Article summary

PSYCHIATRIC SERVICES ♦ June 2001 Vol. 52 No. 6882288

Suicide continues to be a leadingcause of death in the developedworld, and despite numerous ef- forts to improve physicians’ skills in recognizing and assessing suicide risk, no specific treatment or management techniques have yet been shown by a randomized controlled study to have a significant preventive impact.

One major concern in suicide pre- vention efforts is how to provide ongo- ing assistance to high-risk patients af-

ter they are discharged from a psychi- atric inpatient setting. A variety of re- sources are usually available for com- pliant patients, but a special challenge to mental health care is presented by high-risk persons who decline contin- ued outpatient treatment or, having accepted such treatment, quickly dis- continue the planned program.

The problem of patients’ refusing follow-up care is widespread, ranging from 11 percent to 50 percent of pa-

tients in various studies (1). Van Heeringen and colleagues (2) used a program of home visits to provide “additional motivation” for 318 non- compliant patients who had attempt- ed suicide to accept outpatient treat- ment after discharge from the hospi- tal. This program was associated with an increase in compliance from 43 percent to 53 percent, although the difference in the rate of repeated sui- cidal behaviors in one year was not significantly different from that of a control group. Similar findings were reported by Torhorst and colleagues in a sample of 226 patients (3).

The use of personal contact was also tried by Litman (4), who had vol- unteers maintain a continuing rela- tionship with 200 patients in a two- year aftercare program. The patients’ personal relationships and depression improved, but the rate of suicide was not lower than that in a control group. Chronic alcohol abuse was seen to prevent the potential effectiveness of this method.

Bronisch and Hecht (5) reported that 40 percent of the 72 patients in their sample who attempted suicide did not accept any treatment program after discharge. De Vanna and co- workers (6) found that 57 percent of 60 patients in their study had no con- tact with the medical staff after leav- ing the hospital. This finding was at- tributed to the patients’ resistance to any program of regular and frequent meetings with a care provider, to the focus on somatic treatment during hospitalization, and to the patients’ resistance to being considered “psy- chiatric cases.” Kreitman (7) reported comparable results, finding that among patients who attempted sui- cide and were referred to day hospi-

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Dr. Motto is professor of psychiatry emeritus in the department of psychiatry at the Uni- versity of California, San Francisco, School of Medicine, 401 Parnassus Avenue, San Francisco, California 94143 (e-mail, [email protected]). Dr. Bostrom is senior statis- tician in the department of social and behavioral science at the University of California, San Francisco, School of Nursing.

Objective: This study tested the hypothesis that professionals’ mainte- nance of long-term contact with persons who are at risk of suicide can exert a suicide-prevention influence. This influence was hypothesized to result from the development of a feeling of connectedness and to be most pertinent to high-risk individuals who refuse to remain in the health care system. Methods: A total of 3,005 persons hospitalized be- cause of a depressive or suicidal state, populations known to be at risk of subsequent suicide, were contacted 30 days after discharge about fol- low-up treatment. A total of 843 patients who had refused ongoing care were randomly divided into two groups; persons in one group were con- tacted by letter at least four times a year for five years. The other group—the control group—received no further contact. A follow-up procedure identified patients who died during the five-year contact pe- riod and during the subsequent ten years. Suicide rates in the contact and no-contact groups were compared. Results: Patients in the contact group had a lower suicide rate in all five years of the study. Formal sur- vival analyses revealed a significantly lower rate in the contact group (p=.04) for the first two years; differences in the rates gradually dimin- ished, and by year 14 no differences between groups were observed. Conclusions: A systematic program of contact with persons who are at risk of suicide and who refuse to remain in the health care system ap- pears to exert a significant preventive influence for at least two years. Diminution of the frequency of contact and discontinuation of contact appear to reduce and eventually eliminate this preventive influence. (Psychiatric Services 52:828–833, 2001)

tals, only half kept in touch with the health care system. Möller (8) provid- ed an excellent review of noncompli- ance as a central problem in the post- discharge care of suicidal patients.

We approached the problem of high-risk patients’ declining contin- ued treatment by using a prospective, randomized, controlled study based on three hypotheses. The first hypo- thesis was that a suicidal person’s sense of isolation would be reduced and his or her feelings of connected- ness enhanced by regular, long-term contact with someone concerned about that person’s well-being. The second hypothesis was that to be ef- fective this contact must be initiated by the concerned individual and must make no demands on the suicidal per- son. The third hypothesis was that a systematic program of this kind would exert a suicide-prevention influence on high-risk persons who refuse assis- tance by traditional means.

