Estrategias de mantenimiento de contacto e intervenciones psicoterapéuticas breves para la prevención del suicidioestudio de implementación, efectividad y coste-efectividad

Resum

Suicide is a leading cause of death. Non-lethal suicidal behavior, the single most salient risk marker of future death by suicide, is a major reason for emergency medical care with an increasing incidence globally. Reversing this trend constitutes a crucial public health challenge. The period following a suicide attempt entails great reattempt risk, hence providing an opportunity window for individual-level suicide prevention efforts. Most post-discharge suicide prevention interventions seek to bolster contact between suicide attempters and mental health providers, in order to reduce the sense of social isolation and increase treatment compliance with outpatient visits and treatments. Psychotherapeutic interventions can also prevent suicidal behaviors among recent attempters. However, whether psychotherapy provides additional value as compared to simpler, less costly, and more practicable contact interventions remains partially unanswered. This real-world study evaluated three post-discharge suicide prevention interventions currently in use in the Community of Madrid, Spain. First, we estimated the degree of implementation and effectiveness of the Suicide Risk Prevention Program (ARSUIC is its Spanish acronym), an emergency-department scheduled priority visit at an outpatient clinic within one week after hospital discharge that is currently considered treatment as usual throughout Madrid. We found that, compared to the previous standard of care, ARSUIC reduced time between discharge and first visit an average 1.5 days, and lowered the risk of suicide re-attempt by 24% over a three-year follow-up. Then, we compared ARSUIC to two augmentation strategies based on increased telephone and in-person brief contacts (Enhanced Contact) and on 8 sessions of individual problem-solving therapy (Psychotherapy), finding that both outperformed ARSUIC by an additional 40% risk reduction over a one-year follow-up. The difference in effectiveness between Enhanced Contact and Psychotherapy was negligible. Last, we compared the three interventions in terms of cost-effectiveness, finding that both augmentation strategies are probably cost-effective, in comparison to ARSUIC, under a variety of possible scenarios, and that Enhanced Contact attained similar effectiveness at a slightly lower cost than Psychotherapy. Further research is warranted to identify the predictors of success for each of the studied interventions: although contact interventions seem the most efficient choice of treatment for an unselected sample of high-risk individuals, certain subtypes of patients may benefit greatly from individual psychotherapy.