Community mental health care after self-harm: A retrospective cohort study

Exploring community mental health service use following hospital-treated intentional self-harm among older Australians: a survival analysis

OBJECTIVES

This study aimed to examine the impact of community mental health (CMH) care following index hospital-treated intentional self-harm (ISH) on all-cause mortality. A secondary aim was to describe patterns of CMH care surrounding index hospital-treated ISH.

DESIGN

A longitudinal whole-of-population record linkage study was conducted (2014-2019), with index ISH hospitalization (Emergency Department and/or hospital admissions) linked to all available hospital, deaths/cause of death, and CMH data.

SETTING

Australia's most populous state, New South Wales (NSW) comprised approximately 7.7 million people during the study period. CMH services are provided statewide, to assess and treat non-admitted patients, including post-discharge review.

PARTICIPANTS

Individuals with an index hospital presentation in NSW of ISH during the study period, aged 45 years or older.

INTERVENTION

CMH care within 14 days from index, versus not.

MEASUREMENTS

Cox-proportionate hazards regression analysis evaluated all-cause mortality risk, adjusted for relevant covariates.

RESULTS

Totally, 24,544 persons aged 45 years or older experienced a nonfatal hospital-treated ISH diagnosis between 2014 and 2019. CMH care was received by 56% within 14 days from index. Survival analysis demonstrated this was associated with 34% lower risk of death, adjusted for age, sex, marital status, index diagnosis, and 14-day hospital readmission (HR 0.66, 95% CI 0.58, 0.74, p < 0.001). Older males and chronic injury conveyed significantly greater risk of death overall.

CONCLUSIONS

CMH care within 14 days of index presentation for self-harm may reduce the risk of all-cause mortality. Greater effort is needed to engage older males presenting for self-harm in ongoing community mental health care.

Shortcomings of services for persons with severe and persistent mental health challenges: a qualitative study of service users and family carers

Introduction

The opinions of service users and carers are crucial to identifying ways to innovate and implement system change. This study aims to explore the views and experiences of service users and carerson the services they have used for their mental health challenges and their suggestions for service reform.

Methods

Twenty participants (15 carers and 5 service users) were interviewed for the study.

Results

Eight categories emerged from the data. They were: Several gaps in the system, Barriers to accessing services, Services are not fit for purpose, Services operate in isolation, System is not person focused, Service users and carers are treated poorly, Services are overloaded and under resourced and Recommendations for service reform. Respondents reported that a persistent lack of funding and resources for mental health services was a main cause of these shortcomings. Respondents also noted that innovations were needed to re-orient services to enable continuity of care, and training of mental health professionals was needed for a better understanding of the needs of service users and their carers.

Discussion

Additional research is needed with larger and more diverse samples to further explore these findings.

Repeat self-harm and mental health service use after self-harm in Culturally and Linguistically Diverse communities: Insights from a data linkage study in Victoria, Australia

PURPOSE

To examine the associations between Culturally and Linguistically Diverse backgrounds (vs non-Culturally and Linguistically Diverse) and in-hospital death due to self-harm, repeat self-harm and mental health service use after self-harm.

METHOD

A retrospective study of 42,127 self-harm hospital inpatients aged 15+ years in Victoria, Australia, from July 2008 to June 2019. Linked hospital and mental health service data were used to assess in-hospital death, repeat self-harm and mental health service use in the 12 months following index self-harm hospital admission. Logistic regression and zero-inflated negative binomial regression models were used to estimate associations between cultural background and outcomes.

RESULTS

Culturally and Linguistically Diverse people accounted for 13.3% of self-harm hospital inpatients. In-hospital death (0.8% of all patients) was negatively associated with Culturally and Linguistically Diverse background. Within 12 months, 12.9% of patients had self-harm readmission and 20.1% presented to emergency department with self-harm. Logistic regression components of zero-inflated negative binomial regression models showed no differences in the odds of (hospital-treated) self-harm reoccurrence between Culturally and Linguistically Diverse and non- Culturally and Linguistically Diverse self-harm inpatients. However, count components of models show that among those with repeat self-harm, Culturally and Linguistically Diverse people (e.g. born in Southern and Central Asia) made fewer additional hospital revisits than non-Culturally and Linguistically Diverse people. Clinical mental health service contacts following self-harm were made in 63.6% of patients, with Culturally and Linguistically Diverse people (Asian backgrounds 43.7%) less likely to make contact than the non-Culturally and Linguistically Diverse group (65.1%).

