Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide

A Self-Help Crisis Outreach Effort for At-Risk Primary Care Patients: A Pilot Study of Veterans During the COVID-19 Pandemic

Stressful events can exacerbate symptoms of psychiatric disorders among primary care patients, putting them at increased risk for suicide. In a pilot study that ran from August to December of 2020, researchers evaluated the acceptability and implementation of Managing Emotions in Disaster and Crisis (MEDIC), a self-help intervention designed to assist at-risk primary care patients. A total of 108 at-risk veterans completed baseline and 6-week assessments. Results were promising, with high patient acceptability and engagement along with improvement in all measures of mental illness symptoms from baseline to posttreatment. Self-help interventions like MEDIC may offer a low-burden way for primary care providers to support more patients.

Predicting Lifetime Suicide Attempts in a Community Sample of Adolescents Using Machine Learning Algorithms

Suicide is a major global health concern and a prominent cause of death in adolescents. Previous research on suicide prediction has mainly focused on clinical or adult samples. To prevent suicides at an early stage, however, it is important to screen for risk factors in a community sample of adolescents. We compared the accuracy of logistic regressions, elastic net regressions, and gradient boosting machines in predicting suicide attempts by 17-year-olds in the Millennium Cohort Study (N = 7,347), combining a large set of self- and other-reported variables from different categories. Both machine learning algorithms outperformed logistic regressions and achieved similar balanced accuracies (.76 when using data 3 years before the self-reported lifetime suicide attempts and .85 when using data from the same measurement wave). We identified essential variables that should be considered when screening for suicidal behavior. Finally, we discuss the usefulness of complex machine learning models in suicide prediction.

Efficacy of a short message service brief contact intervention (SMS-SOS) in reducing repetition of hospital-treated self-harm: randomised controlled trial

BACKGROUND

Hospital-treated self-harm is common and costly, and is associated with repeated self-harm and suicide.

AIMS

To investigate the effectiveness of a brief contact intervention delivered via short message service (SMS) text messages in reducing hospital-treated self-harm re-presentations in three hospitals in Sydney (2017-2019), Australia. Trial registration number: ACTRN12617000607370.

METHOD

A randomised controlled trial with parallel arms allocated 804 participants presenting with self-harm, stratified by previous self-harm, to a control condition of treatment as usual (TAU) (n = 431) or an intervention condition of nine automated SMS contacts (plus TAU) (n = 373), over 12 months following the index self-harm episode. The primary outcomes were (a) repeat self-harm event rate (number of self-harm events per person per year) at 6-, 12- and 24-month follow-up and (b) the time to first repeat at 24-month follow-up.

RESULTS

The event rate for self-harm repetition was lower for the SMS compared with TAU group at 6 months (IRR = 0.79, 95% CI 0.61-1.01), 12 months (IRR = 0.78, 95% CI 0.64-0.95) and 24 months (IRR = 0.78, 95% CI 0.66-0.91). There was no difference between the SMS and TAU groups in the time to first repeat self-harm event over 24 months (HR = 0.96, 95% CI 0.72-1.26). There were four suicides in the TAU group and none in the SMS group.

CONCLUSIONS

The 22% reduction in repetition of hospital-treated self-harm was clinically meaningful. SMS text messages are an inexpensive, scalable and universal intervention that can be used in hospital-treated self-harm populations but further work is needed to establish efficacy and cost-effectiveness across settings.

Nurses' Attitudes and Perceptions Regarding Suicidal Patients: A Quasi-Experimental Study of Depression Management Training

Suicide prevention is a priority globally. Community nurses are on the frontline of healthcare, and thus well placed to identify those at risk of suicide and act to prevent it. However, they are often ill-equipped to do so. This study examines whether depression management training for nurses may also help them manage suicide-risk patients.

METHOD

This quasi-experimental study used a questionnaire that included a randomly assigned textual case vignette, measures related to patient descriptions portrayed in the vignette, and demographic and clinical/training information. The participants were 139 Israeli nurses who were mostly Jewish, Israeli-born, and married women working as community nurses. Almost half had completed depression management training (DMT) in their routine work.

RESULTS

Nurses who completed depression management training were more likely than non-trainees to query the patient regarding mental status and suicide plans and were more likely to refer them to appropriate further treatment. The graduate nurses also reported higher self-competence and more positive attitudes regarding their ability to assess depression and suicide risk than nurses who had not received depression management training.

DISCUSSION

The results highlight the importance of depression management training, as suicide assessment and referral are among the major steps to suicide prevention.

Effect of synchronous remote-based interventions on suicidal behaviours: protocol for a systematic review and meta-analysis

INTRODUCTION

Suicide is among the leading causes of preventable death worldwide. The impact of suicide affects the personal, social and economic levels. Therefore, its prevention is a priority for public health systems. Previous studies seem to support the efficacy of providing active contact to people who have made a suicide attempt. The current systematic review and meta-analysis aims to investigate the efficacy of distance suicide prevention strategies implemented through synchronous technology-based interventions.

METHODS AND ANALYSIS

This protocol is designed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. The bibliographical searches were conducted in the databases PubMed, PsycINFO, Scopus and Web of Science in April 2022, with no restrictions on the time of publication and limited to publications in English or Spanish. The search strategy was performed using free-text terms and Medical Subject Headings terms: suicide, follow-up, synchronous, remote, telehealth, telephone, hotline, video-conference and text message. Two reviewers will independently conduct study screening, selection process, data extraction and risk of bias assessment. The analysis and synthesis of the results will be both qualitative and quantitative. A narrative synthesis, presented in a comprehensive table, will be performed and meta-analysis will be conducted, as appropriate, if sufficient data are provided.

ETHICS AND DISSEMINATION

The present review and meta-analysis will not require ethical approval, as it will use data collected from previously published primary studies. The findings of this review will be published in peer-reviewed journals and widely disseminated.

PROSPERO REGISTRATION NUMBER

CRD42021275044.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol

BACKGROUND

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

METHODS

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

CONCLUSIONS

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Evidence that implementation intentions reduce self-harm in the community

OBJECTIVES

Implementation intentions are 'IF-THEN' plans that encourage goal-intended behaviour. This study was designed to test whether an intervention encouraging the formation of implementation intentions can reduce self-harm in the community.

DESIGN

A randomized controlled design was used.

METHODS

At pre-intervention, outcome variables (self-harm in both specified and unspecified critical situations and suicidality) and potential moderators of implementation intentions (goal intention, mental imagery, and exposure to self-harm) were measured using self-report questionnaires. The participants (N = 469, aged 18-66 years, 86.4% female, 6.8% male and 6.7% other) were then randomized to either an experimental (implementation intention) or control task. At three-months post-intervention, self-report questionnaires were used again to measure the outcome variables.

RESULTS

There were no overall differences between the conditions at post-intervention. However, goal intention and mental imagery, but not exposure to self-harm, moderated the effects of condition on self-harm in specified critical situations. At high (mean + 1SD) levels of both goal intention and mental imagery, the experimental condition reported self-harming less frequently in the situations specified in their implementation intentions.

CONCLUSIONS

Implementation intentions therefore represent a useful intervention for reducing self-harm in specified critical situations for people in the community who wish to avoid self-harm and those who frequently experience self-harm and suicide related mental imagery.

