Effectiveness of Telephone-Delivered Interventions Following Suicide Attempts: A Systematic Review

Effect of synchronous remote-based interventions on suicidal behaviours: protocol for a systematic review and meta-analysis

INTRODUCTION

Suicide is among the leading causes of preventable death worldwide. The impact of suicide affects the personal, social and economic levels. Therefore, its prevention is a priority for public health systems. Previous studies seem to support the efficacy of providing active contact to people who have made a suicide attempt. The current systematic review and meta-analysis aims to investigate the efficacy of distance suicide prevention strategies implemented through synchronous technology-based interventions.

METHODS AND ANALYSIS

This protocol is designed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. The bibliographical searches were conducted in the databases PubMed, PsycINFO, Scopus and Web of Science in April 2022, with no restrictions on the time of publication and limited to publications in English or Spanish. The search strategy was performed using free-text terms and Medical Subject Headings terms: suicide, follow-up, synchronous, remote, telehealth, telephone, hotline, video-conference and text message. Two reviewers will independently conduct study screening, selection process, data extraction and risk of bias assessment. The analysis and synthesis of the results will be both qualitative and quantitative. A narrative synthesis, presented in a comprehensive table, will be performed and meta-analysis will be conducted, as appropriate, if sufficient data are provided.

ETHICS AND DISSEMINATION

The present review and meta-analysis will not require ethical approval, as it will use data collected from previously published primary studies. The findings of this review will be published in peer-reviewed journals and widely disseminated.

PROSPERO REGISTRATION NUMBER

CRD42021275044.

Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial

Importance

Suicide is a leading cause of deaths in the US. Although the emergency department (ED) is an opportune setting, ED-initiated interventions remain underdeveloped and understudied.

Objective

To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors.

Design, Setting, and Participants

The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US, used an interrupted time series design with three 12-month sequential phases: baseline, implementation, and maintenance. A random sample of 25 patients per month per site 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. The primary analyses focused on those who were discharged from the ED, while secondary analyses focused on all patients who screened positive, regardless of disposition. Data were collected on patients who presented for care from January 2014 to April 2018, and data were analyzed from April to December 2022.

Interventions

Each site received lean training and built a continuous quality improvement (CQI) team to evaluate the current suicide-related workflow in the ED, identify areas of improvement, and implement efforts to improve. Each site was expected to increase their universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged home from the ED. Site teams were centrally coached by engineers experienced in lean CQI and suicide prevention specialists.

Main Outcomes and Measures

The primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window.

Results

Across 3 phases, 2761 patient encounters were included in the analyses. Of these, 1391 (50.4%) were male, and the mean (SD) age was 37.4 (14.5) years. A total of 546 patients (19.8%) exhibited the suicide composite during the 6-month follow-up (9 [0.3%] died by suicide and 538 [19.5%] of a suicide-related acute health care visit). A significant difference was observed for the suicide composite outcome between the 3 phases (baseline, 216 of 1030 [21%]; implementation, 213 of 967 [22%]; maintenance, 117 of 764 [15.3%]; P = .001). The adjusted odds ratios of risk of the suicide composite during the maintenance phase was 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, which reflect a 43% and 39% reduction, respectively.

Conclusions and Relevance

In this multisite randomized clinical trial, using CQI methods to implement a department-wide change in suicide-related practices, including the implementation of a safety plan intervention, yielded a significant decrease in suicide behaviors in the maintenance period of the study.

Trial Registration

ClinicalTrials.gov Identifier: NCT02453243.

Suicide and Telehealth Treatments: A PRISMA Scoping Review

BACKGROUND

This PRISMA scoping review explored worldwide research on the delivery of suicide-specific interventions through an exclusive telehealth modality. Research over telehealth modalities with suicidal individuals highlights the importance of facilitating participants' access to treatments despite location and circumstances (e.g., rural, expenses related to appointments, etc.).

AIM

The review sought evidence of outcomes of trials or projects in which both the patient and therapist attended sessions conjointly and openly discussed suicide over a telehealth modality (e.g., phone, zoom).

METHOD

To explore this topic the authors searched for research trials and quality improvement projects using Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO Social Services Abstracts, and Web of Science on 3/3/2021.

RESULTS

Nine different articles were included that each spanned distinct treatments, with eight being research studies and one being a quality improvement project.

LIMITATIONS

Publications featuring ongoing or upcoming research in which complete study results were not available did not meet inclusion criteria for this review.

CONCLUSION

Several important research gaps were identified. While this approach has been largely understudied, exclusive telehealth delivery of suicide-specific interventions has great potential for the prevention of suicidality, especially in the era of COVID-19 and beyond.

