Skip to main content
×
×
Home

Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning

  • Hossein Hassanian-Moghaddam (a1), Saeedeh Sarjami (a2), Ali-Asghar Kolahi (a3) and Gregory L. Carter (a4)
Abstract
Background

Hospital-treated self-poisoning is common, with limited effective interventions for reducing subsequent suicidal behaviour.

Aims

To test the efficacy of a postcard intervention to reduce suicidal behaviour.

Method

Randomised controlled trial of individuals who self-poisoned (n = 2300), the intervention consisted of nine postcards sent over 12 months versus usual treatment. Outcomes assessed at 12 months (n = 2113) were suicidal ideation, suicide attempts and self-cutting (proportion and event rates).

Results

There was a significant reduction in any suicidal ideation (relative risk reduction (RRR) = 0.31, 95% CI 0.22–0.38), any suicide attempt (RRR = 0.42, 95% CI 0.11–0.63) and number of attempts (incidence rate ratios (IRR) = 0.64, 95% CI 0.42–0.97). There was no significant reduction in any self-cutting (RRR = 0.14, 95% CI −-0.29 to 0.42) or self-cutting events (IRR = 1.03 95% CI 0.76–1.39).

Conclusions

A postcard intervention reduced suicidal ideation and suicide attempts in a non-Western population. Sustained, brief contact by mail may reduce suicidal ideation and suicide attempts in individuals who self-poison.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning
      Available formats
      ×
Copyright
Corresponding author
Hossein Hassanian-Moghaddam, MD, Department of Internal Medicine, Division of Clinical Toxicology, Loghman-Hakim Poison Hospital, Kamali Avenue, South Karegar, Tehran, Iran. Email: Hassanian@sbmu.ac.ir
Footnotes
Hide All

This study was supported by a grant from the Legal Medicine Organization of Iran and the Loghman-Hakim Research Development Unit, Shahid Beheshti Medical University.

Declaration of interest

None.

Footnotes
References
Hide All
1 House, A, Owens, D, Patchett, L. Deliberate self-harm. Eff Health Care 1998; 4: 112.
2 Owens, D, Horrocks, J, House, A. Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 2002; 181: 193–9.
3 Owens, D, House, A. General hospital services for deliberate self-harm. Haphazard clinical provision, little research, no central strategy. J R Coll Physicians Lond 1994; 28: 370–1.
4 Liu, KY. Suicide rates in the world: 1950-2004. Suicide Life Threat Behav 2009; 39: 204–13.
5 Fleischmann, A, Bertolote, JM, Wasserman, D, De Leo, D, Bolhari, J, Botega, NJ, et al. Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. Bull World Health Organ 2008; 86: 703–9.
6 Bateman, A, Fonagy, P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 1999; 156: 1563–9.
7 Bateman, A, Fonagy, P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009; 166: 1355–64.
8 Linehan, MM, Armstrong, HE, Suarez, A, Allmon, D, Heard, HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48: 1060–4.
9 Linehan, MM, Comtois, KA, Murray, AM, Brown, MZ, Gallop, RJ, Heard, HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006; 63: 757–66.
10 Wood, A, Trainor, G, Rothwell, J, Moore, A, Harrington, R. Randomized trial of group therapy for repeated deliberate self-harm in adolescents. J Am Acad Child Adolesc Psychiatry 2001; 40: 1246–53.
11 Guthrie, E, Kapur, N, Mackway-Jones, K, Chew-Graham, C, Moorey, J, Mendel, E, et al. Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ 2001; 323: 135–8.
12 Brown, GK, Ten, H, Henriques, GR, Xie, SX, Hollander, JE, Beck, AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA 2005; 294: 563–70.
13 Slee, N, Garnefski, N, van der Leeden, R, Arensman, E, Spinhoven, P. Cognitive–behavioural intervention for self-harm: randomised controlled trial. Br J Psychiatry 2008; 192: 202–11.
14 Carter, GL, Clover, K, Whyte, IM, Dawson, AH, D'Este, C. Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. BMJ 2005; 331: 805–7.
15 Carter, GL, Clover, K, Whyte, IM, Dawson, AH, D'Este, C. Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry 2007; 191: 548–53.
16 Shadnia, S, Esmaily, H, Sasanian, G, Pajoumand, A, Hassanian-Moghaddam, H, Abdollahi, M. Pattern of acute poisoning in Tehran-Iran in 2003. Hum Exp Toxicol 2007; 26: 753–6.
17 Hollis, S. A graphical sensitivity analysis for clinical trials with non-ignorable missing binary outcome. Stat Med 2002; 21: 3823–34.
18 Mackinnon, A. A spreadsheet for the calculation of comprehensive statistics for the assessment of diagnostic tests and inter-rater agreement. Comput Biol Med 2000; 30: 127–34.
19 Motto, JA, Bostrom, AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv 2001; 52: 828–33.
20 Berwick, DM. Disseminating innovations in health care. JAMA 2003; 289: 1969–75.
21 Hatcher, S, Owens, D. Do get in touch. BMJ 2005; 331: 788–9.
22 Beautrais, AL, Gibb, SJ, Faulkner, A, Fergusson, DM, Mulder, RT. Postcard intervention for repeat self-harm: randomised controlled trial. Br J Psychiatry 2010; 197: 5560.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
PDF
Supplementary materials

