BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access Protocol Effect of synchronous remote-­based interventions on suicidal behaviours: protocol for a systematic review and meta-­analysis Laura Comendador,1,2 María Paola Jiménez-­Villamizar,3 Josep-­Maria Losilla ‍ ‍,4 Juan P Sanabria-­Mazo,3,5 Corel Mateo-­Canedo,3 Ana Isabel Cebrià ‍ ‍,1,2 Antoni Sanz ‍ ‍,3 Diego J Palao ‍ ‍1,2 To cite: Comendador L, ABSTRACT Jiménez-­Villamizar MP, Losilla J-­ Introduction Suicide is among the leading causes of STRENGTHS AND LIMITATIONS OF THIS STUDY M, et al. Effect of synchronous preventable death worldwide. The impact of suicide affects ⇒ Study screening, quality assessment and data ex- remote-­based interventions on traction will be determined by transparency, pre- the personal, social and economic levels. Therefore, its suicidal behaviours: protocol cision and significance according to the Preferred prevention is a priority for public health systems. Previous for a systematic review and studies seem to support the efficacy of providing active Reporting Items for Systematic Review and meta-­analysis. BMJ Open 2023;13:e075116. doi:10.1136/ contact to people who have made a suicide attempt. Meta-­Analysis. bmjopen-2023-075116 The current systematic review and meta-­analysis aims ⇒ The systematic review will focus on peer-­reviewed to investigate the efficacy of distance suicide prevention articles, and findings will be limited to articles writ- ► Prepublication history and ten in English or Spanish. strategies implemented through synchronous technology-­ Protected by copyright. additional supplemental material ⇒ Randomised clinical trials, quasi-­experimental trials based interventions. for this paper are available Methods and analysis This protocol is designed and observational case–controlled studies will be online. To view these files, please visit the journal online according to the Preferred Reporting Items for Systematic included to obtain sufficient data and adequate sta- (http://dx.doi.org/10.1136/​ Review and Meta-­Analysis Protocols. The bibliographical tistical power for meta-­analysis. bmjopen-2023-075116). searches were conducted in the databases PubMed, ⇒ There is a potential limitation attributed to the ex- PsycINFO, Scopus and Web of Science in April 2022, with pected small sample size of the included studies The research has been previously presented at a no restrictions on the time of publication and limited to and the heterogeneity of the study designs. conference and has been publications in English or Spanish. The search strategy published as a conference was performed using free-­text terms and Medical Subject abstract.61 Headings terms: suicide, follow-­up, synchronous, remote, for 1.4% of all deaths worldwide.3 Suicide telehealth, telephone, hotline, video-­conference and text rates in European regions (10.5 per 100 000) Received 26 April 2023 message. Two reviewers will independently conduct were higher than the global average (9.0 per Accepted 31 October 2023 study screening, selection process, data extraction and 100 000) in 2019, while the lowest suicide rate risk of bias assessment. The analysis and synthesis of was in the Eastern Mediterranean region (6.4 the results will be both qualitative and quantitative. A per 100 000).2 3 For each suicide death, there narrative synthesis, presented in a comprehensive table, will be performed and meta-­analysis will be conducted, as are 20 suicide attempts,4 constituting one of appropriate, if sufficient data are provided. the leading causes of disease burden in the Ethics and dissemination The present review and meta-­ world.5 6 While most of the world’s suicides analysis will not require ethical approval, as it will use data occur in low-­ income and middle-­ income collected from previously published primary studies. The countries, high-­ income countries have the findings of this review will be published in peer-­reviewed highest age-­ standardised suicide rate (10.9 journals and widely disseminated. per 100 000).2 3 Moreover, suicide represents PROSPERO registration number CRD42021275044. the fourth leading cause of death among © Author(s) (or their people aged 15–29 years in global epidemi- employer(s)) 2023. Re-­use ology.1 3 The number of adolescent deaths permitted under CC BY-­NC. No commercial re-­use. See rights INTRODUCTION due to suicide has increased dramatically, and permissions. Published by Suicide is a universal, complex and multifac- with data reflecting that suicide represents a BMJ. eted public health problem that ranks annu- rate per year of 0.19/100 000 in people under For numbered affiliations see ally among the leading causes of preventable 15 years of age and a rate per year of 2.23/100 end of article. death worldwide. More than 700 000 people 000 in the 15–19 age group, according to the Correspondence to die by suicide per year,1 becoming the 17th Spanish National Institute of Statistics.7 Dr Antoni Sanz; leading cause of death in 2019 in global Suicide prevention is an emerging priority ​Antonio.