Publications

Hofstra E, van Nieuwenhuizen C, Bakker M, Özgül D, Elfeddali I, de Jong SJ, van der Feltz-Cornelis CM Effectiveness of suicide prevention interventions: A systematic review and meta-analysis. Gen Hosp Psychiatry. 2020 Mar-Apr;63:127-140. doi: 10.1016/j.genhosppsych.2019.04.011. Epub 2019 May 8.PMID: 31078311 Review.

Abstract

Objective:

This study provides an estimate of the effect size of suicide prevention interventions and evaluates the possible synergistic effects of multilevel interventions.

Method:

A systematic review and meta-analysis were conducted of controlled studies evaluating suicide prevention interventions versus control published between 2011 and 2017 in PubMed, PsycINFO, and Cochrane databases. Data extraction and risk of bias assessment according to ROBINS criteria were performed by independent assessors. Cohen's delta was calculated by a random meta-analysis on completed and attempted suicides as outcomes. Meta-regression explored a possible synergistic effect in multilevel interventions. PROSPERO ID number: CRD42018094373.

Results:

The search yielded 16 controlled studies with a total of 252,932 participants. The meta-analysis was performed in 15 studies with 29,071 participants. A significant effect was found for suicide prevention interventions on completed suicides (d = -0.535, 95% CI -0.898; -0.171, p = .004) and on suicide attempts (d = -0.449, 95% CI -0.618; -0.280, p < .001). Regarding the synergistic effect of multilevel interventions, meta-regression showed a significantly higher effect related to the number of levels of the intervention (p = .032).

Conclusions:

Suicide prevention interventions are effective in preventing completed and attempted suicides and should be widely implemented. Further research should focus on multilevel interventions due to their greater effects and synergistic potential. Further research is also needed into risk appraisal for completed versus attempted suicide, as the preferred intervention strategy differs with regard to both outcomes.

Hofstra E, Elfeddali I, Metz M, Bakker M, de Jong JJ, van Nieuwenhuizen C, van der Feltz-Cornelis CM A regional systems intervention for suicide prevention in the Netherlands (SUPREMOCOL): study protocol with a stepped wedge trial design. BMC Psychiatry. 2019 Nov 19;19(1):364. doi: 10.1186/s12888-019-2342-x. PMID: 31744476 Free PMC article.

Abstract

Background:

In the Netherlands, suicide rates showed a sharp incline and this pertains particularly to the province of Noord-Brabant, one of the southern provinces in the Netherlands. This calls for a regional suicide prevention effort.

Methods/design: Study protocol.

A regional suicide prevention systems intervention is implemented and evaluated by a stepped wedge trial design in five specialist mental health institutions and their adherent chain partners. Our system intervention is called SUPREMOCOL, which stands for Suicide Prevention by Monitoring and Collaborative Care, and focuses on four pillars: 1) recognition of people at risk for suicide by the development and implementation of a monitoring system with decision aid, 2) swift access to specialist care of people at risk, 3) positioning nurse care managers for collaborative care case management, and 4) 12 months telephone follow up. Eligible patients are persons attempting suicide or expressing suicidal ideation. Primary outcome is number of completed suicides, as reported by Statistics Netherlands and regional Public Health Institutes. Secondary outcome is number of attempted suicides, as reported by the regional ambulance transport and police. Suicidal ideation of persons registered in the monitoring system will, be assessed by the PHQ-9 and SIDAS questionnaires at baseline and 3, 6, 9 and 12 months after registration, and used as exploratory process measure. The impact of the intervention will be evaluated by means of the RE-AIM dimensions reach, efficacy, adoption, implementation, and maintenance. Intervention integrity will be assessed and taken into account in the analysis.

Discussion:

The present manuscript presents the design and development of the SUPREMOCOL study. The ultimate goal is to lower the completed suicides rate by 20%, compared to the control period and compared to other provinces in the Netherlands. Moreover, our goal is to provide specialist mental health institutions and chain partners with a sustainable and adoptable intervention for suicide prevention.

Trial registration:

Netherlands Trial Register under registration number NL6935 (5 April 2018). This is the first version of the study protocol (September 2019).

van der Feltz-Cornelis CM, Hofstra E, Elfeddali I, Bakker M, Metz M, de Jong SJ, van Nieuwenhuizen C. Efficacy of a digitally supported regional systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands. Gen Hosp Psychiatry. 2023 Sep-Oct; 84:73-81. doi: 10.1016/j.genhosppsych.2023.06.010. Epub 2023 Jun 23. PMID: 37399647. Free article.

