Effectiveness of a telephone management programme for patients discharged from an emergency department after a suicide attempt: controlled study in a Spanish population

The effectiveness of telehealth interventions in suicide prevention: A systematic review and meta-analysis

BACKGROUND

Suicidal attempt is a significant risk factor for future attempts, with the highest risk during the first-year post-suicide. Telepsychiatry has shown promise by providing easy access to evidence-based interventions during mental health crises.

AIMS

investigation the effectiveness of telehealth interventions in suicide prevention.

METHODS

Four electronic databases (PubMed, Scopus, Web of Science, and Ovid) were systematically searched for studies on patients undergoing telepsychiatry intervention (TPI) up to June 2022. Following PRISMA guidelines, a systematic review and meta-analysis were conducted to investigate the effectiveness of telehealth interventions in suicide prevention. Continuous data were pooled as standardised mean difference (SMD), and dichotomous data were pooled as risk ratio using the random effects model with the corresponding 95% confidence intervals (CI).

RESULTS

Sixteen studies were included in the review. Most studies were case-control and randomised controlled trials conducted in Europe and North America. The findings of the studies generally showed that TPIs are effective in reducing suicide rates (odds ratio = 0.68; 95% CI [-0.47, 0.98], p = .04) and suicidal reattempts. The interventions were also found to be well-accepted, with high retention rates.

CONCLUSION

Our results suggest that TPIs are well-accepted and effective in reducing suicide rates and reattempts. It is recommended to maintain telephone follow-ups for at least 12 months. Further research is needed to understand the potential of telepsychiatry in suicide prevention fully.

Suicide Interventions in Spain and Japan: A Comparative Systematic Review

(1) Background: This systematic review presents an overview of psychological interventions in suicide published between 2013 and 2023 in Spain and Japan, sparked by Spain's alarming recent increase in suicide rates and the potential exemplar of Japan's reduction efforts. (2) Methods: Following the PRISMA checklist, the databases Web of Science, Scopus, PubMed, and PsycInfo were searched using the terms [("suicide" OR "suicidal behavior" OR "suicidal attempt" OR "suicidal thought" OR "suicidal intention") AND ("prevention" OR "intervention" OR "psychosocial treatment" OR "Dialectical Behavior Therapy" OR "Cognitive Therapy" OR "psychotherap*")] AND [("Spain" OR "Spanish") OR ("Japan" OR "Japanese")]. We included articles published in peer-reviewed academic journals, written in English, Spanish, and Japanese between 2013 and 2023 that presented, designed, implemented, or assessed psychological interventions focused on suicidal behavior. (3) Results: 46 studies were included, concerning prevention, treatment, and training interventions. The risk of bias was low in both Spanish and Japanese studies, despite the lack of randomization of the samples. We identified common characteristics, such as psychoeducation and coping skills. Assertive case management was only highlighted in Japan, making an emphasis on active patient involvement in his/her care plan. (4) Conclusions: The findings will help professionals to incorporate into their interventions broader, more comprehensive approaches to consider more interpersonal components.

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.

The Impact of Allied Health Brief Therapy Clinic Interventions in Consumers in Suicidal Crisis

Brief interventions increase access to and engagement with care for people who are discharged presentation to emergency departments or inpatient care due to suicidal behavior. This study was to investigate the effectiveness of the Allied Health Brief Therapies (AHBT) clinic interventions on suicide ideation, health service utilization, negative emotional states, and functioning and well-being in consumers in suicidal crisis. This research was designed as pre-post study. Three AHBT clinics were established to provide brief interventions in Queensland Australia. Repeated measures ANOVA and McNemar's test were used to measure the impact of the interventions. Sensitivity analysis was conducted to ensure the robustness and appropriate interpretation of the results. Among the 141 consumers who accepted the referral, 106 (75.2%) attended the AHBT sessions, and 35 (24.8%) did not start the interventions. The AHBT clinic interventions reduced consumers' presence and frequency of suicide ideation, emergency department presentations, and negative emotional states (depression, anxiety, and stress), and increased their functioning and well-being with large effect sizes. Change in the frequency of inpatient admission after the AHBT clinic interventions was statistically non-significant. This study provides evidence that the AHBT clinics can reduce suicidal risk factors, decrease health service utilization, and increase functioning and well-being in consumers in suicidal crisis. Future research should consider the use of a control group to increase confidence in the findings.

Information and communication technology-based interventions for suicide prevention implemented in clinical settings: a scoping review

BACKGROUND

A large number of information and communication technology (ICT) based interventions exist for suicide prevention. However, not much is known about which of these ICTs are implemented in clinical settings and their implementation characteristics. In response, this scoping review aimed to systematically explore the breadth of evidence on ICT-based interventions for suicide prevention implemented in clinical settings and then to identify and characterize implementation barriers and facilitators, as well as evaluation outcomes, and measures.

