Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning

Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol

BACKGROUND

The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth.

METHOD

This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys.

CONCLUSION

If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Family psychoeducation in schizophrenia and schizophrenia related disorder, treatment compliance, and suicidal risk reduction: questions about their relationship from a naturalistic observation

Introduction

The Profamille V3.2 multi-family psycho-educational program directed at caregivers of relatives with schizophrenia or schizophrenia related disorder has been shown to decrease the annual prevalence of suicide attempts. It has been reported that psychoeducation of families can sometimes improve compliance with treatment. This study investigates whether the Profamille program improves compliance and thus reduces the risk of suicide among patients.

Method

This is a retrospective study of 179 groups of family caregivers, encompassing 1946 participants enrolled in Module 1 of the Profamille program and followed up one year after completion of the module. Evaluations were conducted using questionnaires filled out by family caregivers at three distinct times: prior to beginning the program, upon its completion, and again one year following its conclusion. The annual prevalence of suicide attempts was measured both before the program began and one year after its conclusion, while compliance to treatment was evaluated at the start and end of the program.

Result

After the Profamille program, the annual prevalence of suicide attempts fell by a factor of 2 (p-value = 0.00002) and patient compliance improved (p-value <0.000001). This reduction in suicide attempts was observed independently of improved compliance. Compliance seems to have an additional effect, but only after participation in the program.

Conclusion

The Profamille program reduces patients' risk of suicide even when patients are not taking the treatment. When family psychoeducation is not proposed in schizophrenia or schizophrenia related disorder, this can represent a loss of chance for patients.

Peer-Written Caring Letters for Veterans after a Suicidal Crisis

OBJECTIVE

In the evidence-based suicide prevention intervention, Caring Letters, healthcare providers send brief, caring messages to patients following psychiatric inpatient care, a time of elevated suicide risk. However, recent studies with military populations have found mixed results. An adaptation of Caring Letters employed a peer framework in which veterans from the community wrote brief caring messages to veterans discharging from psychiatric inpatient treatment after a suicidal crisis.

METHODS

The present study utilized content analysis to assess 90 caring messages generated by 15 peer veterans recruited from veteran service organizations (e.g., American Legion).

RESULTS

Three themes emerged: (1) Shared Military Service, (2) Care, and (3) Overcoming Adversity. Peer-generated content varied in how the coded themes were expressed in the messages.

CONCLUSION

These veteran-to-veteran caring messages may bolster belongingness, social support, and destigmatize mental health struggles, and have the potential to augment existing Caring Letters effects and interventions.

Non-pharmacological interventions for preventing suicide attempts: A systematic review and network meta-analysis

Suicide attempts can cause serious physical harm or death. It would be crucial to gain a better understanding of the comparative efficacy of non-pharmacological interventions. We aimed to identify which non-pharmacological interventions are more effective in preventing suicide attempts. PubMed, Web of Science, and EMBASE databases were searched systematically from their inception until 3 April 2023. To be eligible for inclusion, randomized controlled trials (RCTs) had to meet the following criteria: Participants were individuals who had suicidal ideation or a history of severe self-harm or attempted suicide. A network meta-analysis was performed using a random effects model to estimate the treatment effect of various non-pharmacological interventions. (PROSPERO registration number: CRD42023411393). We obtained data from 54 studies involving 17,630 participants. Our primary analysis found that Cognitive therapy (CT) (OR=0.19, 95%CI =0.04-0.81), Dialectical Behavior Therapy (DBT) (OR=0.37, 95%CI =0.13-0.97), Cognitive-behavioral therapy (CBT) (OR=0.42, 95%CI =0.17-0.99), and Brief intervention and contact (BIC) (OR=0.65, 95%CI=0.44-0.94) were superior to TAU (within the longest available follow-up time) in preventing suicide attempts, while other intervention methods do not show significant advantages over TAU. Secondary analysis showed that the two intervention measures (CT and BIC) were effective when follow-up time did not exceed 6 months, but there was no effective intervention measure with longer follow-up times. CT, DBT, CBT, and BIC have a better effect in preventing suicide attempts than other non-pharmacological interventions. Additional research is necessary to validate which interventions, as well as which combinations of interventions, are the most effective.

Qualitative Evaluation of a Caring Letters Suicide Prevention Intervention for the Veterans Crisis Line

OBJECTIVE

Suicide is a leading cause of death in the United States. This has prompted the U.S. surgeon general to issue a report describing actionable items to reduce suicide rates, including a recommendation to increase the use of the caring letters intervention. This intervention involves mailing brief, nondemanding messages of care. As part of the Department of Veterans Affairs' (VA's) efforts to reduce suicide rates among veterans, a caring letters project was developed for veterans who contact the Veterans Crisis Line (VCL). This article describes the results of qualitative interviews conducted to better understand the experiences of veterans who received caring letters.

METHODS

Beginning in 2020, all identifiable veterans who used Veterans Health Administration services and contacted the VCL received nine letters over 1 year, along with a list of mental health resources. Semistructured interviews (N=23) were conducted, and content analysis was used to identify veterans' perspectives and suggestions for improving the intervention.

RESULTS

Sixteen men and seven women participated (mean age=53 years). Feedback varied, with most participants reporting that receiving caring letters had a positive impact and others noting aspects that could be improved to enhance the intervention's caring intent. Some also reported that the letters helped them engage with community resources and made them more likely to seek VA care.

CONCLUSIONS

The caring letters intervention, received after contact with the VCL, was well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future evaluation examining veteran outcomes.

Bridging the gap: a qualitative study of providers' perceptions of a partnered crisis follow-up program for suicidal patients post-emergency department discharge

BACKGROUND

Effective interventions are needed to address suicide risk following discharge from the hospital emergency department or inpatient setting. Studies that examine follow-up contact methods show promise, but little is known about how follow-up programs are implemented in the real world and who is benefitting. The purpose of this formative evaluation and analysis was to gain insight about the usefulness and value of a partnered suicide prevention follow-up program (academic medical center emergency department partnered with a regional suicide prevention center) from the standpoint of psychiatry resident physicians providing direct care and suicide prevention center crisis counselors making follow-up outreach telephone calls to patients.

METHODS

A qualitative thematic analysis was conducted with focus group data from a convenience sample of psychiatry residents who performed consultations in the emergency department setting and counselors at the suicide prevention center crisis follow-up program. Focus group sessions, using semi-structured question guides, were completed at each participant group's workplace. Grounded theory techniques were used to guide coding and analytic theme development.

RESULTS

Analyses resulted in four overarching themes: valuing the program's utility and benefit to patients, desiring to understand what happens from emergency department discharge to program follow-up, having uncertainty about which patients would benefit from the program, and brainstorming to improve the referral process. Psychiatry residents appreciated the option of an "active" referral service (one that attempts to actively engage a patient after discharge through outreach), while suicide prevention crisis counselors valued their ability to offer a free and immediate service that had potential for fostering meaningful relationships. Both participant groups desired a better understanding of their partner's program operations, a uniform and smooth referral process, and awareness of who may or may not benefit from program services.