CONCLUSIONS

Culturally and Linguistically Diverse and non-Culturally and Linguistically Diverse people did not differ in the likelihood of hospital-treated repeat self-harm, but among those with self-harm repetition Culturally and Linguistically Diverse people had fewer recurrences than non-Culturally and Linguistically Diverse people and utilised mental health services less following self-harm admissions.

Self-harm and suicidal ideation among young people is more often recorded by child protection than health services in an Australian population cohort

OBJECTIVE

We investigated patterns of service contact for self-harm and suicidal ideation recorded by a range of human service agencies - including health, police and child protection - with specific focus on overlap and sequences of contacts, age of first contact and demographic and intergenerational characteristics associated with different service responses to self-harm.

METHODS

Participants were 91,597 adolescents for whom multi-agency linked data were available in a longitudinal study of a population cohort in New South Wales, Australia. Self-harm and suicide-related incidents from birth to 18 years of age were derived from emergency department, inpatient hospital admission, mental health ambulatory, child protection and police administrative records. Descriptive statistics and binomial logistic regression were used to examine patterns of service contacts.

RESULTS

Child protection services recorded the largest proportion of youth with reported self-harm and suicidal ideation, in which the age of first contact for self-harm was younger relative to other incidents of self-harm recorded by other agencies. Nearly 40% of youth with a health service contact for self-harm also had contact with child protection and/or police services for self-harm. Girls were more likely to access health services for self-harm than boys, but not child protection or police services.

CONCLUSION

Suicide prevention is not solely the responsibility of health services; police and child protection services also respond to a significant proportion of self-harm and suicide-related incidents. High rates of overlap among different services responding to self-harm suggest the need for cross-agency strategies to prevent suicide in young people.

Global prevalence of psychiatric in- and out-patient treatment following hospital-presenting self-harm: a systematic review and meta-analysis

Background

Hospital-treated self-harm is common, costly, and strongly associated with suicide. Whilst effective psychosocial interventions exist, little is known about what key factors might modify the clinical decision to refer an individual to psychiatric in- and/or out-patient treatment following an episode of hospital-treated self-harm.

Methods

We searched five electronic databases (CENTRAL, CDSR, MEDLINE, Embase, and PsycINFO) until 3 January 2023 for studies reporting data on either the proportion of patients and/or events that receive a referral and/or discharge to psychiatric in- and/or outpatient treatment after an episode of hospital-treated self-harm. Pooled weighted prevalence estimates were calculated using the random effects model with the Freedman-Tukey double arcsine adjustment in R, version 4.0.5. We also investigated whether several study-level and macro-level factors explained variability for these outcomes using random-effects meta-regression. The protocol of this review was pre-registered with PROSPERO (CRD42021261531).

Findings

189 publications, representing 131 unique studies, which reported data on 243,953 individual participants who had engaged in a total of 174,359 episodes of self-harm were included. Samples were drawn from 44 different countries. According to World Bank classifications, most (83.7%) samples were from high income countries. Across the age range, one-quarter of persons were referred for inpatient psychiatric care and, of these, around one-fifth received treatment. Just over one-third were referred to outpatient psychiatric care, whilst around half of those referred received at least one treatment session across the age range. Event rate estimates were generally of a lower magnitude. Subgroup analyses found that older adults (mean sample age: ≥60 years) may be less likely than young people (mean sample age: ≤25 years) and adults (mean sample age: >25 years to <60 years) to be referred for outpatient psychiatric care following self-harm. More recent studies were associated with a small increase in the proportion of presentations (events) that were referred to, and received, psychiatric outpatient treatment. No macro-level factor explained between-study heterogeneity.

Interpretation

There is considerable scope for improvement in the allocation and provision of both in- and out-patient psychiatric care following hospital-presenting self-harm, particularly considering that the period after discharge from general hospitals represents the peak risk period for repeat self-harm and suicide. Given the marked between-study heterogeneity, the basis for allocation of aftercare treatment is therefore not yet known and should be further studied.

