Introduction
Suicidality is a term which encompasses thoughts and behaviours relating to suicide, from a passive wish for death or active thoughts of killing oneself (suicidal ideation) to acts which involve self-injury, which may or may not be intended to cause immediate death (Posner et al. Reference Posner, Oquendo, Gould, Stanley and Davies2007). According to the last official figures released by the Central Statistics Office, 449 people died by suicide in Ireland during 2021 (Central Statistics Office, 2024). In the same year, the National Self-Harm Registry estimated that 9533 people presented to the Emergency Department with self-harm (National Suicide Research Foundation, 2024). Worldwide more than 720,000 people die due to suicide every year, and many more attempt to take their own life. It is the fourth leading cause of death worldwide for those aged 15 to 29 years. It is a significant public health problem worldwide. Nonetheless, certain suicides may be preventable with timely evidence-based interventions that are often low in cost to healthcare services (WHO 2024).
Research has found clear links between suicidal ideation and completed suicides. Suicidal ideation has been found in several studies to be a strong predictor of suicidal behaviour (Nock et al. Reference Nock, Millner, Joiner, Gutierrez, Han, Hwang, King, Naifeh, Sampson, Zaslavsky and Stein2018; Ribeiro et al. Reference Ribeiro, Franklin, Fox, Bentley, Kleiman, Chang and Nock2016). Rossom and colleague’s (2017) review of almost a million Patient Health Questionnaires-9 (PHQ-9) completed by outpatients at mental health service providers in the USA concluded that ‘Suicidal ideation was a robust predictor of suicide attempts and deaths in all ages’ with the risk rising with the frequency of the ideation reported. Screening instruments for depression typically include questions about suicidal ideation and these questions have been shown to have predictive value regarding subsequent suicide attempts (Louzon et al. Reference Louzon, Bossarte, McCarthy and Katz2016; Simon et al. Reference Simon, Coleman, Rossom, Beck, Oliver, Johnson, Whiteside, Operskalski, Penfold, Shortreed and Rutter2016, Reference Simon, Rutter, Peterson, Oliver, Whiteside, Operskalski and Ludman2013). The ninth question on the Patient Health Questionnaire-9 (PHQ-9) is a commonly used psychometric measure of suicidality (Richards et al. Reference Richards, Hohl, Whiteside, Ludman, Grossman, Simon, Shortreed, Lee, Parrish, Shea and Caldeiro2019).
There is now much evidence which supports the idea that treatments which reduce levels of depression can also reduce suicidal ideation. Suicide commonly occurs within the context of mental illness, with certain studies that suggesting that 60% of people who die by suicide have had a previous diagnosis of depression (Weitz et al. Reference Weitz, Hollon, Kerkhof and Cuijpers2014). Similarly, other studies indicate that the likelihood that someone attempting or contemplating suicide fulfilling the criteria for depression is quite high (Gøtzsche and Gøtzsche Reference Gøtzsche and Gøtzsche2017). Cognitive–Behavioural Therapy (CBT) is routinely used as an effective psychological intervention in the treatment of depression (Chambless and Ollendick Reference Chambless and Ollendick2001; NICE 2022). There is strong evidence suggesting that CBT interventions yield larger short-term decreases in depression scores compared to treatment as usual (i.e. pharmacotherapy, access to information on depression, or appropriate treatment as deemed by General Practitioner) (López-López et al. Reference López-López, Davies, Caldwell, Churchill, Peters, Tallon, Dawson, Wu, Li, Taylor and Lewis2019).
Table 1. Response to intervention of those who reported suicidal ideation at assessment
Table 2. Reliable change (improvement ≥ 5pts) in PHQ-8 scores pre and post intervention
Table 3. Clinical recovery (final score ≥ 9) in PHQ-9 scores pre and post-intervention
However, several papers have highlighted the lack of research which examines interventions for suicidality in primary care settings (Dueweke and Bridges Reference Dueweke and Bridges2018; Wu et al. Reference Wu, Lu, Qian, Jin, Yu, Du, Fu, Zhu and Chen2022). Early intervention is at the forefront of suicide prevention policies, both in Ireland and internationally (McBride et al. Reference McBride, McBride, McHugh and Burns2024). There is a dearth of studies, particularly in Ireland, investigating psychological interventions and whether they reduce suicidality in community settings. Consequently, it remained unclear whether the delivery of brief CBT interventions in an Irish Primary Care setting would have an impact on suicidality in presenting service users. The evidence supporting the use of CBT as an intervention for suicidality have been focussed on adult populations connected with the US military (cf: Nock et al. Reference Nock, Millner, Joiner, Gutierrez, Han, Hwang, King, Naifeh, Sampson, Zaslavsky and Stein2018). Therefore, it may be important to investigate whether similar results can be replicated in an Irish rural community setting and also whether such results may occur separate from, or are associated with, reductions in the symptoms of low mood. Previous research in an Irish setting has demonstrated that swift access to brief psychological intervention positively impacts low mood (Collins et al. Reference Collins, Walsh, Walsh, Corbett, Finnegan, Murphy, Clogher, Cleary and Kearns2020; Walshe et al. Reference Walshe, Walsh, Clogher, Collins and Byrne2019).