CONCLUSION

Results revealed the need for improved communication and implementation, such as expanded inter-agency contacts, consistent provider training, more documentation of the requirements and rules, a consistent message about program logistics for patients, and coordination between the program elements.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol

BACKGROUND

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

METHODS

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

CONCLUSIONS

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Managed Care Updates of Subscriber Jail Release to Prompt Community Suicide Prevention: Clinical Trial Protocol

Background

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

Methods

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

Conclusions

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

Trial Registration

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023, https://beta.clinicaltrials.gov/study/NCT05579600?cond=Suicide&term=Managed%20Care&rank=1.

Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial

BACKGROUND

Suicide is a leading cause of death in adolescents and adults in the US. Follow-up support delivered when patients return home after an emergency department (ED) or primary care encounter can significantly reduce suicidal ideation and attempts. Two follow-up models to augment usual care including the Safety Planning Intervention have high efficacy: Instrumental Support Calls (ISC) and Caring Contacts (CC) two-way text messages, but they have never been compared to assess which works best. This protocol for the Suicide Prevention Among Recipients of Care (SPARC) Trial aims to determine which model is most effective for adolescents and adults with suicide risk.

METHODS

The SPARC Trial is a pragmatic randomized controlled trial comparing the effectiveness of ISC versus CC. The sample includes 720 adolescents (12-17 years) and 790 adults (18+ years) who screen positive for suicide risk during an ED or primary care encounter. All participants receive usual care and are randomized 1:1 to ISC or CC. The state suicide hotline delivers both follow-up interventions. The trial is single-masked, with participants unaware of the alternative treatment, and is stratified by adolescents/adults. The primary outcome is suicidal ideation and behavior, measured using the Columbia Suicide Severity Rating Scale (C-SSRS) screener at 6 months. Secondary outcomes include C-SSRS at 12 months, and loneliness, return to crisis care for suicidality, and utilization of outpatient mental health services at 6 and 12 months.

DISCUSSION

Directly comparing ISC and CC will determine which follow-up intervention is most effective for suicide prevention in adolescents and adults.

"Keep up the messages, sometimes it was a lifesaver": Effects of cultural adaptation on a suicide prevention clinical trial in American Indian/Alaska Native communities

Suicide disproportionately affects many American Indian/Alaska Native (AI/AN) communities. Caring Contacts is one of the few suicide prevention interventions with demonstrated success in diverse populations, but its acceptability and effectiveness have not been evaluated in AI/AN communities. Using community-based participatory research (Phase 1), we conducted focus groups and semi-structured interviews with AI/AN adults, healthcare providers, and leaders in four communities to improve study design and maximize intervention acceptability and effectiveness for implementation in a randomized controlled trial (Phase 2). This paper describes how adaptations made during Phase 1 affected the acceptability, fit, and responsiveness of the study features to the communities' needs. Acceptability of the study procedures and materials in this community appears to be high, with 92% of participants indicating the initial assessment interview was a positive experience. Broadening eligibility criteria with regard to age and possession of a cellular device resulted in the recruitment of an additional 48% and 46% of participants, respectively. Inclusion of locally-informed methods of self-harm allowed us to capture a wider range of suicidal behavior than would have otherwise been identified. Clinical trials would benefit from community-engaged, cultural adaptation studies with populations in which the interventions would eventually be applied.

Comparative effectiveness of two versions of a caring contacts intervention in healthcare providers, staff, and patients for reducing loneliness and mental distress: A randomized controlled trial

BACKGROUND

Caring Contacts can effectively reduce suicide ideation, attempts, and death. In published clinical trials, Caring Contacts were sent by someone who knew the recipient. At scale, Caring Contacts programs rarely introduce the recipient and sender. It is not known whether receiving Caring Contacts from someone unknown is as effective as messages from someone the recipient has met.

METHODS

Pragmatic randomized controlled trial comparing Caring Contacts with (CC+) versus without an introductory phone call (CC). Recruitment occurred January-July 2021, with outcomes assessed at 6 months. Participants were primary care patients or healthcare providers/staff reporting adverse mental health outcomes on a qualifying survey. Participants were sent 11 standardized caring text messages over 6 months; when participants replied, they received personalized unscripted responses. CC+ calls were semi-structured. The primary outcome was loneliness (NIH Toolkit).

RESULTS

Participants included 331 patients (mean [SD] age: 45.5 [16.4], 78.9 % female) and 335 healthcare providers/staff (mean [SD] age: 40.9 [11.8], 86.6 % female). There were no significant differences in loneliness at 6 months by treatment arm in either stratum. In patients, mean (SD) loneliness was 61.9 (10.7) in CC, and 60.8 (10.3) in CC+, adjusted mean difference of -1.0 (95 % CI: -3.0, 1.0); p-value = 0.31. In providers/staff, mean (SD) loneliness was 61.2 (11) in CC, and 61.3 (11.1) in CC+, adjusted mean difference of 0.2 (95 % CI: -1.8, 2.2); p-value = 0.83.

LIMITATIONS

Study population was 93 % white which may limit generalizability.

CONCLUSIONS

Including an initial phone call added operational complexity without significantly improving the effectiveness of a Caring Contacts program.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design Setting and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15003 youths (7044 47.0%] male; 10209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.Appeared originally in JAMA Netw Open 2019; 2:e1914070.

Caring Contacts to Reduce Psychiatric Morbidity Following Hospitalization During the COVID-19 Pandemic: A Pilot Randomized Controlled Trial

OBJECTIVES

Caring Contacts are an emerging intervention that aims to reduce distress and suicide risk after acute psychiatric care. This trial aimed to determine whether, during a pandemic, there was any evidence that the mental health benefits and reduction in suicidal ideation (SI) associated with delivering Caring Contacts to recently discharged psychiatric patients were greater than a control communication. The secondary objective was to identify whether the predicted benefits were greater among people living alone or those diagnosed with depression.

METHOD

A single-site pilot randomized clinical trial (n = 100), with patients recruited from the adult Inpatient Psychiatry Unit at Sunnybrook Health Sciences Centre, Toronto, Canada between August 2020 and May 2021. Participants were randomized (1:1) to the Caring Contact or control group. Participants received three Caring Contact or control communications via email or mail (on days 4, 21, and 56 post-discharge). Mental health symptoms were assessed using the self-report Hopkins Symptom Checklist-25 (HSCL-25) scores at discharge (baseline) and when participants received each communication. Analysis of variance was used for the primary comparisons and exploratory analyses for subgroups.

RESULTS

Both groups experienced a significant worsening of mental health symptoms at all time points post-discharge relative to baseline. There were no significant differences between groups at any time point, however, on day 4 there was a 24.2% and 72.6% attenuated worsening in the Caring Contact group compared to the control group for total symptom severity and SI, respectively. There was no significant interaction effect for the depression subgroup or those living alone.

