Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Effect of Systematic Follow-Up by General Practitioners after Deliberate Self-Poisoning: A Randomised Controlled Trial

  • Tine K. Grimholt ,

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    tinegrim@yahoo.no

    Affiliations Department of Acute Medicine, Oslo University Hospital, Oslo, Norway, Regional Centre of Violence, Traumatic Stress and Suicide Prevention Eastern Norway, Oslo, Norway

  • Dag Jacobsen ,

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    Affiliation Department of Acute Medicine, Oslo University Hospital, Oslo, Norway

  • Ole Rikard Haavet ,

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    Affiliation Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway

  • Leiv Sandvik ,

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    Affiliation Department of Biostatistics, Oslo University Hospital, Oslo, Norway

  • Trond Jorgensen ,

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    Affiliation Psychiatric Consultation Team, Akershus University Hospital, Akershus,Norway

  • Astrid Berge Norheim ,

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    Affiliations Regional Centre of Violence, Traumatic Stress and Suicide Prevention Eastern Norway, Oslo, Norway, Diakonhjemmet Hospital, Oslo,Norway

  • Oivind Ekeberg

    Contributed equally to this work with: Tine K. Grimholt, Dag Jacobsen, Ole Rikard Haavet, Leiv Sandvik, Trond Jorgensen, Astrid Berge Norheim, Oivind Ekeberg

    Affiliations Department of Acute Medicine, Oslo University Hospital, Oslo, Norway, Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway

Effect of Systematic Follow-Up by General Practitioners after Deliberate Self-Poisoning: A Randomised Controlled Trial

  • Tine K. Grimholt, 
  • Dag Jacobsen, 
  • Ole Rikard Haavet, 
  • Leiv Sandvik, 
  • Trond Jorgensen, 
  • Astrid Berge Norheim, 
  • Oivind Ekeberg
PLOS
x

Abstract

Objective

To assess whether systematic follow-up by general practitioners (GPs) of cases of deliberate self-poisoning (DSP) by their patients decreases psychiatric symptoms and suicidal behaviour compared with current practice.

Design

Randomised clinical trial with two parallel groups.

Setting

General practices in Oslo and the eastern part of Akershus County.

Participants

Patients aged 18–75 years admitted to hospital for DSP. We excluded patients diagnosed with psychoses, without a known GP, those not able to complete a questionnaire, and patients admitted to psychiatric in-patient care or other institutions where their GP could not follow them immediately after discharge.

Intervention

The GPs received a written guideline, contacted the patients and scheduled a consultation within one week after discharge, and then provided regular consultations for six months. We randomised the patients to either intervention (n = 78) or treatment as usual (n = 98).

Main Outcome Measures

Primary outcome measure was the Beck Scale for Suicide Ideation (SSI). Secondary outcomes were Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS), self-reported further self-harm and treatment for DSP in a general hospital or an emergency medical agency (EMA). We assessed patients on entry to the trial and at three and six months. We collected data from interviews, self-report questionnaires, and hospital and EMA medical records.

Results

There were no significant differences between the groups in SSI, BDI, or BHS mean scores or change from baseline to three or six months. During follow-up, self-reported DSP was 39.5% in the intervention group vs. 15.8% in controls (P = 0.009). Readmissions to general hospitals were similar (13% in both groups (P = 0.963), while DSP episodes treated at EMAs were 17% in the intervention group and 7% in the control group (P = 0.103).

Conclusion

Structured follow-up by GPs after an episode of DSP had no significant effect on suicide ideation, depression or hopelessness. There was no significant difference in repeated episodes of DSP in hospitals or EMAs. However, the total number of incidents of deliberate self-harm reported by the patients was significantly higher in the intervention group.

Trial registration

Trial registration ClinicalTrials.gov Identifier: NCT01342809

Introduction

When hospitalised with deliberate self-harm (DSH), most of the admissions are because of deliberate self-poisoning (DSP) [1,2]. DSP patients often present a complex picture of mental illness and physical comorbidity due to substance abuse [3,4]. Both suicide risk and mortality from other causes are significantly increased compared with the general population [5]. Suicide attempt rates are high, especially the first year after discharge [6]. In a follow-up study after DSP, a considerable proportion of patients reported high levels of depression and need for professional help [7].

When planning aftercare, the general practitioner (GP) should have an important role [8], [9]. Also, one out of four patients reported their GP as being most important in the early discharge period [7]. Knowing the patient’s background and often also relationship to other people, a GP can maintain a broader perspective, a good continuity of care [10], and address both the DSP patient’s physical illness and psychological problems. General practice also represents a low threshold and short waiting time, which is important for this patient group reporting barriers to seeking help [11].