This analysis was conducted as a part of a service evaluation auditing routine service outcomes within a primary care psychology service located in a rural county in Ireland. The NICE (2022) guidelines for the treatment of low mood and depression have set out explicit criteria for stepped-care provision of psychological intervention, as provided in this service. Namely, it highlights that treatments should ‘monitor suicidal ideation, particularly in the early weeks of treatment; and consider routine outcome monitoring (using appropriate validated sessional outcome measures, for example PHQ-9)’ (NICE 2022; criterion 1.4.3 pg 113). This service was established, in alignment with NICE guidelines, with the explicit criteria of providing swift access to evidence-based psychological intervention that would improve clinical presentations while reducing associated suicidal risk (Bourke and Byrne Reference Bourke and Byrne2012; Kelly et al. Reference Kelly, Sammon and Byrne2014; McHugh et al. Reference McHugh, Gordon and Byrne2014). As such, this project aimed to explicitly audit the service’s data on clinical outcomes and suicidal ideation. Furthermore to ensure this evaluation explicitly sought ‘to improve patient care and outcomes’ we analysed the data to see whether our service provision meaningfully achieved the criterion set by NICE that services review ‘how well the treatment is working’ (NICE 2022; criterion 1.4.3 pg. 113). Specifically, in this evaluation, we set out as objectives to (a) identify whether, in those reporting low mood in the clinical range, the stepped-care intervention offered by this service reduced suicidal ideation (as reported by Q9 in the PHQ-9). (b) Identify whether the intervention offered impacted low mood (as measured by the PHQ-9) and, if so, whether any impact was associated with suicidal ideation as reported at assessment.
Method
Service design/procedure
The evaluation involved analysis of anonymised, routinely collected service data. As the work constituted an evaluation of a clinical service rather than primary research, it did not require formal external ethical approval (cf: ‘Understanding the difference between research and other activities’ Health Services Executive, 2021). Nevertheless, to ensure appropriate ethical oversight the clinical evaluation was independently reviewed by the clinical head of service and also by the regional Clinical Research Ethics Committee (CREC) who confirmed in writing that additional approval was not required. All service users provided informed consent for the use of their anonymised clinical outcome data for service evaluation purposes.
The service provides swift access to low-intensity psychological interventions for adults across six community bases. Self-referrals are accepted, and interventions are offered at no cost to service users. Following referral, clients are typically offered an assessment within days to determine suitability for brief psychological input. Presentations involving acute or high-risk needs requiring multidisciplinary or longer-term input are signposted to appropriate services.
Interventions are delivered by a team comprising of a senior clinical psychologist, trainee clinical psychologists, and assistant psychologists, under clinical supervision. Assistant psychologists are psychology graduates, typically with postgraduate training, who have received service-specific training in delivering brief, evidence-based interventions. The interventions provided are brief (typically 1–6 sessions) and commonly based on cognitive-behavioural therapy (CBT) principles, including psychoeducation, guided self-help, behavioural activation, and problem-solving. Clinical outcome measures, including the PHQ-9, are administered at assessment and discharge. Inclusion criteria for the service included a mild to moderate mental health condition likely to benefit from a brief psychological intervention. Exclusion criteria included severe mental health conditions, significant neurodevelopmental conditions or presentations with acute or pronounced clinical risk.
Participants
This clinical audit included all service users who completed a brief, individual CBT-based intervention between January 1st, 2018, and April 30th, 2024, and who scored ≥ 10 on the PHQ-9 at assessment (clinical cut-off for depression). The sample included 428 participants, all residents of one rural Irish county. The participants were 70.09% female and 29.91% male. A significant proportion of participants were within early adulthood (ages 18–39; 43.43%) or middle adulthood (ages 40–59; 40.85%), with 15.73% of clients being above the age of 60 (older adulthood).
Measures
The PHQ-9 was used to assess symptoms of depression. The PHQ-9 includes nine items rated on a 4-point scale, with total scores ranging from 0 to 27. Item 9 (‘Thoughts that you would be better off dead or of hurting yourself in some way’) was used to assess suicidal ideation. This item is widely recognised as a valid indicator of suicidality (Kroenke et al. Reference Kroenke, Spitzer and Williams2001; Rossom et al. Reference Rossom, Coleman, Ahmedani, Beck, Johnson, Oliver and Simon2017).