Funding

There was no specific funding for this review.

Identification of young females at high risk of suicide following hospital-treated self-harm in Victoria, Australia

OBJECTIVE

We conducted a data linkage study in Victoria, Australia, to determine the proportion of young females who are treated in hospital for self-harm who go on to die by suicide within 5 years and to identify factors associated with increased suicide risk in this same cohort.

METHOD

We undertook a cohort study following 3689 female patients aged 10-24 years, who were initially treated in hospital for self-harm during the 2-year period January 2011 to December 2012. We followed each patient for 5 years unless they died first, in which case, they were followed until their date of death. We used inpatient admissions from the Victorian Admitted Episodes Dataset and emergency department presentations from the Victorian Emergency Minimum Dataset linked to death data from two sources, the Victorian Suicide Register and the National Death Index.

RESULTS

Twenty-eight individuals (0.76% of the total cohort) died by suicide within 5 years of their index admission. In multivariate survival analysis, only suicide ideation at the time of self-harm (hazard ratio = 4.59; 95% confidence interval: 1.70, 12.38) and a decreasing time between successive self-harm episodes (hazard ratio = 4.38; 95% confidence interval: 1.28, 15.00) were associated with increased suicide risk.

CONCLUSION

Although the vast majority of young females who present to hospital for self-harm do not die by suicide within 5 years, our results suggest young females expressing suicide ideation and those presenting frequently with decreasing time between successive episodes should be prioritised for suicide-prevention efforts.

Presentations to the emergency department with self-harm or suicidal behaviours: A role for digital mental health services?

Emergency Department (ED) is an important site for assessing people presenting with self-harm or suicidal behaviors. Digital mental health services (DMHS) offer evidence-based interventions for mental health issues, but are often under-utilised, and information about them is rarely provided in ED. This feasibility study explored whether offering information about a DMHS to individuals presenting to ED with self-harm/suicidal behaviors resulted in self-enrolment in DMHS interventions for anxiety, depression and/or chronic pain.

METHODS

all individuals aged 18+ presenting with self-harm/suicidal behaviors to a metropolitan ED were screened for symptoms of anxiety, depression and/or chronic pain. Those with these symptoms were invited to participate in a study investigating enrolment with a DMHS. Study participants were provided with information about DMHS and followed up at one month.

RESULTS

260 individuals presented with self-harm/suicidal behaviors over the 6-month study period. Many reported low mood (73.5%, n = 191) anxiety (67.2%, n = 174) and/or chronic pain (18.5%, n = 48). Half of those eligible for DMHS agreed at point of ED discharge to be contacted about participation in the DMHS study (51.4%, n = 108). One-third of these participated in the study (35.2%, n = 38). Rates of past-month high-risk SB (65.8%, n = 25), depression (92.1%, n = 35), anxiety (78.9%, n = 30) and chronic pain (57.9%, n = 22) were very high. Of these, 39.5% (n = 15) self-enrolled with the DMHS; almost all (80.0%, n = 13) engaged with an online intervention.

CONCLUSIONS

A subset of people presenting to emergency department with suicidal behaviors will engage with DMHS. Better understanding is needed of factors contributing to uptake of DMHS in this group.

Effectiveness of the Hunter Way Back Support Service: An historical controlled trial of a brief non-clinical after-care program for hospital-treated deliberate self-poisoning

INTRODUCTION

Active contact and follow-up interventions have been shown to be effective in reducing repetition of hospital-treated self-harm. The Way Back Support Service (WBSS) is a new service funded by the Australian government to provide three months of non-clinical after-care following a hospital-treated suicide attempt. The aim of this study was to investigate the effectiveness of WBSS in reducing deliberate self-poisoning (DSP) and psychiatric hospital admissions over a 12-month follow-up period for a population of DSP patients within the Hunter (Australia) region.

METHODS

A non-randomized, historical controlled (two periods) trial design with intention-to-treat analyses. Outcome data were drawn from hospital records.