Effects of Community-Based Caring Contact in Reducing Thwarted Belongingness Among Postdischarge Young Adults With Self-Harm: Randomized Controlled Trial

BACKGROUND

For patients with self-harm behaviors, the urge to hurt themselves persists after hospital discharge, leading to costly readmissions and even death. Hence, postdischarge intervention programs that reduce self-harm behavior among patients should be part of a cogent community mental health care policy.

OBJECTIVE

We aimed to determine whether a combination of a self-help mobile app and volunteer support could complement treatment as usual (TAU) to reduce the risk of suicide among these patients.

METHODS

We conducted a pragmatic randomized controlled trial on discharged patients aged between 18 and 45 years with self-harm episodes/suicide attempts, all of whom were recruited from 4 hospital emergency departments in Hong Kong. Participants were randomly assigned to one of three groups: (1) mobile app + TAU ("apps"), (2) mobile app + volunteer support + TAU ("volunteers"), or (3) TAU only as the control group ("TAU"). They were asked to submit a mobile app-based questionnaire during 4 measurement time points at monthly intervals.

RESULTS

A total of 40 participants were recruited. Blending volunteer care with a preprogrammed mobile app was found to be effective in improving service compliance. Drawing upon the interpersonal-psychological theory of suicide, our findings suggested that a reduction in perceived burdensomeness and thwarted belongingness through community-based caring contact are linked to improvement in hopelessness, albeit a transient one, and suicide risk.

CONCLUSIONS

A combination of volunteer care with a self-help mobile app as a strategy for strengthening the continuity of care can be cautiously implemented for discharged patients at risk of self-harm during the transition from the hospital to a community setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03081078; https://clinicaltrials.gov/study/NCT03081078.

Modelling the cost-effectiveness of brief aftercare interventions following hospital-treated self-harm

BACKGROUND

Prior self-harm represents the most significant risk factor for future self-harm or suicide.

AIM

To evaluate the cost-effectiveness of a theoretical brief aftercare intervention (involving brief follow-up contact, care coordination and safety planning), following a hospital-treated self-harm episode, for reducing repeated self-harm within the Australian context.

METHOD

We employed economic modelling techniques to undertake: (a) a return-on-investment analysis, which compared the cost-savings generated by the intervention with the overall cost of implementing the intervention; and (b) a cost-utility analysis, which compared the net costs of the intervention with health outcomes measured in quality-adjusted life years (QALYs). We considered cost offsets associated with hospital admission for self-harm and the cost of suicide over a period of 10 years in the base case analysis. Uncertainty and one-way sensitivity analyses were also conducted.

RESULTS

The brief aftercare intervention resulted in net cost-savings of AUD$7.5 M (95% uncertainty interval: -56.2 M to 15.1 M) and was associated with a gain of 222 (95% uncertainty interval: 45 to 563) QALYs over a 10-year period. The estimated return-on-investment ratio for the intervention's modelled cost in relation to cost-savings was 1.58 (95% uncertainty interval: -0.17 to 5.33). Eighty-seven per cent of uncertainty iterations showed that the intervention could be considered cost-effective, either through cost-savings or with an acceptable cost-effectiveness ratio of 50 000 per QALY gained. The results remained robust across sensitivity analyses.

CONCLUSIONS

A theoretical brief aftercare intervention is highly likely to be cost-effective for preventing suicide and self-harm among individuals with a history of self-harm.

Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial

Importance

Suicide is a leading cause of deaths in the US. Although the emergency department (ED) is an opportune setting, ED-initiated interventions remain underdeveloped and understudied.

Objective

To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors.

Design, Setting, and Participants

The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US, used an interrupted time series design with three 12-month sequential phases: baseline, implementation, and maintenance. A random sample of 25 patients per month per site 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. The primary analyses focused on those who were discharged from the ED, while secondary analyses focused on all patients who screened positive, regardless of disposition. Data were collected on patients who presented for care from January 2014 to April 2018, and data were analyzed from April to December 2022.

Interventions

Each site received lean training and built a continuous quality improvement (CQI) team to evaluate the current suicide-related workflow in the ED, identify areas of improvement, and implement efforts to improve. Each site was expected to increase their universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged home from the ED. Site teams were centrally coached by engineers experienced in lean CQI and suicide prevention specialists.

Main Outcomes and Measures

The primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window.

Results

Across 3 phases, 2761 patient encounters were included in the analyses. Of these, 1391 (50.4%) were male, and the mean (SD) age was 37.4 (14.5) years. A total of 546 patients (19.8%) exhibited the suicide composite during the 6-month follow-up (9 [0.3%] died by suicide and 538 [19.5%] of a suicide-related acute health care visit). A significant difference was observed for the suicide composite outcome between the 3 phases (baseline, 216 of 1030 [21%]; implementation, 213 of 967 [22%]; maintenance, 117 of 764 [15.3%]; P = .001). The adjusted odds ratios of risk of the suicide composite during the maintenance phase was 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, which reflect a 43% and 39% reduction, respectively.

Conclusions and Relevance

In this multisite randomized clinical trial, using CQI methods to implement a department-wide change in suicide-related practices, including the implementation of a safety plan intervention, yielded a significant decrease in suicide behaviors in the maintenance period of the study.

Trial Registration

ClinicalTrials.gov Identifier: NCT02453243.

"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors

OBJECTIVES

Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018.

RESULTS

After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies).

CONCLUSIONS

The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Brief Interventions for Self-injurious Thoughts and Behaviors in Young People: A Systematic Review

Rates of self-injurious thoughts and behaviors (SITBs) increase sharply across adolescence and remain high in young adulthood. Across 50 years of research, existing interventions for SITBs remain ineffective and inaccessible for many young people in particular need of mental healthcare. Briefer intervention options may increase access to care. However, many traditional interventions for SITBs take 6 months or more to complete-making it difficult for providers to target SITBs under real-world time constraints. The present review (1) identifies and (2) summarizes evaluations of brief psychosocial interventions for SITBs in young people, ages 10-24 years. We conducted searches for randomized and quasi-experimental trials conducted in the past 50 years that evaluated effects of "brief interventions" (i.e., not exceeding 240 min, or four 60-min sessions in total length) on SITBs in young people. Twenty-six articles were identified for inclusion, yielding a total of 23 brief interventions. Across all trials, results are mixed; only six interventions reported any positive intervention effect on at least one SITB outcome, and only one intervention was identified as "probably efficacious" per standard criteria for evidence-based status. While brief interventions for SITBs exist, future research must determine if, how, and when these interventions should be disseminated.

Sensitivity to ostracism is blunted in suicide attempters only when they report suicidal ideation

BACKGROUND

Modified pain perception is at the core of many theories on suicide; however, studies on the relationship between pain perception and suicidal behavior (attempt) have produced contradictory results. In this experimental study, we investigated whether physical pain and social pain are concomitantly influenced by suicidal ideation (SI) and past suicidal behavior.

METHODS

155 inpatients with depression (90 with and 65 without past history of suicide attempt) were included. They underwent thermal stimulation of the skin to assess physical pain tolerance and played the Cyberball game to assess their sensitivity to ostracism (social pain). Participants self-assessed current SI through the specific item in the Beck Depression Inventory.

