A Review of Evidence-Based Follow-Up Care for Suicide Prevention: Where Do We Go From Here?

doi:10.1016/j.amepre.2014.06.006

American Journal of Preventive Medicine

Volume 47, Issue 3, Supplement 2, September 2014, Pages S209-S215

https://doi.org/10.1016/j.amepre.2014.06.006 Get rights and content

Context

Follow-up services are an important component of a comprehensive, national strategy for suicide prevention. Increasing our knowledge of effective follow-up care has been identified as an Aspirational Goal by The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force.

Evidence acquisition

Several recent comprehensive reviews informed the selection of studies included in this brief review. Studies of follow-up services that reported significant effects for the outcomes of death by suicide, suicide attempts, or suicidal ideation were included.

Evidence synthesis

Although there is a paucity of research in this area, promising paradigms that have demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideation will be discussed. The major limitations of the literature in this area include numerous methodological flaws in the design and analyses of such studies and the lack of replication of studies with positive findings.

Conclusions

This paper identifies several breakthroughs that would be helpful for advancing this area of research and describes a comprehensive research pathway for achieving both short- and long-term research objectives.

Introduction

The development and implementation of effective follow-up care for individuals at risk for suicide is important for reducing rates of suicide and related behaviors. In response to the ongoing need for effective treatments aimed at preventing suicide, the National Action Alliance for Suicide Prevention’s (Action Alliance) Research Prioritization Task Force (RPTF) developed a comprehensive set of goals.¹

Specifically, Aspirational Goal 6 aims to “ensure that people who have attempted suicide can get effective interventions to prevent further attempts.” Follow-up care is defined as services interventions that aim to both increase access to and engagement in care, as well as to prevent suicide and related behaviors, as opposed to more acute care interventions, such as psychotherapy.

The aims of this article are to (1) briefly review the state of the science for follow-up care; (2) summarize limitations of the current research and needed breakthroughs; and (3) describe both short- and long-term research objectives as well as a step-by-step research pathway to advance the field of providing follow-up care for suicide prevention.

Section snippets

Evidence Acquisition

As a comprehensive review was beyond the scope of this paper, several recent comprehensive systematic reviews2, 3, 4, 5 were used to identify studies to include in this brief review. Those studies with significant findings for the outcomes of death by suicide, suicide attempts, or suicidal ideation were selected for inclusion. There are additional studies2, 3, 4, 5 that have examined the effectiveness of follow-up approaches, primarily on the outcome of suicide attempts or self-injury behavior,

Evidence Synthesis

The primary finding noted from these reviews is that only two RCTs have examined the effect of follow-up care on death by suicide. The first study⁶ followed patients who had attempted suicide and refused or discontinued outpatient treatment in the month after discharge from the hospital, and then randomized them to receive either a caring letters intervention or no follow-up. The study found that the rate of suicide for the intervention condition was significantly lower than that for the

Discussion

Future research should seek to achieve breakthroughs, which are needed to address these limitations and increase our knowledge about effective follow-up services for suicide prevention. These needs include (1) improving methodological rigor in future studies; (2) developing additional follow-up services and paradigms that are cost-effective and innovative; (3) expanding research to additional settings and subpopulations; and (4) replicating and disseminating evidence-based follow-up services.

Acknowledgments

Publication of this article was supported by the Centers for Disease Control and Prevention, the National Institutes of Health Office of Behavioral and Social Sciences, and the National Institutes of Health Office of Disease Prevention. This support was provided as part of the National Institute of Mental Health-staffed Research Prioritization Task Force of the National Action Alliance for Suicide Prevention.

No financial disclosures were reported by the authors of this paper.

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Cited by (33)

