Training mental health professionals in suicide practice guideline adherence: Cost-effectiveness analysis alongside a randomized controlled trial

The cost of illness and burden of suicide and suicide attempts in France

BACKGROUND

With 11,558 deaths and 200,000 suicide attempts in 2019, France is among the European countries most affected. The aim of this study was to determine the costs and burden of suicides and suicide attempts in France (population 67 million).

METHODS

We estimated direct costs, comprising healthcare, as well as post-mortem costs including autopsy, body removal, funeral expenses, police intervention and support groups; indirect costs comprised lost productivity, daily allowances; the burden of disease calculations used a monetary value for death and disability based on incidence data. Data was obtained from the national statistics, health and social care database, registries, global burden of disease, supplemented by expert opinion. We combined top down and bottom up approaches.

RESULTS

The total costs and burden of suicides and suicide attempts was estimated at €18.5 billion and €5.4 billion, respectively. Direct costs were €566 million and €75 million; indirect costs were €3.8 billion and €3.5 billion; monetary value for death and disability was €14.6 billion and €1.3. The monetary value for death and disability represented 79.1% and 24.8% of total costs for suicide and suicide attempt respectively. Some costs were based upon expert opinion, caregivers' burden was not counted and pre COVID data only is reported.

CONCLUSIONS

In France, the total cost and burden of suicides and suicide attempts was several billion €, suggesting major potential savings from public health interventions.

The Cost-Effectiveness of Psychosocial Interventions Following Self-Harm in Australia

Background: Psychosocial interventions following self-harm in adults, in particular cognitive behavioral therapy (CBT), can be effective in lowering the risk of repeated self-harm. Aims: To evaluate the cost-effectiveness of CBT for reducing repeated self-harm in the Australian context. Method: The current study adopted the accessing cost-effectiveness (ACE) approach using return-on-investment (ROI) analysis. Uncertainty and sensitivity analyses (Sas) tested the robustness of the model outputs to changes in three assumptions: general practitioner referral pathway (SA1), private setting intervention delivery (SA2), and training costs (SA3). Results: The intervention produced cost savings of A$ 46M (95% UI -223.7 to 73.3) and A$ 18.3M (95% UI -86.2 to 24.6), subject to the effect of intervention lasting 2- or 1-year follow-up. The ROI ratio reduced to 5.22 in SA1 (95% UI -10.1 to 27.9), 2.5 in SA2 (95% UI -4.8 to 13.3), and 5.1 in SA3 (95% UI -9.8 to 27.8). Limitations: We assumed that the effectiveness would reduce 50% within 5 years in the base case, and we used Australian data and a partial social perspective. Conclusions: The current study demonstrated cost-effectiveness of CBT for adults who have self-harmed with the return-on-investment ratio of A$ 2.3 to $6.0 for every A$ 1 invested.

Implementation fidelity, student outcomes, and cost-effectiveness of train-the-trainer strategies for Masters-level therapists in urban schools: results from a cluster randomized trial

BACKGROUND

Little is known about the effectiveness and cost-effectiveness of train-the-trainer implementation strategies in supporting mental health evidence-based practices in schools, and about the optimal level of support needed for TT strategies.

METHODS

The current study is part of a larger type 2 hybrid cluster randomized controlled trial. It compares two train-the-trainer strategies, Train-the-Trainer (TT) and Train-the-Trainer plus ongoing consultation for trainers (TT +) on the delivery of a group cognitive behavioral treatment protocol for anxiety disorders. Participants were 33 therapists, 29 supervisors, and 125 students who were at risk for anxiety disorders from 22 urban schools. Implementation outcomes were implementation fidelity and treatment dosage. Student outcomes were child- and parent-reported symptoms of anxiety, child-reported symptoms of depression, and teacher-reported academic engagement. We estimated the cost of implementing the intervention in each condition and examined the probability that a support strategy for supervisors (TT vs TT +) is a good value for varying values of willingness to pay.

RESULTS

Therapists in the TT and TT + conditions obtained similarly high implementation fidelity and students in the conditions received similar treatment dosages. A mixed effects modeling approach for student outcomes revealed time effects for symptoms of anxiety and depression reported by students, and emotional disaffection reported by teachers. There were no condition or condition × times effects. For both conditions, the time effects indicated an improvement from pre-treatment to post-treatment in symptoms of anxiety and depression and academic emotional engagement. The average cost of therapist, supervisor, and consultant time required to implement the intervention in each condition was $1002 for TT and $1431 for TT + (p = 0.01). There was a greater than 80% chance that TT was a good value compared to TT + for all values of willingness to pay per one-point improvement in anxiety scores.

