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Boland LL, Ryan KE, Flynn JM, Fox A, Duren JL. Use of Emergency Mental Health Dispatch Training by a 9-1-1 Medical Dispatcher Assisting a Caller Expressing Suicidal Intent: A Case Report. PREHOSP EMERG CARE 2024:1-4. [PMID: 39230348 DOI: 10.1080/10903127.2024.2399800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/26/2024] [Accepted: 08/26/2024] [Indexed: 09/05/2024]
Abstract
A growing number of individuals with unmet mental health needs in the United States rely on emergency medical services during mental health crises, and 9-1-1 emergency medical dispatchers (EMD) are often a critical lifeline to help. Unfortunately, current industry-standard dispatching protocols and training required for EMD certification largely lack specificity for managing 9-1-1 calls related to mental health emergencies. The purpose of this report is to illustrate the value of additional targeted training for EMDs that enables them to more effectively assist callers struggling with mental illness or suicidal thoughts. We review a 9-1-1 call in which an EMD utilized specific strategies and language learned during a 3-day emergency mental health dispatch (EMHD) training course to assist a middle-aged male who was expressing suicidal intent with a firearm. Key principles and phrasing from the training were used successfully by the EMD to dissuade the caller from self-harm, and he was ultimately safely met by first responders on scene and transported for care. We also share post-call recollections and reactions from the EMD to demonstrate how in addition to reducing risks for callers and their families, EMHD training has the potential to reduce on-scene risks for field responders and may increase confidence and mitigate negative stress responses in EMDs. Emergency medical services systems in the United States should continue to explore enhanced training and protocols to improve care for 9-1-1 callers experiencing mental health crises.
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Affiliation(s)
- Lori L Boland
- Allina Health Emergency Medical Services, St. Paul, Minnesota
- Care Delivery Research, Allina Health, Minneapolis, Minnesota
| | - Kelly E Ryan
- Allina Health Emergency Medical Services, St. Paul, Minnesota
| | | | - Angie Fox
- Allina Health Emergency Medical Services, St. Paul, Minnesota
| | - Joey L Duren
- Allina Health Emergency Medical Services, St. Paul, Minnesota
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Draper J, McKeon RT. The Journey Toward 988: A Historical Perspective on Crisis Hotlines in the United States. Psychiatr Clin North Am 2024; 47:473-490. [PMID: 39122341 DOI: 10.1016/j.psc.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
This article reviews the historical trajectory of crisis hotlines in the United States from their 1960's inception as 24/7 alternatives to traditional mental health services to becoming "the front door" of the 988 Suicide and Crisis Lifeline in 2022. The Substance Abuse and Mental Health Services Administration's (SAMHSA's) 2001 effort to network, certify, and evaluate crisis hotlines laid the foundation for demonstrating the efficacy of crisis hotlines and their ability to reduce distress and suicidality in people accessing these services. SAMHSA-funded evaluations and the collective leadership of the National Suicide Prevention Lifeline network established evidence-based standards, policies, and practices.
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Affiliation(s)
- John Draper
- Behavioral Health Link, Inc, 7423 Narrows Avenue, Brooklyn, NY 11209, USA.
| | - Richard T McKeon
- Center for Mental Health Services, SAMHSA, 988 and Behavioral Health Crisis Coordinating Office, 5600 Fishers Ln, Rockville, MD 20852, USA
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Pope LG, Patel A, Watson AC, Compton MT. Making Decisions About Calling 988 Versus 911: Understanding End-User Views Before the Launch of 988. Psychiatr Serv 2024; 75:646-651. [PMID: 38410036 DOI: 10.1176/appi.ps.20230016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVE The 988 telephone number was implemented in July 2022 as an easily accessible way to reach the National Suicide Prevention Lifeline and has been envisioned as one step in building a more robust crisis care continuum in the United States. This study aimed to describe how various stakeholders anticipated using 988 compared with the most widely known crisis line: 911. METHODS Focus groups (N=15, with 76 total participants) were conducted in three counties in New York State between October and November 2021, before the launch of 988. Five stakeholder groups were included: mental health services consumers, family members of consumers, community members, mental health providers, and crisis call takers. Thematic analysis was used to code and analyze all focus group transcripts. RESULTS Participants anticipated that key uses for 988 would be accessing support during a crisis, obtaining connections to local resources and services, and receiving alternatives to law enforcement response. However, participants continued to articulate uses for 911 during a mental health crisis, especially for situations involving "safety concerns." CONCLUSIONS The broad expectations for 988 suggest that the line must be flexible and responsive to a range of needs and that communities should clearly define what is available through 988. More implementation research is needed to ensure a detailed understanding of those whom 988 is serving, how the line meets callers' needs, and the line's potential for connecting people to needed services.