Hassanian-Moghaddam et al. supplementary material
Supplementary Material

 PDF (52 KB)
52 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning

  • Hossein Hassanian-Moghaddam (a1), Saeedeh Sarjami (a2), Ali-Asghar Kolahi (a3) and Gregory L. Carter (a4)
Submit a response

eLetters

Re: Role of Postcard Intervention in Reducing Suicidal Behaviours

Hossein Hassanian-Moghaddam, Assistant Professor of Clinical Toxicology
21 July 2011

Dr. Jhangee, has mentioned a number of strengths and limitations, which were specifically addressed in the paper. For other issues:

1. Postcards is a minimal intervention sustained over 12 months. Optimal assessment is end of treatment and at follow-up, which allows comparison with similar studies (1;2). Repeated contact and assessment might “wash out” the effect of intervention and telephone contacts might specifically influence suicide attempts (3). The costs for three assessments for over 2000 participants was considerable and the additionalbenefits of endpoints measured before treatment completion are unlikely tooffset the additional costs.

2. Instruments assessing suicidal intention (rather than ideation) are contextualised to an episode of self-harm, suicide attempt or ideation. These were relatively uncommon and so intention would only have been measureable in a minority, if there was an instrument for the relevant languages and shown to be valid in the study population. Had there been such an instrument it might have been considered for baseline assessment.

3. Using consecutive admissions is a superior to any alternate sampling strategy. We acknowledged the limitations of restriction to a four month period.

4. Psychiatric diagnostic assessments were done for all inpatients. We were mindful of the dangers of sub-group analyses in general. Initiallywe analysed for gender; based on benefit only for women in (1;2) and a differential gender repetition rate of deliberate self harm or poisoning in western populations. We accepted the editorial suggestion of a second analysis based on previous suicide attempt at baseline, since this might be the highest risk factor for subsequent suicidal behaviour. Postcards inPersia and Postcards from the EDge intended to develop interventions available to almost all EDs with DSP patients, even EDs without psychiatric services required for diagnosis; so analyses based on psychiatric diagnosis was of low importance. We have tested alternate approaches to psychiatric diagnosis, which had low agreement with clinicaldiagnosis (4).

5. There were several post hoc analyses based on recall of the numberof postcards received. Since this was an efficacy trial we conducted the main analyses based on randomisation, not exposure or dosage of the intervention.

6. The research psychologist was not masked to allocation and may have inadvertently influenced responses at follow-up. Participants may have guessed the study end-points from questions asked of them, however their reports of the hospital-treated suicide attempts were found to be accurate.

7. There were two points in the paper that suggested that a substantial response bias was unlikely. The report of hospital treated episodes was accurate. Although ideation and attempt were significantly different, self-cutting was not, which would require a differential response bias in favour of two outcomes but against another.

