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A Review of Evidence-Based Follow-Up Care forSuicide Prevention
Where Do We Go From Here?Gregory K. Brown, PhD, Kelly L. Green, PhD
Context: Follow-up services are an important component of a comprehensive, national strategy forsuicide prevention. Increasing our knowledge of effective follow-up care has been identified as anAspirational Goal by The National Action Alliance for Suicide Prevention’s Research PrioritizationTask Force.
Evidence acquisition: Several recent comprehensive reviews informed the selection of studiesincluded in this brief review. Studies of follow-up services that reported significant effects for theoutcomes of death by suicide, suicide attempts, or suicidal ideation were included.
Evidence synthesis: Although there is a paucity of research in this area, promising paradigms thathave demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideationwill be discussed. The major limitations of the literature in this area include numerous methodologicalflaws in the design and analyses of such studies and the lack of replication of studies with positive findings.
Conclusions: This paper identifies several breakthroughs that would be helpful for advancing thisarea of research and describes a comprehensive research pathway for achieving both short- andlong-term research objectives.(Am J Prev Med 2014;47(3S2):S209–S215) & 2014 American Journal of Preventive Medicine
Introduction
The development and implementation of effectivefollow-up care for individuals at risk for suicide isimportant for reducing rates of suicide andrelated behaviors. In response to the ongoing need foreffective treatments aimed at preventing suicide, theNational Action Alliance for Suicide Prevention’s(Action Alliance) Research Prioritization Task Force(RPTF) developed a comprehensive set of goals.1
Specifically, Aspirational Goal 6 aims to “ensure thatpeople who have attempted suicide can get effectiveinterventions to prevent further attempts.” Follow-up careis defined as services interventions that aim to bothincrease access to and engagement in care, as well as toprevent suicide and related behaviors, as opposed to moreacute care interventions, such as psychotherapy.The aims of this article are to (1) briefly review the state
of the science for follow-up care; (2) summarize limitations
of the current research and needed breakthroughs; and (3)describe both short- and long-term research objectives aswell as a step-by-step research pathway to advance the fieldof providing follow-up care for suicide prevention.
Evidence AcquisitionAs a comprehensive review was beyond the scope of this paper,several recent comprehensive systematic reviews2–5 were used toidentify studies to include in this brief review. Those studies withsignificant findings for the outcomes of death by suicide, suicideattempts, or suicidal ideation were selected for inclusion. There areadditional studies2–5 that have examined the effectiveness offollow-up approaches, primarily on the outcome of suicideattempts or self-injury behavior, that failed to report significanteffects and are not included in this brief review. Table 1 providesmore detailed descriptions of the intervention and comparisonconditions evaluated in each study, as well as the assessedoutcomes and results.
Evidence SynthesisThe primary finding noted from these reviews is thatonly two RCTs have examined the effect of follow-upcare on death by suicide. The first study6 followedpatients who had attempted suicide and refused or
From the Perelman School of Medicine of the University of Pennsylvania,Philadelphia, Pennsylvania
Address correspondence to: Gregory K. Brown, PhD, Department ofPsychiatry, University of Pennsylvania, 3535 Market Street, Room 2030,Philadelphia PA 19104-3309. E-mail: gregbrow@mail.med.upenn.edu.
