Smartphone-based safety planning and self-monitoring for suicidal patients: Rationale and study protocol of the CASPAR (Continuous Assessment for Suicide Prevention And Research) study

Background: It remains difficult to predict and prevent suicidal behaviour, despite growing understanding of the aetiology of suicidality. Clinical guidelines recommend that health care professionals develop a safety plan in collaboration with their high-risk patients, to lower the imminent risk of suicidal behaviour. Mobile health applications provide new opportunities for safety planning, and enable daily self-monitoring of suicide-related symptoms that may enhance safety planning. This paper presents the rationale and protocol of the Continuous Assessment for Suicide Prevention And Research (CASPAR) study. The aim of the study is two-fold: to evaluate the feasibility of mobile safety planning and daily mobile self-monitoring in routine care treatment for suicidal patients, and to conduct fundamental research on suicidal processes. Methods: The study is an adaptive single cohort design among 80 adult outpatients or day-care patients, with the main diagnosis of major depressive disorder or dysthymia, who have an increased risk for suicidal behaviours. There are three measurement points, at baseline, at 1 and 3 months after baseline. Patients are instructed to use their mobile safety plan when necessary and monitor their suicidal symptoms daily. Both these apps will be used in treatment with their clinician. Conclusion: The results from this study will provide insight into the feasibility of mobile safety planning and self-monitoring in treatment of suicidal patients. Furthermore, knowledge of the suicidal process will be enhanced, especially regarding the transition from suicidal ideation to behaviour

Evaluating changes in functioning and psychological distress in visitors of the @ease youth mental health walk-in centres

Background:Highly accessible youth initiatives worldwide aim to prevent worsening of mental health problems, but research into outcomes over time is scarce. Aims:This study aimed to evaluate outcomes and support use in 12- to 15-year-old visitors of the @ease mental health walk-in centres, a Dutch initiative offering free counselling by trained and supervised peers.Method:Data of 754 visitors, collected 2018-2022, included psychological distress (Clinical Outcomes in Routine Evaluation 10 (CORE-10)), social and occupational functioning (Social and Occupational Functioning Assessment Scale (SOFAS)), school absenteeism and support use, analysed with change indicators (first to last visit), and mixed models (first three visits).Results:Among return visitors, 50.5% were female, 79.4% were in tertiary education and 36.9% were born outside of The Netherlands (one-time visitors: 64.7%, 72.9% and 41.3%, respectively). Moreover, 29.9% of return visitors presented with suicidal ideations, 97.1% had clinical psychological distress levels, and 64.1% of the latter had no support in the previous 3 months (one-time visitors: 27.2%, 90.7% and 71.1%, respectively). From visit 1 to 3, psychological distress decreased (β = -3.79, 95% CI -5.41 to -2.18; P &lt; 0.001) and social and occupational functioning improved (β = 3.93, 95% CI 0.51-7.36; P = 0.025). Over an average 3.9 visits, 39.6% improved reliably and 28.0% improved clinically significantly on the SOFAS, which was 28.4% and 8.8%, respectively, on the CORE-10, where 43.2% improved in clinical category. Counselling satisfaction was rated 4.5/5. Conclusions:Reductions in psychological distress, improvements in functioning and high counselling satisfaction were found among @ease visitors, forming a basis for future research with a control group.</p

Evaluating changes in functioning and psychological distress in visitors of the @ease youth mental health walk-in centres

