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Haw R, Marsden M, Hartley S, Turpin C, Taylor PJ. A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series. Clin Psychol Psychother 2024; 31:e2976. [PMID: 38757462 DOI: 10.1002/cpp.2976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/21/2024] [Accepted: 03/15/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y). METHODS A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure. RESULTS The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low. CONCLUSIONS The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.
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Affiliation(s)
- R Haw
- Manchester Academic Health Sciences Centre, Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
- Specialist Perinatal Service, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - M Marsden
- Manchester Academic Health Sciences Centre, Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
- Aquarius Ward, South West London and St. George's Mental Health NHS Trust, London, UK
| | - S Hartley
- Manchester Academic Health Sciences Centre, Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
- Tameside and Glossop CAMHS, Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - C Turpin
- Specialist Psychotherapy Service, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - P J Taylor
- Manchester Academic Health Sciences Centre, Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
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Haw R, Hartley S, Trelfa S, Taylor PJ. A systematic review and meta-ethnography to explore people's experiences of psychotherapy for self-harm. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2023; 62:392-410. [PMID: 36883196 DOI: 10.1111/bjc.12414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Self-harm is a major public health concern. Lifetime prevalence is high, and rates of self-harm are rising; however, available interventions do not benefit everyone, and engagement with therapy can be low. Qualitative accounts allow for a greater understanding of what is helpful to individuals. This study aimed to synthesize the experiences of interventions for self-harm, from participants who have participated in these themselves. METHODS Participants had self-harmed at least once and undergone an individual psychotherapeutic intervention for self-harm. Papers not written or translated to the English language were excluded. Four databases (Medline, CINAHL, Web of Science and PsycINFO) were systematically searched and each paper was assessed using the CASP quality appraisal tool. A meta-ethnographic approach to the synthesis was taken. RESULTS Ten studies encompassing 104 participants were included. Four overarching themes were developed and the importance of recognizing the person beyond the self-harm emerged through a line of argument synthesis. Building a trusted, therapeutic relationship founded on patience and without judgement was essential for the perceived success of therapy, which was unique to each person and often went beyond reducing self-harming behaviours. LIMITATIONS Papers included in the study showed a lack of diversity with regard to ethnicity and gender. CONCLUSIONS The findings illustrate the importance of the therapeutic alliance when working with self-harm. Clinical implications of this paper include the importance of utilizing key therapeutic competencies which should be considered fundamental to change within psychotherapeutic interventions for self-harm, with the uniqueness of each patient recognized throughout.
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Affiliation(s)
- Rebecca Haw
- Division of Psychology and Mental Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Samantha Hartley
- Division of Psychology and Mental Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.,Bradford District Care Trust, Shipley, UK
| | | | - Peter J Taylor
- Division of Psychology and Mental Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Uribe FAR, de Oliveira SB, Junior AG, da Silva Pedroso J. Association between the dispositional optimism and depression in young people: a systematic review and meta-analysis. PSICOLOGIA-REFLEXAO E CRITICA 2021; 34:37. [PMID: 34842988 PMCID: PMC8630239 DOI: 10.1186/s41155-021-00202-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
The objective of this study was to perform a meta-analysis of publications that reported the association between dispositional optimism and depression during youth, analyzing if the strength of this relationship varied according to potential factors. Systematic searches were carried out in APA PsycNet, Virtual Health Library, Embase, Web of Science, PubMed Central, and Scopus to collect English, Portuguese, or Spanish studies from 2009 onwards. Two reviewers selected the eligible articles, assessed the quality of each study, and extracted the data. For the synthesis of the results, a meta-analytic approach was used. We identified 4077 publications in the initial searches and 22 in the supplementary searches, from which 31 studies remained for analysis once the eligibility criteria were applied. The results showed a statistically significant negative association between dispositional optimism and depression in the young population, age being a factor that modifies the effect measure between these variables. This meta-analysis provides a consistent and robust synthesis on the interaction effect between dispositional optimism and depression in the young population. Based on these findings, early clinical admissions may effectively improve optimistic tendencies in young people, which could help them prevent depressive symptoms or episodes.