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Affiliation(s)
- Leah G Pope
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute, New York City (Pope, Patel, Compton); School of Social Work, Wayne State University, Detroit (Watson)
| | - Ashnee Patel
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute, New York City (Pope, Patel, Compton); School of Social Work, Wayne State University, Detroit (Watson)
| | - Amy C Watson
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute, New York City (Pope, Patel, Compton); School of Social Work, Wayne State University, Detroit (Watson)
| | - Michael T Compton
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute, New York City (Pope, Patel, Compton); School of Social Work, Wayne State University, Detroit (Watson)
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Norotte C, Zeltner L, Gross J, Delord M, Richard C, Bembaron MC, Caussanel JM, Herbillon A, Rousseau C, Chiquet C, Ehly C, Pain A, Vadillo F, Morisset L, Roux P, Passerieux C, Lambert Y, Koukabi-Fradelizi M, Younes N, Richard O. Telephone Assessment of Suicidal Risk at Prehospital Emergency Medical Services: A Direct Comparison with Face-to-Face Evaluation at Psychiatric Emergency Service. Arch Suicide Res 2024; 28:979-993. [PMID: 37812246 DOI: 10.1080/13811118.2023.2265432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Assessment of suicidal risk is one of the most challenging tasks faced by health professionals, notably in emergency care. We compared telephone suicide risk assessment at prehospital Emergency Medical Services Dispatch Center (EMS-DC), with subsequent face-to-face evaluation at Psychiatric Emergency Service (PES), using French national Risk-Urgency-Danger standards (RUD). METHOD Data were collected for all suicidal adult patients (N = 80) who were addressed by EMS-DC to PES between December 2018 and August 2019 and benefited from RUD assessment at both services. Suicidal risk was given a score of 1, 2, 3 or 4, in order of severity. RESULTS Mean of the differences between the RUD score at EMS-DC and PES was -0.825 (SD = 1.19), and was found to be significant (p < 0.01). The average time between RUD assessments was 420 min (SD = 448) and was negatively correlated with the difference in the RUD score (r = -0.295, p = 0.008). Associated suicide attempt increased the odds of a decrease in the RUD score (OR = 2.989; 95% CI = 1.141-8.069; p < 0.05). CONCLUSIONS Telephone evaluation of suicidal risk using RUD at EMS-DC yielded moderately higher scores than those obtained by a subsequent face-to face evaluation at PES, with this difference partially explained by the time between assessments, and by clinical and contextual factors.
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O'Connell KL, Hassler M, Moreira N, Barnette B, Gilbert A, Widman C, Law KC. Do Crisis Details Differentiate Suicide-Related 911 Call Outcomes? CRISIS 2024; 45:65-73. [PMID: 37554044 DOI: 10.1027/0227-5910/a000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Background The outcomes of calling 911 for suicide crises remain largely unexplored. Aims To investigate how characteristics of individuals in a suicidal crisis (e.g., age, gender identity, help-seeking source, means, disclosure of historical suicidality, or self-harm) may differentiate outcomes when contacting 911. Method The authors analyzed 1,073 Washington State Police 911 call logs, coding for characteristics and outcome (unknown, monitoring, intervention, adverse outcome). Descriptive and inferential statistics, including multinomial logistic regressions, were used to explore associations. Results When individuals experiencing a suicidal crisis were referred by bystander or associates' observations, there was a greater likelihood of adverse outcome. Self-referral led to a greater likelihood of intervention. Referral from the suicidal individual contacting a known associate led to a greater likelihood of monitoring. Any disclosure of means led to a greater likelihood of intervention or adverse outcomes. Positive disclosure of historical suicidality or self-harm was more likely to result in monitoring. Limitations The dataset was intended for operational use in acute suicidality triage rather than research purposes. Conclusion This study highlights the importance of supporting first responders with research to enhance their triage of people experiencing suicidal crises.