CONCLUSIONS

While this pilot study was not powered to identify significant differences between groups, results are indicative of feasibility and acceptability of the intervention and provide some indication that Caring Contacts may have benefited patients in the days following discharge, supporting the need for larger-scale trials. The study was registered with clinicaltrials.gov (study ID NCT04456062).

The association between reattempted suicide and incoming calls to the brief contact intervention service, VigilanS: a study of the clinical profile of callers

BACKGROUND

Suicide is a major health problem globally. As attempted suicide is a major risk factor for suicide, specific prevention strategies have been designed for use thereafter. An example is the brief contact intervention (BCI). In this regard, France employs a composite BCI, VigilanS, which utilizes three types of contact: phone calls, postcards and a 'who to contact in a crisis' card. Previous studies have found that this system is effective at preventing suicide. Nevertheless, VigilanS was not effective in the same way for all the patients included. This observation raises the question of specific adaptation during follow-up for populations that were less receptive to the service. In consideration of this issue, we identified one study which found that incoming calls to the service were linked with a higher risk of suicide reattempts. However, this study did not document the profiles of the patients who made these calls. Better understanding of why this population is more at risk is important in terms of identifying factors that could be targeted to improve follow-up. This research therefore aims to bring together such data.

METHODS

We performed a retrospective analysis of 579 patients referred to VigilanS by Toulouse University Hospital (France). We examined the sociodemographics, clinical characteristics, and follow-ups in place and compared the patients who made incoming calls to the service versus those who did not. Subsequently, we conducted a regression analysis using the significantly associated element of patients calling VigilanS. Then, in order to better understand this association, we analyzed the factors, including such calls, that were linked to the risk of suicide reattempts.

RESULTS

We found that 22% of the patients in our sample called the VigilanS service. These individuals: were older, at 41.4 years versus 37.9 years for the non-callers; were more likely to have a borderline personality disorder (BPD) diagnosis (28.9% versus 19.3%); and had a history of suicide attempts (71.9% versus 54.6%). Our analysis confirmed that incoming calls to VigilanS (OR = 2.9) were associated with reattempted suicide, as were BPD (OR = 1.8) and a history of suicide attempts (OR = 1.7).

CONCLUSION

There was a high risk that the patients calling VigilanS would make another suicide attempt. However, this association was present regardless of the clinical profile. We postulate that this link between incoming calls and reattempted suicide may arise because this form of contact is, in fact, a way in which patients signal that a further attempt will be made.

Culturally Adapting Caring Contacts for Suicide Prevention in Four Alaska Native and American Indian Communities

AIM

Despite substantial tribal, state, and federal effort, American Indian and Alaska Native (AI/AN) suicide rates have changed little in the last 30 years, prompting attention to new and innovative approaches to this persistent health disparity. Suicide prevention interventions with demonstrated success in other populations may be useful in AI/AN communities. Caring Contacts is a suicide prevention intervention that has been adapted and shown to reduce suicide ideation, attempts, and deaths in other populations.

CONCLUSION

Overall, AI/AN study participants in four diverse AI/AN communities endorsed the use of Caring Contacts for suicide prevention in their communities. Intervention adaptations for use in these communities centered primarily on message frequency and timing as well as expanding access to Caring Contacts. The results of this study may be applicable to other populations that experience suicide-related health disparities.

METHODS

We used a community-based participatory research approach to gather qualitative data from community members, healthcare providers, and leaders in four AI/AN communities. These data were analyzed thematically and used to adapt Caring Contacts for use in a subsequent clinical trial with AI/AN people at high risk for suicide.

RESULTS

A total of 189 community members and other health system stakeholders in four tribal communities participated in focus groups and interviews. Caring Contacts was perceived in all communities to be acceptable. Feedback for intervention adaptations focused on the themes of trial eligibility criteria; instruments; message frequency, timing, and content; and cultural considerations.

Brief contact interventions to reduce suicide among discharged patients with mental health disorders-A meta-analysis of RCTs

BACKGROUND

Worldwide, about 1 million died from suicide in 2000. People with mental health disorders are at greater risk of suicide, and they are especially susceptible during 1-week period after discharge from the hospital.

OBJECTIVE

This meta-analysis paper aims to evaluate the effectiveness of brief contact interventions in preventing (1) suicidal deaths, (2) suicidal attempts, and (3) suicidal ideations among mental health patients discharged from the hospital.

METHODS

Search for published and unpublished articles were conducted using 10 databases: CINAHL, Cochrane Central Register of Controlled Trials, Embase, Scopus, Pubmed, PsycINFO, Web of Science, Randomised Control Trial Registry Website, ClinicalTrials.gov, and Proquest Dissertation and Theses Global, using the keywords "suicide" AND "discharged," AND "patients." All articles printed in English and published from the year 1995 to August 2019 were included.

RESULTS

A total of 23 articles were included in the meta-analysis. Contact interventions significantly reduced suicidal attempts within (1) 12-14 months and (2) suicide ideations within 12 months. There were no significant findings on suicidal deaths.

DISCUSSION

A new finding of this meta-analysis is that combining several brief contact interventions could potentially reduce suicidal attempts and ideations. This is important in preserving the lives of discharged patients.

Effectiveness of distance-based suicide interventions: multi-level meta-analysis and systematic review

BACKGROUND

The use of distance-based interventions (DBIs) to reduce suicidal ideation and behaviours are an increasingly relevant form of intervention. DBIs are more affordable, scalable and available than traditional face-to-face interventions, helping to narrow the gap between needed and provided care.

AIMS

To evaluate the overall effectiveness of DBIs against suicidal ideation and behaviours.

METHOD

We systematically searched Web of Science, Scopus and PubMed for all DBIs primarily aimed at reducing suicidal ideation and behaviours. Data were analysed with a robust variance estimation corrected, multi-level meta-analysis.

RESULTS

We found 38 studies, reporting 110 outcomes. Effectiveness in reducing suicidal ideation was low (standardised mean difference -0.174, 95% CI -0.238 to -0.110). DBIs were significantly less effective against suicidal behaviours than against suicidal ideation, although still effective (standardised mean difference -0.059, 95% CI -0.087 to -0.032). Human involvement had no significant effect on effectiveness.

CONCLUSIONS

Despite low effectiveness, DBIs might play a role in large-scale prevention efforts against suicidal ideation within a stepped care approach. Further, DBIs may be helpful in expanding mental health services in low- and middle-income countries with otherwise limited access to mental healthcare. Although the evidence for DBIs efficacy is well grounded, the technical and scientific evaluation of DBIs regarding their set up, functionality and components needs to be addressed in future studies.

Effectiveness of the Hunter Way Back Support Service: An historical controlled trial of a brief non-clinical after-care program for hospital-treated deliberate self-poisoning

INTRODUCTION

Active contact and follow-up interventions have been shown to be effective in reducing repetition of hospital-treated self-harm. The Way Back Support Service (WBSS) is a new service funded by the Australian government to provide three months of non-clinical after-care following a hospital-treated suicide attempt. The aim of this study was to investigate the effectiveness of WBSS in reducing deliberate self-poisoning (DSP) and psychiatric hospital admissions over a 12-month follow-up period for a population of DSP patients within the Hunter (Australia) region.