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Affiliation(s)
- Fabio Alexis Rincón Uribe
- Programa de Pós-Graduação Psicologia, Universidade Federal do Pará, Rua Augusto Corrêa, 01-Guamá, Belém, Pará 66075-110 Brazil
| | | | - Amauri Gouveia Junior
- Programa de Pós-Graduação em Teoria e Pesquisa do Comportamento, Universidade Federal do Pará, Belém, Brazil
| | - Janari da Silva Pedroso
- Programa de Pós-Graduação em Teoria e Pesquisa do Comportamento, Universidade Federal do Pará, Belém, Brazil
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Rosebrock HY, Batterham PJ, Chen NA, McGillivray L, Rheinberger D, Torok MH, Shand FL. Nonwillingness to Return to the Emergency Department and Nonattendance of Follow-Up Care Arrangements Following an Initial Suicide-Related Presentation. CRISIS 2021; 43:442-451. [PMID: 34547919 DOI: 10.1027/0227-5910/a000812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background: For people experiencing a suicidal crisis the emergency department (ED) is often the only option to find help. Aims: The aims of this study were (a) to identify predictors of patients' nonwillingness to return to the ED for help with a future suicidal crisis, and (b) whether nonwillingness to return was associated with follow-up appointment nonattendance. Method: This study utilized baseline data from the RESTORE online survey, and included 911 participants who had presented to an ED for suicidal crisis in the past 18 months, across participating local health districts in the Australian Capital Territory and New South Wales. Results: Patients who reported a more negative ED experience and longer triage wait times were less willing to return. Those who were less willing to return were also less likely to attend their follow-up appointment. Limitations: Due to the cross-sectional study design, causal inferences are not possible. Additionally, the self-report measures used are susceptible to recall bias. Conclusion: Patients' experience of service at EDs is a key indicator to drive improvement of patient outcomes for individuals experiencing a suicidal crisis.
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Affiliation(s)
- Hannah Y Rosebrock
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Philip J Batterham
- Centre for Mental Health Research, Australian National University, Canberra, ACT, Australia
| | - Nicola A Chen
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Lauren McGillivray
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Demee Rheinberger
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Michelle H Torok
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Fiona L Shand
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
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Woodford R, Spittal MJ, Milner A, McGill K, Kapur N, Pirkis J, Mitchell A, Carter G. Accuracy of Clinician Predictions of Future Self-Harm: A Systematic Review and Meta-Analysis of Predictive Studies. Suicide Life Threat Behav 2019; 49:23-40. [PMID: 28972271 DOI: 10.1111/sltb.12395] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022]
Abstract
Assessment of a patient after hospital-treated self-harm or psychiatric hospitalization often includes a risk assessment, resulting in a classification of high risk versus low risk for a future episode of self-harm. Through systematic review and a series of meta-analyses looking at unassisted clinician risk classification (eight studies; N = 22,499), we found pooled estimates for sensitivity 0.31 (95% CI: 0.18-0.50), specificity 0.85 (0.75-0.92), positive predictive value 0.22 (0.21-0.23), and negative predictive value 0.89 (0.86-0.92). Clinician classification was too inaccurate to be clinically useful. After-care should therefore be allocated on the basis of a needs rather than risk assessment.
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Affiliation(s)
- Rachel Woodford
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, NSW, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Allison Milner
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Katie McGill
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, NSW, Australia.,Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
| | - Navneet Kapur
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - Jane Pirkis
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Alex Mitchell
- Cancer Studies & Molecular Medicine, University of Leicester, Leicester, UK
| | - Gregory Carter
- Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
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Sayal K, Roe J, Ball H, Atha C, Kaylor-Hughes C, Guo B, Townsend E, Morriss R. Feasibility of a randomised controlled trial of remotely delivered problem-solving cognitive behaviour therapy versus usual care for young people with depression and repeat self-harm: lessons learnt (e-DASH). BMC Psychiatry 2019; 19:42. [PMID: 30678674 PMCID: PMC6346566 DOI: 10.1186/s12888-018-2005-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-harm and depression are strong risk factors for repeat self-harm and suicide. We aimed to investigate the feasibility of a randomised controlled trial (RCT) of remotely delivered problem-solving cognitive behaviour therapy (PSCBT) plus treatment as usual (TAU) versus TAU in young people with repeat self-harm and depression. METHODS Single-blind multi-centre RCT with an internal pilot, pre-set stop-go criteria and qualitative semi-structured interviews. Eligible participants (aged 16-30 years) were recruited from 9 adult or child and adolescent self-harm and crisis services; had ≥ 2 lifetime self-harm episodes, one in the preceding 96 h; and Beck Depression Inventory-II (BDI-II) score ≥ 17. Participants were randomised (1:1) to either TAU or TAU and 10-12 sessions of PSCBT delivered by mobile phone or video-calling. RESULTS Twenty-two participants were recruited (11 in each arm), 10 (46%) completed follow-up at 6 months, 9 (82%) started the PSCBT and 4 (36%) completed it. The study did not meet three of its four stop-go criteria, reflecting considerable barriers to recruitment and retention. Participants had severe depression symptoms: with mean BDI-II 38.9 in the PSCBT and 37.2 in TAU groups, respectively. Three (14%) unblindings occurred for immediate safety concerns. Barriers to recruitment and retention included lack of agency for participants, severity of depression, recency of crisis with burden for participants and clinicians who diagnosed depression according to pervasiveness. CONCLUSIONS RCTs of PSCBT for young people with depression and self-harm are not feasible using recruitment through mental health services that conduct assessments following self-harm presentations. Clinician assessment following self-harm presentation mainly identifies those with severe rather than mild-moderate depression. TRIAL REGISTRATION ClinicalTrials.gov ( NCT02377011 ); Date of registration: March 3rd 2015. Retrospectively registered: within 21 days of recruitment of the first participant.