0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2014.06.006
& 2014 American Journal of Preventive Medicine � Published by Elsevier Inc. Am J Prev Med 2014;47(3S2):S209–S215 S209
Table1.Stud
iesreview
edwith
cond
ition
descrip
tions,a
ssessedou
tcom
es,a
ndresults
Stud
yRCT
nFo
llow-upservicede
scrip
tion
Com
paris
oncond
ition
descrip
tion
Prim
ary
outcom
e(s)
Results
Motto
and
Bostrom
,20016
Yes
389Interven
tion
454Con
trol
Subjects
weresent
lettersexpressing
care
andconcernby
research
staff(24letters
over
5years);letters
wereno
n-de
man
ding
(i.e.,sub
jectswereinvitedto
respon
difthey
wishe
d,bu
tthiswas
notrequ
ired)
Subjects
received
noad
ditio
nalcon
tact
from
stud
ystaff
Dea
thby
suicide
Kap
lan–
Meier
survival
prob
abilitie
sbe
twee
ngrou
psweresign
ificantly
differen
tforthefirst2yearsof
follow-up
(p¼0
.043);M
(SE):
Year
1:
Trea
tmen
t,0.990(0.005)
Con
trol,0
.978(0.007)
Year
2:
Trea
tmen
t,0.983(0.006)
Con
trol,0
.964(0.009)
Fleischm
ann
etal.,20087
Yes
922Interven
tion
945Con
trol
Subjects
received
abrief1-hou
rpsycho
educationa
linterventioncloseto
discha
rgean
d9follow-upcontacts
(eith
erby
phon
eor
in-person)
over
18mon
ths
Subjects
received
TAU
Dea
thby
suicide
At18-m
onth
follow-up,
sign
ificantlymore
subjects
died
bysuicidein
theTA
Ucond
ition
than
theinterven
tioncond
ition
:χ²¼1
3.83,p
o0.001
Welu,
19778
Yes
62Interven
tion
57Con
trol
Subjectsreceived
trea
tmen
twith
inthecontext
ofaspecialo
utreachprogram,inwhich
they
werecontactedby
amen
talhea
lthclinicianas
soon
aspo
ssible
followingdischa
rge,
and
follow-upcontacts
includ
edaho
mevisitan
dwee
klyor
biwee
klycontactover
a4-mon
thfollow-uppe
riod
Subjects
received
TAU
Suicide
attempt
At4-m
onth
follow-up,
Fisher’sexacttest
indicatedthat
fewer
subjects
inthe
interven
tioncond
ition
repo
rted
asuicide
attempt
compa
redto
theTA
Ucond
ition
:p¼
0.04573
Carteret
al.,
20059an
d200710
Yes
378Interven
tion
394Con
trol
Subjects
received
8po
stcardsexpressing
care
andconcernover
a12-m
onth
perio
dSu
bjects
received
nopo
stcards
Intentiona
lself-po
ison
ing
At12-m
onth
follow-up,
therewereno
sign
ificant
differen
cesintheprop
ortio
nof
subjectsinea
chgrou
pwho
repe
ated
self-
poison
ing;
however,the
numbe
rof
repe
titions
was
sign
ificantlylower
inthe
interven
tiongrou
pcompa
redto
the
controlg
roup
:IRR¼0
.55,p
¼0.01,9
5%
CI¼
0.35,0
.87
At24-m
onth
follow-up,
therewas
nosign
ificant
differen
cein
theprop
ortio
nof
subjects
who
repe
ated
self-po
ison
ing;
however,the
numbe
rof
repe
titions
was
sign
ificantlylower
intheinterven
tion
grou
pcompa
redto
thecontrolg
roup
for
wom
enon
ly:IRR¼0
.49,p
¼0.004,9
5%
CI¼
0.30,0
.80
Hassanian
-Mogha
ddam
etal.,201111
Yes
1,150Interven
tion
1,150Con
trol
Subjects
received
9po
stcardsexpressing
care
andconcernover
a12-m
onth
perio
d.Su
bjects
received
TAU
Suicide
attempt,
suicidal
At12-m
onth
follow-up,
theinterven
tion
grou
pde
mon
stratedless
suicidal
idea
tion
(con
tinue
don
next
page
)
Brown and Green / Am J Prev Med 2014;47(3S2):S209–S215S210
www.ajpmonline.org
Table1.S
tudies
review
edwith
cond
ition
descrip
tions,a
ssessedou
tcom
es,a
ndresults
(con
tinue
d)
Stud
yRCT
nFo
llow-upservicede
scrip
tion
Com
paris
oncond
ition
descrip
tion
Prim
ary
outcom
e(s)
Results
idea
tion
(RRR¼0
.31,9
5%
CI¼
0.22,0
.38),an
dlower
rate
ofsuicideattempt
(RRR¼0
.42,
95%
CI¼
0.11,0
.63)c
ompa
redwith
the
controlcon
ditio
nAd
ditiona
lly,the
numberofsuicide
attempts
was
also
redu
cedin
theinterven
tion
cond
ition
comparedto
thecontrolcon
dition
(IRR¼0
.64,
95%CI¼0
.42,
0.97
)Va
ivaet
al.,
200612
Yes
147
Phon
ecalls
after
1mon
th145
