Outreach Programs vs. Usual Care for Self-Harm Prevention
March 18, 2022
In a recent clinical trial conducted in four U.S. health systems, researchers compared the effectiveness of two low-intensity outreach programs with usual care for preventing self-harm. Participants were 18,882 outpatients who reported recent frequent thoughts of death or self-harm on the nine-item Patient Health Questionnaire (PHQ-9) between March 2015 and September 2018.
Participants were randomly assigned to one of three groups: (1) usual care plus an online care management intervention, (2) usual care plus an online skills training intervention to learn four dialectical behavior therapy (DBT) skills, or (3) usual care only (no offer of additional services). The care management intervention included regular outreach for suicide risk screening and follow-up. The skills training intervention provided video instruction in mindfulness, mindfulness of current emotion, opposite action, and paced breathing, supported by a skills coach.
The two outreach programs lasted up to 12 months, delivered mostly through electronic health record messaging, and were designed to supplement ongoing mental health care. The primary outcome was first observed fatal or non-fatal self-harm within 18 months of randomization. Analyses compared groups according to randomized assessment, regardless of participation in the intervention.
This study tested the effectiveness of the two outreach programs under everyday practice conditions and found that neither program decreased risk of self-harm compared to usual care only. Compared to the group that was offered usual care only, the risk of self-harm was not statistically significantly different in the care management group. Compared to usual care only, the risk of self-harm was statistically significantly higher in the skills training group. The findings from the study do not support implementation of the outreach programs as they were tested.
While the findings of the study indicate that the two tested programs have no benefit over usual care in the participating health systems, the findings should not discourage systematic patient screening and intervention to prevent suicide in health care settings.
Study limitations include restrictive inclusion criteria and low participant engagement in the tested interventions. It should also be noted that all subjects had access to specialty mental health services and the comparative effectiveness of the two interventions tested might differ for patients without such services.
Simon, G. E., Shortreed, S. M., Rossom, R. C., Beck, A., Clarke, G. N., Whiteside, U., Richards, J. E., Penfold, R. B., Boggs, J. M., & Smith, J. (2022). Effect of offering care management or online dialectical behavior therapy skills training vs. usual care on self-harm among adult outpatients with suicidal ideation: A Randomized Clinical Trial. JAMA, 327(7), 630–638.