Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning

Efficacy of a short message service brief contact intervention (SMS-SOS) in reducing repetition of hospital-treated self-harm: randomised controlled trial

BACKGROUND

Hospital-treated self-harm is common and costly, and is associated with repeated self-harm and suicide.

AIMS

To investigate the effectiveness of a brief contact intervention delivered via short message service (SMS) text messages in reducing hospital-treated self-harm re-presentations in three hospitals in Sydney (2017-2019), Australia. Trial registration number: ACTRN12617000607370.

METHOD

A randomised controlled trial with parallel arms allocated 804 participants presenting with self-harm, stratified by previous self-harm, to a control condition of treatment as usual (TAU) (n = 431) or an intervention condition of nine automated SMS contacts (plus TAU) (n = 373), over 12 months following the index self-harm episode. The primary outcomes were (a) repeat self-harm event rate (number of self-harm events per person per year) at 6-, 12- and 24-month follow-up and (b) the time to first repeat at 24-month follow-up.

RESULTS

The event rate for self-harm repetition was lower for the SMS compared with TAU group at 6 months (IRR = 0.79, 95% CI 0.61-1.01), 12 months (IRR = 0.78, 95% CI 0.64-0.95) and 24 months (IRR = 0.78, 95% CI 0.66-0.91). There was no difference between the SMS and TAU groups in the time to first repeat self-harm event over 24 months (HR = 0.96, 95% CI 0.72-1.26). There were four suicides in the TAU group and none in the SMS group.

CONCLUSIONS

The 22% reduction in repetition of hospital-treated self-harm was clinically meaningful. SMS text messages are an inexpensive, scalable and universal intervention that can be used in hospital-treated self-harm populations but further work is needed to establish efficacy and cost-effectiveness across settings.

Prevention of Re-attempt Suicide Through Brief Contact Interventions: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Controlled Trials

Brief contact intervention (BCI) is a low-cost intervention to prevent re-attempt suicide. This meta-analysis and meta-regression study aimed to evaluate the effect of BCI on re-attempt prevention following suicide attempts (SAs). We systematically searched using defined keywords in MEDLINE, Embase, and Scopus up to April, 2023. All randomized controlled trials (RCTs) were eligible for inclusion after quality assessment. Random-effects model and subgroup analysis were used to estimate pooled risk difference (RD) and risk ratio (RR) between BCI and re-attempt prevention with 95% confidence intervals (CIs). Meta-regression analysis was carried out to explore the potential sources of heterogeneity. The pooled estimates were (RD = 4%; 95% CI 2-6%); and (RR = 0.62; 95% CI 0.48-0.77). Subgroup analysis demonstrated that more than 12 months intervention (RR = 0.46; 95% CI 0.10-0.82) versus 12 months or less (RR = 0.67; 95% CI 0.54-0.80) increased the effectiveness of BCI on re-attempt suicide reduction. Meta-regression analysis explored that BCI time (more than 12 months), BCI type, age, and female sex were the potential sources of the heterogeneity. The meta-analysis indicated that BCI could be a valuable strategy to prevent suicide re-attempts. BCI could be utilized within suicide prevention strategies as a surveillance component of mental health since BCI requires low-cost and low-educated healthcare providers.

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.

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.

Design of CLARO+ (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses, Plus): A randomized trial of collaborative care to decrease overdose and suicide risk among patients with co-occurring disorders

BACKGROUND

The United States is mired in two intertwined epidemics of death from suicide and overdose. Opioid use disorder (OUD) and mental illness contribute to both, and individuals with co-occurring disorders (CODs) are a complex population at high risk. Although universal prevention makes sense from a public health perspective, medical and behavioral health providers often lack the time to proactively address these issues with all patients. In this study, we build upon a parent study called Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO), a model of collaborative care in which care coordinators deliver preventative measures to high-risk patients and coordinate care with the patients' care team, with the goal of increasing MOUD retention and decreasing risk of suicide and overdose.

METHODS

CLARO+ adds intervention components on overdose prevention, recognition, and response training; lethal means safety counseling; and an effort to mail compassionate messages called Caring Contacts. Both CLARO and CLARO+ have been implemented at 17 clinics in New Mexico and California, and this study seeks to determine the difference in effectiveness between the two versions of the intervention. This paper describes the design protocol for CLARO+.

CONCLUSION

CLARO+ is an innovative approach that aims to supplement existing collaborative care with additional suicide and overdose prevention strategies.

