From the Editor

Social disconnectedness contributes to suicide. Past studies have tried to connect with people at risk, using simple tools like postcards.

This week, we look at a JAMA Psychiatry paper. The University of Washington’s Katherine Anne Comtois and her co-authors use a text message-based intervention (Caring Contacts) to try to reduce suicidal thoughts and behaviours in active military personal. They find: “Although the primary hypotheses were not supported, Caring Contacts was found to be a simple, scalable intervention that may be effective in reducing the occurrence of suicide ideation and attempts.”

Military man texts using smart phone in the city Suicide prevention by text: clever? Too clever?

We consider the paper and two editorials. We also consider a New York Times essay that asks: “If suicide is preventable, why are so many people dying from it?”



Texts and Suicide Prevention

Effect of Augmenting Standard Care for Military Personnel With Brief Caring Text Messages for Suicide Prevention: A Randomized Clinical Trial”

Katherine Anne Comtois, Amanda H. Kerbrat, Christopher R. DeCou, David C. Atkins, Justine J. Majeres, Justin C. Baker, Richard K. Ries

JAMA Psychiatry, May 2019

Suicide rates in the military remain elevated despite increased awareness and implementation of targeted interventions. Service members screening positive for mental health concerns, including suicide, frequently do not attend behavioral health outpatient care. Barriers to care, such as stigma and organizational obstacles (eg, difficulty getting time off work to attend treatment), are persistent despite considerable efforts within the Department of Defense (DoD) to reduce them. Mental health problems also contribute to attrition from military service. This highlights the need for suicide prevention interventions that do not require ongoing visits to a behavioral health clinic and can follow service members into civilian life.

Caring Contacts is an intervention that periodically reaches out to suicidal individuals by letter or other brief contact with nondemanding expressions of care, concern, and interest over 1 or more years. It is the only intervention shown to prevent death by suicide in randomized clinical trials, as was shown in the original study and an international trial. Use of Caring Contacts has also reduced hospitalizations, suicide attempts, and suicidal ideation in 2 large randomized clinical trials but has shown null effects in 3 smaller studies…

katherine-comtoisKatherine Anne Comtois

So begins a paper by Comtois et al.

Here’s what they did:

  • The study was “a randomized clinical trial of Caring Contacts via text message intervention.”
  • “Recruitment took place between April 18, 2013, and September 19, 2016, at 3 military installations…”
  • Inclusion criteria included: aged 18 or older and suicidal thoughts – “identified as having current suicidal ideation, defined by a score greater than 0 on the Scale for Suicide Ideation (SSI) administered at screening.”
  • “Participants were randomly assigned to receive Caring Contacts via text message in addition to standard care… or standard care alone.”
  • The intervention: “11 non-demanding caring text messages at regular intervals over 1 year.”
  • Outcome measures included suicidal ideation, suicide attempts, and suicide risk incidents (i.e., medical evacuation or inpatient admission) and emergency department visits.
  • Statistical analyses were done.

Here’s what they found:

  • 658 participants were randomized with 329 assigned to each group.
  • Demographically: participants were male (82%), young (mean age of 25.2), white (60.7%), and divided between the US Army and Marines (54% to 46%).
  • “A hurdle model demonstrated no significant effect of Caring Contacts on the presence or severity of current suicidal ideation (i.e., during the 2 weeks prior to follow-up assessment). Logistic regression results indicated that Caring Contacts did not significantly decrease the odds of a suicide risk incident during the follow-up period.”
  • In terms of the secondary outcomes: “A hurdle model of the SSI-Worst during the follow-up period demonstrated that Caring Contacts led to a 44% decrease in the odds of reporting any suicidal ideation during the follow-up period (172 of 216 participants [79.6%] in the group receiving Caring Contacts vs 179 of 204 participants [87.7%] in the standard-care group; odds ratio, 0.56…), but there was no significant effect of Caring Contacts on the severity of worst-point suicidal ideation among those with any suicidal ideation.”

They note:

We proposed and powered the study for 2 outcomes: current suicidal ideation (at 12 months) and suicide risk incidents for Marines and Soldiers who were thinking of suicide. Contrary to our hypotheses, neither of these outcomes were improved by Caring Contacts. Caring Contacts also did not decrease the odds of emergency department presentation for suicidality. However, results indicated that Caring Contacts was effective in preventing suicidal ideation and suicide attempts throughout follow-up. Treatment effects were modest in regard to the absolute rates of suicidal ideation (80% vs 88%) and attempts (9% vs 15%), yet clinically meaningful, given the brevity and potential reach of this intervention.