RESULTS

There were a total of 2770 participants across study periods. There were no significant differences between cohorts for proportion with any, or number of, re-admissions for DSP in the follow-up period. For psychiatric admissions, the intervention cohort had a non-significantly greater proportion with any psychiatric admission and significantly more admissions compared to one of the control cohorts.

CONCLUSION

The WBSS model of care should be modified to strengthen treatment engagement and retention and to include established, clinical, evidence-based treatments shown to reduce DSP repetition. Any modified WBSS model should be subject to further evaluation.

They Told Me "This Isn't a Hotel": Young People's Experiences and Perceptions of Care When Presenting to the Emergency Department with Suicide-Related Behaviour

In Australia, the number of young people presenting to the emergency department with mental health concerns, in particular, suicidal behaviour (defined here as suicidal ideation, thoughts, intent and attempts) is increasing. Little is known about the experiences of Australian young people who present to hospital emergency departments with suicidal behaviour. In this qualitative study, we conducted a series of focus groups with 55 young people aged 16–25 years, with a view to developing a framework for youth suicide prevention for Western Australia. The data were analysed using a general inductive analysis approach. We explored the experiences and perceptions of the care and management of 35 young people presenting to Western Australian hospital emergency departments. Participants described a range of negative experiences relating to the emergency department environment, staff attitudes and their treatment by staff. We argue that adapting ED practices and approaches to young people presenting with suicidal thoughts and behaviours based on these findings will result in lower rates of repeated presentations and admissions to hospital and lower rates of suicide attempts and deaths by suicide.

Socioeconomic differences in psychiatric treatment before and after self-harm: an observational study of 4,280 adolescents and young adults

BACKGROUND

Individuals in higher socioeconomic positions tend to utilise more mental health care, especially specialist services, than those in lower positions. Whether these disparities in treatment exist among adolescents and young adults who self-harm is currently unknown.

METHODS

The study is based on Finnish administrative register data on all individuals born 1986-1994. Adolescents and young adults with an episode of self-harm treated in specialised healthcare at ages 16-21 in 2002-2015 (n=4280, 64% female) were identified and followed 2 years before and after the episode. Probabilities of specialised psychiatric inpatient admissions and outpatient visits and purchases of psychotropic medication at different time points relative to self-harm were estimated using generalised estimation equations, multinomial models and cumulative averages. Socioeconomic differences were assessed based on parental education, controlling for income.

RESULTS

An educational gradient in specialised treatment and prescription medication was observed, with the highest probabilities of treatment among the adolescents and young adults with the highest educated parents and lowest probabilities among those whose parents had basic education. These differences emerged mostly after self-harm. The probability to not receive any treatment, either in specialised healthcare or psychotropic medication, was highest among youth whose parents had a basic level of education (before self-harm 0.39, 95% CI 0.34-0.43, and after 0.29, 95% CI 0.25-0.33 after) and lowest among youth with higher tertiary educated parents (before self-harm: 0.22, 95% CI 0.18-0.26, and after 0.18, 95% CI 0.14-0.22). The largest differences were observed in inpatient care.

CONCLUSIONS

The results suggest that specialised psychiatric care and psychotropic medication use are common among youth who self-harm, but a considerable proportion have no prior or subsequent specialised treatment. The children of parents with lower levels of education are likely to benefit from additional support in initiating and adhering to treatment after an episode of self-harm. Further research on the mechanisms underlying the educational gradient in psychiatric treatment is needed.

"A Sustained, Productive, Constructive Relationship with Someone Who Can Help"-A Qualitative Exploration of the Experiences of Help Seekers and Support Persons Using the Emergency Department during a Suicide Crisis

For Australians experiencing a suicide crisis, the emergency department (ED) is the recommended point of contact for intervention and to ensure personal safety. However, negative ED experiences can deter individuals from returning, thus impacting future suicide risk. In order to improve the ED environment for individuals in suicidal crisis, an in-depth understanding of this experience is needed. In-depth semi-structured interviews with 17 help seekers and 16 support persons were conducted. A grounded theory approach uncovered a core organising concept—all participants wanted a “a sustained, productive, constructive relationship with someone who can help” during the ED visit—which guided analysis. Thematic analysis resulted in two themes and four subthemes exploring the systemic and interpersonal aspects of the ED visit and the roadblocks and pathways to development of the relationship. Interpersonal factors included aspects of staff interaction and presence of a support person. Systemic factors related to aspects controlled by the physical space and internal policies and procedures and included aspects such as the chaotic environment, long waiting times, and access to staff. Overwhelmingly, there were more roadblocks than pathways reported by participants. Improving the ED environment, increasing staff training and encouraging the presence of support persons may help mitigate some of these roadblocks.