METHODS

A non-randomized, historical controlled (two periods) trial design with intention-to-treat analyses. Outcome data were drawn from hospital records.

RESULTS

There were a total of 2770 participants across study periods. There were no significant differences between cohorts for proportion with any, or number of, re-admissions for DSP in the follow-up period. For psychiatric admissions, the intervention cohort had a non-significantly greater proportion with any psychiatric admission and significantly more admissions compared to one of the control cohorts.

CONCLUSION

The WBSS model of care should be modified to strengthen treatment engagement and retention and to include established, clinical, evidence-based treatments shown to reduce DSP repetition. Any modified WBSS model should be subject to further evaluation.

[Suicide prevention: How to act?]

Although being complex, suicide is a phenomenon considered as preventable, and its prevention has been made as a public health priority. Some interventions to prevent suicide have been evaluated, such as the education of the healthcare workers, especially in the suicidal assessment (suicidal risk and suicidal emergency/dangerousness), the diagnosis and management of common mental disorders, the care provided after a suicide attempt, the restriction access to common means of suicide, the use of websites to educate the public, or the appropriate reports of suicide in media. Other interventions, even not rigorously evaluated, are implemented in France as in many parts of the world. It is the case of interventions among identified high-risk groups. To be efficient, prevention programs should simultaneously include different strategies targeting several known risk factors for suicide. Clinicians play a crucial role in the suicide prevention strategies.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Importance

Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review.

Methods

A narrative review was performed.

Observations

Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed.

Conclusions and Relevance

The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

Loss to follow-up in a population-wide brief contact intervention to prevent suicide attempts - The VigilanS program, France

Background

Brief Contact Interventions (BCIs) after a suicide attempt (SA) are an important element of prevention against SA and suicide. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls and sending postcards, according to a predefined algorithm. However, a major obstacle to such real-life intervention is the loss of contact during follow-up. Here, we analyze the occurrence of loss of follow-up (LFU) and compare characteristics of patients LFU with follow-up completers.

Methods

The study concerned patients included in VigilanS over the period from 1^st January 2015 to 31 December 2018, with an end of follow-up on 1^st July 2019. We performed a series of descriptive analysis and logistic regressions. The outcome was the loss to follow-up, relative to the 6th month call marking the end of the follow-up; the predictive variables were the characteristics of the patient at entry and during follow-up. Age and sex were considered as adjustment variables.

Results

11879 inclusions occurred during the study period, corresponding to 10666 different patients. The mean age was 40.6 ± 15 years. More than a third were non-first suicide attempters (46.6%) and the most frequent means of suicide was by voluntary drug intoxication (83.2%). 8335 patients were LFU. After simple and multiple regression, a significant relationship with loss to follow-up was identified among non-first suicide attempters, alcohol consumers, patients having no companion on arrival at the emergency room, patients who didn’t make or receive any calls. An increased stay in hospital after a SA was a protective factor against loss of follow-up.

Conclusion

A majority of patients were lost to follow-up by the expected surveillance time of 6 months. Characteristics of lost patients will help focusing efforts to improve retention in the VigilanS program and might give insights for BCI implemented elsewhere.

Sequential multiple assignment randomised trial of a brief contact intervention for suicide risk management among discharged psychiatric patients: an implementation study protocol

INTRODUCTION

The postdischarge suicide risk among psychiatric patients is significantly higher than it is among patients with other diseases and general population. The brief contact interventions (BCIs) are recommended to decrease suicide risk in areas with limited mental health service resources like China. This study aims to develop a postdischarge suicide intervention strategy based on BCIs and evaluate its implementability under the implementation outcome framework.

METHODS AND ANALYSIS

This study will invite psychiatric patients and family members, clinical and community mental health service providers as the community team to develop a postdischarge suicide intervention strategy. The study will recruit 312 patients with psychotic symptoms and 312 patients with major depressive disorder discharged from Shenzhen Kangning Hospital (SKH) in a Sequential Multiple Assignment Randomised Trial. Participants will be initially randomised into two intervention groups to receive BCIs monthly and weekly, and they will be rerandomised into three intervention groups to receive BCIs monthly, biweekly and weekly at 3 months after discharge according to the change of their suicide risk. Follow-ups are scheduled at 1, 3, 6 and 12 months after discharge. With the intention-to-treat approach, generalised estimating equation and survival analysis will be applied. This study will also collect qualitative and quantitative information on implementation and service outcomes from the community team.

ETHICS/DISSEMINATION

This study has received ethical approval from the Ethics Committee Review Board of SKH. All participants will provide written informed consent prior to enrolment. The findings of the study will be disseminated through peer-reviewed scientific journals, conference presentations. A project report will be submitted to the National Natural Science Foundation of China as the concluding report of this funded project, and to the mental health authorities in the Shenzhen to refine and apply evidence-based and pragmatic interventions into health systems for postdischarge suicide prevention.

TRIAL REGISTRATION NUMBER

NCT04907669.

Designed and created for a veteran by a veteran: A pilot study of caring cards for suicide prevention

INTRODUCTION

This pilot study investigates feasibility and acceptability of Caring Cards, a suicide prevention intervention inspired by Caring Contacts and the Recovery Model, where Veteran peers create cards that are sent to Veterans recently discharged from a VA psychiatric hospitalization for suicide risk.

METHODS

Caring Cards consists of: (1) a weekly outpatient group where Veterans (card makers) create cards, and (2) sending cards to recently discharged Veterans (card recipients). Feasibility for card makers was measured by attendance; acceptability (satisfaction) was examined. Card recipients were sent one caring card, one week post-discharge. Feasibility for recipients was measured by the percentage of Veterans that met eligibility and follow-up response rate; acceptability (satisfaction) was examined.

RESULTS

Caring Cards is feasible and acceptable. The outpatient group had a higher attendance rate (81%) compared with other clinic groups. The percentage of eligible card recipients was 61%. Of these, 69% were reached for follow-up and 50% provided follow-up responses. Card makers and recipients both expressed positive experiences with Caring Cards.

CONCLUSION

Caring Cards is a low-intensity, feasible, and acceptable intervention with potential benefits for both Veteran card makers and recipients. Additional research is needed to determine the efficacy of Caring Cards as a suicide prevention intervention.

Hospital-Based Case Management for Suicide High-Risk Group Using Delphi Survey

OBJECTIVE

As of 2019, suicide is serious problem in Korea, with the highest suicide rate among OECD countries. To reduce suicide rates Emergency Department Based Post-Suicide Attempt Case Management carried out with government funding in South Korea, but it is insufficient to address the issue. Aim of this study is to prevent suicide attempts through continuous provision of mental health services even after discharge from acute care.

METHODS

We selected 15 mental health specialists who are multidisciplinary experts in Suicide Prevention. Two-round Delphi survey was conducted on them to reach an agreement for hospital-based case management.