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Affiliation(s)
| | - Molly Hassler
- Clinical Psychology Department, Seattle Pacific University, Seattle, WA, USA
| | - Nicole Moreira
- Clinical Psychology Department, Seattle Pacific University, Seattle, WA, USA
| | - Ben Barnette
- Clinical Psychology Department, Seattle Pacific University, Seattle, WA, USA
| | - Anna Gilbert
- Clinical Psychology Department, Seattle Pacific University, Seattle, WA, USA
| | - Cammy Widman
- Clinical Psychology Department, Seattle Pacific University, Seattle, WA, USA
| | - Keyne C Law
- Clinical Psychology Department, Seattle Pacific University, Seattle, WA, USA
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Soderlund PD, Cheung EH, Cadiz MP, Siddiq H, Yerstein M, Lee S, Wells K, Heilemann MV. Bridging the gap: a qualitative study of providers' perceptions of a partnered crisis follow-up program for suicidal patients post-emergency department discharge. BMC Psychiatry 2023; 23:854. [PMID: 37978360 PMCID: PMC10655296 DOI: 10.1186/s12888-023-05106-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/11/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Effective interventions are needed to address suicide risk following discharge from the hospital emergency department or inpatient setting. Studies that examine follow-up contact methods show promise, but little is known about how follow-up programs are implemented in the real world and who is benefitting. The purpose of this formative evaluation and analysis was to gain insight about the usefulness and value of a partnered suicide prevention follow-up program (academic medical center emergency department partnered with a regional suicide prevention center) from the standpoint of psychiatry resident physicians providing direct care and suicide prevention center crisis counselors making follow-up outreach telephone calls to patients. METHODS A qualitative thematic analysis was conducted with focus group data from a convenience sample of psychiatry residents who performed consultations in the emergency department setting and counselors at the suicide prevention center crisis follow-up program. Focus group sessions, using semi-structured question guides, were completed at each participant group's workplace. Grounded theory techniques were used to guide coding and analytic theme development. RESULTS Analyses resulted in four overarching themes: valuing the program's utility and benefit to patients, desiring to understand what happens from emergency department discharge to program follow-up, having uncertainty about which patients would benefit from the program, and brainstorming to improve the referral process. Psychiatry residents appreciated the option of an "active" referral service (one that attempts to actively engage a patient after discharge through outreach), while suicide prevention crisis counselors valued their ability to offer a free and immediate service that had potential for fostering meaningful relationships. Both participant groups desired a better understanding of their partner's program operations, a uniform and smooth referral process, and awareness of who may or may not benefit from program services. CONCLUSION Results revealed the need for improved communication and implementation, such as expanded inter-agency contacts, consistent provider training, more documentation of the requirements and rules, a consistent message about program logistics for patients, and coordination between the program elements.
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Affiliation(s)
- Patricia D Soderlund
- Memory Keepers Medical Discovery Team, University of Minnesota Medical School, 624 East 1St St, Duluth, MN, 20155805, USA.
- Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, National Clinician Scholars Program, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA.
| | - Erick H Cheung
- David Geffen School of Medicine, Department of Psychiatry and Biobehavioral Sciences, University of California, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Resnick Neuropsychiatric Hospital, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Madonna P Cadiz
- Luskin School of Public Affairs, University of California Los Angeles, 337 Charles E Young Dr E, Los Angeles, CA, 90095, USA
| | - Hafifa Siddiq
- Charles R. Drew University College of Nursing, 1731 E. 120th St., Los Angeles, CA, 90059, USA
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA
| | - Maria Yerstein
- Boston University School of Medicine, St. Elizabeth's Medical Center, 736 Cambridge St, Brighton, MA, 02135, USA
| | - Sae Lee
- Didi Hirsch Mental Health Services, 4760 S. Sepulveda Blvd, Culver City, CA. 90230, USA
| | - Kenneth Wells
- David Geffen School of Medicine, Department of Psychiatry and Biobehavioral Sciences, University of California, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Resnick Neuropsychiatric Hospital, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
- Research Center for Health Services and Society, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, Suite 17.369B, Los Angeles, CA, 90024, USA
- David Geffen School of Medicine, National Clinician Scholars Program, Division of General Internal Medicine and Health Services Research, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA
- Department of Mental Health, Veterans Affairs Greater Los Angeles HealthCare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA
| | - MarySue V Heilemann
- School of Nursing, Factor Building, University of California Los Angeles, Box 6919, Los Angeles, CA, 90095, USA
- Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, National Clinician Scholars Program, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA
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Kasal A, Táborská R, Juríková L, Grabenhofer-Eggerth A, Pichler M, Gruber B, Tomášková H, Niederkrotenthaler T. Facilitators and barriers to implementation of suicide prevention interventions: Scoping review. Glob Ment Health (Camb) 2023; 10:e15. [PMID: 37854412 PMCID: PMC10579684 DOI: 10.1017/gmh.2023.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/12/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
We know that suicide is preventable, yet hundreds of thousands of people still die due to suicide every year. Many interventions were proven to be effective, and dozens of others showed promising results. However, translating these interventions into new settings brings several challenges. One of the crucial obstacles to success is not anticipating possible barriers to implementation nor enhancing possible benefits of factors facilitating the implementation. While we witnessed great support for suicide prevention activities globally in the past years, implementation barriers and facilitating factors are yet to be comprehensively mapped to help implementation activities worldwide. This scoping review maps current knowledge on facilitators and barriers to the implementation of suicide prevention interventions while using the Consolidated Framework for Implementation Research (CFIR) for classification. We included 64 studies. Barriers and facilitators were most commonly identified in the outer setting CFIR domain, namely in the sub-domain of patient needs and resources, which refers to the way in which these needs and resources are reflected by the reviewed interventions. The second most saturated CFIR domain for facilitators was intervention characteristics, where relative advantage, adaptability and cost of intervention sub-domains were equally represented. These sub-domains refer mostly to how the intervention is perceived by key stakeholders, to what extent it can be tailored to the implementation context and how much it costs. While intervention characteristics domain was the second most common also for barriers, the complexity sub-domain referring to high perceived difficulty of implementation was the most frequently represented. With reference to the results, we recommend adapting interventions to the needs of the target groups. Furthermore, carefully selecting the intervention to suit the target context concerning their adaptability, costs and complexity is vital for a successful implementation. Further implications for practice and research are discussed.