CLINICALTRIALS

gov: NCT04559893.

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.

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.

Differences in overdose deaths by intent: Unintentional & suicide drug poisonings in North Carolina, 2015-2019

Comprehensive fatal overdose prevention requires an understanding of the fundamental causes and context surrounding drug overdose. Using a social determinants of health (SDOH) framework, this descriptive study examined unintentional and self-inflicted (i.e., suicide) overdose deaths in North Carolina (NC), focusing on specific drug involvement and contextual factors. Unintentional and suicide overdose deaths were identified using 2015-2019 NC death certificate data. Specific drug involvement was assessed by searching literal text fields for drug mentions. County-level contextual factors were obtained from NC Institute of Medicine and County Health Rankings, encompassing five SDOH domains (economic stability, social/community context, health care access/quality, education access/quality, neighborhood/built environment). Descriptive statistics were calculated by intent for drug involvement and a variety of contextual factors. During 2015-2019, 9% of NC drug overdose deaths were self-inflicted and 89% were unintentional (2% other/undetermined). Unintentional overdoses largely involved illicit drugs [fentanyl (47%), cocaine (33%), heroin (29%)]. Suicide overdoses frequently involved prescription opioids [oxycodone (18%), hydrocodone (10%)] and antidepressants (32%). Overall, overdose deaths tended to occur in under-resourced counties across all SDOH domains, though unintentional overdoses occurred more often among residents of under-resourced counties than suicide overdoses, with differences most pronounced for economic stability-related factors. There are notable distinctions between unintentional and suicide overdose deaths in demographics and drug involvement, though the assessment of SDOH demonstrated that overdose mortality is broadly associated with marginalization across all domains. These findings highlight the value of allocating resources to prevention and intervention approaches that target upstream causes of overdose (e.g., housing first, violence prevention programs).

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.

Applying user-centered design in the development of nudges for a pragmatic trial to reduce no-shows among veterans

OBJECTIVE

To incorporate user-centered design processes into the refinement of nudges designed to reduce no-shows among healthcare appointments for military veterans in the Veterans Health Administration (VA).

METHODS

We developed candidate nudges as brief messages based on four broad concepts in behavioral science. We then conducted iterative waves of multi-stage interviews (N = 27) that included a pile sorting task, a "think-aloud" review of each message, and prototype letter reviews. Rapid consensus analysis of each wave's feedback iteratively refined message language.

RESULTS

Veterans rejected several theoretically plausible messages focusing on avoiding the burden of rescheduling missed appointments or the monetary cost of no-shows. Participants suggested framing calling to cancel an appointment as helping other veterans and emphasized a new motivational theme: expressing personal concern for the veteran.

CONCLUSION

Use of iterative UCD methods allowed for early identification of both messages inappropriate for veterans and new veteran-generated nudges around non-judgmental validation that could be incorporated in the design of our pragmatic trial.

PRACTICE IMPLICATIONS

Rapid team-based qualitative analysis, iterative material design, and space in the study design to incorporate entirely new insights from participants into study materials are all approaches that can improve communications of what matters most to a specific population.

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.

Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation: A Randomized Clinical Trial

IMPORTANCE

People at risk of self-harm or suicidal behavior can be accurately identified, but effective prevention will require effective scalable interventions.

OBJECTIVE

To compare 2 low-intensity outreach programs with usual care for prevention of suicidal behavior among outpatients who report recent frequent suicidal thoughts.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020.

INTERVENTIONS

Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first nonfatal or fatal self-harm. Nonfatal self-harm was ascertained from health system records, and fatal self-harm was ascertained from state mortality data. Secondary outcomes included more severe self-harm (leading to death or hospitalization) and a broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm).

RESULTS

A total of 18 644 patients (9009 [48%] aged 45 years or older; 12 543 [67%] female; 9222 [50%] from mental health specialty clinics and the remainder from primary care) contributed at least 1 day of follow-up data and were included in analyses. Thirty-one percent of participants offered care management and 39% offered skills training actively engaged in intervention programs. A total of 540 participants had a self-harm event (including 45 deaths attributed to self-harm and 495 nonfatal self-harm events) over 18 months following randomization: 172 (3.27%) in care management, 206 (3.92%) in skills training, and 162 (3.27%) in usual care. Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07; 97.5% CI, 0.84-1.37) but was significantly higher in the skills training group than in usual care (HR, 1.29; 97.5% CI, 1.02-1.64). For severe self-harm, care management vs usual care had an HR of 1.03 (97.5% CI, 0.71-1.51); skills training vs usual care had an HR of 1.34 (97.5% CI, 0.94-1.91). For the broader self-harm definition, care management vs usual care had an HR of 1.10 (97.5% CI, 0.92-1.33); skills training vs usual care had an HR of 1.17 (97.5% CI, 0.97-1.41).

