Prevention of Suicide Mortality in Noord-Brabant: The Effect of Implementation of a Regional Suicide Prevention system. A staggered implementation stepped wedge trial design.

Suicidal behaviour, defined as suicidal ideation, suicide attempts and
completed suicides, is a major public health problem. In the Netherlands,
suicide rates have risen since 2007 with 38% to 1871 suicides in 2015. The
province Noord-Brabant ranks second in the national rating. Of the completed
suicides in Noord-Brabant, 60% occurs in persons not receiving mental health
care, although completed suicides occur in the context of mental disorders in
80-90% of the cases. This urgently calls for a regional suicide prevention
effort.

The aim of this study is to lower suicide rates in Noord-Brabant with 20% by
establishing a chain of care and a suicide prevention system in this regional
network of chain partners. To this end, two sub-objectives are: (1) to evaluate
the effect of the suicide prevention system in terms of completed suicides,
non-fatal suicide attempts and patients* suicidal ideation and (2) to explore
which factors facilitate or hinder the implementation of the suicide prevention
system, or are associated with early withdrawal.

The study is built on four research questions that relate to the objectives,
each with a separate study design:
1. Does the suicide prevention system lead to a reduction of completed suicides
by 20%? This research question will be examined with a pre-post design
evaluating the number of completed suicides before and after the rollout of the
suicide prevention system.
2. Does the suicide prevention system lead to a reduction of non-fatal suicide
attempts and completed suicides? This question will be examined with a stepped
wedge trial design.
3. Does the suicide prevention system lead to a reduction of suicidal ideation
in persons who are registered in the monitoringsystem? This research question
will be examined with a longitudinal observational design. This design will be
nested in the stepped wedge trial design. Patients* informed consent will be
asked.
4. Which factors facilitate or hinder the implementation of the suicide
prevention system and what are stakeholders* experiences with the system? This
research question will be evaluated with a mixed methods design including a
RE-AIM evaluation and a qualitative process evaluation.

The study setting of the first two research questions consists of the
participating chain partners such as general hospital emergency rooms, general
practitioners,police, NS and ProRail and safety houses signalling persons with
suicidal behaviour in Noord-Brabant, and specialty mental health institutions
(SMHIs) providing the specialised MH care. During the project other chain
partners, who may play a role in signaling persons with an increased suicide
risk, may be included. Research question 3 and 4 are conducted in the clinical
setting.

The suicide prevention system consists of at organisational level, implementing
a regional chain of care based on four pillars: (1) implementing a monitoring
system with decision aid to support health care professionals in assessing,
reporting and monitoring patients at risk for suicide, (2) providing swift
access into SMHIs for persons established to be at risk for suicide by the
decision aid and provision of treatment (3) positioning nurse care managers
collaborating with psychiatrists in assessment, care management and treatment
of the persons at risk according to a collaborative care model and (4)
providing telephone monitoring of adherence to treatment and treatment
experiences, during one year by the nurse care manager.

For patients, benefits will be considerable as they will receive regular
treatment in organizations collaborating closely to provide a well functioning
chain of care for suicidal patients, swift access to care for patients at risk,
treatment by trained personnel receiving support of a evidence based decision
aid, and 12 months follow up aimed at providing care taking the patient
preference for treatment into account, and this will be treatment as usual for
these organizations as it will be implemented over all speciality mental health
institutions in Noord-Brabant. These benefits account for patients who provide
informed consent to participate in the research * which entails filling out the
five-item SIDAS and nine-item PHQ-9 questionnaires, and once: the ACE
questionnaire, questions on demographics, chronic diseases, pain and first
experiences with the monitoring system* and patients who do not give their
consent will be the same, since they will receive the same treatment. The
burden for the patients providing informed consent for filling out the
additional two questionnaires mentioned above will be limited; as this will be
done in the context of treatment aimed at their suicidal ideation and thus will
not provide an extra mental burden. The time needed to fill out these
questionnaires is limited: approximately 10 minutes in total. There are no
indications that risks are involved for the patients who will provide informed
consent, because all patients will receive treatment as usual as indicated
above. The burden of participation in this study is expected to be minimal, and
the risks of participation in this study are considered low for the
participating organizations, as they will receive support for their regular
health care tasks by this suicide prevention system, and the monitoring system
will be built on a secured website. There are potential substantial benefits
for the participating professionals as the monitoring system supports the
professionals by providing an evidence based decision aid, providing a
communication channel that enhances swift referral to specialised mental health
care, thus eliminating previous delays in referrals and transitions of care.
The additional burden for professionals will be low as they only need to spent
time and effort in the use of the monitoring system when they provide treatment
to the patients at risk, and this extra time will not exceed 5 minutes per
patient, which is the time to take for logging into the system. Finally, all
participants will receive an e-booklet and a test account for the monitoring
system before they participate, and implementation meetings are organized on a
regular basis with the participating professionals, in which all participating
professionals can share their experiences and ask questions