Nonwillingness to Return to the Emergency Department and Nonattendance of Follow-Up Care Arrangements Following an Initial Suicide-Related Presentation

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.

The voice of mental health practice in Australia: a mixed-method cross-sectional study of gaps and areas of need

OBJECTIVES

To examine the perceptions of health professionals regarding the gaps in mental health service provision in Australia and their need for assistance in managing patients with mental illness.

METHOD

A total of 570 health professionals participated in an anonymous online survey in January 2018 that assessed: i) health professionals' current levels of need for assistance in the management of patients with mental health conditions; and ii) perceived gaps in the mental health care system, and how these can be addressed. Data were analysed using a mixed-methods approach.

RESULTS

Of those surveyed, 71.2% of health professionals and 77.3% of general practitioners reported that they required assistance in managing their patients with at least one stage of care for at least one type of mental disorder. Qualitative analyses revealed eight major themes in health professionals' perceptions of gaps in mental health service provision, including affordability and accessibility, the problems with crisis-driven care and the 'missing middle'.

CONCLUSION

Overall, the results of this study provide a concerning insight into the substantial gaps in mental health care within the Australian system. Implications for public health: The results of this study add weight to ongoing calls for reform of and increased investment in the Australian mental health care system.

Contact with Mental Health Services After Acute Care for Self-Harm Among Adults Released from Prison: A Prospective Data Linkage Study

OBJECTIVE

To determine the care pathway and rate and predictors of mental health care contact within seven days of discharge from acute care following self-harm.

METHOD

In a representative cohort of adults released from prisons in Queensland, Australia, we probabilistically linked person-level, statewide ambulance, emergency department, and hospital records, both prospectively and retrospectively, and community mental health service and Medicare records prospectively, to baseline survey data. We fit multivariate modified log-linked Poisson regression models to examine the association between sociodemographic, health, and criminal justice factors and mental health care contact after self-harm.

RESULTS

Of 217 discharges from acute care following self-harm, 55% (n = 119) received mental health care within seven days of discharge. Mental health care contact was associated with substance use disorder (adjusted relative risk (ARR) = 0.48; 95% CI: 0.27-0.85), dual diagnosis (ARR = 0.58; 95% CI: 0.41-0.82), physical health-related functioning (ARR = 0.98; 95% CI: 0.97-0.99), being female (ARR = 1.39; 95% CI: 1.02-1.90), being identified as at risk of self-harm by correctional authorities (ARR = 1.50; 95% CI: 1.07-2.09), and prior engagement with state-funded mental health care (ARR = 1.55; 95% CI: 1.08-2.22).

CONCLUSION

Our findings highlight the need to improve the integration of community mental health care for people who present to acute care following self-harm with a recent history of incarceration, particularly for men and those with substance use disorder or dual diagnosis.

Pre-existing mental disorder, clinical profile, inpatient services and costs in people hospitalised following traumatic spinal injury: a whole population record linkage study

BACKGROUND

Risk of traumatic injury is increased in individuals with mental illness, substance use disorder and dual diagnosis (mental disorders); these conditions will pre-exist among individuals hospitalised with acute traumatic spinal injury (TSI). Although early intervention can improve outcomes for people who experience mental disorders or TSI, the incidence, management and cost of this often complex comorbid health profile is not sufficiently understood. In a whole population cohort of patients hospitalised with acute TSI, we aimed to describe the prevalence of pre-existing mental disorders and compare differences in injury epidemiology, costs and inpatient allied health service access.

METHODS

Record linkage study of all hospitalised cases of TSI between June 2013 and June 2016 in New South Wales, Australia. TSI was defined by specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes. Mental disorder status was considered as pre-existing where specific ICD-10-AM codes were recorded in incident admissions.