Background:Highly accessible youth initiatives worldwide aim to prevent worsening of mental health problems, but research into outcomes over time is scarce. Aims:This study aimed to evaluate outcomes and support use in 12- to 15-year-old visitors of the @ease mental health walk-in centres, a Dutch initiative offering free counselling by trained and supervised peers.Method:Data of 754 visitors, collected 2018-2022, included psychological distress (Clinical Outcomes in Routine Evaluation 10 (CORE-10)), social and occupational functioning (Social and Occupational Functioning Assessment Scale (SOFAS)), school absenteeism and support use, analysed with change indicators (first to last visit), and mixed models (first three visits).Results:Among return visitors, 50.5% were female, 79.4% were in tertiary education and 36.9% were born outside of The Netherlands (one-time visitors: 64.7%, 72.9% and 41.3%, respectively). Moreover, 29.9% of return visitors presented with suicidal ideations, 97.1% had clinical psychological distress levels, and 64.1% of the latter had no support in the previous 3 months (one-time visitors: 27.2%, 90.7% and 71.1%, respectively). From visit 1 to 3, psychological distress decreased (β = -3.79, 95% CI -5.41 to -2.18; P &lt; 0.001) and social and occupational functioning improved (β = 3.93, 95% CI 0.51-7.36; P = 0.025). Over an average 3.9 visits, 39.6% improved reliably and 28.0% improved clinically significantly on the SOFAS, which was 28.4% and 8.8%, respectively, on the CORE-10, where 43.2% improved in clinical category. Counselling satisfaction was rated 4.5/5. Conclusions:Reductions in psychological distress, improvements in functioning and high counselling satisfaction were found among @ease visitors, forming a basis for future research with a control group.</p

A proof of concept study on individual trends in suicidal ideation: an ecological momentary assessment study of 5 patients over three months

Background: Suicidal ideation (SI) is a significant and long-lasting mental health problem, with a third of individuals still experiencing SI after two years. To date, most Ecological Momentary Assessment (EMA) studies of SI have assessed its day-to-day course over one to four consecutive weeks and found no consistent trends in average SI severity over time. Aim: The current proof of concept study assessed daily fluctuations of SI over a time span of 3 to 6 months to explore whether individual trends in SI severity could be detected, and if so, if the trajectory of changes were gradual or sudden. The secondary aim was to explore whether changes in SI severity could be detected at an early stage. Method: Five adult outpatients with depression and SI used an EMA app on their smartphone in addition to their regular treatment for 3 to 6 months, where SI was assessed 3 times a day. To detect trends in SI for each patient, three models were tested: a null model, a gradual change model and a sudden change model. To detect changes in SI before a new plateau was reached, Early Warning Signals and Exponentially Weighted Moving Average control charts were used. Results: In each patient, average SI severity had a unique trajectory of sudden and/or gradual changes. Additionally, in some patients, increases in both sudden and gradual SI could be detected at an early stage. Conclusions: The study presents a first indication of unique individual trends in SI severity over a 3 to 6 months period. Though replication in a larger sample is needed to test how well results generalize, a first proof-of-concept is provided that both sudden and gradual changes in SI severity may be detectable at an early stage using the dynamics of time-series data

Referral for Intensive Home Treatment or Psychiatric Inpatient Care? A Retrospective, Observational Comparison of Patient and Process Characteristics

Introduction: Intensive home treatment (IHT) is intended to prevent the (mostly voluntary) admission of mentally ill patients by providing intensive care in their domestic environment. It requires approaches to referral that ensure the delivery of the best possible acute care. Indications for referral may be improved by greater understanding of the clinical profiles of patients referred for IHT and of those referred for inpatient care. As such understanding may also further the development of IHT and innovations within it, we compared the patient and process characteristics associated with IHT referral for those associated with inpatient care. Methods: This retrospective, observational, explorative study was conducted from 2016 to 2019. Patients aged 18 years and older were assessed by the emergency psychiatric outreach services in the greater Rotterdam area (Netherlands). Anonymized data were used to compare patient and process characteristics between patients referred for IHT and those admitted voluntarily. Patient characteristics included gender, age, cultural background, living situation and main diagnosis. Additional the case mix was measured using the Severity of Psychiatric Illness (SPI) scale. Process characteristics included psychiatric history, the total number of contacts with the emergency psychiatric outreach services, assessments during office hours, place of assessment, referrer, and the reason for referral. Using multiple logistic regression analysis, the patient and process characteristics associated with IHT referral were compared with those associated with voluntary admission. Results: The emergency psychiatric outreach services undertook 12,470 assessments: 655 were referred for HT and 2,875 for voluntary admission. Patient characteristics: referral for IHT rather than voluntary admission was associated with higher motivation for treatment and better family involvement. Process characteristics: referral for IHT rather than voluntary admission was associated with assessment by the crisis services within office hours, no mental health treatment at the time of referral, and referral by a family doctor. Discussion: IHT in a specific Dutch setting seems to function as an intensive crisis intervention for a subgroup of patients who are motivated for treatment, have social support, and are not in outpatient treatment. The patient and process characteristics of patients referred for IHT should now be studied in more detail, especially, for having more social support, the role of the family members involved

