evidence table
duneski
ARTICLE2.pdf
Association of Suicide Prevention Interventions With Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings A Systematic Review and Meta-analysis Stephanie K. Doupnik, MD, MSHP; Brittany Rudd, PhD; Timothy Schmutte, PhD; Diana Worsley, MPH; Cadence F. Bowden, MSW, MPH; Erin McCarthy, MD; Elliott Eggan, MD; Jeffrey A. Bridge, PhD; Steven C. Marcus, PhD
IMPORTANCE To prevent suicide deaths, acute care settings need tools to ensure individuals at risk of suicide access mental health care and remain safe until they do so.
OBJECTIVE To examine the association of brief acute care suicide prevention interventions with patients’ subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up.
DATA SOURCES Ovid MEDLINE, Scopus, CINAHL, PsychINFO, Embase, and references of included studies using concepts of suicide, prevention, and clinical trial to identify relevant articles published January 2000 to May 2019.
STUDY SELECTION Studies describing clinical trials of single-encounter suicide prevention interventions were included. Two reviewers independently reviewed all articles to determine eligibility for study inclusion.
DATA EXTRACTION AND SYNTHESIS Two reviewers independently abstracted data according to PRISMA guidelines and assessed studies’ risk of bias using the Cochrane Risk of Bias tool. Data were pooled for each outcome using random-effects models. Small study effects including publication bias were assessed using Peter and Egger regression tests.
MAIN OUTCOMES AND MEASURES Three primary outcomes were examined: subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up. Suicide attempts and linkage to follow-up care were measured using validated patient self-report measures and medical record review; odds ratios and Hedges g standardized mean differences were pooled to estimate effect sizes. Depression symptoms were measured 2 to 3 months after the encounter using validated self-report measures, and pooled Hedges g standardized mean differences were used to estimate effect sizes.
RESULTS A total of 14 studies, representing outcomes for 4270 patients, were included. Pooled-effect estimates showed that brief suicide prevention interventions were associated with reduced subsequent suicide attempts (pooled odds ratio, 0.69; 95% CI, 0.53-0.89), increased linkage to follow-up (pooled odds ratio, 3.04; 95% CI, 1.79-5.17) but were not associated with reduced depression symptoms (Hedges g = 0.28 [95% CI, −0.02 to 0.59).
CONCLUSIONS AND RELEVANCE In this meta-analysis, breif suicide prevention interventions were associated with reduced subsequent suicide attempts. Suicide prevention interventions delivered in a single in-person encounter may be effective at reducing subsequent suicide attempts and ensuring that patients engage in follow-up mental health care.
JAMA Psychiatry. 2020;77(10):1021-1030. doi:10.1001/jamapsychiatry.2020.1586 Published online June 17, 2020.
Editorial page 997
Supplemental content
Author Affiliations: Author affiliations are listed at the end of this article.
Corresponding Author: Stephanie K. Doupnik, MD, MSHP, Roberts Center for Pediatric Research, University of Pennsylvania, 2716 South St, #10-242, Philadelphia, PA 19146 ([email protected]).
Research
JAMA Psychiatry | Original Investigation
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S uicide rates have been rising for 2 decades in the US.1 In response to this crisis, the National Action Alliance for Suicide Prevention has called for health care organiza-
tions to incorporate suicide prevention into routine practice. Health care organizations are well positioned to prevent sui- cide deaths because more than one-third of people who die by suicide have a health care encounter in the week before their death2 and half within a month before their death.3 Emer- gency department visits for suicidal ideation and suicide at- tempts have doubled in recent decades.4,5 However, acute health care settings including hospitals, emergency depart- ments, and urgent care centers as well as other settings that deliver acute suicide prevention services, such as jails and shel- ters, are not well staffed with specialty mental health clini- cians and may not have the capacity to offer continuity of men- tal health care. Nevertheless, these settings are at the front line of suicide prevention and require effective tools to reduce pa- tients’ risk of morbidity from suicide ideation and attempts and their risk of suicide death.