Phon
ecalls
after
3mon
ths
312Con
trol
Subjects
received
follow-upph
onecalls
either
1or
3mon
thsafterthesuicide
attempt
from
apsychiatris
tdu
ringwhich
the
psychiatris
treview
edthetrea
tmen
trecommen
dedby
theED
andsuggesteda
newtrea
tmen
tplan
iftheoriginal
was
too
difficultforthepa
tient
tofollow;a
nurge
ntap
pointm
entw
asalso
sche
duledat
theED
ifthepa
tient
was
considered
athigh
riskfor
suicide
Subjects
received
TAU
Suicide
attempt
At13-m
onth
follow-up,
thenu
mbe
rof
subjects
who
attempted
suicidewas
sign
ificantlylower
over
the6mon
ths
post-con
tact
forthosethat
received
contactafter1mon
thcompa
redto
the
TAUgrou
p:χ²¼4
.7,p
¼0.03,
differen
ce¼1
0%,9
5%
CI¼
2%,1
8%;
therewereno
sign
ificant
differen
ces
betwee
nthe3-m
onth
contactgrou
pan
dtheTA
Ugrou
p
Term
ansen
andByw
ater,
197513
No
57Interven
tionwith
samemen
tal
health
worke
r57Interven
tionwith
crisiscenter
voluntee
r50
Assessmen
tinED
38Iden
tificationfrom
EDad
mission
records
Subjects
inthefollow-upcare
cond
ition
sreceived
either:(1)a
ssessm
entin
theED
andfollow-upfor3mon
thsby
samemen
tal
health
worke
rwho
assessed
thepa
tient
intheED
;or(2)a
ssessm
entin
theED
and
follow-upfor3mon
thswith
acrisiscenter
voluntee
r;contactoccurred
with
tape
ring
freq
uencyover
thecourse
of12wee
ks
Subjects
inthecontrol
cond
ition
sreceived
either:(1)a
ssessm
entin
theED
andno
follow-up;
or(2)ide
ntificatio
nfrom
emerge
ncyad
mission
recordson
ly
Suicide
attempt
At3-m
onth
follow-up,
subjects
inthefirst
grou
pwho
received
follow-upby
thesame
men
talh
ealth
cliniciande
mon
strated
sign
ificantlyfewer
suicideattempts
compa
redto
theothe
rthreegrou
ps(no
test
statistic
repo
rted
,p¼0
.05)
Torhorst
etal.,198714
Yes
68Trea
tmen
tfrom
sametherap
ist
85Rou
tinereferral
tolocala
gency
73Trea
tmen
tat
suicide
preven
tioncenter
Subjects
received
trea
tmen
tfrom
thesame
therap
istthey
sawin
theho
spita
lSu
bjectsinthecomparison
cond
itionsreceived
either
(1)a
routinereferralto
alocalagency;or
(2)
treatm
entfro
madiffe
rent
therapistat
aspecialized
suicidepreven
tioncenter
Suicide
attempt
At12-m
onth
follow-up,
subjects
who
received
trea
tmen
tfrom
adifferen
ttherap
istat
asuicidepreven
tioncenter
hadalower
suicideattempt
rate
than
thosein
theexpe
rimen
talg
roup
(χ²¼
5.363,d
f¼2,p
o0.1)
Kinget
al.,
200115
No
600Con
trol
300Decea
sed
Thisstud
ywas
aretrospe
ctivechartreview
stud
y;subjects
wereeither
discha
rged
individu
alswho
subseq
uentlydied
bysuicide
ormatched
psychiatric
controls;the
presen
ceof
continuityof
care
andcontactwith
the
sameprofession
alwereexam
ined
NA
Dea
thby
suicide
Bothcontinuo
uscare
(OR¼0
.57,9
5%
CI¼
0.37,0
.87,p
¼0.01)a
ndcontactw
iththesameprofession
al(OR¼1
8.45,9
5%
CI¼
4.46,7
6.32,p
o0.001)p
redicted
decrea
sedris
kof
deathby
suicide
ED,e
merge
ncyde
partmen
t;IRR,inciden
ceris
kratio
;RRR,relativeris
kredu
ction;
TAU,treatmen
tas
usua
l
Brown and Green / Am J Prev Med 2014;47(3S2):S209–S215 S211
September 2014
discontinued outpatient treatment in the month afterdischarge from the hospital, and then randomized themto receive either a caring letters intervention or no follow-up. The study found that the rate of suicide for theintervention condition was significantly lower than thatfor the control group for the first 2 years of follow-up.The second study7 enrolled suicide attempters from
eight emergency departments (EDs) in five low- tomiddle-income countries and randomized them toreceive either treatment as usual (TAU) or a briefintervention with follow-up contact. Follow-up over an18-month period revealed that individuals in the inter-vention condition had a significantly lower rate of suicidethan those receiving TAU.More attention has been given to investigating the
