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One low-intensity outpatient intervention failed to prevent future self-harm in adults with frequent suicidal ideation, while another was associated with patient harm, a randomized trial found.

In the three-armed study involving nearly 20,000 adults, there was no difference for the risk of fatal or nonfatal self-harm events over 18 months of follow-up between a care management intervention that included systematic outreach and usual care (3.3% vs 3.1%; HR 1.07, 97.5% 0.84-1.37), reported Gregory Simon, MD, MPH, of Kaiser Permanente Washington Health Research Institute in Seattle, and colleagues.

And an online dialectical behavior therapy (DBT) skills training intervention increased rates of self-harm when compared with usual care (3.9%; HR 1.29, 97.5% CI 1.02-1.64), according to the findings in .

These same trends were reflected in the researchers' secondary outcome measures as well, which assessed rates of severe self-harm (leading to death or hospitalization) and broader definitions of self-harm that included potential events not confirmed by chart.

"These findings do not argue against systematic efforts to identify and address suicide risk in health care settings," Simon's group wrote. "Instead, they indicate that the low-intensity adaptations of care management and DBT skills training tested in this trial have no benefit over usual care in these health systems, especially when offered to the broad population reporting frequent suicidal ideation."

The results suggest that perhaps more vigorous or modified versions of these low-intensity interventions could be more effective.

In an , Barbara Stanley, PhD, of Columbia University Vagelos College of Physicians and Surgeons in New York City, and Lisa Dixon, MD, MPH, of New York State Psychiatric Institute, took greater issue with the study design itself rather than the actual interventions.

"Although the findings from this study do not support implementation of the programs as tested, it may be that the implementation strategy failed, rather than the therapeutic approaches from which their interventions were derived," the editorialists wrote.

They argued that no theory-based rationale or hard data were used to describe why the researchers chose the DBT skills they did for this trial (mindfulness, mindfulness of current emotion, opposite action, and paced breathing). Another more important issue was the low rate of patient engagement, Stanley and Dixon highlighted.

Around 31% of those offered care management initially accepted the invitation, and approximately 17% stayed engaged for over 9 months. For the skills training group, 39% accepted the invitation, yet only 2% remained engaged for over 9 months.

For their study, Simon's group randomized 18,882 outpatients with frequent suicidal ideation 1:1:1 to either usual care alone or along with the care management intervention or DBT training skills intervention. Over the 18-month follow-up period there were 540 self-harm events (45 of which were fatal).

Both interventions kicked off with a series of invitation messages from the study clinician via an electronic health record patient portal.

Patients randomized to the care management group received regular outreach messages from care managers, depending on how their suicidal thoughts ranked on the . These master's degree-level clinicians also sent motivational notes and information about additional recommended outpatient care, which they also shared with patients' primary care clinicians.

Those assigned to the DBT training skills intervention participated in an interactive online program led by a skills coach, during which patients received video instruction to the four DBT skills. Coaches did not provide psychotherapy, but did send outreach messages to encourage participants to practice these specific skills.

Along with usual care, participants in all groups were also free to seek non-study mental health services. A total of 48% were 45 or older and 67% were women. About half were recruited from a mental health speciality clinic, while the other half came from primary care.

The study findings stand in contrast with past research, which has generally supported the effectiveness of caring message interventions and traditional DBT programs.

"Those contrasts could reflect differences in study populations, intervention content, and intervention delivery," Simon's group noted. "Participants in this trial represented a wider range of risk and willingness to accept suicide prevention services compared with populations in other studies."

The authors explained that basing their trial largely on healthcare records posed a major limitation, as self-harm and intent can often be improperly coded.

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