The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysis

Nahid Darvishi; Mehran Farhadi; Bita Azmi-Naei; Jalal Poorolajal

doi:10.1371/journal.pone.0293620

. 2023 Oct 31;18(10):e0293620. doi: 10.1371/journal.pone.0293620

The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysis

Nahid Darvishi ^1,², Mehran Farhadi ³, Bita Azmi-Naei ⁴, Jalal Poorolajal ^4,^5,^*

Editor: Humayun Kabir⁶

PMCID: PMC10617726 PMID: 37906576

Abstract

Background

This meta-analysis was conducted to assess the association between problem-solving skills and suicidal behaviors and elucidate the potential role of problem-solving skills in influencing the occurrence of suicidal behaviors.

Methods

PubMed, Web of Science, and Scopus were searched until August 16, 2023. Studies addressing the associations between problem-solving skills and suicidal behaviors were included. The I² statistics were used to examine between-study heterogeneity. The Begg and Egger tests were used to determine the possibility of publication bias. Using a random-effects model, the overall effect size was presented as an odds ratio (OR) or standard mean difference (SMD) with 95% confidence intervals (CIs).

Results

Of 8040 identified studies, 29 (including 974,542 participants) were eligible. Based on observational studies, problem-solving skills were found to be inversely related to suicidal ideation (OR = 0.64; 95% CI: 0.50, 0.82); suicide attempts (OR = 0.75; 95% CI: 0.63, 0.89), and suicide death (OR = 0.02; 95% CI: 0.01, 0.03). The overall score of problem-solving skills was higher in those who did not attempt suicide than those who did (SMD = 0.84; 95% CI: 54, 1.13). Based on randomized clinical trials, problem-solving therapy was found to reduce the risk of suicide (OR = 0.51; 95% CI: 0.29, 0.87). Furthermore, the overall risk of suicide was lower among those who received problem-solving therapy than those who did not (SMD = -0.02; 95% CI: -0.29, 0.25).

Conclusions

This meta-analysis revealed an inverse association between problem-solving skills and suicidal behaviors. However, further research is needed to better understand the complex relationship between problem-solving skills and suicidal behaviors.

Introduction

Suicide is a significant problem for public health worldwide. Every year, more than 700,000 individuals die by suicide throughout the world [1]. Additionally, there are around 25 suicide attempts for every suicide [2]. Suicide is one of the main causes of death worldwide, accounting for more deaths than homicide, war, breast cancer, malaria, and HIV/AIDS [1].

Every 40 seconds a person dies due to suicide somewhere in the world [1]. However, suicides are preventable. One of the strategies suggested for the prevention of suicide is implementing universal and targeted school-based socio-emotional learning programs to help adolescents with problem-solving and coping abilities [3]. Problem-solving is a process that involves identifying and defining a problem, determining its underlying causes, generating and prioritizing solutions, implementing a chosen solution, and evaluating the results [4]. This process can be broken down into five key steps, including: (a) defining the problem, (b) identifying the causes of the problem, (c) generating potential solutions, (d) implementing the chosen solution, and (e) evaluating the effectiveness of the solution. This step-by-step approach to problem-solving can be used in a variety of settings, from personal decision-making to complex organizational problem-solving.

Suicidal behaviors are a major public health concern, with devastating consequences for individuals, families, and communities [5]. Despite extensive research on the topic, there is still much to learn about the factors that contribute to suicidal behaviors and how they may be prevented. One potential protective factor for suicidal behaviors is problem-solving ability, which involves the ability to identify and implement effective solutions to problems. However, the relationship between problem-solving ability and suicidal behaviors is complex and multifaceted, with different types of problem-solving abilities potentially relating to different types of suicidal behaviors. For example, deficits in emotion regulation or cognitive flexibility may be associated with suicidal ideation, while deficits in problem-solving ability may be more strongly related to suicide attempts [6–8]. Understanding these different types of problem-solving abilities and how they relate to suicidal behaviors is essential for developing effective prevention and intervention strategies.

Past studies have investigated the relationship between problem-solving ability and suicidal behaviors, but the results have been mixed and conflicting. Some studies have found that high problem-solving ability is associated with a lower risk of suicidal behaviors [7, 9–13], while others have found no significant association or even a positive association between problem-solving ability and suicidal behaviors [14–16]. Some interventional studies have shown that improving problem-solving skills can reduce the risk of suicide [17, 18]. These conflicting results may be due to differences in study design, population characteristics, and measurement tools.

Given the variation in existing work in terms of definitions, measurement, and populations, it is challenging to directly compare existing studies and draw clear conclusions about the relationship between problem-solving ability and suicidal behaviors. Therefore, this study aims to conduct a meta-analysis of existing studies to provide a comprehensive understanding of the association between problem-solving ability and suicidal behaviors. The broad focus of this study is an initial step towards finding points of consensus and difference between existing studies while acknowledging the challenges of comparing studies with different methodologies and definitions. By synthesizing the existing evidence, this study aims to advance our understanding of the relationship between problem-solving ability and suicidal behaviors and to inform the development of effective prevention and intervention strategies.

Methods

Eligibility criteria (PICOS)

Population

The population of interest for this study was broad and included diverse groups such as the general population, students, veterans, inmates, workers, and patients with mental illness.

Intervention/Exposure

The exposure of interest was problem-solving skills regardless of the tools used to measure the skills. Problem-solving skills are the ability to identify, analyze, and solve problems in a logical and systematic way. Effective problem-solving involves several steps, including defining the problem, gathering information, analyzing the problem, developing solutions, implementing the chosen solution, and evaluating the results [19]. The assessment of “problem-solving skills” was carried out through the utilization questionnaires that have been developed and validated for the purpose of evaluating problem-solving abilities. A comprehensive list of these questionnaires is provided in Table 1.