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Affiliation(s)
- Kapil Sayal
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK. .,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK. .,Division of Psychiatry & Applied Psychology, School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - James Roe
- 0000 0004 1936 8868grid.4563.4Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK ,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK
| | - Harriet Ball
- 0000 0004 1936 8868grid.4563.4Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK ,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK
| | - Christopher Atha
- 0000 0004 1936 8868grid.4563.4Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK ,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK
| | - Catherine Kaylor-Hughes
- 0000 0004 1936 8868grid.4563.4Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK ,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK
| | - Boliang Guo
- 0000 0004 1936 8868grid.4563.4Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK ,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK
| | - Ellen Townsend
- Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK ,0000 0004 1936 8868grid.4563.4School of Psychology, University of Nottingham, Nottingham, UK
| | - Richard Morriss
- 0000 0004 1936 8868grid.4563.4Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK ,Centre for Mood Disorders, Institute of Mental Health, Nottingham, UK
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Bartoli C, Berland-Benhaim C, Tuchtan-Torrents L, Kintz P, Leonetti G, Pelissier-Alicot AL. Suicide by Medication Overdose in Prison: A Study of Three Cases. J Forensic Sci 2017; 63:1316-1320. [DOI: 10.1111/1556-4029.13671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Christophe Bartoli
- CNRS; EFS; ADES; Aix Marseille Univ; Marseille France
- Service de Médecine Légale; APHM, CHU Timone; Marseille France
| | | | - Lucile Tuchtan-Torrents
- CNRS; EFS; ADES; Aix Marseille Univ; Marseille France
- Service de Médecine Légale; APHM, CHU Timone; Marseille France
| | - Pascal Kintz
- X-Pertise Consulting; 84 route de Saverne 67205 Oberhausbergen France
- IML; Strasbourg France
| | - Georges Leonetti
- CNRS; EFS; ADES; Aix Marseille Univ; Marseille France
- Service de Médecine Légale; APHM, CHU Timone; Marseille France
| | - Anne-Laure Pelissier-Alicot
- Service de Médecine Légale; APHM, CHU Timone; Marseille France
- INSERM; INMED; 1 Aix Marseille Univ, CNRS, EFS, ADES; Marseille France
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Surgenor PWG, Meehan V, Moore A. Early attrition among suicidal clients. BRITISH JOURNAL OF GUIDANCE & COUNSELLING 2016. [DOI: 10.1080/03069885.2015.1134766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bastiampillai T, Jones GM, Furber G, Moreau M, Healey D, Watson J, Battersby M. The IAPT@Flinders Service: adapting the Improving Access to Psychological Therapies model to the emergency department setting in Australia. Australas Psychiatry 2014; 22:277-280. [PMID: 24699191 DOI: 10.1177/1039856214530016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the implementation of an Improving Access to Psychological Therapies (IAPT) service at Flinders Medical Centre emergency department (IAPT@Flinders). IAPT, a population-based model of guided self-help for anxiety and depression delivered mainly by phone, was rolled-out nationally in the UK in 2010. There is a growing body of evidence demonstrating its clinical effectiveness and efficiency that can improve treatment adherence, reduce stigma, remove appointment attendance barriers and improve access for hard-to-reach populations. CONCLUSIONS IAPT@Flinders was the test site for the first IAPT in Australia and also the first IAPT service that was integrated with an emergency department (ED). IAPT@Flinders offers rapid access, low-intensity cognitive behavioural therapy, social prescribing and signposting to clients with adjustment disorders, anxiety and/or depressive symptoms. Successful implementation within an Australian crisis setting has demonstrated that many IAPT structures and protocols are applicable to ED settings and the model can be implemented with fidelity. Adaption required consideration of positioning of the service within the Australian mental health framework; staff qualifications; the referral pathways; and exclusion criteria. It is recommended additional test sites and larger scale trials are conducted to provide further evidence of the applicability of large-scale adoption of the UK IAPT model into Australian ED settings.