National suicide prevention best practices recommend that individuals identified as being at risk of suicide receive treat- ment specifically directed to reduce their risk of suicide and services to ensure they remain engaged in mental health care.6
To achieve these goals, clinical teams need evidence-based in- terventions to directly address suicide risk and to ensure that patients transition to ongoing, longitudinal mental health care. Brief interventions are used in acute care to identify and pro- vide initial management for a number of mental health and other problems and offer several practical advantages.7 Brief interventions can be delivered in a single time-limited encoun- ter by trained professionals and include an emphasis on on- going treatment. Some of these interventions are augmented by care coordination or follow-up after the patient leaves the acute encounter. Brief interventions that focus on immediate suicide risk reduction and transition to ongoing mental health care are well suited for settings not equipped to offer ongo- ing, longitudinal mental health care.
To establish evidence for brief acute care suicide preven- tion interventions, we conducted a systematic review of clini- cal trials of brief suicide prevention interventions delivered in a single in-person encounter (in some cases, with telephone follow-up) that directly addressed suicide risk, promoted con- tinuity of mental health care, or both. Among interventions in- cluded in the review, we conducted a meta-analysis of the 3 suicide prevention outcomes reported by the largest number of studies: subsequent suicide attempts, linkage to follow-up care (ie, attending at least 1 follow-up visit), and depression symptoms at follow-up. The objectives of the research were to (1) describe the contents, resource intensity, and target popu- lations for brief acute care suicide prevention interventions and (2) examine the association of brief acute care suicide preven- tion interventions with patient outcomes.
Methods We conducted and reported the systematic review and meta- analysis in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.8 Our protocol was registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42019114964).
Search Strategy We searched Ovid MEDLINE, Scopus, CINAHL, PsychINFO, and Embase for English language studies published between Janu- ary 1, 2000, and December 31, 2019. We based search terms on the following key concepts: suicide, prevention, and clini- cal trial. Keywords were developed using database-specific vo- cabularies. eTable 1 in the Supplement shows the complete da- tabase search strategy for Ovid MEDLINE. References of included studies were reviewed for possible inclusion.
Study Selection Two study authors (E.M. and E.E.) independently reviewed titles and abstracts of retrieved studies to identify studies eli- gible for inclusion. Studies were eligible for inclusion if they (1) examined an intervention delivered in a single in-person encounter to patients with identified suicide risk; (2) in- cluded a comparison group; (3) measured patient outcomes; and (4) were available in English. Interventions consisting solely of a brief follow-up contact were ineligible for inclu- sion, as these have been reviewed previously.9 If the interven- tion or study design could not be ascertained from title and abstract review, 2 authors (D.W. and C.F.B.) reviewed the full text to determine eligibility. We held team meetings to dis- cuss and resolve discrepancies and reach consensus on all in- clusion decisions.
Among included studies, the most commonly reported out- comes were subsequent suicide attempts, linkage to fol- low-up care, and depression symptoms at follow-up. We se- lected these outcomes for meta-analysis. All studies reported sufficient data to examine intervention effects on at least 1 out- come.
Data Abstraction, Evaluation, and Synthesis Two study authors (either E.M. or E.E. and either D.W. or C.F.B.) independently abstracted relevant data for each study using a structured form, including study setting, intervention de- scription, characteristics of the sample, inclusion/exclusion cri- teria, and study outcomes. We abstracted raw event numbers
Key Points Question Are brief interventions delivered in a single encounter to individuals at risk of suicide effective at improving patient outcomes?
Findings In this systematic review and meta-analysis of 14 studies, brief acute care suicide prevention interventions were associated with reduced subsequent suicide attempts and increased chances of linkage to follow-up care. Most interventions included multiple components; the most common components were care coordination, safety planning, brief follow-up contacts, and brief therapeutic interventions.
Meaning The evidence supports incorporating brief suicide prevention interventions into routine acute care practice.