RESULTS

The first Delphi survey consisted of 8 areas and 39 questions. Among them, 30 questions draw agreement above the reference value. The second Delphi survey, consisted of 37 questions, resulted in 32 above-standard questions.

CONCLUSION

Consensus was reached in most category of the Hospital Based Case Management for Suicide High-Risk Group. Core of the developed plan was to provide services to patients who visited the hospital, pursue the stability and universalization of services through a medical insurance fee system. In the future, hospital-based case management service will be implemented as a new model contributing to the reduction of suicide rates in Korea.

Effectiveness of assertive case management for patients with suicidal intent

The aim of this study was to examine the effectiveness of assertive case management intervention in preventing suicidal behaviour in self-poisoning patients. We conducted a secondary analysis of data from the ACTION-J study. Participants were self-poisoning patients with clear suicide intent admitted to emergency departments and with a primary psychiatric diagnosis (as per DSM-IV-TR axis 1). Patients were randomly assigned either to assertive case management or enhanced usual care. The primary outcome measure was the incidence of a first recurrent suicide attempt within 6 months. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). There were 297 self-poisoning patients in the intervention group and 295 in the control group. The primary outcome was significantly lower in the intervention group than in the control group. The incidence of a first recurrent suicide attempt within 1 and 3 months was also significantly lower in the intervention group, as was the number of overall self-harm episodes over the entire study period. Furthermore, the number of non-suicidal self-harm episodes and suicide attempts was significantly lower in the intervention group. Assertive case management is effective when promptly introduced in a hospital setting as an intervention following a suicide attempt, particularly for self-poisoning patients.

Adolescents with suicidal behaviours: A qualitative study about the assessment of Inpatient Service and Transition to Community

WHAT IS KNOWN ON THE SUBJECT?: Only a small number of adolescents with suicidal behaviour receives any follow-up treatment. The implementation of recurrent behaviour prevention strategies is crucial in the period following suicide attempts and should take into account adolescents' opinions to be effective and congruent. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper shows that the 33 adolescent participants in the study identified the following protective factors of recurrent suicidal behaviour: family, friends and other trusted persons, as well as the self and newly learned strategies. The adolescents described their family as a constant presence and reported wishing that their parents maintain their current family support. Psychological support, health professionals and occupational activities are what the adolescents value most about hospitalization, and some criticisms are related to the environment, activities and health professionals. The adolescents also emphasize the need to maintain contact with the nurses after hospital discharge and make suggestions for service improvement related to the environment and the interventions implemented. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Knowing the protective factors of recurrent suicidal behaviours, perception of the impact of the intervention, the expectation of future support and healthcare follow-up is crucial for adapting suicide prevention strategies to be put in place by health services for better quality care delivery. The results obtained allow us to define as specific implications the implementation of psychoeducational intervention directed at the adolescent's family with suicidal behaviour during hospitalization and the definition of strategies for maintaining contact and follow-up with the adolescent after discharge. This study emphasizes the need to reinforce training in suicidology for all health professionals for the improvement of clinical practice.

ABSTRACT

INTRODUCTION: The prevention of recurrent suicidal behaviours in adolescents should consider their perceptions, needs and expectations.

AIM/QUESTION

To identify the protective factors of recurrent suicidal behaviours in adolescents; To describe the family and the expectations for future involvement; To know the most important aspects of hospitalization and discuss expectations of nursing care follow-up after hospital discharge.

METHOD

A descriptive, qualitative and exploratory study was carried out in a sample of 33 adolescents with suicidal behaviours. Data were collected through semi-structured interviews, and the data processing used the content analysis technique.

RESULTS

Findings arising from data allowed identifying the protective factors: family, friends and other trusted persons. During the hospitalization, the adolescents reinforce the knowledge about themselves and the newly learnt coping strategies. Psychological support and health professionals are what they value most about hospitalization and emphasize the need to maintain contact with the nurses after discharge.

DISCUSSION

Knowing the needs and expectations of adolescents with suicidal behaviour will make nursing psychotherapeutic interventions more effective and congruent in this vulnerable group.

IMPLICATIONS FOR PRACTICE

Ensuring psychoeducational intervention to the families of adolescents with suicidal behaviour and continuity of care after discharge, and reinforcing the training in suicidology for all health professionals.

SUICIDE REATTEMPT IN A POPULATION-WIDE BRIEF CONTACT INTERVENTION TO PREVENT SUICIDE ATTEMPTS - THE VIGILANS PROGRAM, FRANCE

Objective

Among the postcrisis suicide prevention programmes, brief contact interventions (BCIs) have been proven to be efficient. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls, and sending postcards, according to a predefined algorithm. However, a major problem in suicide prevention is the suicide reattempt, which can lead to final suicide. Here, we analyze the suicide reattempt in VigilanS.

Methods

The study concerned patients included in VigilanS over the period from January 1, 2015 to December 31, 2018, with an end of follow-up on July 1, 2019. We performed a series of descriptive analyses, survival curves, and regressions. The outcome was the suicide reattempt, and the predictive variables were the characteristics of the patient at entry and during follow-up in VigilanS. Age and sex were considered as adjustment variables.

Results

A total of 11,879 inclusions occurred during the study period, corresponding to 10,666 different patients, among which 905 reattempted suicide. More than half were primary suicide attempters (53.4%). A significant relationship with suicide reattempt was identified for the following characteristics: being a non-primary suicide attempter, having attempted suicide by voluntary drug intoxication and phlebotomy, alcohol consumption among primary suicide attempters, and having no companion at the emergency room visit among non-primary suicide attempters. Hanging (as suicide method), having made no call to VigilanS were protective factors.

Conclusion

This study provides us with a valuable insight into the profiles of patients repeating a suicide attempts, which is important for suicide prevention in general.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

[Preventing recidivism: as easy as a phone call?]

Created in 2015 in the Nord-Pas-de-Calais region by Professor Guillaume Vaiva, the VigilanS system for maintaining a post-hospital link with suicidal patients is the result of a long process of maturation. Its effectiveness in reducing recidivism and suicidal mortality has led the Ministry of Health and Solidarity to request its extension to the entire country by 2022. Supported by a new type of caregiving, it can only be legitimate if it is integrated into the various measures of the global and multimodal suicide prevention policy.

Effects of psychosocial interventions among people cared for in emergency departments after a suicide attempt: a systematic review protocol

BACKGROUND

The care of the emergency department (ED) for a person after a suicide attempt can act as a protector against future suicidal behavior. For this reason, it is essential that the ED ensure an assistance that involves effective interventions in preventing suicidal behaviors. Among suicidal behaviors, it is known that suicide attempt is one of the most lethal risk factors for consummated suicide. In addition, the risk for further attempts is greater in the period from the immediate post-discharge up to 12 months after the last attempt. This makes the ED a key link in the suicide prevention chain. The purpose of this review is to investigate the effects of psychosocial interventions on suicide prevention, when applied in the ED after a suicide attempt.