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Affiliation(s)
- Alexandr Kasal
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
- Faculty of Social Sciences, Charles University, Prague, Czech Republic
| | - Roksana Táborská
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
| | - Laura Juríková
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
- Department of Psychology, Faculty of Arts, Charles University, Prague, Czech Republic
| | | | - Michaela Pichler
- Department of Psychosocial Health, Gesundheit Österreich GmbH, Wien, Austria
| | - Beate Gruber
- Department of Psychosocial Health, Gesundheit Österreich GmbH, Wien, Austria
| | - Hana Tomášková
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
- Department of Psychology, Faculty of Arts, Charles University, Prague, Czech Republic
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Development of Internet suicide message identification and the Monitoring-Tracking-Rescuing model in Taiwan. J Affect Disord 2023; 320:37-41. [PMID: 36162682 DOI: 10.1016/j.jad.2022.09.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 09/09/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Suicide messages can be transmitted infinitely online; the Internet is influential in suicide prevention. Identifying suicide risks online via artificial technological advances may help predict suicide. METHODS We built a classifier that detects open messages containing suicidal ideation or behavior-related words in social media via text mining methods and developed the Monitoring-Tracking-Rescuing model, which links data monitoring and tracking to high-risk suicide rescues. Natural language processing (NLP) techniques such as Long Short-Term Memory and Bidirectional Encoder Representations from Transformers were applied to online posts of common social media sites in Taiwan. This model uses a two-step high-risk identification procedure: an automatic prediction process using NLP to classify suicide-risk levels, followed by professional validation by a senior psychiatrist and a nursing faculty specialized in suicidology. RESULTS From a dataset containing 404 high-risk and 2226 no- or low-risk articles, the sensitivity and specificity of our model reached 80 %. LIMITATIONS The model is limited to data platforms that can be "crawled" and excludes suicide-risk content from graphics, video and audio files. Additionally, machine learning does not provide the best recognition rate from complex online messages. Keywords for high-risk suicide in long articles are difficult to interpret using this model. Finally, the model lacks keywords for suicide-protective factors. CONCLUSIONS Artificial intelligence techniques may help detect and monitor high-risk suicide posts and inform mental health professionals of these posts. Periodic tracking plus manual validation to determine risk levels are recommended to enhance the reliability and effectiveness of Internet suicide-prevention tasks.
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Matthews S, Cantor JH, Brooks Holliday S, Eberhart NK, Breslau J, Bialas A, McBain RK. Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021). Psychiatr Serv 2022; 74:513-522. [PMID: 36254453 DOI: 10.1176/appi.ps.20220128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations. METHODS A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria. RESULTS Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding. CONCLUSIONS Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.
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Affiliation(s)
- Samantha Matthews
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
| | - Jonathan H Cantor
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
| | - Stephanie Brooks Holliday
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
| | - Nicole K Eberhart
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
| | - Joshua Breslau
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
| | - Armenda Bialas
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
| | - Ryan K McBain
- RAND Corporation, Santa Monica, California (Matthews, Cantor, Brooks Holliday, Eberhart), Pittsburgh (Breslau, Bialas), and Washington, D.C. (McBain)
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Gould MS, Pisani A, Gallo C, Ertefaie A, Harrington D, Kelberman C, Green S. Crisis text-line interventions: Evaluation of texters' perceptions of effectiveness. Suicide Life Threat Behav 2022; 52:583-595. [PMID: 35599358 PMCID: PMC9322288 DOI: 10.1111/sltb.12873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Crisis Text Line (CTL), the largest provider of text-based crisis intervention services in the U.S., has answered nearly 7 million conversations since its inception in 2013. The study's objective was to assess texter's perceptions of the effectiveness of CTL crisis interventions. METHOD Survey data completed by 85,877 texters linked to volunteer crisis counselor (CC) reports from October 12, 2017, to October 11, 2018 were analyzed. The relationship of several effectiveness measures with texters' demographic and psychosocial characteristics, frequency of CTL usage, and texters' perceptions of engagement with their CCs was examined using a series of logistic regression analyses. RESULTS By the end of the text-based conversation, nearly 90% of suicidal texters reported that the conversation was helpful, and nearly half reported being less suicidal. CONCLUSIONS Our study offers evidence for CTL's perceived effectiveness. These findings are of critical importance in light of the launch of a nationwide three-digit number (988) for suicide prevention and mental health crisis supports in the U.S., which will include texting.