Research Original Investigation Association of Suicide Prevention Interventions With Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms
1022 JAMA Psychiatry October 2020 Volume 77, Number 10 (Reprinted) jamapsychiatry.com
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for subsequent suicide attempt and linkage to follow-up care to estimate pooled odds ratios (ORs) and raw depression scores on the validated scales used in each of the studies to calcu- late standardized mean differences (SMDs) in depression score means at follow-up.
Study design and threats to inference were evaluated by applying the Cochrane Risk of Bias tool.10 Each study’s risk of bias was assigned low, medium, or high risk in each of the tool’s 9 domains.
Meta-analysis For each of the 3 outcomes, we developed a random-effects model to calculate pooled effect size estimates weighted for the inverse of the variance of the individual effects (ie, ac- counting for the size of the sample). For the outcomes of sub- sequent suicide attempt and linkage to follow-up care, we com- pared pooled ORs and Hedges g statistic, a technique for pooling SMDs in studies with small sample sizes. We used the for- mula: SMD = ln(OR) × (�3/π) to convert ORs to SMDs. To take into account small sample sizes, we multiplied SMD by a cor- rection factor J= 1 − (3 / [4 × (N − 2) − 1]) to calculate Hedges g.11 For depression symptoms at follow-up, we examined pooled effect sizes using Hedges g. We conducted sensitivity analyses to determine whether any study had a large influ- ence on the pooled-effect estimates and subgroup analyses to investigate sources of heterogeneity.
We used I2 statistics to assess how much of the observed heterogeneity in effect sizes was due to differences in inter- vention characteristics. A higher I2 statistic suggests that in- terventions have different effect sizes, whereas a lower I2 sta- tistic suggests that the variation in estimated effect sizes is more likely due to chance.12
We examined for evidence of small study effects, such as publication bias, using the Peter regression test for binary out- comes (suicide attempt and linkage to follow-up care) and the Egger test for the continuous outcome of depression symp- toms at follow-up. Although these tests are a widely used method for estimating small study effects, there is known risk of false-positive detection of small study effects when fewer than 10 studies are included in the analysis or there is sub- stantial between-study heterogeneity.13,14 We also generated contour-enhanced funnel plots to help evaluate for publica- tion bias as a source of small-study effects. Two-sided P val- ues had a significance threshold of .05. We conducted analy- ses using Stata, version 15 (StataCorp). Analysis began October 2019.
Results Evidence Synthesis Database searches returned 3968 articles. After removing du- plicates, we screened titles and abstracts for 2235 records, and of those, we reviewed the full article for 125 studies. We iden- tified 4 additional eligible articles from review of references of included studies. Ultimately, we identified 14 studies eli- gible for inclusion in the narrative synthesis (Figure 1), repre- senting outcomes for 4270 patients. All 14 contributed data to
a meta-analysis of at least 1 outcome. The Table outlines se- lected characteristics of included studies.
Description of Brief Suicide Prevention Interventions Included studies evaluated brief suicide prevention interven- tions to promote ongoing mental health care and reduce sub- sequent suicide attempts. We identified 4 main components of interventions delivered in the study: brief contact interven- tions, care coordination, safety planning interventions, and other brief therapies.
Brief contact interventions include telephone calls, post- cards, and letters, and these interventions alone have been re- viewed elsewhere.9 Brief contact was included as a compo- nent of a suicide prevention intervention for 6 of 14 included studies (42.9%). In 5 studies (35.7%), the brief contact in- cluded telephone calls, and of those studies, patients also re- ceived handwritten mailed notes.22 The schedules and focus for the follow-up telephone calls varied, ranging from 1 ap- pointment reminder to a schedule of telephone calls at 1, 2, 4, and 8 weeks after the encounter.26 One study18 used text mes- saging to provide brief caring contacts at 1 day, 1 week, and 9 other times throughout 12 months, and trained counselors re- sponded to recipients’ replies either with supportive state- ments or to ensure the recipient engaged with mental health treatment.
