Aftercare

Aftercare is designed to increase access to, and engagement with care, to prevent future suicidal behaviour during the critical period immediately following a suicide attempt.

Providing supportive and effective care to people after a suicide attempt is a high priority for reducing further suicide attempts and suicide deaths. The group at highest risk of suicidal behaviour are those who have previously attempted suicide and survived, and this risk is particularly heightened in the first six months following a suicide attempt.

Support following a suicide attempt is known as aftercare, and is designed to increase access to and engagement with care providers to prevent repetition of suicidal behaviour or self-harm.

As part of the Fifth National Mental Health and Suicide Prevention Plan, all Health Ministers in Australia have committed to universal aftercare, where anyone who presents to hospital, a GP or other government service following an attempt receives at least three months of follow up support.

Types of aftercare services

There are various types of interventions used as part of an aftercare approach. In Australia, the types of services being implemented can be broadly grouped into three types: 1

1. Brief contact interventions

These interventions focus on outreach and contact with suicidal persons following their engagement with hospital and short-term specialist health services. Generally, their intention is to encourage patient engagement with longer term services and adherence to treatment programs through supportive messages via text message, letter or postcard.

2. Brief interventions

These interventions involve a limited number of sessions (usually fewer than six) and/or sessions of limited duration (10-20 minutes), usually with a clinician, but more recently a ‘buddy’ (e.g. friend or family member) and peer (a person who also has lived experience of suicide) approaches have been utilised. The sessions may be face-to-face, via telephone, or a combination of both modes, and are usually followed by a series of letters, postcards or text messages.

3. Assertive aftercare and case management

Assertive aftercare is when a person’s case manager/care provider is responsible for maintaining contact, rather than relying on the person to make contact with the service. This may include different methods of contact, for example, phone calls, texts, or home/off-site visits.

What works?

A systematic review and meta-analysis published in 20152 found that brief contact interventions produced a non-significant reduction in repeated self-harm, suicide attempt and suicide, and concluded that brief contact interventions are promising but further evidence is needed before widespread rollout.

A more recent evidence check commissioned by the NSW Ministry of Health1 found that both brief interventions and assertive aftercare models have demonstrated effectiveness in reducing repeat suicide attempts. It is suggested that brief contact interventions may best be used as a follow-up to other programs once the client has been stabilised and established a connection with a clinician or other service provider.1

An example of an aftercare model that has demonstrated positive outcomes and received government funding is the Way Back Support Service developed by Beyond Blue.3 This service provides non-clinical assertive aftercare and psychosocial support for people discharged from hospital following a suicide attempt. It was first piloted in the Northern Territory in 2014/15 and, based on positive acceptability and feasibility studies was funded by the Commonwealth Government to be rolled out to up to 30 sites nationally. An evaluation of the Way Back Support Service was also conducted in the Hunter region of NSW from 2016-2019. As a result of participation in this program, 97% of people reported positive progress on their recovery plan, psychological distress scores dropped on average from severe to mild, and people reported less concern about the issues contributing to their attempt, as well as fewer of those issues.

Components of effective programs

The NSW Ministry of Health review attempted to identify which components of interventions contribute to their effectiveness. While they could not identify any research examining this, they note that effective interventions have some common elements: rapid follow-up with greater intensity in the early weeks, a strong focus on continuity of care, engagement and therapeutic alliance, having first contact face-to-face where possible, assertive follow-up, addressing a broad range of psychosocial goals, involvement of a support person where possible, engaging people at the first attempt, and integration with clinical care.1

Lived experience and peer support in aftercare

Few aftercare models to date have incorporated peer support. The Next Steps service run by Grand Pacific Health in Illawarra/Shoalhaven region of NSW combines clinical and peer support to assist individuals to set goals and maintain engagement in care following discharge from hospital. On the final survey completed by consumers, 94% identified peer worker involvement as the ‘most helpful’ aspect of the program.4

Establishing genuine human connection between a suicidal person and their carers has consistently been found to be a key factor in maintaining engagement with support services.1 The inclusion of peer support workers who can provide non-judgmental and compassionate support, and connect based on shared experience, is an important for consideration in the design of interventions.

What else is needed?

Evidence for aftercare models among priority populations is very limited and more research is needed.1 The Sax Institute evidence check found no studies that examined tailored models of care for LGBTIQ+ people, Aboriginal and Torres Strait Islander people or older people. One study was identified focussing on young people, utilising a brief telephone intervention of up to six calls, which resulted in a greater confidence rating in their safety plan and a lower rate of suicidal behaviour compared to the comparison group of one call.5

New research

EXPAAND – aftercare intervention for young people

Suicide is the leading cause of death for young people under the age of 25. A collaborative team which includes researchers from Telethon Kids Institute, Perth Children’s Hospital, WA Country Health Service, Geraldton Regional Aboriginal Medical Service and Youth Focus has secured funding to evaluate a brief intervention aimed at children, adolescents and young people (aged 10-17 years). The aim is to examine whether the EXPAAND (Exploring Psychiatric and Attentional comorbidities in Adolescents and children Needing intervention for Deliberate self-harm) program reduces rates of re-presentation to hospital emergency departments, as well as engagement with subsequent treatment and clinical presentation.6

The funding, awarded by the Suicide Prevention Research Fund and administered by University of Western Australia, will allow investigators to test the EXPAAND project across metropolitan and regional settings, and across cultural contexts.

Brief contact intervention for those bereaved by suicide

Following the death of a loved one, those bereaved by suicide are vulnerable to future suicidal ideation and behaviours themselves. A team of researchers from the University of New England, Australian University and Hunter New England Local Health District received funding under a Suicide Prevention Research Fund innovation grant to develop and evaluate a mobile phone-based brief contact intervention (currently recruiting participants). The intervention is evidence-informed, and is comprised of a series of text messages sent over a period of six weeks following the death of a loved one, with the aim of preventing harms associated with suicide bereavement. The intervention has the potential to be a low cost, easy to implement and accessible support for those bereaved by suicide.7

Notes

1

Shand F, Woodward A, McGill K, Larsen M, Torok M et al. (2019). Suicide aftercare services: an Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for the NSW Ministry of Health. Available from: https://www.saxinstitute.org.a...

2

Milner, A., Carter, G., Pirkis, J., Robinson, J., & Spittal, M. (2015). Letters, green cards, telephone calls and postcards: Systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide. British Journal of Psychiatry, 206(3), 184-190. doi:10.1192/bjp.bp.114.147819

3

Beyond Blue. The Way Back Support Service. Available from: https://www.beyondblue.org.au/...

4

Grand Pacific Health. (2019). Next Steps Suicide Prevention Aftercare Program. Available from: https://www.nswmentalhealthcom...

5

Rengasamy M, Sparks G. Reduction of Postdischarge Suicidal Behavior Among Adolescents Through a Telephone-Based Intervention. Psychiatr Serv. 2019 Jul 1;70(7):545-552. doi: 10.1176/appi.ps.201800421. Epub 2019 Apr 5. PMID: 30947634.

6

Telethon Kids Institute. (2021). Improving aftercare for young people at risk of suicide. Available from: https://www.telethonkids.org.a...

7

Suicide Prevention Australia (2019). Professor Myfanwy Maple. Available from: https://www.suicidepreventiona...