Encouraging results of this pro- gram over a five-year period (9) raised the question of whether the ap- parent influence of ongoing contact in this population would remain after the contact was discontinued. This ar- ticle reviews the five-year outcome and considers a 15-year perspective on this question.

Methods Between 1969 and 1974, a total of 3,005 persons were identified in nine psychiatric inpatient facilities in San Francisco as having been admitted because of a depressive or suicidal state. Previous studies have indicated that this population has a high risk of subsequent suicide, especially in the first two years after discharge (10). Each patient was interviewed by a member of the research staff in a thorough, two- to four-hour psy- chosocial evaluation.

Thirty days after each patient’s dis- charge, a follow-up inquiry deter- mined whether the patient had ac- cepted a posthospital therapy plan and had continued the plan for the entire 30 days. A program was consid- ered to be therapy if it entailed thera- peutic work with a professional from a field such as psychiatry, psychology, social work, and pastoral counseling. An arrangement for such therapeutic

follow-up was a routine part of dis- charge planning for this population.

Patients who accepted continuing assistance were designated treatment patients; those who had declined treatment or discontinued treatment in less than 30 days were designated no-treatment patients. The no-treat- ment patients were randomly as- signed to one of two groups, designat- ed the contact group and the no-con- tact group. Subsequent procedures were directed only at patients in the contact group, without further active involvement with patients in the no- contact group or those in the treat- ment group.

In this process a fourth category emerged, designated “undeter- mined,” comprising patients who had died within 30 days of discharge and patients whom we were unable to lo- cate or who did not respond to three inquiries about ongoing care. Al- though this group, which appears to be at the greatest risk of suicide, could not be studied, such patients would be an interesting subject of fu- ture studies.

Patients in the contact group were started on a schedule of regular com- munications, in the form of a short letter, from the research staff mem- ber who had interviewed them in the hospital. Each contact letter was sim- ply an expression of concern that the

person was getting along all right and invited a response if the patient wished to send one. The letters were always worded differently, were indi- vidually typed, and included respons- es to comments from the patients if such comments had previously been received. A self-addressed, unstamped envelope was always enclosed. An ex- ample of a contact letter is “Dear_______: It has been some time since you were here at the hospital, and we hope things are going well for you. If you wish to drop us a note we would be glad to hear from you.”

We were careful to avoid suggest- ing that we desired any specific infor- mation or action from the patients. By doing so we hoped to show that our intention was simply and entirely to let the person know that we remained aware of his or her existence and maintained positive feelings toward him or her. One such letter was not expected to have much impact, but we believed that the cumulative ef- fect of repeated contacts of this kind might have considerable psychologi- cal force.

The schedule for these contacts was monthly for four months, then every two months for eight months, and finally every three months for four years—a total of five years and 24 contacts. Many of the patients contacted changed addresses repeat- edly, and a subcategory of “lost after contact” was soon established. The number of contact letters known to have been received varied from two to 24, but, in order to incorporate an- ticipated field conditions and to make the interpretation of data as conserva- tive as possible, all patients who were contacted at all were considered to be in the contact group. In addition, if any patient in the contact group ac- cepted treatment during the follow- up period, that patient was still con- sidered to be in the contact group.

We postulated that whatever pre- ventive influence might have been ex- erted by this program would be meas- ured most simply by the difference in suicide rates between the contact and no-contact patients, the latter serving as a control group. Information about mortality was obtained from the Cali- fornia State Department of Health, coroners’ records, death certificates,

PSYCHIATRIC SERVICES ♦ June 2001 Vol. 52 No. 6 882299

We

addressed

the question of

whether the apparent

benefits of ongoing contact

with patients at risk for

suicide would remain

after the contact was

discontinued.

clinical sources, and family members and other individuals.

Informed consent involved an oral statement of our special interest in understanding the patient’s particular difficulties; assurance that no identi- fying information would be pro- cessed—the patients were identified only by number; assurance that no special procedures in the hospital be- yond the assessment interview would be required; and assurance that the patients were free to decline partici- pation. The committee on human subjects of the University of Califor- nia, San Francisco, Medical Center approved the project.