RESULTS

Pain tolerance was not associated with history of suicide attempt, current SI, and their interaction. Social pain was associated with the interaction between history of suicide attempt and current SI. Social pain was decreased in suicide attempters, compared with non-attempters, only when they reported current SI.

LIMITATIONS

Cyberball game may not be representative of everyday stress and ecological social context.

CONCLUSIONS

Unlike what suggested by many theories, pain tolerance does not seem to be necessary to attempt suicide. Suicide attempters with current SI displayed blunted sensitivity to ostracism and could be less willing to restore social affiliation compared with non-attempters.

Feasibility of a Supportive Text Messaging Intervention in Northwest Alaska

Suicide disproportionately impacts young Alaska Native people in the northwestern region of Alaska. As part of its efforts to address this challenge, Maniilaq Association developed a program to determine the feasibility of sending short text messages of caring and support. Process evaluation measures included the number of enrollees and the number of text messages sent each month. To determine participant satisfaction and seek recommendations for improvements, a short, online survey was disseminated to enrollees via text message in 2021 and 2022. Between January 2020 and September 2021, text messages were sent each month to about 100 participants, each with an accompanying image. Messages included "You are capable of amazing things" and "You are enough". Twenty-five individuals completed the 2021 survey and 11 the 2022 survey; three quarters lived in Northwest Arctic. Respondents said the messages improved their mood and made them feel like they mattered a lot or a great deal. The intervention was well-received by participants, inspiring individuals to reach out to others and reach out for help for themselves. Recommendations for improvements included increasing culturally relevant and meaningful quotes and the frequency and consistency of messages. Due to concerns around confidentiality, it is unclear if the initiative reached those most at-risk for suicide. However, participants sharing the messages among the small population of the region may have facilitated a broader reach than would otherwise be expected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41347-022-00293-z.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Psychosocial interventions addressing suicidality in inpatient psychiatry: a scoping review protocol

OBJECTIVE

The objective of this review is to provide an overview of the existing literature on psychosocial interventions aimed at addressing suicidality among adults in the context of an inpatient psychiatric admission.

INTRODUCTION

For individuals admitted to a psychiatric inpatient unit, their risk of suicide in the period following discharge is significantly higher compared to the prevalence of death by suicide in the general population. During an inpatient admission, there is opportunity for supportive interventions that may lead to reduced risks of suicide. Yet, interventions that directly address suicidality have primarily been studied in outpatient settings. A broader understanding of inpatient interventions will assist clinicians in understanding key considerations when implementing suicide-related interventions in this setting.

INCLUSION CRITERIA

Studies involving adult patients (≥18 y) that describe psychosocial interventions aiming to address suicidality in the context of inpatient psychiatry will be considered. Studies that only describe pharmacological interventions will be excluded, as will studies that describe psychosocial interventions initiated in the context of an outpatient setting.

METHODS

We will search MEDLINE (Ovid), CINAHL (EBSCO), APA PsycINFO (EBSCOhost), the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), and Web of Science for studies in English and Spanish. Gray literature and materials will also be searched for using Google and websites relevant to the review topic. No date limit will be set. Two independent reviewers will screen titles and abstracts from studies that meet the inclusion criteria and review eligible studies at full text. Data will be extracted and synthesized and then presented in tabular and graphical formats accompanied by a narrative summary.

REVIEW REGISTRATION NUMBER

Open Science Framework (https://osf.io/5cwhx).

Brief contact interventions to reduce suicide among discharged patients with mental health disorders-A meta-analysis of RCTs

BACKGROUND

Worldwide, about 1 million died from suicide in 2000. People with mental health disorders are at greater risk of suicide, and they are especially susceptible during 1-week period after discharge from the hospital.

OBJECTIVE

This meta-analysis paper aims to evaluate the effectiveness of brief contact interventions in preventing (1) suicidal deaths, (2) suicidal attempts, and (3) suicidal ideations among mental health patients discharged from the hospital.

METHODS

Search for published and unpublished articles were conducted using 10 databases: CINAHL, Cochrane Central Register of Controlled Trials, Embase, Scopus, Pubmed, PsycINFO, Web of Science, Randomised Control Trial Registry Website, ClinicalTrials.gov, and Proquest Dissertation and Theses Global, using the keywords "suicide" AND "discharged," AND "patients." All articles printed in English and published from the year 1995 to August 2019 were included.

RESULTS

A total of 23 articles were included in the meta-analysis. Contact interventions significantly reduced suicidal attempts within (1) 12-14 months and (2) suicide ideations within 12 months. There were no significant findings on suicidal deaths.

DISCUSSION

A new finding of this meta-analysis is that combining several brief contact interventions could potentially reduce suicidal attempts and ideations. This is important in preserving the lives of discharged patients.

A peer approach to suicide prevention and recovery: Study protocol for a feasibility and acceptability trial of Caring Cards for veterans

Introduction

There is a need to develop, evaluate, and implement interventions that reduce Veteran suicide. Caring Cards (CC) is a novel intervention that integrates aspects of caring contacts and peers (i.e., persons with lived mental health experience). In CC, Veterans meet in a weekly group to create hope-filled cards that are sent to Veterans with mental health concerns. This study will examine feasibility and acceptability of CC with Veterans with a history of and current elevated suicide risk via in-person and virtual modalities and preliminarily evaluate pre/post changes on suicide-specific outcomes.

Methods

This 2-year open-trial study will employ a pre/post research design. Recruited Veterans with a history of suicide risk (n = 30) will make up CC groups (card makers) and Veterans currently at high-risk for suicide (n = 50) will be card recipients. Feasibility and acceptability (recruitment, retention, attendance, card receipt rates, and satisfaction questionnaire responses) and pre/post changes on suicide-specific outcomes (i.e., thwarted belonginess, perceived burdensomeness, social connectedness, suicidal ideation, and behavior) will be evaluated. Groups will meet weekly for 90–120 min for three to six months; card recipients will receive one card per month for six months.

Discussion

This study builds on preliminary data which indicate Veterans are interested in and find participating in CC highly meaningful. This study is innovative as it will target two new Veteran populations and use both in-person and virtual modalities. If feasible and acceptable, a large-scale efficacy trial will be conducted to further examine CC as a suicide prevention intervention for Veterans.

Suicide and Telehealth Treatments: A PRISMA Scoping Review

BACKGROUND

This PRISMA scoping review explored worldwide research on the delivery of suicide-specific interventions through an exclusive telehealth modality. Research over telehealth modalities with suicidal individuals highlights the importance of facilitating participants' access to treatments despite location and circumstances (e.g., rural, expenses related to appointments, etc.).

AIM

The review sought evidence of outcomes of trials or projects in which both the patient and therapist attended sessions conjointly and openly discussed suicide over a telehealth modality (e.g., phone, zoom).

METHOD

To explore this topic the authors searched for research trials and quality improvement projects using Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO Social Services Abstracts, and Web of Science on 3/3/2021.

RESULTS

Nine different articles were included that each spanned distinct treatments, with eight being research studies and one being a quality improvement project.

LIMITATIONS

Publications featuring ongoing or upcoming research in which complete study results were not available did not meet inclusion criteria for this review.

