempel att minska stigma eller öka kunskaperna om psykisk hälsa och suicidalitet. Dessa typer av insatser är ofta svåra att utvärdera och saknar därför specifik evidens gällande utfallsmåtten självmord. Trots detta anses de av arbetsgruppen vara så uppenbart viktiga att de rekommenderas oavsett evidensgrad (så länge evidens inte finns på att de ökar suicidalitet).

Evidensbaserade insatser är specifika insatser som har identifierats genom återkommande vetenskapliga litteraturgranskningar, och vars suicidpreventiva effekt har bedömts och evidensgraderats. Eftersom litteraturöversikterna endast har inkluderat utvärderingsstudier med fullbordat suicid och/eller suicidförsök som utfallsmått, så syftar ’effekten’ på en kvantifierbar förändring av just sådana beteenden (exempelvis minskade självmordstal), och inte förbättring av indirekta indikatorer (exempelvis minskning i psykisk ohälsa). Evidensgraderingen syftar vidare på hur konsekvent den suicidpreventiva effekten har rapporterats vara i litteraturen, och är en bedömning som författarna har gjort enligt följande kriterier:

Evidensgrader

Varje insats (eller typer av insatser) har bedömts utifrån fyra evidensgrader:

Stark evidens \| Starkt underlag	Minst en högkvalitativ studie (exempelvis en randomiserad kontrollerad studie) med positiva resultat, utan motsvarande motsägande studier
Måttlig evidens \| Måttligt underlag	En eller flera studier av suboptimal kvalitet, utan motsvarande motsägande studier. Eller flera högkvalitativa studier med motsägande resultat
Svag evidens \| Svagt underlag	Icke-empiriskt underlag, studier med inkonsekventa resultat (motsvarande motsägande studier finns) eller inga studier
Ingen evidens \| Inget underlag	Flera studier indikerar ökad ohälsa, eller visar konsekvent på nollresultat

Vid beskrivningen av varje evidensbaserad insats som rekommenderas på denna hemsida har läsaren möjligheten att ta sig vidare till en djupare evidensbeskrivning genom att klicka på respektive rekommendation.

Litteraturöversikt 2018 till 2022

En uppdatering av det vetenskapliga underlaget genomfördes under 2022 och 2023 för att granska den senaste litteraturen bestående av systematiska översikter, metaanalyser och originalstudier publicerade från 20 september 2018 till och med den 31 augusti 2022.

Samma fyra databaser som under den första litteraturgenomgången söktes igenom för att identifiera systematiska översikter och metaanalyser och originalstudier. Databaserna PubMed, Cochrane, WebOfScience och PsycInfo användes för de två förstnämnda publikationstyperna, medan endast PubMed användes för originalstudier. Sökkriterierna inkluderade publikationer som utvärderat universella eller populationsbaserade suicidpreventiva insatser, som undersökt självmordsförsök eller fullbordade självmord, som var publicerade mellan den 20 september 2018 och den 31 augusti 2022, och var skrivna på engelska eller svenska. Exklusionskriterier var publikationer som utvärderat kliniska eller farmakologiska insatser, som endast undersökt självskadehandlingar med oklar avsikt eller självmordstankar, som publicerades utanför den angivna tidsramen, eller som var skrivna på ett annat språk än engelska eller svenska.

Den uppdaterade sökningen identifierade totalt 688 systematiska översikter/sammanställningar, metaanalyser som studerat insatser med suicid och suicidförsök som utfallsmått. Tre personer ur arbetsgruppen granskade dessa sammanställningar separat och valde ut publikationer som de ansåg vara relevanta att inkludera. Efter detta diskuterades de artiklar som det inte rådde total överensstämmelse kring och beslut fattades utifrån konsensus. Vad gäller originalstudier identifierades totalt 1085 publikationer. Två personer ur arbetsgruppen valde individuellt ut de studier de ansåg uppfyllde kriterierna och diskuterade sedan på samma sätt för att nå konsensus. Därefter kategoriserade arbetsgruppen alla publikationer i de befintliga insatskategorierna och beslutade om vilka som bara behövde citeras i RESPI, vilka som behövde beskrivas i detalj och vilka som skulle kunna påverka evidensnivån för en insats. Totalt identifierades 54 publikationer som inkluderades i uppdateringen av RESPI, varav 13 metaanalyser, 27 översiktsartiklar, och 13 originalstudier. Regelbundna granskningar gjordes också av de enskilda originalstudierna som metaanalyserna och översiktsartiklarna hade omfattat. Syftet med detta var att kunna beskriva relevanta studier och interventioner i större detalj på de olika RESPI-sidorna.

Två personer ur arbetsgruppen sammanfattade översikterna och originalstudierna, varefter övriga personer i arbetsgruppen granskade texterna, samt gav kommentarer och förslag för att förbättra eller förtydliga det nya innehållet.

Foto: NASP

En ändring har gjorts gällande kategoriseringen av insatser. Kategorin ”Informationskampanjer” har gjorts om till att bli två separata kategorier: ”Informations- och mediekampanjer” och ”Medierapportering”.

På sidan Innehållsförändringar kan du läsa om eventuella ändringar i evidensgraderingen för respektive insatskategori efter uppdateringen.

