Back in the 1970s, Californian psychiatrist Jerome Motto was grappling with a problem that remains familiar today: many people admitted to hospital because of suicidality disengaged from services once they were discharged. Rather than trying to draw them back into intensive treatment, Motto tested a remarkably simple idea. He sent periodic letters to former patients containing brief, non-demanding messages such as, “We hope things are going well for you” (Motto, 1976).
The letters offered no therapy, required no response, and placed no expectations on recipients. Yet, in one of the earliest randomised studies in suicide prevention, people who received these caring letters were less likely to die by suicide than those who received usual care (Motto & Bostrom, 2001). The findings were striking because the intervention appeared to work not through treatment, but through something much simpler: maintaining a sense of human connection.
What makes Motto’s work particularly interesting is that it emerged outside the dominant medical model of the time. Years later, he reflected that the idea was partly inspired by his own experiences of receiving letters during military service in World War II, which helped him feel remembered and connected during difficult periods. In many ways, the intervention was built on a simple but powerful premise: that knowing someone is thinking about you can matter.
Over the following decades, this idea evolved into what are now known as brief intervention and contact (BIC) approaches. Despite varying in format, these interventions share a common goal: providing brief, structured support during the period of heightened risk that follows a suicide attempt. Usually delivered by clinicians or trained paraprofessionals, they involve between one and twelve contacts and are used in a range of healthcare and emergency settings to support recovery and encourage ongoing engagement with care (Stanley, Brodsky & Monahan, 2023).
The current review builds on this tradition, systematically examining the evidence for brief interventions and contacts among adults following a suicide attempt (Homan et al, 2026).
What began as a simple letter expressing care and concern has evolved into a whole family of suicide prevention interventions.
Methods
This was a well conducted systematic review that searched 6 databases with a well formulated search strategy formulated according to the PICO framework. Inclusion criteria were randomised controlled trials that evaluated specific brief psychosocial interventions in adults who sought treatment following a suicide attempt. All screening, data extraction and risk of bias processes were conducted in parallel, enhancing the rigour of the study. In addition to assessing risk of bias (RoB 2; Sterne et al., 2019), the authors also independently graded the certainty of evidence (GRADE; Guyatt et al., 2008). Post-treatment effects were explored using random-effects meta-analyses with post hoc subgroup analyses and meta-regression analyses also conducted to explore i) the difference in intervention type and ii) potential moderators of treatment effects.
Results
A total of 36 studies were included in the review, and 33 of these included in the meta-analysis. Studies were conducted between 1993 and 2025 and took place across the world, though predominantly in Europe and America.
Interventions comprised brief psychotherapeutic interventions (n=17), remote contact interventions (n=11) and multimodal interventions (n=4). Four studies had ‘other’ interventions which included psychoeducation with brief contacts and brief admission. Interventions were typically brief, with most involving between 3 and 5 sessions, although the number of contacts varied considerably across studies.
The majority of included studies (n=22) were rated as having some concerns, primarily due to deviations from intended interventions and bias in the measurement of the outcome.
Compared to control group, brief intervention and contact (BIC) approaches:
- Significantly reduced suicide re-attempts both immediately after treatment and at follow-up, although the effect appeared to diminish slightly over time. Evidence was rated as moderate certainty.
- Significantly reduced suicidal thoughts post-treatment, though this was not sustained over time. Evidence was rated as moderate certainty.
- Did not significantly reduce self-harm post-treatment, nor over time, though only four studies contributed data to this analysis; evidence was rated as very low certainty.
- Might improve linkage to mental health services post-treatment. Although results favoured BICs, the effect was not statistically significant and was based on only six studies; evidence was rated as low certainty.
Subgroup analyses revealed that the reduced risk was strongest for brief psychotherapeutic interventions, owing to sparse or heterogeneous research on other types of BIC such as remote contact interventions or multimodal interventions.
Meta-regression analyses found that intervention type, population, intervention format, risk of bias and year of publication did not explain the between-study heterogeneity.
Across 36 studies, brief interventions and contacts were associated with fewer suicide re-attempts, particularly when psychotherapeutic approaches were used.
Conclusions
Brief interventions and contacts, particularly ‘ultra-brief’ (less than 6 sessions) psychotherapeutic interventions, appear to have an effect on both suicide attempts and thoughts immediately post-treatment, with some evidence to show a longer-term effect for suicide attempts. Results should be taken cautiously though; the evidence was sparse, had a moderate level of bias, and was rated as generally moderate to low certainty.