CONCLUSION

Several important research gaps were identified. While this approach has been largely understudied, exclusive telehealth delivery of suicide-specific interventions has great potential for the prevention of suicidality, especially in the era of COVID-19 and beyond.

Interventions for attempted suicide

PURPOSE OF REVIEW

Suicide is a major, global, public health issue. Those who attempt suicide represent a high-risk subgroup for eventual death by suicide. We provide an update on emerging evidence for interventions for attempted suicide to reduce subsequent suicidal behavior.

RECENT FINDINGS

Major approaches that have been examined recently include pharmacological, psychosocial, brief active contact and outreach interventions, and digitally driven interventions. Notwithstanding the limited evidence base for most of these approaches, brief contact and follow-up interventions appear to have more robust effects on reduction of repeat suicidal behavior, including attempts; such approaches may have especial significance in emergency settings because of their brevity. Digital interventions for self-harm appear promising in the short-term whereas the evidence for pharmacological and psychosocial strategies remain inconclusive.

SUMMARY

Although current evidence supports the use of brief interventions, contact, and outreach for reducing risk of subsequent suicide attempts and suicidal behavior, there are large gaps and limitations in the evidence base related to trial design, lack of long-term efficacy data, and implementational challenges. More robustly designed long-term trials that examine integrated intervention approaches with well defined outcomes are needed to develop recommendations in this area.

Umbrella review of nursing interventions NIC for the treatment and prevention of suicidal behavior

PURPOSE

The aim of this umbrella review was to determine the most effective nursing interventions for the prevention and management of suicidal behavior. In order to do so, the review identifies interventions from the Nursing Interventions Classifications taxonomy with evidence to this end.

METHODS

A systematic search was conducted for systematic reviews included in the PubMed, CINAHL, Cochrane, Scopus, Web of Knowledge, and Joanna Briggs Institute databases between January 1, 2011 and May 1, 2020.

FINDINGS

The review is made up of 21 systematic reviews. In order to carefully analyze the interventions described, these were coded into categories, grouping the interventions into those based on psychological therapy, interventions related to pharmacotherapy, interventions related to the professional relationship between health professional and patient, and interventions aimed at the general public.

CONCLUSIONS

Nursing interventions for suicide risk management are prevalent in the scientific literature and are shown to be effective for patients with suicidal ideation or suicide attempts. Prevention and treatment of suicidal behavior require the provision of coping tools, behavioral interventions that directly address suicidal thoughts and behaviors, and support through therapeutic partnerships, among others.

IMPLICATIONS FOR NURSING PRACTICE

This paper synthesizes the most current evidence on the most effective Nursing Interventions Classifications interventions for the treatment and prevention of suicidal behavior. It provides nursing practitioners with a comprehensive review of the therapeutic interventions with the best evidence and is useful for the development of clinical guidelines and protocols, as well as for the development of health policies and plans.

The effectiveness of remote delivered intervention for loneliness reduction in older adults: A systematic review and meta-analysis

Background

Remotely delivered intervention is widely applied to loneliness treatment in older adults, but the effect is controversial. This study aimed to evaluate the effects of remotely delivered intervention on loneliness using a systematic review and meta-analysis.

Methods

The PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, CINAHL (EBSCO), PsycINFO (EBSCO) databases were searched for studies, the search ended on 7 July 2021. Thirteen randomized controlled trials of remotely delivered intervention compared with usual care, brief contact, or no intervention for loneliness were included. A random-effects model measured estimation of loneliness reduction. Furthermore, standardized mean differences (SMDs), 95% confidence intervals (CIs), publication bias, and heterogeneity were calculated. Subgroup analysis was used to explore the factors that might affect the treatment effects.

Results

The evidence of remotely delivered intervention on loneliness reduction was certain (SMD = −0.41 [95% CI, −0.70 to −0.13]). Media subgroup analysis supported the effectiveness of intervention delivered by video call (SMD = −0.54 [95% CI, −0.83 to −0.25]); treatment strategy subgroup analysis found evidence to support the effectiveness of increasing social support and maladaptive social cognition treatment strategy (SMD = −0.47 [95% CI, −0.77 to −0.18] and SMD = −1.04 [95% CI, −1.98 to −0.10], respectively); participants subgroup analysis shown the effectiveness of intervention for older adults living in LTC and social isolation (SMD = −1.40 [95% CI, −2.43 to −0.36] and SMD = −0.55 [95% CI, −0.74 to −0.36], respectively); group format subgroup analysis testified the effectiveness of intervention carried out in individual format (SMD = −0.39 [95% CI, −0.71 to −0.07]); measurement time points subgroup analysis found the positive effect of intervention at 3 months and 3 to 6 months stage (SMD = −0.33 [95% CI, −0.52 to −0.14] and SMD = −0.32 [95% CI, −0.57 to −0.07], respectively). Significant publication bias was detected (p &lt; 0.05), and the heterogeneity of the studies was substantial.

Conclusion

This systematic review and meta-analysis demonstrate that remotely delivered intervention can reduce loneliness in older adults, and it appears to be affected by media type, treatment strategy, participants characteristics, group format, and measurement time points.

SAFETEL: a pilot randomised controlled trial to assess the feasibility and acceptability of a safety planning and telephone follow-up intervention to reduce suicidal behaviour

BACKGROUND

A previous suicide attempt is an important predictor of future suicide. However, there are no evidence-based interventions administered in UK general hospital contexts to reduce suicidal behaviour in patients admitted following a suicide attempt. Consequently, the objective of this pilot randomised controlled trial was to explore whether a safety planning and telephone follow-up intervention (SAFETEL) was feasible and acceptable for individuals treated in hospital following a suicide attempt.

METHODS

In this three-phase study with an embedded process evaluation, a safety planning intervention was tailored to the UK context (Phase I), piloted (Phase II, n = 32), and tested in a feasibility randomised controlled trial (Phase III). In Phase III, participants were allocated to either the intervention (n = 80) or control group (n = 40) using telephone randomisation with a 2:1 ratio. The acceptability and feasibility of the trial and intervention procedures were evaluated using both qualitative (interviews and focus groups) and quantitative data. The number of hospital representations of suicidal behaviour was also collected 6 months after study recruitment based on electronic patient records.

RESULTS

Findings indicated that SAFETEL was both acceptable and feasible. Hospital staff reported the intervention fitted and complemented existing services, and patients reported that they favoured the simplicity and person-centred approach of the safety planning intervention.

CONCLUSIONS

All progression criteria were met supporting further evaluation of the intervention in a full-scale clinical effectiveness trial.

TRIAL REGISTRATION

ISRCT, ISRCTN62181241 , 5/5/2017.

Effectiveness of distance-based suicide interventions: multi-level meta-analysis and systematic review

BACKGROUND

The use of distance-based interventions (DBIs) to reduce suicidal ideation and behaviours are an increasingly relevant form of intervention. DBIs are more affordable, scalable and available than traditional face-to-face interventions, helping to narrow the gap between needed and provided care.

AIMS

To evaluate the overall effectiveness of DBIs against suicidal ideation and behaviours.

METHOD

We systematically searched Web of Science, Scopus and PubMed for all DBIs primarily aimed at reducing suicidal ideation and behaviours. Data were analysed with a robust variance estimation corrected, multi-level meta-analysis.