We defined care coordination as bidirectional communi- cation between the clinical team referring the patient for men- tal health care and the team receiving the patient for fol- low-up mental health care. Of the 14 included studies, 3 (21.4%) included care coordination.17,19,20 Care coordination in- cluded scheduling an outpatient mental health appointment,17
scheduling a mobile crisis response team evaluation,19 or scheduling an outpatient mental health appointment and col- laborating with the patient’s family to reduce barriers to
Figure 1. PRISMA Flow Diagram
3964 Records identified through database searching
4 Records identified through other sources
2235 Records after duplicate removed
2235 Records screened
2110 Records excluded after title/abstract review
7 Articles included in meta-analysis of subsequent suicide attempts
9 Articles included in meta-analysis of attendance at follow-up visits
6 Articles included in meta-analysis of depression at follow-up
125 Records assessed with full-text review
14 Articles included in narrative synthesis
111 Records excluded after full-text review
Association of Suicide Prevention Interventions With Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms Original Investigation Research
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Research Original Investigation Association of Suicide Prevention Interventions With Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms
1024 JAMA Psychiatry October 2020 Volume 77, Number 10 (Reprinted) jamapsychiatry.com
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Ta bl
e. Se
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Association of Suicide Prevention Interventions With Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms Original Investigation Research
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attending the appointment.20 In 1 study, staff monitoring re- sponses to caring contact text messages gave a warm handoff to mental health clinician colleagues when a study partici- pant’s response indicated they were in distress.18
Brief therapeutic interventions were defined as inter- ventions aiming to prevent patients from engaging in future suicidal behaviors or promote ongoing mental health treat- ment engagement and were delivered to the patient during the single in-person encounter or in brief telephone calls. Of the 14 included studies, all but 1 study19 provided a brief therapeutic intervention. The most common brief therapeu- tic intervention was the Safety Planning Intervention, which was delivered in 5 studies.16,18,24,27,28 Safety Planning Intervention29 components include (1) identifying personal- ized warning signs for an impending suicidal crisis, (2) determining internal coping strategies that distract from suicidal thoughts and urges, (3) identifying family, friends, and social places that can distract from suicidal thoughts and urges, (4) identifying individuals who can help provide support during a suicidal crisis, (5) listing mental health professionals and urgent care services to contact during a suicidal crisis, and (6) lethal means counseling for making the environment safer. For the purposes of this systematic review, any intervention that included at least 4 of 6 compo- nents above was categorized as having delivered a Safety Planning Intervention.
Ten studies delivered brief therapeutic interventions other than a Safety Planning Intervention.15,18,20,22-28 These other brief therapeutic interventions used a variety of thera- peutic techniques to reduce a patient’s likelihood of self- harm, including functional analysis,2 4 therapeutic assessment,25 and the development of implementation intentions,15 as well as techniques informed by motivational interviewing22,23 and therapies focused on improving patients’ problem-solving skills.23 These interventions also used techniques to increase the likelihood of outpatient mental health treatment engagement.20,21,23,26-28
Many eligible studies included a combination of interven- tions. For example, 3 studies (21.4%) included a brief thera- peutic intervention plus a brief contact intervention.16,23,26 One study included a brief therapeutic intervention, care coordi- nation, and a brief contact intervention.20 Finally, 3 studies (21.4%) included the Safety Planning Intervention enhanced with another brief therapeutic intervention such as treat- ment engagement.24,27,28
Risk of Bias The most common domain in which studies were assigned a high risk of bias was in incomplete outcomes data, in some cases owing to handling of missing data. Studies reporting complete data were assigned a low risk score.27,28 Studies that described a standard method for handling missing data during analysis, such as multiple imputation or last obser- vation carried forward, were assigned a medium risk score.15,16,18,19,24,25 Studies that did not mention how miss- ing data were analyzed were assigned a high risk score on the incomplete outcome data domain.17,20-23,26 eTable 2 in the Supplement details risk of bias scores for each study.