Table 1. Characteristics of the included studies.

1^st author, yr	Country	Study population	Age mean/range	sex	Study design	Tools	Suicide type	Suicide time	Sample size	Score of quality
Akbari 2015	Iran	General	25.51	Both	Case-control	BMCQ	Attempt	Past month	600	*******
Angora 2022	Spain	General	35–65	Both	RCT	Unspecified	Attempt	Past year	649	****
Biggam 1999	UK	Inmates	18.80	Male	Case-control	MEPS	Attempt	Past month	40	*****
Burke 2016	USA	General	12.39	Both	Cohort	CRSQ	Ideation	Past year	324	*******
Dieserud 2002	Norway	General	18+	Both	Case-control	PSI	Ideation	Past month	321	*******
Donald 2006	Australia	General	18–24	Both	Case-control	PPSI	Attempt	Past month	475	*******
Eidhin 2002	UK	Inmates	25.29	Male	Case-control	MEPS	Attempt	Past month	31	*****
Eskin 2008	Turkey	General	19.10	Both	RCT	SPS	Ideation	Past month	121	******
Fitzpatrick 2005	USA	General	19.02	Both	RCT	BSS	Ideation	Past month	110	****
Foroughipour 2013	Iran	Epilepsy	No data	Both	Cross-sectional	QCM	Ideation	Past month	74	******
Fried 2013	USA	General	14.86	Both	Cohort	Unspecified	Attempt	Past month	3376	******
Gururaj 2004	India	General	15–69+	Both	Case-control	Unspecified	Death	Lifetime	538	******
Howat 2002	UK	General	74.75	Both	Case-control	MEPS	Attempt	Past month	40	******
Kaviani 2004	Iran	General	27.80	Both	Case-control	MEPS	Attempt	Past month	40	******
Kidd 2007	Canada	General	14–24	Both	Cross-sectional	WCQ	Attempt	Lifetime	208	********
Lannoy 2022	Sweden	General	42.60	Both	Cohort	SMES	Attempt	Past month	951,618	********
Li 2012	China	General	26.23	Both	Case-control	CRI	Attempt	Past month	808	********
Linda 2012	USA	General	19.00	Both	Case-control	MEPS	Attempt	Lifetime	96	******
Mostafavi Rad 2012	Iran	General	45.41	Female	Case-control	MFAD	Attempt	Past month	53	******
Nezu 2017	USA	Veteran	38.03	Both	Case-control	SPSI	Attempt	Lifetime	46	*******
Pollock 2001	UK	General	21–72	Both	Case-control	MEPS	Attempt	Past month	48	******
Roskar 2007	Slovenia	General	43.94	Both	Case-control	TOL	Attempt	Past month	50	******
Sadowski 1993	USA	General	15.02	Both	Case-control	SPSI	Attempt	Past month	60	******
Sarkisian 2021	USA	General	7.70	Both	Case-control	Lab‑TAB	Ideation	Past year	116	*******
Shelef 2014	Israel	Veteran	19.70	Both	Case-control	PSI	Attempt	Lifetime	65	******
Sugawara 2012	Japan	Workers	40–60	Both	Cross-sectional	CES-D	Ideation	Lifetime	6,762	********
Tang 2015	China	Students	20.85	Both	Cross-sectional	CRI	Ideation	Past year	5,972	********
Unützer 2006	USA	Mental	71.20	Both	RCT	HSCL	Ideation	Past month	1,801	*******
Xavier 2019	Brazil	General	17.20	Both	RCT	ISO	Ideation	Past month	100	*******

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The measurement tools used for measuring problem-solving skills and suicidal behavior are listed in alphabetical order. ACS: Adolescent Coping Scale, BMCQ: Billings and Moos Coping Questionnaire, BSS: Beck Suicide Scale, CES-D: Center for Epidemiologic Studies Depression Scale, CRI: Coping Response Inventory, CRSQ: Children’s Response Styles Questionnaire, HSCL: Hopkins Symptoms Checklist, ISO: Inventory of Suicide Orientation, Lab‑TAB: Laboratory Temperament Assessment Battery, MEPS: Means-End Problem-Solving, MFAD: McMaster Family Assessment Device, PPSI: Personal Problem-Solving Inventory, PSI: Problem-Solving Inventory, SMES: Swedish Military Evaluation Scale, SPS: Suicide Probability Scale, SPSI: Social Problem-Solving Inventory, TOL: Tower of London, QCM: Questionnaire of Coping Mechanisms, WCQ: Ways of Coping Questionnaire

Control

In cases where studies categorized individuals based on their problem-solving skills (high vs. low), we examined the odds of suicidal behaviors in those with high problem-solving skills compared to those with low problem-solving skills (reference group). This allowed us to assess the impact of varying problem-solving skill levels on suicidal behaviors. In cases where studies measured the mean problem-solving skill scores among individuals with and without suicidal behaviors, we calculated the standardized mean difference (SMD) of the problem-solving skill scores between these two groups. This approach enabled us to explore the magnitude of difference in problem-solving abilities between individuals exhibiting suicidal behaviors and those who did not.

Outcome

The primary outcome of interest in this study was various types of suicidal behaviors, including suicidal ideation, suicide plans, suicide attempts, and suicide death. Suicidal ideation, suicide plans, and suicide attempts were assessed by taking a history from study participants. Information on suicide death was obtained from medical records or death certificates.