​Sanz@u​ ab.​cat epidemiology.2 Annual suicide rates account for the public health system due to its high Comendador L, et al. BMJ Open 2023;13:e075116. doi:10.1136/bmjopen-2023-075116 1 BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access social burden.8 Evidence suggests that a prior suicide recommend widespread clinical implementation of brief attempt is one of the most important risk factors for contact interventions. In 2016, Noh et al33 examined five suicide, which supports the efforts to protect patients RCTs comparing telephone-­ delivered interventions for who attempt suicide during the acute period following an preventing suicide reattempts with no telephone inter- episode of self-­harm.9 10 It is estimated that 20% of people vention. The results suggest that, in the case of providing who had engaged in suicidal behaviour showed a subse- telephone-­delivered intervention only, more aggressive, quent episode, and that 88% of these reattempts occurred structured and theory-­based telephone interventions led within 2 years of the initial episode.11 Furthermore, a lack by mental health professionals should be designed and of follow-­up care provided by healthcare professionals has examined in the form of large-­scale RCTs. It should be been identified as a risk factor for repeat suicide attempts noted that there is an overlap in the studies included in in patients discharged from the emergency department the Milner et al32 and Noh et al33 meta-­analyses. (ED).12 Although there is no clear consensus on the effect of Over the last decades, the relevance of developing these programmes in previous systematic reviews and meta-­ evidence-­based prevention strategies focused on reducing analyses,32 33 there are data that appear to support the effi- the likelihood of suicide attempts in high-­risk patients cacy of providing active contact to individuals who have has become evident.13–16 Suicide prevention programmes made a suicide attempt.12 17 34 Overall, there are studies include a wide range of follow-­up actions that promote with positive results in the reduction of suicide-­related connectivity between the patient and the mental health outcomes23 26 29 30 and others that have found conflicting provider (sending letters, conducting telephone calls, or inconclusive evidence,25 35 36 suggesting the suitability texting via SMS (Short Message Service), providing of conducting a systematic review with meta-­analysis of the follow-­up visits in specialised healthcare centres or imple- current scientific literature. Despite evidence describing menting 24/7 hotlines).17 18 The development of infor- a broad range of telecommunications-­ based suicide mation and communication technologies has created prevention approaches,21 37 we are not aware of any publi- opportunities and challenges in prevention, research and cations that provide a synthesis of the literature on inter- clinical practice. eHealth interventions represent tools ventions that develop the use of synchronous strategies that allow reaching a larger number of at-­risk popula- in suicide prevention. Based on the concept of connec- Protected by copyright. tions, facilitating proactive follow-­up compared with face-­ tivity,34 combined with a component of immediacy in the to-­face treatments.19 communication system, synchronous communication can Considering that remotely delivered distance-­ based increase accessibility, adherence and treatment efficacy. programmes can reach affected people regardless of This study aims to collect and synthesise informa- their location, it is reasonable to expect that these inter- tion on the efficacy and effectiveness of remote suicide ventions could be part of future suicide prevention prevention strategies implemented through technology-­ efforts.17 18 Remotely, brief contact-­ based interventions based synchronous interventions (ie, via digital tools that can be a cost-­effective strategy for suicide prevention in allow interactive and immediate real-­time communica- healthcare settings.20–22 In a recent meta-­analysis, Inagaki tion conducted remotely). et al12 found that secondary prevention programmes involving active contact and follow-­up can be effective in reducing the risk of a repeat suicide attempt within METHODS AND ANALYSIS 6 months of admission to an ED for suicidal behaviour. The primary source used to describe the methods of Moreover, promising results