Safety planning interventions to address suicidality in adults: a protocol for a systematic review of the literature

Abstract

Introduction

Suicide is a significant public health issue worldwide. Many deaths by suicide occur in moments of crisis. Therefore, interventions which support individuals to manage moments of acute distress are needed. Safety Planning Interventions (SPI) are a group of brief interventions which aim to reduce imminent risk of suicide through the collaborative creation of a written set of coping strategies a person can use when suicidal ideation and/or urges occur. A number of studies, including systematic reviews, have supported the efficacy of SPIs in reducing suicidal behaviour, and sometimes ideation. However, there is notable heterogeneity in SPI effectiveness research. Our review aims to synthesise and critically examine the methodological characteristics of research on SPI effectiveness and to provide recommendations for the reporting of future research.

Method and analysis

A predetermined search strategy will be used to search six electronic databases. Eligible studies will examine the effectiveness of SPIs for suicidality in adults aged 18+. There will be no restrictions to inclusion based on study design, study setting and participant characteristics. Two independent reviewers will perform study selection, data extraction and quality assessment. Disagreements between reviewers will be resolved by a third reviewer. Data gathered will include study design, participant characteristics, study setting, type of SPI delivered, theoretical approach used to guide research, outcomes measured and results reported. A narrative synthesis of the methodological characteristics of the included studies will be provided. Recommendations for the development and reporting of future research will be provided. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis guidance.

Ethics and dissemination

Ethical approval is not required as no original data will be collected. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO registration number

This protocol has been registered on Prospero (registration ID CRD42025641027).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This systematic review protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis-Protocols guidelines.

• The study will address a gap in the literature. It will have a methodological focus, it will include mixed methods and it will cross intervention modalities.

• The search strategy was developed in consultation with an independent, experienced research librarian and was piloted prior to commencement of the review.

• Studies published in a language other than English will be excluded. This may cause a language bias.

• No grey literature will be included.

Introduction

Suicidal behaviour is a significant public health issue worldwide. According to the WHO,¹ more than 720 000 people die due to suicide each year, and a greater number attempt suicide. Many deaths by suicide occur in moments of crisis. While longer-term risk factors are often present, the acute period of heightened risk for suicidal behaviour is often very short.^{2 3} Therefore, interventions which support individuals to manage such moments of crisis are needed. Furthermore, a number of individuals who present to services (eg, emergency departments, helplines, mental health services) may be lost to follow-up or face a delay in receiving further support.⁴ Consequently, brief interventions, which can be used as standalone interventions or in conjunction with other supports, designed for use in moments of crisis may play a key role in suicide prevention.

Safety Planning Interventions (SPIs) refer to a group of brief interventions which aim to reduce imminent risk of suicidal behaviour.⁵ The interventions involve the construction of a written, prioritised set of coping strategies and sources of support that a person can use when they experience distress and/or urges to engage in suicidal behaviour.⁴ There are typically six components included in a safety plan, which can be followed in a stepped way. The six components are (1) identify warning signs of impending crisis; (2) employ internal coping strategies, such as ways of distracting oneself; (3) use social contacts and settings as a form of distraction; (4) use family members/friends to help resolve the crisis; (5) contact mental health professionals or agencies; and (6) restrict access to lethal means.⁴ SPIs are typically offered to individuals following a suicide attempt, or to those experiencing suicidal ideation, after a risk assessment is completed. Although designed to be used as a standalone, brief intervention, SPIs have been integrated with structured follow-up contact⁶ and with other intervention approaches and models.⁷ SPIs have also been translated into digital modalities for use among those who may not seek or access traditional clinical support.⁷

Numerous studies have examined the effectiveness of SPIs in reducing suicidal behaviours and/or ideation. Indeed, three previous systematic reviews of effectiveness research7,9 have supported the effectiveness of SPIs in reducing suicidal behaviour and sometimes suicidal ideation. However, the authors of these reviews highlight the heterogeneity of the included studies. There are notable differences in outcomes measured, populations, settings, type of SPI and mode of SPI delivery in the reviewed studies. Given this heterogeneity, there is limited ability to examine the mechanisms by which SPIs impact suicidal behaviour.¹⁰ Rogers et al¹¹ proposed a number of potential mechanisms which may underpin the effectiveness of safety planning and highlighted the need to investigate this further in future research. Therefore, a systematic review of the methodological characteristics of existing research is warranted in order to advance research efforts and to add to our theoretical understanding of SPIs.

Method and analysis

This protocol has been developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines, as shown in the PRISMA-P checklist (see online supplemental file 1).

Review questions:

This review will critically examine the methodological characteristics of effectiveness research on SPIs. The following questions will be addressed:

1. What are the methodological characteristics of research examining SPIs for suicidality in adults?

2. What data collection procedures, study designs, populations, study settings, types of SPIs, modality of intervention delivery, suicide specific outcomes, additional outcomes and results are reported?

3. What theoretical approaches to suicidality are reported to inform data collection procedures?

Method

PRISMA guidelines¹² will be followed.

Timeline and current status

Searches were conducted in January 2025. The final review was submitted to a peer-reviewed journal for consideration in August 2025.