effect of follow-up care on preventing or reducing suicideattempts and self-directed violence (i.e., some studiesreported one outcome that combined suicide attemptsand non-suicidal self-injury) than has been given to theoutcome of death by suicide. For example, one study8
found that fewer participants who were assigned toreceive an intensive follow-up contact interventionexperienced a repeat suicide attempt over a 4-monthfollow-up period relative to those assigned to TAU.Three studies have examined less time-intensive fol-
low-up services. An Australian study9,10 recruitedpatients from toxicology units following intentionalself-poisoning and randomly assigned them to receiveeither follow-up postcards or no intervention. This studyfound that participants assigned to receive the postcardshad fewer numbers of intentional self-poisoning behav-iors than controls over a 24-month follow-up period.A similar study11 recruited individuals who intention-
ally self-poisoned and randomized participants to receiveeither follow-up postcards or TAU. Results indicated thatthose in the intervention condition demonstrated fewerinstances of suicidal ideation and suicide attempts (bothin terms of rate and total numbers) than those in TAU.A third study12 involving patients discharged from the
ED following an intentional overdose randomized par-ticipants to receive a follow-up call 1-month post-discharge, a call at 3 months post-discharge, or TAU.Participants in the intervention condition that receivedthe 1-month call were less likely to make subsequentsuicide attempts than those in TAU over the first 6months of the 13-month follow-up period.Three other studies have found significant results for
follow-up interventions, depending on the specific indi-vidual who performed the follow-up contact. Onecompared13 follow-up by a mental health worker,follow-up by a crisis volunteer, and no follow-up forpatients discharged from a hospital after a suicideattempt. The study found a significant reduction in
repeat suicide attempts for follow-up by a mental healthworker compared to follow-up by a crisis center volun-teer or no follow-up.Torhorst and colleagues14 reported that the rate of
suicide attempts in the group of patients who saw a differenttherapist for treatment following discharge from thehospital was lower than that of patients who saw the sameclinician who treated them in the hospital. A retrospectivechart review study,15 on the other hand, found that bothcontinuity of care alone and contact with the sameprofessional predicted reduced suicide risk in dischargedpatients who had died by suicide and matched controls.In summary, there are several studies with promising
initial findings concerning the efficacy of follow-up careand suicide prevention. Specifically, research suggeststhat clinicians who reach out to patients (especially thosepatients not engaged in treatment) using caring letters toexpress concern and support may help to reduce the rateof suicide following discharge from a psychiatric hospital.Additionally, low-cost follow-up interventions (e.g.,
phone calls, postcards) may be effective and particularlyimportant for reducing death by suicide and repeatsuicide attempts, especially in areas with limited resour-ces. Outreach programs that provide comprehensivemental health treatment and emphasize follow-up andcontinuity of care following discharge from the hospitalmay also help to prevent repeat suicide attempts.