METHODS

We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was applied to the following six databases between August 17-20, 2021: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Library, Information Science and Technology Abstracts. We also supplemented our search with Google searches and hand-searching reference lists of relevant reviews. To be included in this review, studies must include ICT-based interventions for any spectrum of suicide-related thoughts and behaviours including non-suicidal self-injury. Additionally, these ICTs must be implemented in clinical settings, such as emergency department and in-patient units. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to prepare this full report.

RESULTS

This review included a total of 75 citations, describing 70 studies and 66 ICT-based interventions for suicide prevention implemented in clinical settings. The majority of ICTs were computerized interventions and/or applications (n = 55). These ICTs were commonly used as indicated strategies (n = 49) targeting patients who were actively presenting with suicide risk. The three most common suicide prevention intervention categories identified were post-discharge follow-up (n = 27), screening and/or assessment (n = 22), and safety planning (n = 20). A paucity of reported information was identified related to implementation strategies, barriers and facilitators. The most reported implementation strategies included training, education, and collaborative initiatives. Barriers and facilitators of implementation included the need for resource supports, knowledge, skills, motivation as well as engagement with clinicians with research teams. Studies included outcomes at patient, clinician, and health system levels, and implementation outcomes included acceptability, feasibility, fidelity, and penetration.

CONCLUSION

This review presents several trends of the ICT-based interventions for suicide prevention implemented in clinical settings and identifies a need for future research to strengthen the evidence base for improving implementation. More effort is required to better understand and support the implementation and sustainability of ICTs in clinical settings. The findings can also serve as a future resource for researchers seeking to evaluate the impact and implementation of ICTs.

Risk of suicide attempt repetition after an index attempt: A systematic review and meta-analysis

OBJECTIVES

To estimate the risk of suicide attempt repetition among individuals with an index attempt. It also aims to study the role of risk factors and prevention programme in repetition.

METHODS

This systematic review and meta-analysis was conducted in keeping with the PRISMA 2020 guidelines. Studies on attempt repetition (both cohort studies and intervention studies) were searched from inception to 2022.

RESULTS

A total of 110 studies comprising 248,829 attempters was reviewed. The overall repetition rate was 0.20 (0.17, 0.22). Repetition risk linearly increased over time. A higher risk of attempt repetition was associated with female sex and index attempts in which self-cutting methods were used. Moreover, a mental disorder diagnosis was associated with an increasing repetition risk (OR = 2.02, p < .01). The delivery of a preventive programme reduced the repetition risk, OR = 0.76, p < .05; however, this effect was significant for psychotherapy interventions, OR = 0.38, p < .01.

CONCLUSION

One in five suicide attempters will engage in a new suicide attempt. An elevated repetition risk is associated with being female, more severe index methods and psychiatric disorder diagnosis. Preventive programmes, particularly psychotherapy, may contribute to reducing repetition risk and eventually save lives.

Telephone-Delivered Interventions for Suicide Prevention in Schizophrenia and Related Disorders: A Systematic Review

BACKGROUND

Suicide is a health problem among patients diagnosed with schizophrenia. Telehealth technology has become an emerging intervention that may offer opportunities to reach this at-risk group. However, to consider the implementation of telehealth systems in the prevention of suicidal behaviors in patients diagnosed with schizophrenia, a review of the evidence is required. The present aim was to explore the effectiveness of telephone-based suicide prevention programs among patients with schizophrenia and related disorders.

METHODS

A bibliographic search was carried out in the PubMed, PsycInfo, Scopus and Web of Science electronic databases following PRISMA guidelines. Two reviewers performed the selection, data extraction and methodological quality assessment. A total of 352 articles were retrieved, of which five studies met the eligibility criteria.

RESULTS

Globally, an adherence was observed ranging from 78 to 100%. Three studies reported a reduction in suicidal ideation and two studies showed a reduction in the risk of relapse observed in the intervention group compared to a control group.

CONCLUSIONS

In accordance with the limited data available, the use of a telephone contact approach appears to be feasible and effective in schizophrenia patients with suicidal behaviors. The preliminary evidence also suggests that this system appears to reduce suicidal ideation. Further research is required to design evidence-based future interventions and to determine whether this approach can improve patient outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Suicide Prevention and Intervention Study (SURVIVE): Study protocol for a multisite cohort study with nested randomized-controlled trials

INTRODUCTION

Suicide is one of the leading causes of avoidable death. Gathering national data on suicidal behaviour incidence is crucial to develop evidence-based public policies. The study has two primary objectives: (1) to determine the incidence of suicide attempts in Spain and related risk factors, and (2) to analyze the efficacy of secondary prevention programmes to prevent suicide re-attempting in comparison to treatment as usual (TAU).

MATERIALS AND METHODS

Multisite, coordinated, cohort study with three nested randomized controlled trials. A cohort of 2000 individuals (age >=12) with suicidal behaviour will be recruited at ten sites distributed across Spain. Assessments will be conducted within 10 days of the suicide attempt (V0-baseline visit) and after 12 months (V4-last visit) and will include clinician reported and participant reported outcomes (PROs). Between V0 and V4, PROs will be collected remotely every three months (V1, V2 and V3). Optatively, cohort participants will participate in three nested randomized-controlled-trials (RCTs) evaluating different secondary prevention interventions: Participants aged 18 years and older will be randomly allocated to: Telephone-based Management+TAU vs. TAU or iFightDepression-Survive+TAU vs. TAU. Participants aged between 12 and 18 years will be allocated to a specific intervention for youths: Self Awareness of Mental Health+TAU vs. TAU.