Leite V, Porto DM, Robis KP, Fidalgo TM, Rocha GA, Diaz AP, Meleiro A, Correa H, Tung TC, Malloy-Diniz L, Quevedo J, da Silva AG. Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eighty-five articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention. Systematic review registry number: CRD42020206517.

Effectiveness of a French Program to Prevent Suicide Reattempt (VigilanS)

AIM

Brief contact interventions (such as letters, green cards, telephone calls or postcards) for reducing suicide reattempt (SR) and suicide have been evaluated since the 1980s, but results have been inconsistent. VigilanS is one of these programs that has benefited patients hospitalized for suicide attempt (SA) after discharge in 2 departments of northern France since 2015. The purpose of this study is to demonstrate its effectiveness in reducing SR.

METHODS

Patients exposed to VigilanS in 2016 were recruited from the medical administrative database of the program, and the nonexposed patients from a database of the medico-surgical ward outside the scope of the program. First, a Cox model was used to compare the probability of SR during the 12-month follow-up period between the 2 groups. Second, a propensity score using the variables sex, age, source, SA history and SA method was used to match the VigilanS-exposed and the nonexposed patients. A Cox model propensity score adjusted analysis was reiterated on the matched data.

RESULTS

The exposed and nonexposed groups included 3,068 and 3,694 individuals, respectively. In the bivariate analyses, the cumulative probability of SR at 12 months was significantly lower in the exposed group (6.0%, 95% confidence interval (CI): 5.5-6.5%) than in the nonexposed group (16.8%, 95% CI: 15.9-17.7%; p < 0.001). In the Cox model, the hazard ratio of SR was 0.38 in the exposed patients (95% CI: 0.36-0.40, p < 0.001). After matching, the cumulative probability of SR at 12 months was 5.2% in exposed versus 22.2% in nonexposed patients (p < 0.001). In the propensity score-adjusted Cox model, the hazard ratio of SR in the exposed patients was 0.19 (95% CI: 0.14-0.24, p < 0.001).

CONCLUSION

The results suggest the effectiveness of this real-life program for reducing SR. However, VigilanS only benefits a portion of the patients hospitalized for SA and therefore could be extended.

Effectiveness of suicide prevention interventions: A systematic review and meta-analysis

OBJECTIVE

This study provides an estimate of the effect size of suicide prevention interventions and evaluates the possible synergistic effects of multilevel interventions.

METHOD

A systematic review and meta-analysis were conducted of controlled studies evaluating suicide prevention interventions versus control published between 2011 and 2017 in PubMed, PsycINFO, and Cochrane databases. Data extraction and risk of bias assessment according to ROBINS criteria were performed by independent assessors. Cohen's delta was calculated by a random meta-analysis on completed and attempted suicides as outcomes. Meta-regression explored a possible synergistic effect in multilevel interventions. PROSPERO ID number: CRD42018094373.

RESULTS

The search yielded 16 controlled studies with a total of 252,932 participants. The meta-analysis was performed in 15 studies with 29,071 participants. A significant effect was found for suicide prevention interventions on completed suicides (d = -0.535, 95% CI -0.898; -0.171, p = .004) and on suicide attempts (d = -0.449, 95% CI -0.618; -0.280, p < .001). Regarding the synergistic effect of multilevel interventions, meta-regression showed a significantly higher effect related to the number of levels of the intervention (p = .032).

CONCLUSIONS

Suicide prevention interventions are effective in preventing completed and attempted suicides and should be widely implemented. Further research should focus on multilevel interventions due to their greater effects and synergistic potential. Further research is also needed into risk appraisal for completed versus attempted suicide, as the preferred intervention strategy differs with regard to both outcomes.

Combining green cards, telephone calls and postcards into an intervention algorithm to reduce suicide reattempt (AlgoS): P-hoc analyses of an inconclusive randomized controlled trial

BACKGROUND

Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.

METHODS

AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.

RESULTS

1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.46 [0.25-0.85] and 0.50 [0.31-0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.84 [0.57-1.25] and 1.00 [0.73-1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.

CONCLUSIONS

This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.

Combining green cards, telephone calls and postcards into an intervention algorithm to reduce suicide reattempt (AlgoS): P-hoc analyses of an inconclusive randomized controlled trial

BACKGROUND

Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.

METHODS

AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.

RESULTS

1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.46 [0.25-0.85] and 0.50 [0.31-0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.84 [0.57-1.25] and 1.00 [0.73-1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.

CONCLUSIONS

This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.