seem to be reported in this protocol was the Cochrane Handbook for System- studies that conduct telephone follow-­up interventions atic Reviews of Interventions (V.6.2),38 specifically Part for individuals at risk as a suicide prevention strategy.23–30 2: Core methods ‘Chapter 2: Determining the scope of Telephone management in a clinical practice setting the review and the questions it will address’ to ‘Chapter could be a useful and not expensive programme to imple- 10: Analysing data and undertaking meta-­analyses’. The ment in mental health centres.23 31 protocol was constructed according to the Preferred In 2015, Milner et al32 conducted a systematic review Reporting Items for Systematic Review and Meta-­Analysis and meta-­ analysis of 14 randomised controlled trials Protocols39 40 (see online supplemental file 1). A version (RCTs) using brief contact interventions and found of the protocol was registered in the International that considerable differences in outcomes are likely to Prospective Register of Systematic Reviews (PROSPERO), exist depending on the intervention condition and time under identification number CRD42021275044. period over which the study was conducted (ie, studies that reported on the effectiveness of the intervention Systematic review question condition in reducing suicide attempts were conducted The research question was built according to PICOS criteria some decades ago and were rated as having a high risk (Population, Intervention, Comparison, Outcomes and of bias (RoB), whereas recent studies find more conser- deSign).41 In adolescents and adults (≥12 years of age) vative results). Given the possible benefits, low cost and with suicidal ideation or prior suicide attempts (P), what unlikely adverse effects, large-­scale trials in clinical popu- is the efficacy and effectiveness of synchronous remote-­ lations would be worthwhile; however, the authors do not based interventions (I) in the prevention of non-­ fatal 2 Comendador L, et al. BMJ Open 2023;13:e075116. doi:10.1136/bmjopen-2023-075116 BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access suicide attempts and suicide deaths (O) compared with control. Therefore, the review will include active (ie, active or inactive control groups (C) with any follow-­up participants engaged in some tasks unrelated to suicide length? prevention during the study period) or inactive control groups. The control group may involve a combina- Criteria for included and excluded studies tion of strategies: visits to mental health services, non-­ Types of studies psychological therapies (eg, pharmacotherapy) and other The review will consider published empirical research expected interventions. Studies that do not include a with the following study designs: randomised clinical control group will be excluded (eg, cross-­sectional trials). trials, quasi-­experimental trials and observational case– controlled studies. Primary data from cohort study Types of outcome measures designs or qualitative studies and secondary sources (eg, The main outcomes will be the repetition of suicide systematic reviews, meta-­analyses) will be excluded. attempt, suicide ideation and suicide death. Suicide is defined as a self-­ inflicted and potentially injurious Types of participants behaviour that is performed as a deliberate method to The population of interest will include adolescents and die.42 Suicide attempts are defined as self-­inflicted harm adults, defined as anyone over the age of 12 years, who with a non-­fatal outcome for which there is evidence, have reported suicidal ideation or prior suicide attempts. explicit or implicit, of the intention to die.3 Furthermore, No restriction will be placed on gender, geographical suicidal ideation is described by thoughts, ideas or rumi- provenance or diagnosis. Participants with non-­suicidal nations about the possibility of ending one’s life.43 self-­injury will be excluded. The assessment can be conducted post-­ intervention with no limit on the length of follow-­ up, employing Types of interventions quantitative measurement of suicidal-­related outcomes. Synchronous remote-­based interventions will be defined The suicidal ideation outcome may be measured using as programmes delivered through a technology device different validated instruments (table 1). According to a that is characterised by (a) ensuring interactive and recent systematic review,44 the most common instruments immediate communication, and (b) not requiring the are the Beck Scale for Suicide Ideation and the Columbia Protected by copyright. patient to be at the same physical location as the mental Suicide Severity Rating Scale. The non-­ fatal suicide health provider. Interventions should aim to reduce attempts