Results The distribution of patients by cate- gory and cumulative five- and 15-year outcome is shown in Table 1. The contact and no-contact groups had similar age and sex distributions, as shown in Table 2.

Nonsuicidal deaths in the treatment, contact, and no-contact groups were compared for the five-year and 15-year periods. Although our concern was pri- marily with patients in the contact and no-contact groups, the treatment group was included for comparison. No significant differences were found between groups in the rate of nonsuici- dal deaths during these periods.

The comparison of suicidal deaths over the five-year contact period is shown in Figure 1. A clear separation of the categories is seen—the contact group had the lowest rate every year. The difference between suicide rates in the contact and no-contact groups was greatest in the first and second years. The curves became parallel in years 3 and 4 and began to converge in year 5.

A formal survival analysis was car- ried out on survival time from the date of discharge to January 1, 1978. Persons who died a nonsuicidal death were removed from the sample as of their time of death. Estimated Ka- plan-Meier probabilities of survival by number of years after admission to the study are shown in Table 3. The differences between groups were in the predicted direction, and the Bres- low generalized Kruskal-Wallis test for equality of survival distributions indicated that for the first two years only, the difference in survival distri- butions was significant (one-tailed p=.043). When the same test was ap- plied to the entire five-year period, the differences were not significant.

It is especially interesting that the period during which there was a sig- nificant difference is also the period during which suicides are most likely to occur—the first two years after dis- charge from the hospital—and that this period included the time of max- imum frequency of contact—year 1.

The comparison of suicidal deaths over the 15-year follow-up period is shown in Figure 2. The gradual con- vergence of the suicide rates in the contact and no-contact groups, noted to begin in year 5, continued irregu- larly after the contact patients were no longer being contacted, until the rates finally converged in the 14th year.

The year-by-year suicide data for the contact and no-contact groups are shown in Table 4. These data repli- cate the contrasting patterns of the two groups, in that suicides continue to occur among the contact patients at a relatively constant rate over the entire follow-up period. In contrast, the no-contact group followed the an- ticipated pattern in which most sui- cides are observed during the first two years, especially during the first

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TTaabbllee 11

Suicides and nonsuicidal deaths among 3,005 patients during five and 15 years af- ter hospital discharge, by whether they accepted or declined ongoing treatment and whether they were periodically contacted by letter

Suicides Nonsuicidal deaths Total deaths

Category N % N % N %

During first five years Treatment (N=1,939) 121 6.2 84 4.33 205 10.6 No treatment

Contact (N=389) 15 3.9 19 4.9 34 8.7 No contact (N=454) 21 4.6 21 4.6 42 9.3

Undetermined (N=223) 35 15.7 13 5.8 48 21.5 Total (N=3,005) 192 6.4 137 4.6 329 10.9

Over 15 years Treatment (N=1,939) 159 8.2 243 12.5 402 20.7 No treatment

Contact (N=389) 25 6.4 55 14.1 80 20.6 No contact (N=454) 26 5.7 61 13.4 87 19.2

Undetermined (N=223)1 39 17.5 27 12.1 66 29.6 Total (N=3,005) 249 8.3 386 12.8 635 21.1

1 The undetermined group comprised patients who had died within 30 days of discharge and pa- tients who could not be located or who did not respond to three inquiries about ongoing care.

TTaabbllee 22

Age and sex of 3,005 patients, by whether they accepted or declined ongoing treat- ment and whether they were contacted by letter

Age over Male Female 39 years

Category N % N % Mean age N %

Treatment 830 43 1,109 57 34.0 600 31 No treatment

Contact 164 42 225 58 34.4 114 29 No contact 211 46 243 54 32.8 127 28

Undetermined1 123 55 100 45 32.6 55 25 Total 1,328 44 1,677 56 33.9 896 30

1 The undetermined group comprised patients who had died within 30 days of discharge and pa- tients who could not be located or who did not respond to three inquiries about ongoing care.

year, after discharge from the hospi- tal. During those two years the sui- cide rate of the no-contact group was approximately twice that of the con- tact group.

Discussion and conclusions The outcome of our study is consis- tent with our hypotheses: during the period of maximum contact, year 1, and during the subsequent year, the suicide rate was significantly lower in the contact group than in the control group. It also appears that no obvious extraneous influence distorted the data—for example, age or sex differ- ences or concealment of suicides as accidental or natural deaths.