Outreach Psychiatric Emergency Service:Characteristics of Patients with Suicidal Behavior and Subsequent Policy

Background: Outreach psychiatric emergency services play an important role in all stages of a suicidal crisis; however, empirical assessment data are scarce. This study describes characteristics of patients assessed by these services and involved in suicidal crises. Method: During a 5-year period, detailed information from psychiatric emergency service assessments was recorded; 14,705 assessments were included. Characteristics of patients with/without suicidal behavior and with/without suicide attempts were compared. Outcomes were adjusted for clustering of features within individual patients. Results: Suicidal behavior was assessed in 32.2% of patients, of whom 9.2% attempted suicide. Suicidal behavior was most commonly associated with depression or adjustment disorder and these patients were referred to the service by a general practitioner or a general hospital, whereas those who attempted suicide were less likely to be referred by a general practitioner. Those who attempted suicide were more likely to be female and have had a referral by a general hospital. Self-poisoning by medication was the most common method of attempting suicide. Limitations: Bias could be due to missed or incomplete assessments. Primary diagnoses were based on clinical observation at the time of the assessment or on the primary diagnosis previously recorded. In addition, suicidal behavior or attempted suicide might have been underestimated. Conclusions: Suicidal behavior is commonplace in assessments by psychiatric emergency services. Suicidal patients with/without a suicide attempt differed with respect to demographic features, primary diagnoses, and referring entities, but not with respect to treatment policy. About 40% of the suicidal patients with/without an attempt were admitted following assessment

Diverging effects of mentalization based treatment for patients with borderline personality disorder and schizophrenia:an explorative comparison

Introduction: There is robust evidence that both patients with schizophrenia (SCZ) and borderline personality disorder (BPD) display mentalizing difficulties. Less is known however about differences in the way mentalization based treatment (MBT) impacts mentalizing capacity in SCZ and BPD patients. This study compares the impact of MBT on mentalizing capacity in individuals with SCZ and BPD. Method: The thematic apperception test was used to measure mentalizing capacity. It was administered at the beginning and end of treatment to 26 patients with SCZ and 28 patients with BPD who enrolled in an 18-month long MBT program. For comparison a sample of 28 SCZ patients who did not receive MBT was also included. Using the social cognition and object-relations system, these narratives were analyzed and scored. Missing data was imputed and analyzed using intention-to-treat ANCOVAs with post-treatment measures of mentalizing capacity as dependent variables, group type as independent variable and baseline mentalizing capacities as covariates. Results: Results showed that patients with BPD showed significantly more improvement on several measures of mentalizing, including complexity of representation (?p2 = 0.50, ppooled &lt; 0.001), understanding of social causality (?p2 = 0.41, ppooled &lt; 0.001) and emotional investment in relationships (?p2 = 0.41, ppooled &lt; 0.001) compared to patients with SCZ who received MBT. No differences were found regarding affect-tone of relationships (?p2 = 0.04, ppooled = 0.36). SCZ patients who received MBT showed greater performance on understanding of social causality (?p2 = 0.12, ppooled = 0.01) compared to SCZ patients who did not receive MBT, but no differences were observed on complexity of representations, capacity for emotional investment or affect-tone of relationships. Discussion: Patients with BPD performed better after receiving MBT on three dimensions of mentalizing capacity than SCZ patients who received MBT. Remarkably, SCZ patients who received MBT performed better on one dimension of mentalizing capacity compared to SCZ patients who did not receive MBT. Whereas MBT for BPD clearly involves improvement on most aspects of mentalizing, MBT for SCZ seems to thwart a further decline of other-oriented, cognitive mentalizing. Treatment goals should be adapted toward these disorder-specific characteristics