Taking care of suicidal patients with new technologies and reaching-out means in the post-discharge period

Table 1 Summary of studies reporting contact with patients involving new technologies and reaching-out means in the post-discharge period

Ref.	Study design	Sample	Criteria	Methods	Outcomes	Follow-up	Results
Postcard/ letters/crisis card/green card
Motto et al[26], 2001	RCT	843 participants	843 patients who had refused ongoing care after hospitalization because of a depressive or suicidal state	843 patients randomized to Intervention group: (n = 389) contacted by short letter for five years (a total of 24 letters for five years); control group: (n = 454) received no contact	Suicide rate	5 yr (contact period) and 10 yr	Patients in the contact group had a lower suicide rate in all five years of the study Intervention group: Suicide rate: 0.77% Control group: Suicide rate: 1.32% only for the first two years (P value = 0.043). Differences gradually decreased and at 15-yr no differences were observed
Hassanian- Moghaddam et al[27], 2011	RCT	2300 participants	Subjects admitted to the Loghman-Hakim Poison Hospital from March to June 2006, above 12 yr of age with self-poisoning defined by exclusion of poisoning classified as recreational, habitual misuse, accidental or iatrogenic by the treating medical toxicologist	2300 patients randomized to Intervention group: (n = 1150) received nine postcards sent over 12 mo. Eight postcards are mailed at 1, 2, 3, 4, 6, 8, 10 and 12 mo after discharge. A ninth postcard is sent for each participant's birthday Control group: (n = 1150) received no contact	Suicidal ideation; suicide attempt; cutting or self-mutilation; deaths	12 mo	A postcard intervention reduced suicidal ideation and suicide attempts. Sustained, brief contact by mail may reduce suicidal ideation and suicide attempts in individuals who self-poison Suicidal ideation: Intervention group: 29.0%. Control group: 41.7% Relative risk reduction: 0.31 (0.22 to 0.38). Number needed to treat: 7.9 (6.0 to 11.5) Suicide attempt: Intervention group: 3.0%. Control group: 5.1% Relative risk reduction 0.42 (0.11 to 0.63). Number needed to treat 46.1 (26 to 203.7) Self-cutting: Intervention group: 4.0%. Control group: 4.7% Relative risk reduction 0.14 (-0.29 to 0.42) Number needed to treat NA
Hassanian- Moghaddam et al[28], 2017						24 mo	There was a beneficial effect demonstrated for suicidal ideation and suicide attempt during the 24 mo follow-up period (after cessation of the intervention), however, there was no effect on self-cutting behavior during the same period Suicidal ideation: Intervention group: 46.6%. Control group: 58.6% ARR: 11.93% (95%CI: 7.58-16.27), OR: 0.62 (95%CI: 0.52-0.74) Suicide attempt: Intervention group: 6.2%; control group: 9.1% ARR: 2.85% (95%CI: 0.52-5.17), OR: 0.67 (95%CI: 0.48-0.93) Self-cutting: Intervention group: 1.5%; control group: 1.5% ARR: 0.00% (95%CI: -0.01-0.01), OR: 1.01 (0.49-2.07)
Carter et [29], 2005	RCT	772 participants	Participants (> 16 yr) presented to the toxicology service with deliberate self poisoning from April 1998 to December 2001	772 patients randomized To Intervention group: (n = 378) received a postcard at 1, 2, 3, 4, 6, 8, 10 and 12 mo after discharge Control group: (n = 394) received no contact after discharge	Proportion of patients who repeat episodes of deliberate self poisoning; the number of repeat episodes of deliberate self poisoning per person	12 mo	A postcard intervention reduced repetitions of deliberate self poisoning, although it did not significantly reduce the proportion of individual repeaters Proportion of patients who repeated episode of self poisoning: Intervention group: 15.1%; control group: 17.3% N° of repeat episodes: Intervention group: 101; control group: 192 Incidence risk ratio of repetition: Intervention group: 0.55 vs Control group: 1.00 [ES = 0.13 (CI: 0.35 to 0.87); P value = 0.010]