RESULTS

This study will provide interesting data to estimate suicide attempt incidence in Spain. and will provide evidence on three.

CONCLUSIONS

Evidence on three potentially efficacious interventions for individuals at high risk of suicide will be obtained, and this could improve the treatment given to these individuals.

TRIAL REGISTRATION

NCT04343703.

Suicide Attempt Aftercare in Geriatric Patients: A Pilot Project

Hospitalized patients after suicide attempts gave informed consent to a postvention project after discharge. A continuous caregiver contacted the subjects monthly by phone for a period of 1 year. In case of significant worsening and reoccurrence of suicidal ideations, immediate re-admission was possible. Ten subjects 65 years and older and hospitalized because of suicide attempts were included. The sample was presumed to be at high risk for repeated suicides because of somatic comorbidities and social isolation. Affective state was monitored using the PHQ-9. At the end, the social situation was assessed using the MILVA inventory. Of 16 patients screened for participation only 10 gave informed consent. Six subjects completed the study per protocol. Three subjects died (one suicide, two deaths by natural causes) and one dropped out for other reasons. At the end of the study, all completers appreciated the continuous guidance. While the affective state remained relatively stable in most subjects during the observed period, activities and social isolation could not be modified. Only one patient was readmitted during the project. Phone contacts proved to be feasible in the follow-up after suicide attempts especially in old age, because of the limited mobility of this vulnerable population.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS/DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT04907669.

Effectiveness of a telephone prevention programme on the recurrence of suicidal behaviour. One-year follow-up

People who have attempted suicide are considered a risk population for repeating the behaviour. Therapeutic interventions, such as telephone follow-up programmes (TFPs), are promising but more evidence for its efficacy is needed. In this multicentre, open, ex-post-facto, pre/post, one year prospective study, a previous cohort discharged from the emergency department for a suicide attempt (SA) and given routine treatment (n=207) was compared with a similar group who received the same intervention plus a structured TFP of six calls (n=203). At one year of follow-up, the efficacy of the TFP at preventing SA was assessed. A total of 53.2% (n=108) of the patients finished the TFP. A total of 20.3% (n=42) of the routine treatment group and 23.6% (n=48) of the TFP group re-attempted at least once in the follow-up period (χ²=0.7;df=1;p=.412). However, in both groups, different subsamples of patients who presented extreme risk of SA at follow-up (0-57%) were identified. In the TFP group, the recurrence of suicidal behaviour was lower in patients admitted after the index attempt and in those who had more severe psychopathological symptoms, but not in the other profiles. Thus, this study has identified a specific profile of patients who could benefit from a brief-contact intervention.

Cost-effectiveness of a Contact Intervention and a Psychotherapeutic Program for Post-discharge Suicide Prevention

OBJECTIVE

To determine the cost-effectiveness of 2 strategies for post-discharge suicide prevention, an Enhanced Contact intervention based on repeated in-person and telephone contacts, and an individual 2-month long problem-solving Psychotherapy program, in comparison to facilitated access to outpatient care following a suicide attempt.

METHODS

We conducted a cost-effectiveness analysis based on a decision tree between January and December 2019. Comparative effectiveness estimates were obtained from an observational study conducted between 2013 and 2017 in Madrid, Spain. Electronic health care records documented resource use (including extra-hospital emergency care, mortality, inpatient admission, and disability leave). Direct cost data were derived from Madrid's official list of public health care prices. Indirect cost data were derived from Spain's National Institute of Statistics.

RESULTS

Both augmentation strategies were more cost-effective than a single priority outpatient appointment considering reasonable thresholds of willingness to pay. Under the base-case scenario, Enhanced Contact and Psychotherapy incurred, respectively, €2,340 and 6,260 per averted attempt, compared to a single priority appointment. Deterministic and probabilistic sensitivity analyses showed both augmentation strategies to remain cost-effective under several scenarios. Enhanced Contact was slightly cost minimizing in comparison to Psychotherapy (base-case scenario: €-196 per averted attempt).

CONCLUSIONS

Two post-discharge suicide prevention strategies based on Enhanced Contact and Psychotherapy were cost-effective in comparison to a single priority appointment. Increasing contacts between suicide attempters and mental health-care providers was slightly cost minimizing compared to psychotherapy.

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.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42019131040.

A Randomized Controlled Trial to Assess Feasibility and Acceptability of Telephone-Based Psychosocial Interventions in Individuals who Attempted Suicide

BACKGROUND

Brief contact interventions such as telephone-based contacts appear to be useful in individuals who attempted suicide. Most studies of telephone-based contacts in such individuals typically consisted of frequent phone reminders for adherence to treatment and seeking help for mental health issues. Telephone-based psychosocial interventions that incorporate elements of supportive and problem-solving strategies are of interest in Indian settings due to their potential application in mitigating the wide mental health gap. Feasibility studies of telephone-based psychosocial interventions could help ascertain the difficulties that arise in the implementation of such treatments.