Studies

Regardless of publication status or language, we included observational studies (cross-sectional studies, case-control studies, and cohort studies) as well as randomized clinical trials (RCTs) addressing the association between problem-solving skills and suicide behaviors (suicidal ideation, suicide attempts, and suicide death). Studies that provided the data required to report the effect size in the form of odds ratio (OR), hazard ratio (HR), or mean difference (MD). The results of these different studies were pooled and reported separately.

Search methods

PubMed, Web of Science, and Scopus were searched until August 16, 2023. The reference lists of all retrieved studies and pertinent reviews were also screened for additional references. The following keywords were searched: (problem solving or coping skills or resilience skills or solution-oriented skills or cognitive flexibility or decision-making abilities or critical thinking or creative thinking or analytical thinking) and (suicide or suicidal or suicidality) [S1 Table].

Study selection

The search results obtained from electronic databases were merged and duplicates were eliminated using the EndNote program. Two authors evaluated independently the titles and abstracts to determine which studies matched the eligibility criteria for this review. The authors discussed and agreed upon any differences. For more information, we downloaded the complete texts of research that seemed pertinent.

Data extraction

The extracted data from the relevant studies were entered into an electronic data sheet prepared in Stata software. The following data were extracted: first author’s name, year of publication, country, language, age (mean, range), gender, study population (general population, students, veterans, inmates, mental illness), study design (cross-sectional, case-control, cohort, RCTs), measurement tools, suicidal behaviors (suicidal ideation, suicide attempts, suicide death), suicide time (past month, past year, lifetime), sample size, analysis of potential confounders (adjusted, unadjusted), and effect size (OR, HR, MD) with associated 95% confidence interval (CI).

Methodological quality

The quality of the observational studies was explored using the Newcastle-Ottawa Scale (NOS) [20] and that of RCTs was assessed by the Delphi List [21]. Each study received a maximum of nine stars using either of these tools. Studies were categorized as either high-quality or low-quality based on their star rating, with high-quality studies receiving 7 stars or more [S2 Table].

Data synthesis

The overall effect size was reported as an odds ratio (OR) or standard mean difference (SMD) with 95% CIs. SMD values of 0.2–0.5 were regarded as small, 0.5–0.8 as medium, and values greater than 0.8 as large [22]. Data were analyzed using Stata software version 14 (StataCorp, College Station, TX, USA) and Review Manager 5. The meta-analysis was performed to create a summary measure using the random effects model at a 0.05 significance level [23].

The random-effects model assumes that the true effect size varies across studies due to differences in study design, population, and other factors. This model takes into account both within-study and between-study variability to produce a more conservative estimate of the effect size and a wider confidence interval.

Heterogeneity and publication bias

The chi-square (χ²) test was used to examine study heterogeneity and the tau-square (τ²) test to estimate the variance between studies [23]. The I² value [24] was used to assess the possibility of heterogeneity across studies. Based on the I² value, heterogeneity was classified as low (50%), moderate (50–74%), or high (75%) [24]. We performed a meta-regression analysis to find the potential sources of heterogeneity.

The likelihood of publication bias was evaluated using the Egger [25] and Begg [26] tests and the Trim-and-Fill method.

Results

Description of studies

In total, 8040 studies were discovered, including 6713 studies that were found by searching the electronic databases until August 16, 2023, and 1327 articles were discovered by screening the reference lists of the included studies. After excluding duplicates and ineligible studies, 29 studies [7, 9–13, 15–18, 27–45] including 974,542 individuals were included in the meta-analysis (Fig 1). Table 1 provides information about the included studies in more detail.

Synthesis of results

Based on five observational studies (Fig 2), the overall OR for high versus low problem-solving skills and suicidal ideation was 0.64 (95% CI: 0.50, 0.82). According to the overall effect measure, high problem-solving skills lower the probability of suicide ideation by about 36% (P = 0.0004). Between-study heterogeneity was moderate (I² = 66%). The Begg test (P = 0.348) and the Egger test (P = 0.636) revealed no evidence of publication bias.

Based on five observational studies (Fig 2), the overall OR for high versus low problem-solving skills and suicide attempts was 0.75 (95% CI: 0.63, 0.89). According to the overall effect measure, high problem-solving skills lower the probability of attempting suicide by about 25% (P = 0.001). Between-study heterogeneity was high (I² = 99%). The Begg test (P = 0.348) and the Egger test (P = 0.361) revealed no evidence of publication bias.

Based on one observational study (Fig 2), the OR for high versus low problem-solving skills and suicide death was 0.02 (95% CI: 0.01, 0.03). According to this finding, high problem-solving skills lower the probability of suicide death by about 98% (P<0.001).

Based on the results of two RCTs (Fig 3), the OR for high versus low problem-solving skills and suicide death was 0.51 (95% CI: 0.29, 0.87). According to this finding, high problem-solving skills lower the probability of suicide death by about 49% (P = 0.010). Between-study heterogeneity was moderate (I² = 70%).

According to the results of 13 studies (Fig 4), the total score of problem-solving skills was higher in those who did not attempt suicide than those who did (SMD = 0.84; 95% CI: 54, 1.13; P<0.001). That means the overall standard mean score of problem-solving skills in people who did not attempt suicide was 0.84 larger than those who attempted suicide. Between-study heterogeneity was moderate (I² = 79%).

According to the results of three RCTs (Fig 5), the total score of risk of suicide was lower in those who received problem-solving therapy versus those who did not (SMD = -0.02; 95 CI: -0.29, 0.25) but the results were not statistically significant (P = 0.870). Between-study heterogeneity was low (I² = 14%).

Meta-regression

We conducted a multivariate meta-regression analysis taking into account several factors including study population, study design, suicide time, and measurement tools (Table 2) to investigate the possible sources of heterogeneity. The results revealed that none of the factors affected the observed heterogeneity.

