Assertive outreach no better than standard care at preventing further suicide attempts in young people


Regular close contact with specially trained staff is generally regarded as the best course of treatment for someone who has recently attempted to kill themselves, in order to prevent a repeat suicide attempt.

Of course it can be difficult to engage with this group of patients after-treatment, but recent research suggests that assertive and motivational consultations can help reduce rates of suicide (Hvid et al).

However, a new study published yesterday in the BMJ brings this approach into question, as it appears to show that assertive outreach is no better than standard care at reducing the negative spiralling that can lead to further attempted suicides.

The research team from the Psychiatric Centre in Copenhagen carried out a randomised controlled trial with blinded outcome assessment of 243 patients who had recently attempted suicide from 2007 to 2010. Patients were all older than 12 years and those living in institutions or with a diagnosis of schizophrenia spectrum disorders were excluded.

Patients were randomly assigned to one of two groups:

  1. Standard group, where treatment involved care by the patient’s GP or psychologist, but crucially where the patient was responsible for seeking help
  2. Intervention group, where trained nurses visited the patient in their homes a few days after discharge from hospital and continued to do this for the following 6 months (totalling 8-20 appointments) in addition to standard care. Nurses sometimes accompanied patients to doctors’ appointments or meetings with social services, and other support (e.g. phone or text messages) was also on offer

Patients were followed up for 12 months and here’s what they found:

  • 16% patients in the intervention group had been registered in hospital records with subsequent suicide attempt, compared with 11% in the control group (odds ratio 1.60, 95% confidence interval 0.76 to 3.38; P=0.22)
  • By contrast, self reported data on new events showed 12% in the intervention group versus 18% in the control group (0.61, 0.26 to 1.46; P=0.27)
  • The research team attributed missing self-report data and estimated 12% events in the intervention group and 19% in the control group (0.69, 0.34 to 1.43; P=0.32)

The researchers concluded:

Assertive outreach showed no significant effect on subsequent suicide attempt. The difference in rates of events between register data and self reported data could indicate detection bias.

The authors go on to point out that patients who received the assertive outreach were more likely than controls to be hospitalised and treated for subsequent suicide attempts.

Lead author Britt Morthorst said:

Unfortunately, the conclusion must be that neither standard treatment nor additional assertive outreach is good enough. My suggestion is that we try to get hold of young people at risk before they attempt suicide the first time. We are looking with interest at some American Teen-Screen programmes, which look at young people’s mental health generally, to see if we can identify any danger signals to which we could respond earlier.

If you need help

If you need help and support now and you live in the UK or the Republic of Ireland, please call the Samaritans on 116 123.

If you live elsewhere, we recommend finding a local Crisis Centre on the IASP website.

We also highly recommend that you visit the Connecting with People: Staying Safe resource.


Morthorst B, Krogh J, Erlangsen A, Alberdi F, Nordentoft M. Effect of assertive outreach after suicide attempt in the AID (assertive intervention for deliberate self harm) trial: randomised controlled trial. BMJ 2012;345:e4972.

Hvid M, Vangborg K, Sorensen HJ, Nielsen IK, Stenborg JM, Wang AG. Preventing repetition of attempted suicide-II. The Amager Project, a randomized controlled trial. Nord J Psychiatry 2011;65:292-8. [PubMed abstract]

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