Background
Objectives
Methods
Protocol and registration
Eligibility criteria
Inclusion criteria
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Interactions between professionals/paraprofessionals (e.g. lay mental health workers, nursing assistants, educators, volunteers) and patients
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Addressing suicidal thoughts and plans
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Two-way communication (i.e. not one-way communication in the form of letters/postcards/text messages or exclusively self-guided questionnaires/instruments) between at least one professional/paraprofessional and one patient; other people can be present
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Focus on suicidal thoughts and plans rather than diagnostic conditions, e.g. depression, anxiety, borderline personality disorder
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Focus on routine clinical encounters
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Brief interventions, defined as up to three sessions delivered in/soon after presenting episode, which can be supplemented by further follow-up contact
Search and information sources
Study selection
Data extraction
Risk of bias
Analysis
Results
Study selection
Risk of bias
Characteristics of participants and outcomes
Participants | Nature of suicide risk | Study Design | Setting | Intervention | Control | Pre-intervention patient measures | Post-intervention patient measures | Outcomes | Follow up period | |
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Fleischmann et al 2008 [23] 5 sites (Brazil; India; Sri Lanka; Iran; and China) | 1867 Adults 57% female, median age 23 years | Patients who have attempted suicide | RCT Individual randomization | Emergency care settings | One-hour individual information session & periodic follow-up contacts after discharge for 18 months | TAU (as per norms in the respective EDs) | Questionnaire based on the European Parasuicide Study Interview Schedule (EPSIS) and adapted to each site | One-page questionnaire: if patient still alive; if not cause of death; if yes any further suicide attempts; how the patient felt; needs for support | Primary: Completed suicide | 18 months |
Gysin-Maillart et al 2016 [24] Switzerland | 120 Adults 55% female, Mean age 37.8 years | Patients admitted to the ED who attempted suicide | RCT Individual randomization | Emergency department | 3 face-to-face therapy sessions supplemented by regular, personalized letters to the participants for 24 months | Enhanced TAU: TAU (inpatient, day patient, and individual outpatient care as considered necessary by the clinicians in charge) and one clinical interview | Suicide Status Form (SSF-III) and 33-item questionnaire to collect sociodemographic, health and suicidal behaviour data | Penn Helping Alliance Questionnaire; Beck Depression Inventory; Beck Scale for Suicide Ideation | Primary: Repeat suicide attempts Secondary: Suicidal ideation, Depression, Health-care utilisation. | 2 years |
King et al 2015 [25] United States | 49 Adolescents 65% female 14–19 years, | Patients with suicide risk factors | Pilot RCT Individual randomization | Emergency department | Personalized feedback, adapted motivational interview and follow-up note | Enhanced TAU (basic mental health resources: crisis card, written information about depression, suicide risk, firearm safety and local mental health services) | 2 questions based on the Columbia-Suicide Severity Rating Scale; 15-item Suicidal Ideation Questionnaire – Junior (SIQ-JR); Reynolds Adolescent Depression Scale; Alcohol Use Disorders Identification Test; Beck Hopelessness Scale | Two questions adapted from the Columbia-Suicide Severity Rating Scale; Reynolds Adolescent Depression Scale; The Beck Hopelessness Scale; The Alcohol Use Disorders Identification Test; Motivational interviewing | Depression, hopelessness, suicidal ideation and alcohol use. | 2 months |
Miller et al 2017 [22] United States | 1376 Adults 55.9% female median age 37 | Patients attending ED with suicide attempt or ideation in previous week | Interrupted time series design | Emergency department | 1. Secondary suicide risk screening 2. Self-administered safety plan & information provided by nurses 3. Telephone follow-up to patients and a significant other | TAU (usual care at each site) and contacts for 1 year | None | 1. Telephone interviews using the Columbia Suicide Severity Rating Scale 2. Medical records | Suicide attempts, Suicide composite: occurrence of suicide, suicide attempt, interrupted/ aborted attempts & suicide preparatory acts | 1 year |
Characteristics of interventions
Theoretical foundation | Characteristics of professionals delivering the intervention | Professional training in intervention | When was the intervention started | Intervention Components | No. & length of initial session/s | No., mode & frequency of follow up contacts | Who delivers contact/s in the ED | Who delivers contact/s after ED | Content of follow-up contacts | Intervention completion | |