Randomised controlled studies have been limited in this field [12]. More evidence is required to provide sufficient aftercare and treatment choices in order to prevent further suicidal behaviour [13]. Bennewith et al. randomised patients into intervention or treatment as usual groups to follow-up after DSH [14]. The intervention comprised a letter from the GP inviting the patient to consult and guidelines to use in consultations. The attendance rate at the GP was not registered and there was no evidence that repeated DSH was lower among the patients in the intervention group. In a trial where overdose patients were randomised to either GP or outpatient clinic treatment, no significant differences were found [15]. However, low-cost universal interventions of postcard or telephone contact following DSH have shown promising results [16], [17], [18], [19,20]. Further, problem-solving therapy has given decreased depression, hopelessness and suicidal ideation among suicidal patients [21,22].

We designed a randomised controlled trial with structured follow-up by the GP after DSP. The main elements were to schedule an appointment within one week after discharge from hospital and further regular consultations for the following six months. The GPs received a guideline with suggestions of elements to address in consultations. We hypothesised that this structured follow up by GPs would decrease symptoms of suicidal ideation, depression, hopelessness and further DSH after three and six months.

Methods

Participants

Participants were patients admitted for DSP to acute emergency units and intensive care units in five regional hospitals in Oslo and Akershus County, Norway. We arranged meetings with the formal leaders in each hospital and provided a written trial protocol. Further, we organised cooperation with the psychiatric consultation liaison teams, physicians and nurses in the participating hospitals. We distributed envelopes with a registration form containing inclusion and exclusion criteria, written informed consent forms, the Beck Suicidal Intent Scale interview, and the baseline-questionnaire (described in the methods section). In advance, we sent an invitation to all the registered GPs with information about the trial and a written consent letter with possibility to participate or decline if a patient on their list was included in the trial. When a patient was included, we telephoned their GP to provide information about the trial and ask if they wanted to participate and follow the patient. The participating GPs then received an information letter, written consent form, the guidelines and a registration form to return after six months. For those who declined to participate, we followed the patient with questionnaires in a comparison group. The GPs in the control group received a letter with information about the patient on their list, the objectives of the trial and an invitation to treat the patient as usual and fill out a registration form.

Eligibility criteria for participants

Eligible participants were all adults aged 18 to 75, hospitalised in acute medical wards with DSP [23], who met the eligibility criteria for receiving follow-up by their GP after discharge. We excluded patients with present psychosis, intellectual disability or organic cognitive impairment. Were also excluded patients who were not able to complete the questionnaire because of language difficulties. Patients with no GP (or unable to be registered with one, e.g. non-Norwegian citizens), those requiring transfer to psychiatric in-patient treatment or other forms of further in-patient treatment (e.g. general medical or misuse treatment) were also excluded.

Settings

The trial was conducted at five hospitals and general practices in Oslo and Akershus County. The total period of inclusion was from November 2009 to December 2013. The area has a population of about one million.

Intervention

The intervention group received systematic follow-up by their GP and a consultation as soon as possible, preferably within a week after discharge. Further, at least one consultation each month the first three months and then two consultations the last three months were scheduled. The GPs received short guidelines developed from the WHO guide to general practice [24] and discussed with a liaison senior psychiatrist (OE) and general practitioner (ORH). Finally, the content and its practical use were discussed and refined in a research group with GPs (S1 Fig).

The guidelines consisted of three main points:

  1. To schedule an appointment as soon as possible after discharge, preferably within a week.
  2. To clarify with the patient: reason for poisoning, main present problem, suicidal thoughts, details about present treatment, and need for further help.
  3. Schedule further appointments.

We gave the GPs an option to contact a psychiatrist to discuss challenges during the follow-up period.

Treatment as usual

By routine, all patients were evaluated by psychiatric personnel in the hospital before discharge. The treatment as usual consisted of referral to a psychiatric outpatient clinic, GP and other treatment modalities like family counselling or drug abuse clinics, depending on the patient’s problems and needs at the time of discharge, and during the following six months.

Measures

We obtained data at baseline (in the hospital) and after three and six months post discharge. We interviewed the patients to fill out the Beck Suicidal Intent Scale at baseline. The patients filled out self-report questionnaires with the Beck scales of suicidal ideation, depression and hopelessness at all three times. All the Beck scales have previously been validated and translated into Norwegian.

Baseline data were demographic, clinical characteristics, and intention.

The Beck Suicidal Intent Scale (BSI) [25] is based on a clinical interview scale with 15 items referring to the patient’s precautions and beliefs about the act. The items are scored on a scale from 0 to 2, with a possible total score of 30 indicating the strongest intention of suicide. It covers precautions, planning, communication, expectations regarding the medication load, the degree of planning, and the wish to die or live.

To measure self-reported reason and intention the following options were listed: wanted to die, escape problems, influence personal relations, accident or drug related, do not remember, do not want to give reason, and other. The answer categories were yes or no. The question was based on the study by Bancroft et al. of reasons people give for taking overdoses [26].

The patients were asked whether they wanted help to solve the problems that triggered this episode (yes/no).

Demographic variables after three and six months were change or occurrence of negative life events in the patient’s life: divorce, financial problems, own or family illness, or death in close family.

