From the Editor

Can we do better at suicide prevention?

In recent years, several studies have tried brief contact interventions – that is, interventions aimed at maintaining a post-discharge connection – reporting success. These interventions have been relatively simple, such as handwritten postcards or phone calls for people post-attempt.

In this week’s selection, we look at a new paper from The Journal of Clinical Psychiatry. Involving 23 emergency departments and crisis centres in France, the authors pulled together different interventions, coming up with an algorithm offering patients care informed by the best evidence. So some patients received calls, but others were given crisis cards.

It’s an ambitious project. Did it work? The results weren’t statistically significant.

p1110389Postcards: colourful and pretty – and life-saving?

We consider this paper, the negative result, and ask: what does this say about suicide prevention? And then, looking at the evolving literature on suicide, we briefly consider a paper written by Sunnybook’s Mark Sinyor that uses IV ketamine for suicidal thoughts.

Please note: there will be no Reading next week.



Suicide Prevention and Outcomes

“Combining Postcards, Crisis Cards, and Telephone Contact Into a Decision-Making Algorithm to Reduce Suicide Reattempt: A Randomized Clinical Trial of a Personalized Brief Contact Intervention”

Guillaume Vaiva, Sofian Berrouiguet, Michel Walter, Philippe Courtet, François Ducrocq et al.

The Journal of Clinical Psychiatry, November/December 2018

A previous suicide attempt is a strong predictor of suicide-related premature death. Approximately one third of those attempting suicide seek treatment for their injuries from hospital emergency departments (EDs). For people who have made a suicide attempt, the immediate postdischarge period constitutes a critical challenge for emergency and mental health care services. Thus, much research has been conducted to develop indicated prevention programs targeting patients with a history of suicide attempt. However, these strategies face specific issues related to the characteristics of suicide attempts and those attempts suicide. First, suicide is a rare event, which makes the design of powerful studies especially challenging. Furthermore, in those who have had a suicide attempt, adherence to intensive treatment over time is often poor. Finally, specific interventions can be difficult to perform in the emergency setting, where psychiatric staff availability is often limited or absent. Given these issues, there has been growing interest in developing interventions that focus on maintaining postdischarge contact and offering re-engagement with health care services to people who have made a suicide attempt. These brief contact interventions (BCIs) occur according to a structured schedule and remain operational over a sustained period of time. BCIs can be employed in parallel to any existing health care. These programs do not impose on the daily life of people who have made a suicide attempt; BCIs can be short letters, postcards, phone calls, and ‘crisis cards.’ All these forms of support encourage help-seeking and may facilitate access to health care services in the case of recurrence of suicidal ideation. A recent review showed that only a few studies indicated that BCIs significantly reduced repeat suicide attempts and deaths by suicide in the intervention group. Other BCIs showed mixed or inconclusive results but did show trends toward preventive effects in several at-risk subgroups: crisis cards, sometimes also referred to as “green cards,” for people who have made a first suicide attempt; telephone contact for people with history of 1 or more suicide attempts; and postcards for unreachable or noncompliant patients…

baivaGuillaume Vaiva

So begins a paper by Vaiva et al.

Here’s what they did:

  • The study was “multicenter, prospective, comparative, single-blind, randomized controlled trial” involving 23 emergency departments and psychiatry crisis centres in France. “We designed a decision-making algorithm that assigned each BCI to the subgroup in which the invention generated trends or significant results in reducing suicide reattempts in suicide attempters.”
  • Inclusion criteria included: adults “who had survived a suicide attempt with suicide intent that had occurred within the previous 7 days.”
  • Patients were randomized into two groups. In the treatment as usual (TAU) group, patients had a follow-up appointment within 48 hours after discharge and a referral to a physician consultation.
  • In the intervention group, patients had the TAU, and they also were offered several interventions. Delivery of a crisis card for a first attempt. The crisis card, given when leaving the ED, including an emergency contact number, available 24 hours a day. Telephone contact for those with previous attempts. Between days 10 and 21 post-suicide attempt, patients were called and offered psychological support. Sending postcards. For those who were unavailable for calls, or who declined care, or seemed stressed during their calls, handwritten cards were sent at months 2, 3, 4, and 5.
  • “The primary outcome was the proportion of participants who reattempted suicide (fatal or nonfatal) within 6 months of discharge.” Outcomes were measured with phone interviews at 6 and 13 months.
  • Different statistical analyses were done.

