Employing crisis postcards with case management in Kaohsiung, Taiwan: 6-month outcomes of a randomised controlled trial for suicide attempters

Abstract

BackgroundSuicide attempts constitute a serious clinical problem and have important implications for healthcare resources. The aim of the present study was to evaluate the effectiveness of case management using crisis postcards over a 6-month follow-up period.MethodA randomised controlled trial was conducted in Kaohsiung, Taiwan. Prevention of further suicide attempts was compared between two groups with and without the postcard intervention. The intervention group consisted of 373 participants (139 males, 234 females; age: 39.8 ± 14.0 yrs.). The control group consisted of 388 participants (113 males, 275 females; age: 40.0 ± 16.0 yrs.). A survival analysis was used to test the effectiveness of the crisis postcard intervention for the prevention of suicide reattempts. Per-protocol and intention-to-treat analyses were conducted.ResultsThe intention-to-treat analysis indicated that the crisis postcard had no effect (hazard ratio = 0.84; 95% CI = 0.56 – 1.29), whereas the per-protocol analysis showed a strong benefit for the crisis postcard (hazard ratio = 0.39; 95% CI = 0.21 – 0.72).ConclusionAlthough the results of the present study indicated that the postcard intervention did not reduce subsequent suicide behaviour, our study provides an alteration to the postcard intervention. Further studies need to be conducted to clarify whether this type of intervention can reduce subsequent suicidal behaviour, with a particular focus on reducing the rate of loss to follow-up.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

“…A recent review and meta-analysis (Milner et al, 2015) assessed the effectiveness of brief interventions in reducing suicide attempt, self-harm or suicide outcomes across 12 studies. The interventions included various methods of contact: telephone calls (Bertolote et al, 2010;Cedereke et al, 2002;Fleischmann et al, 2008;Hassanzadeh et al, 2010;Vaiva et al, 2006;Vijayakumar et al, 2011), postcards (Beautrais et al, 2010;Carter et al, 2005bCarter et al, , 2007Carter et al, , 2013Hassanian-Moghaddam et al, 2011;Robinson et al, 2012), 'green cards' or 'crisis cards' (Chen et al, 2013;Cotgrove et al, 1995;Evans et al, 1999bEvans et al, , 2005Morgan et al, 1993) and letters (Bennewith et al, 2002;Kapur et al, 2013b;Motto and Bostrom, 2001).…”

Letters, green cards, telephone calls and postcards: Systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide

“…33,34 Follow-up ranged from 6 months to 15 years and there were considerable differences in number of contacts made with those in the intervention between studies. Eight studies had five contacts or fewer, 27,28,31,35,36,[38][39][40] ten studies had between 6 and 10 contacts, 9,10,[24][25][26]29,30,34,37,41 and two studies had over 11 contacts. 32,33 Study quality Three studies were rated as having high risk of bias because they had unclear or imprecise details about randomisation and allocation procedures, masking, and/or incomplete reporting.…”

“…Studies had been conducted in a variety of locations, including the USA, 33 the UK, 27,28,31,34–36 New Zealand, 37 Australia, 24–26,32 Taiwan, 38 France, 39 Sweden 40 and Iran. 41 The review also contained a large multicentre study carried out in a variety of locations, including India, 30 Iran 29 and several other countries.…”

Mechanisms of brief contact interventions in clinical populations: a systematic review

“…Alternate behaviours Learning of alternate behaviours, (p 379) Cedereke, Monti et al, 2002 [ 22 ] RCT Sweden SA Suicide Phone calls ( n = 216) 12 mths No difference in SA in IX compared to TAU Nil - cites methodological factors influencing results. Chen, Ho et al, 2013 [ 23 ] RCT Taiwan SA Crisis card ( n = 761) 6 mths Non- significant reductions in SA in IX compared to TAU Nil - cites other external factors influencing results. The effectiveness of the postcard intervention relies on the level of social support already available and the overall treatment setting.…”