Meta-analysis Results Seven studies (50%) examined subsequent suicide attempts as an outcome,16-18,21,23,24,28 9 (64.3%) examined link to fol- low-up care as an outcome,16,19-21,24-28 and 6 (42.9%) exam- ined depression as an outcome.15,16,19-22 Forest plots shown in Figure 2 demonstrate the associations of the interventions with each outcome, and eTable 3 in the Supplement displays the raw numbers used to calculate effect size estimates.
The pooled effect size of suicide prevention interven- tions was toward fewer subsequent suicide attempts (pooled OR, 0.69 [95% CI, 0.55-0.87]; Hedges g = 0.21 [95% CI, 0.08- 0.33]). We did not find statistically significant heterogeneity in the studies’ associations with subsequent suicide at- tempts (I2 = 0%; P = .72), suggesting that included interven- tions had a similar effect in reducing subsequent suicide at- tempts. Studies followed up study participants for 2 months to 1 year after the intervention to identify subsequent suicide attempts and used either medical record review28 or vali- dated patient self-report measures16-18,21,23,24 to ascertain sui- cide attempts. We conducted sensitivity analyses excluding each study from the pooled-effect estimate. We found that the pooled effect of the interventions was consistently toward a reduction in subsequent suicide attempts regardless which study was excluded, suggesting that no individual study dis- proportionately affected findings.
We found that the pooled effect size of included interven- tions was toward an increase in linkage to follow-up mental health care (pooled OR, 2.74 [95% CI, 1.80-4.17]; Hedges g = 0.55 [95% CI, 0.32-0.78]). We found that heterogeneity be- tween studies was statistically significant (I2 = 55.4%; P = .02), suggesting that the included interventions varied in their as- sociations with patients’ likelihood of linkage to follow-up care. Studies measured follow-up visit attendance at an outpatient appointment from 1 week to 3 months after the intervention. Studies ascertained follow-up visit attendance using either a validated patient self-report measure16,19-21,24,26 or elec- tronic health record information.25,27,28 We conducted sensi- tivity analyses excluding each study from the pooled-effect es- timate. The pooled effect of the interventions consistently showed higher odds of linkage to follow-up care regardless of which study was excluded from the analysis, suggesting that no individual study had an outsize influence on the findings. We also conducted subgroup analyses for adult-only and ado- lescent-only populations. The subgroup analysis of adults showed no difference in effect size or heterogeneity com- pared with the main analysis. The subgroup analysis includ- ing only adolescent populations had no difference in effect size from the main analysis; however, there was no statistically sig- nificant heterogeneity (I2 = 39%; P = .18).
The pooled effect size of included interventions on de- pression symptoms at follow-up was not significantly signifi- cant (Hedges g = 0.28 [95% CI, −0.02 to 0.59]). The interven- tion groups had nonsignificantly lower depression scores (ie, fewer depression symptoms) at follow-up compared with the control groups at follow-up. Studies measured follow-up de- pression symptoms between 2 and 3 months after the inter- vention using validated patient self-report measures. We found that heterogeneity between studies was statistically signifi-
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cant (I2 = 72.2%; P = .003), suggesting that true differences ex- isted between the studies’ associations with patients’ depres- sion symptoms 2 to 3 months after the index encounter. We conducted sensitivity analyses excluding each study from the pooled-effect estimate. Excluding the study by Asarnowet al16
resulted in the pooled effect size for the remaining studies being statistically significant (Hedges g = 0.38 [95% CI, 0.05-0.71]). For the remaining studies, exclusions did not result in a change in the direction or statistical significance of the findings.