METHODS

A multicentric randomized controlled trial (RCT) is currently underway in general hospital settings in two Indian cities to study the efficacy of telephone-based psychosocial interventions in individuals with a recent suicide attempt, with routine telephone contacts (TCs) serving as the comparator. Prior to that RCT, this feasibility study was conducted to assess the acceptability of the telephone-based intervention and telephone contacts. Feasibility was assessed using dropout rates. Acceptability was assessed using participant-rated Likert-based visual analog scores from 0 to 10, with higher scores indicating greater acceptability.

RESULTS

Dropout rates and mean acceptability scores for telephone-based psychosocial interventions were 38.5% and 8.63, while those for TCs were 41.7% and 7.57, respectively.

CONCLUSIONS

Telephone-based psychosocial interventions are feasible and acceptable in individuals with a recent suicide attempt.

Aftercare and Suicide Reattempt Prevention in Tehran, Iran

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

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.

Suicidal Risk Following Hospital Discharge: A Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate risk of suicide and suicide attempts following psychiatric hospitalization• Assess the relationship between suicide attempts and completed suicides BACKGROUND: Suicidal risks among psychiatric patients appear to be especially high soon after hospitalization. Given the importance of such outcomes, and the lack of recent reviews of post-discharge suicide attempt risks, we evaluated reported findings on the risk of suicide and attempts following psychiatric hospitalization.

METHODS

With systematic, computerized searching, we identified 48 studies (1964-2017) involving 1,700,785 subjects. Follow-up was limited to ≥12 months after discharge from psychiatric hospitalization to avoid inflation of annualized rates due to shorter exposure times.

RESULTS

The overall observed pooled, annualized rate of completed suicide was 241 (confidence interval, 238-243) per 100,000 person-exposure years in 41 studies, and for attempts, 722 (698-746) in 13 studies. In six studies (64,848 subjects) reporting on both suicides and attempts, the ratio of annualized rates for attempts/completed suicides was 8.79 (6.63-12.0). Among all 48 studies, cumulative distribution of suicidal events included 26.4% (25.9-26.9) within the initial month, 40.8% (40.2-41.4) within 3 months, and 73.2% (72.7-73.7) within 12 months of discharge.

CONCLUSIONS

Among patients recently discharged from psychiatric hospitalization, rates of suicide deaths and attempts were far higher than in the general population or even in unselected clinical samples of comparable patients, with a strong inverse association with time post-discharge. Improved monitoring and care of patients discharged from psychiatric hospitalization are needed, ideally with detailed planning and implementation of aftercare prior to discharge.

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

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

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.

Prevention of Suicidal Behavior with Telemedicine in Patients with a Recent Suicide Attempt: Is a 6-month Intervention Long Enough?

OBJECTIVE

To analyze the results of a 6-month telephone follow-up program for the prevention of suicidality in adult patients discharged from three general hospitals after a suicide attempt. Results are compared with traditional programs lasting 12 months or more.

METHODS

This is a prospective, multicenter, study with the control group. Patients in the intervention group received five protocolized telephone calls which were added to their usual treatment. Those in the control group only received usual treatment. Each patient was followed up for 12 months.

RESULTS

A total of 123 patients were included in the intervention group and 463 in the control group. 57.7% received at least three calls. Patients in the intervention group took longer to perform a reattempt (p = .05). The percentage of those who did a reattempt (p = .67) and the number of reattempts per patient (p = .66) did not differ between groups. Those in the intervention group showed higher percentages of adherence to the outpatient follow-up (p < .001).

CONCLUSION

The intervention was well accepted and showed improved percentages of adherence to outpatient follow-up; however, the results in the prevention of suicidality were worse than those obtained by programs lasting 12 months or more. It is advisable to maintain the telephone follow-up for a minimum of 12 months.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Why Are Suicide Rates Increasing in the United States? Towards a Multilevel Reimagination of Suicide Prevention

Suicide, a major public health concern, takes around 800,000 lives globally every year and is the second leading cause of death among adolescents and young adults. Despite substantial prevention efforts, between 1999 and 2017, suicide and nonfatal self-injury rates have experienced unprecedented increases across the United States - as well as in many other countries in the world. This chapter reviews the existing evidence on the causes behind increased suicide rates and critically evaluates the impact of a range of innovative approaches to suicide prevention. First, we briefly describe current trends in suicide and suicidal behaviors and relate them to recent time trends in relevant suicide risk markers. Then, we review the existing evidence in suicide prevention at the individual and the population levels, including new approaches that are currently under development. Finally, we advocate for a new generation of suicide research that examines causal factors beyond the proximal and clinical and fosters a socially conscious reimagining of suicidal prevention. To this end, we emphasize the need for the conceptualization of suicide and suicidal behaviors as complex phenomena with causes at several levels of organization. Future interdisciplinary research and interventions should be developed within a multilevel causal framework that can better capture the social, economic, and political settings where suicide, as a process, unfolds across the life course.

