Study setting {9}
All aspects of the study are taking place at the Gold Coast Mental Health and Specialist Services (GCMHSS) in Queensland, Australia. The Gold Coast region has a population of around 593,200 and is projected to grow at a rate of 27% by 2026. Gold Coast Health delivers a broad range of secondary and tertiary health services across two public hospitals and several health precincts and community health centres. Databases and processes used for the evaluation of the SPP clinical pathway provide an established infrastructure for undertaking research to further the understanding of the clinical needs of this population. Research arising from the SPP will be directly translated into clinical services to optimise addressing the needs of the Gold Coast population. The GCMHSS is well placed to access large volumes of rigorous data, to provide evidence-based insight into the implementation challenges of a large-scale clinical suicide prevention strategy, and to provide information on the characteristics of people in crisis with suicidal presentations and their acute psychiatric management.
Eligibility criteria {10}
People aged 16 and above who attempt suicide and present to the GCMHSS, who are placed on the SPP and who meet the study eligibility criteria, are offered the opportunity to participate. All participants undergo a formal informed consent process by the research assistant (RA) and a research clinician. The interventions are delivered by the research clinicians.
Inclusion criteria
Inclusion criteria for people going on the clinical SPP pathway are as follows: presenting to the GCMHSS with a suicide attempt, presenting with suicidal ideation and having a past history of a suicide attempt, or presenting with a suicidal presentation (suicide attempt or ideation or non-suicidal self-injury [NSSI]) and being deemed eligible for the SPP as per a psychiatrist’s clinical assessment.
The inclusion criteria for the study were people on the SPP, who had made a suicide attempt. People eligible to participate in the study were thus a subset of people treated on the SPP.
Exclusion criteria
The following are the exclusion criteria: decline of, or inability to, consent; inability to consent may include a significant language or speech problems, acute psychosis/thought disorder, cognitive impairment, or significant developmental disorder (e.g. learning disabilities, autism, dementia); and people with a currently clinically relevant diagnosis of borderline personality disorder are excluded, as ASSIP is not recommended for consumers with a history of complex trauma (Michel 2018, developer of ASSIP); however, clinicians can refer at their own discretion following an MDT discussion.
People who are already receiving specialised psychological interventions or who are taking psychotropic medication will still be able to participate in this study. We follow a pragmatic study design model [32], with the study being conducted in a busy “real-world” mental health setting to test the applicability of these interventions to consumers from different backgrounds, including previous service use and treatment plans. Information about dropout for each individual (including reasons for dropping out) is being collected for this study and defined as a participant who completes the baseline assessment (conducted at the same time as the formal consent process), but does not attend any of the follow-up assessment or treatment sessions since that. If a person has been rebooked three times or more and does not attend, they will be considered as someone who has dropped out of the study; that person is then discussed in MDT (e.g. for referral back to the Acute Care Team if appropriate). A CONSORT diagram will be provided in the publication of results [33].
Who will take informed consent? {26a}
The Lived Experience Suicide Prevention Research Advisory Committee has provided specific feedback on the content and language of the information and consent forms, when and how to approach potential participants, and time frames for recruitment relative to likely distress. It was agreed that approaching potential participants with information about the study was reasonable between 48- and 72-h post-event.
Participants are approached with information about the study by the clinician or a trained research assistant (RA) between 48- and 72-h post-event. Participants are allowed time for consideration of their participation, with RAs following up if more time is required.
The RAs and clinicians then obtain formal consent.
Additional consent provisions for collection and use of participant data and biological specimens {26b}
This is not applicable, as no additional participant data or biological specimens will be used in ancillary studies.
Interventions
Explanation for the choice of comparators {6b}
Both ASSIP and the Brief CBT for Suicide Prevention have an existing evidence base and both have been shown to be cost-effective in their own right [17, 34]. In addition, the effect and cost-effectiveness of both interventions are not known when delivered in the context of a clinical Suicide Prevention Pathway, which has, itself, been shown to reduce representations with suicide attempts compared to traditional treatment [35]. Different interventions may work for different people (e.g. video-assisted narrative vs. traditional approach to identifying core beliefs driving behaviour), so it is important for the field to know which works best with whom.