Primary outcome measure

Beck Scale for Suicide Ideation (SSI): a 19-item instrument that measures the intensity, duration and specificity of a patient’s thoughts about committing suicide. The scores range from 0–38. If the patient scores 0 on both items 4 and 5, which indicates active suicidal desire, the instruction is to skip the next 14 items, which address specific suicide plans and attitudes. The scale that measure suicide ideation (SSI) is therefore calculated for the 19 items only if the patient scores 1 or 2 on item 4 or 5, leaving a sub group with no active suicidal ideation [27]

Secondary outcome measures

Beck Depression Inventory (BDI): this scale measures the severity of depression during the previous week. It is composed of 21 items related to depressive symptoms. Each item has a set of at least four possible answers, varying in intensity. The standard cut-offs are: scores of 0 to 9 indicate that a person is not depressed, 10 to 18 indicate mild to moderate depression, 19 to 29 moderate to severe depression and 30 to 63 severe depression [28,29]

Beck Hopelessness Scale (BHS): a 20-item scale with true/false statements for measuring positive and negative expectations about the future. The total BHS score ranges from 0 (no hopelessness) to 20 (maximum hopelessness). The classification of scores is: 0 to 3, minimal; 4 to 8, mild; 9 to 14, moderate; and 15 to 20, severe hopelessness [29].

The Cronbach’s alpha for all the Beck scales ranged from 0.74 (BDI at baseline) up to 0.93 (BDI at six months).

Repeated deliberate self-harm was measured with self-report of poisoning, cutting or other potentially harmful methods. Further, whether the patients considered the most recent episode to be a suicide attempt (yes/no).

We reviewed medical records to determine whether the general hospital or the emergency medical agencies (EMAs) treated the patients for DSP. DSP was registered in line with the same definition as used in the inclusion criteria. Contacts regarding suicide ideation without a self-inflicted overdose or methods other than poisoning were not included.

Sample size

In a similar trial, a 5-point reduction on SSI was considered clinically significant [22]. We therefore based the sample size calculation on a mean difference of 5.0 between the intervention group and the control group. A previous trial found SD 7.69 [30]. With an alpha = 0.05 and beta = 0.2 it is necessary to include 60 patients in each group. Given an estimated dropout rate of 40%, we decided to include 200 patients in the trial.

Randomisation

The randomisation was 1:1 equal block distribution into the intervention or control group. Whether a patient would be allocated to the intervention or control group was determined by reference to a statistical series based on random sampling numbers. We generated a code list and randomisation plan from the web-based programme http://www.randomization.com. The list was stored at the hospital department’s secretary’s office to assure that it was not possible to manipulate it after the trial had started. We distributed envelopes containing forms and questionnaires with the code to each hospital. If a GP did not participate in the trial, either by declining beforehand or when approached, the patients were followed in a comparison group and received treatment as usual. Fig 1 shows the participant flow through the trial.

Blinding

The patients and the assigning staff were blinded to the treatment category at the time of inclusion to prevent selection bias. The numbers were random and not predictable to assigners. The treatment as usual in the hospital was therefore not biased with regard to initiated follow-up planned at the hospital. The patients and GPs were naturally not blinded to treatment during the trial. The GPs in the control group also received a letter with information and a questionnaire about their contacts with the patient in the six-month study period. The raters were masked to allocation in more than 70% of the cases when they reviewed medical records to obtain data regarding repeated DSP in hospital and EMAs.

Statistical methods

Means and frequencies describe demographic and clinical data. We used a chi square test to compare differences between the groups on categorical variables. We used independent sample t test for normally distributed continuous data to compare the baseline variables Cronbach’s alpha was used to calculate reliability scores for all the measures. We used mixed between-within subjects analysis of variance (ANOVA) to find differences between the intervention group and the control group on the Beck Suicide Ideation Scale, Beck Hopelessness Scale and Beck Depression Inventory.

For each missing value on a specific item, we identified the item that was most strongly associated with the selected item by using Cohen’s kappa. Then we replaced the missing value with the patient’s value on this item. If more than 50% of the values on a scale were missing for a patient, this patient’s sum-score was not included in the statistical analyses. Otherwise, missing values were imputed before the sum score was calculated. Significance level was set at P<0.05. We used SPSS (version 21.0, IBM SPSS, Armonk, NY) software to perform the analyses.

Ethics

We informed patients at the hospital and they received written information. We obtained written informed consent from the patients, consistent with guidelines of the Oslo University Hospitals Personal Protection Agency manual and the Norwegian Ethics Committee (NEC). All the participating hospitals in the multicentre study approved the trial after the NEC. Because the assignment personnel and the patients were blinded to treatment at the time of inclusion, it was important to inform them that if they did not receive an appointment at their GP, they would receive a questionnaire by mail in three months. Further, it was important that their participation would not interfere with other planned aftercare and previous appointments. The Ethics Committee required us to telephone patients when they were sent the questionnaire to make sure that filling out sensitive questions did not trigger a suicidal crisis, and allowed just one reminder letter to be sent. We provided a telephone number in the informed consent form, and the letters at three and six months, so the patients could contact the coordinator if they had questions or wanted to leave the trial. During the trial period, we were also required by the Ethics Committee to have a back-up plan, so that if acute situations with suspected suicidal risk occurred, professional help would be offered to the patient. Because the risk of suicide and death by other causes is elevated among DSP patients, the Electronic Patient Record (Pasdoc) was used to double-check that the patient was alive before patients were mailed the questionnaire.

