A critical review of the first six months of operation of a trial Hospital Outreach Post-suicidal Engagement (HOPE) service in Australia

Abstract

Objective:

To review the Hospital Outreach Post-suicidal Engagement (HOPE) service in the first six months of the pilot program in a metropolitan Melbourne setting, including a description of: (a) socio-demographic, health and psychosocial stressors of people referred; (b) method of presentation; (c) interventions provided and (d) outcomes measured.

Method:

A retrospective case file analysis reviewed the first six months of HOPE service operation.

Results:

Forty people received HOPE service during the study period, 60% female, mean age 35 years (range 17–58). The majority had previously engaged in self-harm (72.5%) or attempted suicide (67.5%). Stressors included social isolation, relationship breakdown, unemployment, financial stress, medical problems, history of mental illness, exposure to family violence and adverse childhood events. Statistically significant improvements occurred in the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) following intervention. There were no deaths by suicide during the study period.

Conclusion:

People referred to HOPE had significant health and psychosocial stressors. Engagement significantly improved subjective well-being and connection with supports. Findings highlighted the need for an integrated clinical and psychosocial model to promote hope and connection in life post suicide attempt. It remains unclear which interventions improved well-being and if this contributes to suicide prevention.

Keywords

suicide prevention Hospital Outreach Post-suicidal Engagement (HOPE)mental health service evaluation model of care

Preventing suicide is a global imperative.¹ In Australia, suicide is a leading cause of death; Victoria’s Suicide Prevention Framework seeks to halve the rate of suicide deaths by 2025.² As part of this objective, Hospital Outreach Post-suicidal Engagement (HOPE) initiatives have been piloted in selected Victorian health services. This outreach service provides up to 90 days of psychosocial care to individuals who have presented to an emergency department (ED), or had an admission to a medical unit following a suicide attempt who do not meet the threshold for entry into specialist public mental health care. At the area mental health service of this study, HOPE provides a person-centred, family-inclusive and recovery-oriented care approach utilising the collaborative recovery model (CRM).³ The referral criteria includes that the person: (a) presents to ED following a suicide attempt, (b) agrees to referral and is aware of the model of support, (c) has needs that can be safely and appropriately met, (d) is aged over 18 years (unless clinical director approval is provided). Key interventions delivered by multidisciplinary practitioners included CRM, assertive outreach, family support, clinical risk assessment and management, safety planning, substance use intervention, referral and warm handover, and provision of therapeutic letters to GP, family, person and/or other practitioners.

Suicide prevention literature highlights the need to prioritise intervention research.⁴ The aim of this study was to critically review the first six months of the HOPE service to address the following research questions:

(1) What were the socio-demographic, health and psychosocial stressors of people referred?

(2) What were the circumstances of presentation including suicide methodology?

(3) What were the main intervention components provided?

(4) What were the outcomes in relation to well-being and preventing suicide?

Method

A retrospective case file analysis reviewed all HOPE episodes of care during the first six months of operation (November 2017–May 2018). Relevant data were sourced from the clinical patient file including socio-demographic, health characteristics and categories of known suicide stressors (personal, interpersonal, physical, situational, exposure to suicide and previous suicide attempt) consistent with previous research.⁵

The Outcome Rating Scale (ORS) measured personal, interpersonal, social and overall well-being on a 10-point self-rated Likert scale, and the Session Rating Scale (SRS) similarly measured the relationship, goals and topics, approach or method, and overall session satisfaction.⁶ The scales have demonstrated psychometric properties, and the ORS has a clinically relevant cut-off score.⁶ Family experience was measured using the Family Rating Scale (FRS), a locally developed measure of relationships, family inclusion, referral to carer supports, carer worry and stress level, overall well-being.

Data were imported into the Statistical Package for Social Sciences (SPSS V26). Study approval was granted by the hospital’s Human Research Ethics Committee QA87-2018.

Results

Referrals

Forty people received HOPE service in the first six months of operation. Referrals were received from ED (32.5%), Consultation Liaison Psychiatry Service (27.5%), Psychiatric Assessment and Planning Unit (25%) and the Crisis Assessment Treatment Team (15%).

Participant socio-demographic, mental health and substance misuse characteristics, stressors (personal, interpersonal, physical, situational), exposure to suicide and number of previous suicide attempts are summarised in Table 1.

Table 1.