Our expectation that patients in the treatment group would be older on average, given the reputation of younger patients to decline help, was not borne out. An explanation for the consistently higher suicide rate among the patients who accepted treatment than among those who de- clined was not evident but may be re- lated to the severity and chronicity of illness, which would affect the num- ber of options a patient has about whether to accept ongoing assistance. Torhorst and colleagues (3) found such a pattern, noting that patients with good compliance seemed to be more at risk than patients with poor compliance.

The most challenging questions posed by the findings are, first, whether maintaining the most inten- sive contact schedule, as used in year 1, would have continued to be associ- ated with a significantly lower suicide rate among patients in the contact group and, second, whether extend- ing the duration of the program would have prolonged the apparent benefit. In a study pertinent to the latter question, Stein and Test (11) found that after a 14-month program to stabilize chronically disabled psy- chiatric patients, many clear gains de- teriorated when the program was dis- continued. Similarly, Caton and col- leagues (12) observed a deterioration in the positive effects of a day treat- ment program for homeless mentally ill men when the men were re- assessed six and 18 months after the 14-month program was terminated. The need for ongoing programs was

stressed in both of these reports. Similarly, Salkovskis and colleagues

(13), using cognitive-behavioral prob- lem solving, found evidence of a treatment effect on the rate of re- peated suicide attempts. This effect persisted for six months after termi- nation of treatment, but patients ceased to show any benefit one year after treatment. This phenomenon was also shown by Linehan and coworkers (14), who found in a ran- domized clinical trial that dialectical behavior therapy for one year was as- sociated with a lower rate of parasui- cidal behaviors and a lower number of hospital days among female pa- tients with borderline personality dis- order, but the benefit could be shown for only six months after the treat- ment ended.

Inherent in these questions is the basic concept of the role of a feeling of being joined to something mean- ingful outside oneself as a stabilizing force in emotional life. Kaiser (15) re- ferred to this concept as a healthy “delusion of fusion,” and Frank (16) called it a sense of “connectedness to others.” However characterized, it is this force that we postulate as having exerted whatever suicide-prevention influence the contact program might have generated. Morgan (17) ex- pressed this concept clearly after re- counting suicide prevention meas- ures over 600 years and contemplat-

ing what is really new, observing that “there is surely at least one common theme through the centuries—it is the provision of human contact, the comfort of another concerned per- son, often authoritative but maybe not, conveying a message of hope consonant with the assumptions and values relevant to that particular time.”

Each patient has a unique potential to respond to efforts of this kind. Among the 389 people in the contact group, 11 requested that the letters be discontinued, and they were. About 25 percent of the patients in the contact group expressed positive reactions in writing, such as “Thank you for your continued interest,” “It is a good feeling to know you are still in-

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TTaabbllee 33

Estimated Kaplan-Meier probabilities of survival by number of years after ad- mission to the study, expressed as mean±SE

Number of years after Contact No-con- discharge group tact group

1 .990±.005 .978±.007 2 .983±.006 .964±.009 3 .976±.008 .960±.009 4 .968±.009 .955±.010 5 .957±.010 .955±.010

FFiigguurree 11

Cumulative percentage of suicidal deaths among 2,782 patients during the five years after hospital discharge, by whether they accepted or declined ongoing treatment and whether they were periodically contacted by letter

1

0

2

3

4

5

6

7

8

Contact (N=389) No contact (N=454) Treatment (N=1,939)

C um

ul at

iv e

pe rc

en ta

ge o

f su

ic id

es

10 2 3 4 5 Years at risk

terested,” “Farewell until your next note,” “After I threw the last letter out I wished I hadn’t, so I was glad to get this one,” “I really appreciate your persistence and concern,” “It gives me great pleasure to know that some- one is concerned,” “Your note gave me a warm, pleasant feeling. Just knowing someone cares means a lot,” “I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there,” “You will never know what your little

notes mean to me. I always think someone cares about what happens to me, even if my family did kick me out. I am really grateful,” and “You are the most persistent son of a bitch I’ve ever encountered, so you must really be sincere in your interest in me.”

A definite impression was conveyed that the responses of the contact pa- tients were not simply “dose specif- ic”—that is, determined only by the number of contacts received—but were primarily characterologic. Thus

some patients responded to very few contacts, others required more con- tacts, and some were impervious to the contacts.

