Chiaki Kawanishi1, Tohru Aruga2, Naoki Ishizuka3, Naohiro Yonemoto4, Kotaro Otsuka5, Yoshito Kamijo6, Yoshiro Okubo7, Katsumi Ikeshita8, Akio Sakai5, Hitoshi Miyaoka9, Yoshie Hitomi10, Akihiro Iwakuma11, Toshihiko Kinoshita12, Jotaro Akiyoshi13, Naoshi Horikawa14, Hideto Hirotsune15, Nobuaki Eto16, Nakao Iwata17, Mototsugu Kohno18, Akira Iwanami19, Masaru Mimura20, Takashi Asada21, Yoshio Hirayasu22. 1. Health Management and Promotion Center, Yokohama City University Graduate School of Medicine, Yokohama, Japan. Electronic address: chiaki.kawanishi@gmail.com. 2. Department of Emergency and Critical Care Medicine, Showa University School of Medicine, Tokyo, Japan. 3. Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan. 4. Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan. 5. Department of Neuropsychiatry, Iwate Medical University, Morioka, Japan. 6. Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Japan. 7. Department of Neuropsychiatry, Nippon Medical School, Tokyo, Japan. 8. Department of Psychiatry, Nara Medical University, Kashihara, Japan. 9. Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Japan. 10. Department of Neuropsychiatry, Kinki University Faculty of Medicine, Osakasayama, Japan. 11. Department of Psychiatry, Mito Medical Center, Mito, Japan. 12. Department of Neuropsychiatry, Kansai Medical University, Hirakata, Japan. 13. Department of Neuropsychiatry, Oita University Faculty of Medicine, Yufu, Japan. 14. Department of Psychiatry, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan. 15. Department of Psychiatry, Osaka National Hospital, Osaka, Japan. 16. Department of Psychiatry, Fukuoka University Faculty of Medicine, Fukuoka, Japan. 17. Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Japan. 18. Department of Emergency Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan. 19. Department of Psychiatry, Showa University School of Medicine, Tokyo, Japan. 20. Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan. 21. Department of Psychiatry, University of Tsukuba Graduate School of Comprehensive Human Sciences, Tsukuba, Japan. 22. Department of Psychiatry, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
Abstract
BACKGROUND: Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. METHODS: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive eitherassertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). FINDINGS:Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to theassertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698). INTERPRETATION: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. FUNDING: The Ministry of Health, Labour, and Welfare of Japan.
RCT Entities:
BACKGROUND: Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. METHODS: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). FINDINGS: Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698). INTERPRETATION: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. FUNDING: The Ministry of Health, Labour, and Welfare of Japan.
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