People referred to HOPE: socio-demographic, mental health, personal stressors, interpersonal stressors, physical stressors, situational stressors, exposure to suicide and previous suicide attempt

		Present	Absent	Unknown
Socio-demographic characteristics	Sex
	Male	40%
	Female	60%
	Other	0%
	Age at suicide attempt
	<18	5%
	18–25	25%
	26–35	70%
	36–45	22.5%
	46–55	17.5%
	56–65	2.5%
	>65	0%
	Evidence of Indigenous identification	5%	90%	5%
	Evidence of cultural linguistic diversity (Born overseas)	7.5%	85%	7.5%
	Evidence of LGBTI identification	5%	17.5%	77.5%
	Employment status	37.5%	57.5%	7.5%
	Centrelink status	42.5%	40%	17.5%
	Relationship status	32.5%	62.5%	5%
	Children	35%	47.5%	12.5%
	Proportion of children ⩽18 years	64%	28%	8%
	Religion identified	30%	35%	35%
Mental health-related information	History of mental ill healthDepressionAnxietyBPDBPADPTSDAdjustment disorderEating disorderAnorexia nervosaPanic disorderIdentity dissociationGambling addiction	85%62.5%27.5%32.5%15%12.5%7.5%7.5%2.5%2.5%2.5%2.5%	15%	0%
	History of treatment for mental ill health
	Psychiatric medication	70%	27.5%	2.5%
	Inpatient treatmentwithin 12 months	42.5%15%	42.5%	15%
	Community treatmentwithin 12 months	25%5%	65%	10%
	Other treatment^a	77.5%	17.5%	5%
	ED presentation within 6 weeks	12.5%	72.5%	5%
	Family history of mental illness	57.5%	2.5%	40%
Substance-related information	Substance misuse	62.5%	35%	2.5%
	Alcohol misuse	55%	42.5%	2.5%
	Illicit substance misuse	25%	72.5%	2.5%
Personal Stressors	Sexuality	5%	0%	95%
	Social isolation	85%	12.5%	2.5%
	Experience of abuse
	Recent exposure to family violence	17.5%	70%	12.5%
	History of sexual abuse	25%	5%	70%
	History of childhood exposure to family violence	37.5%	5%	57.5%
Interpersonal stressors	Relationship breakdown past 6 weeks	35%	47.5%	17.5%
	Relationship breakdown past 12 months	42.5%	50%	17.5%
	Recent exposure to domestic violence	17.5%	70%	12.5%
	Bereavement by suicide	15%	2.5%	82.5%
Physical stressors	Medical diagnosis	62.5%	15%	22.5%
	Non-psychiatric medication	55%	15%	30%
	Physical health risk	55%	45%
	Pain identified	42.5%	15%	42.5%
Situational stressors	Unemployment	57.5%	37.5%	7.5%
	Financial stress identified	50%	42.5%	7.5%
	Legal issues identified	40%	50%	10%
	Homelessness	17.5%	75%	7.5%
Exposure to suicide	Family history of suicide	22.5%	5%	72.5%
A previous suicide attempt	History of suicide attempts	67.5%	27.5%	5%
A previous suicide attempt	History of self-harm	72.5%	17.5%	10%

Note. BPD = Borderline Personality Disorder or traits; BPAD = Bipolar Affective Disorder; ED = emergency department; HOPE = Hospital Outreach Post-suicidal Engagement; LGBTI = Lesbian, Gay, Bisexual, Transgender or Intersex; PTSD = Post Traumatic Stress Disorder.

Other mental health treatment included with private psychiatrist, psychologist, general practitioner, ED, Crisis Assessment Treatment Team, or other non-tertiary mental health service practitioner.

Socio-demographics

The sample was aged 17–58 years (mean 35.3 years). Sixty per cent were female and 40% male. Aboriginal Torres Strait Islander people represented 5% of the sample. Identification of Lesbian, Gay, Bisexual, and Transgender, Intersex (LGBTI) was largely unknown (77.5%). Education was completed at secondary level 7–10 (22.5%), 11–12 (27.5%), tertiary (15%) and vocational education (5%). Employment (37.5%) was in nursing, trades, hospitality, retail and transport.

Mental health

A history of mental ill health was evident for 85% (including 62.5% depression, 32.5% borderline personality disorder or traits, 27.5% anxiety). Over half had two or more diagnoses (52.5%). At the time of suicide attempt, 70% were prescribed psychiatric medication (including 55% antidepressant, 12.5% antipsychotic, 10% mood stabilisers) and 55% non-psychiatric medication. Previous mental health treatment included: inpatient (42.5%), community (25%) and ED presentation within six weeks (12.5%).

Substance misuse

Substance misuse was a current issue for 62.5%, substance use disorder was recorded for 22.5% (including 15% alcohol use disorder, 2.5% cannabis use disorder, 2.5% opioid use disorder).

Recent stressors

Social isolation was identified by 85%. Other frequent stressors included exposure to trauma (sexual abuse, current or historic issues relating to violence, family violence), recent relationship breakdown, medical diagnosis, pain, unemployment, and financial, legal and homelessness experiences.

Historical risk

History of violence (52.5%), incarceration (5%) and family violence (37.5%) is detailed in Table 2. A family history of suicide was documented as present for 22.5%.

Table 2.