Carter et al[30], 2007					Proportion of patients who repeat episodes of deliberate self poisoning; number of repeat admissions	24 mo	A postcard intervention maintained the halving of the rate of hospital-treated-self-poisoning events over 2-yr period, although it did not significantly reduce Proportion of patients who repeated episode of self poisoning: Intervention group: 21.2%; control group: 22.8% N° of readmissions: Intervention group: 145. Control group: 310 Incidence risk ratio of repetition: Intervention group: 0.49; control group: 1.00 [ES = 0.10 (CI: 0.33 to 0.73); P value = 0.010] The treatment was effective only for women: Intervention group: 0.49; control group: 1.00 [ES = 0.12 (CI: 0.30 to 0.80); P value = 0.004]
Carter et al[31], 2013					Proportion of patients who repeat episodes of deliberate self poisoning; number of repeat admissions; proportion of patients admitted to the hospital for any psychiatric reason; number of readmissions to a psychiatric hospitals; all-cause mortality; suicide deaths	5 yr	A postcard intervention halved self-poisoning events and reduced psychiatric admissions by a third after 5 yr Proportion of patients who repeat episodes of deliberate self poisoning: Intervention group: 24.9%. Control group: 27.2% Number of repeat admissions: Intervention group: 252; control group: 484 Incidence risk ratio of readmission: Intervention group: 0.54; control group: 1.00 (CI: 0.37 to 0.81; P value < 0.01) The treatment was effective only for women: Intervention group: 0.55; control group: 1.00 [CI: 0.34 to 0.88); P value = 0.01] Proportion of patients admitted to the hospital for any psychiatric reason: Intervention group: 38.1%. Control group: 35.5% Number of readmissions to a psychiatric hospital: Intervention group: 447; control group: 710 All-cause mortality: Intervention group: 5.8%; control group: 5.6% Suicide deaths: Intervention group: 1.3%. Control group: 1.5%
Beautrais etal[32], 2010	RCT	327 participants	Participants (> 16 yr) admitted to psychiatric emergency services at Christchurch Hospital, New Zealand, following self-harm or attempted suicide during the period August 1, 2006 to April 6, 2007	327 participants randomized to Intervention group: (n = 153) received treatment as usual + postcard intervention (six "postcards" sent by mail during the 12 mo following) Control group: (n = 174) received treatment as usual	Percentage of patients re-submitted at the psychiatric emergency service and at the emergency department for self-harm; numbers of self-harm re-presentations	12 mo	There were no significant differences between the control and intervention groups in the proportion of participants re-presenting with self-harm or in the total number of re-presentations for self-harm Percentage of patients re-submitted at the psychiatric emergency service and at the emergency department for self-harm: Intervention group: 25.5%; control group: 28.2% Numbers of self-harm re-presentations: Intervention group: 56.9%; control group: 78.2% (IRR 0.73; CI: 0.5-0.95; P value < 0.03)
Evans et al[33], 1999	RCT	827 participants	Patients admitted to hospital following deliberate self-harm between November 1994 and July 1996	827 patients randomized to Intervention group: (n = 417) received the green card offering 24-h crisis telephone consultation with an on-call psychiatrist for up to 6 mo Control group: (n = 410) received standard treatment	Patients who repeated self-harm	6 mo	At 6 mo, there was no effectiveness of the provision of a card offering 24-h crisis telephone consultation on repetition of self-harm but there was a possible benefit among those presenting following a first episode Patients with repeated self-harm: Intervention group: 16.8%; control group: 14.4% Median time to repetition: Intervention group: 33 d; control group: 40 d Intervention with green card seemed to have a protective effect on self-harm first timers vs people with history of previous self-harm. First timers: 18 (OR: 0.64; 0.34-1.22) Previous history of self-harm: 52 (OR: 1.85; CI: 1.14-3.03)
Evans et al[34], 2005						12 mo	At 12 mo there was no overall benefit of the intervention. Among those with a first episode of self-harm, the possible benefit of the intervention had diminished Patients with repeated self-harm: Intervention group: 21.6%; control group: 18.8% Median time to repetition did not differ between the two groups Among those with a first episode of self-harm, the possible benefit of the intervention had diminished compared to Evans et al[33] 1999 (OR: 0.89, CI: 0.52-1.52)