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Fleischmann et al 2008 [23] | Not described | Trained psychiatrists, medical doctors, psychologists or psychiatric nurses | Not described | Within 3 days after assessment in ED | 1. Information session: information about suicidal behaviour as a sign of psychological and/or social distress, risk and protective factors, basic epidemiology, repetition, alternatives to suicidal behaviours, and referral options. 2. Follow up contacts over 18 months | One 1-hr individual information session | 9 telephone /face-to-face contacts at 1, 2, 4, 7 and 11 week(s), and 4, 6,12 and 18 months) | Trained psychiatrists doctors, psychologists or psychiatric nurses | Doctor, nurse, psychologist | Phone calls or visits | 91% received the full intervention |
Gysin-Maillart et al 2015 [24] | Action Theory, Cognitive Behaviour Therapy, and Attachment Theory. | Four therapists: one psychiatrist, one psychologist experienced in clinical suicide prevention and two psychological therapists | 1-week ASSIP training. Adherence: peer reviews and supervision | Soon after assessment in ED | 1. Session 1: narrative interview - patients were asked to tell their personal stories about how they had reached the point of attempting suicide 2. Session 2: Watch session 1 video-recording & psychoeducative handout-homework 3. Session 3: Discussion & case conceptualization: goals, warning signs, and safety strategies. Written case conceptualization, safety strategies & leaflet 4. 6 follow-up letters | Three 60–90 min sessions on a weekly basis | 6 letters over 24 months: every 3 months in the first year and every 6 months in the second year | Clinicians and therapists | Clinicians and therapists | Semi-standardized letters –to maintain the therapeutic relationship & reinforce safety strategy | 93% completed the intervention at 24 months (95% at 12 months) |
King et al 2015 [25] | Motivational Interviewing, Self Determination Theory, Theory of Health Behavior, and Theory of Planned Behavior | Three licensed Social Workers | Min 40 Hours - conducted by a member of the Motivational Interviewing Trainers’ Network | After initial emergency room visit | 1. Individual AMI: personalized feedback to the teen, to explore ambivalence, build discrepancy, enhance teen’s problem importance and readiness to change 2. Family AMI: with parent/guardian to develop Personalized Action Plan Form, provide supplemental resource materials 3. Follow-up letter & telephone call | One individual 30–45 min session One family 15–20 min session | Handwritten follow-up note and a telephone check-in two to five days after ED visit to support and facilitate action plan implementation | Study therapists | Study therapists | Personalized follow up note & telephone check-in: Half receive telephone follow-up only. | 85% received the full intervention |
Miller et al 2017 [22] | Not described | ED physicians & nurses | Detailed manual of procedures, meetings and monthly teleconference to receive training updates, and problem solve | In the ED | 1. Secondary suicide risk screening by ED physician following an initial positive screen 2. self-administered safety plan and information to patients by nursing staff 3. follow-up telephone calls | Not described | Up to 7 brief (10–20 min) telephone calls to the patient and up to 4 calls to a significant other, at 6, 12, 24, 36, and 52 weeks | ED physicians and nursing staff | 10 advisors: 6 PhD psychologists, 3 psychology fellows, and 1 masters-level counselor | Case management, individual psychotherapy and significant other involvement following Coping Long Term with Active Suicide (CLASP)-ED protocol | 1. Secondary suicide risk screening: 89.4% 2. Safety plan: 37.4% 3. Follow-up: 60.8% patients completed at least 1 phone call: of these median number 6 calls (range 2–7). 19.9% patients had a significant other who completed at least 1 call: of these median number of 4 calls (range 3–4) |
Theoretical rationale and aims of the interventions
Completion of the intervention
Completion of outcome assessments
Effectiveness of interventions
Suicide | Repeat suicide attempts | Suicide composite | Suicidal ideation | Depression | Health-care utilization | Hopelessness | Alcohol Use | |
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Type of outcome | Behavioural | Behavioural | Behavioural | Self-rated | Self-rated | Self-report & records | Self-rated | Self-rated |
Fleischmann et al 2008 [23] n = 1867 Risk of bias scorea: 14/15 | Fewer suicides: 0.2% intervention vs. 2.2% control (x2 = 13.83; P < 0.001) RR = 0.10 (0.02 to 0.45) | n/a | n/a | n/a | n/a | n/a | n/a | n/a |
Gysin-Maillart et al 2016 [24] n = 120 Risk of bias score: 13/15 | n/a | Fewer suicide attempts 8.3% intervention vs. 26.7% control (Wald χ21 = 13.1, 95% CI 12.4–13.7, p < 0.001) HR 0.17 (0.07–0.46) | n/a | No difference found | No difference found | 72% fewer days in hospital after 1 year (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038) but not significant at 2 years | n/a | n/a |
King et al 2015 [25] n = 49 Risk of bias score: 13/15 | n/a | n/a | n/a | No difference found | Lower depression intervention Mean (SD) 25.4 (4.7) vs. 30.9 (4.0) control, F = 10.84, df = 1,44; p < .01 (Cohen’s d = 1.07; large effect size) | n/a | No difference found | No difference found |
Miller et al 2017 [22] n = 1376 Risk of bias score: 10/15 | n/a | Fewer suicide attempts: TAU, 22.9% (114/497); INT, 18.3% (92/502) RR 0.80 (0.63 to 1.02) | Lower suicide composite: TAU: 48.9% (243/497) INT: 41.4% (208/502) RR 0.85 (0.74 to 0.97) | n/a | n/a | n/a | n/a | n/a |