Suicide is a global challenge and a major public health problem worldwide. Suicide accounts for almost 1 million deaths annually, and an estimated 10 million suicide attempts occur every year . Approximately 32% of all deaths due to suicide occur in the Western Pacific region . This disproportionately high rate of suicide is geographically constrained to 37 countries and an estimated 29% of the world’s population. The suicide rate in this region is approximately 19.3 per 100,000 individuals . According to the 2011 report by the Department of Health, Executive Yuan in Taiwan, suicide was one of the ten leading causes of death in the nation between 1998 and 2010. The suicide rate was 16.8 per 100,000 individuals in 2010. In Kaohsiung City, Taiwan’s second largest metropolitan city, suicide has become a major public health issue, a fact that is reflected in a relatively high suicide rate, which reached 18.4 deaths for every 100,000 people in 2010.
The repetition rate of self-harm reported in a review of findings from Western countries is 15-16% at 1 year with a slow increase to 20-25% over the following few years . In Taiwan, the cumulative risk of non-fatal repetitions of self-harm is 5.7% within the first year and 9.5% over 4 years . Suicidal behaviours are multifactorial phenomena associated with a range of negative outcomes, most notably, the risk of another suicide attempt, a completed suicide, and other forms of premature mortality [6–8]. However, Hawton and colleagues have noted that there is insufficient evidence on which to make firm recommendations about the most effective forms of treatment for people who have recently deliberately harmed themselves .
Cognitive behavioural therapy is a pragmatic, action-oriented intervention for major mental disorders, and its methods are modified for use in many other conditions . One particularly useful way to encourage clients to use behavioural skills learned in therapy sessions is to develop a coping card . The key elements of a coping strategy are recorded on a small card that the patient carries with them at all times. These coping cards might contain, for instance, an anti-suicide plan that details what to do if suicidal thoughts return. Coping strategies that are generated and rehearsed in intervention sessions are then utilised in real life with coping cards. The “postcard” intervention is first proposed by Motto . Research shows that contacting at-risk people via letter or postcard can reduce suicide risk . The postcard intervention can reduce repeated suicide attempts after discharge for deliberate self-poisoning [14, 15]. A “crisis card” contains the details of a patient’s treatment plan in anticipation of a later occasion when the patient might be too ill to remember their treatment plan .
The gold standard used to evaluate the efficacy of an intervention is a randomised controlled trial, but few studies have successfully tested suicide interventions using a randomised controlled trial design . Due to ethical considerations, it is difficult to deny any intervention or treatment to individuals in this high-risk population . Therefore, ethical constraints prevented us from randomly assigning subjects to a control group that was denied any treatment and an intervention group that used a crisis postcard intervention to test the postcard’s effectiveness. Of the existing randomised controlled trials, it is noteworthy that most used an add-on intervention versus a standard intervention trial design [18, 19].
Based on these constraints, we added a crisis postcard intervention to case management services to treat individuals who had repeatedly attempted suicide. The aim of the present study was to evaluate whether the use of crisis postcards in addition to case management is more effective than case management alone in preventing suicide reattempts over a six-month follow-up period.