Cotgrove etal[35], 1995	RCT	105 participants	Adolescents (aged 16 yr or under), admitted to the study hospitals between January 1987 and January 1990 for a suicide attempt (all acts of deliberate self-poisoning and deliberate self-harm are also considered)	105 participants randomized to Intervention group: (n = 47) received a token, a green card, which acted as a passport to re-admission into a pediatric ward in their local hospital Control group: (n = 58) received standard treatment	Rate of further suicide attempts; rate of the use of the token	12 mo	There were lower rates of repeat suicide attempts in the intervention group. The differences between two groups did not reach the level of statistical significance Further suicide attempts: Intervention group: 6%; control group: 12% Rate of repetition: Intervention group: 6%; control group: 12%
Letters and telephone contacts
Mouaffak etal[36], 2015	RCT	320 participants	Adult subjects (men and women > 18 older) surviving a suicide attempt, discharged from the Emergency Department from January 2009 until December 2011	320 participants randomized to Intervention group: (n = 160) destined to OSTA program (provided a card with a telephone number of a psychiatrist available 24 h a day and telephone calls at 2 wk post discharge, at months 1 and 3) Control group: (n = 160) received no contact	Proportion of patients who reattempted suicide; proportion of patients who started a medical follow-up	12 mo	There were no significant differences, between the two groups, in the number of patients who reattempted suicide and in suicide attempts Proportion of patients who reattempted suicide: Intervention group: 14.5%; control group: 14% Number of suicide attempts: Intervention group: 0.2 ± 0.58. Control group: 0.23 ± 0.84 Patients who started a medical follow-up: Intervention group: 24.2%; control group: 31%
Kapur et al[37], 2013	RCT	66 participants	Participants (> 18 yr), resident in Manchester, who presented to 2 of the 3 Emergency Department in the city with self-harm during November 2010 to May 2011	66 participants randomized to Intervention group: an information leaflet listing local and national sources of help mailed as soon as possible after consent, two telephone calls within the first 2 wk, and then a series of letters over a 12-mo period (at 1, 2, 4, 6, 8 and 12 mo). Control group: Received treatment as usual	Proportion of patients with at least one repeat episode of self-harm resulting in hospital attendance within 12 mo; number of repeat episodes during the same time period	12 mo	The rate of repetition of self-harm behavior was higher in the intervention group than control group. Repeat rate of self-harm over 12 mo: Intervention group: 34.4%. Control group: 12.5% (OR: 3.67, 95%CI: 1.0-13.1; P = 0.046) Total number of episodes of repeat self-harm over 12 mo: Intervention group: 41; control group: 7. [IRR = 5.86, 95%CI: 1.4-24.7; P value = 0.016] Adjusting for baseline clinical factors (centre, method of harm (self-poisoning vs other), previous self-harm, previous psychiatric treatment): repetition: (adjusted OR: 4.35, 95%CI: 0.9-19.8; P value = 0.057) repeat episodes: (adjusted IRR = 7.16, 95%CI: 1.6-32.8, P value = 0.011)
Telephone contact
De Leo etal[38], 1995	Ecological study	12135 participants	Participants (> 65 years old) who were living in the Veneto region of Italy connected to the Tele Help/Tele-Check service from January 1, 1998 and December 31, 1998	Authors compared the rate of suicide between Tele-Help/Tele Check users and the general population	Rate of suicide	4 yr	Only one suicide death occurred among elderly service users than expected. Ratio: 1:7.44 between observed and expected suicides. Standardized mortality ratio: (1/7.44 × 100%): 13.44% (χ² = 2.54, df = 1, 95%CI: 0.3%-74.8%; P value < 0.05)
De Leo etal[39], 2002	Ecological study	18641 participants		Comparison between observed and expected suicide rates among older Tele-Help/Tele-Check users		10 yr	Significantly fewer suicide deaths occurred among elderly service users than expected. Suicide deaths: Observed n = 6; expected n = 20.86, χ² = 10.58, df = 1; P value < 0.001 with an SMR for users of 28.8% (95%CI: 11.5-62.5)
