Low and middle income countries (LMIC) hold 75% of the world's suicides. Suicide
disproportionately affects those living in poverty and in adverse conditions and, in LMIC
settings, up to 20% of maternal deaths are due to suicide. In Nepal, suicide is a leading
cause of death among women of reproductive age. Despite the disproportionate burden,
systematic suicide detection and prevention mechanisms are nearly non-existent. Deaths
are only a fraction of the burden, where evidence from Nepal reports between 5 and 27% of
individuals have current thoughts of suicide. Suicidal behavior remains under-reported
and is difficult for clinicians to properly identify and monitor, especially in limited
health systems. This calls for improved understanding of how to identify and monitor
individuals at risk for suicidal behavior. Therefore, this study seeks to integrate
existing hospital healthcare providers into suicide prevention, contributing much needed
evidence for multi-pronged, accessible strategies to reduce a leading cause of death
worldwide.
This study's purpose is to adapt and pilot the implementation of packaged suicide
prevention strategies in a low-resource setting. The impact involves informing an
implementation plan to test in a fully powered future trial. Findings will contribute to
the evidence of systems-integrated suicide prevention strategies and result in a
multi-level package for mental health service integration that can be utilized around the
world. Ultimately, this project will save lives and improve under-resourced health
systems. The pilot trial is not powered for statistical analysis, but data will be
monitored monthly and continuously analyzed to facilitate iterative revision, then
finalization of the protocol.
The implementation package to be tested (the Suicide Prevention Package, SuPP) will
include a culturally adapted suicide crisis response plan and a series of contacts via
phone call from a hospital healthcare provider. This is a small open, non-randomized,
pilot trial to assess the feasibility and acceptability of SuPP within the existing
health system. The investigators will select delivery agents, an implementation strategy,
and complete SuPP training. The investigators will train the selected delivery agents and
their supervisory team (e.g., hospital nurses, physicians, and department heads) in SuPP
(detection, safety planning, brief contact follow up). Participants will be recruited
through the hospital's emergency department. Following suicide risk detection (e.g.,
suicide attempt in the past 6 months), 24 at-risk patients will be enrolled in the open
trial and given the full SuPP package. All participants will receive standard of care,
the SuPP package is in addition. In accordance with recommendations for pilot trial
studies, The investigators have established qualitative and quantitative indicators to
guide decisions about what procedures to carry through to the full trial and when
modifications should be made. Each patient will be provided contact and suicide crisis
response planning (weekly, then tapering to monthly) for at least 6 months. SuPP
feasibility and acceptability will be determined by the following criteria: delivery
agent fidelity to SuPP elements at 75% or greater; retention of at least 70% of
participants through 6 months of SuPP; fewer than 15% missing items on outcome measures
across all assessments; 80% of delivery agents and patients finding SuPP acceptable. In
domains where criteria are met, the investigators will retain the procedure for a future
full trial. In domains where criteria are not met, the investigators will modify
procedures for the future full trial.