Do individuals follow up with mental health services after a suicide attempt? Findings from the assertive management of attempted suicide service, Bengaluru, India

OBJECTIVE

There is limited information from India on whether individuals follow up with mental health services after a suicide attempt. The objective of this study was to determine follow-up rates after a suicide attempt with mental health services of those individuals treated as part of the assertive management of attempted suicide service in a general hospital in Bengaluru, India.

MATERIALS AND METHODS

Records from 284 persons from January 2016 to December 2016 were analyzed to ascertain their follow-up rates with mental health services after a suicide attempt.

RESULTS

After discharge, 25% individuals followed up on a single occasion with mental health services. Individuals with a psychiatric diagnosis were significantly more likely to follow up with mental health services as compared to those without a psychiatric diagnosis (P < 0.011, odds ratio: 2.875, confidence interval at 95%: 1.276-6.481). 90.8% were contacted through telephone as part of aftercare.

CONCLUSIONS

Most individuals in India, especially those without a psychiatric diagnosis, do not follow up with mental health services after a suicide attempt. Periodic telephonic contacts are a useful aftercare strategy to reach out to this high-risk population. Limitation of this study is that findings are from an urban general hospital setting.

An Emergency Department-Initiated Intervention to Lower Relapse Risk after Attempted Suicide

OBJECTIVE

According to randomized trials, contact after a suicide attempt lowers relapse risk. However, effectiveness studies based on real clinical data can provide additional external validity.

METHOD

We conducted an observational study to determine if an emergency department (ED)-initiated intervention for suicide attempt risk reduction, consisting on scheduling a single added appointment within 7 days after discharge following a suicide attempt, can reduce the risk of relapse. The study included 1,775 patients who had been treated at a general hospital ED due to a suicide attempt. The principal outcome measure was ED return after a new attempt. We obtained Kaplan-Meier survival functions and used Cox proportional hazard regression models to estimate unadjusted and adjusted risks of relapse by treatment phase. Covariates included: age, gender, history of suicide attempts, history of psychiatric disorders, concurrent alcohol/drug abuse, number of attempts during follow-up, admission as an inpatient and family support.

RESULTS

A total of 497 (22.5%) attempts were followed by a relapse. Subjects exposed to the studied intervention had a lower risk of relapse after a suicide attempt, with a 24% adjusted risk reduction estimate.

CONCLUSION

Our real-world results suggest that an additional early appointment, scheduled before discharging suicide attempters, reduces suicide reattempt risk.

A regional systems intervention for suicide prevention in the Netherlands (SUPREMOCOL): study protocol with a stepped wedge trial design

BACKGROUND

In the Netherlands, suicide rates showed a sharp incline and this pertains particularly to the province of Noord-Brabant, one of the southern provinces in the Netherlands. This calls for a regional suicide prevention effort.

METHODS/DESIGN

Study protocol. A regional suicide prevention systems intervention is implemented and evaluated by a stepped wedge trial design in five specialist mental health institutions and their adherent chain partners. Our system intervention is called SUPREMOCOL, which stands for Suicide Prevention by Monitoring and Collaborative Care, and focuses on four pillars: 1) recognition of people at risk for suicide by the development and implementation of a monitoring system with decision aid, 2) swift access to specialist care of people at risk, 3) positioning nurse care managers for collaborative care case management, and 4) 12 months telephone follow up. Eligible patients are persons attempting suicide or expressing suicidal ideation. Primary outcome is number of completed suicides, as reported by Statistics Netherlands and regional Public Health Institutes. Secondary outcome is number of attempted suicides, as reported by the regional ambulance transport and police. Suicidal ideation of persons registered in the monitoring system will, be assessed by the PHQ-9 and SIDAS questionnaires at baseline and 3, 6, 9 and 12 months after registration, and used as exploratory process measure. The impact of the intervention will be evaluated by means of the RE-AIM dimensions reach, efficacy, adoption, implementation, and maintenance. Intervention integrity will be assessed and taken into account in the analysis.

DISCUSSION

The present manuscript presents the design and development of the SUPREMOCOL study. The ultimate goal is to lower the completed suicides rate by 20%, compared to the control period and compared to other provinces in the Netherlands. Moreover, our goal is to provide specialist mental health institutions and chain partners with a sustainable and adoptable intervention for suicide prevention.

TRIAL REGISTRATION

Netherlands Trial Register under registration number NL6935 (5 April 2018). This is the first version of the study protocol (September 2019).

Fatal and Non-fatal Self-Injury in the USA: Critical Review of Current Trends and Innovations in Prevention

PURPOSE OF REVIEW

To examine current trends in suicide and self-injury in the USA, as well as potential contributors to their change over time, and to reflect on innovations in prevention and intervention that can guide policies and programs to reduce the burden of suicide and self-injury in the USA.

