Evaluating the Cost Effectiveness of a Suicide Prevention Campaign Implemented in Ontario, Canada



Although suicide-prevention campaigns have been implemented in numerous countries, Canada has yet to implement a strategy nationally. This is the first study to examine the cost utility of the implementation of a multidimensional suicide-prevention program that combines several interventions over a 50-year time horizon.


We used Markov modeling to capture the dynamic changes to health status and estimate the incremental cost per quality-adjusted life-year gained over a 50-year period for Ontario residents for a suicide-prevention strategy compared to no intervention. The strategy consisted of a package of interventions geared towards preventing suicide including a public health awareness campaign, increased identification of individuals at risk, increased training of primary-care physicians, and increased treatment post-suicide attempt. Four health states were captured by the Markov model: (1) alive and no recent suicide attempt; (2) suicide attempt; (3) death by suicide; (4) death (other than suicide). Analyses were from a societal perspective where all costs, irrespective of payer, were included. We used a probabilistic analysis to test the robustness of the model results to both variation and uncertainty in model parameters.


Over the 50-year period, the suicide-prevention campaign had an incremental cost-effectiveness ratio (ICER) of $18,853 (values are in Canadian dollars) per QALY gained. In all one-way sensitivity analyses, the ICER remained under $50,000/QALY. In the probabilistic analysis, there was a probability of 94.8% that the campaign was cost effective at a willingness-to-pay of $50,000/QALY (95% confidence interval of ICER probabilistic distribution: 2650–62,375). Among the current population, the intervention was predicted to result in the prevention of 4454 suicides after 50 years (1033 by year 10; 2803 by year 25). A healthcare payer perspective sensitivity analysis showed an ICER of $21,096.14/QALY.


These findings demonstrate that a suicide-prevention campaign in Ontario is very likely a cost-effective intervention to reduce the incidence of suicide and suggest suicide-prevention campaigns are likely to be cost effective for some other Canadian provinces and potentially other countries.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

Data availability

Data are available from the authors upon request.


  1. 1.

    Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22:3–18.

    Article  Google Scholar 

  2. 2.

    Skinner R, McFaull S, Draca J, Frechette M, Kaur J, Pearson C, et al. Suicide and self-inflicted injury hospitalizations in Canada (1979 to 2014/15). Health Promot Chronic Dis Prev Can. 2016;36:243–51.

    CAS  Article  Google Scholar 

  3. 3.

    Statistics Canada. Health Fact Sheets—the ten leading causes of death, 2012 [Internet]. 2015. http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14296-eng.htm. Accessed 29 Aug 2019.

  4. 4.

    Corso PS, Mercy JA, Simon TR, Finkelstein EA, Miller TR. Medical costs and productivity losses due to interpersonal and self-directed violence in the United States. Am J Prev Med. 2007;32:474–82.

    Article  Google Scholar 

  5. 5.

    Matsubayashi T, Ueda M. The effect of national suicide-prevention programs on suicide rates in 21 OECD nations. Soc Sci Med. 2011;73:1395–400.

    Article  Google Scholar 

  6. 6.

    Hegerl PDU, Wittmann M, Arensman E, van Audenhove C, Bouleau J-H, van der Feltz-Cornelis C, et al. The ‘European Alliance Against Depression (EAAD)’: a multifaceted, community-based action programme against depression and suicidality. World J Biol Psychiatry. 2008;9:51–8.

    Article  Google Scholar 

  7. 7.

    Eggertson L, Patrick K. Canada needs a national suicide-prevention strategy. CMAJ. 2016;188:E309–10.

    Article  Google Scholar 

  8. 8.

    Eggertson L. Quebec cuts suicide rates despite lack of a national prevention strategy. iPolitics [Internet]. https://ipolitics.ca/2015/06/19/quebec-cuts-suicide-rates-despite-lack-of-a-national-prevention-strategy/. Accessed 29 Aug 2019.

  9. 9.

    Vasiliadis H-M, Lesage A, Latimer E, Seguin M. Implementing suicide prevention programs: costs and potential life years saved in Canada. J Ment Health Policy Econ. 2015;18:147–55.

    PubMed  Google Scholar 

  10. 10.

    Statistics Canada. Population by year, by province and territory (CANSIM table 051-0001) [Internet]. http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo02a-eng.htm. Accessed 22 June 2019.

  11. 11.

    Patten SB, Williams JV, Lavorato DH, Wang JL, McDonald K, Bulloch AG. Descriptive epidemiology of major depressive disorder in Canada in 2012. Can J Psychiatry. 2015;60:23–30.

    Article  Google Scholar 

  12. 12.

    Pil L, Pauwels K, Muijzers E, Portzky G, Annemans L. Cost-effectiveness of a helpline for suicide-prevention. J Telemed Telecare. 2013;19:273–81.

