Suicidal behaviors are multifactorial phenomena. It is therefore difficult to define only one strategy to manage a suicidal attempt (SA) for the whole population [1
]. In a review of literature of the last 25 years, considering only randomized controlled trials (RCT) with suicidal repetition as primary endpoint, we only find 7 positive trials out of 24 studies. However, all studies show an improvement of compliance to the healthcare plan, which has led some to say that it doesn't matter what is suggested to suicide attempters, as long as they are offered something [2
The seven positive trials can be divided into two categories: intensive intervention programs (nursing at home [4
], and a series of Brief Psychotherapy Interventions (IPB) [5
]) and, case management programs.
The strategies of intensive intervention demonstrate their effectiveness in reducing the number of SA repetitions at short and medium term, but their weakness lies in the institutional heaviness of deployment and their expensive financial costs.
The other case management strategies have one common point: they are distinct from classical interventions, by proposing a "stay in contact" program, which does not invade the daily life of suicidal attempter, and can be employed in parallel to the eventual healthcare and offers a reliable and effective treatment in cases of suicidal crisis. This kind of case management has inspired the pioneer Jerome Motto about the neologism of "connectedness" [6
Each one of these strategies is of a great interest in certain categories of suicide attempters. They differ from the first two ones by having not only a lower financial cost but also an easier set up for the entire population in a given territory.
In the "SYSCALL" study, 605 suicidal patients discharged directly from Emergency Departments (ED) were included [7
]. A specially trained psychologist contacted patients by telephone, one or three months after the SA. The aim of this psychological supportive intervention was to evaluate the success of the treatment plan defined during the ED stay and eventually adjust it. Over the 13 months follow-up, there were 150 participants who reattempted suicide, 48 of them before the one month' telephone contact. Considering only the subjects effectively contacted (per protocol analysis), the telephone contact at one month proved to be very effective, by reducing to about the half the number of suicidal reattempts over one year (12% versus 21.6% in the control group). The post-hoc analysis showed no effect of the contact in first-attempters. The proposal of telephone contact was very well accepted and positively perceived by the population of this study. In addition, no major side effects were reported by the participants [8
The strategy based on the delivery of a "crisis card" was proposed by the English team of Bristol and was especially interesting for first-attempters. In addition to usual treatment, the intervention group was offered a "resource card" with the telephone number of a junior doctor in psychiatry available 24 hours a day. The intervention had a significant effect on the rate of SA repetition at 6 months in the first attempters subgroup only, compared to a control group (odds ratio 0.64, 95% CI 0.34-1.26) [9
]. The beneficial effect observed at 6 months was not maintained at one year [10
Jerome Motto proposed the strategy of sending letters to maintain contact with patients at high risk of suicide, who refused to remain in the healthcare system. Patients were contacted by short letters, sent by a person who met them during their hospital stay. The letters were personalized whenever possible. A self-addressed, unstamped envelope was always enclosed. These letters were sent monthly for four months, then every two months for eight months, and finally every three months for four years (24 letters in total). The objective was to make the patient realize that there is a person concerned about him (its existence), and who maintains positive feelings towards him, hence the neologism of "connectedness" proposed by the author. This study included 3.005 patients admitted to hospital for a depression or a suicidal crisis in San Francisco from 1969 to 1974. Thirty days after hospital discharge, subjects were questioned by telephone about adherence to the defined therapy plan; non-compliant subjects were then randomized into two parallel groups with (N = 389) or without sending letters (N = 454). The primary endpoint of the study was to evaluate the impact on suicide rate. This study showed contrasted results at 5 and 15 years. Patients in the contact group had a lower suicide rate at five years (15/389 vs 21/454). Formal survival analyses revealed a significantly lower rate in the contact group (p = .04) for the first two years; differences in the rates gradually diminished, and by year 14 no differences between groups were observed (25/389 vs 26/454) [11
Like Motto's intervention, an Australian study tested the effectiveness of a programmed systematic sending of a postcard (postcards from the EDge project) during the year following the SA [12
]. The intervention consisted of a postcard sent to participants in a sealed envelope at 1, 2, 3, 4, 6, 8, 10, and 12 months after discharge (a total of 8 postcards). The message was the same for all postcards: «It has been a short time since you were here at the hospital, and we hope things are going well for you... if you wish to drop us a note, we would be happy to hear from you»
. The evaluation concerned all deliberate self poisoning patients admitted for few days in a toxicology unit. The initial follow-up was for 12 months, completed later with a one-year extension [13
]. The proportion of SA repeaters in the intervention group did not differ significantly from that in the control group (15.1% vs. 17.3% at one year, 21.2% vs. 22.8% at two years). However, among SA repeaters there was a lower number of reattempts in contact group (incidence risk ratio 0.55 at one year, and 0.49 at two years).
These findings were recently replicated by the New Zealand team of Beautrais: 327 suicide attempters aged 16 years or older, presenting consecutively to ED were included [14
]. The intervention consisted of sending four "postcards" to participants at two weeks, 1, 3 and 6 months. Patients allocated to control group did not receive any postcards. All subjects received a standard treatment in parallel. The number of SA repeaters was significantly lower in intervention group (31/153, 20.3%) than in control group (88/174, 50.6%).
Thus, by taking into consideration the strengths and limitations of each of these four strategies, we propose to construct a decisional tree of contact type, a case management algorithm. This monitoring algorithm entitled «ALGOS» is based on the two interventions that showed a significant reduction in the number of SA repeaters: systematic telephone contact (ineffective in first-attempters) and «crisis card» (effective only in first-attempters). Participants non contacted during phone call periods and those refusing proposed healthcare, can then benefit from the «short letters» of Motto or the «postcards» of Carter.