To distinguish depressive symptom change from suicidal ideation change, the first eight items of the PHQ-9 (PHQ-8) were used as a measure of depression severity, consistent with the methodology of previous studies (Schneider et al. Reference Schneider, Chen, Lungu and Grasso2020; Wells et al. Reference Wells, Horton, LeardMann, Jacobson and Boyko2013). Reports of past or current self-harming behaviour and suicidality were also recorded at the assessment stage in accordance with routine clinical procedure.
Analyses
Analyses were conducted using SPSS v.29 (IBM 2023). The audit evaluated whether service outcomes met expected standards of care, focusing on symptom reduction and improvement in suicidal ideation.
Rates of clinically significant improvement (or reliable change) were calculated, defined as a decrease of at least 5 points on the PHQ-8 (Wells et al. Reference Wells, Horton, LeardMann, Jacobson and Boyko2013). A Bowker’s Test of Symmetry was used to examine changes in responses on PHQ-9 Item 9 between assessment and discharge. Mann–Whitney U tests were conducted to explore whether baseline suicidal ideation predicted differences in reliable change and clinical recovery outcomes.
All analyses were based on anonymised clinical outcome data collected as part of routine service delivery.
Results
Descriptive statistics
The sample consisted of N = 428 participants, including n = 300 (70.1%) women and n = 128 (29.9%) men. The age of participants ranged from 19 to 86 (M = 43.07, SD = 14.86). Participants all lived in one rural Irish county. A total of n = 53 (12.4%) participants indicated that they had self-harmed in the past. On PHQ-9 Q9 (in relation to the previous two weeks), n = 304 (71%) answered ‘not at all’ (i.e. no presence of suicidal ideation), n = 87 (20.3%) had suicidal ideation on ‘several days’, n = 25 (5.8%) expressed suicidal ideation on ‘more than half the days’, and n = 12 (2.8%) expressed suicidal ideation ‘nearly every day’. Regarding past suicidality, n = 283 (66.1%) indicated no past risk, n = 96 (22.4%) reported past suicidal ideation, n = 15 (3.5%) reported past suicide intent/plan, n = 30 (7%) reported a past suicide attempt and n = 4 (1%) provided no or insufficient information.
Evaluation Question 1: Impact on suicidal ideation – differences in pre and post intervention scores on PHQ-9 Q9
Of the 124 clients who reported some form of suicidal ideation at assessment (from some to daily), n = 113 (91%) reported a reduction in suicidal ideation after an intervention with the service (see Table 1). Of these 124 clients, n = 105 (85%) reported no longer having any suicidal ideation after a brief intervention by the service.
A Bowker’s Test of Symmetry was conducted to examine the difference in responses of clients between pre-intervention and post-intervention on PHQ-9 Q9. The results indicated a significant change in the distribution of responses, x 2(6, n = 428) = 56/90, p < 0.001, indicating that the improvement in scores was statistically significant.
Evaluation Question 2: Clinical outcomes (PHQ-8) by scores on PHQ-9 Q9 at assessment
A Mann-Whitney U test was conducted to determine whether there was a difference in PHQ-9 Q9 scores at assessment between those who achieved reliable change (see Table 2) and those who did not. The results indicated a statistically significant difference in the distributions of scores between the two groups, U = 15,022.50, z = −2.21, p = 0.027. Participants who did not show reliable change had higher ranks in PHQ-9 Q9 scores (mean rank = 232.93) at assessment, compared to those who showed reliable change (mean rank = 208.52). This suggests that individuals who did not experience reliable change reported higher scores on assessment on PHQ-9 Q9 compared to those who experienced reliable change.
A Mann-Whitney U test was conducted to determine whether there was a difference in PHQ-9 Q9 scores at assessment between those who achieved clinical recovery (see Table 3) and those who did not. The results indicated a statistically significant difference in the distributions of scores between the two groups, U = 16,960.50, z = −4.50, p = <0.001. Participants who did not show clinical recovery had higher ranks in PHQ-9 Q9 scores (mean rank = 242.22) compared to those who showed clinical recovery (mean rank = 198.05). This suggests that individuals who did not achieve clinical recovery reported higher scores on assessment on PHQ-9 Q9 than those who experienced clinical recovery.