Results

Baseline data

Table 1 displays the baseline characteristics of demographic and clinical variables. There were no significant differences between the intervention and the control groups. There were 61.8% in the intervention and 51.9% in the control group who had previously been hospitalised for DSH.

The intention measured with the Beck Suicidal Intent Scale (BSI) was not significantly different between the groups (Table 2). Neither were there significant differences when each item in the scale was analysed separately. There were no significant differences at baseline between the intervention group and the control group on the Beck Suicide Ideation Scale, Beck Depression Inventory and Beck Hopelessness Scale. The most common reasons for DSP were to escape from problems and a wish to die (Table 2). Ten per cent in the intervention group and 6% in the control group did not want help to solve the problems that triggered the DSP episode (χ2 = 0.65, P = 0.42).

thumbnail
Table 2. Beck Suicidal Intent Scale, Beck Suicide Ideation Scale, Beck Depression Inventory, Beck Hopelessness Scale and Self-reported intention at baseline.

https://doi.org/10.1371/journal.pone.0143934.t002

Patients lost to follow-up were not significantly different in terms of baseline demographics, clinical characteristics or the scales BSI, SSI, BDI and BHS.

Life events during the follow-up period

A higher number of serious living problems were reported in the intervention group at three months (15.6% vs. 2.2%, (χ2 = 4.68, P = 0.031). In total, the prevalence of experienced negative life events after three and six months was not significantly different between the intervention and control group (41.9 vs. 46.9%, (χ2 = 0.19,P = 0.66) and (53.1% vs. 55.6%, χ2 = 0.05, P = 0.83) respectively.

Suicide ideation, depression and hopelessness

A mixed between–within subjects analyses of variance was conducted to assess the impact of the intervention on the participants scores on the SSI, BDI and BHS across the three time periods (baseline at hospital, after three and six months follow up).

For SSI, there was no significant interaction between intervention and the time, Wilks Lambda = 0.70, F (2,10) = 2.08, p = 0.18, partial eta squared = 0.29.

There were no effect for time, Wilks Lambda = 0.91, F (2,10) = 0.15, p = 0.61, partial eta squared = 0. 09. In both groups the scores declined after three months, but in the intervention group it increased after six months. (Table 3). The main effect comparing the intervention and treatment as usual was not significant, F (1,11) = 0.15, p = 0.71, partial eta squared = 0.01, suggesting no effectiveness of the structured follow up from GP.

thumbnail
Table 3. Scores for the Intervention and Control groups on Beck Suicide Ideation Scale, Beck Hopelessness Inventory and Beck Depression Inventory Across three time periods.

https://doi.org/10.1371/journal.pone.0143934.t003

For BDI there were no significant interaction between intervention and time, Wilks Lambda = 0.94 F (2,37) = 1.20, p = 0.31, partial eta squared 0.06. The intervention group decreased the BDI scores after three months and increased after six months. The control group decreased the scores across all the measurement times (Table 3).

It was no substantial effect for time, Wilks Lambda = 0.95, F (2,37) = 1.00, p = 0.38, partial eta squared = 0.05. The main effect comparing the intervention and the control group was not significant, F (1,38) = 1.01, p = 0.32, partial eta squared = 0.03, suggesting no difference in the effectiveness of the structured follow up from GP.

For BHI there were no significant interaction between intervention and time, Wilks Lambda = 0.95 F (2,41) = 1.06, p = 0.36, partial eta squared 0.05. The BHS scores in the intervention group increased -, and decreased in the control group across the time period from baseline to six months (Table 3). It was no substantial effect for time, Wilks Lambda = 1.0, F (2,41) = 0.23, p = 0.78, partial eta squared = 0.01.

The main effect comparing systematic follow up by GP with treatment as usual was not significant, F (1,42) = 1.22, p = 0.28, partial eta squared 0.03, suggesting no difference in the effectiveness of the structured follow up from GP.

