Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J): A multicentre, randomised controlled trial

Chiaki Kawanishi, Tohru Aruga, Naoki Ishizuka, Naohiro Yonemoto, Kotaro Otsuka, Yoshito Kamijo, Yoshiro Okubo, Katsumi Ikeshita, Akio Sakai, Hitoshi Miyaoka, Yoshie Hitomi, Akihiro Iwakuma, Toshihiko Kinoshita, Jotaro Akiyoshi, Naoshi Horikawa, Hideto Hirotsune, Nobuaki Eto, Nakao Iwata, Mototsugu Kohno, Akira IwanamiMasaru Mimura, Takashi Asada, Yoshio Hirayasu

Research output: Contribution to journalArticle

32 Citations (Scopus)

Abstract

Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. Methods: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). Findings: Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698). Interpretation: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. Funding: The Ministry of Health, Labour, and Welfare of Japan.

Original languageEnglish
Pages (from-to)193-201
Number of pages9
JournalThe Lancet Psychiatry
Volume1
Issue number3
DOIs
Publication statusPublished - 01-08-2014

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Attempted Suicide
Hospital Departments
Case Management
Suicide
Hospital Emergency Service
Mental Health
Japan
Randomized Controlled Trials
Incidence
Random Allocation
Mortality
Mental Disorders
Internet
Odds Ratio
Control Groups

All Science Journal Classification (ASJC) codes

  • Psychiatry and Mental health
  • Biological Psychiatry

Cite this

Kawanishi, Chiaki ; Aruga, Tohru ; Ishizuka, Naoki ; Yonemoto, Naohiro ; Otsuka, Kotaro ; Kamijo, Yoshito ; Okubo, Yoshiro ; Ikeshita, Katsumi ; Sakai, Akio ; Miyaoka, Hitoshi ; Hitomi, Yoshie ; Iwakuma, Akihiro ; Kinoshita, Toshihiko ; Akiyoshi, Jotaro ; Horikawa, Naoshi ; Hirotsune, Hideto ; Eto, Nobuaki ; Iwata, Nakao ; Kohno, Mototsugu ; Iwanami, Akira ; Mimura, Masaru ; Asada, Takashi ; Hirayasu, Yoshio. / Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J) : A multicentre, randomised controlled trial. In: The Lancet Psychiatry. 2014 ; Vol. 1, No. 3. pp. 193-201.
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abstract = "Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. Methods: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). Findings: Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95{\%} CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6{\%}] of 460 vs 30 [7{\%}] of 454, log-rank p=0·660) or all-cause mortality (46 [10{\%}] of 460 vs 42 [9{\%}] of 454, log-rank p=0·698). Interpretation: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. Funding: The Ministry of Health, Labour, and Welfare of Japan.",
author = "Chiaki Kawanishi and Tohru Aruga and Naoki Ishizuka and Naohiro Yonemoto and Kotaro Otsuka and Yoshito Kamijo and Yoshiro Okubo and Katsumi Ikeshita and Akio Sakai and Hitoshi Miyaoka and Yoshie Hitomi and Akihiro Iwakuma and Toshihiko Kinoshita and Jotaro Akiyoshi and Naoshi Horikawa and Hideto Hirotsune and Nobuaki Eto and Nakao Iwata and Mototsugu Kohno and Akira Iwanami and Masaru Mimura and Takashi Asada and Yoshio Hirayasu",
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Kawanishi, C, Aruga, T, Ishizuka, N, Yonemoto, N, Otsuka, K, Kamijo, Y, Okubo, Y, Ikeshita, K, Sakai, A, Miyaoka, H, Hitomi, Y, Iwakuma, A, Kinoshita, T, Akiyoshi, J, Horikawa, N, Hirotsune, H, Eto, N, Iwata, N, Kohno, M, Iwanami, A, Mimura, M, Asada, T & Hirayasu, Y 2014, 'Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J): A multicentre, randomised controlled trial', The Lancet Psychiatry, vol. 1, no. 3, pp. 193-201. https://doi.org/10.1016/S2215-0366(14)70259-7

Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J) : A multicentre, randomised controlled trial. / Kawanishi, Chiaki; Aruga, Tohru; Ishizuka, Naoki; Yonemoto, Naohiro; Otsuka, Kotaro; Kamijo, Yoshito; Okubo, Yoshiro; Ikeshita, Katsumi; Sakai, Akio; Miyaoka, Hitoshi; Hitomi, Yoshie; Iwakuma, Akihiro; Kinoshita, Toshihiko; Akiyoshi, Jotaro; Horikawa, Naoshi; Hirotsune, Hideto; Eto, Nobuaki; Iwata, Nakao; Kohno, Mototsugu; Iwanami, Akira; Mimura, Masaru; Asada, Takashi; Hirayasu, Yoshio.

In: The Lancet Psychiatry, Vol. 1, No. 3, 01.08.2014, p. 193-201.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J)

T2 - A multicentre, randomised controlled trial

AU - Kawanishi, Chiaki

AU - Aruga, Tohru

AU - Ishizuka, Naoki

AU - Yonemoto, Naohiro

AU - Otsuka, Kotaro

AU - Kamijo, Yoshito

AU - Okubo, Yoshiro

AU - Ikeshita, Katsumi

AU - Sakai, Akio

AU - Miyaoka, Hitoshi

AU - Hitomi, Yoshie

AU - Iwakuma, Akihiro

AU - Kinoshita, Toshihiko

AU - Akiyoshi, Jotaro

AU - Horikawa, Naoshi

AU - Hirotsune, Hideto

AU - Eto, Nobuaki

AU - Iwata, Nakao

AU - Kohno, Mototsugu

AU - Iwanami, Akira

AU - Mimura, Masaru

AU - Asada, Takashi

AU - Hirayasu, Yoshio

PY - 2014/8/1

Y1 - 2014/8/1

N2 - Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. Methods: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). Findings: Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698). Interpretation: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. Funding: The Ministry of Health, Labour, and Welfare of Japan.

AB - Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments. Methods: In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). Findings: Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698). Interpretation: Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research. Funding: The Ministry of Health, Labour, and Welfare of Japan.

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