RESULTS

13 489 individuals sustained acute TSI during this study. 13.11%, 6.06% and 1.82% had pre-existing mental illness, substance use disorder and dual diagnosis, respectively. Individuals with mental disorder were older (p<0.001), more likely to have had a fall or self-harmed (p<0.001), experienced almost twice the length of stay and inpatient complications, and increased injury severity compared with individuals without mental disorder (p<0.001).

CONCLUSION

Individuals hospitalised for TSI with pre-existing mental disorder have greater likelihood of increased injury severity and more complex, costly acute care admissions compared with individuals without mental disorder. Care pathway optimisation including prevention of hospital-acquired complications for people with pre-existing mental disorders hospitalised for TSI is warranted.

Program Evaluation and Decision Analytic Modelling of Universal Suicide Prevention Training (safeTALK) in Secondary Schools

BACKGROUND

Universal suicide education and awareness training in schools are promising suicide prevention initiatives. This study aims to evaluate a suicide awareness training (safeTALK) and to model potential return on investment (ROI) on a population basis. SafeTALK, comprises a 3-h education session, and has been delivered to secondary school students (aged 15-16 years) in Mackay, located in the Australian state of Queensland.

METHODS

Evaluation consisted of two phases, ex-post and ex-ante. Phase I was a pre-post, follow-up analysis using a mixed-method questionnaire administered immediately prior (Time 1), immediately after (Time 2), and 4 weeks after training (Time 3). Phase II involved decision analytic modelling comparing safeTALK to the status quo. ROI was modelled using Markov chains for a hypothetical population of students aged 15-19 years in Mackay (n = 2561; suicide rate 78.1 per 100,000), Queensland (n = 296,287; 10.2) and Australia (n = 1,421,595; 8.3). Model parameters, including rates of hospitalised self-harm and suicide, cost implications and effectiveness of safeTALK were drawn from published literature. The baseline model adapted a health and justice system's perspective, with an alternative model incorporating a societal perspective. All costs were adjusted to reflect AU$2017-2018.

RESULTS

Students reported seeking help mostly from friends (79%) or parents (68%); in the last 6 months 61% considered another student's behaviour as suicidal, but only 21% reported asking about this. The main barriers to help-seeking were (i) being too embarrassed, (ii) shy or (iii) being judged. Students who attended safeTALK gained suicide-related knowledge (p < 0.001), confidence (p < 0.001), willingness (p = 0.006), and likelihood of seeking help (p = 0.044) and retained these up until follow-up assessment 4 weeks later with the exception of seeking help. From a health and justice system's perspective, the model estimated a cumulative return of AU$1.45 per AU$1 invested in safeTALK in Mackay; AU$0.19 in Queensland; AU$0.15 across Australia. From a societal perspective, ROI increased to AU$31.21, AU$4.05 and AU$3.28, respectively.

CONCLUSION

Results strengthen the premise that safeTALK is feasible to implement within a school setting. The economic case for implementation of safeTALK is promising on a population basis, especially in high-risk communities, but further research is required to confirm the study results.

Community-based aftercare following an emergency department presentation for attempted suicide or high risk for suicide: study protocol for a non-randomised controlled trial

BACKGROUND

Suicide is a major public health issue worldwide. Those who have made a recent suicide attempt are at high risk for dying by suicide in the future, particularly during the period immediately following departure from a hospital emergency department. As such the transition from hospital-based care to the community is an important area of focus in the attempt to reduce suicide rates. There is a need for evaluation studies to test the effectiveness of interventions directed to this stage (termed 'aftercare' interventions).

