Repercusiones de los polímeros en la sociedad

Multiple suicide attempts by the same patient may be reduced by sustained outreach services and/or intensive case management:Patients that make multiple attempts present enormous challenges to every ED and inpatient unit. Repeat attempts are the subject of an important Aus- tralian investigation led by Carter. 381 _{Carter’s research is modeled after the study by Motto} and Bostrom, which is described immediately above. 26, 36 _{The population of interest differed,} however. In Carter’s study, repeat suicide attempts is the outcome variable; all patients were hospitalized after self-poisoning (i.e., overdose). Beginning 30 days after discharge, the interven- tion involved sending eight, non-demanding postcards to patients (in sealed envelopes) over the 12-month, post-discharge period. This study found no significant differences between groups in the proportion of participantsthat made a repeat overdose during the one-year follow-up period. However, it did have an impact on the number of attempts. When multiple attempts made by the same patient in the follow-up period were considered, the patients, mostly female, who were sent the postcards made approximately half the total number of repeat attempts than individuals in the control condition.

Even seemingly inconsequential contacts may be of some benefit in some suicide-risk groups. Connectedness may be an important reason why this postcard intervention succeeded, but this is

sheer speculation. The reasons simple letters or postcards obtained favorable outcomes is un- known, and research is needed to identify the ingredients for success. Reasons aside, these appear to be low-budget methods to thwart some repeat suicide attempts and, possibly, prevent suicide deaths. If so, research is needed to better characterize the precise means for this accomplishment. The limitations of intensive case management are illustrated by a randomized control trial (RCT) done by De Leo and Heller. 382 _{(The De Leo and Heller study is not represented in any of the} tables.) The aim of the research was to evaluate the impact of intensive case management for males with a history of suicide attempts. In addition, the study participants had psychiatric illness and were recruited at the time of discharge from an inpatient psychiatry unit. Sixty patient-sub- jects were randomly assigned to either intensive case management or the control group, treatment as usual. For one year, the intervention featured weekly face-to-face contact with a community case manager and outreach telephone calls from an experienced telephone counselor. People in the treatment condition had significant improvements in depression scores, suicide ideation, and quality of life; they had more contacts and more satisfying contacts with mental and allied health professionals. No differences were found across conditions in the key variable—self-harming behaviors. This study is mentioned, however, for its limitations. In both groups there was a high attrition rate—73 percent (only 8 people remaining) for treatment as usual and 53 percent (only 14 people remaining) for the intervention condition.

An RCT led by Dixon has somewhat parallel results. The Dixon study examined the effectiveness of a three-month critical time intervention model in improving continuity of care for consenting veterans (n=135) with mental illness who were discharged from inpatient psychiatry facilities. 383 These two forms of intensive case management (i.e., De Leo and Heller; Dixon and colleagues) significantly improved continuity of care, but failed to produce significant changes in mental health outcomes. One possible conclusion is that intensive case management alone may be a

necessary but insufficient condition to keep suicide-prone people engaged. Some form of actual

treatment pertaining more directly to suicidality is necessary, and the following studies provide treatment and are far more successful.

Suicide attempts may be prevented by a specific anti-suicide therapy beginning at or soon after the ED visit: The efficacy of cognitive behavioral therapy in reducing suicide attempts is illus- trated by two studies. The study led by Gregory Brown is the first to be reviewed.

Published in 2005, the randomized control trial lead by Brown deserves special mention as it sets the present standard against which other trials will be compared. 32 _{Unlike most studies previously} mentioned, Brown used a sample of patients that were at high risk for suicide behaviors anda therapy specifically designed to treat suicide-attempt behaviors. This special form of cognitive behavioral therapy (CBT) is standardized and manual-based. 32, 384

Post-suicide-attempt patients in both the experimental and control condition were contacted while they were still in the ED or shortly after being discharged. Once randomized, each of two study groups received active case management services (e.g., coordination of appointments, help with transportation, identifying alcohol and drug rehabilitation agencies and so forth). Each patient in

Continuity of Care for Suicide Prevention and Research

the experimental population agreed to attend a minimum of 10 CBT sessions. So as to be treated equally, patients in both treatment conditions were encouraged to attend the usual forms of treat- ment provided in the community. At the 18-month follow-up, the experimental sample made significantly fewer suicide attempts, and patients in this group were 50 percent less likely to reat- tempt (Figure 5. Kaplan-Meier survival curves; 0.51 hazard ratio.) Depression and hopelessness scores were significantly reduced during follow-up compared to the control conditions.

Figure 5:

Reprinted with permission from the Journal of American Medical Association 2005; 294:563-570. Copyright 2005 American Medical Association. All rights reserved.

Published in 2008 and done in The Netherlands, the second study’s main outcomes are several: reduction in self-harm as well as suicidal cognitions and symptoms of depression and anxiety, and improvement in self-esteem and problem-solving ability. 385 _{This RCT, led by Slee and others, pro-} vides patient-participants, ages 15 to 35 years, a maximum of 12 sessions of cognitive-behavioral therapy (CBT) after an episode of acute suicide behaviors largely without suicidal intent. Of the 100 eligible patients, 90 were randomized to either cognitive behavioral therapy plus treatment as usual (n=48) or to the control condition, treatment as usual (n=42). Excluded were patients with a severe psychiatric disorder requiring intensive inpatient treatment. The initial assessment took place two weeks after the initial episode, and CBT started three weeks after; outcome measures were obtained at 3, 6, and 9 months (Table 3). Despite eligibility for the study, 45 percent declined