    Article  Google Scholar 

  13. 13.

    Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS One. 2014;9:e89944.

    Article  Google Scholar 

  14. 14.

    Finkelstein Y, Macdonald EM, Hollands S, Sivilotti ML, Hutson JR, Mamdani MM, et al. Risk of suicide following deliberate self-poisoning. JAMA Psychiatry. 2015;72:570–5.

    Article  Google Scholar 

  15. 15.

    Statistics Canada. Elements of the life table, Canada, provinces and territories (CANSIM Table 053-0003) [Internet]. http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=530003. Accessed 22 June 2019.

  16. 16.

    Fleurence RL, Hollenbeak CS. Rates and probabilities in economic modelling: transformation, translation and appropriate application. PharmacoEconomics. 2007;25:3–6.

    Article  Google Scholar 

  17. 17.

    Hawton K, Witt KG, Salisbury TLT, Arensman E, Gunnell D, Hazell P, et al. Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. Lancet Psychiatry. 2016;3:740–50.

    Article  Google Scholar 

  18. 18.

    MHASEF Research Team. Mental health and addictions system performance in Ontario: a baseline scorecard. Toronto: Institute for Clinical Evaluative Sciences; 2018.

    Google Scholar 

  19. 19.

    Speechley M, Stavraky KM. The adequacy of suicide statistics for use in epidemiology and public health. Can J Public Health Rev Can Sante Publique. 1991;82:38–42.

    CAS  Google Scholar 

  20. 20.

    Van den Hout W. The value of productivity: human-capital versus friction-cost method. Ann Rheum Dis. 2010;69:i89–91.

    Article  Google Scholar 

  21. 21.

    Canadian Institute for Health Information. National Health Expenditure Trends|CIHI [Internet]. 2018. https://www.cihi.ca/en/national-health-expenditure-trends. Accessed 22 June 2019.

  22. 22.

    Statistics Canada. Average weekly earnings (including overtime), by province and territory [Internet]. 2017. http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/labr79-eng.htm. Accessed 22 June 2019.

  23. 23.

    Tanuseputro P, Wodchis WP, Fowler R, Walker P, Bai YQ, Bronskill SE, et al. The health care cost of dying: a population-based retrospective cohort study of the last year of life in Ontario, Canada. PLoS One. 2015;10:e0121759.

    Article  Google Scholar 

  24. 24.

    Statistics Canada. Labour Force Survey estimates (LFS), by provinces, territories and economic regions based on 2011 Census boundaries [Internet]. http://www5.statcan.gc.ca/cansim/a26?lang=eng&retrLang=eng&id=2820123&&pattern=&stByVal=1&p1=1&p2=37&tabMode=dataTable&csid=. Accessed 22 June 2019.

  25. 25.

    Krol M, Papenburg J, Tan SS, Brouwer W, Hakkaart L. A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs. Eur J Health Econ. 2016;17:391–402.

    Article  Google Scholar 

  26. 26.

    Organisation for Economic Co-operation and Development. Purchasing Power Parity [Internet]. 2018. https://data.oecd.org/conversion/purchasing-power-parities-ppp.htm. Accessed 22 June 2019.

  27. 27.

    Statistics Canada. Consumer Price Index, health and personal care, by province (Canada) [Internet]. 2018. https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1810000501#timeframe. Accessed 22 June 2019.

  28. 28.

    Fleishman JA. Demographic and clinical variations in health status [Internet]. Agency for healthcare research and quality. 2005. https://meps.ahrq.gov/data_files/publications/mr15/mr15.shtml. Accessed 22 June 2019.

  29. 29.

    van Spijker BA, van Straten A, Kerkhof AJ, Hoeymans N, Smit F. Disability weights for suicidal thoughts and non-fatal suicide attempts. J Affect Disord. 2011;134:341–7.

    Article  Google Scholar 

  30. 30.

    Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Health and Welfare; 1999.

    Google Scholar 

  31. 31.

    Canadian Agency for Drugs and Technologies in Health. Guidelines for the economic evaluation of health technologies, 4th ed. Canada, Ottawa. 2017.

  32. 32.

    Manchanda R, Legood R, Burnell M, McGuire A, Raikou M, Loggenberg K, et al. Cost-effectiveness of population screening for BRCA mutations in Ashkenazi jewish women compared with family history-based testing. JNCI J Natl Cancer Inst. 2015;107:dju380.

    PubMed  Google Scholar 

  33. 33.

    Marra CA, Esdaile JM, Anis AH. Practical pharmacogenetics: the cost effectiveness of screening for thiopurine s-methyltransferase polymorphisms in patients with rheumatological conditions treated with azathioprine. J Rheumatol. 2002;29:2507–12.

    PubMed  Google Scholar 

  34. 34.