CONCLUSIONS

A TT implementation approach consisting of a thorough initial training workshop for therapists and supervisors as well as ongoing supervision for therapists resulted in adequate levels of fidelity and student outcomes but at a lower cost, compared to the TT + condition that also included ongoing external expert consultation for supervisors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02651402.

A Clinical Model for the Differentiation of Suicidality: Protocol for a Usability Study of the Proposed Model

BACKGROUND

Even though various types of suicidality are observed in clinical practice, suicidality is still considered a uniform concept. To distinguish different types of suicidality and consequently improve detection and management of suicidality, we developed a clinical differentiation model for suicidality. We believe that the model allows for a more targeted assessment of suicidal conditions and improves the use of evidence-based treatment strategies. The differentiation model is based on the experience with suicidality that we have encountered in clinical practice. This model distinguishes 4 subtypes of entrapment leading to suicidality. The earliest description of this model and a proposal for usability research has been previously presented in a book chapter.

OBJECTIVE

In this study, we present the most recent version of the 4-type differentiation model of suicidality and a protocol for a study into the usability of the proposed model.

METHODS

The 4-type differentiation model of suicidality distinguishes the following subtypes: (1) perceptual disintegration, (2) primary depressive cognition, (3) psychosocial turmoil, and (4) inadequate coping or communication. We plan to test the usability of the 4 subtypes in a pilot study of 25 cases, and subsequently, we will include 75 cases in a follow-up study. We looked at the case notes of 100 anonymized patients with suicidality who presented to mental health care emergency service in The Hague International Center. The summary and conclusions of the letters sent to the patients' general practitioners after suicide risk assessment will be independently rated by 3 psychiatrists and 3 nurse-scientists for absolute and dimensional scores. The Suicidality Differentiation version 2 (SUICIDI-II) instrument, developed for this study, is used for rating all the cases. Intraclass correlation coefficients for absolute and dimensional scores will be calculated to examine type agreement between raters to examine the usability of the model and the feasibility of the SUICIDI-II instrument.

RESULTS

We consider the model tentatively valid if the intraclass correlation coefficients are ≥0.70. Subsequently, if the model turns out to be valid, we plan to rate 75 other cases in a follow-up study, according to a similar or adjusted procedure. Study results are expected to be published by the end of 2023.

CONCLUSIONS

The theoretical roots of the differentiation model stem from classic and contemporary theoretical models of suicidality and from our clinical practice experiences with suicidal behaviors. We believe that this model can be used to adjust the diagnosis, management, treatment, and research of suicidality, in addition to distinguishing different dynamics between practitioners and patients with suicidality and their families.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45438.

Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer!

BACKGROUND

UK cancer survival rates are much lower compared with other high-income countries. In primary care, there are opportunities for GPs and other healthcare professionals to act more quickly in response to presented symptoms that might represent cancer. ThinkCancer! is a complex behaviour change intervention aimed at primary care practice teams to improve the timely diagnosis of cancer.

AIM

To explore the costs of delivering the ThinkCancer! intervention to expedite cancer diagnosis in primary care.

DESIGN & SETTING

Feasibility economic analysis using a micro-costing approach, which was undertaken in 19 general practices in Wales, UK.

METHOD

From an NHS perspective, micro-costing methodology was used to determine whether it was feasible to gather sufficient economic data to cost the ThinkCancer!

INTERVENTION

Owing to the COVID-19 pandemic, ThinkCancer! was mainly delivered remotely online in a digital format. Budget impact analysis (BIA) and sensitivity analysis were conducted to explore the costs of face-to-face delivery of the ThinkCancer! intervention as intended pre-COVID-19.

RESULTS

The total costs of delivering the ThinkCancer! intervention across 19 general practices in Wales was £25 030, with an average cost per practice of £1317 (standard deviation [SD]: 578.2). Findings from the BIA indicated a total cost of £34 630 for face-to-face delivery.

CONCLUSION

Data collection methods were successful in gathering sufficient health economics data to cost the ThinkCancer!

INTERVENTION

Results of this feasibility study will be used to inform a future definitive economic evaluation alongside a pragmatic randomised controlled trial (RCT).