8. It would be useful to know the reasons for withdrawal. However, less than 2.3% of the treatment group withdrew, suggesting acceptability was rather good and improved retention in treatment would be small. The most innovative analysis addressed the issue of the possible impact causedby subjects withdrawn or lost to follow up. We expect that sensitivity analyses (5) that account for all possible outcomes might become a future standard for reporting RCTs that cannot guarantee an intention to treat analysis based on all participants or which rely on imputed values for non-ignorable missing binary endpoints.

Reference List

(1) Carter GL, Clover K, Whyte IM, Dawson AH, D'Este C. Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. British Medical Journal 2005; 331(7520):805-807.

(2) Carter GL, Clover K, Whyte IM, Dawson AH, D'Este C. Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry 2007; 191(6):548-553.

(3) Vaiva G, Ducrocq F, Meyer P, Mathieu D, Philippe A, Libersa C etal. Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study. BMJ 2006; 332(7552):1241-1245.

(4) Jayasekera H, Carter G, Clover K. Comparison of the Composite International Diagnostic Interview (CIDI-Auto) with Clinical Diagnosis in a Suicidal Population. Arch Suicide Res 2011; 15(1):43-55.

(5) Hollis S. A graphical sensitivity analysis for clinical trials with non-ignorable missing binary outcome. Stat Med 2002; 21(24):3823-3834.

Hossein Hassanian-Moghaddam and Gregory Carter
... More

Conflict of interest: None Declared

Write a reply

Role of Postcard Intervention in Reducing Suicidal Behaviours

ANURAG JHANJEE, Senior Resident (Psychiatry)
17 June 2011

ROLE OF POSTCARD INTERVENTION IN REDUCING SUICIDAL BEHAVIOURSThe article by Hassanian-Moghaddam et al1 is an interesting article providing useful insights into the potential utility of Postcard intervention in reducing suicidal behavior. The authors by virtue of this study have found that among the subjects who had self-poisoned, nine postcards sent sequentially over a period of 12 months produced reduction in suicidal ideation and suicidal attempts. The study deserves accolades for various reasons viz. including a large sample of non-western population, having a randomized control design, ensuring an over 90 % retention rate and nearly equal rates of loss to follow-up in both groups. The results of the study are illuminating but their generalisability and applicability in day to day clinical practice needs to be analysed in the backdrop of following limitations:1.The study provided for assessment of outcomes only at 12 months. It would have been better if the assessments were performed more frequently like once in 2 or 3 months.2.The study at no point assessed suicidal intent among the subjects.3.Instead of employing any standard sampling technique, the participants of the study included consecutive individuals with poisoning, admitted from March to June 2006 in the Loghman-Hakim Poison Hospital.4.Baseline assessment did not include a comprehensive psychiatric evaluation that could have ascertained the specific psychiatric diagnosis of the participants and permitted subgrouping of the participants based on psychiatric diagnosis thereby providing a valuable opportunity to study the differential impact of postcard intervention in reducing suicidal ideation and suicidal attempt among the participants with different psychiatric disorders.5.There is no mention in the article if the delivery of the postcards was confirmed at the recepient’s end by any means.6. The participants were masked to study outcomes but the research psychologist was not masked to allocation, and this could have inadvertently influenced responses at follow up. 7.The subjects may have got some clue about the study outcomes from the questions asked from them and this could have influenced the final results of the study8.A small minority of participants withdrew from the postcard intervention but the specific reasons for the same were not assessed. To make the Postcard intervention more accepatable and effective, one needs to ascertain the specific reasons which made the participants withdraw from this intervention.References:1.Hassanian-Moghaddam H, Sarjami S, Kolahi A, Carter GL. Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning. British J Psychiatry 2011; 198: 309–316 ... More

Conflict of interest: None Declared

Write a reply

Postcards in Persia: reducing suicidal behaviours

MOHINDER KAPOOR, Specialty Registrar (ST5) Old Age Psychiatry
03 May 2011

Hassanian-Moghaddam et al 1 present interesting findings in their randomised controlled trial study of postcard intervention to reduce suicidal behaviour 12 months after hospital treated self-poisoning. They concluded that a postcard intervention reduced suicidal ideation and suicide attempts in a non-Western population of individuals who self-poisoned. If these findings can be replicated and translated into daily practice, then it will go long way in reducing suicidal behaviour following hospital treated self-poisoning.