Searches

A predetermined search strategy will be used in the following databases from inception to January 2025: Cochrane Trials, Pubmed, Embase, PsychInfo (EBSCO), Web of Science (Clarivate) and Medline (EBSCO). The references of included articles will be hand-searches to identify any additional relevant studies.

The search strategy was developed by ER, with supervision from RM and in consultation with a trained research librarian. Development of the search strategy was guided by the Peer Review of Electronic Search Strategies guidelines¹³ and was developed by identifying subject headings for key concepts relevant to the research questions and aims (ie, suicide, safety planning, adults). The search strategy has been adapted for the required input of each database.

The following is an example of the search strategy for PubMed:

(“Suicide”[MeSH Terms] OR “Self-Injurious Behavior”[MeSH Terms] OR (“suicid*“[Title/Abstract] OR “self injur*“[Title/Abstract] OR “self harm*“[Title/Abstract] OR “suicidal behavio*r*“[Title/Abstract] OR “automutilation”[Title/Abstract]))

AND

(“Crisis Intervention”[MeSH Terms] OR (“safety plan*“[Title/Abstract] OR “crisis intervention*“[Title/Abstract] OR “crisis plan*"[Title/Abstract]))

AND

(“Adult”[MeSH Terms] OR “adult*"[Title/Abstract])

Results will be limited to studies published in English language only. This is due to the language competence of the research team and the lack of resources available for translation services.

Eligibility criteria

• Studies examining the efficacy and/or effectiveness of SPIs for suicidality.

• Terms such as safety planning, safety plan or SPI are used to describe the studied intervention, and/or Stanley and Brown⁴ intervention is referenced.

• Studies that explore SPIs in isolation and in combination with other interventions/ supports.

• Studies that use quantitative, qualitative or mixed methodologies to explore the efficacy/effectiveness of safety planning will be included.

• There will be no restrictions to inclusion based on study design.

• There will be no restrictions to inclusion based on intervention/study setting and participant characteristics (with the exception of age).

• Studies with participants aged 18 years or over. Where studies include both under and over 18, they may be included if there is clear separation between reported outcomes for over 18 and under 18.

• Studies published in English language.

• Studies published from inception of the databases used to January 2025.

• Peer-reviewed studies.

Primary outcomes

The primary outcomes of the review will be the study design, participants, study settings, types of SPIs, modalities of intervention delivery, recruitment methods, monitoring periods, outcomes and measures used, results reported and guiding Theories.

Secondary outcomes

Secondary outcomes will include the outcomes of the interventions.

Data extraction (selection and coding)

Search results will be imported into Endnote reference management software,¹⁴ and duplicates will be removed. Following deduplication, Covidence software¹⁵ will be used for screening, data extraction and data management. Titles and abstracts of retrieved studies will be screened independently by two review authors (ER and AR) to identify studies that potentially meet the inclusion criteria. Discrepancies will be discussed. If agreement cannot be reached, this will be resolved through discussion with a third reviewer.

Based on title/abstract screening, the full text of potentially eligible studies will be retrieved. Full text of these studies will be independently assessed for suitability by two reviewers (ER and AR). Discrepancies will be discussed. If agreement cannot be reached, this will be resolved through discussion with a third reviewer. A PRISMA flow chart will be used to show the selection process.

A standardised, pre-piloted form will be used to extract data from the included studies for assessment of study quality and evidence synthesis. The following information will be extracted: authors, date of publication, title, guiding theories, participants, recruitment method, study design, intervention setting, intervention type, details of intervention, mode of delivery, monitoring period, suicide-specific outcomes (and measures used), additional outcomes (and measures used) and results reported. Two independent reviewers (ER and AR) will extract data from a randomly selected 20% of studies. If a 90% agreement rate is reached at this stage, ER will extract data from the remaining 80% of studies. If 90% agreement is not reached, discrepancies will be resolved through discussion with a third reviewer, and data extraction from a further 20% of studies will be conducted by two reviewers (ER and AR). This process will be repeated until 90% agreement is reached, or data from all papers has been extracted. This approach was chosen to balance thoroughness of the review with resource constraints.

A narrative synthesis of the findings from the included studies will be provided, structured around the theoretical approaches used, intervention characteristics, study populations, study designs, outcomes studied, themes identified (qualitative studies) and results reported (quantitative studies).

Risk of bias

Four Joanna Briggs Institute critical appraisal tools will be used to assess risk of bias at the study level, based on the primary design of each study (randomised control trials, quasi-experimental studies, cross-sectional studies and qualitative studies,16,19 as per previous reviews).^{7 9} This is due to the potential diversity in study designs of included studies. The items in each tool are rated as yes, no, unclear or not applicable. An overall quality score is not given for each paper.

The risk of bias assessment will be performed independently by two authors (ER and AR), with a third reviewer consulted in the case of disagreement. Papers will not be excluded from the review based on quality. Study quality and risk of bias will instead be discussed as part of the narrative synthesis.

Patient and public involvement

Patients and the public were not involved in the development of this protocol, due to the proposed use of secondary data.

Ethics and dissemination

As the planned study is a systematic review of existing literature and primary data will not be collected, ethical approval is not required. This systematic review is registered in the International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/view/CRD42025641027). The results of this study will be submitted to relevant peer-reviewed journals for publication. The results may also be submitted for presentation at academic conferences.

Amendment process

Amendments made to the protocol will be documented in the manuscript of the systematic review.