METHODS

This systematic review protocol was built and registered with the collaboration of a multidisciplinary scientific team. The review will include randomized clinical studies, quasi-experimental trials, and comparative observational studies, all conducted with people (11 years old or more) who have received a psychosocial suicide prevention intervention initiated in the ED after a suicide attempt. The research will be conducted across databases such as Cochrane Library, PubMed, EMBASE, PsycINFO, and DARE. The repetition of a suicide attempt and death by suicide as primary outcomes will be analyzed. The eligibility of the studies and data extraction will be carried out by matched and blind researchers. The risk of bias will be addressed using appropriate instruments. The analyses and synthesis of the results will be both qualitative and quantitative.

DISCUSSION

From a public health point of view, suicide is in itself a public health problem and requires appropriate interventions at different levels of care in order to be prevented. Taking into account that a high percentage of people who died by suicide sought the ED for suicide attempt in the year before their death, the ED is a clinical context with a privileged potential to implement these interventions. Presently, several clinical studies seek to validate interventions to be adopted regarding the prevention of suicidal behavior. Current evidence indicates that different interventions must be strategically combined to reduce suicide attempts and their mortality.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42019131040.

Aftercare and Suicide Reattempt Prevention in Tehran, Iran

Background: A previous suicide attempt is one of the strongest risk factors for subsequent suicide. Effective care following a suicide attempt may reduce the risk of suicide reattempts. Aims: We aimed to investigate the effect of a brief educational intervention and contact program on suicide reattempts. Method: This study was performed as a randomized clinical trial (RCT) recruiting 305 individuals who had attempted suicide (brief intervention and contact = 153 individuals, BIC; treatment as usual = 152 individuals, TAU) who were referred to Baharlu Hospital in Tehran. The SUPRE-MISS questionnaire and a discharge follow-up questionnaire were used for data collection. Cox proportional hazard models and log-rank tests were used to assess the association of the variable with the event (reattempt). Kaplan-Meier curves were used to depict the time to the event of reattempt. Results: In the BIC group, 11% of the individuals had attempted suicide once, and 25% of the TAU group had attempted suicide once (12.4%), twice (9.3%), and three times (3.8%), respectively. The results of Kaplan-Meier analysis indicated the mean time of reattempt in the BIC (0.76) and TAU groups (0.25) as the fourth and second months of follow-up, respectively (log rank, χ² = 12.48, p < .001). The hazard ratio for the TAU group was 2.57 (95% CI [1.4, 5.9]). Limitations: Loss to follow-up due to stigma is one of the serious problems of follow-up services. Conclusion: Implementing a brief educational intervention and contact program on suicide reattempts is feasible and effective in reducing the rate of reattempt; however, it should be accommodated within the mental health services of the county.

Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.

An implementation evaluation of "Zero Suicide" using normalization process theory to support high-quality care for patients at risk of suicide

Background

Suicide rates continue to rise across the United States, galvanizing the need for increased suicide prevention and intervention efforts. The Zero Suicide (ZS) model was developed in response to this need and highlights four key clinical functions of high-quality health care for patients at risk of suicide. The goal of this quality improvement study was to understand how six large health care systems operationalized practices to support these functions-identification, engagement, treatment and care transitions.

Methods

Using a key informant interview guide and data collection template, researchers who were embedded in each health care system cataloged and summarized current and future practices supporting ZS, including, (1) the function addressed; (2) a description of practice intent and mechanism of intervention; (3) the target patient population and service setting; (4) when/how the practice was (or will be) implemented; and (5) whether/how the practice was documented and/or measured. Normalization process theory (NPT), an implementation evaluation framework, was applied to help understand how ZS had been operationalized in routine clinical practices and, specifically, what ZS practices were described by key informants (coherence), the current state of norms/conventions supporting these practices (cognitive participation), how health care teams performed these practices (collective action), and whether/how practices were measured when they occurred (reflexive monitoring).

Results

The most well-defined and consistently measured ZS practices (current and future) focused on the identification of patients at high risk of suicide. Stakeholders also described numerous engagement and treatment practices, and some practices intended to support care transitions. However, few engagement and transition practices were systematically measured, and few treatment practices were designed specifically for patients at risk of suicide.

Conclusions

The findings from this study will support large-scale evaluation of the effectiveness of ZS implementation and inform recommendations for implementation of high-quality suicide-related care in health care systems nationwide.

Characterization of adopted suicidal behavior and its main influencing factors: A qualitative study with adolescents

INTRODUCTION

A better understanding of the meanings that adolescents associate with suicide, contributes to the development of psychotherapeutic intervention programs to be implemented by nurse specialists in mental health and psychiatric nursing. Therefore, adolescents need to characterize their adopted suicidal behaviors and identify the personal characteristics that contribute to this same behavior.

METHODOLOGY

A descriptive, exploratory, and qualitative study was conducted with 33 adolescents with suicidal behavior, hospitalized in a child psychiatry unit. Data were collected through a structured interview, and data treatment used the content analysis technique.

RESULTS

Suicidal behaviors are characterized according to causality, meaning, and intent. Causality is mostly related to psychological factors (sadness, desperation, mental suffering, internal pain, emptiness, and rejection). As to the meaning, suicidal behavior is understood as an escape but also as a personal choice, sometimes regarded as rational. In what concerns intent, the intent to die is the most frequently reported. The most-reported personal characteristics which contributed to the suicidal behavior are feelings of exclusion, rejection, and humiliation, and also introversion.

CONCLUSIONS

The results point to the need to reflect on the perceptions of adolescents with suicidal behavior. The current intervention strategies should be adjusted especially through the identification of the signs associated with mental distress in adolescents and the training of gatekeepers, contributing to productive and congruent suicide prevention in this vulnerable group.

Suicide during Transition of Care: a Review of Targeted Interventions

The risk of suicide is significant during the transition of care; the highest in the first few weeks after discharge from a healthcare facility. This systematic review summarizes the evidence for interventions providing care during this high-risk period. In January 2019, PubMed and Scopus were systematically searched using the search terms: Suicide AND (Hospital OR Emergency department) AND Discharge. Articles relevant to interventions targeting suicidal behaviors during the transition of care were selected after the title and abstract screening followed by full-text screening. This review article included 40 articles; with a total patient population of 24,568. The interventions included telephone contacts, letters, green cards, postcards, structured visits, and community outreach programs. An improvement in the engagement of patients in outpatient services was observed but the evidence for suicidal behaviors was conflicting. The reviewed interventions were efficacious in linking patients to outpatient services, reducing feelings of social isolation and helping patients in navigating the available community resources. For patients with repetitive suicidal behaviors, psychosocial interventions such as dialectical behavioral therapy can be helpful. Patients should be followed by targeted interventions based on risk categorization of the patients by using evidence-based tools.