ASSIP is an evidence-based intervention for reducing suicidal behaviour, while also reducing healthcare costs [36]. In the seminal randomised controlled trial (RCT) of ASSIP, conducted in Switzerland by the developers of the intervention, the ASSIP treatment, which added one session of risk assessment to treatment as usual, reduced suicide reattempts dramatically compared to treatment as usual. Over a 24-month period, individuals in the treatment group had an 80% risk reduction for suicide reattempt and an average of 72% fewer hospital days than control patients over 24 months [17, 37, 38].
CBT can challenge maladaptive beliefs, improve problem-solving skills, and social competence. Systematic reviews and meta-analyses have found CBT to be highly effective in reducing suicidal behaviour [34]. Denchev et al. found CBT to be a cost-effective intervention that reduced suicide risk among patients who presented to general hospital EDs [39]. A systematic review of the evidence on CBT concluded that it was effective in reducing self-harm behaviour and repeated suicide attempts in fewer than 10 individual sessions in patients who had made a previous suicide attempt [40]. Brief CBT for suicide prevention compared to conventional CBT has the advantage of being more cost-effective and time-efficient [24].
The standard care approach involves a Suicide Prevention Pathway (SPP) modelled on the Zero Suicide Framework [26]. It utilises a comprehensive assessment, the CASE approach to elicit suicidal intent [27] and a Prevention Orientated Risk Formulation model (i.e. risk formulation that takes into account a person’s risk status, risk state, available resources, and foreseeable changes) [28]. This is followed by safety planning (including counselling on access to lethal means) with the consumer during their initial assessment and prior to the above outlined additional treatment interventions [29, 30], brief patient/carer education, individualised care planning, rapid referral, structured follow up [31], and safe transitions of care to further providers.
Intervention description {11a}
Attempted Suicide Short Intervention Program (ASSIP)
ASSIP is a manualised brief therapy composed of three therapy sessions following a suicide attempt and subsequent follow-up over 2 years with personalised mailed letters [23]. The first session consists entirely of a video-recorded, narrative interview with the consumer relating the personal story of how the point of attempting suicide was reached. The second session involves the therapist and consumer watching the video of the recorded session together and collaboratively reflecting on the suicidal dynamic in a safe environment. Automatic thoughts, emotions, psychological pain and stress, and contingent behaviour are discussed. A psycho-educative handout and homework are given to consumers. The third session starts with a discussion of the homework. This is followed by jointly formulating the ASSIP case conceptualisation. A credit card size leaflet (i.e. a leporello) is provided on which is printed the agreed long-term goals, individual warning signs, and safety strategies. A second card is provided with crisis contact phone numbers. These sessions are followed by letters, which asks consumers how things were going [38]. These letters (written by the therapist) are sent regularly over 24 months (i.e. every 3 months in the first year, and every 6 months in the second year) [38].
Brief Cognitive Behavioural Therapy (CBT) for Suicide Prevention
This is a manualised approach involving brief CBT for suicide in six 60-min sessions and has been adapted by the research team. After a comprehensive search of the literature, various online CBT resources were accessed to create the manual. More specifically, permission was obtained from two authors who had created and published CBT manuals for the treatment of suicide: the Pakistan Institute of Living and Learning [41] and Stewart [42]. The elements of both these manuals were taken to create the Brief CBT for Suicide Prevention manual used for this study. The Brief CBT for Suicide Prevention incorporates skills development and emphasises internal self-management [24]. The therapy focuses on the identification of internal, external, and/or thematic triggers for suicidal thinking and behaviours, as well as factors that maintain the desire to suicide, using thought records and/or chain analyses. The brief CBT for Suicide Prevention aims to challenge distortions and misconceptions, including core beliefs that interfere with the motivation to initiate the process of problem-solving and distress tolerance, by working on acceptance of emotional and/or physical pain. The final phase of the brief intervention focuses on relapse prevention [43].