Table 2. Assessing the source of heterogeneity across studies reporting the association between problem-solving skills and suicidal ideation and suicide attempt using the meta-regression.

Suicidal behaviors/covariates	Coefficient	SE	t	P-value	95% CI
Suicidal ideation
Study population	1.037649	0.029803	1.29	0.421	0.720373	1.494664
Study design	0.810272	0.094484	-1.80	0.322	0.184145	3.565335
Suicide time	1.190113	0.228958	0.90	0.532	0.103269	13.71531
Measurement tools	0.995766	0.001889	-2.24	0.268	0.972050	1.020061
Constant	0.982424	0.359994	-0.05	0.969	0.009337	103.3646
Suicide attempt
Study population	3.677053	5.454414	0.88	0.473	0.006218	2174.425
Study design	0.661504	0.528518	-0.52	0.657	0.021261	20.58216
Suicide time	0.377527	0.565420	-0.65	0.582	0.000600	237.4479
Measurement tools	0.991331	0.009826	-0.88	0.472	0.949943	1.034522
Constant	2.548539	7.327621	0.33	0.776	0.000011	601158.0

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Discussion

The meta-analysis found that high problem-solving skills were associated with a lower probability of suicidal ideation, suicide attempts, and suicide death and that the total score of problem-solving skills was higher in individuals who did not attempt suicide than those who did. The meta-analysis also found that the total score of problem-solving skills was higher in individuals who did not attempt suicide than those who did and that receiving problem-solving therapy was associated with a lower risk of suicide, although the latter result was not statistically significant. However, there was high between-study heterogeneity for some of these results, which may limit the generalizability of the findings. In addition, there was evidence of publication bias for some of the results, which suggests that some studies with negative or non-significant findings may not have been published. This may have influenced the overall effect size and could limit the validity of the conclusions.

The results of the meta-regression analysis did not reveal any significant factors that contributed to the observed heterogeneity. This suggests that the variability in the results may be due to differences in study characteristics or other unmeasured factors.

The meta-analysis included 29 studies that varied in terms of study design, population characteristics, and measurement tools. For example, some studies included in the meta-analysis used self-report measures to assess problem-solving skills and suicidal behaviors, while others used clinical interviews or medical records. Additionally, some studies included individuals with specific clinical diagnoses (e.g., students, veterans, inmates, workers, and patients with mental illness), while others included community-based samples. These differences in study design and population characteristics may contribute to the observed between-study heterogeneity in the meta-analysis. For example, some studies may have included individuals with more severe mental health problems or a higher risk of suicidal behaviors, which could influence the observed associations between problem-solving skills and suicidal behaviors. Additionally, differences in measurement tools may have introduced variability in the results, as different tools may assess different aspects of problem-solving skills or suicidal behaviors. Despite these differences, the association between high problem-solving skills and a lower probability of suicidal behaviors suggests that improving problem-solving skills may be an effective strategy for reducing the risk of suicide. However, it is important to consider the potential impact of these differences on the observed associations and to interpret the results in light of the potential biases and limitations of the study.

According to the results of this meta-analysis, problem-solving skills have a protective effect against suicidal ideation, suicide attempts, and suicide death. We must keep in mind, though, that there is not just one single risk or protective factor for suicide. It typically happens as a result of a complex interplay between several risk factors and protective factors [46–49]. As a result, risk and protective factors cannot be broken down into discrete components and must instead be seen as a whole. Risk factors encourage suicide while protective factors deter it. In this regard, if risk and protective variables are equal or if protective factors outweigh risk factors, suicide will not occur [50]. Therefore, the role of problem-solving skills in the prevention of suicidal behaviors should be taken into account along with other influential factors.

One of the important cognitive risk factors connected with suicidal behaviors is problem-solving deficits or difficulties in identifying problems and producing suitable solutions [51, 52]. Lack of problem-solving skills can be characterized by a negative problem orientation (e.g., seeing problems as threats, doubting problem-solving abilities, or a tendency to become frustrated when facing problems); an impulsive/careless style (e.g., attempting to address problems quickly or insufficiently), and/or an avoidant style (e.g., passivity, inaction, and overdependence on others) [53]. Indeed, suicide attempters may be more passive in their problem-solving approach than non-suicidal attempters consistent with an avoidant problem-solving style [54]. On the other hand, some suicide attempters may be characterized by an increased rate of impulsivity and carelessness and a tendency to develop a pessimistic attitude toward problems [55].

Consistent with this meta-analysis, Townsend et al. assessed the effect of problem-solving therapy on deliberate self-harm. They concluded that problem-solving therapy appeared to produce better results than the control group concerning improvement in depression, hopelessness, and problems [56]. Another systematic review was conducted by Gray et al. to address the applications of problem-solving therapy to prevent suicide in patients with bipolar disorder. They concluded that training problem-solving strategies can be considered either as a part of psychological treatment in patients with bipolar disorder or as a specific preventive intervention [57].

Limitations

This systematic review was associated with several limitations and potential biases. First, there was high between-study heterogeneity in some of the results, which may be due to differences in study characteristics or other unmeasured factors. This variability may limit the generalizability of the findings. Second, our findings revealed evidence of publication bias for some of the results, which suggests that some studies with negative or non-significant findings may not have been published. This may have influenced the overall effect size and could limit the validity of the conclusions. Third, this meta-analysis included a relatively small number of studies, which may limit the statistical power and generalizability of the findings. Fourth, the studies included in the meta-analysis used different tools to measure problem-solving skills, which may have introduced variability in the results. Fifth, most of the studies included in the meta-analysis were observational studies, which may limit the ability to establish causality. It is important to consider these limitations when interpreting the results and drawing conclusions. Further research is needed to confirm these findings and to address these limitations.