CONCLUSIONS AND RELEVANCE

Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce risk of self-harm, and offering brief dialectical behavior therapy skills training significantly increased risk of self-harm, compared with usual care. These findings do not support implementation of the programs tested in this study.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02326883.

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.

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.

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.

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.

Supportive effect of body contact care with ylang ylang aromatherapy and mobile intervention team for suicide prevention: A pilot study

OBJECTIVES

To assess understudied, alternative suicide prevention modalities in a mental health care setting.

METHODS

This was a prospective study of patients (n = 140, 68 cases and 72 controls) who were admitted to hospital or who contacted an SOS suicide crisis line for suicidal ideation or attempts. Psychiatric diagnoses (Mini-International Neuropsychiatric Interview) and intensity of anxiety/depression/suicidality (Hamilton Anxiety Rating Scale, Montgomery-Åsberg Depression Rating Scale, and Beck Scale for Suicidal Ideation) were assessed. All intervention group subjects received a crisis card with a crisis line number, interviews with psychologists or volunteers and a telephone call on days 10 to 21, then 6 months later. These subjects also had a choice between two further 4-month interventions: body contact care or mobile intervention team visits.

RESULTS

The interventions significantly reduced the number of suicide attempts and suicide (3%) at 6 months compared with the control condition (12%). There were fewer losses to follow-up in the intervention group (7.35%) than in the control group (9.72%).

CONCLUSIONS

The results favour the implementation of integrated care and maintaining contact in suicide prevention.

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.

Pilot randomized clinical trial of the Teachable Moment Brief Intervention for hospitalized suicide attempt survivors

OBJECTIVE

The aim of this study was to further evaluate the acceptability and feasibility of the Teachable Moment Brief Intervention (TMBI).

METHOD

A single blind, pilot randomized controlled trial of the TMBI + care as usual (CAU) compared to CAU was conducted for patients who survived a recent suicide attempt that required medical inpatient hospitalization. The intervention was delivered on medical/surgical and inpatient psychiatry units in the medical center. Interviews were completed at baseline, 1, 3, and 12 months.

RESULTS

Patients reported high ratings of satisfaction with the TMBI. Interventionists representing fields of Psychiatry, Social Work, and Counseling were able to deliver the intervention with fidelity to the treatment manual with equal adherence ratings. The TMBI patients were more likely to maintain a positive recovery trajectory on motivation and engagement in mental health services at 3 months.

CONCLUSION

The TMBI provides an option for targeted intervention to health care providers as they engage patients admitted to an acute medical setting after a serious suicide attempt. This is the second pilot study demonstrating enhanced motivation in the post-hospitalization period.

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.

Perceived Burdensomeness Among Adolescents: A Mixed-Methods Analysis of the Contexts in Which Perceptions of Burdensomeness Occur

Introduction: This study explored the contexts in which adolescents report perceptions of being a burden on others, via a mixed-methods approach, to inform the development of interventions targeting perceived burdensomeness as a risk factor for suicide ideation.

Method: Participants were 41 adolescents, 13–19 years of age (M = 16.95, SD = 1.61), with elevated perceived burdensomeness on the Interpersonal Needs Questionnaire. Adolescent were predominantly female (70.7%) and Hispanic (73.2%). Adolescents provided up to three examples of times they experienced perceived burdensomeness. Examples (N = 102) were qualitatively coded to identify common themes, followed by quantitative analyses of demographic factors associated with identified themes.

Results: Seven main categories emerged from the qualitative analyses of examples: Drain on Resources, Perceptions of Failure and Brokenness, Relationship Conflict/Withdrawal, Misbehavior, Emotional Distress, Academic Problems, and Lack of Belongingness. Adolescent boys reported a greater proportion of burdensomeness attributions related to Misbehavior and a lower proportion related to Emotional Distress, relative to girls.

Discussion: Major themes aligned with theorized components of perceived burdensomeness. Adolescent examples focused predominantly on normative experiences, supporting the notion that perceived burdensomeness may represent a distorted cognition. The results may inform the development of interventions targeting perceived burdensomeness.