RECENT FINDINGS

Suicide and non-fatal self-injury are on the rise in the USA. Reasons for such trends over time remain speculative, although they seem linked to coincident increases in mood disorders and drug use and overdose. Promising innovative prevention and intervention programs that engage new technologies, such as machine learning-derived prediction tools and computerized ecologic momentary assessments, are currently in development and require additional evidence. Recent increases in fatal and non-fatal self-harm in the USA raise questions about the causes, interventions, and preventive measures that should be taken. Most innovative prevention efforts target individuals seeking to improve risk prediction and access to evidence-based care. However, as Durkheim pointed out over 100 years ago, suicide rates vary enormously between societal groups, suggesting that certain causal factors of suicide act and, hence, should be targeted at an ecological level. In the next generation of suicide research, it is critical to examine factors beyond the proximal and clinical to allow for a reimagining of prevention that is life course and socially focused.

Reduction of Postdischarge Suicidal Behavior Among Adolescents Through a Telephone-Based Intervention

OBJECTIVE

Brief telephone follow-up for a patient with suicidal tendencies after he or she has been discharged from an emergency room or hospital has been shown to decrease subsequent suicide attempts. However, despite the high rate of suicidal behavior in adolescents, this intervention has not been examined in this population. As part of a quality improvement intervention, postdischarge telephone contacts were used to attempt to reduce suicidal behavior and inpatient rehospitalizations among adolescents.

METHODS

Adolescents who were hospitalized for suicidal ideation or attempt (N=142) were randomly assigned to one of two telephone interventions delivered over a 90-day period: either a single call intervention (SCI) or a multiple calls intervention (MCI). The intervention consisted of assessment of suicidality, review of safety plan, and discussion of medication and weapon safety, with up to six telephone contacts in the MCI and up to one contact in the SCI. Primary outcome measures included suicidal behavior and inpatient rehospitalizations; secondary outcome measures included adolescents' confidence in their safety plan.

RESULTS

Adolescents receiving the MCI had a significantly lower rate of suicidal behavior (6%) compared with adolescents receiving SCI (17%; odds ratio [OR]=0.28, p=0.037); results persisted while the analysis controlled for relevant covariates (OR=0.25, p=0.032). Similarly, adolescents receiving the MCI reported significantly greater confidence in their safety plan at 90 days (95%vs. 74%; p=0.001), which, in turn, was associated with a lower rate of suicidal behavior (OR=0.95, p=0.019).

CONCLUSIONS

A telephone-based intervention for providing recurrent follow-up soon after discharge is feasible in the adolescent population and may be effective in reducing postdischarge suicidal behavior.

Gun prevalence and suicide

In light of the ongoing debate over tighter firearm regulations, this paper considers the relationship between gun prevalence and suicide. I exploit a reform in Switzerland that reduced the prevalence of military-issued guns in private households. In Switzerland, military service is compulsory for men, and military-issued guns account for nearly half of the total number of firearms available. The results show that the firearm suicide rate decreases by 9% for a reduction in gun prevalence of 1000 guns per 100,000 inhabitants. The elasticity of gun suicides with respect to firearm prevalence is +0.48, but converges towards zero for low levels of gun prevalence. The overall suicide rate is negatively and significantly related to firearm prevalence, which indicates that non-gun methods of suicide are not perfect replacements for firearms.

Short- and Long-term Effects of Case Management on Suicide Prevention among Individuals with Previous Suicide Attempts: a Survival Analysis

BACKGROUND

This study examined the long-term preventive effects of a case management service on suicide reattempts, and clarified the factors related to suicide reattempts.

METHODS

We reviewed the medical records of suicide attempters who visited the emergency department of Ulsan University Hospital from August 28, 2013 to July 31, 2017. A 4-week case management service was provided to consenting participants, either face-to-face or by telephone. Using survival analysis, we analyzed differences in the time to the next emergency department visit for a suicide attempt according to whether participants completed the case management service. We also assessed which characteristics of participants were associated with suicide reattempts.

RESULTS

We found no overall difference in time to suicide reattempt between case-managed participants and controls over the entire observation period (median period: 19 months). However, in the first 24 weeks after the initial suicide attempt, the case-managed group showed a longer time to reattempt than did the control group (log-rank test = 4.243; P = 0.039). A higher risk of reattempt was found among participants with the medical benefit type of health insurance compared to those with national health insurance (hazard ratio [HR], 5.134; P < 0.001) and among participants aged 20-39 compared to those aged ≥ 60 (HR, 3.502; P = 0.05).

CONCLUSION

Case management had only short-term benefits (within 24 weeks of initial suicide attempt). Risk factors for suicide reattempts were having a medical benefit health insurance and being aged 20-39 years.

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.

Risk of re-attempts and suicide death after a suicide attempt: A survival analysis

BACKGROUND

Suicide is the primary cause of unnatural death in Spain, and suicide re-attempts a major economic burden worldwide. The risk factors for re-attempt and suicide after an index suicide attempt are different. This study aims to investigate risk factors for re-attempt and suicide after an index suicide attempt.