The meta-analysis findings suggest that bolstering problem-solving skills is linked to decreased likelihood of suicidal ideation, attempts, and deaths, prompting health policies to prioritize the advancement of problem-solving skills training. This approach can be integrated into school curricula, workplace wellness initiatives, and community mental health programs. Additionally, the inclusion of problem-solving therapy within mental health treatments, particularly for individuals vulnerable to suicide, warrants consideration. Acknowledging the diverse impacts of problem-solving skills on distinct facets of suicide (ideation, attempts, death), health policies should tailor interventions, accounting for individual risk factors and needs to optimize efficacy. Equipping healthcare professionals—therapists, counselors, educators—with problem-solving strategies can bolster their ability to aid at-risk individuals and foster improved mental health outcomes. These recommendations should be contextualized within existing mental health policies, available resources, and specific population requirements, with ongoing research to gauge effectiveness and adaptability as essential components.

Conclusion

This meta-analysis suggests that high problem-solving skills are associated with a lower probability of suicidal ideation, suicide attempts, and suicide death. Improving problem-solving skills may have a protective effect against suicidal behaviors. However, there is high between-study heterogeneity for some of these results, and evidence of publication bias for some of the outcomes. Therefore, further research is needed to confirm these findings and to identify the specific factors that contribute to the observed associations. It is important to consider the limitations and potential biases of the study when interpreting these results.

Supporting information

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

Click here for additional data file.^{(30.3KB, docx)}

S1 Table. Search strategies.

(DOCX)

Click here for additional data file.^{(23.6KB, docx)}

S2 Table. The detailed risk of bias assessment.

(DOCX)

Click here for additional data file.^{(27.6KB, docx)}

S1 Dataset

(RM5)

Click here for additional data file.^{(63.9KB, rm5)}

Acknowledgments

These results were obtained as part of a PhD thesis in Phycology. We would like to appreciate the Vice-Chancellor for Research and Technology of Azad University for approval of this study.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0293620.r001

Decision Letter 0

Humayun Kabir

26 Jul 2023

PONE-D-23-15949The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysisPLOS ONE

Dear Dr. Poorolajal,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Humayun Kabir

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PLOS ONE

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Reviewers' comments:

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Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This paper makes a welcome contribution to understanding about problem solving skills and suicidal behaviour. At present, however, it is somewhat lacking in detail, and I strongly encourage the author/s to consider the suggestions below.

First and foremost, in a full length research article I would expect to see more depth and sophistication in the introduction. There is an opportunity to discuss ways in which different types of problem solving ability are thought to relate to different suicidal behaviors (and why), to elaborate on the different concepts raised and/or to give examples of some past studies (and how conflicts in previous results point to the need for meta-analysis), and to touch on some of the reasons for why the current study used a fairly broad focus (i.e., the paper can be framed as an initial step towards finding points of consensus and difference between existing studies, while also acknowledging that the variation in existing work in terms of definitions, measurement etc makes it challenging to directly compare those studies).

I would also like to see more information about the selection criteria and study selection procedures. For example, what was considered a study on problem solving, vs what was not considered problem solving?

I am also concerned that at a few points, causality seems to be inferred. While it is certainly fair to say that the evidence is very suggestive of a protective effect of problem solving skills, it is not clear at this stage how and why that may be operating (for example, potential mediators or moderators, confounds, etc). This is especially relevant in light of the diverse nature of the different studies included in the meta-analysis.

Finally, I would very much like to see some discussion about the differences between the studies that were included and how and why that may relate to the results.

Reviewer #2: 1. Since WHO reports in 2019 (ref 2) has been listed and cited, it is redundant to list and cite 2014 report (ref 1). Relevant data has been updated in the 2019 report.

2. My major concern is that the conclusion is not sufficiently supported by findings. Findings of RCT studies argued that the problem sovling skills could NOT reduce suicide risk (small effective size), although results of observational studies substantially supported such association. Might such association be attributed to, at least partly, other factors which did not assessed in this study.

3. In the table 1, 17 studies focused on suicidal ideation, 9 on suicide attempt, why in the Figure 2, only 6 and 7 studies have been included? What about the other 13 studies?

4.Only one study focused on suicide death, it is meaningless to review or meta-analyze one study.

5.Authors did not describe any data or information on how to assess so-called problem solving skill, and measure tool or methods were not included in assessing the source of heterogeneity, why? Good psychometric performance and consistent measures are important to assess research findings. Different tools or cut-off points might result in different findings.

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2023 Oct 31;18(10):e0293620. doi: 10.1371/journal.pone.0293620.r002

Author response to Decision Letter 0

29 Jul 2023

Reviewers' comments

Reviewer #1

This paper makes a welcome contribution to understanding about problem solving skills and suicidal behaviour. At present, however, it is somewhat lacking in detail, and I strongly encourage the author/s to consider the suggestions below.

Answer: Thank you for your feedback. We agree that a full-length research article should have a more comprehensive and sophisticated introduction, and we appreciate the opportunity to revise ours. We carefully revised the introduction section to provide a thorough review of the literature, outline the rationale for the study, and provide context for the research question. We also discussed the existing evidence and gaps in the literature related to the relationship between problem-solving ability and suicidal behaviors. We hope that our revised introduction provides a clearer and more comprehensive understanding of the importance and relevance of our study.

Answer: In the methods section, we provided a detailed explanation of the selection criteria used and presented a definition of problem-solving skills along with the measurement tools that were utilized.