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Affiliation(s)
- Madelyn S. Gould
- Department of PsychiatryColumbia UniversityNew YorkNew YorkUSA
- Department of EpidemiologyColumbia UniversityNew YorkNew YorkUSA
| | - Anthony Pisani
- Departments of Psychiatry and PediatricsCenter for the Study and Prevention of SuicideUniversity of Rochester MedicalRochesterNew YorkUSA
| | - Carlos Gallo
- Department of Psychiatry and Behavioral ScienceNorthwestern UniversityChicagoIllinoisUSA
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational BiologyUniversity of RochesterRochesterNew YorkUSA
| | - Donald Harrington
- Department of Biostatistics and Computational BiologyUniversity of RochesterRochesterNew YorkUSA
| | - Caroline Kelberman
- Departments of Psychiatry and PediatricsCenter for the Study and Prevention of SuicideUniversity of Rochester MedicalRochesterNew YorkUSA
| | - Shannon Green
- Data and Research Team, Crisis Text LineNew YorkNew YorkUSA
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Gould MS, Lake AM, Kleinman M, Galfalvy H, McKeon R. Third-party callers to the national suicide prevention lifeline: Seeking assistance on behalf of people at imminent risk of suicide. Suicide Life Threat Behav 2022; 52:37-48. [PMID: 34032311 PMCID: PMC9292340 DOI: 10.1111/sltb.12769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assist suicidal individuals, people in their social network are often directed to the National Suicide Prevention Lifeline (Lifeline). The study's objective was to provide information on third-party calls made out of concern for another person. METHOD Reports on 172 third-party calls concerning individuals deemed to be at imminent suicide risk were completed by 30 crisis counselors at six Lifeline crisis centers. RESULTS Third-party callers were most likely to be calling about a family member or friend and were significantly more likely than persons at risk to be female and middle-aged or older. Counselors were able to collect information about suicide risk, and counselors and third-parties were nearly always able to identify at least one intervention to aid the person at risk. Emergency services were contacted on 58.1 percent of the calls, which represents a somewhat higher rate of emergency services involvement than previously reported on imminent risk calls placed by the person at risk. Characteristics of third-parties and persons-at-risk each predicted emergency service involvement, but counselor characteristics did not. Non-emergency interventions were implemented on 68.6 percent of calls. CONCLUSIONS Individuals calling the Lifeline when they are worried about someone are provided a range of interventions which can supplement, and at times replace, calling 911.
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Affiliation(s)
- Madelyn S. Gould
- Division of Child and Adolescent PsychiatryCollege of Physicians & SurgeonsColumbia UniversityNew YorkNYUSA,Department of EpidemiologySchool of Public HealthColumbia UniversityNew YorkNYUSA,New York State Psychiatric InstituteNew YorkNYUSA
| | - Alison M. Lake
- Division of Child and Adolescent PsychiatryNew York State Psychiatric InstituteNew YorkNYUSA
| | - Marjorie Kleinman
- Division of Child and Adolescent PsychiatryNew York State Psychiatric InstituteNew YorkNYUSA
| | - Hanga Galfalvy
- Department of PsychiatryCollege of Physicians & SurgeonsColumbia UniversityNew YorkNYUSA,Department of BiostatisticsSchool of Public HealthColumbia UniversityNew YorkNYUSA
| | - Richard McKeon
- Division of Prevention, Traumatic Stress, and Special Programs in the Center for Mental Health Services (CMHS)Substance Abuse and Mental Health Services AdministrationRockvilleMDUSA
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Gould MS, Chowdhury S, Lake AM, Galfalvy H, Kleinman M, Kuchuk M, McKeon R. National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness. Suicide Life Threat Behav 2021; 51:1126-1137. [PMID: 34331471 PMCID: PMC9292033 DOI: 10.1111/sltb.12795] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/05/2021] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE As part of the National Suicide Prevention Lifeline's crisis response system, the Lifeline Crisis Chat Network (LCC) answers chats from hundreds of thousands of at-risk individuals yearly. The study's objective was to assess the effectiveness of these online crisis interventions. METHOD Data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys completed by LCC chatters from October 2017-June 2018 were analyzed. The relationship of several effectiveness measures with chatter demographics, pre-chat distress, suicidal ideation, and chatters' perceptions of engagement with their counselors was examined using a series of logistic regression analyses. RESULTS Chatters were significantly and substantially less distressed at the end of the chat intervention than at the beginning. By the end of the chat, two-thirds of suicidal chatters reported that the chat had been helpful, while just under half reported being less suicidal. CONCLUSIONS Our study offers empirical evidence for the Lifeline's online crisis chat services' effectiveness, but also highlights areas for improvement. This is of critical import in light of the recent designation of 988 as the nationwide number for the Lifeline beginning in 2022, which will increase the Lifeline's prominence in providing suicide prevention and mental health crisis interventions in the United States.