Repeated episodes of self-harm

The self-reported DSP during follow-up was 39.5% in the intervention group vs 15.8% in the control group (χ2 = 6.77,P = 0.009). Cutting and other potentially harmful episodes did not differ significantly between the groups. There was no significant difference in whether the patients evaluated the episodes as suicide attempt (27.8% vs. 52.9%, (χ2 = 2.31, P = 0.13) (Table 4). According to the hospital medical records, 13.3% in both groups had been hospitalised for one or more repeated episodes of DSP during the six-month follow-up. The prevalence of patients treated at EMAs was 16.7% in the intervention group vs. 7.2% in the control group (χ2 = 2.67, P = 0.10). One patient in each group committed suicide during the follow-up.

thumbnail
Table 4. Summary results for each study group on repeated DSH after six months.

https://doi.org/10.1371/journal.pone.0143934.t004

Discussion

Main findings

In this randomised controlled clinical trial, structured follow-up by a GP was studied for patients presenting to a general hospital with DSP. There were no statistically significant differences between the study groups in the level of, and development of, suicide ideation, depression, or hopelessness from baseline to three or six months. Neither were there any significant differences in the number of admissions to hospitals or EMAs for DSH. However, there was significantly more DSP in the intervention group in the follow-up period without medical attention. We have no explanation why the intervention group reported more self-harm than the control group. We consider that the most reliable measure of DSP is the number of admissions to hospital, where there was no significant difference. The only statistically significant difference was on self-reported DSP, which we consider least reliable. Therefore, we think that this finding should be replicated before we make any hypotheses on possible mechanisms.

Methodological considerations

A strength of the trial was the randomised design associated with a low risk of bias [31]. In Norway, no official surveillance of DSH exists. The diagnosis setting in hospitals according to ICD-10 (10th edition of the International Statistical Classification of Diseases and Related Health Problems) is not used systematically; hence, the distinction between acute poisoning and DSP is not reliable. A Danish trial showed that the clinical classification of a self-inflicted episode as a suicide attempt did not consistently correspond to the diagnoses in hospital records [32]. Therefore, we based the classification of repeated DSP on careful assessment of hospital and EMA records.

There was disagreement between self-reported data of DSP and hospital and EMA records. Reporting or interpretation bias may affect self-reported data, although the phrasing in the questionnaire was in line with the standardised definition. However, the patients have probably included episodes when they had not sought medical care, most likely because of less severe DSP. The finding that the patients more seldom reported the episode as a suicide attempt highlights this. A GP or psychiatric wards might also have treated episodes. From the patient’s reports, it was not possible to distinguish whether medical staff treated the episode or not.

The follow-up period of six months might have been too short. An extended follow-up period could have clarified whether the lack of effects persisted or developed further over time. One trial found that the decrease in depressive symptoms and suicidal behaviour first began at six months and continued until the end of treatment at 18 months [33]. It is, however, unlikely that the very similar pattern between the groups should differ half a year after the intervention was finished.

The repetition rate of hospitalised DSP in the current trial was 13.3%, and is about the same as the 12%–16% reported in a systematic review by Owens [34], and in studies from Denmark [32] and Baerum county, Norway [35].

However, the hospital rates from Oslo must be interpreted with caution because many patients are admitted to the EMA. This is an outpatient clinic that receives a considerable number of self-poisoning patients. Only about 17% of the severe cases are transferred to hospital, and most of the suicide attempts [36].

Seventy per cent of the eligible participants agreed to participate, and the recruitment rate was higher compared with previous studies [37,38]. The samples in this trial had similar demographic and clinical background characteristics compared with the general DSP population [39,40].

The inclusion criteria may have resulted in exclusion of people who were at somewhat higher risk of future suicidal behaviour, e.g. because those who were still suicidal after medical treatment were transferred to psychiatric wards. The withdrawal rates and missing data on the questionnaires turned out to be somewhat higher than expected despite telephone calls and reminder letters, therefore limiting the effect size and statistical power. This affects the findings because the dropouts might have responded different. And further also the generalization of the findings to a population similar to the baseline sample.

There were no significant differences between the groups in reported negative life events, but other unknown factors might have influenced the outcome. However, there were no significant differences between the groups with regard to extent, type, adherence and place of treatment received during follow-up (details will be reported separately). It is difficult, in clinical trials with a pragmatic design, to differentiate clearly the standard treatment and intervention treatment. Variations within each treatment group in the kind of treatment and amount of contact can be wide. Although several components of aftercare were registered we cannot exclude the possibility that patients in the treatment as usual group received overlapping forms of treatment or were exposed to unknown factors [41]. Missing information regarding whether the GPs actually used the guidelines further limits this knowledge of overlap.

The sample size was too small to perform sub-group analyses by age, sex, or variables related to previous DSH, psychiatric treatment or socio-economic characteristics. The scale measuring suicide ideation (SSI) is calculated for the 19 items only if the patient scores 1 or 2 on item 4 or 5. The number of patients who completed all the 19 items is therefore lower than the total. In retrospect, it is clear that the power calculation preferably should have been based on the Beck Hopelessness Inventory and Beck Depression Inventory, and the largest sample size could be chosen, so that all the outcome measures would have been fully powered. The participation in the trial per se could have represented a potential bias, because of the ethical condition of the safety procedure of telephoning all the patients after three and six months and providing an open access telephone number. There is also a possibility that the physicians in the control group may have been more careful than usual to provide better follow-up when they knew that they were participating in clinical research.