METHODS

This observational study is part of a one-year telephone management program. We included all first-time suicide attempters evaluated in the emergency department at Parc Taulí-University Hospital (n = 1241) recruited over a five-year period (January 2008 to December 2012). Suicide attempters were evaluated at baseline using standardized instruments. Bivariate logistic regression models were used to identify risk factors. Kaplan-Meier curves were used to compare the time to re-attempt between categorical variables. Comparisons were performed using Log-Rank and Wilcoxon tests. Variables with a p-value lower than 0.2 were included in a multivariate Cox regression model. Bivariate logistic regression models were considered to identify risk factors for suicide. The significance level was set to 0.05.

RESULTS

Suicide re-attempters were more likely diagnosed with cluster B personality disorders (36.8% vs. 16.6%; p < 0.001), and alcohol use disorders (19.8 vs. 13.9; p = 0.02). Several [1.2% (15/1241)] of them died by suicide. Attempters who suicide were more likely alcohol users (33.3% vs. 17.2%; p = 0.047), and older (50.9 ± 11.9 vs. 40.7 ± 16.0; p = 0.004).

CONCLUSIONS

Alcohol use, personality disorders and younger age are risk factors for re-attempting. Older age is a risk factor for suicide among suicide attempters. Current prevention programs of suicidal behaviour should be tailored to the specific profile of each group.

Effect of telephone follow-up on repeated suicide attempt in patients discharged from an emergency psychiatry department: a controlled study

BACKGROUND

Attempted suicide is a major public health problem, and the efficacies of current postvention protocols vary. We evaluated the effectiveness of telephone follow-up of patients referred to an emergency psychiatric unit for attempted suicide on any further attempt/s over the following year.

METHOD

In a single-center, controlled study with intent to treat, we evaluated the efficacy of a protocol of telephone follow-up of 436 patients at 8, 30, and 60 days after they were treated for attempted suicide. As controls for comparison, we evaluated patients with similar social and demographic characteristics referred to our emergency psychiatric unit in the year prior to the study who did not receive telephone follow-up after their initial hospitalization. Data were analyzed using logistic regression.

RESULTS

Very early telephone follow-up of our patients effectively reduced recidivism and seemed to be the only protective factor against repeated suicide attempt.

CONCLUSIONS

Implementing a protocol of early telephone follow-up after attempted suicide could help prevent repeated attempt/s. More controlled studies are needed to assess optimal techniques to prevent such repetition.

Multicomponent Intervention for Patients Admitted to an Emergency Unit for Suicide Attempt: An Exploratory Study

Suicide is a major cause of premature deaths worldwide and belongs to the top priority public health issues. While suicide attempt is the most important risk factor for completed suicide, intervention for suicide attempters (SA) have produced mixed results. Since an important proportion of SA request medical care, emergency units (EU) are an opportune setting to implement such interventions. This exploratory study evaluated the feasibility and acceptability of a multicomponent intervention for SA admitted to an EU. The intervention consisted of coordination by a case manager of a joint crisis plan (JCP), an early meeting with relatives and the existing care network, as well as phone contacts during 3 months after suicide attempt. Among 107 SA admitted to the emergency unit during the study period, 51 could not be included for logistical reason, 22 were excluded, and intervention was offered to 34. Of these, 15 refused the intervention, which was thus piloted with 19 SA. First-time attempters most frequently declined the intervention. Feasibility and acceptability of phone contacts and case manager were good, while JCPs and meetings were difficult to implement and perceived as less acceptable. Refusal pattern questions the global acceptability and is discussed: JCPs and meetings will have to be modified in order to improve their feasibility and acceptability, especially among first-time attempters.

Telephone Management Program for Patients Discharged From an Emergency Department After a Suicide Attempt: A 5-Year Follow-Up Study in a Spanish Population

AIM

In a previous controlled study, the authors reported on the significant beneficial effects of a telephone intervention program for prevention of suicide attempts by patients for up to 1 year. This study reports the 5-year follow-up data. Outcomes were number of recurrences and time to recurrence.

METHOD

The intervention was carried out on patients discharged from the emergency room (ER) following attempted suicide (Sabadell). It consisted of a systematic, 1-year telephone follow-up program: after 1 week, and thereafter at 1-, 3-, 6-, 9-, and 12-month intervals to assess the risk of suicide and encourage adherence to treatment. The population in the control group (Terrassa) received treatment as usual after discharge, without additional telephone contact.

RESULTS

The effect of reattempt prevention observed in the first year was not maintained over the long term.

CONCLUSION

A telephone management program for patients discharged from an ER after attempted suicide could be considered a useful strategy in delaying further suicide attempts and reducing the rate of reattempts in the first year. However, results showed that the beneficial effects were not maintained at the 5-year follow-up.

[Follow-up interventions after suicide attempt. What tools, what effects and how to assess them?]