Small Study Effects and Publication Bias For depression symptoms at follow-up, the Egger test did not show evidence of small study effects (regression coefficient, −0.62 [95% CI, −1.49 to 0.25]; P = .06). For subsequent suicide attempts, the Peter test did not show evidence of small study effects (regression coefficient, −3.67 [95% CI, −93.45 to 86.10]; P = .79). However, sample sizes were small for both outcomes, so there is insufficient information to exclude small study ef- fects. For linkage to follow-up care, the Peter test showed sta- tistically significant evidence of small study effects (regression coefficient, 53.07 [95% CI, 10.47-95.66]; P = .02). Given known risk of false positives when a small number of publications are included in the analysis and when there is substantial hetero-
geneity of effects between studies, this finding could be a false positive. If a true positive, small study effects could be ex- plained by publication bias (ie, studies with nonsignificant find- ings are not published in the literature), selective reporting (ie, studies only reported those outcomes with statistically signifi- cantdifferences),ortrueheterogeneity(ie,theinterventionshave a different effect in studies with small samples).
For each outcome, we generated a contour-enhanced fun- nel plot to visually evaluate for publication bias by identify- ing whether areas of asymmetry in the funnel plot (ie, miss- ing studies) correspond with the area representing statistically nonsignificant findings (Figure 3). For depression at follow- up, although asymmetrical, the funnel plot shows 4 studies with nonsignificant P values. For subsequent suicide at- tempts, the funnel plot appears symmetrical and shows 2 stud- ies with nonsignificant P values. Therefore, for the depres- sion and suicide attempt outcomes, funnel plots do not show strong evidence of publication bias, which is consistent with the Egger test showing no evidence of small study effects. For linkage to follow-up mental health care, the funnel plot is asym- metrical and only 1 study had a nonsignificant P value, indi- cating that there could be publication bias (ie, suppression of studies with nonsignificant findings) for this outcome.
Figure 2. Forest Plots for 3 Study Outcomes: Depression, Linkage to Follow-up Care, and Subsequent Suicide Attempts
Weight, %Study Hedges g (95% CI)
20.29Asarnow et al,16 2011 Depression at follow-up
–0.13 (–0.42 to 0.16) 19.49Armitage et al,15 2016 0.18 (–0.14 to 0.50) 18.59Currier et al,19 2019 0.31 (–0.05 to 0.66) 9.28Grupp-Phelan et al,20 2012 0.57 (–0.22 to 1.37) 19.79Grupp-Phelan et al,21 2019 0.05 (–0.26 to 0.36) 12.56King et al,22 2015 1.23 (0.62 to 1.83)
0.28 (–0.02 to 0.59) 100Subtotal I2 = 72.2%; (P = .003)
10.42Asarnow et al,16 2011 Linkage to follow-up care
0.71 (0.18 to 1.24) 13.06Currier et al,19 2010 0.93 (0.50 to 1.36) 4.06Grupp-Phelan et al,20 2012 1.21 (0.17 to 2.24) 14.85Grupp-Phelan et al,21 2019 0.21 (–0.16 to 0.58) 8.15O’Connor et al,24 2020 0.75 (0.10 to 1.40) 9.06Ougrin et al,25 2011 0.89 (0.29 to 1.49)
Spirito et al,26 2002 0.15 (–0.87 to 1.16)
Stanley et al,27 2015 0.49 (0.11 to 0.88)
Stanley et al,28 2018 0.26 (0.11 to 0.41)
0.55 (0.32 to 0.78)
4.20 14.35 21.86 100Subtotal I2 = 55.4%; (P = .02)
2.98Asarnow et al,16 2011 Subsequent suicide attempt
0.11 (–0.63 to 0.85) 1.86Bryan et al,17 2017 0.57 (–0.36 to 1.51) 16.76Comtois et al,18 2019 0.29 (–0.02 to 0.60) 1.04Grupp-Phelan et al,21 2019 –0.61 (–1.86 to 0.64) 56.75Miller et al,23 2017 0.16 (–0.01 to 0.33) 1.33O’Connor et al,24 2020 –0.05 (–1.16 to 1.06)
Stanley et al,28 2018 0.32 (0.03 to 0.61)
0.21 (0.08 to 0.33)
19.28 100Subtotal I2 = 0.0%; (P = .72)
–2 0–1 21 3 Hedges g (95% CI)
Favors control Favors intervention
Studies were weighted according to sample size using random effects models. The vertical line shows the pooled odds ratio across all 3 outcomes. The boxes vary in size according to the weight of each study (proportional to the study’s
sample size), and horizontal black lines represent the confidence intervals for each study. The diamond at the bottom of each outcome plot represents the pooled odds ratio and CI for the individual outcome.