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Affiliation(s)
- Madelyn S. Gould
- Division of Child and Adolescent PsychiatryCollege of Physicians & SurgeonsColumbia UniversityNew YorkNew YorkUSA,Department of EpidemiologySchool of Public HealthNew YorkNew YorkUSA,New York State Psychiatric InstituteNew YorkNew YorkUSA
| | - Saba Chowdhury
- Division of Child and Adolescent PsychiatryNew York State Psychiatric InstituteNew YorkNew YorkUSA
| | - Alison M. Lake
- Division of Child and Adolescent PsychiatryNew York State Psychiatric InstituteNew YorkNew YorkUSA
| | - Hanga Galfalvy
- Department of PsychiatryCollege of Physicians & SurgeonsNew YorkNew YorkUSA,Department of BiostatisticsSchool of Public HealthNew YorkNew YorkUSA
| | - Marjorie Kleinman
- Division of Child and Adolescent PsychiatryNew York State Psychiatric InstituteNew YorkNew YorkUSA
| | | | - Richard McKeon
- Division of Prevention, Traumatic Stress, and Special ProgramsCenter for Mental Health Services (CMHS)Substance Abuse and Mental Health Services AdministrationRockvilleMarylandUSA
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13
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Crawford A. Advancing Public Mental Health in Canada through a National Suicide Prevention Service: Setting an Agenda for Canadian Standards of Excellence. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:446-450. [PMID: 33517766 PMCID: PMC8107950 DOI: 10.1177/0706743721989153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The Public Health Agency of Canada is funding a new Canada Suicide Prevention Service (CSPS), timely both in recognition of the need for a public health approach to suicide prevention, and also in the context of the COVID-19 pandemic, which is causing concern about the potential for increases in suicide. This editorial reviews priorities for suicide prevention in Canada, in relation to the evidence for crisis line services, and current international best practices in the implementation of crisis lines; in particular, the CSPS recognizes the importance of being guided by existing evidence as well as the opportunity to contribute to evidence, to lead innovation in suicide prevention, and to involve communities and people with lived experience in suicide prevention efforts.
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Affiliation(s)
- Allison Crawford
- Canada Suicide Prevention Service, Toronto, Ontario, Canada.,Department of Psychiatry, 7938University of Toronto, Ontario, Canada
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14
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Tong Y, Conner KR, Wang C, Yin Y, Zhao L, Wang Y, Liu Y. Prospective study of association of characteristics of hotline psychological intervention in 778 high-risk callers with subsequent suicidal act. Aust N Z J Psychiatry 2020; 54:1182-1191. [PMID: 33050732 DOI: 10.1177/0004867420963739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to assess the association of the quality scores of hotline psychological intervention and the reduction of subsequent suicidal acts among high suicidal risk callers. METHODS High-risk callers at a national crisis hotline service in China were recruited and prospectively followed for up to 3 months after receiving a hotline psychological intervention. The quality of the intervention was evaluated by supervisors who listened to the tape-recorded calls using the Counseling Skills Rating Scale for Psychological Support Hotlines, which assessed three counseling domains: process, attitude and communication skill. The primary outcome was the occurrence of suicidal acts during the follow-up period. Secondary outcomes were before versus after changes during the intake intervention call in hopefulness, psychological stress and suicide intention reported by the callers. RESULTS Over the 3-month follow-up, 45 of 778 high-risk callers reported 61 suicide attempts, and 3 other callers died by suicide. Subsequent suicidal act was significantly more common in callers classified as being at higher risk during the intake call. Higher scores on the quality of suicidality assessing of the Counseling Skills Rating Scale for Psychological Support Hotlines were associated with reduced risk of suicidal acts during follow-up (hazard ratio = 0.38, 95% confidence interval = [0.18, 0.85]). Higher scores on the communication skill domain were associated with increases in hopefulness (β = 0.09) after the intervention, and higher scores on the counseling process domain (β = -0.12) and higher suicidal risk scores (β = -0.12) were associated with decreased suicide intention after intervention. CONCLUSION Several characteristics of a hotline intervention for suicide prevention were associated with decreased risk of suicidal acts during follow-up. Intervention skill training for hotline operators should emphasize these specific counseling skills.