Cedereke etal[40], 2002	RCT	216 participants	Patients treated after a suicide attempt at the Medical Emergency Inpatient Unit of the University Hospital of Lund between February 1995 and April 1997	216 participants randomized to Intervention group: (n = 107) received telephone call at 4 and 8 mo Control group: (n = 109) destined to no such interventions	Attendance to treatment; repetition of suicide attempts; GAF, CSI, SSI score	12 mo	At follow-up, attendance and repetition of suicide attempts did not differ between the two groups Attendance to treatment repetition of suicide attempts: At baseline: Intervention group: 76%, Control group: 72% At follow-up: Intervention group: 72%. Control group: 65% Repetition of suicide attempts: Intervention group: 17% made 26 suicide attempts. Control group: 17% made 27 suicide attempts GAF: Intervention group: 1st month = 50.5 ± 19.9. 12th month = 61.4 ± 20.4 (P value < 0.001) Control group: 1st month = 50.3 ± 21.1. 12th month = 58.6 ± 20.2 (P value < 0.01) SSI score Intervention group: 1st month = 7.9 ± 8.4 (P < 0.10). 12th month = 5.8 ± 7.8 (P value < 0.05) Control group: 1st month = 5.0 ± 6.8 (P < 0.10). 12th month = 4.0 ± 6.2 (P value < 0.05) SCL90-GSI Intervention group: 1st month = 1.05 ± 0.74. 12th month = 0.82 ± 0.78 (P value < 0.05) Control group: 1st month = 1.02 ± 0.77. 12th month = 0.88 ± 0.72
Vaiva et al[41], 2006	RCT	605 participants	People (18-65 yr) discharged from an emergency department after attempted suicide by deliberate self poisoning	605 participants randomized to Intervention group: (n = 147) received telephone contact at one month after a suicide attempt Intervention group: (n = 146) received telephone contact at three months Control group: (n = 312) without telephone intervention	Proportion of participants who reattempted suicide, number of deaths by suicide and losses to follow up at 13 mo	13 mo	For participants contacted at one month, the number of who reattempted suicide is significantly lower than that of controls. For participants contacted at three months, the number who attempted suicide was not significantly lower than that of control Proportion of participants who reattempted suicide: At 1 mo: Intervention groups: 16%. Control group: 19% At 3 mo: Intervention group: 14%). Control group: 19% Number of deaths by suicide: At 1 mo: Intervention group: 0 %. Control group: 1% At 3 mo: Intervention group: 1%. Control group: 1% Lost to follow up: At 1 mo: Intervention group: 7%. Control group: 10% At 3 mo Intervention group: 10%. Control group: 10%
Fleischmann et al[42], 2008	RCT	1867 participants	Suicide attempters identified by medical staff in the emergency units of eight collaborating hospitals in five different countries	1867 participants randomized to Intervention group: (n = 922) received treatment as usual plus brief intervention and contact (which provided a standard 1-h individual information session combined with periodic follow-up phone calls or visit) Control group: (n = 945) received treatment as usual	Deaths from suicide	18 mo	Significantly fewer suicide deaths occurred in the intervention group than in the control group. Suicide deaths: Intervention group: 0.2%. Control group: 2.2% (P value < 0.001)
Bertolote et al[43], 2010					Repeated suicide attempts		At follow up, repeated suicide attempts did not differ between the two groups. Repeated suicide attempts: Intervention group: 7.6%. Control group: 7.5%
Cebrià etal[44], 2013	Case-control study	991 participants	Patients without age limit treated for attempted suicide during the years 2007-2008. They were identified following a systematic review of electronic medical records of the emergency departments of psychiatry, medicine, traumatology, surgery and pediatrics in the area of Sabadell	991 participants randomized to Intervention group: (n = 604) received telephone call for 1-yr after discharge from Emergency Department for suicide attempt Control group: (n = 387) received treatment as usual	Days to first reattempt; rate of patients who reattempted suicide	12 mo	The rate of patients who reattempted suicide was lower