Answer: We revised the conclusion sections in both the abstract and main text, and modified the final inference based on our findings. Also, in the discussion section, we highlighted the limitations and potential biases of the study.

Finally, I would very much like to see some discussion about the differences between the studies that were included and how and why that may relate to the results.

Answer: In the third paragraph of the discussion section, we provided a detailed explanation of the differences between the studies included in the meta-analysis and how these differences may have impacted the overall results.

Reviewer #2

1. Since WHO reports in 2019 (ref 2) has been listed and cited, it is redundant to list and cite 2014 report (ref 1). Relevant data has been updated in the 2019 report.

Answer: We have replaced the old reference with a new one and revised the introduction accordingly.

Answer: We revised the conclusion sections in both the abstract and main text.

3. In the table 1, 17 studies focused on suicidal ideation, 9 on suicide attempt, why in the Figure 2, only 6 and 7 studies have been included? What about the other 13 studies?

Answer: Thank you for your attention.

Out of the 27 studies included, 17 focused on suicidal ideation, 9 on suicide attempt, and 1 on suicide death.

Within the 17 studies related to suicidal ideation, 5 reported OR (upper part of Figure 2), 10 reported mean difference (shown in Figure 3), and 2 were RCTs (shown in Figures 2 & 4). Therefore, the total number of studies related to suicidal ideation was 17 (5+10+2).

Within the 9 studies related to suicide attempt, 6 reported OR (shown in Figure 2) and 3 were RCTs (shown in Figures 2 & 4). Therefore, the total number of studies related to suicide attempt was 9 (6+3).

4. Only one study focused on suicide death, it is meaningless to review or meta-analyze one study.

Answer: We appreciate the reviewer's concern about the inclusion of only one study that focused on suicide death. While we agree that it is not possible to conduct a meaningful meta-analysis with only one study, we decided to include this study in our systematic review to provide a comprehensive assessment of the existing literature on the relationship between social support and suicidal behaviors. The study in question is the only case-control study that provides valuable information on the association between social support and suicide death. We acknowledge that further research is needed to confirm these findings, and we have emphasized in the conclusion section the need for additional studies to explore the complex relationship between social support and suicidal behaviors.

5. Authors did not describe any data or information on how to assess so-called problem solving skill, and measure tool or methods were not included in assessing the source of heterogeneity, why? Good psychometric performance and consistent measures are important to assess research findings. Different tools or cut-off points might result in different findings.

Answer: In the method section, we provided an explanation of problem-solving skills and presented a comprehensive list of tools used to measure them in Table 1. As part of our meta-regression analysis, we also included measurement tools to investigate potential sources of heterogeneity.

PLoS One. doi: 10.1371/journal.pone.0293620.r003

Decision Letter 1

Humayun Kabir

15 Aug 2023

PONE-D-23-15949R1The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysisPLOS ONE

Dear Dr. Poorolajal,

Please submit your revised manuscript by Sep 29 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Humayun Kabir

Academic Editor

PLOS ONE

Additional Editor Comments:

Please revise the interpretation of the pooled estimate as the statistical significance should be not emphasized in the meta-analysis.

limitation section and a recommendation section are missing.

is it only search strategy, "The following

keywords were searched: (problem solving OR problem-solving) AND (suicide OR suicidal OR

suicidality)"? If yes, then the search is very narrow and may be no longer systematic research. Describe the details of the search like if you used the MES heading and keywords both. The search strategies should be provided in a supplementary file.

EMBASE and other databases were not covered which may be the potential limitation of the review.

how was the RCT incorporated in this study along with other designs?

"randomized clinical trials (RCT) addressing

the association between problem-solving skills and suicide behaviors" RCT does not incorporate association.

use subheadings while reporting the results.

"problem-solving skills" how this intervention was measured throughout the study?

inclusion and exclusion are missing.

"Control: In cases where studies categorized problem-solving skills, we examined the possibility of

suicidal behaviors in individuals with high problem-solving skills compared to those with low problem solving skills as a control group." what does it mean? specify who is the comparator. if the intervention is problem-solving skills then the comparator should be something else, maybe not having the skill.

"In cases where studies reported the mean score of problem-solving

skills, we examined the standard mean difference between those with and without suicidal behaviors." SMD of which groups? does it a suicidal idea vs no suicidal ideation? if yes, then I think, it is a serious gap in the planning.

cross-sectional study and RCT can not be pooled in same study and should have followed different tools for doing the risk of bias and certainty of the evidence. meta-analysis should not be pooling apple and orange.

"This meta-analysis was conducted to determine to

what extent problem-solving skills can prevent suicidal behaviors" if this is the objective of this review and then I think this review failed to achieve the objective.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

PLoS One. 2023 Oct 31;18(10):e0293620. doi: 10.1371/journal.pone.0293620.r004

Author response to Decision Letter 1

21 Aug 2023

Additional Editor Comments

Please revise the interpretation of the pooled estimate as the statistical significance should be not emphasized in the meta-analysis.

Answer: We omitted the terms "significant" and "significantly" from both the abstract and the main results and discussion sections, where we highlighted the outcomes of the meta-analysis.

Limitation section and a recommendation section are missing.

Answer: These sections were added to the end of the Discussion section.

Is it only search strategy, "The following keywords were searched: (problem solving OR problem-solving) AND (suicide OR suicidal OR suicidality)"? If yes, then the search is very narrow and may be no longer systematic research. Describe the details of the search like if you used the MES heading and keywords both. The search strategies should be provided in a supplementary file.