Results in relation to other studies

Previous trials with contact following DSH have had mixed results. The missing effects in the present trial are consistent with previous studies that have also failed to show benefit on several outcomes [14,15,32,39]. Further, the finding of increased suicidal behaviour in the intervention group are consistent with a pilot trial where information regarding sources of help, telephone calls soon after presentation and a series of letters over 12 months,[39] and guidelines for GPs were provided [14]. Taken together, these negative findings of increased suicidal behaviour in follow up studies are important to highlight. Especially since the findings challenge the hypothesis that closer follow up from health care services is a key to decreased suicidal behaviour. One pitfall is that eventual previous negative results have not been published, and the importance of publishing such negative results should be stressed. One factor in clinical trials with patients presenting with suicidal behaviour is the drop out rates. It is not possible to study the patients that leave the trial, and maybe recover well. Another explanation could be that the patients that were most severely depressed chose to stay in the treatment plan and the recovered wanted to leave the trial and also the episode behind. There are many possible explanations for the negative result in the current trial, but it is not possible to draw any firm conclusions about the reasons. However, if follow up by GP increases suicidal behaviour, could it be that the amount of drug prescription also increases and give the patients easier access to an overdose? Or could a confident patient-GP relationship lower the threshold for seeking help from the GP outside office hours lead to a lower limit for taking an overdose? It is important to pay more attention also to more qualitative aspects of the follow up to gain more in depth- knowledge about such factors.

Dialectical behaviour therapy, cognitive behavioural therapy and mindfulness-based cognitive therapy have documented reduced suicidal behaviour [42,43]. Problem-solving therapy for DSH patients appears to improve depression, hopelessness, and problems [21]. These interventions are more extensive than in the present trial.

Online self-help-based Internet intervention also found improvement in suicidal thoughts and depression [44].

Clinical implications

The levels on BDI indicated moderate to severe depression in both groups. Even though we observed a slight decline, it seems that the symptom levels are rather persistent. We found somewhat fewer symptoms in both groups, but the levels indicate that more treatment is necessary and will take time.

One study indicated that patients with a score of 9 or above on BHS are nearly 11 times more likely to die subsequently by suicide or to self-harm compared with those who score below [45]. After three and six months, the scores in the intervention group (10.6 and 9.6 respectively) also indicate the importance of more extensive treatment.

However, although the GPs might be familiar with suicide risk factors, it can be difficult to identify an impending act of suicidal behaviour, as the vast majority of the acts are impulsive [46]. Further, the majority of DSH patients are hospitalised outside office hours [47]. This might to some extent limit the GPs’ possibility for intervention.

Further research

Although the contribution of general practice physicians has been indicated as important in suicide prevention [48], the evidence from intervention studies in general practice is sparse. Taken in conjunction with the findings from Bennewith’s trial, where more patients repeated DSH in the intervention group, it is important to confirm or reject the hypothesis that follow-up by a GP decreases suicidal behaviour. Although we added variables related to suicidal behaviour, further RCTs with higher power are needed. More tailored interventions with cooperation between GPs and e.g. psychiatric follow-up may be more relevant, in order to resolve various aspects of the intervention. In addition, interventions may be more tailored if more homogenous patient groups were studied, e.g. patients with depression, personality disorders, or other major diagnoses. It is possible that interventions that are more intensive should include education or supervision. General practitioner educational programmes were indicated as one important suicide preventive measure 20 years ago [49], and again 10 years later [50]. Norwegian GPs perceived their skills to be intermediate in taking care for suicide attempters, 39% had participated in courses and theoretical training in assessment and treatment, but most did not report a need for more training [51].

Further studies should provide sufficiently detailed information about how the intervention was actually conducted.

Conclusion

Structured follow-up by a GP after an episode of DSP in one of their patients had no significant effect on suicide ideation, depression and hopelessness. There was no significant difference in repeated episodes of DSP in hospitals or EMAs. However, the total number of DSH episodes reported by the patients was significantly higher in the intervention group.

Acknowledgments

We thank all the patients who participated in this trial and provided valuable knowledge. Further thanks are due to all the GPs in the intervention group for participating. Thanks to all staff for asking their patients, interviewing and completing the forms, and to all other collaborating staff in the participating units for allowing us to perform this trial, providing us with additional information, and facilitating interviews in their busy clinical practices.

Author Contributions

Conceived and designed the experiments: TKG OE ORH. Performed the experiments: TKG. Analyzed the data: TKG LS OE. Contributed reagents/materials/analysis tools: TKG TJ ABN. Wrote the paper: TKG DJ ORH LS TJ ABN OE.