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Discussion
In this systematic review, we identified 14 brief suicide pre- vention interventions that included 4 main components: brief contact, care coordination, safety planning, and other brief therapies. The 3 most common outcomes were subsequent sui- cide attempts, linkage to follow-up care, and depression symp- toms at follow-up. Meta-analyses showed that the pooled ef- fect of the interventions was to reduce subsequent suicide attempts and increase linkage to follow-up care. Reduction in depression symptoms at follow-up was not statistically sig- nificant. The US National Action Alliance for Suicide Preven- tion has specifically prioritized research to prevent suicide- related behavior after an initial suicide attempt and identify strategies to retain patients in care.30 Our findings help ad- vance these research goals by providing evidence that brief in- terventions may reduce risk of subsequent suicide attempt and increase continuity of mental health care.
The pooled OR for subsequent suicide attempts was 0.69, corresponding to a risk difference of −0.035, a 3.5% reduc- tion or 78 fewer suicide attempts in 2241 patients in the pooled intervention groups. For linkage to follow-up care, the pooled OR was 2.74, which corresponds to a 22.5% absolute increase in rates of completed follow-up in patients receiving the in- tervention. Because other brief interventions have not shown statistically significant reductions in suicide attempts or ex- amined linkage to follow-up care, these effect sizes have im- portant clinical implications.
The evidence base in support of other brief suicide pre- vention interventions suited for acute care has been mixed. Brief contact interventions reduce the number of suicide at- tempts per person but not the total number of suicide at- tempts or suicide deaths.9 Smartphone applications for self- management of suicide risk were associated with reduced suicide ideation but not subsequent suicide attempts or deaths.31 Consistent with our findings, a small meta-analysis of 2 studies of interventions involving active follow-up after emergency department discharge found that these interven- tions reduced subsequent suicide attempts.32 Our study builds on these previous findings by evaluating a broader range of in- terventions, including those focused on safety planning and care coordination, and a broader range of outcomes, includ- ing successful linkage to follow-up care. Our findings provide important evidence that brief suicide prevention interven- tions may be effective at targeting important end points that reduce risk of suicide deaths.
The most common component among all interventions was to promote connectedness via engagement with health care clinicians and with the patient’s community. Safety planning interventions explicitly focused on these goals during the in- person encounter. Other interventions promoted connected- ness by providing care coordination or brief follow-up con- tacts to improve connectedness with health care clinicians. Finally, many of the suicide prevention interventions in- cluded a brief therapeutic component that addressed pa- tients’ coping or engagement during their in-person acute care encounter, thereby addressing their connection to a commu-
Figure 3. Contour-Enhanced Funnel Plots for 3 Study Outcomes: Depression, Linkage to Follow-up Care, and Subsequent Suicide Attempts
0
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The vertical axis shows the standard error of the natural logarithm of the effect size for each study, and the horizontal axis shows the natural logarithm of the effect size of each study. If no publication bias is present, dots are expected to be distributed symmetrically.
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nity and to mental health care. Nevertheless, in the US and many other countries, mental health care remains difficult to access, and care coordination was likely included as a compo- nent of many interventions due to the complexity of navigat- ing mental health care systems.