in the intervention group compared to the previous year Mean time in days to first reattempt Intervention group: Baseline: 316.64; Intervention year: 346.47 (Baseline vs intervention years log rank P value < 0.0005) Control group: Baseline: 273.05; Intervention year: 300.36 Intervention group vs control group during the intervention year (respectively 346.47 vs 300.36; log rank P value < 0.0005) Rate of patients who reattempted suicide Intervention group: Baseline: 14%; Intervention year: 6% (Baseline vs intervention years log rank P value < 0.0005) Control group: Baseline: 21%; Intervention year: 14% Intervention group vs control group during the intervention year (respectively 6% vs 14%; log rank P value = 0.005)
Cebrià etal[45], 2015	Nonrandomized, controlled, parallel study	514 participants		All participants (Cebria et al[45] 2013) were called after 5 yr	Rate of reattempts; time to recurrence	5 yr	There was a reduction of the rate of reattempts in the first year. The effects of the intervention was not be maintained at 5 yr Rate of reattempts Intervention group: 0.864. Control group: 0.839 Time to recurrence Intervention group: 1429 d. Control group: 1332 d
Amadéo etal[46], 2015	RCT	200 participants	Participants admitted to the Emergency Department of the Centre Hospitalier de Polynésie Française for intentional self harm over the period 2008-2010. All patients included in this study had a short psychiatric hospitalization (minimum 24 h)	200 patients Randomized to Intervention group: (n = 100) received treatment as usual plus brief intervention and contact (which provided nine follow-up phone calls Control group: (n = 100) received treatment as usual	Number of suicides and repeated non-fatal suicidal behavior	18 mo	There were a reduction in the number of suicides and episodes of non-fatal suicide behaviour in the intervention group Episodes of non-fatal suicide behaviour: Intervention group: 26.7% vs Control group: 21% Suicide: Intervention group: 0% vs Control group: 2.0%
Telephone, e-mail, text message, letters
Hvid etal[47], 2009	Cohort study	151 participants	Participants arrived at the hospital’s emergency rooms and clinical departments of Copenhagen University Hospital Amager for attempted suicide and self-harm actions through spring 2002 and spring 2004	151 participants are randomized to Intervention group: Cohort of 2004 (n = 93) received a primary contact while the patient was in hospital and followed-up visits (8) after hospital discharge, by personal contact, telephone calls, letters, text messaging and emails. The intervention period was limited to 6 mo Control group: Cohort of 2002 (n = 58) received no contact	Participation by acceptance and adherence; repetition of suicide attempt and suicide; number of repetitive acts in 1 yr after the attempted suicide episode	1 yr	There were a significant lower repetition rate and fewer suicidal acts in the intervention group. The programme had a high acceptability Acceptability: 65 of 94 patients of the Cohort of 2004 remained in the programme (70% participation) Repetitions during 1 yr: Cohort of 2002: 18 repetitive patients and 1 suicide (32.8%) 37 repetitive acts Cohort of 2004: 12 repetitive patients and 1 suicide (13.9%), 22 repetitive acts RR = 0.427 (95%CI: 0.228-0.797)
Hvid etal[48], 2011	RCT	133 participants	Subjects admitted to the emergency room and clinical departments and screened for attempted suicide and self-harm actions during a period from 2005-2007	133 participants randomized to Intervention group: (n = 69) received home visit and additional contact (telephone calls and text messages) Control group (n = 64) received no contact	Proportion of patients who repeated suicide attempt; number of suicidal acts	12 mo	There were a significant lower proportion who repeated a suicide attempt the intervention group and the number of repetitive acts was also significant lower Proportion of patients who repeated suicide attempt: Intervention group: 8.7%; Control group: 21.9% (Fewer events for intervention group vs control group; log rank P = 0.0414) Number of suicidal acts: Intervention group: 8; Control group: 22 (log rank P = 0.0037)

RCT: Randomized controlled trial.