RESULTS

We found 38 studies, reporting 110 outcomes. Effectiveness in reducing suicidal ideation was low (standardised mean difference -0.174, 95% CI -0.238 to -0.110). DBIs were significantly less effective against suicidal behaviours than against suicidal ideation, although still effective (standardised mean difference -0.059, 95% CI -0.087 to -0.032). Human involvement had no significant effect on effectiveness.

CONCLUSIONS

Despite low effectiveness, DBIs might play a role in large-scale prevention efforts against suicidal ideation within a stepped care approach. Further, DBIs may be helpful in expanding mental health services in low- and middle-income countries with otherwise limited access to mental healthcare. Although the evidence for DBIs efficacy is well grounded, the technical and scientific evaluation of DBIs regarding their set up, functionality and components needs to be addressed in future studies.

Effectiveness of Brief Contact Interventions for Bereavement: A Systematic Review

Brief contact interventions are an efficient and cost-effective way of providing support to individuals. Whether they are an effective bereavement intervention is not clear. This systematic review included articles from 2014 to 2021.711 studies were identified, with 15 meeting inclusion criteria. The brief contact interventions included informational and emotional supports. Narrative synthesis identified that participants valued brief contact interventions, however some did not find them helpful. Exposure to a brief contact intervention was typically associated with improvements in wellbeing. Studies with comparison groups typically found significant but modest improvements in grief, depression symptoms and wellbeing associated with the intervention. However, one intervention was associated with significant deterioration of depression symptoms. Existing brief contact interventions for bereavement appear feasible, generally acceptable to the target population and are associated with improvements in wellbeing. Further development and evaluation to account for why improvements occur, and to identify any unintended impacts, is required.

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.

A Novel Recovery-Based Suicide Prevention Program in Upstate New York

Suicide prevention efforts have focused primarily on screening, education, and brief interventions rather than on treatment of underlying vulnerabilities. The Psychiatry High Risk Program (PHRP) is a specialized outpatient program for suicidal youths and young adults that facilitates transitions in care and provides comprehensive treatment aimed at healing and recovery. The authors evaluated the program's impact on inpatient utilization and suicide risk for patients (N=32) who were referred to the PHRP after psychiatric hospitalization for suicidality. Results indicate that program participants had large reductions in depression and suicidal ideation over 180 days postdischarge; they also had significantly fewer rehospitalizations than did a matched historical cohort, with an average savings of >6 hospital days per patient. These preliminary results suggest that a recovery-based suicide prevention program can be feasible and sustainable and may be cost-effective in a value-based system of care.

Suicide Prevention Interventions and Their Linkages in Multilayered Approaches for Older Adults: A Review and Comparison

Multilayered approaches to suicide prevention combine universal, selective, and indicated prevention interventions. These approaches may be more successful in reducing suicide rates among older adults if they link these layers more systematically: that is, if the programs are designed so that interventions at a lower level facilitate involvement at a higher level when appropriate. This study aimed to examine the effect on suicide rates of the structure of multilayered approaches, and in particular the types of interventions and the connections or linkages between them. We also wished to consider any different effects by sex. A literature search used PubMed and PsycINFO to identify systematic reviews of interventions in this age group. From the reference lists of these articles, we identified controlled studies assessing the impact of a multilayered program on suicide incidence among older adults. We were particularly interested in initiatives linking different kinds of prevention interventions. We found three relevant systematic reviews, and from these, we identified nine eligible studies. These included seven non-randomized controlled studies from rural areas in Japan (average eligible population: 3,087, 59% women, average duration: 8 years). We also found two cohort studies. The first was from a semi-urban area in Padua, Italy (18,600 service users, 84% women, duration: 11 years). The second was from urban Hong Kong, with 351 participants (57% women) over a 2-year follow-up period. We used a narrative synthesis of these studies to identify five different multilayered programs with different forms of connections or linkages between layers. Two studies/programs (Italy and Hong Kong) involved selective and indicated prevention interventions. One study/program (Yuri, Japan) included universal and selective prevention interventions, and the final six studies (two programs in northern Japan) involved linkages between all three layers. We also found that these linkages could be either formal or informal. Formal linkages were professional referrals between levels. Informal linkages included advice from professionals and self-referrals. Several of the studies noted that during the program, the service users developed relationships with services or providers, which may have facilitated movements between levels. All five programs were associated with reduced suicide incidence among women in the target groups or communities. Two programs were also associated with a reduction among men. The study authors speculated that women were more likely to accept services than men, and that the care provided in some studies did less to address issues that are more likely to affect men, such as suicidal impulsivity. We therefore suggest that it is important to build relationships between levels, especially between selective and indicated prevention interventions, but that these can be both formal and informal. Additionally, to reach older men, it may be important to create systematic methods to involve mental health professionals in the indicated prevention intervention. Universal interventions, especially in conjunction with systematically linked indicated and selective interventions, can help to disseminate the benefits across the community.

A Systematic Review of Training Interventions for Emergency Department Providers and Psychosocial Interventions delivered by Emergency Department Providers for Patients who self-harm

OBJECTIVES

People who self-harm frequently present to the emergency department (ED) and are treated by generalist healthcare staff with no specialist mental health training. We systematically reviewed (i) training interventions for generalist ED providers and (ii) psychosocial interventions delivered predominantly by generalist ED providers for people who self-harm.

METHOD

Five databases were searched for studies reporting on training interventions for generalist ED staff (at least 50% of the sample needed to be generalist ED staff) or psychosocial interventions for people who self-harm delivered predominantly by generalist ED staff. No limitations were placed regarding study design/country. Narrative synthesis was conducted.

RESULTS

Fifteen studies from high-income countries were included. Nine studies of moderate methodological quality evaluated training for generalist ED providers (n = 1587). Six studies of good methodological quality evaluated psychosocial interventions for adults who self-harm (n = 3133). Only one randomized controlled trial was identified. Training was linked with pre-post improvements in staff knowledge, and less consistently with improvement in skills, attitudes, and confidence. Evidence on patient outcomes was lacking. Patient-level interventions involving common suicide prevention strategies-safety planning and follow-up contact-were consistently linked to pre-post reductions in suicide attempts. Effects on treatment engagement and psychiatric admissions were unclear.

CONCLUSIONS

There is a clear need for further RCTs to improve the evidence base for ED generalist providers managing patients with self-harm. Evidence supports potential benefits of training for improving staff knowledge, attitudes, and skills, and of safety planning and follow-up contact for reducing repeat suicide attempts. HIGHLIGHTSMore RCTs are needed to improve the evidence base for ED providers managing self-harmSafety planning and follow up contacts are linked to reductions in repeat suicide attemptsFuture research should investigate the impact of staff training on patient outcomes.

Developing a post-discharge suicide prevention intervention for children and young people: a qualitative study of integrating the lived-experience of young people, their carers, and mental health clinicians

BACKGROUND

Suicide in young people is a leading cause of death. Interventions that are reflexive, tailored, and developed in concert with this at-risk population are needed. This study aimed to integrate lived-experience into the design of a suicide prevention intervention delivered by phone to young people post-discharge from an emergency department (ED) for suicide risk or self-harm.

