Intervention for suicide attempters: A randomized controlled study.

AIM: To determine whether brief intervention and contact (BIC) is effective in reducing subsequent suicidal behavior among suicide attempters.
MATERIALS AND METHODS: Suicide attempters (n=680) admitted in a general hospital in Chennai were randomly allocated to treatment as usual and BIC whose components include brief intervention at the time of discharge and contact for 18 months.
RESULTS: Completed suicide was significantly lower in the BIC group, OR 35.4 (CI 18.4 - 78.2) as also attempted suicide, OR 17.3 (CI 10.8 - 29.7).
CONCLUSIONS: This low-cost intervention which can be readily implemented may be an important suicide prevention strategy in healthcare settings in India.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Suicide is a global public health problem. The majority of suicides (85%) in the world occur in low and middle-income countries.[1] Non-fatal suicide attempts occur mostly in young persons[2] and are up to 10-40 times more frequent than suicides.[3] Persons with a history of previous suicide attempt are at a high risk of dying by suicide[45] with up to 2% dying within one year[67] and up to 7% within 10 years.[8]

Over 100,000 people die by suicide in India every year.[9] In the last two decades the suicide rate has increased from 7.9 to 10.8/100,000. Two large epidemiological verbal autopsy studies in rural Tamil Nadu revealed that the actual suicide rate is six to nine times the official rate.[1011] If these figures are extrapolated it is estimated that half a million suicides occur every year[12] and at least 5 million attempt suicide each year in India.[13]

There are many studies on attempted suicide in India that discuss the various sociodemographic, clinical, psychosocial factors in attempted suicide[14-20] but studies on interventions are sparse.

Most research about intervention for attempted suicides is conducted in developed countries and little is known about the burden of attempted suicide and effectiveness of intervention for suicide attempters in developing countries.

The SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS), launched by the World Health Organization (WHO) in 2000, aimed at increasing the knowledge about suicidal behaviors and the effectiveness of brief interventions for suicide attempters in culturally diverse places around the world and Chennai was the centre in India.

The brief intervention and contact (BIC) employed in the SUPRE-MISS trial is an adaptation of brief interventions used for alcohol problems.[21] Brief interventions were found to be effective in reducing alcohol-related problems and facilitating treatment referral of problem drinkers and in reducing suicide in high-risk patients. Regular contact has been found to reduce suicidal behavior in those who have attempted suicide.[22]

Compared to the usual psychological and medical interventions employed for suicide attempters, the advantage of this type of intervention is that it requires little space, equipment or highly trained personnel. Given the resource limitations of low and middle-income countries, interventions that involve highly trained staff are not feasible while BIC interventions are easily implementable. Consequently, the SUPRE-MISS study aimed at assessing the potential benefits of BIC as an add-on to the usual care for suicide attempters.

The current paper discusses the effectiveness of BIC in reducing suicides and attempted suicide in Chennai, India.

MATERIALS AND METHODS

The study was carried out in the Government Royapettah General Hospital in Chennai. Persons who attempted suicide were initially seen in the emergency department and all were routinely admitted to the intensive medical care unit of the hospital. All those over the age of 12 years who attempted suicide, identified from January 2002 to January 2004, were invited to participate in the study. Those who agreed were interviewed after obtaining informed consent.

The interviews were conducted face-to-face and took place in the intensive medical care unit. Two experienced psychiatrists conducted the interview after the interviewee was medically stable, at the most three days after admission. Those who were over the age of 12 years and were medically unable to give consent or interview or refused were excluded. The study was approved by the ethics committee.

The 680 enrolled participants were randomly assigned to the BIC (n=320) or treatment as usual (TAU) (n=360) group. The allocation sequence was based on random number table and maintained in a separate location to ensure that the clinician responsible for the assignment of the subject could not bias the assignment throughout the duration of study.

Brief intervention and contact

The BIC procedure included a standard one-hour individual information session as close to the time of discharge as possible combined with periodic follow-up contacts after discharge. The individual session provided information about the psychological and social distress that often underlies suicidal behavior, risk and protective factors for suicidal behaviors, basic community-specific epidemiology of suicide, repetition of suicidal behaviors, alternatives for constructive instead of self-destructive coping strategies, and contacts/referral options. Follow-up contacts involved visits at 1 week, 2, 4, 7, 11 weeks and 4, 6, 12 and 18 months after discharge.

During each visit the subjects in the BIC group were asked how they felt and whether they perceived the need for any support. If they reported needing support they would be referred to an appropriate service agency. If a person denied the need for support, but was considered to be at current suicide risk, referral to a local treatment service was suggested. These visits were conducted by two psychologists with a one-day special training and documented using a short one-page form. The goal was to “check-in” with the patients and to determine their current status. If the individual had died, the cause of death as reported by relatives or other informants was recorded; if the individual was alive, information on subsequent suicide attempts (if any) was recorded.

Treatment as usual

The TAU modality was based on the norms prevailing in the hospital. Typically, treatment was limited to acute management of the somatic squeal of the suicide attempt and did not include psychiatric or psychological assessment or treatment, or any psychological or social consultation. If there were no physical complications, patients were usually discharged after somatic treatment was completed, typically within 24 h. Rarely, patients were discharged with a referral to outpatient mental health services. Subjects in the TAU group were contacted at six months and eighteen months after discharge to assess the suicidal behaviour using the same questionnaire used for the BIC group. Figure 1 shows the flow chart of persons recruited and followed for 18 months.