Abstract

Objective:

We evaluated the effect of a digitally supported systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands.

Method:

Non-randomized stepped wedge trial design (SWTD). Stepwise implementation in the five subregions of the systems intervention. Pre-post analysis for the whole province (Exact Rate Ratio Test, Poisson count). SWTD Hazard Ratios of suicides per person-years for subregional analysis of control versus intervention conditions over five times three months. Sensitivity analysis.

Results:

Suicide rates dropped 17.8% (p = .013) from 14.4 suicides per 100,000 before the start of implementation of the systems intervention (2017), to 11.9 (2018) and 11.8 (2019) per 100, during implementation; a significant reduction (p = .043) compared to no changes in the rest of the Netherlands. Suicide rates dropped further by 21.5% (p = .002) to 11.3 suicides per 100,000 during sustained implementation in 2021. Sensitivity analysis confirmed the reduction (p = .02). The SWTD analysis over 15 months in 2018-2019 did not show a significant association of this reduction with implementation per subregional level, probably due to insufficient power given the short SWTD timeframe for implementation and low suicide rates per subregion.

Conclusions:

During the SUPREMOCOL systems intervention, over four years, there was a sustained and significant reduction of suicides in Noord-Brabant.

van der Feltz-Cornelis CM, Elfeddali I, Metz M, de Jong SJ, van Nieuwenhuizen C. Efficacy of a regional systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands. European Psychiatry, 2023 March; 66: S560-S561. DOI: https://doi.org/10.1192/j.eurpsy.2023.1179 Special Issue S1: Abstracts of the 31st European Congress of Psychiatry,

Abstract

Introduction:

Worldwide, annually more than 800,000 suicides occur. In the Netherlands, suicide rates rose from 8.6 per 100,000 in 2007 to 11.4 per 100,000 in 2016. Rates in the province of Noord-Brabant were consistently higher than the national average. Noord-Brabant is a province in the south of the Netherlands covering an area of over 4700 km2 with 2.5 million inhabitants. Although Noord-Brabant has five specialised mental healthcare institutions (SMHIs), and 90% of suicides are deemed related to mental disorders, 60% of those who died by suicide did not receive mental health treatment. However, with good access to treatment, suicide could be preventable.

Objectives:

To evaluate whether the systems intervention compared to the regular care approach led to a reduction in suicides in Noord-Brabant. We aimed to attain a reduction in suicides of at least 20%.

Methods:

Co-design and development of a digital monitoring system and decision aid. Stepwise implementation per subregion of the systems intervention by the five specialized mental healthcare institutions (SMHIs) and their chain partners. Pre-post analysis for the whole province (Exact Rate Ratio Test, Poisson count).

Results:

The SUPREMOCOL systems intervention consisted of four pillars, which were all supported by a digital decision aid and monitoring system. This was provided via a desktop computer with a secured login. The data were kept on a secured encrypted server. The number of professionals accessing the system was limited to two per SMHI or other chain partner. They could only see patients in their subregion, not in the whole of the province. The pillars of our systems intervention for suicide prevention are:

Swift identication of people at risk for suicide by triage on the spot after a non-fatal suicide attempt.
Provision of swift access to specialised mental health care for those at risk
Accommodating transitions in care following a collaborative care approach
Prevention of suicidal attempts after discharge or treatment dropout by 12 months telephone follow-up.

Suicide rates dropped 17.8% (p=.013) from baseline (2017) to implementation in 2018 and 2019. This is a significant reduction (p=0.043) compared to the non-significant drop in the rest of the Netherlands. Suicide rates dropped further by 21.5% (p = 0.002) in 2021.

Noord-Brabant also dropped in the relative rank of the number of suicides, from second place in 2015 to third in 2018.

Conclusions:

During the SUPREMOCOL systems intervention, over a period of 4 years, there was a sustained and significant reduction of suicides in Noord-Brabant. We attained a reduction of 21,5% in total. Noord-Brabant dropped in the relative rank of the number of suicides, from second place in 2015 to third in 2018. This is a result that warrants further research and implementation into system interventions for suicide prevention with digital support such as SUPREMOCOL.

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