Gaps and Limitations of the Current State ofthe ScienceAlthough findings from these studies warrant optimismthat follow-up services can ultimately be an effectivestrategy for suicide prevention, there are several gaps inour current knowledge, as well as major limitations (i.e.,methodological flaws) of the work that has been donethus far.With regard to gaps in the literature, the first major
limitation is the paucity of RCTs, especially thoseinvestigating effects of follow-up services on death bysuicide.4 Specifically, only two studies6,7 have demon-strated efficacy for preventing suicide. Although severalstudies have demonstrated efficacious follow-up servicesfor preventing suicide attempts and self-directed vio-lence, these outcomes are only proxies for death bysuicide and may not generalize to services that willactually prevent suicide. Additionally, the studies thathave found positive results have not investigated themechanisms by which the follow-up services affectedoutcomes (e.g., greater engagement in care).Further, our knowledge of effective services for specific
subpopulations, particularly those at high risk relative tothe general population, is severely limited. For example,
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there are no RCTs of follow-up services that havedemonstrated efficacy to prevent suicide or relatedbehaviors for adolescents, older adults, and other minor-ity groups.Additionally, existing studies have recruited patients
mostly from acute treatment settings (e.g., hospitals,EDs). Research16 has found that most individuals whoattempt suicide seek no treatment following theirattempt. Thus, it is unclear whether findings from studiesof follow-up services conducted to date can be general-ized to other settings, such as primary care, outpatientmental health, or other community settings.Finally, the failure to replicate studies that have found
significant effects is a major gap in the literature.Although developing novel interventions is important,there has been less emphasis placed on replicating studieswith positive results or improving existing interventionsthat have been found to be effective.With regard to methodological problems, there are
many major flaws in the RCTs that have been conductedthus far that have been described in previous reviews.2,4
Many of these methodological problems also apply toacute intervention research and were discussed in moredetail in Brown and Jager-Hyman’s psychotherapyreview17 in this issue.Those problems discussed previously that also apply to
follow-up services research include (1) failure to provideoperational definitions or use a standardized nomencla-ture for assessing suicide, suicide attempts, suicidalideation, and other related behaviors; (2) failure toinclude reliable and validated outcome measures; and(3) failure to control for sources of bias. Methodologicalproblems such as those outlined here led to the followingconclusion in the Veterans Affairs systematic review:“Overall, these intervention trials had methodologicallimitations that resulted in their providing only lowstrength and insufficient evidence to properly drawconclusions on the effectiveness of the various treatmentinterventions and follow-up strategies.”4
DiscussionFuture research should seek to achieve breakthroughs,which are needed to address these limitations andincrease our knowledge about effective follow-up servicesfor suicide prevention. These needs include (1) improv-ing methodological rigor in future studies; (2) developingadditional follow-up services and paradigms that arecost-effective and innovative; (3) expanding research toadditional settings and subpopulations; and (4) replicat-ing and disseminating evidence-based follow-up services.Improving the methodological rigor in designing
future RCTs and other studies is of paramount
importance. There are several short-term research goalsthat can achieve this aim. First, it is important thatstudies use standardized assessments that have beenfound to be valid and reliable, and it is important thatsuch measures correspond to standardized nomenclatureof suicide ideation and behavior such as the CDC’s Self-Directed Violence Classification System (SDVCS).18
Second, future research should be devoted to develop-ing novel assessment methods, such as ecologicalmomentary assessment, to more accurately track suicidalideation and behavior over time. Third, future researchshould include methods to address ambivalent suicidalbehavior (e.g., suicide adjudication boards).Fourth, future studies should include methods for
controlling sources of bias, such as performing intent-to-treat analyses, identifying and measuring non-study co-interventions, and blinding research staff and/or researchparticipants and assessing any breaks in blinding. Finally,future studies should develop innovative methods forretaining participants in studies and monitoring long-term outcomes.Developing and testing novel follow-up services for