A few thoughts:

  1. This is a good study.
  1. There is much to like here, building on published work. As noted above, past research has suggested that social disconnectedness is a contributor to suicide; Caring Contacts seeks to address this. The study adds a modern twist: the use of text messaging. Their intervention is low cost, with just 11 messages over 12 months.
  1. Unfortunately, the study yielded middling results. The intervention failed on the two primary outcomes.
  1. Was the text messaging too simplistic? Text messages were sent on day 1, week 1, and then at months 1, 2, 3, 4, 6, 8, 10, and 12 and birthdays. The message on month 12 reads “hope you had a good day today,” personalized with the name of the participant and the clinician. Does this offer much connectedness to people in the military, who may be well connected already? Would the results have been more impressive with another population? (And many thanks to my colleague Dr. Juveria Zaheer for helping me better understand this study.)
  1. The paper runs with two editorials.

In “Reframing the Suicide Prevention Message for Military Personnel,” Dr. Murray B. Stein, Ronald C. Kessler, and Dr. Robert J. Ursano, from the University of California (San Diego), Harvard Medical School, and Uniformed Services University of the Health Sciences, respectively, write about the rising suicide rate in the United States.

32933Murray B. Stein

They discuss the paper, noting the lack of result with the two primary outcomes. The authors conclude:

Given the multifactorial and heterogeneous nature of the problem, no single intervention will prevent all suicide deaths – and not all suicide deaths are preventable. Suicide is not a disorder to be treated but rather an action to be discouraged and thwarted. As such, we need new ideas and new approaches to suicide prevention. Although being caring in our contacts is certainly important, sending caring texts to high-risk soldiers might not be the answer for many.

In “Suicide Reduction and Research Efforts in Service Members and Veterans – Sobering Realities,” Dr. Charles W. Hoge from the Office of the Army Surgeon General summarizes the study:

Unfortunately, it joins other intervention trials in delivering predominantly null or uncertain findings in military and veteran populations. The study showed no significant differences in primary outcomes between groups. While the number of individuals who attempted suicide was significantly lower in the caring text group (21 individuals) than the group receiving standard care (34 individuals) after controlling for lifetime attempts, there were no significant differences in the total number of attempts and proportional decrease in individuals making attempts between baseline and follow-up years…

He concludes:

Multimodal strategies can be broadly grouped into clinical and nonclinical approaches, with the greatest attention and investment in clinical components but the greatest benefits likely from certain nonclinical components. Noteworthy clinical strategies include routine depression screening in primary care, assessment for key risk factors and warning signs, development of a safety plan (including lethal means safety; two-thirds of veteran suicides involve firearms), cognitive behavioral therapies, treatment of underlying mental disorders, and appropriate follow-up after hospitalization or emergency care. While these are all responsible clinical steps, policies and clinical guidelines aimed at standardizing and disseminating these practices can evolve into overly complex requirements that go well beyond the evidence.

The editorials can be found here:

and here:

  1. A recent New York Times essay considered the success and failure of our efforts at suicide prevention. Dr. Amy Barnhorst, a psychiatrist affiliated with the University of California (Davis), writes: “If suicide is preventable, why are so many people dying from it? Suicide is the 10th leading cause of death in the United States, and suicide rates just keep rising.”

The essay makes a number of good points, including about the impulsive nature of the action: “According to a 2016 study, almost half of people who try to kill themselves do so impulsively. One 2001 study that interviewed survivors of near-lethal attempts (defined as any attempt that would have been fatal without emergent medical intervention, or any attempt involving a gun) found that roughly a quarter considered their actions for less than five minutes. This doesn’t give anyone much time to notice something is wrong and step in.”

The essay has drawn sharp criticism.

Dr. Jeffery Lieberman of Columbia University tweeted that Dr. Barnhorst “doesn’t read scientific literature or skipped training. this article is wrong. #suicide is largely preventable, if proper measures taken n Rx provided. @nytimes please vet authors better” [sic].

Is the essay thoughtful or glib? You can judge for yourself.

The essay can be found here:

  1. Suicide is a subject often discussed in the Reading of the Week series.

A past Reading considered the ED-SAFE study, for example. It can be found here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.