Effectiveness of a Flexible and Continuous Case Management Program for Suicide Attempters

The purpose of this study was to investigate the effect of continuous case management with a flexible approach on the prevention of suicide by suicide reattempt in a real clinical setting. The subjects in this study were 526 suicide attempters who visited emergency rooms in a teaching hospital in South Korea. Subjects were provided a continuous case management program with a flexible approach according to the severity of their suicide risk and needs. During the entire observation period (from 182 days to 855 days, mean = 572 ± 254), 18 patients (3.7%) died by suicide reattempt: Eight patients (2.27%) in the case management group and 10 patients (7.35%) in the no-case management group. The Cox regression analysis showed that the case management group had a 75% lower risk of death from suicide attempts than the no-case management group (HR = 0.34, 95% CI = 0.13–0.87). This result was shown to be more robust after adjusting for confounding factors such as gender, age, psychiatric treatment, suicide attempts, and family history of suicide (adjusted HR = 0.27, 95% CI = 0.09–0.83). This study was conducted in a single teaching hospital and not a randomized controlled one. A flexible and continuous case management program for suicide attempters is effective for preventing death by suicide reattempts.

A novel engagement of suicidality in the emergency department: Virtual Collaborative Assessment and Management of Suicidality

OBJECTIVE

A novel avatar system (Virtual Collaborative Assessment and Management of Suicidality System; V-CAMS) for suicidal patients and medical personnel in emergency departments (EDs) was developed and evaluated. V-CAMS facilitates the delivery of CAMS and other evidence-based interventions to reduce unnecessary hospitalization, readmissions, and suicide following an ED visit.

METHOD

Using iterative user-centered design with 24 suicidal patients, an avatar prototype, "Dr. Dave" (based on Dr. Jobes) was created, along with other patient-facing tools; provider-facing tools, including a clinical decision support tool were also designed and tested to aid discharge disposition.

RESULTS

Feasibility tests supported proof of concept. Suicidal patients affirmed the system's overall merit, positive Perception of Care, and acceptability; medical providers (n = 21) viewed the system as an efficient, effective, and safe method of improving care for suicidal ED patients and reducing unnecessary hospitalization.

CONCLUSIONS

Technology tools including a patient-facing avatar and e-caring contacts, along with provider-facing tools may offer a powerful method of facilitating best-practice suicide prevention interventions and point-of-care tools for suicidal patients seeking ED services and their medical providers. Future directions include full development of V-CAMS and integration into a health electronic medical record and a rigorous randomized controlled trial to study its effectiveness.

Caring E-mails for Military and Veteran Suicide Prevention: A Randomized Controlled Trial

OBJECTIVE

The purpose of this multisite study was to conduct a randomized controlled trial of an e-mail version of the caring letters (CL) suicide prevention intervention to determine whether the intervention is efficacious in preventing suicide behaviors among U.S. service members and veterans.

METHOD

Psychiatric inpatients (N = 1,318) were recruited from four military medical centers and two VA hospitals and randomized to receive either 13 caring e-mails over two years or usual care.

RESULTS

There were 10 deaths from any cause in the CL group (three suicides) and 14 in the usual care group (seven suicides) during the individual two-year follow-up intervals. There was no statistically significant difference in the rate of all-cause hospital readmission between the study groups (RR = 1.13; 95% CI = 0.94, 1.36). There were no differences observed between groups on self-reported psychiatric hospital readmissions, self-reported suicide attempts, or other measures associated with risk for suicide.

CONCLUSIONS

No firm conclusions about the efficacy of the intervention can be made because the study was inadequately powered. There were no adverse events associated with the intervention, and implementation of the procedures was feasible in the military and veteran hospital settings. These results provide important methodological considerations for caring contact trials in military populations.

Changes in the number of suicide re-attempts in a French region since the inception of VigilanS, a regionwide program combining brief contact interventions (BCI)

BACKGROUND

Brief Contact Interventions (BCIs) after a suicide attempt (SA) are an important element of prevention against SA and suicide. They are easier to generalize to an entire population than other forms of intervention. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls and mailings, according to a predefined algorithm. It was implemented gradually in the Nord-Pas-de-Calais (NPC), France, between 2015 and 2018. Here, we evaluate the effectiveness of VigilanS, in terms of SA reduction, using annual data collected by participating centers. Hypothesis tested: the higher the VigilanS implementation in a center (measured by penetrance), the greater the decrease in the number of SA observed in this center.

METHODS

The study period was from 2014 to 2018, across all of NPC centers. We performed a series of linear regressions, each center representing a statistical unit. The outcome was the change in the number of SA, relative to the initial number, and the predictive variable was VigilanS' penetrance: number of patients included in VigilanS over the total number of SA. Search for influential points (points beyond threshold values of 3 influence criteria) and weighted least squares estimations were performed.

RESULTS

Twenty-one centers were running VigilanS in 2018, with an average penetrance of 32%. A significant relationship was identified, showing a sharp decrease in SA as a function of penetrance (slope = - 1.13; p = 3*10^- 5). The model suggested that a 25% of penetrance would yield a SA decrease of 41%.

CONCLUSION

VigilanS has the potential to reduce SA. Subgroup analyzes are needed to further evaluate its effectiveness. Subgroup analyses remain to be done, in order to evaluate the specific variations of SA by group.

Psychosocial Interventions for People Who Self-Harm: Methodological Issues Involved in Trials to Evaluate Effectiveness

We have assessed the methodological quality of randomized controlled trials (RCTs) of interventions to prevent self-harm repetition and suicide. Trials were identified in two systematic reviews of RCTs of psychosocial treatments following a recent (within six months) episode of self-harm indexed in any of five electronic databases (CCDANCTR-Studies and References, CENTRAL, Medline, Embase, and PsycINFO) between 1 January, 1998 and 29 April, 2015. A total of 66 trials were included, 55 in adults and 11 in children and adolescents. While evidence for efficacy of some approaches has grown, there were few trials from low-to-middle income countries, little information on interventions for males, information on the control condition was often limited, data on suicides were often not reported, and, while trials have increased in size in recent years, most have included too few participants to detect clinically significant results. There are major limitations in many trials of interventions for individuals who self-harm. Improved methodology, especially with regard to study size, provision of details of control therapy, and evaluation of key outcomes, would enhance the evidence base for clinicians and service users.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

BACKGROUND

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

OBJECTIVES

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

SELECTION CRITERIA

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

AUTHORS' CONCLUSIONS

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Community-based aftercare following an emergency department presentation for attempted suicide or high risk for suicide: study protocol for a non-randomised controlled trial

BACKGROUND

Suicide is a major public health issue worldwide. Those who have made a recent suicide attempt are at high risk for dying by suicide in the future, particularly during the period immediately following departure from a hospital emergency department. As such the transition from hospital-based care to the community is an important area of focus in the attempt to reduce suicide rates. There is a need for evaluation studies to test the effectiveness of interventions directed to this stage (termed 'aftercare' interventions).