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.

Effect of Augmenting Standard Care for Military Personnel With Brief Caring Text Messages for Suicide Prevention: A Randomized Clinical Trial

IMPORTANCE

Accessible and cost-effective interventions for suicidality are needed to address high rates of suicidal behavior among military service members. Caring Contacts are brief periodic messages that express unconditional care and concern and have been previously shown to prevent suicide deaths, attempts, ideation, and hospitalizations.

OBJECTIVE

To test the effectiveness of augmenting standard military health care with Caring Contacts delivered via text message to reduce suicidal thoughts and behaviors over 12 months.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 3 military installations in the southern and western United States. Soldiers and Marines identified as being at risk of suicide were recruited between April 2013 and September 2016. The final follow-up was in September 2017.

INTERVENTIONS

Both groups received standard care, and the Caring Contacts group also received consisted of 11 text messages delivered on day 1, at week 1, at months 1, 2, 3, 4, 6, 8, 10, and 12, and on participants' birthdays.

MAIN OUTCOMES AND MEASURES

Primary outcomes were current suicidal ideation and suicide risk incidents (hospitalization or medical evacuation). Secondary outcomes were worst-point suicidal ideation, emergency department visits, and suicide attempts. Suicidal ideation was measured by the Scale for Suicide Ideation, suicide risk incidents, and emergency department visits by the Treatment History Interview; attempted suicide was measured by the Suicide Attempt Self-Injury Count.

RESULTS

Among 658 randomized participants (329 randomizely assigned to each group), data were analyzed for 657 individuals (mean [SD] age, 25.2 [6.1] years; 539 men [82.0%]). All participants reported suicidal ideation at baseline, and 291 (44.3%) had previously attempted suicide. Of the 657 participants, 461 (70.2%) were assessed at 12 months. Primary outcomes were nonsignificant. There was no significant effect on likelihood or severity of current suicidal ideation or likelihood of a suicide risk incident; there was also no effect on emergency department visits. However, participants who received Caring Contacts (172 of 216 participants [79.6%]) had lower odds than those receiving standard care alone (179 of 204 participants [87.7%]) of experiencing any suicidal ideation between baseline and follow-up (odds ratio, 0.56 [95% CI, 0.33-0.95]; P = .03) and fewer had attempted suicide since baseline (21 of 233 [9.0%] in the group receiving Caring Contacts vs 34 of 228 [14.9%] in the standard-care group; odds ratio, 0.52 [95% CI, 0.29-0.92]; P = .03).

CONCLUSIONS AND RELEVANCE

This trial provides inconsistent results on the effectiveness of caring text messages between primary and secondary outcomes, but this inexpensive and scalable intervention offers promise for preventing suicide attempts and ideation in military personnel. Additional research is needed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01829620.

Cognitive behavioral therapy for suicide prevention (CBT-SP): Implications for meeting standard of care expectations with suicidal patients

Accumulating evidence supports the efficacy of cognitive behavioral therapy for suicide prevention (CBT-SP) as an empirically supported treatment approach for suicidal patients. In light of these findings, several procedures pulled from CBT-SP have been recommended for standard care with suicidal patients. The present article provides an overview of the procedures used in CBT-SP and discusses how these procedures meet, or even exceed, standard of care expectations for outpatient mental healthcare clinicians. Finally, the relevance of clinician fidelity to the CBT-SP model when evaluating standard of care expectations is discussed.

SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging

BACKGROUND

Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia.

METHODS/DESIGN

Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge.

DISCUSSION

This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense.

TRIAL REGISTRATION AND ETHICS APPROVAL

This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370 . Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).

Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis

BACKGROUND

There is evidence that several intervention types, including psychotherapy, reduce repeat suicide attempts. However, these interventions are less applicable to the heterogeneous patients admitted to emergency departments (EDs). The risk of a repeat suicide attempt is especially high in the first 6 months after the initial attempt. Therefore, it is particularly important to develop effective ED interventions to prevent repeat suicide attempts during this 6-month period.

METHODS

We systematically reviewed randomized controlled trials of ED-initiated interventions for suicidal patients admitted to EDs using the databases MEDLINE, PsychoINFO, CINAHL, and EMBASE up to January 2015 in accordance with an a priori published protocol (PROSPERO: CRD42013005463). Interventions were categorized into four types, including active contact and follow-up interventions (intensive care plus outreach, brief interventions and contact, letter/postcard, telephone, and composite of letter/postcard and telephone), and a meta-analysis was conducted to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of a repeat suicide attempt within 6 months.