suicide prevention is also especially warranted. In orderto improve the feasibility of conducting adequatelypowered studies to detect the treatment effects on deathby suicide, it would be beneficial to develop interventionsof minimal economic cost as a short-term research goal.Studies of these approaches should determine whetherfollow-up care actually facilitates treatment engagementand reduces rates of suicide, suicide attempts, or suicidalideation. Cost-effectiveness studies should also be con-ducted alongside efficacy and effectiveness trials of testedinterventions.Additionally, the development of follow-up services that
use innovative electronic health technologies (e.g., chatrooms, texting, smartphone apps, and other web-basedapplications) as stand-alone or adjunctive services is alsoneeded and achievable over the short term. These tech-nologies have the potential to reach a larger segment of thepopulation at a low cost. Thus far, one small pilot test19 oftext messaging over 4 weeks following discharge foundthis intervention to be feasible and acceptable to patientswho attempted suicide. To date, however, no study hasbeen conducted to evaluate the impact of electronicservices on suicide, suicide attempts, or suicidal ideation.Ultimately, identifying and developing evidence-based
follow-up services that can be delivered following dis-charge from acute care settings for the prevention ofsuicide is especially needed. This long-term goal can beattained by conducting large-scale, adequately poweredRCTs. These studies should determine whether theeffects of an intervention are partially mediated byengagement in mental health care or whether there is a
Brown and Green / Am J Prev Med 2014;47(3S2):S209–S215 S213
September 2014
direct effect on outcomes. Such studies should alsoexplore whether there are other moderating or mediatingeffects of the intervention by identifying and testingpotential mechanisms of action in effective interventionsand developing valid and reliable measures of suchmechanisms.Once effective follow-up services are identified,
expanding the research into new settings and populationsis also needed in order to investigate the generalizabilityof these interventions. Thus, over the long term,researchers should continue to develop novel methodsto recruit and screen at-risk individuals both in acute caresettings such as EDs as well as in the community at large.Schools, community centers, primary care settings, andworkplaces are also potential areas to target in order toobtain more representative samples and reach individu-als at risk for suicide who may not present to mentalhealth facilities. Future research should also examine therelative efficacy of evidence-based follow-up services forspecific subpopulations that are at an increased risk forsuicide, such as adolescents, older adults, and otherminority populations, as warranted by empirical data.Finally, studies with positive findings of follow-up
services should be replicated by independent researchgroups to ensure that robust effects are generalizableacross locations and populations. An especially impor-tant long-term objective is for researchers to develop andtest models to efficiently disseminate evidence-basedfollow-up services so that they can be widely availableand become the standard of care for facilitating engage-ment in treatment and ultimately preventing suicide.Figure 1 illustrates a proposed step-by-step research
pathway that can serve as a model for future studies thattest the effectiveness of follow-up services to reduce
suicide risk. Briefly, following this pathway, researchparticipants should be screened using standardizedmeasures. Following screening, enrolled participantsshould be randomized to either TAU alone or in additionto the study intervention. Potential mechanisms of actionshould then be assessed over the course of care todetermine what aspects of an intervention lead toreductions in suicide-related outcomes. Increasedengagement in care as a result of the study interventionshould also be evaluated as a potential mediator of therelationship between the intervention and outcome.
ConclusionsAlthough promising initial findings on follow-up careand services for suicide prevention exist in the literature,there are significant research gaps. Thus, additionalresearch is warranted to both improve the quality ofthe research in this area and expand current knowledge.A major research goal involves the rigorous study ofnovel, cost-effective approaches to follow-up care acrossa variety of populations and settings. Ultimately, suchstudies may result in the improvement of the standardof care for individuals who are at risk for suicide bydisseminating evidence-based strategies to preventsuicide.
Publication of this article was supported by the Centers forDisease Control and Prevention, the National Institutes ofHealth Office of Behavioral and Social Sciences, and theNational Institutes of Health Office of Disease Prevention.This support was provided as part of the National Institute ofMental Health-staffed Research Prioritization Task Force ofthe National Action Alliance for Suicide Prevention.