References

  1. 1. Gunnell D, Bennewith O, Peters TJ, House A, Hawton K (2005) The epidemiology and management of self-harm amongst adults in England. J Public Health (Oxf) 27: 67–73. fdh192 [pii];
  2. 2. Zahl DL, Hawton K (2004) Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11,583 patients. Br J Psychiatry 185: 70–75. pmid:15231558
  3. 3. De LD, Scocco P, Marietta P, Schmidtke A, Bille-Brahe U, Kerkhof AJ et al. (1999) Physical illness and parasuicide: evidence from the European Parasuicide Study Interview Schedule (EPSIS/WHO-EURO). Int J Psychiatry Med 29: 149–163. pmid:10587812
  4. 4. Mitchell AJ, Dennis M (2006) Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Emerg Med J 23: 251–255. 23/4/251 [pii]; pmid:16549567
  5. 5. Nordentoft M, Breum L, Munck LK, Nordestgaard AG, Hunding A, Laursen Bjaeldager PA (1993) High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts. BMJ 306: 1637–1641. pmid:8324430
  6. 6. Carroll R, Metcalfe C, Gunnell D (2014) Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS One 9: e89944. ;PONE-D-13-44092 [pii]. pmid:24587141
  7. 7. Grimholt TK, Bjornaas MA, Jacobsen D, Dieserud G, Ekeberg O (2012) Treatment received, satisfaction with health care services, and psychiatric symptoms 3 months after hospitalization for self-poisoning. Ann Gen Psychiatry 11: 10. 1744-859X-11-10 [pii]; pmid:22520705
  8. 8. Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R et al. (1998) Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ 317: 441–447. pmid:9703526
  9. 9. Houston K, Haw C, Townsend E, Hawton K (2003) General practitioner contacts with patients before and after deliberate self harm. Br J Gen Pract 53: 365–370. pmid:12830563
  10. 10. Freeman GK, Olesen F, Hjortdahl P (2003) Continuity of care: an essential element of modern general practice? Fam Pract 20: 623–627. pmid:14701883
  11. 11. Bruffaerts R, Demyttenaere K, Hwang I, Chiu WT, Sampson N, Kessler RC et al. (2011) Treatment of suicidal people around the world. Br J Psychiatry 199: 64–70. bjp.bp.110.084129 [pii]; pmid:21263012
  12. 12. Arensman E, Townsend E, Hawton K, Bremner S, Feldman E, Goldney R et al. (2001) Psychosocial and pharmacological treatment of patients following deliberate self-harm: the methodological issues involved in evaluating effectiveness. Suicide Life Threat Behav 31: 169–180. pmid:11459249
  13. 13. [Anonymous] (2015) Hawton KKE, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD001764.
  14. 14. Bennewith O, Stocks N, Gunnell D, Peters TJ, Evans MO, Sharp DJ (2002) General practice based intervention to prevent repeat episodes of deliberate self harm: cluster randomised controlled trial. BMJ 324: 1254–1257. pmid:12028981
  15. 15. Hawton K, McKeown S, Day A, Martin P, O'Connor M, Yule J (1987) Evaluation of out-patient counselling compared with general practitioner care following overdoses. Psychol Med 17: 751–761. pmid:2819914
  16. 16. Kapur N, Cooper J, Bennewith O, Gunnell D, Hawton K (2010) Postcards, green cards and telephone calls: therapeutic contact with individuals following self-harm. Br J Psychiatry 197: 5–7. 197/1/5 [pii]; pmid:20592425
  17. 17. Carter GL, Clover K, Whyte IM, Dawson AH, D'Este C (2013) Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry 202: 372–380. bjp.bp.112.112664 [pii]; pmid:23520223
  18. 18. Motto JA, Bostrom AG (2001) A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv 52: 828–833. pmid:11376235
  19. 19. De LD, Dello BM, Dwyer J (2002) Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. Br J Psychiatry 181: 226–229. pmid:12204927
  20. 20. Vaiva G, Vaiva G, Ducrocq F, Meyer P, Mathieu D, Philippe A et al. (2006) Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study. BMJ 332: 1241–1245. 332/7552/1241 [pii]; pmid:16735333
  21. 21. Townsend E, Hawton K, Altman DG, Arensman E, Gunnell D, Hazell P et al. (2001) The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med 31: 979–988. pmid:11513383
  22. 22. Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E et al. (2001) Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ 323: 135–138. pmid:11463679
  23. 23. Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P et al. (1992) Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 85: 97–104. pmid:1543046
  24. 24. [Anonymous] (2015) Preventing Suicide A resource for general physicians.
  25. 25. Beck RW, Morris JB, Beck AT (1974) Cross-validation of the Suicidal Intent Scale. Psychol Rep 34: 445–446. pmid:4820501
  26. 26. Bancroft JH, Skrimshire AM, Simkin S (1976) The reasons people give for taking overdoses. Br J Psychiatry 128: 538–548. pmid:179651