METHODS

Qualitative study was conducted at the Queensland Children's Hospital, Brisbane Australia. Four focus groups with young people with lived-experience, parents or carers and ED mental health clinicals were conducted. In total 5 young people with lived-experience of suicidality (17-21 years, M_age = 19.20), 3 parents and carers with a lived-experience of caring for a young person with mental illness, and 10 ED mental health clinicians participated in focus groups. The first phase of qualitative analysis involved a phenomenological analysis and second phase included a deductive content analysis. The paper is following the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

First phase, a phenomenological analysis identified three foundational themes to structure future follow-up phone interventions: a person-centred focus, the phone-call dynamic, and the phone-call purpose. Second phase, a deductive content analysis found that participants preferred an intervention that was structured, consistent, and finite. Moreover, an intervention that was authentic, able to facilitate and empower growing independence, and achievable of young people after an ED presentation was desired.

CONCLUSIONS

Participants expressed their desire for a responsive, structured, and clearly focused phone call that would recognise the young person and parent/carer's needs while providing tailored support to ease transition from the ED to available community and family led care.

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

Background

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

Methods

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

Results

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

Conclusion

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

Predictors and incidence rate of suicide re-attempt among suicide attempters: A prospective study

OBJECTIVE

Recent investigations and advances include improved understanding of trends, epidemiology, risk and protective factors on suicide. However, predictors of suicide re-attempt are poorly understood in a prospective design, at least in Iran. This prospective study was performed to investigate predictors and epidemiological aspects of suicide re-attempt during a 5-years of follow-up among Suicide Attempters (SAs).

METHODS

All the 1034 SAs of Malekan County were followed up and interviewed from 2014 to 2018. Cox regression analysis was used to estimate crude and adjusted hazard ratios and 95% confidence intervals for suicide re-attempt risk.

RESULTS

The overall prevalence of re-attempt was 117 (11.7%) over 5 years period. The overall incidence and person-time incidence rates of re-attempt were 113.15 per 1000 attempters and 7.1 per 100 person-year, respectively. The majority of re-attempts 161 (81.3%) took place within the first-18 months of follow-up while the peak of re-attempt was 6 months after attempts. In the final analysis, age ≤ 25, family income (≥ 10 million Rials), having any psychiatric disorder, poor education, stressful life events, alcohol abuse, and smoking were the most reliable predictors of suicide re-attempt.

CONCLUSION

Health systems should be informed about the predictors for subsequent SA after any attempt. Appropriate suicide prevention strategies should be tailored to the specific profile of each group for moderating predictors of suicide re-attempt.

The Potential Impact of Adjunct Digital Tools and Technology to Help Distressed and Suicidal Men: An Integrative Review

Suicidal men feel the need to be self-reliant and that they cannot find another way out of relationship or socioeconomic issues. Suicide prevention is of crucial importance worldwide. The much higher rate of suicide in men engenders action. The prelude is a subjective experience that can be very isolating and severely distressing. Men may not realize a change in their thinking and behaviors, which makes it more difficult to seek and get help, thereby interrupting a "downward spiral". Stoicism often prevents men from admitting to their personal struggle. The lack of "quality" connections and "non-tailored" therapies has led to a high number of men "walking out" on traditional clinical approaches. But there are complicated relationships in motivations and formative behaviors of suicide with regards to emotional state, psychiatric disorders, interpersonal life events and suicidal behavior method selection. Middle-aged and older men have alternated as the most at-risk of suicide. There is no one solution that applies to all men, but digital tools may be of assistance (e.g., video conferences, social networks, telephone calls, and emails). Digital interventions require higher levels of effectiveness for distress and suicidality but self-guided approaches may be the most suitable for men especially where linked with an integrated online suicide prevention platform (e.g., quick response with online chats, phone calls, and emails). Furthermore, technology-enabled models of care offer promise to advance appropriate linking to mental health services through better and faster understanding of the specific needs of individuals (e.g., socio-cultural) and the type and level of suicidality experienced. Long-term evidence for suicidality and its evaluation may benefit from progressing human computer-interaction and providing impetus for an eminent integrated digital platform.

Lithium Treatment in the Prevention of Repeat Suicide-Related Outcomes in Veterans With Major Depression or Bipolar Disorder: A Randomized Clinical Trial

IMPORTANCE

Suicide and suicide attempts are persistent and increasing public health problems. Observational studies and meta-analyses of randomized clinical trials have suggested that lithium may prevent suicide in patients with bipolar disorder or depression.

OBJECTIVE

To assess whether lithium augmentation of usual care reduces the rate of repeated episodes of suicide-related events (repeated suicide attempts, interrupted attempts, hospitalizations to prevent suicide, and deaths from suicide) in participants with bipolar disorder or depression who have survived a recent event.

DESIGN, SETTING, AND PARTICIPANTS

This double-blind, placebo-controlled randomized clinical trial assessed lithium vs placebo augmentation of usual care in veterans with bipolar disorder or depression who had survived a recent suicide-related event. Veterans at 29 VA medical centers who had an episode of suicidal behavior or an inpatient admission to prevent suicide within 6 months were screened between July 1, 2015, and March 31, 2019.

INTERVENTIONS

Participants were randomized to receive extended-release lithium carbonate beginning at 600 mg/d or placebo.

MAIN OUTCOMES AND MEASURES

Time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide.

RESULTS

The trial was stopped for futility after 519 veterans (mean [SD] age, 42.8 [12.4] years; 437 [84.2%] male) were randomized: 255 to lithium and 264 to placebo. Mean lithium concentrations at 3 months were 0.54 mEq/L for patients with bipolar disorder and 0.46 mEq/L for patients with major depressive disorder. No overall difference in repeated suicide-related events between treatments was found (hazard ratio, 1.10; 95% CI, 0.77-1.55). No unanticipated safety concerns were observed. A total of 127 participants (24.5%) had suicide-related outcomes: 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and 3 in the placebo group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the addition of lithium to usual Veterans Affairs mental health care did not reduce the incidence of suicide-related events in veterans with major depression or bipolar disorders who experienced a recent suicide event. Therefore, simply adding lithium to existing medication regimens is unlikely to be effective for preventing a broad range of suicide-related events in patients who are actively being treated for mood disorders and substantial comorbidities.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01928446.

Methods and efficacy of social support interventions in preventing suicide: a systematic review and meta-analysis

QUESTION

Suicide is a global public and mental health problem. The effectiveness of social support interventions has not been widely demonstrated in the prevention of suicide. We aimed to describe the methods of social support interventions in preventing suicide and examine the efficacy of them.

STUDY SELECTION AND ANALYSIS

We searched literature databases and conducted clinical trials. The inclusion criteria for the summary of intervention methods were as follows: (1) studies aimed at preventing suicide through method(s) that directly provide social support; (2) use of one or more method(s) to directly provide social support. The additional inclusion criteria for meta-analysis on the efficacy of these interventions included: (1) suicide, suicide attempt or social support-related outcome was measured; (2) randomised controlled trial design and (3) using social support intervention as the main/only method.

