Research Article: Combining green cards, telephone calls and postcards into an intervention algorithm to reduce suicide reattempt (AlgoS): P-hoc analyses of an inconclusive randomized controlled trial

Date Published: February 1, 2019

Publisher: Public Library of Science

Author(s): Antoine Messiah, Charles-Edouard Notredame, Anne-Laure Demarty, Stéphane Duhem, Guillaume Vaiva, Natalie Riblet.


Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.

AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.

1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13–14 months (RR [95% CI]: 0.46 [0.25–0.85] and 0.50 [0.31–0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13–14 months (RR [95% CI]: 0.84 [0.57–1.25] and 1.00 [0.73–1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.

This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.

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With a toll nearing one million per year, suicide is the 17th leading cause of death worldwide, and the 10th cause of death for adults 18–40 years old [1,2]. Suicide prevention is now considered a global public-health priority, and large-scale multimodal programs are deemed the most efficient strategy to adopt [1]. Brief Contact Interventions (BCIs) in the immediate aftermath of suicide attempts (SAs) were identified as relevant pieces to integrate into such programs [3]. BCIs encompass a range of timely interventions designed to help patients in coping with prospective suicide crisis, notably by maintaining connection with the health care system. From a public health perspective, BCIs are particularly appropriate because (1) they target one of the most highly at-risk population, since SA is the main predictor for subsequent suicide behavior, with a maximum risk in the immediate aftermath of an index SA [2,4–7]; (2) rather than a substitute, they are intended to complement usual treatment and augment its effectiveness; and (3) as they can easily be initiated from emergency departments (EDs), they do not require on-site mental-health specialist, and are therefore easily scalable up to an entire population [8,9].

The Algos trial was authorized by the French Ministry of Health, and approved by the Comité de Protection des Personne of Nord-Pas-de-Calais (Ethics Committee). It was registered with (NCT01123174).




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