An important future direction in integrating brief suicide prevention interventions into acute care encounters is to iden- tify and test implementation strategies. Numerous barriers ex- ist to integrating these potentially lifesaving interventions into general medical care. First, health care settings need robust systems to identify patients with suicide risk. The Joint Com- mission’s 2016 mandate to identify patients at risk of suicide33
has increased the number of health care settings screening for suicide risk; however, the success of screening initiatives likely varies, particularly in settings with limited mental health ex- pertise. Second, teams seeking to implement suicide preven- tion interventions need champions who have the skills and knowledge to deliver them. In many cases, social workers have the right combination of skills and expertise to offer brief in- person therapy, brief follow-up contacts, and care coordina- tion. However, many settings have limited access to social workers and may rely on other professionals including nurses, physicians, or case managers to deliver components of the in- terventions. Settings with limited access to mental health pro- fessionals may consider using telehealth solutions to im- prove access to mental health specialists, and telehealth mental health care professionals should consider whether their ser- vices could comprise the follow-up and care coordination that were a key component of many of the included suicide pre- vention interventions. To assure appropriate resources, health care systems need to identify mechanisms to reimburse the time and resources required to deliver evidence-based sui- cide prevention interventions. Finally, these interventions
likely have applications outside of traditional health care set- tings, and their implementation in other settings providing acute care, such as jails and crisis homeless shelters, war- rants future study.
Limitations This study should be interpreted in the context of several im- portant limitations. Our literature search was limited to pub- lished articles and reports available in English. We did not in- clude unpublished findings about suicide prevention interventions, such as findings from local quality improve- ment initiatives or unpublished research. The systematic re- view identified only 14 studies, and only the subsets with rel- evant outcomes were included in each meta-analysis. One large study23 accounted for a large proportion of the study partici- pants and was therefore heavily weighted in the meta- analyses. We were not able to examine whether brief suicide interventions ultimately reduced suicide deaths because most studies in the review did not include death as an outcome. Nev- ertheless, we were able to examine 3 important outcomes from the published literature, and for 2 of the 3 outcomes we found no evidence of publication bias using a conservative test.
Conclusions Suicide prevention interventions delivered during and after a single in-person acute care encounter may be effective at re- ducing subsequent suicide attempts and improving patients’ odds of linkage to follow-up mental health care. Future ef- forts to implement brief suicide prevention interventions in acute care are likely to reduce patients’ risk of future suicide attempts and improve their continuity of mental health care.
ARTICLE INFORMATION
Accepted for Publication: March 19, 2020.
Published Online: June 17, 2020. doi:10.1001/jamapsychiatry.2020.1586
Author Affiliations: PolicyLab, Center for Pediatric Clinical Effectiveness, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Doupnik, Worsley, Bowden, McCarthy, Eggan); Department of Pediatrics, University of Pennsylvania, Philadelphia (Doupnik); Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Doupnik, Marcus); Center for Mental Health, University of Pennsylvania, Philadelphia (Rudd, Marcus); now with Institute for Juvenile Research, Department of Psychiatry, University of Illinois at Chicago, Chicago (Rudd); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Schmutte); Department of Psychiatry, Massachusetts General Hospital, Boston (Eggan); Research Institute at Nationwide Children’s Hospital, Department of Pediatrics, Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus (Bridge).
Author Contributions: Dr Doupnik had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Doupnik, Rudd, Worsley, Bowden, Marcus. Acquisition, analysis, or interpretation of data: Doupnik, Rudd, Schmutte, Worsley, Bowden, McCarthy, Eggan, Bridge. Drafting of the manuscript: Doupnik, Rudd, Schmutte, Worsley, Bowden, McCarthy. Critical revision of the manuscript for important intellectual content: Doupnik, Rudd, Schmutte, Worsley, Bowden, Eggan, Bridge, Marcus. Statistical analysis: Doupnik, Bowden, Bridge, Marcus. Obtained funding: Doupnik. Administrative, technical, or material support: Doupnik, Rudd, Schmutte, Worsley, Bowden, Eggan, Marcus. Supervision: Doupnik.
Conflict of Interest Disclosures: Dr Bridge reports being a member of the Scientific Advisory Board of Clarigent Health. Dr Marcus reports personal fees from Allergan, Sage Therapeutics, Johnson & Johnson, and Sunovion outside the submitted work. No other disclosures were reported.
Funding/Support: Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health (grants K23MH115162 [Dr Doupnik], T32MH109433 [Dr Rudd], and R01MH107452 [Dr Marcus]).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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