Research report
Effectiveness of a telephone management programme for patients discharged from an emergency department after a suicide attempt: Controlled study in a Spanish population

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Abstract

Objective

To determine the effectiveness over one year of a specific telephone management programme on patients discharged from an emergency department (ED) after a suicide attempt. We hypothesized that the programme will reduce the percentage of patients re-attempting suicide and delay the time between attempts.

Design

A multicentre, case-control, population-based study. The effect of the 1-year intervention on the main outcome measures was evaluated with respect to a 1-year baseline period and a control group.

Setting

Two hospitals with distinct catchment areas in Catalonia (Spain).

Participants

A total of 991 patients discharged from the ED of either hospital after a suicide attempt during the baseline year and the intervention year.

Intervention

The intervention was carried out on patients discharged from the ED for attempted suicide (Sabadell). It consisted of a systematic, one-year telephone follow-up programme: after 1 week, thereafter at 1, 3, 6, 9 and 12-month intervals, to assess the risk of suicide and increasing adherence to treatment. The population in the control group (Terrassa) received treatment as usual after discharge, without additional telephone management.

Main outcome measures

Time elapsed between initial suicide attempt and subsequent one, and changes in the annual rate of patients who reattempted suicide in the year of the intervention and the preceding one.

Results

The telephone management programme delayed suicide reattempts in the intervention group compared to the baseline year (mean time in days to first reattempt, year 2008=346.47, sd=4.65; mean time in days to first reattempt, year 2007=316.46, sd=7.18; P<0.0005; χ²=12.1, df=1) and compared to the control population during the same period (mean time in days to first reattempt, treatment period=346.47, sd=4.65; mean time in days to first reattempt, pre-treatment period=300.36, sd=10.67; P<0.0005; χ²=16.8, df=1). The intervention reduced the rate of patients who reattempted suicide in the experimental population compared to the previous year (Intervention 6% (16/296) v Baseline 14% (39/285) difference 8%, 95% confidence interval 2% to 12%) and to the control population (Intervention 6% (16/296) v Control 14% (31/218) difference 8%, −13% to −2%)

Limitations

One of the main obstacles was the difficulty to contact all patients within the established deadlines. Another limitation of our study was that patients under the age of 18 underwent an intensive intervention in the day hospital, although their number was very small (13/319 in 2008) and did not significantly influence the results. But the main limitation of our study was that it was performed within the EAAD project. This project includes a comprehensive multilevel intervention practically in the same experimental area and aimed at an early diagnosis and treatment of depression, which is the main psychiatric disorder associated with suicide. Moreover, longer-term studies should be encouraged to determine whether such interventions really reduce suicide

Conclusion

A telephone management programme for patients discharged from an ED after a suicide attempted would be a useful strategy in delaying further suicide attempts and in reducing the rate of reattempts, which is known as the highest risk factor for suicide completion.

Introduction

Major depressive disorder (MDD) is the most prevalent mental disorder in primary care with an annual prevalence of 9.6%. It is considered as one of the major risk factors for suicide, whether it is associated with substance abuse or not (Serrano-Blanco et al., 2010, Sofront et al., 2005). Individuals who attempt suicide and self-harm are even at a higher risk (Yoshimasu et al., 2008). Suicide is a serious worldwide health problem and ranked first as external cause of death in Spain in 2008, accounting for 3421 deaths (Instituto Nacional de estadística [sitio web], 2010).

Furthermore, people who attempt suicide are at high risk of further repetition during the following year (12–30%), mainly over the first 12 weeks (Kapur et al., 2002, Kapur et al., 2004, Kapur et al., 2005, Spirito et al., 2003, De Leo et al., 2002, Vajda and Steinbeck, 2000, Colman et al., 2004).

Given this evidence, it should be a priority to design effective intervention programmes for the prevention of suicide, improving the treatment of depression and reducing the repetition of suicidal behaviour. Evidence on such interventions is scarce, but two studies stand out for their large scope and clinical impact: the “Gotland-Study”, which showed a reduction of the number of suicides; and the multilevel intervention project for improving the care of depresses patients undertaken by the Nuremberg Alliance Against Depression (NAAD) in Germany within the “German Research Network on Depression and Suicidality (Rutz et al., 1990). This programme obtained highly satisfactory results as the rate of suicide attempts was reduced by 26.5% (Hegerl et al., 2010). After these successful results, a larger-scale project was undertaken aiming to improve strategies to prevent depression and suicide in the European Union: the European Alliance Against Depression (EAAD) (Hegerl et al., 2008). Funded by the European Commission, this organization encourages multilevel intervention programmes in 18 European countries.

