Marieke de Groot

Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial

Objective To examine the effectiveness of a family based grief counselling programme to prevent complicated grief among first degree relatives and spouses of someone who had committed suicide. Design Cluster randomised controlled trial with follow-up at 13 months after the suicide. Setting General practices in the Netherlands. Participants 122 first degree relatives and spouses of 70 people who committed suicide; 39 families (68 participants) were allocated to intervention, 31 families (54 participants) to control. Intervention A family based, cognitive behaviour counselling programme of four sessions with a trained psychiatric nurse counsellor between three to six months after the suicide. Control participants received usual care. Main outcome measures Self report complicated grief. Secondary outcomes were the presence of maladaptive grief reactions, depression, suicidal ideation, and perceptions of being to blame for the suicide. Results The intervention was not associated with a reduction in complicated grief (mean difference −0.61, 95% confidence interval −6.05 to 4.83; P=0.82). Secondary outcomes were not affected either. When adjusted for baseline inequalities, the intervention reduced the risk of perceptions of being to blame (odds ratio 0.18, 0.05 to 0.67; P=0.01) and maladaptive grief reactions (0.39, 0.15 to 1.01; P=0.06). Conclusions A cognitive behaviour grief counselling programme for families bereaved by suicide did not reduce the risk of complicated grief or suicidal ideation or the level of depression. The programme may help to prevent maladaptive grief reactions and perceptions of blame among first degree relatives and spouses. Trial registration Current Controlled Trials ISRCTN66473618.

Course of bereavement over 8-10 years in first degree relatives and spouses of people who committed suicide: longitudinal community based cohort study

Objective To identify factors predicting the long term course of complicated grief, depression, and suicide ideation in a community based sample of relatives bereaved through suicide. Design Longitudinal cohort study. Included in the multilevel regression models were sociodemographic and personality features, mental health history, records of received help, long term complicated grief, depression, and suicide ideation. Setting Community based sample located in the northern part of the Netherlands. Participants 153 first degree relatives and spouses of 74 people who had committed suicide. Main outcome measures Complicated grief, depression, and suicide ideation assessed at 2.5 months, 13 months and 96-120 months (8-10 years) by means of self report questionnaires. Results Complicated grief, depression, and suicide ideation were mutually associated in relatives and spouses of people who had committed suicide. A history of attempted suicide was associated with long term suicide ideation (odds ratio 5.5, 95% confidence interval 1.8 to 16.7; P=0.003). Depression was more likely to be predicted by female sex and low mastery, whereas complicated grief was more likely to be predicted by the trauma of losing a child. The risk of both complicated grief and depression decreased over time; for complicated grief the change corresponded with a Cohen’s d effect size of 0.36 at 13 months and 0.89 at 96-120 months; for depression these figures were 0.28 at 13 months and 0.94 at 96-120 months. The long term course of bereavement was not affected by family based cognitive behavioural therapy, support from a general practitioner, and/or mental healthcare. Mutual support was associated with an increased risk of complicated grief: B regression coefficient=6.4 (95% confidence interval 1.8 to 11.0; P=0.006). Throughout this long term study, selection bias might have affected some outcomes. Conclusion In relatives bereaved by suicide, suicide ideation is associated with an increased risk of long term complicated grief and depression. The risk of complicated grief and depression decreases over time. Although mutual support is associated with an increased risk of complicated grief, we could not draw conclusions about a causal relation.

The effect of an e-learning supported train-the-trainer programme on implementation of suicide guidelines in mental health care

BACKGROUND Randomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline. METHODS 45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments. RESULTS Multilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found. LIMITATIONS The ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study. CONCLUSIONS Our results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients. TRIAL REGISTRATION Netherlands Trial Register (NTR3092 www.trialregister.nl).

Applying computer adaptive testing to optimize online assessment of suicidal behavior: a simulation study

Background The Internet is used increasingly for both suicide research and prevention. To optimize online assessment of suicidal patients, there is a need for short, good-quality tools to assess elevated risk of future suicidal behavior. Computer adaptive testing (CAT) can be used to reduce response burden and improve accuracy, and make the available pencil-and-paper tools more appropriate for online administration. Objective The aim was to test whether an item response–based computer adaptive simulation can be used to reduce the length of the Beck Scale for Suicide Ideation (BSS). Methods The data used for our simulation was obtained from a large multicenter trial from The Netherlands: the Professionals in Training to STOP suicide (PITSTOP suicide) study. We applied a principal components analysis (PCA), confirmatory factor analysis (CFA), a graded response model (GRM), and simulated a CAT. Results The scores of 505 patients were analyzed. Psychometric analyses showed the questionnaire to be unidimensional with good internal consistency. The computer adaptive simulation showed that for the estimation of elevation of risk of future suicidal behavior 4 items (instead of the full 19) were sufficient, on average. Conclusions This study demonstrated that CAT can be applied successfully to reduce the length of the Dutch version of the BSS. We argue that the use of CAT can improve the accuracy and the response burden when assessing the risk of future suicidal behavior online. Because CAT can be daunting for clinicians and applied scientists, we offer a concrete example of our computer adaptive simulation of the Dutch version of the BSS at the end of the paper.

The Effectiveness of Family-Based Cognitive-Behavior Grief Therapy to Prevent Complicated Grief in Relatives of Suicide Victims: The Mediating Role of Suicide Ideation

Grief interventions are more effective for high risk individuals. The presence of suicide ideation following suicide bereavement was examined to determine whether it indicates a high risk status. Using data from a randomized controlled trial (n = 122) on the effectiveness of cognitive-behavior therapy, the effect of suicide ideation on the effectiveness of grief therapy on the bereavement outcome at 13 months post loss was examined. Results show that suicide ideators more often have a history of mental disorder and suicidal behavior than non-ideators, and suicide ideation indicates a high risk for adverse bereavement outcome. Grief therapy likely reduces the risk of maladaptive grief reactions among suicide ideators. Therefore, suicide ideators may benefit from grief therapy following a loss through suicide.