METHODS

A controlled non-randomised two group (intervention vs treatment-as-usual control) design, using an intention-to-treat model, will evaluate the effectiveness of a suicide prevention aftercare intervention providing follow-up after presentations to a hospital emergency department as a result of a suicide attempt or high risk for suicide. The intervention is a community-based service, utilising two meetings with a mental health clinician and follow-up contacts by peer workers via a combination of face-to-face and telephone for four weeks, with the option of extension to 12 weeks. Seventy-five participants of the intervention service will be recruited to the study and compared to 1265 treatment-as-usual controls. The primary hypotheses are that over 12 months, those who participate in the aftercare follow-up intervention are less likely than controls to present to a hospital emergency department for a repeat suicide attempt or because of high risk for suicide, will have fewer re-presentations during this period and will have lower all-cause mortality. As a secondary aim, the impact of the intervention on suicide risk factors for those who participate in the service will be evaluated using pre- and post-intervention repeated measures of depression, anxiety, stress, hopelessness, belongingness, burdensomeness, and psychological distress. Enrolments into the study commenced on 1 November 2017 and are anticipated to cease in November 2019.

DISCUSSION

The study aims to contribute to the understanding of effective interventions for individuals who have presented to a hospital emergency department as a result of a suicide attempt or at high risk for suicide and provide evidence in relation to interventions that incorporate peer-workers.

TRIAL REGISTRATION

ACTRN12618001701213 . Registered on 16 October 2018. Retrospectively registered.

Adapting and implementing Caring Contacts in a Department of Veterans Affairs emergency department: a pilot study protocol

Background

Suicide among veterans is a problem nationally, and suicide prevention remains a high priority for the Department of Veterans Affairs (VA). Focusing suicide prevention initiatives in the emergency department setting provides reach to veterans who may not be seen in mental health and targets a critical risk period, transitions in care following discharge. Caring Contacts is a simple and efficacious suicide prevention approach that could be used to target this risk period. The purpose of this study is to (1) adapt Caring Contacts for use in a VA emergency department, (2) conduct a pilot program at a single VA emergency department, and (3) create an implementation toolkit to facilitate spread of Caring Contacts to other VA facilities.

Methods

This project includes planning activities and a pilot at a VA emergency department. Planning activities will include determining available data sources, determining logistics for identifying and sending Caring Contacts, and creating an implementation toolkit. We will conduct qualitative interviews with emergency department staff and other key stakeholders to gather data on what is needed to adapt and implement Caring Contacts in a VA emergency department setting and possible barriers to and facilitators of implementation. An advisory board of key stakeholders in the facility will be created. Qualitative findings from interviews will be presented to the advisory board for discussion, and the board will use these data to inform decision making regarding implementation of the pilot. Once the pilot is underway, the advisory board will convene again to discuss ongoing progress and determine if any changes are needed to the implementation of the Caring Contacts intervention.

Discussion

Findings from the current project will inform future scale-up and spread of this innovation to other VA medical center emergency departments across the network and other networks. The current pilot will adapt Caring Contacts, create an implementation toolkit and implementation guide, evaluate the feasibility of gathering outcome measures, and provide information about what is needed to implement this evidence-based suicide prevention intervention in a VA emergency department.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design, Setting, and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

Veteran Preferences for the Caring Contacts Suicide Prevention Intervention

OBJECTIVE

The Caring Contacts intervention has been implemented with a variety of methodologies. The purpose of this study was to examine high-risk inpatient preferences for the Caring Contacts intervention.

METHOD

Veteran psychiatric inpatients (N = 154) completed an anonymous patient preferences survey to obtain feedback on Caring Contact methods such as message wording, preferred correspondent, frequency of contact, duration of the intervention, imagery, and mailing modality.

RESULTS

Eighty-five percent of veterans Agreed or Strongly Agreed that they would like to receive Caring Contacts from at least one of the correspondent options, with inpatient or outpatient mental health counselor, or primary care physician most preferred. Example messages based on prior studies were overwhelmingly rated as caring and helpful; 84% believed that Caring Contacts could help suicidal individuals. Letters or postcards sent through postal mail were preferred over e-mail or text messages. Participants most commonly thought Caring Contacts should be sent monthly for a period of a year.

CONCLUSIONS

The results of this study suggest that most high-risk veterans would perceive Caring Contacts as helpful and caring. The results provide several practical, helpful tips for programs seeking to establish a Caring Contacts program.

Intervening on Thwarted Belongingness and Perceived Burdensomeness to Reduce Suicidality Among Veterans: Subanalyses From a Randomized Controlled Trial

Suicide is a growing public health crisis among military veterans. Despite recent attention to this area, there are few empirically supported preventative interventions for suicidality among veterans. In the context of an empirically supported theoretical framework, the Interpersonal Theory of Suicide, the current study targeted suicide risk factors (i.e., perceived burdensomeness and thwarted belongingness) among a sample of 46 veterans selected from a larger clinical trial. Participants were randomized to receive either a newly developed computerized intervention aimed at decreasing perceived burdensomeness and thwarted belongingness, or participate in a repeated contact control condition. Results indicated a direct effect of the intervention on both perceived burdensomeness and thwarted belongingness. Temporal mediation analyses also revealed an indirect effect of condition on suicidality at Month 1 follow-up via reductions in perceived burdensomeness. The current results are the first to indicate that factors from the interpersonal theory of suicide can be reduced among veterans, and to demonstrate that these reductions in perceived burdensomeness lead to reductions in suicidality. Because of the brevity and computer delivery system, this intervention could be widely and rapidly disseminated among military veterans to reduce the public health burden of suicide in this population.

Disparities in Access to Mental Health Services Among Patients Hospitalized for Deliberate Drug Overdose

OBJECTIVE

The authors examined patient and hospitalization characteristics associated with receiving a mental health assessment and disposition to an inpatient psychiatric facility among patients hospitalized for deliberate drug overdose.

METHODS

This retrospective analysis of 2012-2013 South Carolina all-payer data included adults ages 18-64 with at least one inpatient admission for a primary diagnosis of deliberate illicit or pharmaceutical drug overdose (N=2,686). Outcomes were receipt of a mental health assessment and disposition to an inpatient psychiatric facility. Multivariable logistic regression models were used to estimate the effects of patient and hospitalization characteristics on study outcomes.

RESULTS

Non-Hispanic blacks and people of other races-ethnicities were less likely than non-Hispanic whites to receive a mental health assessment (non-Hispanic blacks, adjusted odds ratio [AOR]=0.52, 95% CI=0.34-0.81; other races-ethnicities, AOR=0.24, 95% CI=0.12-0.49). Non-Hispanic blacks were also less likely than non-Hispanic whites to be discharged to an inpatient psychiatric facility than to home (AOR=0.60, 95% CI=0.47-0.77). Compared with persons without insurance, those with insurance, except those with Medicaid, were more likely to be discharged to an inpatient psychiatric facility than to home (Medicare, AOR=3.06, 95% CI=2.36-3.96; private, AOR=2.78, 95% CI=2.23-3.47; other, AOR=7.58, 95% CI=4.21-13.6).

CONCLUSIONS

Non-Hispanic white race-ethnicity and having insurance were predictive of receipt of a mental health assessment and disposition to an inpatient psychiatric facility among patients hospitalized for deliberate drug overdose. Study findings can inform clinical strategies and interventions aimed at reducing mental health care disparities among populations who are vulnerable to overdose or suicide.