Answer: We have diligently expanded upon our search strategy and incorporated the latest search findings up until August 16, 2023. Our search encompassed a range of pertinent keywords, including terms such as (problem solving or coping skills or resilience skills or solution-oriented skills or cognitive flexibility or decision-making abilities or critical thinking or creative thinking or analytical thinking) and (suicide or suicidal or suicidality). It is noteworthy that both MeSH terms and keywords were thoughtfully integrated into our comprehensive search approach. Fortuitously, the implementation of the new search strategy yielded two additional studies, culminating in a total of 29 studies now included in our analysis. The detailed outline of our search strategies can be found in the supplementary file, providing a clear reference for the methods employed.

EMBASE and other databases were not covered which may be the potential limitation of the review.

Answer: Regrettably, we did not have access to the EMBASE database during our research phase. Nonetheless, a silver lining exists as both the EMBASE and Scopus databases fall under the umbrella of Elsevier Publications. This interconnection ensures that a substantial portion of the resources cataloged in EMBASE are encompassed within the scope of Scopus. Notably, Mann et al. conducted a thorough investigation in 2016 [1] aimed at evaluating coverage, overlap, and distinctive contributions of EMBASE and Scopus. Their findings revealed that 32 of the 34 studies included were sourced from either the EMBASE or Scopus searches. These results offer a compelling insight into the interplay between these databases.

[1] Mann M, Hood K, Trubey R, Powell C. A tale of two databases: a comparison of Embase versus Scopus. In: Challenges to evidence-based health care and Cochrane. Abstracts of the 24th Cochrane Colloquium; 2016 23-27 Oct; Seoul, Korea. John Wiley & Sons; 2016.

How was the RCT incorporated in this study along with other designs? Randomized clinical trials (RCT) addressing the association between problem-solving skills and suicide behaviors" RCT does not incorporate association. Use subheadings while reporting the results.

Answer: We acknowledge the distinct nature of observational studies and randomized controlled trials (RCTs), and we concur that they should be treated as separate entities when consolidating data. To address this valid concern, we have been diligent in our approach, ensuring that each study type receives the due attention it warrants. In the "Methodological Quality" subsection within the Methods section of our manuscript, we have clearly outlined our strategy. Specifically, we employed the Newcastle-Ottawa Scale (NOS) to assess the quality of observational studies and utilized the Delphi List to evaluate the quality of RCTs. Furthermore, we have taken into account the differentiation between the outcomes of observational studies and RCTs in our results. As a result, we have represented the results of observational studies in Figures 2 & 4 and RCTs in Figures 3 & 5. We deeply value your insights and have diligently addressed the issues raised to ensure the accuracy and clarity of our manuscript.

"Problem-solving skills" how this intervention was measured throughout the study?

Answer: In our study, the assessment of “problem-solving skills” was carried out through the utilization of dedicated questionnaires that have been developed and validated for the purpose of evaluating problem-solving abilities. These questionnaires have been widely recognized and accepted within the field as reliable tools for assessing the proficiency of individuals in problem-solving. We addressed this matter by incorporating an explanatory note at the outset of the Methods section to provide clarification. Additionally, a comprehensive listing of these questionnaires is available in Table 1 for reference.

Inclusion and exclusion are missing.

Answer: The inclusion and exclusion criteria for our meta-analysis were defined using the PICOS framework, which encompasses Population, Intervention/Exposure, Comparison, Outcome, and Study design characteristics. These criteria were systematically applied to identify relevant studies for our analysis. We incorporated these criteria at the outset of the Methods section to provide a clear understanding of our study's criteria for study selection.

“Control: In cases where studies categorized problem-solving skills, we examined the possibility of suicidal behaviors in individuals with high problem-solving skills compared to those with low problem solving skills as a control group.” What does it mean? Specify who is the comparator. If the intervention is problem-solving skills then the comparator should be something else, maybe not having the skill.

Answer: Certainly, I appreciate your feedback. In our study, we adopted two distinct approaches to investigate the association between problem-solving skills and suicidal behaviors.

Firstly, in cases where studies categorized individuals based on their problem-solving skills (high vs. low), we examined the odds of suicidal behaviors in those with high problem-solving skills compared to those with low problem-solving skills (reference group). This allowed us to assess the impact of varying problem-solving skill levels on suicidal behaviors.

Secondly, we encountered studies that measured the mean problem-solving skill scores among individuals with and without suicidal behaviors. In these cases, we calculated the standardized mean difference (SMD) of the problem-solving skill scores between these two groups. This approach enabled us to explore the magnitude of difference in problem-solving abilities between individuals exhibiting suicidal behaviors and those who did not.

To present these distinct analyses accurately, we reported the pooled odds ratios for the first approach and the SMD values for the second approach separately. By employing these two different methodologies, we aimed to comprehensively capture the relationship between problem-solving skills and suicidal behaviors, providing a more nuanced understanding of their interplay. We clarified these points further in revised manuscript for better clarity and transparency.

“In cases where studies reported the mean score of problem-solving skills, we examined the standard mean difference between those with and without suicidal behaviors.” SMD of which groups? Does it a suicidal idea vs no suicidal ideation? If yes, then I think, it is a serious gap in the planning.

Answer: Thank you for your feedback. We have taken your current comments into consideration and addressed the concerns raised in response to your previous comment. We are committed to ensuring the clarity and accuracy of our manuscript, and we have incorporated the suggestions and considerations discussed earlier. We appreciate your guidance and are dedicated to producing a thorough and well-structured manuscript that adheres to the highest standards of research integrity.

Cross-sectional study and RCT cannot be pooled in same study and should have followed different tools for doing the risk of bias and certainty of the evidence. Meta-analysis should not be pooling apple and orange.