Calculation of Costs Related to Death by Suicide in Finland

There are relatively few calculations of the costs related to suicides. The aim was to produce a monetary estimate of the costs incurred as a result of suicides. The costs were divided into three categories: (1) loss of labor input, (2) costs directly following a suicide, and (3) costs associated with family members. In our two sample cases, the costs related to suicides were from EUR 309,020 to EUR 456,279. By putting the monetary costs of suicide prevention intervention and the calculation of costs related to a death by suicide side by side, this study may help when allocating funding for effective intervention.

Wirken Online-Peer-Suizidpräventionsprogramme?

Zusammenfassung. Theoretischer Hintergrund. Suizid ist weltweit die zweithäufigste Todesursache bei jungen Menschen. Es scheint sinnvoll, speziell auf diese Zielgruppe zugeschnittene Angebote anzubieten. Fragestellung. Ziel dieser Untersuchung ist, den von den Nutzenden wahrgenommenen Beratungserfolg eines Online-Peer-Suizidpräventionsprogramms zu ermitteln und zu prüfen, welche Merkmale mit dem Beratungserfolg zusammenhängen. Methode. Daten eines Online-Fragebogens wurden ausgewertet ( N = 318). Ergebnisse. Bei zwei Drittel der Befragten verminderte sich die Suizidalität. Wichtige Variablen zur Vorhersage der Veränderung der Suizidalität waren der Eindruck der Ratsuchenden, dass die Peers die persönlichen Anliegen verstehen und die Anregung zu einer Verhaltensänderung. Das Peerverhalten trug signifikant zur Vorhersage der subjektiven Nützlichkeit und der allgemeinen Situation bei. Schlussfolgerungen. Die Studie liefert positive Ergebnisse hinsichtlich der Evaluierung der Online-Suizidpräventions-Beratung. Da das Verstanden fühlen und das Peerverhalten im Zusammenhang mit dem Beratungserfolg steht, könnte der Peer-Ansatz und die damit einhergehende positive Beziehungserfahrung wichtig sein.

Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Brief Psychological Randomized Controlled Trial

OBJECTIVES

Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained a reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness.

METHODS

Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life-years (QALYs) was measured using the EQ-5D with 3 levels instrument at baseline, 3 months, and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US$ and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties and sensitivity analysis to examine the impact of hospitalization costs.

RESULTS

A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 (95% confidence interval [CI] 0.00-0.08) more QALYs 6 months after enrolment. The mean cost per participant in the intervention arm was $1001 (95% CI 968-1031), resulting in an incremental cost of the intervention of $640 (95% CI 595-679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was $16 254 (95% CI 7116-99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between $20 000 and $30 000. Cost-effectiveness results remained robust to sensitivity analyses.

CONCLUSIONS

C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.

Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Problem-Solving Training Randomized Controlled Trial

OBJECTIVES

Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained the reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness.

METHODS

Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life years (QALYs) was measured using the Euro Qol-5D-3L instrument at baseline and at 3 months and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US dollars and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties, and sensitivity analysis to examine the impact of hospitalization costs.

RESULTS

A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 more QALYs (95% confidence interval [CI] 0.00-0.08) 6 months after enrolment. The mean cost per participant in the intervention arm was US $1001 (95% CI 968-1031), resulting in an incremental cost of the intervention of US $640 (95% CI 595-679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was US $16 254 (95% CI 7116-99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between US $20 000 and US $30 000. Cost-effectiveness results remained robust to sensitivity analyses.

CONCLUSIONS

C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.

Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions

Abstract. Background: Death following self-harm constitutes a major global public health challenge and there is an urgent need for governments to implement cost-effective, national suicide prevention strategies. Aim: To conduct a systematic review and quality appraisal of the economic evaluations of interventions aimed at preventing suicidal behavior. Method: A systematic literature search was performed in several literature databases to identify relevant articles published from 2003 to 2016. Drummond's 10-item appraisal tool was used to assess the methodological quality of the included studies. Results: In total, 25 documents encompassing 30 economic evaluations were included in the review. Of the identified evaluations, 10 studies were found to be of poor quality, 14 were of average quality, and six studies were considered of good quality. The majority of evaluations found the interventions to be cost-effective. Limitations: Several limitations were identified and discussed in the article. Conclusion: A notable few economic evaluations were identified. The studies were diverse, primarily set in high-income countries, and often based on modeling, emphasizing the need for more primary research into the topic. The discussion of suicide and self-harm prevention should be as nuanced as possible, including health economics along with cultural, social, and political aspects.