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Affiliation(s)
- Yongsheng Tong
- Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China.,WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China.,Peking University Huilongguan Clinical Medical School, Beijing, China
| | - Kenneth R Conner
- Departments of Emergency Medicine and Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Cuiling Wang
- Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China.,WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China
| | - Yi Yin
- Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China.,WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China.,Peking University Huilongguan Clinical Medical School, Beijing, China
| | - Liting Zhao
- Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China.,WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China
| | - Yuehua Wang
- Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China.,WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China
| | - Yue Liu
- Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China.,WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China.,Peking University Huilongguan Clinical Medical School, Beijing, China
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15
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Heinz I, Mergl R, Hegerl U, Rummel-Kluge C, Kohls E. Depression stigma and management of suicidal callers: a cross-sectional survey of crisis hotline counselors. BMC Psychiatry 2019; 19:342. [PMID: 31694588 PMCID: PMC6836490 DOI: 10.1186/s12888-019-2325-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/15/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Crisis hotlines play a key role in suicide prevention worldwide following different approaches regarding risk assessment and management of suicidality. This is to our knowledge the first study investigating depression stigma in crisis hotline counselors. The association between stigma and self-rated knowledge and their exploration of suicide risk and consecutive management of suicidal callers is being investigated. METHODS Data on depression stigma, self-rated knowledge, self-reported exploration and management of suicidality was collected from 893 counselors working for the German crisis hotline. Stigma in counselors had been compared to matched population sample (1002). RESULTS Crisis hotline counselors reported significantly lower depression stigma compared to the general population. Depression stigma and age associations differed in both samples. The reported exploration of suicide risk in callers differed depending on the self-rated knowledge about suicidality and depending on the personal depression stigma, but not the reported consecutive management. CONCLUSION Compared to the general population, crisis hotline counselors seem to have fewer stigmatizing attitudes toward depression. Attitudes and self-rated knowledge seem to influence the confidence in counselors regarding the exploration of suicidal callers, but not the consecutive management. The results indicate that a profound training and hands-on information about depression and suicide risk seem to be essential.
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Affiliation(s)
- Ines Heinz
- Department of Psychiatry and Psychotherapy, Medical Faculty, University Leipzig, Semmelweisstr. 10, Haus 13, 04103, Leipzig, Germany. .,German Alliance Against Depression, Goerdelerring 9, 04109, Leipzig, Germany.
| | - Roland Mergl
- 0000 0000 8801 1556grid.7752.7Bundeswehr University Munich, Institute of Clinical Psychology and Psychotherapy, Werner-Heisenberg-Weg 39, 85577 Neubiberg, Germany
| | - Ulrich Hegerl
- German Alliance Against Depression, Goerdelerring 9, 04109 Leipzig, Germany ,0000 0004 1936 9721grid.7839.5Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University Frankfurt (Distinguished Professorship funded by Dr. Senckenbergische Stiftung), Heinrich-Hoffmann-Strasse 10, 60528 Frankfurt am Main, Germany
| | - Christine Rummel-Kluge
- 0000 0001 2230 9752grid.9647.cDepartment of Psychiatry and Psychotherapy, Medical Faculty, University Leipzig, Semmelweisstr. 10, Haus 13, 04103 Leipzig, Germany
| | - Elisabeth Kohls
- 0000 0001 2230 9752grid.9647.cDepartment of Psychiatry and Psychotherapy, Medical Faculty, University Leipzig, Semmelweisstr. 10, Haus 13, 04103 Leipzig, Germany
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16
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Abstract
PURPOSE OF REVIEW The aim of this review is to evaluate recent literature on the use of telepsychiatry in mental crises or emergency situations. RECENT FINDINGS Results from recent studies which evaluated the implementation of a telepsychiatric consultation model in emergency departments point at a reduction of length of stay and a drop in admissions, increased cost-effectiveness, and improved satisfaction of patients and staff. There was almost no empirical evidence on videoconferencing in crisis intervention within the context of crisis resolution teams or online therapies. No study reporting on telepsychiatry videoconferencing in the context of disasters was found. There is still very little but increasing empirical evidence supporting the implementation of telepsychiatry in emergencies. Other mental crisis-related implementation settings remain to be researched. The implications and future research potential are discussed.
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17
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Vattø IE, Lien L, DeMarinis V, Kjørven Haug SH, Danbolt LJ. Caught Between Expectations and the Practice Field. CRISIS 2019; 40:340-346. [PMID: 30813826 DOI: 10.1027/0227-5910/a000573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Volunteer crisis line responders are a valuable resource for suicide prevention crisis lines worldwide. Aim: The aim of this study was to gain a deeper understanding of how volunteers operating a diaconal crisis line in Norway experienced challenges and how these challenges were met. Method: A qualitative, explorative study was conducted. A total of 27 volunteers were interviewed through four focus groups. The material was analyzed using systematic text condensation. Results: The greatest challenge to the volunteers was the perception of a gap between their expectations and the practice field. The experience of many volunteers was that the crisis line primarily served a broad ongoing support function for loneliness or mental illness concerns, rather than a suicide prevention crisis intervention function. Limitations: The focus group design may have made the participants more reluctant to share experiences representing alternative perspectives or personally sensitive information. Conclusion: The findings of this study suggest that a uniform response to callers using crisis lines as a source of ongoing support is warranted and should be implemented in volunteer training programs.