Brief interventions may help people navigate the high-risk period following a suicide attempt.
Strengths and limitations
This is clearly a well-conducted systematic review. The attention paid to statistical considerations is impressive, resulting in a set of findings that are both accessible and appropriately nuanced. By examining heterogeneity, conducting multiple supplementary analyses, and grading the certainty of evidence, the authors provide readers with a clear understanding of not only what the evidence suggests, but also where it should be interpreted with caution. At no point do they appear to overstate their conclusions.
As is often the case with systematic reviews, many of the limitations lie not with the review itself, but with the studies available to include. Despite the authors’ best efforts, they were synthesising a body of evidence that was highly heterogeneous and, in many cases, at risk of bias. Again, the authors are refreshingly transparent about these limitations and are careful not to overstate their findings.
One thing that particularly stood out to me was that almost all of the included studies were conducted in high-income Western countries. This reflects a broader issue within mental health research, but it does leave me wondering what the state of play is for brief interventions and contacts in low- and middle-income countries. How might these interventions need to be adapted for different healthcare systems, cultures, and communities? And would they be equally effective?
Most included studies came from high-income Western countries, raising questions about global applicability.
Implications for practice
The findings of this review add to a growing body of evidence suggesting that brief interventions and contacts can reduce the risk of repeat suicide attempts following a hospital-treated suicide attempt. For policymakers and service providers, this is encouraging. The interventions included in this review were relatively brief, generally low-cost, and often delivered by existing services. At a time when mental health systems are stretched and demand continues to outstrip capacity, approaches that can be implemented without intensive resource requirements are understandably attractive.
However, what struck me most about this review was not necessarily what it tells us about what works, but what it does not tell us about why it works.
As discussed earlier, the origins of brief contacts can be traced back to Jerome Motto’s caring letters: simple messages sent to people following discharge from hospital to let them know that somebody remembered them and cared about what happened next. Over time, that simple idea has evolved into a range of structured interventions, many of which now sit firmly within clinical models of care. Indeed, the strongest evidence in this review was observed for brief psychotherapeutic interventions rather than simple contact-based approaches.
This is not necessarily a bad thing. The review suggests that structured interventions can save lives and reduce repeat suicide attempts, and that alone is an important finding. Yet I am left wondering whether, in our efforts to develop, refine, and manualise these approaches, we risk overlooking the very thing that inspired them in the first place.
More than 50 years after Motto first posted his caring letters, we still know surprisingly little about the mechanisms underpinning brief interventions and contacts. Is it the therapeutic content that matters? The continuity of care? The practical support? The opportunity to problem-solve? Or is there something inherently powerful about knowing that somebody has not forgotten you during a period of profound distress?
For me, this is where future research should focus. The question is no longer whether brief interventions and contacts can reduce suicide re-attempts; this review suggests they can. The more interesting question is how these interventions achieve that effect, and whether the active ingredient lies within the intervention itself or within the human connection it seeks to create. Understanding that distinction may ultimately help us design more effective, more scalable, and perhaps even more compassionate approaches to suicide prevention.
Perhaps the most important question is not whether brief interventions work, but why they work.
Statement of interests
Laura Hemming has none to declare.
Editor
Edited by André Tomlin.
Links
Primary paper
Stephanie Homan, Marta Anna Marciniak, Sofia Michel, Anna-Marie Bertram, Charlotta Rühlmann, Annamária Pethő, Lara Kirchhofer, Leonie Biele, Robin Segerer, Philipp Homan, Sebastian Olbrich, Rory C O’Connor, Birgit Kleim (2026). Effectiveness of brief interventions and contacts after suicide attempt: a systematic review and meta-analysis. EClinicalMedicine, 93.
Other references
Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., & Schünemann, H. J. (2008). GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Bmj, 336(7650), 924-926.
Motto, J. A. (1976). Suicide prevention for high‐risk persons who refuse treatment. Suicide and Life‐Threatening Behavior, 6(4), 223-230.
Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric services, 52(6), 828-833.
Stanley, B., Brodsky, B., & Monahan, M. (2023). Brief and ultra-brief suicide-specific interventions. Focus, 21(2), 129-136.
Sterne, J. A., Savović, J., Page, M. J., Elbers, R. G., Blencowe, N. S., Boutron, I., … & Higgins, J. P. (2019). RoB 2: a revised tool for assessing risk of bias in randomised trials. bmj, 366.
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