Efficacy of Different Strategies of Aftercare for Patients who have Attempted Suicide

The initial psychiatric/psychotherapeutic intervention in smaller general hospitals will be performed by the treating internist or surgeon, in larger facilities this intervention will usually come from a consulting or liaison psychiatrist or from the team of a special psychiatric crisis intervention station'r', Depending on the specific type of management required and the amount of staff and time available as well as on the psychiatric/psychotherapeutic qualification of the staff involved, there will be significant differences in aftercare regimens with respect to duration, effort and quality. When there is an adequate psychiatric crisis intervention within the setting of a general hospital, according to our experiences only about 12% of the patients of a general hospital who have attempted suicide must be transferred to a psychiatric hospital for further treatment", In such cases the patients will usually have an endogenous psychosis or a major depression. Most patients can be discharged from the general hospital within a few days, with the duration of the inpatient stay depending on the somatic complications of the suicide attempt and also the severity of the psychiatric disorders. A large proportion of patients will be judged by the managing physicians or psychiatrists as requiring outpatient aftercare. The management of patients following attempted suicide doesnot followa uniform procedure. Depending on who is managing a specific case, different aspects will be emphasized and different treatment methods preferred. Besides the psychotherapeutic component of aftercare, rational use of psychoactive medication at the time of crisis intervention must be emphasized here", especially in cases where the patient is severely depressed, anxious or psychotic. It is difficult to establish rules for psychotherapeutic aftercare. As elsewhere in psychotherapy, the only rule that might apply is that the therapist should use the method with which he is familiar. Psychodynamically oriented approaches are very frequently employed in Germany, reflecting the training possibilities presently available in Germany. It should be emphasized that, in the aftercare of patients who have attempted suicide, the psychoanalytic protocol has to be extensively modified. The therapist must be more supportive and generally more active than it is customarily the case in analytic therapy", Individual therapy is definitely to be preferred over group therapy, since parasuicide patients seem to be seeking the trust in the close relationship implicit in the one-on-one setting", The results of evaluative research on the prevention of suicidal behaviour are, in general, controversial and inconclusive. There is considerable disagreement, particularly on the issue of effective prevention of suicidal behaviour. The most important limitation on clinical investigations into the efficacy of suicide prevention is of an ethical nature. A patient who is at risk of committing suicide should not be left without aftercare. Therefore, controlled clinical trials must compare one form of therapy with another. Mostly the so-called care is compared to more intensive therapeutic strategies in terms of hours of therapy, specification of the therapist, etc. Differences in outcome however, can only be expected if the two treatments are sufficiently distinct. The second problem concerns the choice of outcome measures. The only convincing evidence for the efficacy of suicide prevention would be a significant reduction of suicides within a certain follow-upperiod in the patients who were treated according to that programme as compared with control cases. Given the low probability of future suicide even in high risk groups, large patient samples are required to obtain interpretable differences in suicide rates. Therefore researchers prefer other outcome criteria, such as the frequency of suicidal attempts (parasuicides) or ratings of psychopathology and social adjustment at follow-up. Certainly these measures can reflect benefit from treatment. If prevention of suicide is at issue, however, they must be considered secondary. Nevertheless it can be assumed that there might exist a theoretical (causal) link between these variables and the other variables. Summarizing the results of the controlled clinical studies (Table 1), it appears not yet proven that psychotherapeutically-oriented aftercare programmes for patients who attempted suicide are actually effective with regard to preventing suicidal behaviour". But this uncertainty is not an excuse for resignation in practical work, but rather should serve as stimulation for the development of better aftercare models and Paper read to Section of Psychiatry, 13 December 1988