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Affiliation(s)
- Ingvild Engh Vattø
- Center for Psychology of Religion, Innlandet Hospital Trust, Hamar, Norway.,MF Norwegian School of Theology, Oslo, Norway
| | - Lars Lien
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Hamar, Norway.,Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
| | - Valerie DeMarinis
- Center for Psychology of Religion, Innlandet Hospital Trust, Hamar, Norway.,Department of Public Health and Clinical Medicine, Umeå University, Sweden.,Department of Theology, Psychology of Religion and Cultural Psychology, Uppsala University, Sweden
| | - Sigrid Helene Kjørven Haug
- Center for Psychology of Religion, Innlandet Hospital Trust, Hamar, Norway.,Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
| | - Lars Johan Danbolt
- Center for Psychology of Religion, Innlandet Hospital Trust, Hamar, Norway.,MF Norwegian School of Theology, Oslo, Norway
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18
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Mokkenstorm JK, Eikelenboom M, Huisman A, Wiebenga J, Gilissen R, Kerkhof AJFM, Smit JH. Evaluation of the 113Online Suicide Prevention Crisis Chat Service: Outcomes, Helper Behaviors and Comparison to Telephone Hotlines. Suicide Life Threat Behav 2017; 47:282-296. [PMID: 27539122 DOI: 10.1111/sltb.12286] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 04/12/2016] [Indexed: 11/30/2022]
Abstract
Recognizing the importance of digital communication, major suicide prevention helplines have started offering crisis intervention by chat. To date there is little evidence supporting the effectiveness of crisis chat services. To evaluate the reach and outcomes of the 113Online volunteer-operated crisis chat service, 526 crisis chat logs were studied, replicating the use of measures that were developed to study telephone crisis calls. Reaching a relatively young population of predominantly females with severe suicidality and (mental) health problems, chat outcomes for this group were found to be comparable to those found for crisis calls to U.S. Lifeline Centers in 2003-2004, with similar but not identical associations with specific helpers' styles and attitudes. Our findings support a positive effect of the 113Online chat service, to be enhanced by practice standards addressing an apparent lack of focus on the central issue of suicidality during chats, as well as by the development of best practices specific for online crisis intervention.
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Affiliation(s)
- Jan K Mokkenstorm
- Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,113Online Foundation, Amsterdam, The Netherlands.,Department of Research & Innovation, GGZIngeest, Amsterdam, The Netherlands
| | - Merijn Eikelenboom
- Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Research & Innovation, GGZIngeest, Amsterdam, The Netherlands
| | - Annemiek Huisman
- 113Online Foundation, Amsterdam, The Netherlands.,Department of Clinical Psychology, The EMGO Institute for Health and Care Research, Faculty of Psychology and Education, VU University Amsterdam, Amsterdam, The Netherlands
| | | | | | - Ad J F M Kerkhof
- 113Online Foundation, Amsterdam, The Netherlands.,Department of Clinical Psychology, The EMGO Institute for Health and Care Research, Faculty of Psychology and Education, VU University Amsterdam, Amsterdam, The Netherlands
| | - Johannes H Smit
- Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Research & Innovation, GGZIngeest, Amsterdam, The Netherlands
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19
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Gould MS, Lake AM, Munfakh JL, Galfalvy H, Kleinman M, Williams C, Glass A, McKeon R. Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: Evaluation of Caller Risk Profiles and Interventions Implemented. Suicide Life Threat Behav 2016; 46:172-90. [PMID: 26242234 DOI: 10.1111/sltb.12182] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/08/2015] [Indexed: 11/29/2022]
Abstract
Crisis lines are settings where identifying individuals at imminent risk of suicidal behavior and intervening to keep them safe are critical activities. We examined clinical characteristics of crisis callers assessed by telephone crisis helpers as being at imminent risk of suicide, and the interventions implemented with these callers. Data were derived from 491 call reports completed by 132 helpers at eight crisis centers in the National Suicide Prevention Lifeline network. Helpers actively engaged the callers in collaborating to keep themselves safe on 76.4% of calls and sent emergency services without the callers' collaboration on 24.6% of calls. Four different profiles of imminent risk calls emerged. Caller profiles and some helper characteristics were associated with intervention type. Our findings provide a first step toward an empirical formulation of imminent risk warning signs and recommended interventions.
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Affiliation(s)
- Madelyn S Gould
- Division of Child and Adolescent Psychiatry, College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, School of Public Health, Columbia University, New York, NY, USA.,New York State Psychiatric Institute, New York, NY, USA
| | - Alison M Lake
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA
| | - Jimmie Lou Munfakh
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA
| | - Hanga Galfalvy
- Department of Psychiatry, College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Department of Biostatistics, School of Public Health, Columbia University, New York, NY, USA
| | - Marjorie Kleinman
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA
| | | | - Andrew Glass
- Division of Biostatistics, Department of Psychiatry, Columbia University, New York, NY, USA
| | - Richard McKeon
- Division of Prevention, Traumatic Stress, and Special Programs, Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
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