Discussion
Suicidality remains a critical public health issue and is closely correlated with depression. Establishing pragmatic, evidence-based models of delivering interventions that reduce suicidality in individuals with low mood is essential at a population level to efforts to reduce suicide. While short-term psychological interventions have proven effective for alleviating depressive symptoms, their impact on suicidality remains less clear. The value of auditing the data of a frontline service provider includes that of it being representative of a ‘real-world’ naturalistic community setting.
The current evaluation provides encouraging evidence that in providing swift access to psychological interventions for those at higher clinical risk of suicide due to the presence of depressive symptoms, this service is achieving a number of positive outcomes in alignment with its key service objectives (of reducing low mood and suicidal ideation).
With 91% of those who had reported suicidality at assessment reporting an improvement at discharge – 85% reporting no suicidality at discharge – the results provide encouraging evidence for the use of brief psychological interventions in the treatment of suicidal and self-harm ideation, building on previous findings from other studies (Bryan et al. Reference Bryan, Peterson and Rudd2018; Mann et al. Reference Mann, Michel and Auerbach2021; Schneider et al. Reference Schneider, Chen, Lungu and Grasso2020).
Similarly, the fact that the majority (61%) of those who reported suicidality at assessment achieved reliable change in depression scores post intervention (with 47% achieving clinical recovery) is also an encouraging finding. The absence of reported suicidal and/or ideation at assessment is associated with a greater likelihood of reliable change and clinical recovery at discharge. However, given that the majority who expressed such ideation also experienced reliable change (and almost half achieved clinical recovery), this indicates that the presence of suicidal or self-harm ideation alone at assessment should not be a determining factor in gaining access to brief psychological interventions in primary care settings.
The swiftness of the service response may be one crucial element to the success of such intervention given the research that the clinical risk of those with ideation engaging in suicidal behaviour is highest in the first 12 months of ideation. Similarly, accessibility may also be an important factor in that requiring a GP referral, or payment for a service, or not providing a service at a base local to the service user, may deter certain individuals in availing of help swiftly, with any delay potentially leading to a deterioration in presentation. Given that service users who presented in acute crisis were signposted to emergency services, this service model may best be understood as complementing rather than replacing the need for acute crisis responses to those in severe distress.
Limitations
While the PHQ-9 is widely used as a screening instrument for depressive symptoms, it is not considered a DSM diagnostic tool for depression. In terms of suicidal ideation while PHQ-9 Q9 is widely used, other measures such as the Columbia Classification Alogorithm of Suicide Assessment (C-CASA), as a more in-depth questionnaire on suicidality, may add additional value in any further studies. No comment can be made on those who didn’t complete the intervention or were sign-posted early to other services. As such these results may not be generalisable to the treatment of cases in acute crisis. As the data relates to all primary care presentations of low mood in the clinical range, it did not seek to exclude those with co-morbid anxiety, substance abuse or other conditions. This may limit its applicability to conclusions about treating those with exclusively low mood. Conversely this could also be seen as a strength in that low mood most commonly presents in community settings with other comorbid conditions (Wittchen et al. Reference Wittchen, Lieb, Wunderlich and Schuster1999). Similarly, if accessibility and speed of response are crucial mediating variables then it may not be possible to presume that such results would occur in services that offer brief input to an individual following an extended period on a long waiting list, or in those services where other structural barriers exist (e.g. requiring payment for the service or requiring the service user to travel some distance for the service).
Implications
Advocating for early intervention as a primary strategy in government suicide prevention policy is now common worldwide (McBride et al. Reference McBride, McBride, McHugh and Burns2024). The World Health Organisation has documented that early intervention is not only effective but also cost-efficient (World Health Organisation 2024). This evaluation supports such calls and more specifically provides initial encouraging evidence that the delivery of brief psychological interventions in rural Irish community settings may effectively reduce suicidal ideation and improve mood in those service users presenting with clinical levels of low mood.
Conclusion
An audit of clinical data from a rural, frontline primary care psychology service appears to indicate that swift access to psychological intervention reduced levels of suicidal and self-harm ideation in those who presented suffering from depressive symptoms in the clinical range. The reductions in suicidal ideation appeared to coincide with reductions in the symptoms of low mood. Replication of these results with larger, more controlled studies with greater statistical power would be required for conclusions generalisable at a broader level. Nevertheless, considering the potential benefits of early intervention on suicidality, the results align with the evidence supporting the provision of swift access to brief psychological interventions across primary care settings.
Funding statement
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors report there are no competing interests to declare.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that Galway Research Ethics Committee determined that ethical approval from the local Ethics Committee was not required for publication of this audit. The authors have provided written confirmation of this from the Ethics Committee and local clinical director. All individuals undertaking the interventions, whose data formed parted of the study, gave written informed consent for their clinical outcome data to be used for service level analyses.
Open access