Characteristics of violence by gender and criminal history

	History of violence			History of incarceration	Criminal history	Current family violence
	Perpetrator	Victim of childhood family violence	Victim of sexual abuse			Current family violence
Male	56%	38%	6%	13%	50%	19%
Female	50%	38%	38%	0%	17%	17%
Total	52.5%	37.5%	25%	5%	30%	17.5%

Attempted suicide

The predominant method of suicide attempt was self-poisoning. The location was the usually the person’s residence (70%) and the time was widely distributed. Alcohol use was associated in over 50%. An impulsive attempt was noted in nearly half, and a self-initiated call for help was present in one-third of presentations. Table 3 summarises details of the suicide attempt that initiated referrals to HOPE.

Table 3.

Details of suicide attempt prior to referral to Hospital Post-suicidal Engagement Service (HOPE)

Method
Overdose of medication (self-poisoning)	62.5%
Sharp object	10%
Single vehicle traffic accident	7.5%
Attempted hanging	7.5%
Engine exhaust gassing	2.5%
Train	2.5%
Plastic bag asphyxia	2.5%
Other method	2.5%
Time
0700–1700 hours	30%
1700–2230 hours	27.5%
2300–0200 hours	25%
Unknown time	12.5%
Location recorded
Usual place of residence	70%
At a hotel	2.5%
At a shopping centre	2.5%
At train station	2.5%
At a local park	2.5%
Whilst driving	5%
Unknown location	12.5%
Presence of others	50%
Evidence of social media use	5%
Unknown evidence of social media	87.5%
Self-initiated call for help	32.5%
Impulsive suicide attempt	45%
Planned suicide attempt	22.5%
Consumption of alcohol	52.5%
Illicit substances	12.5%

HOPE referral followed the first suicide attempt for 27.5%; previous suicide attempt(s) had been made by 67.5%. Figure 1 illustrates the number of previous suicide attempts. Nearly three quarters documented a history of self-harm (72.5%).

Interventions provided

The median length of care was 86 days (mean 71.3, range 2–114 days), with 52.5% over the 90-day target. The median number of face-to-face consultations provided was five (mean 5.5, range 0–22), and the median number telephone calls was 6.5 (mean 7.0, range 0–21). Whilst Consultant Psychiatrist review was not initially part of the model of care, this occurred in 12.5% of episodes of care provided. Key HOPE interventions provided are summarized in Table 4.

Table 4.

Key Hospital Outreach Post-suicidal Engagement (HOPE) interventions provided

Intervention	Documented as completed
Assertive outreach	90%
Clinical risk assessment and management	95%
Substance use screening	82.5%
Safety planning	90%
Safety plan involved family	47.5%
Making the environment safe/reducing access to lethal means (including medication removal, locked box, supervision or regular pharmacy collection; removal of chemicals and poisons; temporary changes in living arrangements)	47.5%
Collaborative recovery model (CRM) intervention	50%
Strengths identified	80%
Personal goals guiding care	77.5%
Worksheets completed (e.g. for collaborative strengths and values identification, motivational enhancement/decisional balance, goal striving, action plan)	20%
Reasons for living identified	47.5%
Family Support	82.5%
Collaboration with support network
General Practitioner (GP)	90%
Other support practitioners	65%
Service referral and linkage	75%
Providing therapeutic letters
To the person	62.5%
To the family	2.5%
To the General Practitioner	72.5%
To other health professionals(including psychologist, psychotherapist, counsellor, alcohol and drug clinician, mental health nurse, family violence service, community health, victims assistance)	55%

Collaboration with support networks was frequent; family contacts (mean 4.5; median 3) included partners, parents, siblings, extended family and friends. Service linkages made included drug and alcohol, vocational, physical health, financial, family and family violence services.

Identification of reasons for living (47.5%) included family, friends, to have a family, become a mother, anticipating grandchild, having a child to look after, not wanting to hurt family, wanting to repair marriage, being able to drive, pet ownership, plans for pet sitting and future plans to travel.

Outcomes

There were no deaths during HOPE service in the study period. During the episode of care, 27.5% were known to engage in non-suicidal self-injury. The clinical risk assessment and management tool did not yield meaningful changes in low-, medium- and high-risk ratings. At referral to HOPE, 55% of people had formal supports; this increased to 82.5% on discharge following service linkage (p < 0.01).

The baseline ORS was completed by 35 people, of whom 15 completed a final ORS. Paired t-tests showed statistically and clinically significant improvements for the total and all subscale scores. Baseline ORS scores above the clinical cut-off increased from 10% (6.7% of the paired initial scores) to 80% at final ORS.

Baseline SRS was completed by 35 people; completion ratings were available for 14 people. Paired t-tests demonstrated a small but statistically significant change. SRS scores were consistently high.

Insufficient FRS data were collected to perform statistical analysis (Table 5).

Table 5.

