Assessment and management of individuals consulting for a suicidal crisis: A European Delphi method-based consensus guidelines.

INTRODUCTION: Managing patient with suicidal thoughts and behaviours presents significant challenges due to the scarcity of robust evidence and clear guidance. This study sought to develop a comprehensive set of practical guidelines for the assessment and management of suicidal crises. MATERIALS AND METHODS: Utilizing the Delphi methodology, 80 suicide clinician and research experts agreed on a series of recommendations. The process involved two iterative rounds of surveys to assess agreement with drafted recommendations, inviting panellists to comment and vote, culminating in 43 consensus recommendations approved with at least 67% agreement. These consensus recommendations fall into three main categories: clinical assessment, immediate care, and long-term approaches. RESULTS: The panel formulated 43 recommendations spanning suicidal crisis recognition to continuous long-term care. These guidelines underscore systematic proactive suicide risk screening, in-depth medical and toxicological assessment, and suicide risk appraisal considering personal, clinical factors and collateral information from family. The immediate care directives emphasize a secure environment, continuous risk surveillance, collaborative decision-making, including potential hospitalization, sensible pharmacological management, safety planning, and lethal means restriction counselling. Every discharge should be accompanied by prompt follow-up care incorporating proactive case management and multi-modal approach involving crisis lines, brief contact, and psychotherapeutic and pharmacological interventions. CONCLUSIONS: This study generated comprehensive guidelines addressing care for individuals in suicidal crises, covering pre- to post-discharge care. These practical recommendations can guide clinicians in managing patients with suicidal thoughts and behaviours, improve patient safety, and ultimately contribute to the prevention of future suicidal crises.

Suicide and All-Cause Mortality Within 1 Year After a Suicide Attempt in the VigilanS Cohort.

Objective: Obtaining better knowledge on the outcomes of patients who attempt suicide is crucial for suicide prevention. The aim of our study was to determine the causes of death 1 year after a suicide attempt (SA) in the VigilanS program, mortality rates, and risk factors associated with any cause of death and suicide.Methods: A prospective cohort of 7,406 people who had attempted suicide between January 1, 2017, and December 31, 2018, was included in the study. The vital status of each participant was sought, and the cause of death was established through a phone call to their general practitioner or psychiatrist. Second, the relationship between sociodemographic and clinical factors and death by suicide within 1 year of an SA was assessed using a multivariable Cox model.Results: At 1 year, 125 (1.7%) participants had died, 77 of whom died by suicide. Half of the deaths occurred within the first 4 months after an SA. Hanging (20.3%; 24/125) and self-poisoning (19.5%; 23/125) were the methods the most often used for suicide. We demonstrated that male sex (HR = 1.79 [1.13-2.82], P = .01) and being 45 years of age or older (between 45 and 64 years old, HR = 2.08 [1.21-3.56], P < .01; 65 years or older, HR = 5.36 [2.72-10.54], P < .01) were associated with a higher risk of death by suicide 1 year after an SA and that being younger than 25 years was associated with a lower risk (HR = 0.22 [0.07-0.76], P = .02).Conclusions: One out of 100 people who attempted suicide died by suicide within 1 year after an SA. Greater vigilance is required in the first months following an SA, especially for males older than 45 years.Trial Registration: ClinicalTrials.gov identifier: NCT03134885.

[Management of suicidal crises and suicidal individuals]. / Prises en charge des crises suicidaires et des suicidants.

Knowing how to assess the suicidal risk of people in crisis, knowing how to orient them, welcome them, treat them and look after them are the keys to these multidisciplinary health care.

[Preventing suicidal crisis and suicide]. / Prévenir la crise suicidaire et le suicide.

Suicide is not the inevitable outcome of a suicidal crisis. The people concerned are most often sensitive to preventive actions, which can prevent them from committing self-destructive acts. Preventing the suicidal crisis and suicide requires the involvement of healthcare professionals. It is also everyone's business.

[Suicide prevention after a suicide attempt: how to stay in touch?] / Comment prévenir la récidive après une tentative de suicide : garder le lien.

Suicide prevention after a suicide attempt: how to stay in touch? Attempted suicide is a major risk factor of further re-attempts and death. Self-harm behaviors are related to multiple causes, explaining why it is ineffective to have a single and simple strategy to offer after the clinical assessment in reducing morbidity and mortality. Furthermore, treatment adherence is known to be especially poor, in a context where social connection seems compromised and source of pain. Effective interventions can be divided into two categories: intensive intervention programs (care at home, supported by a series of brief psychotherapy interventions) and, case management programs that rely on a "stay in contact" dimension(letters, telephone, sms, mail, etc.). A prevention algorithm was further proposed to routine care in 2015, in the northern departments of France, Nord et Pas-de-Calais (4.3 million people), taking the name of VigilanS. The inclusion consists in sending a form for every patient assessed after a suicide attempt in the two departments to the medical staff of VigilanS, in order to provide information about the patient and the context of his suicide attempt. The algorithm consist in giving crisis card to all the patients; an information letter, explaining the aim of the monitoring is also given to the patient, and to his general practitioner. The calling staff is composed of4 nurses and 4 psychologists, all trained in suicidal crisis management. They use a phone platform located in the Emergency Medical Assistance Service (SAMU) of the Nord department, and manage the incoming calls from the patients, plus the outgoing calls towards the patients, their relatives and their medical contacts. A set of 4 postcards (1 per month) can be sent if needed incase of an inconclusive or a failed phone call. Built on a monitoring philosophy, VigilanS has further developd a real crisis case management dimension, requiring enough time to insure an effective medical supervision, and strong networking abilities. A specific time is also needed to take care of all the technical aspects of the organization. We measured the evolution of the number of suicide attempts before and after implantation of VigilanS: we found an acceleration of the reduction of stay for suicide attempt in Nord et Pas-de-Calais after 2014(-16% instead of -6%), instead of the two Picardy departments the most comparable show a degradation of the phenomenon (+13%). The system is currently being deployed across France.