outcome will be measured by the number of suicide risk by communicating with patients through suicide attempts a person has made within a certain time telephone follow-­up or active contact (ie, contact with frame. The suicide death outcome will be measured by healthcare services made spontaneously by participants the number of people who have died by suicide. at elevated risk of suicidal behaviour, such as a phone call or hotline), instant text messaging or video-­conference. Data collection and analysis The synchronous remote communication should include Information sources and search strategy some, but not necessarily all, of the following elements: Literature searches were conducted in the following improving compliance with medication and follow-­ up electronic databases: PubMed (by National Center for appointments, addressing any problems, stressors or risk Biotechnology Information-­National Library of Medicine-­ factors, and reducing reattempts. No restriction will be National Institutes of Health website), PsycINFO (by placed on the intensity or duration of the intervention. ProQuest), Scopus (by w ​w.​ scopus.​ com) and Web of We will include interventions delivered via synchronous Science Core Collection. Grey literature and unpublished remote-­communication technologies; however, synchro- records were searched on the following websites: C ​ linical- nous remote-­ based programmes that include minimal Trials.​gov and Google Scholar. face-­to-­face contact (ie, in-­person contact for a maximum Authors of published articles will be contacted to of one session) or are complemented with multimedia-­ retrieve relevant information about their study that was delivered materials will be also considered. Studies either not reported or unclear. The references cited in using asynchronous telecommunication devices such the included articles will be considered for data collec- as online forums and communities, social networking tion. We will also examine the reference lists of existing sites, video sharing sites, automated one-­way text or voice systematic reviews on similar topics to identify other rele- messages, and self-­directed web-­based programmes will vant articles. In addition, the personnel files of the work- be excluded. Studies that describe treatments focused on group members will be checked and experts in the field of the prevention of non-­suicidal self-­harm will be excluded. suicide will be consulted regarding relevant publications. In addition, the interventions for issues such as psychosis, The search strategy was performed using relevant eating disorders and depression, which are not intended subject headings and search syntax appropriate to each to specifically address suicidal behaviour, are out of the database, including variations and combinations of free-­ scope of this review. text terms and thesaurus of psychological index terms All comparisons identified in the eligible studies will be (American Psychological Association) or Medical Subject included, such as treatment as usual (TAU), enhanced Headings terms, combining with appropriate Boolean TAU, no treatment, placebo, waiting list and historical operators. The general structure of search syntax was: Comendador L, et al. BMJ Open 2023;13:e075116. doi:10.1136/bmjopen-2023-075116 3 BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access Table 1 Instruments most cited in the literature for assessing suicide risk Instrument Reference Beck Scale for Suicide Ideation Beck et al62 Columbia Suicide Severity Rating Scale Posner et al63 Beck Suicidal Intent Scale Beck et al64 Paykel Suicide Scale Fonseca-­Pedrero and Pérez de Albéniz65 Beck Suicide Scale–worst ever version Beck and Steer66 Suicidal Ideation Questionnaire (SIQ; SIQ-­Junior) Reynolds67 Mini-­International Neuropsychiatric Interview Sheehan et al68 Risk of Suicide Questionnaire (RSQ; RSQ-­Revised) Horowitz et al69 Suicide Score Scale Innamorati et al70 Suicide Opinion Questionnaire Domino et al71 World Mental Health Composite International Diagnostic Interview Kessler and Ustün72 InterSePT Suicide Scale Lindenmayer et al73 Plutchik Suicide Risk Scale Koslowsky et al74 Harkavy-­Asnis Suicide Scale Friedman and Asnis75 Suicide Probability Scale Cull and Gill76 (suicid* OR self-­injur* OR self-­harm OR “self-­destructive Selection process behavio*” OR self-­ poisoning) AND (intervention OR In the first phase, duplicate articles in the databases will therap* OR treatment OR psychotherap* OR preven- be automatically removed by Rayyan Systems and manu- tion OR follow-­up OR contact OR post-­discharge) AND ally by the first reviewer (LC). In the second phase, two Protected by copyright. (synchron* OR remote OR non-­presential OR non-­face-­ authors (LC and MPJV) will blind-­screen all articles based to-­face OR distance OR digital OR online OR telehealth on titles, abstracts and keywords. In the third phase, the OR telemedicine OR eHealth OR mHealth OR tele- two reviewers (LC and MPJV) will independently evaluate phone OR phone OR call OR hotline OR helpline OR the full-­text articles according to eligibility criteria. The “suicide line” OR chat OR videoconferen* OR App OR reasons for excluding articles will be recorded. If neces- text messag* OR SMS) AND (“randomised controlled sary, a third reviewer (AS) will be requested for discrep- trial” OR “controlled clinical trials” OR “clinical studies”) ancies that may not be resolved by a consensus among the NOT (review OR protocol). The drafted electronic search two reviewers (LC and MPJV). Inter-­rater agreement will strategy for PubMed database is included in the online be calculated by Cohen’s kappa in the second and third supplemental file 2. phases, prior to reaching a consensus on the discrepan- The search was scheduled to be completed by April cies between the two reviewers or contrasting them with 2022. All searches have been rerun, before publication a third reviewer. The article selection process will be of the article, as more than 12 months have elapsed since described in a Preferred Reporting Items for Systematic the date of the initial search. The search was limited to Review and Meta-­Analysis flow diagram.49 English or Spanish and was performed with no restric- tions on the time of publication. Data collection process The search strategy was developed by the research team Data extraction will be conducted independently by two with the collaboration of an experienced health science authors (LC and MPJV), using a standard extraction librarian (GC), adhering to the Peer Review of Electronic form in line with the template from the Cochrane Collab- Search Strategies.45 Sensitivity (ie, retrieval rate) and oration.50 Data will be managed using Microsoft Excel specificity (ie, precision rate) criteria were considered (V.16.56). For missing information or data that need to in the development of the literature search strategy46 47; be clarified, first or corresponding authors of primary however, sensitivity was prioritised. studies will be contacted by email; one follow-­up email will be sent if no response is received to the first email. Data management Results from the literature search will be imported into Data items Rayyan Systems,48 an internet-­ based software program Data will be extracted from the following categories: that facilitates collaboration and pursuit accelerated (a) general characteristics of the study (authors, date of screening process. During the review process, this tool publication, setting and geographical location, research will be used to identify duplicate records and manage the design, sample size, participant sociodemographic and data. Mendeley (V.1.19.8) will be employed as reference baseline characteristics), (b) intervention and control management software. group details (type of intervention or control group, 4 Comendador L, et al. BMJ Open 2023;13:e075116. doi:10.1136/bmjopen-2023-075116 BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access sample sizes, follow-­up time, dropout rates), (c) outcomes Effect sizes will be considered small (g≥0.2), medium (descriptive and comparative statistical indexes of efficacy (g≥0.5) or large (g≥0.8).54 The Q and tau2 statistics will and effectiveness, assessment measures and procedures) be calculated to assess the statistical heterogeneity of and (d) limitations reported by study authors. effect sizes. Specific functions will be used to examine: (a) the profile likelihood plots of the variance compo- RoB assessment nents; (b) the potential outlying and influential studies The RoB assessment will be conducted independently and/or outcomes; and (c) the potential publication bias. by two reviewers (LC and MPJV), employing the All analyses will be performed using the Metafor package revised Cochrane RoB tool for randomised trials (RoB (V.4.0-­0) for R. 2.0)51 and Risk-­ of-­bias In Non-­ randomised Studies–of Interventions.52 Sensitivity analysis Inter-­ rater agreement will be calculated by Cohen’s The potential effect on the results due to the trial design kappa. Disagreements will be resolved by a consensus with (ie, pragmatic vs explanatory trials), the adjustment for a third blind reviewer (AS). Ratings of bias for each study confounding and the RoB of the studies will be analysed, will be classified as low, high or unclear RoB, according to if feasible. standardised methodology. Intramethodological quality evaluation will be synthesised in tables that will comprise Analysis of