HOPE outcome measures completed by the person and family: Outcome Rating Scale (ORS), Session Rating Scale (SRS), Family Rating Scale (FRS)

	All baseline ratings			Paired baseline ratings			Completion ratings			Paired t-test
Variable	n	Mean	SD	n	Mean	SD	n	Mean	SD	t	p
ORS total score	35	14.0	7.5	15	12.5	7.4	15	31.3	7.1	–7.370	<0.001
Personal well-being	35	3.0	2.2	15	2.7	1.8	15	7.8	2.1	–7.711	<0.001
Interpersonal well-being	35	4.6	2.8	15	4.4	2.6	15	8.3	1.6	–5.249	<0.001
Social well-being	35	3.1	2.6	15	2.5	2.5	15	7.5	2.8	–5.292	<0.001
Overall well-being	35	3.4	2.3	15	2.9	2.0	15	7.9	1.9	–6.492	<0.001
% above clinical cut-off	10%			6.7%			80%
SRS total score	35	36.1	4.7	14	36.4	2.2	14	39.0	1.3	–3.870	0.002
Relationship	35	8.8	1.4	14	9.0	0.8	14	9.7	0.4	–3.271	0.006
Goals and topics	35	9.0	1.4	14	8.8	1.2	14	9.8	0.3	–2.626	0.021
Approach or methods	35	9.1	1.2	14	9.2	0.7	14	9.8	0.3	–2.691	0.019
Overall session satisfaction	35	9.2	1.2	14	9.3	0.6	14	9.7	0.4	–3.011	0.010
FRS total score	9	40.9	6.1
Relationships	9	7.6	2.2
Family inclusion	9	9.1	1.1
Referral to carer supports	9	9.5	0.6
Carer worry and stress level	9	6.8	3.1
Overall well-being	9	7.9	1.8

Note. HOPE = Hospital Outreach Post-suicidal Engagement.

Discussion

The study yielded important findings for the four research questions with important implications for designing, delivering and evaluating of HOPE services.

Participant social-demographic, health and psychosocial characteristics revealed frequent mental ill health, physical ill health, substance misuse, social isolation, relationship breakdown and situational stressors. Of priority populations^1,2 in this sample, Aboriginal and Torres Strait Islander people were overrepresented (5% compared to 0.4% in our local population⁷) and LGBTI was unable to be identified (77.5%). Both men and women demonstrated high rates of exposure to or perpetration of violence (including family violence), which may be underestimated by missing data. This finding is consistent with emerging evidence linking suicide risk to exposure to violence and adverse childhood events.⁸ The majority had made a previous suicide attempt (67.5%). Whilst the psychosocial model of HOPE appeared to provide a service appropriate for the degree of psychosocial challenges experienced, it was not equipped to address the psychiatric and physical health morbidity of the cohort. This necessitated an integrated clinical and psychosocial model with psychiatric and diagnostic review.

Methods of presentation found that the predominant method of suicide attempt was self-poisoning, consistent with the need for population health approaches to means restriction.^1,2

The study provides descriptive evidence of the range of HOPE interventions provided. The interventions appeared to strengthen connections with support services, and address frequent physical health needs and social disconnectedness.

The final study goal was to measure outcomes. Results demonstrated significant improvement in subjective well-being for those who voluntarily provided repeated measures. Sessions were rated highly across all domains. It remains unclear what specific interventions resulted in improved well-being or if the SRS scores correlated with reduced suicidality. Evaluation would be enhanced by a larger sample, tools measuring suicidality, satisfaction with HOPE and qualitative methodology for quality of life.

This study was limited by the small size, its selected sample population, the absence of a control group, the limited follow-up duration and reliance on voluntary completion of rating scales. There were incomplete data for factors known to be associated with increased risk of suicide (e.g. LGBTI, bereavement by suicide).^1,2,4

Nonetheless, international literature calls for local audits, intervention research and service evaluation to identify what is effective in suicide prevention.^2,4,5 This research, including lessons learned from its limitations, was able to inform the local HOPE model of care and the development of a local zero suicide strategy.

Conclusion

This study identified socio-demographic, complex health and psychosocial stressors, and presentations of the first cohort of people who received HOPE. Service engagement led to statistically significant improvements in subjective well-being. It remains unclear which specific interventions resulted in improved well-being and if this contributed to preventing suicide.

Footnotes

Acknowledgements

The authors wish to thank Ms Elia Barresi for her review of the manuscript, HOPE service staff at the mental health programme where the study was located. The authors also wish to acknowledge study participants and people with lived experience of suicidal thoughts, attempt(s), those caring for loved ones through suicidal crisis and those bereaved by suicide.

Disclosure

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval

Approval for this study was granted by Eastern Health Human Research Ethics Committee QA87-2018.

ORCID iDs

Phoebe Williamson

Jose Segal

Lisa Gill

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