Cost-effectiveness of a Brief Structured Intervention Program Aimed at Preventing Repeat Suicide Attempts Among Those Who Previously Attempted Suicide: A Secondary Analysis of the ASSIP Randomized Clinical Trial

A-La Park, Anja Gysin-Maillart, Thomas J Müller, Aristomenis Exadaktylos, Konrad Michel, A-La Park, Anja Gysin-Maillart, Thomas J Müller, Aristomenis Exadaktylos, Konrad Michel

Abstract

Importance: This is the first cost-effectiveness analysis of a brief therapy, the Attempted Suicide Short Intervention Program (ASSIP), for individuals who attempt suicide.

Objective: To explore the cost-effectiveness of the ASSIP intervention in the context of the Swiss health care system.

Design, setting, and participants: In this economic evaluation, the cost-effectiveness analysis was performed from a health care perspective between January 2017 and April 2018 using data from a randomized clinical trial conducted between June 2009 and December 2014. Participants were individuals who had attempted suicide and were receiving treatment at a psychiatric university hospital in Switzerland that provides inpatient and outpatient services for suicide attempters referred from an emergency department of a general hospital.

Interventions: The intervention group received 3 manual-based therapy sessions followed by regular personalized letters over 24 months. The control group was offered a single suicide risk assessment.

Main outcomes and measures: The main economic analysis explored cost per suicide attempt avoided expressed in 2015 Swiss francs (CHF). Cost-effectiveness planes were plotted and cost-effectiveness acceptability curves calculated.

Results: One hundred twenty participants (mean [SD] age, 37.8 [14.4] years; 66 [55%] women and 54 [45%] men) were assigned to an intervention group or a control group, each with 60 participants. At 24 months of follow-up, 5 suicide attempts were reported in the ASSIP group among 59 participants with follow-up data available, and 41 were reported in the control group among 53 participants with follow-up data available. The ASSIP group had higher intervention costs, with CHF 1323 vs CHF 441 for the control group. At 24 months of follow-up, psychiatric hospital costs were lower in the ASSIP group than in the control group, although this difference was not significant (mean [SD], CHF 20 559 [38 676] vs CHF 45 488 [73 306]; mean difference, CHF -16 081; 95% CI, CHF -34 717 to 1536; P = .11). General hospital costs were significantly lower for the ASSIP group. Total health care costs were also lower, but the difference was not significant (mean [SD], CHF 21 302 [38 819] vs 41 287 [74 310]; difference, CHF -12 604; 95% CI, CHF -29 837 to 625; P = .14). In a base-case analysis, ASSIP was dominant, with significantly fewer reattempts at lower overall cost. The intervention had a 96% chance of being less costly and more effective. A sensitivity analysis showed a 96% and 95% chance of ASSIP being more effective and less costly at willingness-to-pay levels of CHF 0 and CHF 30 000, respectively.

Conclusions and relevance: The ASSIP intervention is a cost-saving treatment for individuals who attempt suicide. The findings support the use of ASSIP as a treatment for suicide attempters. Further studies are needed to determine cost-effectiveness in other contexts.

Trial registration: ClinicalTrials.gov Identifier: NCT02505373.

Conflict of interest statement

Conflict of Interest Disclosures: Drs Gysin-Maillart and Michel received royalties from Hogrefe Publishing for ASSIP—Attempted Suicide Short Intervention Program: A Manual for Clinicians. No other disclosures were reported.

Figures

Figure 1.. Cost-effectiveness Plane for 24-Month Results…
Figure 1.. Cost-effectiveness Plane for 24-Month Results for the Number of Suicide Attempts
The majority of bootstrapped paired dots representing differences in pairs of costs and effects were scattered across the southwest quadrant. This indicates that the Attempted Suicide Short Intervention Program is highly likely to be less costly and more effective in reducing the number of reattempts, compared with the control group. The x-axis represents the incremental effect in terms of the number of suicide attempts. The lower the number, the better the effect.
Figure 2.. Cost-effectiveness Acceptability Curve
Figure 2.. Cost-effectiveness Acceptability Curve
The graph shows the probability of the Attempted Suicide Short Intervention Program being cost-effective at different willingness-to-pay levels.