Comment prévenir la récidive après une tentative de suicide : garder le lien. Les tentatives de suicide constituent un facteur de risque majeur de récidives et de décès. Les comportements suicidaires sont poly factoriels et rendent inefficace une stratégie unique de prévention. L'adhésion aux soins est mauvaise dans un contexte où les liens sociaux sont souvent en souffrance. Deux catégories de programme sont montré leur efficacité : les dispositifs d'intervention intensive et les dispositifs de veille. Ces derniers peuvent recouvrir différentes modalités (courriers, téléphone, textos, mails, etc.). Un dispositif régional innovant, baptisé Vigilan S, combine ces différentes stratégies dans l'algorithme suivant : délivrance d'une carte de crise à la sortie de la prise en charge hospitalière ; rappel téléphonique des non-primosuicidants 15 jours après leur sortie ; envoi de cartes postales personnalisées mensuellement pendant 6 mois en cas d'échec de l'appel ;information du médecin traitant. L'équipe de recontact, formée à la gestion de crise, gère tous les appels sortants et entrants vers les patients, leurs proches et leurs soignants. Un jeu de 4 cartes postales peut être envoyé encas d'appel téléphonique non concluant. S'appuyant sur une philosophie de veille, VigilanS a développé un véritable savoir-faire de gestion de crise, nécessitant une supervision médicale constante et de solides capacités de mise en réseau. Une étude « écologique ¼ en population générale a été lancée en 2015 dans les départements du Nord et du Pas-de-Calais. Quatre ans plus tard, il est constaté dans tout ce territoire une baisse moyenne de 13 % des passages aux urgences pour tentative de suicide, ainsi qu'une baisse de 12 % des levées de corps pour suicide par les médecins légistes. Le dispositif est en cours de déploiement en France métropolitaine et ultramarine.

Combining Postcards, Crisis Cards, and Telephone Contact Into a Decision-Making Algorithm to Reduce Suicide Reattempt: A Randomized Clinical Trial of a Personalized Brief Contact Intervention.

BACKGROUND: There is growing evidence in the literature that brief contact interventions (BCIs) might be reliable suicide prevention strategies. OBJECTIVE: To assess the effectiveness of a decision-making algorithm for suicide prevention (ALGOS) combining existing BCIs in reducing suicide reattempts in patients discharged after a suicide attempt. METHODS: A randomized, multicenter, controlled, parallel trial was conducted in 23 hospitals. The study was conducted from January 26, 2010, to February 28, 2013. People who had made a suicide attempt were randomly assigned to either the intervention group (ALGOS) or the control group. The primary outcome was the rate of participants who reattempted suicide (fatal or not) within the 6-month study period. RESULTS: 1,040 patients were recruited. After 6 months, 58 participants in the intervention group (12.8%) reattempted suicide compared with 77 (17.2%) in the control group. The difference between groups (4.4%; 95% CI, -0.7% to 9.0%) was not significant (complete-case analysis, P = .059). CONCLUSIONS: These results may help researchers better integrate BCIs into routine health care and provide new insights concerning personalized suicide prevention strategies. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01123174.

Antiepileptic drugs and risk of suicide attempts: a case-control study exploring the impact of underlying medical conditions.

PURPOSE: Randomized-controlled trials and claims databases suggest that antiepileptic drug (AED) use may increase the risk of suicide attempts (SA). The present case-control study explores the impact of underlying indications on this potential association. METHODS: Physicians collected the medical history; prior 12-month drug use was obtained from standardized telephone interviews with patients. The association between AED use and SA was explored using multivariate conditional logistic regression. The analyses were replicated after stratification on depression and neurological disorders (epilepsy, migraine, and chronic neuropathic pain). RESULTS: Between 2008 and 2012, 506 adults with an incident SA were recruited in suicide treatment centers from across France and socio-demographically matched to 2829 controls from primary care settings. The association between AED use and odds of SA was not significant overall (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9-2.4). No association was observed for patients with neurological disorders (OR, 1.1; 95%CI, 0.5-2.4) as opposed to patients with depression (OR, 1.6; 95%CI, 1.0-2.5), but unmeasured confounding was suspected. CONCLUSIONS: Our results suggest that the association observed between AED use and increased odds of non-fatal SA in patients with either a lifetime history of depression or no neurological disorder may be explained by the presence of an underlying psychiatric disorder. Accounting for underlying indications is crucial in drug safety studies, as these can cause a reported association (or lack thereof) to be misleading. This may require the prospective collection of medical data at a patient level. Copyright © 2017 John Wiley & Sons, Ltd.

[What can we do to prevent the suicide re-attempts?]. / Prévention tertiaire du suicide: que faire pour eviter la récidive?

A subject surviving a suicide attempt (SA) belongs in fact to a group at risk for suicide (40% of lifetime repetition including 20 to 25% over the 12 months following the initial gesture). To prevent the risk of suicide in general is thus effective on the prevention of the repetition. It initially seems important to treat a somatic or psychiatric pathology having taken part in the initial suicidal context: treating a mood depression disorder, prescribing a mood stabilizer to a bipolar patient, managing the global treatment of a borderline personality disorder, etc. Some strategies have been proposed with a specific aim to reduce this rate of suicidal repetition. Certain devices very interventionists appear expensive and difficult to generalize (at home interventions, intensive short psychotherapies carried out starting from the Emergency Rooms...). In a parallel way, "connectedness" devices, which are careful not to invade the suicide attempter life, which does not aim to replace a treatment, but try to propose effective recourse in case of crisis, tend to currently develop on the whole territory.