RESULTS

Of the 28 selected trials, 14 were active contact and follow-up interventions. Two of these trials (n = 984) reported results at 6 months (pooled RR = 0.48; 95% CI: 0.31 to 0.76). There were not enough trials of other interventions to perform meta-analysis. Some trials included in the meta-analysis were judged as showing risk of bias.

CONCLUSION

Active contact and follow-up interventions are recommended for suicidal patients admitted to an ED to prevent repeat suicide attempts during the highest-risk period of 6 months.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005463 (27 August 2013).

Effect of a Crisis Intervention Team for suicide attempt patients in an emergency department in Korea

Background:

South Korea has one of the highest rates of suicide in the world, which poses an immense socioeconomic burden on the healthcare system.

Objectives:

We hypothesized that the implementation of a Crisis Intervention Team would lead to an improvement in completion rates of suicide prevention counseling programs.

Methods:

This is a retrospective before-and-after analysis, and was carried out in the emergency department in the city of Ansan, South Korea. The Crisis Intervention Team, funded by the Ministry of Health and Welfare, counsels suicide attempt patients with the ultimate goal of assuring proper administration of mental healthcare from community suicide support programs. Data on suicide attempt patients were collected using medical records. The primary outcome was defined as completion of the 8-week follow-up period for suicide attempt patients with the community suicide support programs.

Results:

A total of 246 patients from the pre-intervention period and 296 patients from the post-intervention period were included in the study. The completion rates of the 8-week follow-up period increased significantly after the intervention. During the pre-intervention period, 9 patients (3.7%) who were referred to the community suicide support program completed the 8 weeks of follow-up, whereas in the post-intervention period, 56 patients (18.9%) followed up for 8 weeks or more (p < 0.0001). The secondary outcome, overall linkage rates to community suicide support program, did not change significantly, with a minor increase from 46 (18.7%) to 63 (21.3%) (p = 0.45).

Conclusion:

The implementation of an in-hospital Crisis Intervention Team dedicated to active and assertive counseling that begins in the emergency department was correlated with significantly increased completion rates of the 8-week follow-up counseling program.

Prévention du suicide et santé connectée

L’évaluation ponctuelle du risque suicidaire habituellement conduite aux urgences, après un geste suicidaire, ne rend pas compte de son évolution après la sortie des soins, alors même que le risque de récidive reste important plusieurs mois après. Dans ces conditions, les possibilités d’identification, et donc de prise en charge, des patients à risque suicidaire sont limitées. Le développement de la santé connectée (eHealth) donne désormais accès en temps réel à des informations sur l’état de santé d’un patient entre deux séjours en centre de soins. Cette extension de l’évaluation clinique à l’environnement du patient permet de développer des outils d’aide à la décision face à la gestion du risque suicidaire.

Immediate and brief intervention after suicide attempts on patients without major psychiatric morbidity-A pilot study in northern Israel

BACKGROUND

Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events.

METHODS

Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8-12 meetings with a therapist that focused on "crisis intervention" techniques.

RESULTS

212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program's population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts.

CONCLUSIONS

The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

Follow-up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers' Perceptions of Care

Continuity of care for suicidal individuals engaged with a variety of health and mental health care systems has become a national priority, and crisis hotlines are increasingly playing a part in the risk management and continuum of care for these individuals. The current study evaluated a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow-up care to suicidal callers. Data were obtained from 550 callers followed by 41 crisis counselors from 6 centers. Two main data sources provided the information for the current study: a self-report counselor questionnaire on the follow-up activities completed on each clinical follow-up call and a telephone interview with follow-up clients, providing data on their perceptions of the follow-up intervention's effectiveness. The majority of interviewed follow-up clients reported that the intervention stopped them from killing themselves (79.6%) and kept them safe (90.6%). Counselor activities, such as discussing distractors, social contacts to call for help, and reasons for dying, and individual factors, such as baseline suicide risk, were associated with callers' perceptions of the impact of the intervention on their suicide risk. Our findings provide evidence that follow-up calls to suicidal individuals can reduce the perceived risk of future suicidal behavior.

