Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7552.1241 (Published 25 May 2006) Cite this as: BMJ 2006;332:1241
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We agree with professor Jill Manthorpe.
Neverless, only suicide attempters discharged from hospitalization were
included in this study.
In France, all suicide attempters older than 65 years should be
hospitalized : it's our guidelines.
Guillaume Vaiva
Competing interests:
None declared
Competing interests: No competing interests
Positive findings that contact with people who have tried to take
their own lives is effective may encourage professionals that there is
something that can help people in such distress in an otherwise bleak
situation. Guillaume Vaiva and colleagues have provided substantial
support for co-ordinated responses in primary care to reduce the risk of
further attempts.
National suicide prevention strategies show that there are groups for
whom interventions may be particularly valuable. Older people still make
up a large proportion of those who take their own lives and their intent
is often firm. Research on suicide prevention needs to consider responses
to older people rather than apply age cut offs. This habit runs the risk
of limiting our knowledge about what older people would find helpful,
means that we have to hypothesise that what works for adults of working
age will work for older people, and creates separate streams of ‘evidence
informed’ practice.
Is it time for research that excludes older people to be more
explicit about why?
Jill Manthorpe
Professor of Social Work
Social Care Workforce Research Unit
King’s College London
London SE1 9NN
Email: jillmanthorpe@kcl.ac.uk
Steve Iliffe
Reader in General Practice
Royal Free Hospital Medical School
Rowland Hill Street
London NW3
Email: s.iliffe@pcps.ucl.ac.uk
Competing interests:
None declared
Competing interests: No competing interests
Telephone contact one month following a suicide attempt may well have
some benefit in reducing further attempts, but I wonder how many health
professionals would be willing to do this. Telephone assessments are
notoriously unreliable for many forms of doctor-patient consultation and
surely even more so in this situation – unknown patients, possibly in an
ongoing life-crisis, a significant proportion of whom will fulfil the
criteria for emotionally unstable personality disorder and whose actions
may be inherently unpredictable. It would have been useful to know whether
the researchers had predefined criteria for risk stratification and how
they decided upon the appropriate course of action for each patient.
Without clear guidelines of this sort, clinicians would be entering a
medico-legal minefield by undertaking such assessments, where they may be
held responsible for clinical judgements made in the absence of many
observation-based elements vital to a comprehensive mental state
examination.
Competing interests:
None declared
Competing interests: No competing interests
So not much effect then....
The paper by Vaiva et al is an admirable attempt to use a brief
intervention after self posioning - one phone call at four weeks or three
months - to reduce the repetition rate after about a year. However several
questions arise from this study. Firstly the rationale behind thinking
that a single phone call would make a difference at one month or three
months is obscure. We know that most repetitions of self harm occur in the
month after the index attempt when individuals are in crisis. An
intervention that would make more clinical sense would be a phone call
within 48 hours of the index attempt.
Secondly it is hard to undertand the authors power calculation as we
are not told on what outcome it is powered (repetition? adverse events?)
or any of the other usual parameters of a power calculation. This is
important as the study essentially showed no difference between the
different interventions and it is essential to know if the study was big
enough to stand a good chance of detecting a difference.
Next is the issue of the representativeness of the study sample. Only
about one in five of eligible patients were recruited. Were they different
in any important ways, apart from age, from those who were not recruited?
I also note that nearly a quarter of patients who were contacted in the
intervention groups had a DSM IV diagnosis of somatisation disorder - a
remarkably large number which if true would make this a very unusual
population.
Then there are the results. It is unclear as to how many people had
reattempted suicide - in table 2, 103 people report reattempting yet in
the text the numbers add up to 91. Why the discrepancy? Also we are not
told how many episodes occured in each group which may be important as the
study may have had an effect on this outcome. In the analysis of those who
were contactable there is no significant difference between the three
groups using a chi-squared test with two degrees of freedom. However
comparing the individual groups with each other there is a statistically
significant difference between those who received a telephone call at one
month and controls but no difference between the two telephone groups or
between the telephone call at three months and the control group.
So how to make sense of these results? Probably telephoning people at
a month after they have self poisoned doesn't make much difference to
repetition compared to treatment as usual. Any differences observed are
probably due to confounding factors, for example people who are easy to
contact by phone probably have more resources and are more stable (both
geographically and emotionally) than those who cannot be contacted so are
less likely to self-harm.
The lesson for clinical practice is that when people who self harm
are seen in the general hospital, clinicians should be assiduous in
getting at least three telephone numbers and two addresses from them. This
should help in avoiding the one in four people lost to follow-up found in
this study.
Competing interests:
None declared
Competing interests: No competing interests