After attempting suicide, 60 to 70% of patients are discharged from emergency departments and referred to outpatient treatment which entails psychosocial strategies, pharmacological strategies or a combination. The main objective of outpatient care consists in preventing recurrent suicidal behavior. Yet suicide attempters have been found to be very difficult to engage in treatment. Between 11% and 50% of attempters refuse outpatient treatment or drop out of outpatient therapy very quickly. In order to address this extremely serious issue, for the past 20 years monitoring or follow up interventions has been presented as a promising approach. Follow-up intervention is defined as a service that aims at both increased access to and engagement in care as well as to prevent suicide and related behaviors. This approach consists in "stay in contact" or "connectedness" protocols using phone calls or tele-assistance, sending letters, email or mobile phone messages and medical visits or nursing at home. From one study to another these tools have been used separately, associated to one another or reinforced by motivational interviewing or brief psychotherapy. To our knowledge, since 1993 16 controlled and randomized controlled studies assessed the effectiveness of diverse follow-up. Four studies assessing telephone follow up reported a significant decrease in suicide reattempt while one study evaluating a sending letters strategy reported positive results. Among five studies assessing engagement in healthcare, only two (one using phone follow up and the other sending letters reported significantly positive results. The refusal rate of monitoring strategies has not exceeded 11% attesting to the high applicability of these methods. Despite several positive results, we cannot draw firm conclusions on replicability of these results. This is largely due to methodological issues: lack of standardization of interventions, lack of consensus on definition of the main measured variables (recurrent suicidal behavior, engagement in healthcare) but also to the confounding effect of other care approaches frequently associated with follow up intervention services. Further studies and research should be conducted as follow-up intervention services are increasingly used in suicide prevention because of their good acceptability and usefulness.

Technology-enhanced suicide prevention interventions: A systematic review

Objective

Suicide prevention is a high priority. Scalable and sustainable interventions for suicide prevention are needed to set the stage for population-level impact. This systematic review explores how technology-enhanced interventions target suicide risk and protective factors, using the Centers for Disease Control and Prevention (CDC, 2015) Risk and Protective Factors Ecological Model.

Methods

Information databases (PsycINFO, PubMed and CINAHL) were systematically searched and records including technology-enhanced interventions for suicide prevention ( n = 3764) were reviewed. Records with varying technologies and diverse methodologies were integrated into the search.

Results

Review of the records resulted in the inclusion of 16 studies that utilized technology-enhanced interventions to address determinants of suicidal behaviour. This includes the use of standalone or, in most cases, adjunct technology-enhanced interventions for suicide prevention delivered by mobile phone application, text message, telephone, computer, web, CD-ROM and video.

Conclusion

Intervention effectiveness was variable, but several technology-enhanced interventions have demonstrated effectiveness in reducing suicidal ideation and mental health co-morbidities. Large-scale research and evaluation initiatives are needed to evaluate the costs and long-term population-level impact of these interventions.

Benefits of a Secondary Prevention Program in Suicide

Abstract. Background: The effectiveness of suicide intervention programs has not been assessed with experimental designs. Aim: To determine the risk of suicide reattempts in patients engaged in a secondary prevention program. Method: We included 154 patients with suicidal behavior in a quasi-experimental study with a nontreatment concurrent control group. In all, 77 patients with suicidal behavior underwent the Suicide Behavior Prevention Program (SBPP), which includes specialized early assistance during a period of 3–6 months. A matched sample of patients with suicidal behavior (n = 77) was selected without undergoing any specific suicide prevention program. Data on sociodemographics, clinical characteristics, and suicidal behavior were collected at baseline (before SBPP) and at 12 months. Results: After 12 months, SBPP patients showed a 67% lower relative risk of reattempt (χ2 = 11.75, p = .001, RR = 0.33 95% CI = 0.17–0.66). Cox proportional hazards models revealed that patients under SBPP made a new suicidal attempt significantly much later than control patients did (Cox regression = 0.293, 95% CI = 0.138–0.624, p = .001). The effect was even stronger among first attempters. Limitations: Sampling was naturalistic and patients were not randomized. Conclusion: The SBPP was effective in delaying and preventing suicide reattempts at least within the first year after the suicide behavior. In light of our results, implementation of suicide prevention programs is strongly advisable.

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.

Risk Factors for Suicidal Ideation Among Telephone Crisis Hotline Callers in Japan

BACKGROUND

Telephone hotlines are a widely used type of suicide prevention program.

AIMS

The aim of this study was to clarify the risk factors for suicidal ideation by investigating its association with a number of characteristics among telephone hotline callers.

METHOD

Data were collected over a 10-year period from a total of 246,595 calls to Inochi No Denwa, a telephone crisis hotline in Ibaraki, Japan, and subsequently analyzed. Odds ratios for suicidal compared with nonsuicidal ideation were also calculated.

RESULTS

About 6% of the calls to the hotline were suicide related, and about 2% of the callers had attempted suicide in the past. Odds ratios for suicidal ideation increased during winter, but no daily tendencies were evident. Those whose problems were related to their way of life were at the highest risk of suicidal ideation, followed by those with health-related concerns.

CONCLUSION

We were able to identify risk factors for suicidal ideation based on an analysis of enormous amounts of data from a telephone crisis hotline in Japan. Knowledge of these risk factors is expected to lead to improvements in suicide prevention programs.