Litteraturöversikt 2015 till 2018

Det vetenskapliga underlaget baserades på en systematisk litteratursökning och sammanställning av suicidpreventiv forskning publicerad från 1 januari 2015 till 1 mars 2018. Tidigare sammanställningar av evidensläget kring suicidprevention finns dokumenterade i bland annat Mann m.fl. (2005) och Zalsman m.fl. (2016), vilket användes som en utgångspunkt när evidens publicerad efter dessa sammanställningar granskades och sammanfattades.

Den uppdaterade sökningen inkluderar systematiska översikter/sammanställningar, metaanalyser (n = 43) och enskilda originalstudier (n = 15) som studerat interventioner med suicid och suicidförsök som utfallsmått.

Litteraturöversikten avsåg att inkludera utfallsmåtten suicid och suicidförsök men inte självskadehandlingar utan suicidal intention. Dock var denna distinktion inte alltid tydlig i den granskade litteraturen, delvis eftersom den heller inte alltid är tydlig inom den kliniska verksamheten, där självskador klassificeras enligt ICDsnip-10-manualen (då endast avsikten att självskada bedöms, men inte avsikten att dö). Vid sådana oklarheter tillämpades liberala inklusionskriterier. Studier inkluderades alltså om utfallet var en kombination av suicidförsök och självskador (i likhet med Socialstyrelsens klassifikation av skadehändelser: ”Avsiktlig självdestruktiv handling”), eller om det tydligt framgick att endast suicidförsök avsågs (exempelvis om forskningspersonerna hade självrapporterat att suicidal avsikt förelåg). Likaså exkluderades studier eller enskilda studieresultat om det stod klart att utfallet endast inkluderade självskador utan suicidal intention (vissa studier rapporterade exempelvis utfall separata utfall för suicidförsök och ’non-suicidal self-injury’ (NSSI)). Vissa oklarheter vad gäller utfallsmått, liksom andra frågor gällande exempelvis den vetenskapliga metoden och resultat, kunde lösas genom att granska originalstudierna i fråga (och i ett fall genom att kontakta artikelförfattaren). Inga exklusionskriterier tillämpades för på vilka sätt som suicidförsök och suicid rapporterades i studierna, vilket innebär att datakällan kunde vara bland annat olika former av register, journaler, självrapportering eller tredjepartsrapportering.

Sökningen gjordes i databaserna PubMed, Cochrane, WebOfScience, PsychInfo, med söktermerna ’Suicid* AND (prevent* OR = interve*)’. Relevanta studier identifierades även i referenslistorna på de inkluderade sammanställningarna. Efter sökningen granskades titlar och abstrakt för relevans. Relevanta artiklar granskades därefter i fulltext. Det vetenskapliga underlaget, samt det slutgiltiga innehållet på RESPI av individer med klinisk såväl som akademisk kompetens inom områden som psykologi, psykiatri, allmänmedicin, folkhälsovetenskap och hälsoekonomi.

Flödet av inkluderade sammanställningsartiklar redovisas i PRISMA-diagrammet nedan.

Foto: NASP

Utifrån denna forskning har ett antal preventiva insatser identifierats och beskrivits nedan. Insatserna begränsades till folkhälsoinriktade insatser, det vill säga icke-kliniska (såsom terapier och farmakologiska behandlingar), även om insatserna kunde involvera vårdpersonal (t.ex. stärkt vårdkedja, utbildning av kliniker, patientuppföljningar). Endast litteratur som omfattade suicidpreventiva interventioner inkluderades, och exkluderade därmed studier kring riskfaktorer och skyddande faktorer med suicidrelaterade utfall. Insatserna delades upp i 10 generella kategorier, med varierande grad av heterogenitet inom sig:

Prediktion av suicid
Restriktion av suicidmetoder
Minskad alkoholkonsumtion
Stärkt vårdkedja
Utbildning av vårdpersonal
Utbildning av icke-kliniker
Rapportering och informationskampanjer i media
Skolbaserade insatser
Hjälp- och stödinsatser
Suicidpreventiva insatser med multipla komponenter

Under vissa rubriker bedöms evidensen för enskilda insatser (exempelvis rubriken om skolbaserade insatser), men i andra fall bedöms evidensen för flera grupperade insatser (exempelvis rubriken utbildning av sjukvårdspersonal). Valet att gruppera eller inte gruppera insatser görs genom kvalitativa och iterativa bedömningar, enligt principen om att maximera homogeniteten inom insatser, och maximera heterogeniteten mellan olika rubriker. Homogeniteten avser här huvudsakligen insatsernas praktiska innehåll, men även dess påvisade effekter i de granskade studierna. Exempelvis har enskilda evidensbedömningar gjorts för specifika skolbaserade insatser eftersom dessa i hög utsträckning har varit standardiserade. Med andra ord är de innehållsmässigt konsekventa, och deras suicidpreventiva effekter kan troligtvis tillskrivas deras specifika manualer (det vill säga stark evidens för programmet A innebär inte automatiskt att programmet B också har stark evidens om de bygger på olika manualer). Däremot gäller detta inte för exempelvis utbildningar till sjukvårdspersonal eftersom det varit svårt att identifiera komponenter i de olika programmen som skulle kunna förklara varför effekterna varierar mellan studierna. I dessa fall har alltså en samlad evidensbedömning gjorts för alla typer av utbildningar riktade till sjukvårdspersonal.

I referenslistorna på denna sida, samt under respektive sida på RESPI, anges endast förstahandsreferenser, och inte de originalstudier som ingick i översikter/sammanställningar eller metaanalyser.

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