Suicide Prevention Pathway (standard care approach)
The SPP comprises seven inter-related clinical steps that are undertaken with consumers presenting with suicidality:
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i)
Initial screening—persons experiencing suicide ideation and who may also have a history of, or recent, suicide attempt, are placed on the pathway.
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ii)
Comprehensive assessment—assessment of suicide risk through static and dynamic factors. Exploration of suicidal intent based on the comprehensive chronological assessment of suicide events (CASE). The CASE approach examines the presenting suicide event (suicidal feelings, ideation, and intent), recent events (over the last 48 h), recent suicide attempts (2 days to 2 months previously), and past suicide attempts (more than 2 months previously) [27]
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iii)
Formulation of suicide risk—based on a prevention-oriented approach and considers the person’s demographics, culture, history of violence, deliberate self-harm, mental illness, crisis and previous suicide behaviour, current situation (stress, precipitating circumstances), their current risk status (how they compare with a stated population), and risk state (how they compare with themselves at their baseline), their available supports and foreseeable events in their life in order to develop an individualised care plan [28].
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iv)
Safety planning—performed in collaboration with the consumer, prior to leaving the ED, and includes counselling on access to lethal means, provision of brief patient and carer information, and timely referral for face-to-face mental health follow-up [29, 30].
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v)
Structured follow-up—within 24–48 h of discharge, in the community [31].
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vi)
Transition of care plan—“warm handover” is a robust handover to ongoing care services, whether medical/clinical or non-government organisation.
Criteria for discontinuing or modifying allocated interventions {11b}
Consumers are made aware (both verbally and written) that they can withdraw consent to participate in the study at any time without any questions asked, or any impact on their ongoing treatment and care. Participants who withdraw from the study are provided with the option of (a) all their collected data being withdrawn from the study or (b) their collected data being used.
Strategies to improve adherence to interventions {11c}
Both interventions are delivered in person with each participant. Engagement with the process is noted as part of the clinical intervention and addressed as part of the therapy to facilitate engagement if there are any concerns. Participant clinical progress is discussed in multidisciplinary team (MDT) meetings. Clinical progress and missed sessions are discussed, and strategies for engaging or re-engaging participants are deliberated. This occurs with the recognition of both ASSIP and Brief CBT as standardised, manualised interventions.
The therapy clinician further informs the participant of the therapy processes and expectations. ASSIP and Brief CBT are offered as interventions that are very tightly integrated into the clinical SPP in order to maximise continuity of care and provide the consumer with an integrated care experience, enhancing adherence to interventions. Aspects of the consumer experience and perception of therapy and therapeutic alliance are assessed using the revised Helping Alliance Questionnaire (HAqll).
Relevant concomitant care permitted or prohibited during the trial {11d}
Participants can continue to take medications or receive other psychosocial interventions during the study.
Provisions for post-trial care {30}
Gold Coast University Hospital and Bond University (the administering institution) will provide insurance cover for the research project (viz., public liability insurance and professional indemnity). Should this study find evidence of the effectiveness of ASSIP or CBT (in addition to TAU) over another treatment arm, consumers will be able to access the effective intervention.
Outcomes {44}
Primary outcome measures
Primary outcomes are the time to representation to hospital with a suicide attempt and proportion representing within 7, 14, 30, and 90 days. Suicidal ideation will also be examined (in a descriptive analysis) to ascertain whether a rise in suicide ideation is commensurate with a fall in suicide attempts (i.e. an increase in help-seeking behaviours). Death by suicide rates will also be examined to make sure that representations with a suicide attempt are not due to participants dying but due to them getting better. Death clearly assessed as not involving self-harm will be represented as not completing the study. Time to suicide attempt is measured by calculating the total number of days from the initial presentation to the re-presenting date for a subsequent suicide attempt. For participants without a subsequent suicide attempt, the total number of days from enrolment to the last assessment (24 months) will be calculated.
Secondary outcome measures
Self-reported levels of suicidality, depression, anxiety, stress, resilience, problem-solving skills, and self- and therapist-reported level of therapeutic engagement are measured. Scores will be compared for each group at each follow-up time point. A cost comparison will also be done for both interventions (compared to TAU), and estimates will be based on service information regularly collated by GCMHSS and ED (e.g. contact hours, bed stays, ED visits). We expect a low completion rate (see the “Sample size” section). Study completion will be analysed post hoc, as a secondary outcome.
Participant timeline {13}
Please refer to Fig 1 for the ASSIP-CBT study schedule of recruitment, interventions, and baseline and follow-up assessments (SPIRIT figure).
Sample size {14}
The sample size was calculated on the basis of a time to event analysis of the time to representation for suicidality. From previous studies using CBT as an additional treatment component following attempted suicide [24, 39], we anticipated that the proportion of patients re-presenting for attempted suicide over a 2-year follow-up period will be approximately half that of the TAU group. From recent data from our health service, this represents a decrease from 48 to 24%. To detect this difference (equivalent to a hazard ratio of 0.42) by the log rank test in a proportional hazards time-to-event analysis with 80% power at a two-sided significance level of 5%, we require 132 participants in two groups of 66 each. However, we anticipated a dropout rate of approximately 4.5% per month which would result in 35% of participants completing the full 24-month follow-up (65% total dropout). The effective dropout rate is thus 41%, as those dropping out later contribute proportionately more. When accounting for this dropout rate, to maintain the same power, a total of 137 participants in each of the three cohorts are required for a total of 411 in total.
Recruitment {15}
People who present to ED following a suicide attempt (i.e. the act to take their life) are placed on a journey board, which is reviewed by the MDT. The RA regularly monitors journey boards and communicates with clinical teams to recruit potential participants. Any person identified as a potential participant is discussed during the MDT for appropriateness of recruitment to the ASSIP-CBT Research clinic. Names are then provided to the RA who makes contact with the person (obtain formal consent and recruit into the study). The RA will make every reasonable attempt to follow-up eligible participants to recruit into the study.
The characteristics of patients who were eligible for the trial (both participants and non-participants) are also recorded (e.g. age, gender, reason for declining if applicable).
Assignment of interventions: allocation
Sequence generation {16a}
Randomisation occurs after recruitment. Participants are randomised to either SPP, SPP + ASSIP, or SPP + CBT using random block randomisation (ralloc, Stata 15) with blocks of size 6–15. An intention-to-treat approach will be used for analysis.
Concealment mechanism {16b}
Allocation is not concealed, and envelopes with participant numbers and containing the group allocation (treatment arm) are opened by the RA (in front of the participants) after formal consent is obtained. Both the RA and the participant do not have prior knowledge of the group allocation details.
Implementation {16c}
The RA is responsible for the recruitment of participants and for the assignment of participants to intervention arms. The RA enables the treatment pathway by booking an appointment for the appropriate intervention and informing the ASSIP-CBT Clinician (adult > 25 or youth clinician 16–25, as applicable). The allocation sequence is generated by a biostatistician who is not involved in the recruitment or assessment of participants. Clinical processes and interventions, consumer assessment/documentation, and treatments as well as follow-up, are not affected by the recruitment to the ASSIP-CBT study and are progressed by treating teams as clinically appropriate, as per usual practices.
Assignment of interventions: blinding
Who will be blinded {17a}
Given the clear differences in the therapy interventions, participants and those administering the interventions are not blinded. However, those assessing the outcomes will be blinded to group assignment.
Procedure for unblinding if needed {17b}
Not applicable, as those responsible for the healthcare of the participant are not blinded to the group assignment and can inform the statistician to remove data related to a participant with a particular participant number.
Data collection and management
Plans for assessment and collection of outcomes {18a}
Each person who presents to Gold Coast Health is assigned a unique identifying, or UR, number. The Emergency Information System at Gold Coast Health (viz., FirstNet database) records all ED presentations. The ED presentations will be interrogated for the UR number of all study participants, and any presentation within 24 months of an initial presentation will be reviewed for evidence of suicidality. Multivariate Cox proportional hazard regression models will be used to analyse time to re-presentation for a suicide attempt. Time to suicide attempt is measured by calculating the total number of days from the initial presentation (not including days of admission for some consumers with medical and/or psychiatric admission) to the re-presenting date for a subsequent suicide attempt.
For secondary outcomes, data are collected by the RA at five time points: (1) baseline, (2) end of CBT or ASSIP interventions, (3) 6 months, (4) 12 months, and (5) 24 months from baseline. At baseline, demographic data and psychometric data are collected in person or via the telephone with the RA, as outlined below. At end of treatment and 6, 12, and 24 months, psychometric data are collected. Therapeutic alliance is assessed at the completion of the interventions. Cost comparisons will be based on service information regularly collated by GCMHSS and ED (e.g. contact hours, bed stays, ED visits). Study completion will be analysed post hoc, as a secondary outcome.
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i)
Demographic data: includes age, gender, method of suicide attempt, employment status, education history, place of residence, living situation, marriage status, family contact, known diagnoses and co-occurring conditions (e.g. drug and alcohol use), and history of service provision, including use of psychological interventions
It is anticipated that a number of people within the study population will be from specific cultural groups, who may also be high-risk populations, such as Aboriginal and Torres Strait Islander people, people from cultural and linguistically diverse (CALD) communities, people who identify as LGBTQI, older persons (aged over 60 years), and young people (aged 16–18 years). Questions are included to enable the identification of these specific target population subgroups.
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ii)
Psychometric data: participants are assessed on their level of suicidality, depression, anxiety, stress, resilience, therapeutic engagement, and their ability to cope and problem solve. The following measures are used.
Columbia Suicide Severity Rating Scale (C-SSRS) [44] is a rating scale that assesses suicide ideation and behaviour. The scale consists of four subscales: severity of ideation (e.g. plan or method), intensity of ideation (e.g. frequency, duration), behaviour (e.g. attempts, preparatory behaviour, non-suicidal self-harm), and lethality (for suicide attempts). The C-SSRS has been used in clinical and non-clinical populations, including adolescents and adults [44], and has been validated in other countries including Korea [45] and Turkey [46]. The C-SSRS has demonstrated convergent and divergent validity with other established suicide assessment scales (i.e. Scale for Suicide Ideation and the Columbia Suicide History Form) [44] and has also shown to have high sensitivity and specificity for suicidal behaviour compared to the other scales [44]. The intensity of the ideation subscale has also demonstrated good internal consistency [44]. The C-SSRS was originally developed by the US Food and Drug Administration to be used in clinical research trials and is currently recommended as the preferred instrument for clinical trials [47]. The C-SSRS takes around 10 min to complete.
Depression, Anxiety and Stress Scale (DASS)-21 [48,49,50] is the short form of DASS, a self-report scale that aims to measure depression (e.g. dysphoria, hopelessness), anxiety (e.g. situational anxiety, subjective experience of anxious affect), and stress (e.g. difficulty relaxing, feeling nervous, being easily upset). Each subscale (i.e. depression, anxiety, and stress) contains 7 4-point (0–3) Likert scale items. A final score for each subscale is obtained by summation with higher scores indicating higher levels of depression, anxiety, or stress. Scores are multiplied by 2 (to be consistent with scores from the full version of DASS) to give the final score which can range from 0 to 42. The DASS has been used and established in clinical and non-clinical populations and has been shown to have high internal consistency and convergent and divergent validity [48, 51, 52]. The scale takes around 5–10 min to complete.
The Coping Inventory for Stressful Situations (CISS) [53,54,55] is a 48-item self-report questionnaire that assesses thee different types of coping styles: emotional-orientated, task orientated, and avoidant (distraction and social diversion):
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Task-oriented coping: primary control style—the main emphasis is to solve the problem or alter the situation while controlling emotions. This can be helpful when situations are changeable but not helpful for complex social problems.
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Emotion-oriented coping: secondary control style—the main emphasis is to reduce emotional stress and emotional reactions. Can be helpful in the short-term for situations that are uncontrollable but will be maladaptive in the long term.
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Avoidant-distracted coping: focuses on pleasurable or distracting activities that helps one avoid the problem or situation. Can be helpful in the short term but will not be helpful over the long term especially for problems that are uncontrollable.
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Avoidant-social coping: focuses on social diversion as a means of distracting oneself from the problem or situation (or seeking assistance to address the problem or situation). Can be helpful in the short term, but it is more effective to learn how to address problems directly without continually relying on others.
The CISS has shown high internal consistency for clinical and non-clinical samples [55]. The CISS has also demonstrated moderate to high test-retest reliability [55]. Construct validity has been demonstrated through factor analysis work and relationships between the CISS and other measures [55]. The CISS includes separate adolescent and adult forms [55]. Participants are asked to rate each item on a 5-point frequency scale: 1 “not at all” to 5 “very much”. The CISS usually takes around 10 min to complete.
Brief Resilience Scale (BRS) is a 6-item outcome measure designed to assess the ability to bounce back or recover from stress [56]. The BRS is considered to relate more closely to the original meaning of resilience [56]. The BRS has been shown to be a reliable and valid measure of resilience in clinical and non-clinical samples [56, 57], and in a systematic review of resilience measurement scales, the BRS was deemed to have one of the best psychometric ratings [58]. The scale takes around 5 min to complete.
The revised Helping Alliance Questionnaire (HAqII) is a 19-item self-report questionnaire (therapist and patient version) which is an improved version of the 11-item self-rating Penn Helping Alliance Questionnaire (HAq) [59]. It is used to evaluate the quality of the patient–therapist relationship (therapeutic alliance). The HAqII has demonstrated good validity for psychotherapy outcomes, good internal consistency for both patient and therapist (Cronbach’s alpha 0.9–0.93), and good test-retest reliability (test-retest coefficient patient 0.78; therapist 0.56) [59]. The HAqII demonstrated high convergence with another, widely used self-report measure of alliance California Psychotherapy Alliance Scale (CALPAS) total score (patient version: r = 0.59–0.69 and therapist version: r = 0.75–0.79) [59]. The questionnaire takes around 10 min to complete.
Independent-Interdependent Problem-Solving Scale (IIPSS): the IIPSS assesses problem-solving preference: independent problem-solving (e.g. problem-solving without relying on others’ assistance) and interdependent problem-solving (problem-solving relying on others’ assistance). The scale has good reliability, with a single factor structure (eigenvalue = 3.96) and good internal consistency (Cronbach’s α = .77 and .80) [60]. The scale also has good convergent validity (relationship with Relational-Interdependent Self-Construal Scale and Extraversion Scale) and good predictive validity (predicting student’s likelihood of either finding a solution online or asking another student for help) [60].
Plans to promote participant retention and complete follow-up {18b}
The RA contacts participants via telephone call (or other contact means such as emails or text messages) to complete the later stages of the follow-up questionnaires. The RA also monitors the retention rate and reasons for discontinuation of the study (e.g. consent withdrawn, lost to follow-up).
Data management {19}
All assessment data are entered electronically into a database (Microsoft Excel) and scanned into the Consumer Integrated Mental Health Application (CIMHA). Any publication of study results involves de-identified data only, and all study data and information are stored according to established research protocols (paper questionnaires digitised and then securely destroyed, video data stored on secure Queensland Health servers with restricted access), with research team members being supervised by experienced investigators. Participant video files are maintained in storage for a period of 5 years after completion of the study.
Confidentiality {27}
All participants are assigned a participation number when they consent to join the study to ensure information pertaining to their treatment and health outcomes is de-identified during analysis and reporting. All medical/mental health records kept become part of the participants’ medical records and are protected by Gold Coast Health policy (for the State of Queensland, Australia) regarding information privacy and disclosure. This is only viewable by treating clinicians accessing the participants’ medical records and is planned for routine use in clinical studies in Gold Coast Health
Plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use {33}
This is not applicable, as no biological samples are collected.