    You JH, Tam L, Lee NL. Cost-effectiveness of molecular point-of-care testing for influenza viruses in elderly patients at ambulatory care setting. PLoS One. 2017;12:e0182091.

    Article  Google Scholar 

  35. 35.

    International Society for Pharmacoeconomics and Outcomes Research. Pharmacoeconomic guidelines around the world [Internet]. 2017. https://tools.ispor.org/peguidelines/. Accessed 29 Aug 2019.

  36. 36.

    Gray A, Clarke P, Wolstenholme J, Wordsworth S. Applied methods of cost-effectiveness analysis in healthcare. Oxford: Oxford University Press; 2010.

    Google Scholar 

  37. 37.

    Singh SM, Micieli A, Wijeysundera HC. An economic evaluation of percutaneous left atrial appendage occlusion: dabigatran and warfarin for stroke prevention in patients with non-valvular atrial fibrillation. Circulation. 2013;127:2414–23.

    CAS  Article  Google Scholar 

  38. 38.

    Abdel-Qadir H, Roifman I, Wijeysundera HC. Cost-effectiveness of clopidogrel, prasugrel and ticagrelor for dual antiplatelet therapy after acute coronary syndrome: a decision-analytic model. CMAJ Open. 2015;3:E438.

    Article  Google Scholar 

  39. 39.

    Butt T, Patel PJ, Tufail A, Rubin GS. Modelling cost effectiveness in neovascular age-related macular degeneration: the impact of using contrast sensitivity vs. visual acuity. Appl Health Econ Health Policy. 2014;12:289–97.

    Article  Google Scholar 

  40. 40.

    Yang NH, Dharmar M, Yoo B-K, Leigh JP, Kuppermann N, Romano PS, et al. Economic evaluation of pediatric telemedicine consultations to rural emergency departments. Med Decis Making. 2015;35:773–83.

    Article  Google Scholar 

  41. 41.

    Munzer A. Probabilistic Sensitivity Analysis (PSA) on values that change by cycle [Internet]. 2014. http://treeage.zendesk.com/hc/en-us/articles/222718208-Probabilistic-Sensitivity-Analysis-PSA-on-values-that-change-by-cycle. Accessed 22 June 2019.

  42. 42.

    TreeAge Software Inc. TreeAge Pro [Internet]. Williamstown, Massachusetts, USA. 2016. https://www.treeage.com/. Accessed 22 June 2019.

  43. 43.

    Whitmer DA, Woods DL. Analysis of the cost effectiveness of a suicide barrier on the Golden Gate Bridge. Crisis. 2013;34:98–106.

    Article  Google Scholar 

  44. 44.

    Mihalopoulos C, Vos T, Pirkis J, Carter R. The economic analysis of prevention in mental health programs. Annu Rev Clin Psychol. 2011;7:169–201.

    Article  Google Scholar 

  45. 45.

    Park A-L, Gysin-Maillart A, Müller TJ, Exadaktylos A, Michel K. Cost-effectiveness of a brief structured intervention program aimed at preventing repeat suicide attempts among those who previously attempted suicide: a secondary analysis of the ASSIP randomized clinical trial. JAMA Netw Open. 2018;1:e183680.

    Article  Google Scholar 

  46. 46.

    Denchev P, Pearson JL, Allen MH, Claassen CA, Currier GW, Zatzick DF, et al. Modeling the cost-effectiveness of interventions to reduce suicide risk among hospital emergency department patients. Psychiatr Serv. 2017;69:23–31.

    Article  Google Scholar 

  47. 47.

    Kapur N, Cooper J, O’Connor RC, Hawton K. Non-suicidal self-injury vs attempted suicide: new diagnosis or false dichotomy? Br J Psychiatry. 2013;202:326–8.

    Article  Google Scholar 

Download references

Author information




JC and ML are dual first authors for this article. JC and ML conceived the study, undertook the analysis, and wrote the manuscript. All authors assisted with the interpretation of the results and critically reviewed the manuscript.

Corresponding authors

Correspondence to Michael Lebenbaum or Joyce Cheng.

Ethics declarations


The research presented in this article was not funded by any study-specific Grant funding. Michael Lebenbaum is funded by a Vanier Canada Graduate Scholarship.

Conflict of interest

Joyce Cheng, Michael Lebenbaum, Claire de Oliveira, Paul Kurdyak, Juveria Zaheer, and Peter C. Coyte have no conflicts of interests to declare. Rebecca Hancock-Howard was previously employed as a consultant at Amaris, a private firm; clients include pharmaceutical companies and medical device manufacturers.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 27 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lebenbaum, M., Cheng, J., de Oliveira, C. et al. Evaluating the Cost Effectiveness of a Suicide Prevention Campaign Implemented in Ontario, Canada. Appl Health Econ Health Policy 18, 189–201 (2020). https://doi.org/10.1007/s40258-019-00511-5

Download citation