Improving the application of a practice guideline for the assessment and treatment of suicidal behavior by training the full staff of psychiatric departments via an e-learning supported Train-the-Trainer program : study protocol for a randomized controlled trial

BackgroundIn 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program.MethodIn a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments.DiscussionWe aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study.Trial registrationDutch trial register: NTR3092

Longitudinal Measurement invariance of the Beck Scale for Suicide Ideation

In mental health care, both clinical and scientific decisions are based on within-subject comparisons of test scores on the same self-report questionnaire at different points in time. To establish the validity of test score comparisons over time, longitudinal measurement invariance should be established. The current study tested whether the 19 item Beck Scale for Suicide Ideation (BSS) is measurement invariant (MI) over time. As the first five items of the scale are often used to screen for the presence of suicidal thoughts, we also tested a model consisting of only the first five items. Psychiatric in- and out-patients (n=475) completed the questionnaire upon admission and after 3 months. By means of confirmatory factor analysis (CFA) we tested whether the parameters of a single factor model were equal over time. All fit indices indicated that both the 19-item questionnaire and the five-item screener were measurement invariant over time. This means that changes in test-scores over time can be attributed to true changes in the construct of interest. These findings legitimate the use of the 19 item scale and the five-item screener in longitudinal assessments.

A survey of Dutch GPs' attitudes towards help seeking and follow-up care for relatives bereaved by suicide

Background. Relatives who are bereaved by suicide likely consult their GP when they feel the need for professional help. GPs may play a key role in establishing who is at risk for adverse consequences of the loss as they are familiar with relatives’ possible psychiatric vulnerabilities. The availability of evidence-based services for relatives of suicide victims is limited. Successful implementation of services needs analysis of key factors considered critical in the achievement of changes. We investigated GPs’ management of help requests of relatives bereaved by suicide and examined determinants of GPs willingness to refer for evidence-based follow-up care. Methods. A cross-sectional survey among 488 GPs in the northern part of The Netherlands. Results. A 44% response was achieved (n = 214) during the last 3 years, 38 (18%) were exposed to suicide, 21 (10%) to help requests without being exposed to suicide and 52 (24%) to both suicide and help requests. Out of 106 requests, 69 (65%) were handled by the GP; 60 (57%) were either directly or additionally referred, principally for mental health care. Suicide exposure and female gender were associated with the doctors perception that follow-up care following a loss through suicide is useful. The perception that help is useful increased the likelihood of GPs’ referral for evidence-based follow-up care. Conclusions. GPs support the availability of evidence-based follow-up care for relatives of suicide victims. To modify GPs’ key role in referring relatives for it, GPs should be well informed of its usefulness and to whom.

Evaluation of benefit to patients of training mental health professionals in suicide guidelines: cluster randomised trial

BACKGROUND Randomised studies examining the effect on patients of training professionals in adherence to suicide guidelines are scarce. AIMS To assess whether patients benefited from the training of professionals in adherence to suicide guidelines. METHOD In total 45 psychiatric departments were randomised (Dutch trial register: NTR3092). In the intervention condition, all staff in the departments were trained with an e-learning supported train-the-trainer programme. After the intervention, patients were assessed at admission and at 3-month follow-up. Primary outcome was change in suicide ideation, assessed with the Beck Scale for Suicide Ideation. RESULTS For the total group of 566 patients with a positive score on the Beck Scale for Suicide Ideation at baseline, intention-to-treat analysis showed no effects of the intervention on patient outcomes at 3-month follow-up. Patients who were suicidal with a DSM-IV diagnosis of depression (n = 154) showed a significant decrease in suicide ideation when treated in the intervention group. Patients in the intervention group more often reported that suicidality was discussed during treatment. CONCLUSIONS Overall, no effect of our intervention on patients was found. However, we did find a beneficial effect of the training of professionals on patients with depression.

Training mental health professionals in suicide practice guideline adherence: Cost-effectiveness analysis alongside a randomized controlled trial.

BACKGROUND There is a lack of information on the cost-effectiveness of suicide prevention interventions. The current study examines the cost-effectiveness of a multifaceted structured intervention aiming to improve adherence to the national suicide practice guideline in comparison with usual implementation. METHODS In the intervention condition, professionals of psychiatric departments were trained using an e-learning supported Train-the-Trainer program. Newly admitted suicidal patients were assessed as soon as their department was trained and at 3 months follow-up. The primary outcome was improvement in suicide ideation. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes were plotted, and cost-effectiveness acceptability curves were estimated. RESULTS For the total group of suicidal patients (n=566), no effect of the intervention on suicide ideation or costs was found. For a subgroup of depressed suicidal patients (n=154, intervention=75, control=79), mean level of suicide ideation decreased with 2.7 extra points in the intervention condition, but this was not statistically significant. For this subgroup, the intervention may be considered cost-effective in comparison with usual implementation if society is willing to pay≥€ 6100 per unit of effect on the suicide ideation scale extra. LIMITATIONS Considering the cost outcomes, we had almost no cases that were complete, and heavily relied on statistical techniques to impute the missing data. Also, diagnoses were not derived from structured clinical interviews. CONCLUSIONS We presented the first randomized trial (trial registration: The Netherlands Trial Register (NTR3092 www.trialregister.nl)) on cost-effectiveness of a suicide practice guideline implementation in mental health care. The intervention might be considered cost-effective for depressed suicidal patients if society is willing to make substantial investments.