Figure 1

Flow chart of recruitment

Instruments

The questionnaire, based on the European Parasuicide Study Interview Schedule (EPSIS) of the WHO/EURO multicentre study on suicidal behavior was used.[23] It covered detailed sociodemographic information, the history of suicidal behavior and family data, physical health, contact with health services, mental health, questions related to social support, substance use, hopelessness, traumatic events, legal problems, antisocial behavior, Beck suicide intent scale, Beck depression inventory, Spielberger trait anger scale, WHO wellbeing index, WHO psychiatric disability assessment schedule and Eysenk Impulsiveness Scale.

All the instruments were translated, backtranslated and field-tested in the regional language and the interviewers were trained in the administration of the instruments. Appropriate statistical measures and tests were carried out using the SPSS Version 13. Detailed description of the method and instruments can be ascertained in a prior publication.[24]

RESULTS

The study tried to include all suicide attempters consequently seen at the emergency care department. Various factors like rapid departure of the patients, delayed notification of research staff, inadequate recording, constraints in hospitalization, etc. made it difficult to include all eligible patients. Other reasons were refusals, clinical condition not allowing an interview, leaving against medical advice etc. Hence out of the eligible 1691 persona only 680 (40%) were enrolled for the study. Those who did not participate in the study were similar in age and sex to those who participated.

There were no significant differences between the BIC and TAU groups in sociodemographic factors like age, sex, marital status, educational status, employment status and religion as shown in Table 1.

Table 1

Sociodemographic variables

The groups were also comparable in the duration of stay in the hospital, history of previous suicide attempt, number of previous attempts and family history of suicide and suicide attempt [Table 2]. Also, there was no difference in the method used. Table 3 reveals that there were no differences in the psychological and clinical variables, thus suggesting that the BIC and TAU groups are comparable.

Table 2

Suicide history

Table 3

Clinical Factors

Completed and attempted suicide was found to be significantly lower in the BIC group after intervention at 18 months’ follow-up compared to the TAU group [Table 4].

Table 4

Post intervention

In the intervention group, the one completed suicide occurred in the first week itself. While in the TAU group, five occurred before six months and four before 18 months. One attempted suicide occurred in Week 1, three at six months, one at 12 months and three at 18 months during followup in the BIC group while in the TAU group there were three attempts in six months and 14 at 18 months’ follow-up.

Only 2.5% of persons followed up felt that the visits were a disturbance. The visits were considered supportive and helpful by 65%.

DISCUSSION

For the first time a randomized controlled study evaluating the effectiveness of BIC in suicide attempters with suicide and attempted suicide as the primary outcome measure has been carried out in India. The findings demonstrate that a brief intervention session combined with a systematic long-term contact after discharge can have a positive effect on preventing subsequent suicide and suicide attempts. BIC might have acted in a variety of ways to reduce suicidality by acting as a social support network; by increasing awareness about the problems that led to the suicidal act and hence helping in formulating an alternate coping mechanism, by enhancing a feeling of ‘connectedness’ and a feeling of being ‘cared for’.

Carter et al.,[25] have also shown in a randomized trial that intervention using postcards reduced repetition of hospital-treated deliberate self-harm poisoning. Fleischmann et al., (2008)[26] have shown that mortality was reduced in the BIC group compared to the TAU group in all the five sites of the SUPRE-MISS study.

The study has several limitations. Only 40% of eligible patients were recruited for the study. The problem of accurate collection of data in India is compounded by the fact that attempted suicide continues to be a punishable offence unlike in the majority of the countries in the world. The follow-up of subjects proved to be a major challenge due to the complex setting and high mobility. It was time-consuming to trace the subjects and identify their whereabouts. So ideally although the TAU group should have been seen only after 18 months, they were seen at six months and 18 months to reduce the number of “lost to follow-up” patients. Another limitation was that the ascertainment of suicidal behavior during follow-up was from the subject and family members with no corroborating official records.

BIC is not the only strategy to reduce suicidal behavior. Maselk and Patel[27] have suggested that combination strategies that reduce domestic violence, provide poverty relief and strengthen the health system in identification and treatment of mental disorders will contribute to the reduction of suicidal behavior, particularly in women.

CONCLUSION

Taking into consideration the human and economic resource limitations in India, interventions like BIC are readily implementable in the healthcare sector. BIC can be a cost-effective strategy to reduce subsequent suicidal behavior after a suicide attempt.

This paper is based on the data and experience obtained during the participation of the authors in the WHO Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS), a projected funded by the World Health Organization and the participating field research centres. The collaborating investigators in this study were (in alphabetical order): Dr. J. Bolhari, Tehran, Prof. N. Botega, Campinas; Dr. D. De Silva, Colombo, Prof. V.T. Nguyen, Hanoi, Dr. M. Phillips, Beijing; Prof. L. Schlebusch, Durban, Dr. A. Varnik, Tallinn; and Dr. L. Vijayakumar, Chennai. Dr. J.M. Bertolote and Dr. A. Fleischmann coordinated the project at WHO Headquarters, Geneva, Prof. D. De Leo, Brisbane and Prof. D. Wsserman, Stockholm acted as sciedntific advisors. We are grateful to Mrs. Bhanumathi who was responsible for data entry and Dr. Raman for statistical analysis.