FINDINGS

In total, 22 656 records and 185 clinical trials were identified. We reviewed 77 studies in terms of intervention methods, settings, support providers and support recipients. There was a total of 18 799 person-years among the ten studies measuring suicide. The number of suicides was significantly reduced in the intervention group (risk ratio (RR)=0.48, 95% CI 0.27 to 0.85). In 14 studies with a total of 14 469 person-years, there was no significant reduction of suicide attempts in the overall pooled RR of 0.88 (95% CI 0.73 to 1.07).

CONCLUSIONS

Social support interventions were recommended as a suicide prevention strategy for those with elevated suicide risk.

Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: A preliminary analysis

AIM

Brief screening and predictive modeling have garnered attention for utility at identifying individuals at risk of suicide. Although previous research has investigated these methods, little is known about how these methods compare against each other or work in combination in the pediatric population.

METHODS

Patients were aged 8-18 years old who presented from January 1, 2017, to June 30, 2019, to a Pediatric Emergency Department (PED). All patients were screened with the Ask Suicide Questionnaire (ASQ) as part of a universal screening approach. For all models, we used 5-fold cross-validation. We compared four models: Model 1 only included the ASQ; Model 2 included the ASQ and EHR data gathered at the time of ED visit (EHR data); Model 3 only included EHR data; and Model 4 included EHR data and a single item from the ASQ that asked about a lifetime history of suicide attempt. The main outcome was subsequent PED visit with suicide-related presenting problem within a 3-month follow-up period.

RESULTS

Of the N = 13,420 individuals, n = 141 had a subsequent suicide-related PED visit. Approximately 63% identified as Black. Results showed that a model based only on EHR data (Model 3) had an area under the curve (AUC) of 0.775 compared to the ASQ alone (Model 1), which had an AUC of 0.754. Combining screening and EHR data (Model 4) resulted in a 17.4% (absolute difference = 3.6%) improvement in sensitivity and 13.4% increase in AUC (absolute difference = 6.6%) compared to screening alone (Model 1).

CONCLUSION

Our findings show that predictive modeling based on EHR data is helpful either in the absence or as an addition to brief suicide screening. This is the first study to compare brief suicide screening to EHR-based predictive modeling and adds to our understanding of how best to identify youth at risk of suicidal thoughts and behaviors in clinical care settings.

Suicide Risk Among Adults With Mental Health Emergency Department Visits With and Without Suicidal Symptoms

Objective: To describe risk factors and suicide rates during the year following discharge from mental health emergency department (ED) visits by adults with suicide attempts, suicidal ideation, or neither. Methods: National cohorts of patients with mental health ED visits for suicide attempts or self-harm (n = 55,323), suicidal ideation (n = 435,464), or other mental health visits (n = 9,144,807) from 2008 to 2012 Medicaid data were followed for suicide for 1 year after discharge. Suicide rates per 100,000 person-years were determined from National Death Index data. Poisson regression models, adjusted for age, sex, and race/ethnicity, estimated suicide rate ratios (RRs). Suicide standardized mortality ratios (SMRs) were estimated from National Vital Statistics System data. Results: Suicide rates per 100,000 person-years were 325.4 for suicide attempt or self-harm visits (RR = 5.51, 95% CI, 4.64-6.55), 156.6 for suicidal ideation visits (RR = 2.59, 95% CI, 2.34-2.87), and 57.0 for the other mental health ED visits (1.0, reference). Compared to expected suicide general population rates, SMRs were 18.2 (95% CI, 13.0-23.4) for suicide attempt or self-harm patients, 10.6 (95% CI, 9.0-12.2) for suicidal ideation patients, and 3.2 (95% CI, 3.1-3.4) for other ED mental health patients. Among patients with suicide attempt ED visits in the 180 days before their index mental health ED visit, suicide rates per 100,000 person-years were 687.2 (95% CI, 396.5-978.0) for attempt or self-harm visits, 397.4 (95% CI, 230.6-564.3) for ideation visits, and 328.4 (95% CI, 241.5-415.4) for other mental health visits. Conclusions: In the year following discharge, emergency department patients with suicide attempts or self-harm, especially repeated attempts, have a high risk of suicide.

Designed and created for a veteran by a veteran: A pilot study of caring cards for suicide prevention

INTRODUCTION

This pilot study investigates feasibility and acceptability of Caring Cards, a suicide prevention intervention inspired by Caring Contacts and the Recovery Model, where Veteran peers create cards that are sent to Veterans recently discharged from a VA psychiatric hospitalization for suicide risk.

METHODS

Caring Cards consists of: (1) a weekly outpatient group where Veterans (card makers) create cards, and (2) sending cards to recently discharged Veterans (card recipients). Feasibility for card makers was measured by attendance; acceptability (satisfaction) was examined. Card recipients were sent one caring card, one week post-discharge. Feasibility for recipients was measured by the percentage of Veterans that met eligibility and follow-up response rate; acceptability (satisfaction) was examined.

RESULTS

Caring Cards is feasible and acceptable. The outpatient group had a higher attendance rate (81%) compared with other clinic groups. The percentage of eligible card recipients was 61%. Of these, 69% were reached for follow-up and 50% provided follow-up responses. Card makers and recipients both expressed positive experiences with Caring Cards.

CONCLUSION

Caring Cards is a low-intensity, feasible, and acceptable intervention with potential benefits for both Veteran card makers and recipients. Additional research is needed to determine the efficacy of Caring Cards as a suicide prevention intervention.

Nursing interventions of choice for the prevention and treatment of suicidal behaviour: The umbrella review protocol

AIM

To determine which interventions, from a nursing perspective, can be considered as the interventions of choice for the prevention and treatment of suicidal behaviour. In this way, the umbrella review attempts to identify nursing interventions from the Nursing Interventions Classification (NIC) taxonomy with evidence for this purpose.

DESIGN

Descriptive study protocol.

METHODS

This umbrella review will consist of an extensive, systematic search of published systematic reviews and meta-analyses of studies examining interventions of choice for the prevention and treatment of suicidal behaviour. A systematic search of papers indexed in PubMed, CINAHL, Cochrane Database of Systematic Reviews, Scopus, ISI Web of Knowledge and the Joanna Briggs Institute databases will be carried out; the results will be evaluated for inclusion by two independent reviewers. In addition, the bibliographic references of the included reviews will be searched. The assessment of the methodological quality of the included systematic reviews and meta-analyses, and data extraction, will be performed by two independent reviewers. Conflicts between reviewers will be resolved by an independent third reviewer. Research Ethics Committee approval is not required for this umbrella review.

RESULTS

We will determine which of the interventions identified as being of choice in the review are included in the Nursing Interventions Classification (NIC); they may be an effective therapeutic tool for nurses in the prevention and treatment of suicidal behaviour.

Leite V, Porto DM, Robis KP, Fidalgo TM, Rocha GA, Diaz AP, Meleiro A, Correa H, Tung TC, Malloy-Diniz L, Quevedo J, da Silva AG. Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eighty-five articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention. Systematic review registry number: CRD42020206517.

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

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

Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses

BACKGROUND

The Zero Suicide framework is a system-wide approach to prevent suicides in health services. It has been implemented worldwide but has a poor evidence-base of effectiveness.

AIMS

To evaluate the effectiveness of the Zero Suicide framework, implemented in a clinical suicide prevention pathway (SPP) by a large public mental health service in Australia, in reducing repeated suicide attempts after an index attempt.