Development of a 2-h suicide prevention program for medical staff including nurses and medical residents: A two-center pilot trial

BACKGROUND

Suicide is a crucial global health concern and effective suicide prevention has long been warranted. Mental illness, especially depression is the highest risk factor of suicide. Suicidal risk is increased in people not only with mental illness but also with physical illnesses, thus medical staff caring for physically-ill patients are also required to manage people with suicidal risk. In the present study, we evaluated our newly developed suicide intervention program among medical staff.

METHODS

We developed a 2-h suicide intervention program for medical staff, based on the Mental Health First Aid (MHFA), which had originally been developed for the general population. We conducted this program for 74 medical staff members from 2 hospitals. Changes in knowledge, perceived skills, and confidence in early intervention of depression and suicide-prevention were evaluated using self-reported questionnaires at 3 points; pre-program, immediately after the program, and 1 month after program.

RESULTS

This suicide prevention program had significant effects on improving perceived skills and confidence especially among nurses and medical residents. These significant effects lasted even 1 month after the program.

LIMITATIONS

Design was a single-arm study with relatively small sample size and short-term follow up.

CONCLUSIONS

The present study suggests that the major target of this effective program is nurses and medical residents. Future research is required to validate the effects of the program with control groups, and also to assess long-term effectiveness and actual reduction in suicide rates.

Use of New Technologies in the Prevention of Suicide in Europe: An Exploratory Study

BACKGROUND

New technologies are an integral component of today's society and can complement existing suicide prevention programs. Here, we analyzed the use of new technologies in the prevention of suicide in 8 different European countries.

OBJECTIVE

The aim of this paper was to assess the opinions of professionals in incorporating such resources into the design of a suicide prevention program for the region of Zamora in Spain. This investigation, encompassed within the European project entitled European Regions Enforcing Actions against Suicide (EUREGENAS), includes 11 regions from 8 different countries and attempts to advance the field of suicide prevention in Europe.

METHODS

Using a specifically designed questionnaire, we assessed the opinions of 3 different groups of stakeholders regarding the use, frequency of use, facilitators, content, and format of new technologies for the prevention of suicide. The stakeholders were comprised of policy and public management professionals, professionals working in the area of mental health, and professionals related to the social area and non-governmental organizations (NGOs). A total of 416 participants were recruited in 11 regions from 8 different European countries.

RESULTS

The utility of the new technologies was valued positively in all 8 countries, despite these resources being seldom used in those countries. In all the countries, the factors that contributed most to facilitating the use of new technologies were accessibility and free of charge. Regarding the format of new technologies, the most widely preferred formats for use as a tool for the prevention of suicide were websites and email. The availability of information about signs of alarm and risk factors was the most relevant content for the prevention of suicide through the use of new technologies. The presence of a reference mental health professional (MHP) was also considered to be a key aspect. The countries differed in the evaluations given to the different formats suggesting that the cultural characteristics of the country should be taken into account.

CONCLUSIONS

New technologies are much appreciated resources; however they are not often underused in the field of suicide prevention. The results of this exploratory study show that new technologies are indeed useful resources and should be incorporated into suicide prevention programs.

The Impact of Knowledge of Suicide Prevention and Work Experience among Clinical Staff on Attitudes towards Working with Suicidal Patients and Suicide Prevention

Suicide-preventive training has shown to influence attitudes. This study aimed at investigating what impact other factors than knowledge might have on attitudes towards work with suicidal patients and suicide prevention. In 2007, 500 health-care staff working in a psychiatric clinic in Stockholm received a questionnaire with items concerning work with suicidal patients to which 358 (71.6%) responded. A set of attitude items were tested using structural equation modelling (LISREL). Three models were found to be satisfactory valid and reliable: Job clarity, Job confidence and Attitudes towards prevention. These were then used in regression analyses as dependent variables with predictors such as experience of work with suicidal patients, perceived sufficient training,age and gender. Perceived sufficient training was consistently the most important predictor for all three attitude concepts (p < 0.01, β = 0.559 for Job clarity; p < 0.01, β = 0.53 for Job confidence; p < 0.01, β = 0.191 for Attitudes towards prevention). Age was another significant predictor for Job clarity (p < 0.05, β = 0.134), as was experience of patient suicide for Job confidence (p < 0.05, β = 0.137). It is concluded that providing suicide preventive education is likely to improve attitudes towards the prevention of suicide, clarity and confidence regarding their role in the care for suicidal patients. These improvements may contribute to the prevention of suicide in health care settings.