Development and Testing of an Emergency Department Quality Measure for Pediatric Suicidal Ideation and Self-Harm
2022, Academic Pediatrics
Citation Excerpt :
Future use of measure scores may be helpful in identifying high vs low measure performance and thus, help with targeting quality improvement interventions as needed. Based on our conceptual framework and prior evidence showing decreased recurrence of suicidal ideation and suicide attempts,11,16,17 we hypothesized that a mental health care follow-up visit within 7 days would be associated with lower odds of both 30-day ED return visits and inpatient admissions; however, we did not find an association between quality measure scores and these utilization outcomes (all-cause or same-case). There are a few possible explanations for this observed lack of association.
To develop and test a new quality measure assessing timeliness of follow-up mental health care for youth presenting to the emergency department (ED) with suicidal ideation or self-harm.
Based on a conceptual framework, evidence review, and a modified Delphi process, we developed a quality measure assessing whether youth 5 to 17 years old evaluated for suicidal ideation or self-harm in the ED and discharged to home had a follow-up mental health care visit within 7 days. The measure was tested in 4 geographically dispersed states (California, Pennsylvania, South Carolina, Tennessee) using Medicaid administrative data. We examined measure feasibility of implementation, variation, reliability, and validity. To test validity, adjusted regression models examined associations between quality measure scores and subsequent all-cause and same-cause hospital readmissions/ED return visits.
Overall, there were 16,486 eligible ED visits between September 1, 2014 and July 31, 2016; 53.5% of eligible ED visits had an associated mental health care follow-up visit within 7 days. Measure scores varied by state, ranging from 26.3% to 66.5%, and by youth characteristics: visits by youth who were non-White, male, and living in an urban area were significantly less likely to be associated with a follow-up visit within 7 days. Better quality measure performance was not associated with decreased reutilization.
This new ED quality measure may be useful for monitoring and improving the quality of care for this vulnerable population; however, future work is needed to establish the measure's predictive validity using more prevalent outcomes such as recurrence of suicidal ideation or deliberate self-harm.
Implementing an Emergency Department Telephone Follow-Up Program for Suicidal Patients: Successes and Challenges
2019, Joint Commission Journal on Quality and Patient Safety
Citation Excerpt :
However, 93 patients were referred more than once, which could have happened either during the first period of engagement or at a later time. While prior studies have shown the pivotal role the ED and postdischarge telephone outreach may play in suicide prevention,8,14–16,22,23 this statewide hospital ED pilot study aimed to investigate the potential population of nonacademic EDs and their suicidal patients, as well as barriers to program implementation. The detection methods, eligible population, and assessment and discharge planning procedures were deliberately permissive.
Many emergency department (ED) patients are at risk of suicide, and the ED is a key setting for suicide prevention. Although ED interventions are associated with reduced suicide attempts and societal costs, most EDs do not have follow-up programs. This pilot investigated the feasibility and implementation process of a statewide program.
This multicenter prospective pilot program included all patients evaluated for suicidal behavior in, and discharged home from, participating EDs across Colorado. Suicidal ED patients were offered crisis hotline follow-up calls that focused on continued support and connection to outpatient care. Data collection at EDs focused on implementation issues and referral and participation rates; the crisis line collected patient information and call statistics.
From July 1, 2015, to October 31, 2017, the program expanded to 15 EDs covering almost a quarter of ED visits in a large, high-burden state. Some sites achieved 100% referral rates, suggesting that referral became routine, and the mean referral rate was 76%. High referral rates were associated with an ED champion, record system enhancements, repeated training, and regular communication. Of 5,620 visits with referral, 2,737 resulted in participation (48.7%). Although the program was free for patients, half declined it. The call center made 15,414 calls, ultimately reaching all but 9.8% of participants. Few participants reported repeat ED visits or suicide attempts.
This project demonstrated the feasibility of using a state crisis hotline to provide postdischarge follow-up for suicidal ED patients. Continued investigation into sustainable implementation and outcomes of such programs is warranted.
Managing Suicidal Patients in the Emergency Department
2016, Annals of Emergency Medicine
Citation Excerpt :
Such patients should be discharged to supportive, stable environments without access to guns or lethal medications. Caring contacts (Table), which are brief telephone, e-mail, or mail contacts after discharge, appear to decrease suicide attempts and deaths.41 All patients should be given the number for the National Suicide Prevention Hotline (1-800-273-TALK [8255]), a national, free telephone and online chat resource with crisis guidance, connection to local resources, and special services for veterans.
Psychosocial therapy and causes of death after deliberate self-harm: A register-based, nationwide multicentre study using propensity score matching
2016, Psychological Medicine
Bridging the gap: a qualitative study of providers' perceptions of a partnered crisis follow-up program for suicidal patients post-emergency department discharge
2023, BMC Psychiatry
Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol
2023, BMC Health Services Research

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View full text

A Review of Evidence-Based Follow-Up Care for Suicide Prevention: Where Do We Go From Here?

Context

Evidence acquisition

Evidence synthesis

Conclusions

Introduction

Section snippets

Evidence Acquisition

Evidence Synthesis

Discussion

Acknowledgments

Am J Prev Med

Suicide prevention strategies: a systematic review

JAMA

Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force

Ann Intern Med

A randomized controlled trial of postcrisis suicide prevention

Psychiatr Serv

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

Bull World Health Organ

A follow-up program for suicide attempters: evaluation of effectiveness

Suicide Life Threat Behav