Comparing brief interventions for suicidal individuals not engaged in treatment: A randomized clinical trial

BACKGROUND

Non-treatment-engaged individuals experiencing suicidal thoughts have been largely overlooked in the intervention literature, despite reviews suggesting most individuals who die by suicide were not in treatment immediately prior to their death. Most intervention studies recruit individuals from treatment providers, potentially neglecting those individuals who are not already engaged in services. These individuals clearly represent a group in need of additional empirical attention.

METHODS

A randomized clinical trial was conducted to compare a single-session dialectical behavior therapy skills-based intervention to a relaxation training control condition. Ninety-three non-treatment-engaged subjects participated in a single in-person assessment, received one of the intervention protocols, and completed follow-up phone interviews for three months including measures of suicidal ideation, emotion dysregulation, and coping skills, as well as other relevant assessments.

RESULTS

Both conditions reported significantly reduced levels of suicidal ideation, depression, and anxiety; however, analyses revealed no significant differences between conditions on the main outcome measures of suicidal ideation, emotion dysregulation, skills use, depression, or anxiety.

LIMITATIONS

The two interventions may have been too similar to permit detection of differential effects with this sample size. Specifically, the control condition may have been too active and there may have been stylistic overlap by providers who delivered both interventions.

CONCLUSIONS

Encouragingly, half of subjects contacted other mental health services during the follow-up period. Although the two interventions under investigation did not yield differential results, the significant changes in important domains across interventions suggest that brief interventions may hold promise for this difficult-to-reach population.

Taking care of suicidal patients with new technologies and reaching-out means in the post-discharge period

Suicide is a global public health problem with over one million people dying by suicide each year worldwide. Research efforts have focused on developing and testing novel suicide prevention strategies employing recent technological advances. In order to provide a review regarding the role of new technologies (e.g., postcards/letters, text messages, crisis cards, telephone contacts, online interventions) in suicide prevention, we searched PubMed, ScienceDirect, ResearchGate, and Crisis to identify all papers in English from 1977 to 2016. Our results indicated that brief contact interventions show promise in reducing the number of episodes of repeated self-harm and/or suicide attempts following discharge from the Emergency Department or psychiatric units. Innovative methods of contact (e.g., text messages) are easily implemented by clinicians and received by patients in the period of post discharge and have been shown to be beneficial. However, more research employing randomized clinical trials investigating the potential benefits of these novel suicide prevention methods is warranted. Future researchers should continue improving and testing new technologies in the prevention of suicide.

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study

IMPORTANCE

Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped.

OBJECTIVE

To determine whether an ED-initiated intervention reduces subsequent suicidal behavior.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013.

INTERVENTIONS

Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk.

MAIN OUTCOMES AND MEASURES

The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed.

RESULTS

A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99).

CONCLUSIONS AND RELEVANCE

Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Differences in the Effectiveness of Psychosocial Interventions for Suicidal Ideation and Behaviour in Women and Men: A Systematic Review of Randomised Controlled Trials

The objective of this study was to explore outcomes of preventive programs and psychosocial treatments for suicidal ideation and behaviour in gender sub-groups in mixed gender studies and in studies limited to one gender. The method used was a systematic review of randomized controlled trials (RCTs) which included women or men only, or reported and/or examined outcomes of psychosocial interventions in mixed gender samples. A total of 27 (18%) of RCTs reported or examined differences in intervention outcomes. Of the mixed gender RCTs, 5 (33%) reported greater effectiveness for females than males. The review identified promising interventions in female-only samples. None of the trials reported greater effectiveness of the intervention in men. The majority of reviewed studies looking at treatment outcomes in gender sub-groups showed no differences between women and men or indicated that some psychosocial interventions are effective for women. There is a need for studies which look at gender effects and development of interventions more effective and appealing for men at risk of suicide.

Postcards in Persia: A Twelve to Twenty-four Month Follow-up of a Randomized Controlled Trial for Hospital-Treated Deliberate Self-Poisoning

This study reports the outcomes, during follow-up, of a low-cost postcard intervention in a Randomized Control Trial of hospital-treated self-poisoning (n = 2300). The intervention was 9 postcards over 12 months (plus usual treatment) versus usual treatment. Three binary endpoints at 12-24 months (n = 2001) were: any suicidal ideation, suicide attempt, or self-cutting. There was a significant reduction in any suicidal ideation (RRR 0.20 CI 95% 0.13-0.27), (NNT 8, 6-13), and any suicide attempt (RRR 0.31, 0.06-0.50), (NNT 35, 19-195), in this non-western population. However, there was no effect on self-cutting (RRR -0.01, -1.05-0.51). Sustained, brief contact by mail may reduce some forms of suicidal behavior in self-poisoning patients during the post intervention phase.