Answer: We appreciate the editor's observation. We completely understand the importance of maintaining methodological rigor when conducting a meta-analysis. We agree that observational studies and randomized controlled trials (RCTs) are distinct in nature and should be treated as separate entities when pooling data. To address this concern, we would like to highlight that we were meticulous in our approach to ensure that each study type received appropriate attention. Specifically, under the "Methodological Quality" subsection in the Methods section of our manuscript, we clearly delineated our approach. For observational studies, we employed the Newcastle-Ottawa Scale (NOS) to assess their quality, while for RCTs, we used the Delphi List to evaluate their quality. This approach enabled us to rigorously evaluate the risk of bias and the certainty of evidence for each study type, ensuring that the distinct characteristics of observational studies and RCTs were appropriately considered. Certainly, we recognize the importance of maintaining a clear distinction between the results of observational studies and RCTs within our figures. To address this, the results of observational studies are depicted separately in Figures 2 & 4 and that of and RCTs in Figures 3 and 5.

“This meta-analysis was conducted to determine to what extent problem-solving skills can prevent suicidal behaviors”. If this is the objective of this review and then I think this review failed to achieve the objective.

Answer: Thank you for your feedback. We appreciate your insights, and we have carefully considered your comments. In response to your concern, we have revised the objective of the meta-analysis to ensure clarity and alignment with the study's findings. The modified objective now reads: “This meta-analysis was conducted to assess the association between problem-solving skills and suicidal behaviors and elucidate the potential role of problem-solving skills in influencing the occurrence of suicidal behaviors.”

We believe that this modified objective better captures the focus and outcomes of our study, and we are grateful for your input in refining our work.

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PLoS One. doi: 10.1371/journal.pone.0293620.r005

Decision Letter 2

Humayun Kabir

18 Sep 2023

PONE-D-23-15949R2The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysisPLOS ONE

Dear Dr. Poorolajal,

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Reviewers' comments:

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Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #3: Yes

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Reviewer #1: (No Response)

Reviewer #3: Thanks for giving me the opportunity to review this manuscript. After careful revision of this manuscript, I suggest the following minor edits -

1. Methods: the heterogeneity and publication bias section should be reported below the Data synthesis section.

2. Authors are suggested to report the detailed risk of bias assessment in the supplementary file.

3. The recommendation section should be merged with the discussion section without mentioning the heading "Recommendation"

**********

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PLoS One. 2023 Oct 31;18(10):e0293620. doi: 10.1371/journal.pone.0293620.r006

Author response to Decision Letter 2

19 Sep 2023

Reviewer #3

Thanks for giving me the opportunity to review this manuscript. After careful revision of this manuscript, I suggest the following minor edits.

1. Methods: the heterogeneity and publication bias section should be reported below the Data synthesis section.

Response: Thank you for your valuable feedback and for your careful review of our manuscript. We have carefully considered your suggestion regarding the placement of the "Heterogeneity and publication bias" section in our manuscript. Following your recommendation, we have moved this section below the "Data synthesis" section to enhance the logical flow and organization of our paper.

2. Authors are suggested to report the detailed risk of bias assessment in the supplementary file.

Response: Regarding your suggestion to report the detailed risk of bias assessment in the supplementary file, we have taken this recommendation into account. We have included a comprehensive risk of bias assessment in the supplementary material, providing a detailed and transparent account of our evaluation process.

3. The recommendation section should be merged with the discussion section without mentioning the heading "Recommendation"

Response: In accordance with your recommendation, we have removed the heading "Recommendation" and integrated the content seamlessly into the broader "Discussion" section.

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PLoS One. doi: 10.1371/journal.pone.0293620.r007

Decision Letter 3

Humayun Kabir

17 Oct 2023

The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysis

PONE-D-23-15949R3

Dear Dr. Poorolajal,

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Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: (No Response)

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: (No Response)

Reviewer #3: Yes

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Reviewer #3: (No Response)

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PLoS One. doi: 10.1371/journal.pone.0293620.r008

Acceptance letter

Humayun Kabir

23 Oct 2023

PONE-D-23-15949R3

The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysis

Dear Dr. Poorolajal:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

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S1 Table. Search strategies.

(DOCX)

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S2 Table. The detailed risk of bias assessment.

(DOCX)

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S1 Dataset

(RM5)

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Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysis

Nahid Darvishi

Mehran Farhadi

Bita Azmi-Naei

Jalal Poorolajal

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Methods

Eligibility criteria (PICOS)

Population

Intervention/Exposure

Table 1. Characteristics of the included studies.

Control

Outcome

Studies

Search methods

Study selection

Data extraction

Methodological quality

Data synthesis

Heterogeneity and publication bias

Results

Description of studies

Fig 1. The flow of information through the different phases of the systematic review.

Synthesis of results

Fig 2. Forest plot of the association between problem-solving skills and suicidal ideation, suicide attempt, and suicide death.

Fig 3. Forest plot of the association between problem-solving therapy and the risk of suicide.

Fig 4. Forest plot of standard mean difference (SMD) of the total score of problem-solving skills among those who attempted suicide versus those who did not attempt suicide.

Fig 5. Forest plot of standard mean difference (SMD) of the total score of risk of suicide among those who received problem-solving therapy versus those who did not receive problem-solving therapy.

Meta-regression

Table 2. Assessing the source of heterogeneity across studies reporting the association between problem-solving skills and suicidal ideation and suicide attempt using the meta-regression.

Discussion

Limitations

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Humayun Kabir

Roles

Author response to Decision Letter 0

Decision Letter 1

Humayun Kabir

Roles

Author response to Decision Letter 1

Decision Letter 2

Humayun Kabir

Roles

Author response to Decision Letter 2

Decision Letter 3

Humayun Kabir

Roles

Acceptance letter

Humayun Kabir

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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