METHOD

A total of 604 persons with 737 suicide attempt presentations were identified between 1 July and 31 December 2017. Relative risk for a subsequent suicide attempt within various time periods was calculated using cross-sectional analysis. Subsequently, a 10-year suicide attempt history (2009-2018) for the cohort was used in time-to-recurrent-event analyses.

RESULTS

Placement on the SPP reduced risk for a repeated suicide attempt within 7 days (RR = 0.29; 95% CI 0.11-0.75), 14 days (RR = 0.38; 95% CI 0.18-0.78), 30 days (RR = 0.55; 95% CI 0.33-0.94) and 90 days (RR = 0.62; 95% CI 0.41-0.95). Time-to-recurrent event analysis showed that SPP placement extended time to re-presentation (HR = 0.65; 95% CI 0.57-0.67). A diagnosis of personality disorder (HR = 2.70; 95% CI 2.03-3.58), previous suicide attempt (HR = 1.78; 95% CI 1.46-2.17) and Indigenous status (HR = 1.46; 95% CI 0.98-2.25) increased the hazard for re-presentation, whereas older age decreased it (HR = 0.92; 95% CI 0.86-0.98). The effect of the SPP was similar across all groups, reducing the risk of re-presentation to about 65% of that seen in those not placed on the SPP.

CONCLUSIONS

This paper demonstrates a reduction in repeated suicide attempts after an index attempt and a longer time to a subsequent attempt for those receiving multilevel care based on the Zero Suicide framework.

SUICIDE REATTEMPT IN A POPULATION-WIDE BRIEF CONTACT INTERVENTION TO PREVENT SUICIDE ATTEMPTS - THE VIGILANS PROGRAM, FRANCE

Objective

Among the postcrisis suicide prevention programmes, brief contact interventions (BCIs) have been proven to be efficient. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls, and sending postcards, according to a predefined algorithm. However, a major problem in suicide prevention is the suicide reattempt, which can lead to final suicide. Here, we analyze the suicide reattempt in VigilanS.

Methods

The study concerned patients included in VigilanS over the period from January 1, 2015 to December 31, 2018, with an end of follow-up on July 1, 2019. We performed a series of descriptive analyses, survival curves, and regressions. The outcome was the suicide reattempt, and the predictive variables were the characteristics of the patient at entry and during follow-up in VigilanS. Age and sex were considered as adjustment variables.

Results

A total of 11,879 inclusions occurred during the study period, corresponding to 10,666 different patients, among which 905 reattempted suicide. More than half were primary suicide attempters (53.4%). A significant relationship with suicide reattempt was identified for the following characteristics: being a non-primary suicide attempter, having attempted suicide by voluntary drug intoxication and phlebotomy, alcohol consumption among primary suicide attempters, and having no companion at the emergency room visit among non-primary suicide attempters. Hanging (as suicide method), having made no call to VigilanS were protective factors.

Conclusion

This study provides us with a valuable insight into the profiles of patients repeating a suicide attempts, which is important for suicide prevention in general.

Effectiveness of a French Program to Prevent Suicide Reattempt (VigilanS)

AIM

Brief contact interventions (such as letters, green cards, telephone calls or postcards) for reducing suicide reattempt (SR) and suicide have been evaluated since the 1980s, but results have been inconsistent. VigilanS is one of these programs that has benefited patients hospitalized for suicide attempt (SA) after discharge in 2 departments of northern France since 2015. The purpose of this study is to demonstrate its effectiveness in reducing SR.

METHODS

Patients exposed to VigilanS in 2016 were recruited from the medical administrative database of the program, and the nonexposed patients from a database of the medico-surgical ward outside the scope of the program. First, a Cox model was used to compare the probability of SR during the 12-month follow-up period between the 2 groups. Second, a propensity score using the variables sex, age, source, SA history and SA method was used to match the VigilanS-exposed and the nonexposed patients. A Cox model propensity score adjusted analysis was reiterated on the matched data.

RESULTS

The exposed and nonexposed groups included 3,068 and 3,694 individuals, respectively. In the bivariate analyses, the cumulative probability of SR at 12 months was significantly lower in the exposed group (6.0%, 95% confidence interval (CI): 5.5-6.5%) than in the nonexposed group (16.8%, 95% CI: 15.9-17.7%; p < 0.001). In the Cox model, the hazard ratio of SR was 0.38 in the exposed patients (95% CI: 0.36-0.40, p < 0.001). After matching, the cumulative probability of SR at 12 months was 5.2% in exposed versus 22.2% in nonexposed patients (p < 0.001). In the propensity score-adjusted Cox model, the hazard ratio of SR in the exposed patients was 0.19 (95% CI: 0.14-0.24, p < 0.001).

CONCLUSION

The results suggest the effectiveness of this real-life program for reducing SR. However, VigilanS only benefits a portion of the patients hospitalized for SA and therefore could be extended.

Accuracy Requirements for Cost-effective Suicide Risk Prediction Among Primary Care Patients in the US

Importance

Several statistical models for predicting suicide risk have been developed, but how accurate such models must be to warrant implementation in clinical practice is not known.

Objective

To identify threshold values of sensitivity, specificity, and positive predictive value that a suicide risk prediction method must attain to cost-effectively target a suicide risk reduction intervention to high-risk individuals.

Design, Setting, and Participants

This economic evaluation incorporated published data on suicide epidemiology, the health care and societal costs of suicide, and the costs and efficacy of suicide risk reduction interventions into a novel decision analytic model. The model projected suicide-related health economic outcomes over a lifetime horizon among a population of US adults with a primary care physician. Data analysis was performed from September 19, 2019, to July 5, 2020.

Interventions

Two possible interventions were delivered to individuals at high predicted risk: active contact and follow-up (ACF; relative risk of suicide attempt, 0.83; annual health care cost, $96) and cognitive behavioral therapy (CBT; relative risk of suicide attempt, 0.47; annual health care cost, $1088).

Main Outcomes and Measures

Fatal and nonfatal suicide attempts, quality-adjusted life-years (QALYs), health care sector costs and societal costs (in 2016 US dollars), and incremental cost-effectiveness ratios (ICERs) (with ICERs ≤$150 000 per QALY designated cost-effective).

Results

With a specificity of 95% and a sensitivity of 25%, primary care-based suicide risk prediction could reduce suicide death rates by 0.5 per 100 000 person-years (if used to target ACF) or 1.6 per 100 000 person-years (if used to target CBT) from a baseline of 15.3 per 100 000 person-years. To be cost-effective from a health care sector perspective at a specificity of 95%, a risk prediction method would need to have a sensitivity of 17.0% or greater (95% CI, 7.4%-37.3%) if used to target ACF and 35.7% or greater (95% CI, 23.1%-60.3%) if used to target CBT. To achieve cost-effectiveness, ACF required positive predictive values of 0.8% for predicting suicide attempt and 0.07% for predicting suicide death; CBT required values of 1.7% for suicide attempt and 0.2% for suicide death.

Conclusions and Relevance

These findings suggest that with sufficient accuracy, statistical suicide risk prediction models can provide good health economic value in the US. Several existing suicide risk prediction models exceed the accuracy thresholds identified in this analysis and thus may warrant pilot implementation in US health care systems.