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Implementation of a text-messaging intervention for adolescents who self-harm (TeenTEXT): a feasibility study using normalisation process theory

BACKGROUND

There are few interventions that directly address self-harming behaviour among adolescents. At the request of clinicians in Child and Adolescent Mental Health Services (CAMHS) in England and working with them, we redeveloped an adult SMS text-messaging intervention to meet the needs of adolescents under the care of CAMHS who self-harm.

METHODS

We used normalisation process theory (NPT) to assess the feasibility of delivering it through CAMHS. We planned to recruit 27 young people who self-harm and their clinicians, working as dyads and using the intervention (TeenTEXT) for 6 months.

RESULTS

Despite strong engagement in principle from CAMHS teams, in practice we were able to recruit only three clinician/client dyads. Of these, two dropped out because the clients were too unwell. We identified a number of barriers to implementation. These included: a context of CAMHS in crisis, with heavy workloads and high stress levels; organisational gatekeeping practices, which limited the extent to which clinicians could engage with the intervention; perceived burdensomeness and technophobia on the part of clinicians, and a belief by many clinicians that CAMHS may be the wrong delivery setting and that the intervention may have better fit with schools and universal youth services.

CONCLUSIONS

User-centred design principles and the use of participatory methods in intervention development are no guarantee of implementability. Barriers to implementation cannot always be foreseen, and early clinical champions may overestimate the readiness of colleagues to embrace new ideas and technologies. NPT studies have an important role to play in identifying whether or not interventions are likely to receive widespread clinical support. This study of a text-messaging intervention to support adolescents who self-harm (TeenTEXT) showed that further work is needed to identify the right delivery setting, before testing the efficacy of the intervention.

A Pilot Study on the Efficacy of Volunteer Mentorship for Young Adults With Self-Harm Behaviors Using a Quasi-Experimental Design

BACKGROUND

Studies have shown that postdischarge care for self-harm patients is effective in reducing repeated suicidal behaviors. Little is known about whether volunteer support can help reduce self-harm repetition and improve psychosocial well-being.

AIM

This study investigated the efficacy of volunteer support in preventing repetition of self-harm.

METHOD

This study used a quasi-experimental design by assigning self-harm patients admitted to the emergency departments to an intervention group with volunteer support and treatment as usual (TAU) for 9 months and to a control group of TAU. Outcome measures include repetition of self-harm, suicidal ideation, hopelessness, and level of depressive and anxiety symptoms.

RESULTS

A total of 74 cases were recruited (38 participants; 36 controls). There were no significant differences in age, gender, and clinical condition between the two groups at the baseline. The intervention group showed significant improvements in hopelessness and depressive symptoms. However, the number of cases of suicide ideation and of repetition of self-harm episodes was similar for both groups at the postintervention period.

CONCLUSION

Postdischarge care provided by volunteers showed significant improvement in hopelessness and depression. Volunteers have been commonly involved in suicide prevention services. Further research using rigorous methods is recommended for improving service quality in the long term.

Mechanisms of brief contact interventions in clinical populations: a systematic review

BACKGROUND

Brief Contact Interventions (BCIs) have been of increasing interest to suicide prevention clinicians, researchers and policy makers. However, there has been no systematic assessment into the mechanisms underpinning BCIs. The aim of the current paper is to provide a systematic review of the proposed mechanisms underpinning BCIs across trial studies.

METHOD

A systematic review was conducted of trials using BCIs (post-discharge telephone contacts; emergency or crisis cards; and postcard or letter contacts) for suicide or self-harm. Following PRISMA guidelines, we searched CENTRAL, MEDLINE, EMBASE, and the reference lists of all past reviews in the area. Secondary searches of reference lists were undertaken.

RESULTS

Sixteen papers provided a description of possible mechanisms which we grouped into three main areas: social support; suicide prevention literacy, and; learning alternative coping behaviours. After assessment of the studies and considering the plausibility of mechanisms, we suggest social support and improved suicide prevention literacy are the most likely mechanisms underpinning BCIs.

CONCLUSION

Researchers need to better articulate and measure the mechanisms they believe underpin BCIs in trial studies. Understanding more about the mechanisms of BCIs' will inform the development of future interventions for self-harm and suicide.