Here’s what they found:

  • A total of 1,040 patients were enrolled in the study, with half assigned to the intervention group and the other half to the TAU.
  • Demographically: patients were in their late 30s, women, employed. Diagnostically, half had major depressive disorder.
  • Of the patients enrolled in the intervention group, 263 received a crisis card, 155 received phone contacts, and 139 received programmed mailing of postcards.
  • “After 6 months, 58 participants in the intervention group (12.8%) had a repeat suicide attempt (fatal and nonfatal) compared with 77 (17.2%) in the control group. The difference between groups (4.4%) was not significant…”
  • “During the 13-month follow-up, a total of 14 deaths occurred, including 3 (0.6%) deaths by suicide in the [intervention] group and 8 (1.6%) deaths by suicide in the control group. This difference was not significant…” (See figure below.)
  • “At the end of the 6-month follow-up, 85 patients were lost to follow-up (8.6%), rising to 158 at the end of the 13-month follow-up (16.0%).”


A few thoughts:

  1. This is a good study.
  1. But the intervention didn’t work (statistically speaking).
  1. Was the problem with the algorithm? The authors had pulled together different interventions from different studies. Did this ultimately prove too clever by half?
  1. Or was this study a victim of “scaling up?” That is, while past studies could get these interventions to work, the large number of centres (23 in all from different hospitals of different sizes) may have made it difficult to properly train staff and ensure a consistent approach to care. (Assuming all centres prepared to equally care for patients, they would have been aiming to treat about 2 dozen people each over a study period stretching for more than 3 years.)
  1. Or is the problem here deeper? Suicide prevention is challenging – drawing from a point made by Vaiva et al., it is a rare event, making prevention strategies all the more challenging to design and implement.
  1. Past Readings have considered suicide. The ED-SAFE study was considered in a Reading last year. You can find it here:
  1. If Vaiva et al. considered basic interventions (calls, postcard, crisis cards), others are looking at more cutting-edge interventions for suicidal ideation. Sunnybrook Hospital’s Mark Sinyor et al. consider ketamine in a study published in Journal of Affective Disorders,Ketamine augmentation for major depressive disorder and suicidal ideation: Preliminary experience in an inpatient psychiatry setting.” They open:

There is a growing body of evidence demonstrating that intravenous ketamine infusions can provide rapid relief of depressive symptoms in people suffering from treatment-resistant major depressive disorder (MDD) as well as bipolar depression with various studies showing rapid response to a single infusion which persists for at least 72 hours… Collectively, the literature indicates that ketamine infusions may be one of the most effective and rapid treatments for depression available, although optimism about these results must be tempered by the fact that the duration of response in single infusion studies with ketamine is often short-lived.

Could ketamine be used as an adjunct to standard antidepressant treatment to rapidly relieve suicidal ideation in depressed patients?

suicide-talk-invu-sinyor-080618Mark Sinyor

Here’s a concise explanation of the study:

  • Five inpatients with Major Depressive Disorder and suicidal ideation received six infusions of IV ketamine over approximately 12 days, in addition to treatment-as-usual.
  • Suicide and depression rating scores including the Scale for Suicidal Ideation (SSI).
  • SSI scores diminished by 84% from 14.0 (± 4.5) to 2.2 (± 2.5).
  • One patient experienced dissociation, and withdrew.

The authors describe the findings as “promising.”

The paper can be found here:

This is an interesting study. But perspective: the n was 5.

Still the literature for ketamine is growing – and an inpatient setting would seem a natural place to employ such a treatment.

Thus, while the big paper in this Reading has a negative result, we can feel optimistic that the work in this field is moving in the right direction.


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