METHODS

A controlled non-randomised two group (intervention vs treatment-as-usual control) design, using an intention-to-treat model, will evaluate the effectiveness of a suicide prevention aftercare intervention providing follow-up after presentations to a hospital emergency department as a result of a suicide attempt or high risk for suicide. The intervention is a community-based service, utilising two meetings with a mental health clinician and follow-up contacts by peer workers via a combination of face-to-face and telephone for four weeks, with the option of extension to 12 weeks. Seventy-five participants of the intervention service will be recruited to the study and compared to 1265 treatment-as-usual controls. The primary hypotheses are that over 12 months, those who participate in the aftercare follow-up intervention are less likely than controls to present to a hospital emergency department for a repeat suicide attempt or because of high risk for suicide, will have fewer re-presentations during this period and will have lower all-cause mortality. As a secondary aim, the impact of the intervention on suicide risk factors for those who participate in the service will be evaluated using pre- and post-intervention repeated measures of depression, anxiety, stress, hopelessness, belongingness, burdensomeness, and psychological distress. Enrolments into the study commenced on 1 November 2017 and are anticipated to cease in November 2019.

DISCUSSION

The study aims to contribute to the understanding of effective interventions for individuals who have presented to a hospital emergency department as a result of a suicide attempt or at high risk for suicide and provide evidence in relation to interventions that incorporate peer-workers.

TRIAL REGISTRATION

ACTRN12618001701213 . Registered on 16 October 2018. Retrospectively registered.

Experience of Health Care Services After a Suicide Attempt: Results from an Online Survey

Failure to provide follow-up care after a suicide attempt is associated with increased risk of reattempt. This online survey examined the experiences of patients of the Australian health system after a suicide attempt. Just over half of the participants had a psychiatric assessment within 1 week of their attempt. Fewer than half believed they had been offered enough help. Low service satisfaction was associated with lower help-seeking intentions. Support for individuals who have made a suicide attempt needs to be enhanced, and an integrated approach to care is required, including improved referral pathways and staff attitudinal change.

Improving patient care after a suicide attempt

OBJECTIVES

Improving the care that patients receive after a suicide attempt will reduce the risk of a subsequent suicide attempt. We described how care for these patients can be improved and identified the available guidelines.

METHODS

We reviewed the literature on crisis and aftercare, psychosocial assessment, risk assessment, brief contact interventions, and brief interventions.

RESULTS

People who have made a suicide attempt are at increased risk of suicide, and the period immediately after discharge from hospital is particularly risky. Patients require an empathic response at their first point of contact, comprehensive psychosocial assessment, effective discharge planning, rapid and assertive follow-up, and coordinated care in the subsequent months.

CONCLUSIONS

Empathic and effective care that begins in the emergency department and extends through to community care is imperative. Enough is known about the risks of inadequate care and the key ingredients of effective care to proceed with changes to Australia's healthcare response to a suicide attempt.

A Mobile Text Message Intervention to Reduce Repeat Suicidal Episodes: Design and Development of Reconnecting After a Suicide Attempt (RAFT)

BACKGROUND

Suicide is a leading cause of death, particularly among young people. Continuity of care following discharge from hospital is critical, yet this is a time when individuals often lose contact with health care services. Offline brief contact interventions following a suicide attempt can reduce the number of repeat attempts, and text message (short message service, SMS) interventions are currently being evaluated.

OBJECTIVE

The aim of this study was to extend postattempt caring contacts by designing a brief Web-based intervention targeting proximal risk factors and the needs of this population during the postattempt period. This paper details the development process and describes the realized system.

METHODS

To inform the design of the intervention, a lived experience design group was established. Participants were asked about their experiences of support following their suicide attempt, their needs during this time, and how these could be addressed in a brief contact eHealth intervention. The intervention design was also informed by consultation with lived experience panels external to the project and a clinical design group.

RESULTS

Prompt outreach following discharge, initial distraction activities with low cognitive demands, and ongoing support over an extended period were identified as structural requirements of the intervention. Key content areas identified included coping with distressing feelings, safety planning, emotional regulation and acceptance, coping with suicidal thoughts, connecting with others and interpersonal relationships, and managing alcohol consumption.

CONCLUSIONS

The RAFT (Reconnecting AFTer a suicide attempt) text message brief contact intervention combines SMS contacts with additional Web-based brief therapeutic content targeting key risk factors. It has the potential to reduce the number of repeat suicidal episodes and to provide accessible, acceptable, and cost-effective support for individuals who may not otherwise seek face-to-face treatment. A pilot study to test the feasibility and acceptability of the RAFT intervention is underway.