Our one-year telephone intervention programme is included within the EAAD framework for the management of suicidal behaviour. To date, the few controlled studies that have conducted similar telephone interventions have shown optimistic results (Fleischmann et al., 2008, Vaiva et al., 2006). A study performed by the World Health Organisation (WHO) analyzed the effectiveness on suicide prevention of a brief one-hour counselling intervention and a 18 months follow-up (by telephone or face to face) (Fleischmann et al., 2008). The intervention yielded positive results in reducing suicide completion. Another smaller study compared the effect of telephone follow-up at 1 or 3 months with a control group, showing a reduction of reattempts during one year only in patients who had been contacted at one month after suicide attempt (Vaiva et al., 2006). This reduction was attributed to a better detection of patients at a higher risk and an early referral to emergency services. However, another study of telephone follow-up with a reduced sample yielded negative results (Cedereke et al., 2002).

Other studies on Teleassistance or Tele-check with people at risk of suicide have shown that assessment intervention and, specifically, telephone support programmes, provide encouraging results and that should continue to form a part of the care of those at risk (De Leo et al., 2002, De Leo et al., 1995; Gould et al., 2012; Mishara et al., 2007; Krysinska and De Leo, 2007).

In Sabadell, a city of 200,000 inhabitants in the province of Barcelona (Spain), the second phase of the EAAD European project was implemented between 2007 and 2008. The main objective was to improve the general treatment of depression in the whole area and to reduce the risk of suicide. Among the multilevel interventions carried out, specific measures for populations at high risk of suicide were developed, such as for patients treated for suicide attempt in emergency departments. For them, our team designed a specific intervention that was assessed in a controlled setting: the systematic telephone contact of patients discharged from the emergency department after a suicide attempt. We conducted a systematic telephone follow-up of all cases, provided at least one psychiatrist visit after emergency room discharge, independently of diagnosis, and evaluated the outcome of intervention over one year.

The aim of this study is to determine the effectiveness of this specific telephone management on this patients. We hypothesized that the programme will reduce the percentage of patients re-attempting suicide and delay the time between attempts.

Thus, obtaining these satisfactory results should encourage the implementation of such a plain intervention in the current clinical practice, and make it extensible to other centres.

Section snippets

Method

In the present study, we assess the effectiveness of a post-suicide attempt telephone management programme on patients discharged from the emergency room of Corporació Sanitària Parc Taulí (CSPT) in Sabadell over one year. CSPT is a general hospital in the province of Barcelona that covers an area of 400,000 inhabitants and provides urgent medical attention for all suicidal behaviours. All the patients were examined by a psychiatrist who assessed the risk of suicide and formulated the initial

Results

The program starts the day after the patient was discharged from the emergency room, the nurse starts by registering all patient information in the data base and then the patient receive a post-discharge visit with the referring psychiatrist within in 10 days after discharge, and the schedule the following calls.

The data below shows the total number of patients who responded (or not) to calls at 1 week and at 1, 3, 6, 9, and 12 months (Table 1).

Table 2 shows the different socio-demographic and

Discussion

The results obtained suggest that the application of a telephone management programme to patients discharged from an emergency room for suicide attempts significantly delays further attempts and decreases the rates of reattempts in the context of a general reduction.

Knowing that the risk of a subsequent suicide attempt is higher during the first 12 weeks after an initial attempt, it is to be expected that the delay in further suicide attempt is associated with a decrease of up to 6% of the

Conclusion

A telephone management programme for patients with suicide attempts admitted to emergency departments, including an early post-discharge visit by a psychiatrist proves to be more efficient than usual treatment as it reduces complications and potentially prevents suicide completion. Our results show that such an intervention is effective in delaying further suicide attempts and in reducing the rate of reattempts during the year of intervention. This second positive finding of the programme is

Conflict of interest

Funding: This study was funded by the European Commission (Grant Agreement: 06/2005323), Health Department of de Generalitat de Catalunya (doc.240566) and Beca CIR-CSUPT.

Competing interest: None. All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author)

Ethical Committee approval: This study was approved by the ethics committee: Fundació Parc Taulí.

Acknowledgement

We wish to thank:, Sara Crivillés, Marc Marti, María Giró, Marta llorens, Elena Pujals, Iris Perez-Bonaventura, Pere A. Soler-Insa, Antonio Rodríguez, José Antonio Monreal, Albert Granero.

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      From a global perspective, no significant differences were found in terms of the decrease in repetition of suicidal behaviour in the year of follow-up between those who participated in the TFP and the comparison group. ( Bertolote et al., 2010; Cedereke et al., 2002; Gabilondo et al., 2020; Milner et al., 2015; Mousavi et al., 2014), unlike other results that show reductions between 5 and 12% (Cebrià et al., 2013; Fleischmann et al., 2008; Miller et al., 2017; Plancke et al., 2020). These differences could be due to differences in follow-up duration, which has varied between 6 (Cedereke et al., 2002; Gabilondo et al., 2020) and 12 months (Bertolote et al., 2010; Cebrià et al., 2013), the methods used in the different programmes and protocols (some also include written messages) (Plancke et al., 2020), differences in the number of calls, or different inclusion criteria of patients in this type of brief-contact intervention.

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