  27. 27. Beck AT, Steer RA, Ranieri WF (1988) Scale for Suicide Ideation: psychometric properties of a self-report version. J Clin Psychol 44: 499–505. pmid:3170753
  28. 28. Beck AT, Steer RA, Beck JS, Newman CF (1993) Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide Life Threat Behav 23: 139–145. pmid:8342213
  29. 29. Rush A John Jr, Pincus Harold Alan, First Michael B, Blacker Deborah, Endicott Jean et al (2005) Handbook of Psychiatric Measures.
  30. 30. Steer RA, Rissmiller DJ, Ranieri WF, Beck AT (1993) Dimensions of suicidal ideation in psychiatric inpatients. Behav Res Ther 31: 229–236. 0005-7967(93)90090-H [pii]. pmid:8442750
  31. 31. Gluud LL (2006) Bias in clinical intervention research. Am J Epidemiol 163: 493–501. kwj069 [pii]; pmid:16443796
  32. 32. Morthorst B, Krogh J, Erlangsen A, Alberdi F, Nordentoft M (2012) Effect of assertive outreach after suicide attempt in the AID (assertive intervention for deliberate self harm) trial: randomised controlled trial. BMJ 345: e4972. pmid:22915730
  33. 33. Bateman A, Fonagy P (1999) Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 156: 1563–1569. pmid:10518167
  34. 34. Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 181: 193–199. pmid:12204922
  35. 35. Johannessen HA, Dieserud G, De LD, Claussen B, Zahl PH (2011) Chain of care for patients who have attempted suicide: a follow-up study from Baerum, Norway. BMC Public Health 11: 81. 1471-2458-11-81 [pii]; pmid:21294876
  36. 36. Lund C, Vallersnes OM, Jacobsen D, Ekeberg O, Hovda KE (2012) Outpatient treatment of acute poisonings in Oslo: poisoning pattern, factors associated with hospitalization, and mortality. Scand J Trauma Resusc Emerg Med 20: 1. 1757-7241-20-1 [pii]; pmid:22217253
  37. 37. Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E (1998) Management of deliberate self poisoning in adults in four teaching hospitals: descriptive study. BMJ 316: 831–832. pmid:9549454
  38. 38. Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E et al. (2001) Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ 323: 135–138. pmid:11463679
  39. 39. Kapur N, Gunnell D, Hawton K, Nadeem S, Khalil S, Longson D et al. (2013) Messages from Manchester: pilot randomised controlled trial following self-harm. Br J Psychiatry 203: 73–74. 203/1/73 [pii]; pmid:23818535
  40. 40. Bjornaas MA, Hovda KE, Heyerdahl F, Skog K, Drottning P, Opdahl A et al. (2010) Suicidal intention, psychosocial factors and referral to further treatment: a one-year cross-sectional study of self-poisoning. BMC Psychiatry 10: 58. 1471-244X-10-58 [pii]; pmid:20653986
  41. 41. Kraemer HC, Wilson GT, Fairburn CG, Agras WS (2002) Mediators and moderators of treatment effects in randomized clinical trials. Arch Gen Psychiatry 59: 877–883. ynv10179 [pii]. pmid:12365874
  42. 42. Williams JM, Duggan DS, Crane C, Fennell MJ (2006) Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. J Clin Psychol 62: 201–210. pmid:16342287
  43. 43. Brown GK, Ten HT, Henriques GR, Xie SX, Hollander JE, Beck AT (2005) Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA 294: 563–570. 294/5/563 [pii]; pmid:16077050
  44. 44. van Spijker BA, van SA, Kerkhof AJ (2010) The effectiveness of a web-based self-help intervention to reduce suicidal thoughts: a randomized controlled trial. Trials 11: 25. 1745-6215-11-25 [pii]; pmid:20214777
  45. 45. McMillan D, Gilbody S, Beresford E, Neilly L (2007) Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis. Psychol Med 37: 769–778. S0033291706009664 [pii]; pmid:17202001
  46. 46. Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM (2009) The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry 70: 19–24. ej07m03904 [pii]. pmid:19026258
  47. 47. Bergen H, Hawton K (2007) Variations in time of hospital presentation for deliberate self-harm and their implications for clinical services. J Affect Disord 98: 227–237. S0165-0327(06)00341-7 [pii]; pmid:16978707
  48. 48. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A et al. (2005) Suicide prevention strategies: a systematic review. JAMA 294: 2064–2074. 294/16/2064 [pii]; pmid:16249421
  49. 49. Gunnell D, Frankel S (1994) Prevention of suicide: aspirations and evidence. BMJ 308: 1227–1233. pmid:8080520
  50. 50. Richards DA, Hill JJ, Gask L, Lovell K, Chew-Graham C, Bower P et al. (2013) Clinical effectiveness of collaborative care for depression in UK primary care (CADET): cluster randomised controlled trial. BMJ 347: f4913. pmid:23959152
  51. 51. Grimholt TK, Haavet OR, Jacobsen D, Sandvik L, Ekeberg O (2014) Perceived competence and attitudes towards patients with suicidal behaviour: a survey of general practitioners, psychiatrists and internists. BMC Health Serv Res 14: 208. 1472-6963-14-208 [pii]; pmid:24886154