Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study.

OBJECTIVE To evaluate the impact of the US Air Force suicide prevention programme on risk of suicide and other outcomes that share underlying risk factors. DESIGN Cohort study with quasi-experimental design and analysis of cohorts before (1990-6) and after (1997-2002) the intervention. PARTICIPANTS 5,260,292 US Air Force personnel (around 84% were men). INTERVENTION A multilayered intervention targeted at reducing risk factors and enhancing factors considered protective. The intervention consisted of removing the stigma of seeking help for a mental health or psychosocial problem, enhancing understanding of mental health, and changing policies and social norms. MAIN OUTCOME MEASURES Relative risk reductions (the prevented fraction) for suicide and other outcomes hypothesised to be sensitive to broadly based community prevention efforts, (family violence, accidental death, homicide). Additional outcomes not exclusively associated with suicide were included because of the comprehensiveness of the programme. RESULTS Implementation of the programme was associated with a sustained decline in the rate of suicide and other adverse outcomes. A 33% relative risk reduction was observed for suicide after the intervention; reductions for other outcomes ranged from 18-54%. CONCLUSION A systemic intervention aimed at changing social norms about seeking help and incorporating training in suicide prevention has a considerable impact on promotion of mental health. The impact on adverse outcomes in addition to suicide strengthens the conclusion that the programme was responsible for these reductions in risk.