Authors of this study should be congratulated for conducting a study looking at a very important issue of self-poisoning and suicide, and testing the efficacy of a postcard intervention in reducing suicidal behaviour. The study had a large sample size, randomized control group andwas adequately powered. However, I have few reservations in relation to the study design and analysis of outcomes in this study. We all know the strength of a double blind design in eliminating the potential for information (observation) bias.2 Authors have acknowledged that although the participants were masked to study outcomes the research psychologist was not masked to allocation, which might have influenced responses at follow up. This knowledge of the intervention to which participant has been assigned raises the potential of information bias. To make matters worse the authors also mention that the participants might have guessed the study end points from questions asked of them. Knowledge of a participant’s treatment status might, consciously or not, influence the identification or reporting of relevant events. The likelihood of such bias, as we know, is directly related to the subjectivity of the outcomes under study 2. In this study subjective outcome measures were used where cross-validation was not available for majority of them. One way this could have been dealt with was by keeping the study participants and / or the investigators blinded so far as possible to the identity of the interventions until data collection had been completed 2.

I am also aware of the fact that while the effectiveness of blindnessas a means to minimise bias is well recognised, it is not always possible to achieve. I think it would have not been possible to incorporate blinding of the participants, given the nature of intervention, but research psychologist could have been blinded to allocation of the individuals. Although authors have mentioned these shortcomings under the limitations section of the study, it is imperative that we all understand not only the importance of these shortcomings but also the impact these can have on the main findings of this study.

Declaration of interest: None

References:

1.Hassanian-Moghaddam H, Sarjami S, et al. Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning. Br J Psychiatry 2011; 198: 309-316

2. Hennekens CH, Burning JE et al. Epidemiology in Medicine. Little,Brown and Company Boston/Toronto, 1987
... More

Conflict of interest: None Declared

Write a reply

Efficacy of Persian postcard intervention: Interpret with caution

Raman D Pattanayak, Senior Research Associate (CSIR)
12 April 2011

The article (1) evaluates the efficacy of a brief, repetitive postcard intervention for suicidal behaviors in a persian poison-hospital discharged population. The findings of the study should be interpreted in light of following limitations, hitherto not pointed.

We have reservations about using purely subjective primary outcome measures. Direct questions were asked, over telephone, for presence or absence of suicidal ideation and/or attempt over past one year. The self-report is open to a wide variety of errors e.g. recollection bias, hesitation to disclose and socially desirable responses especially for postcard intervention group. The person may even be suffering from hypomania, mania or an active psychotic state at the time of interview since the mental state was not assessed at the time of interview. While the authors tried to corroborate the positive history of suicide attempts from city hospital records, but we are more worried about under-reporting rather than over-reporting. Use of a collateral source of information fromthe family may have added to strength of outcome measure.The study undertook a sample of hospitalized suicide attempters, with a passing mention of assessment by psychiatry department in all cases, however we are not provided with the psychiatric diagnosis in the sample. Failure to include psychiatric diagnosis makes the suicide attempters a heterogeneous population, possibly with borderline personality disorder, mood disorder, schizophrenia or no psychiatric diagnosis. A subset analysis for each diagnostic group may have shown differential efficacy ofpostcard intervention for various groups. Further, it may have been usefulto know the proportion of patients prescribed and using psychotropic drugsand if intervention had an effect on drug compliance.

The study had a large sample size, randomized control group and a novel intervention in a non-western context as its merits. The wide-spreadstigma, illiteracy especially in females and absence of a permanent contact address are some of the commonly encountered challenges which could interfere in its usage in a developing or low-income country.

Reference:(1) Hassanian-Moghaddam H, Sarjami S, Kolahi A, Carter GL. Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning. British J Psychiatry 2011; 198: 309–316
... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *