Project Summary
This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final. In the meantime, results have been published in peer-reviewed journals, as listed below.
What is the research about?
Half of people who die from suicide have contact with a hospital or health system within a month of their death. Having a safety plan and follow-up support may help prevent suicide after people leave the hospital or clinic. In safety planning, healthcare providers or trained specialists help people create action plans to use if they have suicidal thoughts. Patients and their healthcare providers work together to list warning signs of suicide. They work to identify:
- People and social settings they can use for support and distraction
- Coping strategies
- Professional help
- How to keep themselves safe at home, such as by safely storing firearms or medicines
The research team is comparing two kinds of follow-up support to help prevent suicide after people leave the hospital or clinic with a safety plan. The first is support via phone calls, called SPI+. The second is Caring Contacts, or CC. It involves one phone call followed by CC text messages or emails.
Who can this research help?
Results may help health systems, suicide prevention hotlines, and community organizations when considering approaches to prevent suicide.
What is the research team doing?
The research team is working with 9 emergency rooms, or ERs, and 23 primary care clinics. The EDs and clinics are part of a health system in Idaho. The team is recruiting 1,382 adults and teens who report having low, moderate, or high risk for suicide to take part in the study.
All people in the study receive safety planning. The research team is assigning people by chance to follow-up support with SPI+ or CC.
In SPI+, people receive at least one, and up to six, phone calls from a specialist at a suicide prevention hotline. In these calls, people review and revise their safety plan. They discuss ways to overcome barriers to attending mental health appointments. The specialist also connects people to resources to address risk factors for suicide.
In CC, people receive one phone call from a specialist at the suicide prevention hotline. People receive 25 supportive text messages or emails from the hotline over one year. People don’t have to respond. If they do, a follow-up specialist will reply to their message.
After 6 and 12 months, the research team is following up with people to see if they have suicidal thoughts or behaviors. The team is asking patients about loneliness and if they seek care to prevent suicide or go to mental health appointments.
The research team is comparing these outcomes for people who receive SPI+ and people who receive CC. The team is looking to see if outcomes differ for teens compared with adults. Finally, the team is asking people and health providers how well safety planning plus follow-up works for them.
People who have attempted suicide or who are close to someone who has died from suicide are giving input on the study. Healthcare providers, suicide prevention hotline specialists, and mental health providers are also helping to develop and carry out the study.
Research methods at a glance
Design Elements | Description |
---|---|
Design | Randomized controlled trial |
Population | 1,382 patients (790 adults and 592 teens) who screened positive for suicide risk in ERs and primary care clinics |
Interventions/ Comparators |
|
Outcomes |
Primary: suicidal ideation and behavior Secondary: loneliness, return to care for suicidality, uptake of outpatient mental health services |
12-month follow-up for primary outcomes |
COVID-19-Related Study
Comparing Two Ways of Supporting Mental Health among Clinicians, Staff, and Patients during the COVID-19 Pandemic -- The MHAPPS Study
Results Summary
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
What was this COVID-19 study about?
The COVID-19 pandemic increased mental health problems among healthcare workers and the public. Health systems want effective ways to support mental health that are easy to put in place. Previous studies have shown that sending caring text messages can reduce suicidal thoughts and actions. An example of a caring text is “Hello [name], I hope you’re doing OK and wanted to remind you that I’m here for you.”
In this study, the research team compared two approaches to improve mental health for patients and healthcare workers with mental distress:
- Texts alone. People received 11 standard texts with caring messages. The texts addressed people by name. People could respond to the texts if they wanted. Trained staff from a state crisis and suicide hotline sent the texts and replied to responses.
- Texts plus a phone call. Before receiving the same texts with caring messages, people received a phone call from a trained staff member. The purpose of the phone call was for staff to get to know the person and make a personal connection.
What were the results?
After six months, for both patients and healthcare workers, the two approaches worked about the same. The two approaches didn’t differ in reports of:
- Loneliness
- Suicidal thoughts and actions
- Feeling like a burden
- Feelings of not belonging
- Depression symptoms
Who was in the study?
The study included 331 patients ages 12 and older and 335 healthcare workers with mental distress. Mental distress included loneliness, suicidal thoughts or actions, stress, anxiety, and depression. All received care at or worked at a large health system in Idaho. Healthcare workers were clinicians, like doctors and nurses, or other health system staff. Of the people in the study, 93 percent were White, and 8 percent were Hispanic or Latino. The average age was 43, and 83 percent were females.
What did the research team do?
The research team assigned people by chance to one of the two approaches. People received caring texts over six months.
At the start of the study and six months later, people completed surveys about loneliness, suicidal thoughts or actions, feelings of being a burden or of not belonging, and depression.
People who had lived experience with suicide provided input during the study.
What were the limits of the study?
Most people in the study were White females. The study included few teens. People completed surveys during surges in local COVID-19 cases. Results may differ for people from other racial backgrounds, teens, or when surges in COVID-19 cases are not present.
How can people use the results?
Health systems and community partners can use the results when considering approaches to support patients and healthcare workers with mental distress.
Professional Abstract
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
Background
The COVID-19 pandemic increased mental health challenges among the public and also among healthcare workers. To support the mental health of patients, clinicians, and staff, health systems need interventions that are effective and feasible to implement. Previous studies have shown that caring text messages, such as “Hello [name], I hope you’re doing OK and wanted to remind you that I’m here for you,” can significantly reduce suicidal ideation and behavior.
Objective
To compare the effectiveness of receiving caring text messages alone versus receiving caring texts plus an introductory phone call in reducing loneliness, suicidal ideation, and other mental distress among patients, clinicians, and healthcare staff experiencing mental distress
Study Design
Design Element | Description |
---|---|
Design | Randomized controlled trial |
Population | 331 patients ages 12 and older who were receiving primary care and 335 clinicians and healthcare staff ages 18 and older; eligible participants reported experiencing mental distress, defined as a moderate or high-risk score for loneliness, suicidal ideation, psychological stress, anxiety, or depression |
Interventions/ Comparators |
|
Outcomes | Primary: loneliness Secondary: suicidal ideation and behavior; perceived burdensomeness; thwarted belongingness, which is a perceived lack of social connection; depression |
Data Collection Timeframe | January 2021 - January 2022 |
This randomized controlled trial compared two versions of a text messaging intervention for patients, clinicians, and healthcare staff.
The study had two cohorts: patients ages 12 and older who were receiving primary care at a large regional health system in Idaho and clinicians and healthcare staff at the same health system. Researchers randomly assigned participants in each cohort to one of two interventions:
- Caring Contacts (CC). Participants received 11 standard texts with caring messages over six months, personalized with their name. They could reply to converse with the sender.
- CC plus phone call. Participants received the CC intervention plus an introductory phone call for the participant and sender to get to know one another.
In both cohorts, trained non-clinician specialists from the state crisis and suicide hotline sent caring text messages and monitored and responded to texts from participants. They also made introductory phone calls to participants if applicable.
At baseline and six months, participants completed an online survey to assess loneliness, suicidal ideation and behavior, perceived burdensomeness, thwarted belongingness, and depression.
The study included 331 patients and 335 clinicians and staff who were experiencing mental distress. Among participants in both cohorts, 93% were White, and 8% were Hispanic or Latino. The average age was 43, and 83% were female.
People who had lived experience with suicide provided input during the study.
Results
After six months, in both cohorts, the two interventions did not differ significantly in:
- Loneliness
- Perceived burdensomeness
- Thwarted belongingness
- Depression
Patients receiving CC plus a phone call reported slightly higher suicidal ideation or behavior than those receiving CC alone (p=0.05), but the magnitude of this difference was small.
Limitations
Most participants were White and female; few adolescents enrolled in the study. Researchers collected surveys during surges in local COVID-19 cases. Results may differ for people of other backgrounds or when no surges in COVID-19 cases are present.
Conclusions and Relevance
Delivering CC in partnership with a state crisis and suicide hotline is feasible, including in rural and low-resource settings. In this study, including an introductory phone call did not improve the effectiveness of a CC intervention among participants who were experiencing mental distress.
Peer Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
The reviewers asked for additional information on how the survey questions related to COVID-19 attitudes, beliefs and practices were developed. The researchers explained that there were limited measures available at the beginning of the pandemic, but there were two toolkits supported by the National Institutes of Health that included such survey items. Because these were existing measures that would not require additional testing, the researchers reviewed these survey items and chose the most relevant to be included in the current study.
The reviewers noted concerns about the association between employment and mental health outcomes because the report seemed to describe contradictory results. The reviewers suggested that the researchers run the comparison in a simpler analytic model that did not include the covariables so they could clarify the direction of the relationship between employment status and mental health. The researchers reported that this contradiction was related to a flaw in the analytic code and when fixed, the results demonstrated low levels of multicollinearity, confirming the independence of the variables in their multivariate models.
The reviewers asked the researchers to describe their measures for mental health, attitudes about COVID, beliefs and practices in their methods for Aim 1 rather than leaving them out until Aim 2 to better explain the significance of Aim 1 findings. The researchers made this addition and also added explanations of scoring for these outcomes when presenting the Aim 1 results.
The reviewers requested more discussion about the clinical importance of the study findings to help readers better interpret the study. The researchers added more detail in the methods about the clinically important differences on study outcomes and summarized the clinical importance of their findings in the results.
The reviewers questioned whether the Caring Contacts intervention would be considered a proven intervention given reportedly weak evidence for the intervention to reduce suicidal ideation and suicide attempts based on 2018 guidelines. The researchers countered that a more recent efficacy study and systematic review indicated that the intervention does provide protection against suicide attempts for at least the first year after randomization. However, they did change their conclusions to taper their recommendations for the Caring Contacts program given the mixed evidence.
Final Enhancement Report
This COVID-19 study's final enhancement report is expected to be available by May 2024.