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Affiliation(s)
- Tarun Bastiampillai
- Tarun Bastiampillai, Acting Regional Clinical Director Mental Health, Clinical Director Inner Southern Mental Health, Southern Adelaide Local Health Network, Adelaide, SA, and; Associate Professor Mental Health Systems Research, Flinders University, Adelaide, SA, Australia
| | - Gabrielle M Jones
- Research Officer School of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Gareth Furber
- Post Doctoral Research Fellow School of Population Health, Health Economics and Social Policy Group, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Michele Moreau
- Service Design Consultant, Preventing Harm Initiative for Improving Access to Psychological Therapies, Southern Adelaide Local Health Network, Adelaide, SA, and; Southern Mental Health, Flinders Medical Centre, Adelaide, SA, Australia
| | - David Healey
- Safety, Quality & Clinical Risk Coordinator, Mental Health Directorate, Southern Adelaide Local Health Network, Adelaide, SA, and; Clinical Supervisor, New Access, Flinders University, Adelaide, SA, Australia
| | - Julianne Watson
- Team Leader/Clinical Supervisor, Improving Access to Psychological Therapies, Southern Adelaide Local Health Network, Adelaide, SA, and; Training Co-ordinator/Clinical Supervisor, New Access, Flinders University, Adelaide, SA, Australia
| | - Malcolm Battersby
- Professor and Head of Psychiatry, Faculty of Medicine, Nursing and Health Sciences and Director of Flinders Human Behaviour & Health Research Unit (FHBHRU), Flinders University, Adelaide, SA, Australia
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Murphy E, Kapur N, Webb R, Cooper J. Risk assessment following self-harm: comparison of mental health nurses and psychiatrists. J Adv Nurs 2010; 67:127-39. [PMID: 20969616 DOI: 10.1111/j.1365-2648.2010.05484.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper is a report of a study conducted to compare risk assessments by psychiatrists and mental health nurses following an episode of self-harm. BACKGROUND Self-harm assessments by nurses and psychiatrists are similar in terms of overall content, but risk assessment may vary by professional discipline. To our knowledge previous researchers have not compared the positive predictive value of risk assessments by nurses and psychiatrists, the factors that inform those assessments in clinical practice or the management of people assessed as being at high risk. METHODS We conducted a prospective cohort study (2002-2006) of 3491 individuals presenting with self-harm to three hospitals in the North West of England. A standard assessment form including detailed demographic and clinical data was completed by the assessing psychiatrist or nurse. RESULTS The positive predictive value of risk assessments for self-harm repetition was 25% (95% CI: 20-31) among nurses and 23% (95% CI: 13-37) among psychiatrists. There was strong agreement on factors associated with high risk assessment by both professions. Following assessment of high risk, psychiatrists were much more likely than nurses to admit people for inpatient treatment (RR=5.6, 95% CI: 3.2-9.7). This difference remained highly statistically significant after controlling for case-mix differences (RR=4.3, 95% CI: 2.4-7.7). CONCLUSION Our finding that risk assessments were comparable by profession supports the provision of nurse-led assessment services. However, inpatient admission was influenced largely by assessor type rather than patient characteristics. This has important implications for equity of care and may reflect professional differences in referral practices.
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Affiliation(s)
- Elizabeth Murphy
- Centre for Suicide Prevention, Manchester Academic Health Science Centre, The University of Manchester, UK.
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Abstract
Suicide attempters presenting for hospital treatment is a major public health challenge in most countries. Their tendency of dropping out of treatments and their high risk of repeat suicidal behavior call for systematic assessments, in-hospital management, treatment engagement and follow-up treatments after discharge from hospital. However, hospital services provided for suicide attempters and follow-up care may have highly variable quality and favorable care programs may deteriorate over time for various reasons. Effective and sustainable treatments and interventions to create cohesive chains of care are needed to release the substantial suicide prevention potential that exist in this population.
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