Figure 1. Proposed step-by-step research pathway for future RCTs
Brown and Green / Am J Prev Med 2014;47(3S2):S209–S215S214
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No financial disclosures were reported by the authors ofthis paper.
References1. USDHHS Office of the Surgeon General and National Action Alliance
for Suicide Prevention. 2012 National Strategy for Suicide Prevention:Goals and Objectives for Action. Washington, DC: HHS, September2012. http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf.
2. Self-harm: The NICE guideline on longer-term management. London:The British Psychological Society and The Royal College of Psychia-trists, 2012.
3. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: asystematic review. JAMA 2005;294(16):2064–74.
4. O’Neil M, Peterson K, Low A, et al. Suicide prevention interventionsand referral/follow-up services: a systematic review. VA-ESP Project#05-225 2012.
5. O’Connor E, Gaynes BN, Burda BU, Soh C,Whitlock EP. Screening forand treatment of suicide risk relevant to primary care: a systematicreview for the U.S. Preventive Services Task Force. Ann Intern Med2013;158(10):741–54.
6. Motto JA, Bostrom AG. A randomized controlled trial of postcrisissuicide prevention. Psychiatr Serv 2001;52(6):828–33.
7. Fleischmann A, Bertolote JM, Wasserman D, et al. Effectiveness ofbrief intervention and contact for suicide attempters: a randomizedcontrolled trial in five countries. Bull World Health Organ 2008;86(9):703–9.
8. Welu TC. A follow-up program for suicide attempters: evaluation ofeffectiveness. Suicide Life Threat Behav 1977;7(1):17–29.
9. Carter GL, Clover K, Whyte IM, Dawson AH, D’Este C. Postcardsfrom the EDge project: randomised controlled trial of an intervention
using postcards to reduce repetition of hospital treated deliberate selfpoisoning. Br Med J 2005;331(7520):805–7.
10. Carter GL, Clover K,Whyte IM, Dawson AH, D’Este C. Postcards fromthe EDge: 24-month outcomes of a randomised controlled trial forhospital-treated self-poisoning. Br J Psychiatry 2007;191(6):548–53.
11. Hassanian-MoghaddamH, Sarjami S, Kolahi AA, Carter GL. Postcardsin Persia: randomised controlled trial to reduce suicidal behaviours 12months after hospital-treated self-poisoning. Br J Psychiatry 2011;198(4):309–16.
12. Vaiva G, Ducrocq F, Meyer P, et al. Effect of telephone contact on furthersuicide attempts in patients discharged from an emergency department:randomised controlled study. Br Med J 2006;332(7552):1241–5.
13. Termansen PE, Bywater C. S.A.F.E.R.: a follow-up service for attemptedsuicide in Vancouver. Can Psychiatr Assoc J 1975;20(1):29–34.
14. Torhorst A, Möller HJ, Bürk F, Kurz A. The psychiatric managementof parasuicide patients: a controlled clinical study comparing differentstrategies of outpatient treatment. Crisis 1987;8(1):53–61.
15. King EA, Baldwin DS, Sinclair JM, Baker NG, Campbell MJ,Thompson C. The Wessex Recent In-Patient Suicide Study, 1. Case-control study of 234 recently discharged psychiatric patient suicides. BrJ Psychiatry 2001;178:531–6.
16. Bruffaerts R, Demyttenaere K, Hwang I, et al. Treatment of suicidalpeople around the world. Br J Psychiatry 2011;199(1):64–70.
17. Brown GK, Jager-Hyman S. Evidence-based psychotherapies forsuicide prevention: future directions. Am J Prev Med 2014;47(3S2):S186–S194.
18. Crosby AE, Ortega L, Melanson C. Self-directed violence surveillance:uniform definitions and recommended data elements, version 1.0.Atlanta GA: CDC, 2011 www.cdc.gov/violenceprevention/pdf/Self-Directed-Violence-a.pdf.
19. Chen H, Mishara BL, Liu XX. A pilot study of mobile telephonemessage interventions with suicide attempters in China. Crisis 2010;31(2):109–12.
Brown and Green / Am J Prev Med 2014;47(3S2):S209–S215 S215
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