A variant of this program was car- ried out from 1971 to 1973 in Scot- land by the Samaritans, who invited people to write to a friendly and re- ceptive correspondent (18). The re- sponse indicated that there was a real need for supportive letter writing, that there are people who are unable to cope with face-to-face interviews but who can form a relationship by letter, and that many people can ex- press themselves by letter in a way that is cathartic and therapeutic.

Another variant of this approach is being explored in Australia, where a schedule of contact by postcard is be- ing used as a supplement to usual care in a population of patients hospi- talized for deliberate self-poisoning. The targeted outcomes are a reduc- tion in the number of repeated episodes of disability and a reduction in the need for subsequent inpatient care (19).

Clinical studies to date have led to a wide range of views about the effi- cacy of suicide prevention measures. Gunnel and Frankel (20) observed that no single intervention has been shown to reduce suicide rates in a well-conducted randomized con- trolled trial. However, Goldney (21) argued that there is every reason to be optimistic, because an increasing number of studies confirm that sui- cide prevention is possible, but he cautioned that any intervention must be long term. In this regard, McNiel and Binder (22) found that although psychiatric hospitalization was associ- ated with a substantial reduction in the estimated short-term (one week) suicide risk, the decrease in long- term (one year) risk was much less, indicating a need for further research on interventions to improve long- term risk. Our study attempted to ad- dress that need.

An incidental benefit of our contact program that may have contributed to the outcome was that patients in the contact group or their families occa- sionally turned to project personnel for help reentering the health care system. Citing “embarrassment” or “not knowing what to do” because of

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FFiigguurree 22

Cumulative percentage of suicidal deaths among 2,782 patients during 15 years af- ter hospital discharge, by whether they accepted or declined ongoing treatment and whether they were periodically contacted by letter

0

2

4

6

8

10 Contact (N=389) No contact (N=454) Treatment (N=1,939)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Years at risk

C um

ul at

iv e

pe rc

en ta

ge o

f su

ic id

es

0

TTaabbllee 44

Suicides over 15 years among 843 patients who declined ongoing treatment, by whether they were periodically contacted by letter

Contact group (N=389) No-contact group (N=454)

Cumulative Cumulative Number of Suicides suicides Suicides suicides years after discharge N % N % N % N %

1 4 1.03 4 1.03 10 2.20 10 2.20 2 3 .77 7 1.80 6 1.32 16 3.52 3 2 .51 9 2.31 3 .66 19 4.19 4 2 .51 11 2.83 2 .44 21 4.63 5 4 1.03 15 3.86 0 — 21 4.63 6 2 .51 17 4.37 1 .22 22 4.85 7 0 — 17 4.37 3 .66 25 5.51 8 1 .26 18 4.63 0 — 25 5.51 9 0 — 18 4.63 0 — 25 5.51 10 1 .26 19 4.88 0 — 25 5.51 11 2 .51 21 5.40 0 — 25 5.51 12 0 — 21 5.40 1 .22 26 5.73 13 0 — 21 5.40 0 — 26 5.73 14 2 .51 23 5.91 0 — 26 5.73 15 2 .51 25 6.43 0 — 26 5.73

PSYCHIATRIC SERVICES ♦ June 2001 Vol. 52 No. 6 883333

their prior refusal of care, some pa- tients could accept the assistance of the writer of the contact letter to ob- tain professional care in a new crisis.

Möller (8) pointed out that the only convincing evidence for the efficacy of a suicide prevention program would be a significantly lower rate of suicide within a certain follow-up pe- riod among the patients treated ac- cording to that program than among control patients. Our randomized, con- trolled study met those criteria: it showed that a contact program was associated with a significant reduction in suicide rates among high-risk per- sons who refused ongoing treatment; the association was evident for at least two years after discharge from an in- patient setting. An important aspect of this observation is that, when the high-risk person’s refusal of formal therapy is accepted, such a program can be carried out with very modest resources of space, equipment, and personnel. ♦

Acknowledgments

This project was supported by National Institute of Mental Health grants MH- 16524 from the Center for Studies of Sui- cide Prevention and MH-25080 from the Mental Health Services Development Branch. Invaluable assistance in data gathering and project implementation was provided by research assistants Chrisula Asimos, M.A., James Billings, M.A., Patricia Conway, B.A., Douglas Kreider, B.A., Colleen Schurter, M.A., and James Stoll, M.Div., and by staff members Jane Steinberg, B.A., Judith Einzig, B.A., and Linda Nightingale, B.A.

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