subgroups or subsets the summary of each study individually, identifying their Subgroup and subset analyses will be carried out if feasible RoB. Studies will not be excluded based on their level of and warranted to examine potential effect modifiers based RoB. on sociodemographic characteristics of participants, Data synthesis length, type of treatment, research design, adjustment A descriptive summary and explanation of the character- for confounding and RoB assessment. Meta-­regression istics and findings of all included studies will be displayed will be performed to analyse quantitative potential effect in a comprehensive table. A narrative synthesis will be modifiers or covariates that might influence the size of conducted, and a random-­ effects meta-­ analysis will be the intervention effect (eg, age). We plan to summarise Protected by copyright. computed when a suicidal-­related outcome is reported and categorise the below subgroup or subset analyses if in at least three studies. To ensure that the data we are there are enough data: combining from different studies are comparable and a. Age: adolescents (12–17 years of age), adults (18–65 can be appropriately synthesised, several adjustments years of age) and older adults (over 65 years of age). may be necessary. These adjustments could involve b. Type of intervention: type of synchronous remote-­ contacting study authors to request more detailed data based interventions (telephone calls, instant text mes- or transforming the data (eg, if we encounter a situa- saging, 24/7 hotlines, video-­conferencing). tion where some studies report suicide attempts as a c. Number of follow-­up contacts: hotline (24-­hour con- binary outcome while others report them as a count); sultation with a non-­standardised number of follow-­up conducting sensitivity analyses to assess the impact of the contacts), one to three contacts, three to six contacts articles; performing subgroup analyses for each type of and more than six contacts. data; or adopting a narrative synthesis approach when a d. Length of contact period: hotlines (24-­hour consulta- quantitative combination of studies is not feasible. Any tion with a non-­standardised period of follow-­up con- data transformations will be documented in the manu- tacts), up to 1-­month follow-­up, follow-­up 1–3 months, script, and the limitations introduced by differences in follow-­up 3–6 months and longer than 6-­ month data reporting between studies should be acknowledged. follow-­up. Three types of meta-­ analyses will be conducted e. Research design: RCTs, quasi-­experimental trials and according to the type of outcome measure: count (inci- observational case–controlled studies. dence rate ratio between groups of the number of suicide f. Adjustment for confounding: adjusted for confound- attempts), quantitative (standardised mean differences ing variables or no adjustment. of suicidal ideation) and binary (OR between groups in g. RoB assessment: low, high and unclear RoB. the proportion of deaths by suicide). All outcomes will be analysed at different follow-­up time intervals, as indicated Publication bias below in the description of subgroup analyses. Compar- Publication bias will be evaluated using Egger’s test,55 isons adjusted for confounders between groups will be funnel plots,56 and trim-­and-­fill approaches.57 included in meta-­analyses when reported in studies, and the effect of these adjustments on the meta-­analytical Confidence in cumulative evidence summary will be studied using sensitivity and subgroup The overall quality of evidence will be evaluated analyses. Mean differences between the control group according to the Grading of Recommendations Assess- and intervention group will be transformed into Hedges’ ment, Development, and Evaluation58 59 by two indepen- g standardised effect sizes,53 which means different dent researchers (LC and MPJV). Discrepancies will be tools for measuring suicidal ideation will be combined. resolved in a discussion with a third researcher (AS). Comendador L, et al. BMJ Open 2023;13:e075116. doi:10.1136/bmjopen-2023-075116 5 BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access Patient and public involvement of duplication and reduce bias. The meta-­analysis of the Patients and/or the public were not involved in the studies found can allow the quantification of their global design, conduct, reporting or dissemination plans of this efficacy and effectiveness. Likewise, the subgroup or research. subset analyses can provide useful information to guide the design of more efficient and effective efficacy or effec- tiveness of remote-­based synchronous programmes for DISCUSSION suicide prevention in the future. The wide variety of remotely delivered distance-­ based The current registration of the protocol for this review programmes for suicide prevention20 23 26–28 and the at PROSPERO may undergo changes, if approved by all current lack of guidance on their implementation warrant authors. Any changes to the protocol will be described further research to improve and standardise patient care. and explained in the final manuscript. The research has To the best of the researchers’ knowledge, no systematic been previously presented at a conference and has been review and meta-­analysis has been reported that exam- published as a conference abstract.61 ined the efficacy of synchronous and remote telepsychi- atry interventions, assessing suicide-­ specific outcomes. We aim to address a gap in research by examining the efficacy of synchronous remote-­based interventions that are specifically designed for suicide prevention. The ETHICS AND DISSEMINATION proposed approach is pertinent given the recent increase Ethics approval is not needed, as systematic reviews are in the development and usage of technology communica- based on published studies. The results will be dissemi- tion devices for this purpose.19 nated through peer-­reviewed publications. It is anticipated that the systematic review will have predicted limitations that should be considered. The Author affiliations inconsistency of terms used in suicidology is a limiting 1 Department of Psychiatry and Forensic Medicine, Autonomous University of factor regarding the search for articles and the subse- Barcelona, Cerdanyola del Vallès, Spain 2 quent eligibility of studies. In addition, suicide is a rare Parc Taulí Research and Innovation Institute, Sabadell, Spain Protected by copyright. 3 event, making the design of studies with high statistical Department of Basic, Developmental, and Educational Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain power particularly challenging. Furthermore, people who 4 Department of Psychobiology and Methodology of Health Sciences, Autonomous attempt suicide are typified by poor treatment-­seeking and University of Barcelona, Cerdanyola del Vallès, Spain limited adherence to treatment,60 making it important to 5 Institut de Recerca Sant Joan de Déu, Barcelona, Spain provide individuals at risk of suicide with appropriate and cost-­effectiveness treatment options. Twitter Josep-­Maria Losilla @jmlosilla A limited number of available studies are expected, Acknowledgements The authors thank Guillem Cebrián (GC), director of the which explains why the search strategy prioritises sensi- Library Hospital Universitari Parc Taulí and head of the Unitat de Gestió del Coneixement de l'Institut d'Investigació i Innovació Parc Taulí (I3PT-­CERCA), for his tivity over specificity. Moreover, RCTs may not provide invaluable support in the refinement of the search strategies. The authors’ gratitude sufficient evidence to exclude data from non-­randomised also goes to Universitat Autònoma de Barcelona and Hospital Universitari Parc Taulí studies. The inclusion of studies examining a wide range for critically analysing the study proposal and motivational support to conduct this of synchronous remote-­ communication technologies protocol. DP thanks the support of the Spanish Ministry of Science and Innovation/ ISCIII/FEDER (PI21/01148), the Secretaria d’Universitats i Recerca del Departament rather than a specific intervention is intended to address d’Economia i Coneixement of the Generalitat de Catalunya (2021 SGR 01431), the this issue. Similarly, including no restriction on the CERCA programme of the I3PT, the Instituto de Salud Carlos III and the CIBER of mental health condition should allow for the collection of Mental Health (CIBERSAM). comprehensive and relevant data. Research studies that Contributors AS is the guarantor. LC, J-­ML, DP, AIC and AS—writing (original meet eligibility criteria may have a substantial degree of draft). LC, AS, MPJV, JPS-­M and CMC—software. LC, J-­ML, DP and AS—project heterogeneity. In response, we initially planned subgroup administration and supervision. All authors—conceptualisation, methodology and writing (review and editing). J-­ML, AS, JPS-­M and CMC provided statistical and subset analyses. However, the categorisation of inter- expertise. DP and AIC provided expertise in suicidal behaviours. All authors ventions into different typologies may be difficult since approved the final manuscript. multiple research studies combine several interventions Funding This research was funded by the Instituto de Salud Carlos III, simultaneously. Subdirección General de Evaluación y Fomento de la Investigación (ISCIII) and Aside from several limitations, there are poten- Fondo Europeo de Desarrollo Regional (FEDER) (grant number PI21/01148)— Estudio de la relación entre cognición social y dolor psicológico con el riesgo tial strengths. The aim is to contribute to the body of de presentar conductas suicidas (COGNISUI)—Fundación Parc Taulí, SENDO evidence on suicide. The development of the research PI21/01148 (Fondo de Investigación Sanitaria-­ISCiii/FEDER) Instituto Salud Carlos proposed in the present protocol will allow to analyse the III, and by MCIN/AEI/10.13039/501100011033 and 'ERDF A way of making Europe' quality and methodology used in the research of remote-­ (grant number PID2022-­141403NB-­I00). The APC was funded by the Instituto de Salud Carlos III, Subdirección General de Evaluación y Fomento de la Investigación based synchronous interventions for suicide prevention, (ISCIII) and FEDER. The Department of Mental Health of Hospital Universitari Parc synthesising scientific evidence, generating hypotheses Taulí, Unitat Mixta de Neurociència Traslacional I3PT-­INc-­UAB, is the sponsor. and establishing lines of research. In addition, the study Disclaimer The funders had no role in the design of the study; in the collection, protocol per se will provide more transparency in the analysis or interpretation of data; in the writing of the manuscript; or in the decision methods and processes involved, decrease the possibility to publish the results. 6 Comendador L, et al. BMJ Open 2023;13:e075116. doi:10.1136/bmjopen-2023-075116 BMJ Open: first published as 10.1136/bmjopen-2023-075116 on 6 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 7, 2023 at Univesity Autonomous of Barcelona. Open access Competing interests DP has received grants and also served as a consultant or pdf_file/0020/280604/WHO-Europe-Mental-Health-Acion-Plan-2013-​ advisor for Rovi, Angelini, Janssen, Lundbeck and Servier. The other authors declare 2020.pdf [Accessed 15 Feb 2022]. no conflicts of interest. 15 World Health Organization. Preventing suicide: A global imperative. 2014. Available: https://www.who.int/mental_health/suicide-​ Patient and public involvement Patients and/or the public were not involved in prevention/exe_summary_english.pdf?ua=1 [Accessed 15 Feb 2022]. the design, or conduct, or reporting, or dissemination plans of this research. 16 World Health Organization. Comprehensive mental health action plan 2013–2030. 2021. Available: https://apps.who.int/iris/rest/bitstreams/​ Patient consent for publication Not required. 1371507/retrieve [Accessed 15 Feb 2022]. Provenance and peer review Not commissioned; externally peer reviewed. 17 Inagaki M, Kawashima Y, Kawanishi C, et al. Interventions to prevent repeat suicidal behavior in patients admitted to an emergency Supplemental material This content has been supplied by the author(s). It has Department for a suicide attempt: a meta-­analysis. J Affect Disord not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been 2015;175:66–78. peer-­reviewed. Any opinions or recommendations discussed are solely those 18 Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and strategies Revisited: 10-­year systematic review. Lancet Psychiatry responsibility arising from any reliance placed on the content. Where the content 2016;3:646–59. includes any translated material, BMJ does not warrant the accuracy and reliability 19 Lin T, Stone SJ, Heckman TG, et al. Zoom-­in to zone-­out: therapists report less therapeutic skill in Telepsychology versus face-­to-­ of the translations (including but not limited to local regulations, clinical guidelines, face therapy during the COVID-­19 pandemic. Psychotherapy terminology, drug names and drug dosages), and is not responsible for any error 2021;58:449–59. and/or omissions arising from translation and adaptation or otherwise. 20 Gilat I, Shahar G. Emotional first aid for a suicide crisis: comparison Open access This is an open access article distributed in accordance with the between Telephonic Hotline and Internet. Psychiatry 2007;70:12–8. 21 Seong JM, Cho Y, Cho GC, et al. Effects of mobile messenger Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which counseling on case management success for individuals engaging in permits others to distribute, remix, adapt, build upon this work non-­commercially, self-­harm or suicide attempts who were discharged from emergency and license their derivative works on different terms, provided the original work is departments. Clin Exp Emerg Med 2021;8:48–54. properly cited, appropriate credit is given, any changes made indicated, and the use 22 Vijayakumar L, Umamaheswari C, Shujaath Ali ZS, et al. Intervention is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. for suicide attempters: a randomized controlled study. 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