References

    1. Fleischmann A, De Leo D. The World Health Organization’s report on suicide: a fundamental step in worldwide suicide prevention. Crisis. 2014;35(5):-. doi:10.1027/0227-5910/a000293
    1. Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS One. 2014;9(2):e89944. doi:10.1371/journal.pone.0089944
    1. Piscopo K, Lipari RN, Cooney JGC Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. 2016. . Accessed April 20, 2018.
    1. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry. 2002;181(3):193-199. doi:10.1192/bjp.181.3.193
    1. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry. 2003;182(6):537-542. doi:10.1192/bjp.182.6.537
    1. Shepard DS, Gurewich D, Lwin AK, Reed GA Jr, Silverman MM. Suicide and suicidal attempts in the United States: costs and policy implications. Suicide Life Threat Behav. 2016;46(3):352-362. doi:10.1111/sltb.12225
    1. Platt S, McLean J, McCollam A, et al. . Evaluation of the First Phase of Choose Life: The National Strategy and Action Plan to Prevent Suicide in Scotland. Edinburgh, Scotland: Scottish Executive Social Research; 2006.
    1. Tsiachristas A, McDaid D, Casey D, et al. . General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis. Lancet Psychiatry. 2017;4(10):759-767. doi:10.1016/S2215-0366(17)30367-X
    1. Czernin S, Vogel M, Flückiger M, et al. . Cost of attempted suicide: a retrospective study of extent and associated factors. Swiss Med Wkly. 2012;142:w13648.
    1. Hawton K, Witt KG, Salisbury TLT, et al. . Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. Lancet Psychiatry. 2016;3(8):740-750. doi:10.1016/S2215-0366(16)30070-0
    1. Zalsman G, Hawton K, Wasserman D, et al. . Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646-659. doi:10.1016/S2215-0366(16)30030-X
    1. Inagaki M, Kawashima Y, Kawanishi C, et al. . Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis. J Affect Disord. 2015;175:66-78. doi:10.1016/j.jad.2014.12.048
    1. Hetrick SE, Robinson J, Spittal MJ, Carter G. Effective psychological and psychosocial approaches to reduce repetition of self-harm: a systematic review, meta-analysis and meta-regression. BMJ Open. 2016;6(9):e011024. doi:10.1136/bmjopen-2016-011024
    1. Bustamante Madsen L, Eddleston M, Schultz Hansen K, Konradsen F. Quality assessment of economic evaluations of suicide and self-harm interventions. Crisis. 2018;39(2):82-95. doi:10.1027/0227-5910/a000476
    1. Gysin-Maillart A, Schwab S, Soravia L, Megert M, Michel K. A novel brief therapy for patients who attempt suicide: a 24-months follow-up randomized controlled study of the Attempted Suicide Short Intervention Program (ASSIP). PLoS Med. 2016;13(3):e1001968. doi:10.1371/journal.pmed.1001968
    1. Husereau D, Drummond M, Petrou S, et al. ; CHEERS Task Force . Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Clin Ther. 2013;35(4):356-363. doi:10.1016/j.clinthera.2013.03.003
    1. Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE. Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors, part 1: background, rationale, and methodology. Suicide Life Threat Behav. 2007;37(3):248-263. doi:10.1521/suli.2007.37.3.248
    1. World Health Organization The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: World Health Organization; 2014.
    1. Rickham PP. Human Experimentation: Code of Ethics of the World Medical Association: Declaration of Helsinki. BMJ. 1964;2(5402):177. doi:10.1136/bmj.2.5402.177
    1. Michel K, Gysin-Maillart A. ASSIP—Attempted Suicide Short Intervention Program: A Manual for Clinicians. Göttingen, Germany: Hogrefe Publishing; 2015. doi:10.1027/00476-000
    1. Bieleninik L, Geretsegger M, Mössler K, et al. ; TIME-A Study Team . Effects of improvisational music therapy vs enhanced standard care on symptom severity among children with autism spectrum disorder: the TIME-A randomized clinical trial. JAMA. 2017;318(6):525-535. doi:10.1001/jama.2017.9478
    1. Efron B. Better bootstrap confidence intervals. J Am Stat Assoc. 1987;82(397):171-185. doi:10.1080/01621459.1987.10478410
    1. Glick HA, Doshi JA, Sonnad SS, Polsky D. Economic Evaluation in Clinical Trials. Oxford, UK: Oxford University Press; 2014. doi:10.1093/med/9780199685028.001.0001
    1. Blank PR, Ademi Z, Lu X, Szucs TD, Schwenkglenks M. Herpes zoster vaccine: A health economic evaluation for Switzerland. Hum Vaccin Immunother. 2017;13(7):1495-1504. doi:10.1080/21645515.2017.1308987
    1. European Network for Health Technology Assessment Methods for Health Economic Evaluations, a Guideline Based on Current Practices in Europe. Diemen, Netherlands: European Network for Health Technology Assessment; 2015.
    1. National Institute for Health and Care Excellence Methods for the Development of NICE Public Health Guidance. London, UK: National Institute for Health and Care Excellence; 2012.
    1. Olfson M, Marcus SC, Bridge JA. Emergency treatment of deliberate self-harm. Arch Gen Psychiatry. 2012;69(1):80-88. doi:10.1001/archgenpsychiatry.2011.108
    1. 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. doi:10.1136/bmj.e4972
    1. Owens PL, Fingar KR, Heslin K, Mutter R, Booth CL. Emergency Department Visits Related to Suicidal Ideation, 2006–2013. Rockville, MD: Agency for Healthcare Research and Quality; 2017.
    1. Fleischmann A, Arensman E, Berman A, et al. . Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs. Glob Ment Health (Camb). 2016;3:e5. doi:10.1017/gmh.2015.27
    1. Sahlin H, Kuja-Halkola R, Bjureberg J, et al. . Association between deliberate self-harm and violent criminality. JAMA Psychiatry. 2017;74(6):615-621. doi:10.1001/jamapsychiatry.2017.0338

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