Topic: Relationships, Suicide
Target Population: Adolescents, Adults, Service Members, Veterans
Sector: Community-Based
Military Sector: All Branches
This program is for individuals who are at risk for suicide.
Caring Contacts, a community-based program, is designed to reduce suicidal ideation and suicide attempts.
A number of evaluations of Caring Contacts have been conducted in a variety of populations, including individuals who visited the emergency department due to self-harm and military and veteran populations who identified as being at risk of suicide. Results of studies have been mixed. Some studies demonstrated positive effects while contacts were being delivered, some studies showed initial positive effects that faded after contacts were discontinued, some studies indicated no impact of the intervention, and some studies revealed higher rates of repeat self-harm and worsening of mental health symptoms in the intervention group compared to a control group. One recent randomized trial, conducted in active duty, Reserve, and National Guard Soldiers and Marines, demonstrated no significant impact on primary outcomes of presence or severity of current suicidal ideation or suicide-risk incidents or on secondary outcomes of worst-point suicidal ideation or emergency department visits for suicidality. However, participants in the Caring Contacts group had lower odds of experiencing any suicidal ideation between baseline and follow-up and fewer attempts of suicide since baseline compared to the standard care control group. Contrasting results between studies may be due to variables such as differences in program implementation, including variance in the timing, number of, frequency, or modality of contacts; degree of personalization of the contacts; including appointment reminders that encourage participants to go to treatment or giving self-help strategies in addition to the caring contact; differences in measured outcomes; gender differences; and variability in severity of depression or suicidal ideation and history of self-harm among participants.
Caring Contacts involves sending participants who are at risk for suicide brief and non-demanding expressions of care and concern. The program intends to consistently express interest in participants, regardless of any effort on their part, as a way of potentially providing a sense of belongingness and acceptance that could help to prevent suicidal behavior. The original program was guided by the following principles:
Contacts may be delivered in a variety of formats including letters or postcards, email, text messages, phone calls, or in-person visits.
The original Caring Contacts program was created by Jerome Motto in the 1970s. The current version of the program has been evaluated with active duty military personnel and veterans. The program has been adopted by the VA as an intervention for all Service members who are transitioning from military service to VA care.
A 1-hour, interactive, self-paced training is available. Please visit https://uwcspar.org/self-guided-training/caring-contacts-online-training/ for more information.
Considerations for implementing this program include obtaining participant buy-in; ensuring that contacts with participants are made on a consistent and regular basis; confirming staff and participants have suitable technology if email, text messages, and phone calls are used; and providing timely responses to participants if they reply to the contacts.
The Clearinghouse can help address these considerations. Please call 1-877-382-9185 or email clearinghouse@psu.edu
If you are interested in implementing Caring Contacts, the Clearinghouse is interested in helping you! Please call 1-877-382-9185 or email clearinghouse@psu.edu
Contacts are made with participants for 1 year or longer.
Information on implementation costs was not located; however, costs will vary depending on the format of messaging (e.g., email, texts, notes) and may include an online messaging platform, stationery, postage, a mailing database, and staff time.
To move Caring Contacts to the Promising category on the Clearinghouse Continuum, at least two additional well-designed evaluations with large sample sizes must be conducted that demonstrate sustained positive effects on primary outcomes lasting at least one year from program completion.
The Clearinghouse can help you develop an evaluation plan to ensure the program components are meeting your goals. Please call 1-877-382-9185 or email clearinghouse@psu.edu
Contact the Clearinghouse with any questions regarding this program. Phone: 1-877-382-9185 Email: clearinghouse@psu.edu
You may also contact University of Washington Department of Psychiatry & Behavioral Sciences by mail 1959 NE Pacific Street, Box 356560, Seattle, WA 98195-6560, phone 1-206-543-3750, fax 1-206-543-9520, or visit https://psychiatry.uw.edu/who-we-are/contact-us/
Beautrais, A. L., Gibb, S. J., Faulkner, A., Fergusson, D. M., & Mulder, R. T. (2010). Postcard intervention for repeat self-harm: Randomised controlled trial. British Journal of Psychiatry, 197(1), 55-60. https://doi.org/10.1192/bjp.bp.109.075754
Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & Este, C. D. (2005). Postcards from the EDge project: Randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. BMJ, 331(7520), 805-807. https://doi.org/10.1136/bmj.38579.455266.E0
Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & D'Este, C. (2007). Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning. British Journal of Psychiatry, 191(6), 548-553. https://doi.org/10.1192/bjp.bp.107.038406
Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & D'Este, C. (2013). Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning. British Journal of Psychiatry, 202(5), 372-380. https://doi.org/10.1192/bjp.bp.112.112664
Comtois, K. A., Kerbrat, A. H., DeCou, C. R., Atkins, D. C., Majeres, J. J., Baker, J. C., & Ries, R. K. (2019). Effect of augmenting standard care for military personnel with brief caring text messages for suicide prevention: A randomized clinical trial. JAMA Psychiatry, 76(5), 474-483. https://doi.org/10.1001/jamapsychiatry.2018.4530
Fleischmann A., Bertolote J. M., Wasserman D., De Leo D., Bolhari J, Botega N. J., De Silva D., Phillips M., Vijayakumar L., Värnik A., Schlebusch L., Thanh H. T. (2008). Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86(9), 703-709. https://doi.org/10.2471/BLT.07.046995
Hassanian-Moghaddam, H., Sarjami, S., Kolahi, A., & Carter, G. L. (2011). Postcards in Persia: Randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning. British Journal of Psychiatry, 198(4), 309-316. https://doi.org/10.1192/bjp.bp.109.067199
Hassanian-Moghaddam, H., Sarjami, S., Kolahi, A., Lewin, T., & Carter, G. (2017). Postcards in Persia: A twelve to twenty-four month follow-up of a randomized controlled trial for hospital-treated deliberate self-poisoning. Archives of Suicide Research, 21(1), 138-154. https://doi.org/10.1080/13811118.2015.1004473
Holman, S., Steinberg, R., Sinyor, M., Lane, H., Starritt, K., Kennedy, S. H., … Schaffer, A. (2023). Caring contacts to reduce psychiatric morbidity following hospitalization during the COVID-19 pandemic: A pilot randomized controlled trial. Canadian Journal of Psychiatry, 68(3), 152-162. https://doi.org/10.1177/07067437221121111
Kapur, N., Gunnell, D., Hawton, K., Nadeem, S., Khalil, S., Longson, D., ... Cooper, J. (2013). Messages from Manchester: Pilot randomised controlled trial following self-harm. British Journal of Psychiatry, 203(1), 73-74. https://doi.org/10.1192/bjp.bp.113.126425
Luxton, D. D., Kinn, J. T., June, J. D., Pierre, L. W., Reger, M. A., & Gahm, G. A. (2012). Caring letters project: A military suicide-prevention pilot program. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33(1), 5-12. https://doi.org/10.1027/0227-5910/a000093
Luxton, D. D., Smolenski, D. J., Reger, M. A., Relova, R. M. V., & Skopp, N. A. (2020). Caring e‐mails for military and veteran suicide prevention: A randomized controlled trial. Suicide & Life-Threatening Behavior, 50(1), 300-314. https://doi.org/10.1111/sltb.12589
Motto, J. A. (1976). Suicide prevention for high-risk persons who refuse treatment. Suicide & Life-Threatening Behavior, 6(4), 223-230. https://doi.org/10.1111/j.1943-278X.1976.tb00880.x
Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 52(6), 828-833. https://doi.org/10.1176/appi.ps.52.6.828
Robinson, J., Yuen, H. P., Gook, S., Hughes, A., Cosgrave, E., Killackey, E., ... Yung, A. (2012). Can receipt of a regular postcard reduce suicide-related behaviour in young help seekers? A randomized controlled trial. Early Intervention in Psychiatry, 6(2), 145-152. https://doi.org/10.1111/j.1751-7893.2011.00334.x
Vaiva, G., Vaiva, G., Ducrocq, F., Meyer, P., Mathieu, D., Philippe, A., ... Goudemand, M. (2006). Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: Randomised controlled study. BMJ, 332(7552), 1241-1244. https://doi.org/10.1136/bmj.332.7552.1241
Ammerman, B. A., Gebhardt, H. M., Lee, J. M., Tucker, R. P., Matarazzo, B. B., & Reger, M. A. (2020). Differential preferences for the caring contacts suicide prevention intervention based on patient characteristics. Archives of Suicide Research, 24(3), 301-312. https://doi.org/10.1080/13811118.2019.1632231
Bertolote, J. M., Fleischmann, A., De Leo, D., Phillips, M. R., Botega, N. J., Vijayakumar, L., ... Wasserman, D. (2010). Repetition of suicide attempts: Data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS study. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 31(4), 194-201. https://doi.org/10.1027/0227-5910/a000052
Bogic, M., Hebert, L. E., Evanson, A., Wright, B. D., Petras, A., Jansen, K., … Nelson, L. (2023). “Keep up the messages, sometimes it was a lifesaver”: Effects of cultural adaptation on a suicide prevention clinical trial in American Indian/Alaska Native communities. Behaviour Research and Therapy, 166. https://doi.org/10.1016/j.brat.2023.104333
Burkhardt, H. A., Laine, M., Kerbrat, A., Cohen, T., Comtois, K. A., & Hartzler, A. (2022). Identifying opportunities for informatics-supported suicide prevention: The case of caring contacts. AMIA. Annual Symposium Proceedings, 2022, 309-318.
Cedereke, M., Monti, K., & Öjehagen, A. (2002). Telephone contact with patients in the year after a suicide attempt: Does it affect treatment attendance and outcome? A randomised controlled study. European Psychiatry, 17(2), 82-91. https://doi.org/10.1016/S0924-9338(02)00632-6
Chalker, S. A., Pozun, C. T., Chang, C. J., Ehret, B. C., & Treichler, E. B. H. (2024). Preferences of U.S. veterans making and receiving caring cards: A peer approach to recovery-oriented suicide prevention. Practice Innovations, 9(1), 77-85. https://doi.org/10.1037/pri0000230
Dimeff, L. A., Jobes, D. A., Chalker, S. A., Piehl, B. M., Duvivier, L. L., Lok, B. C., ... Koerner, K. (2020). A novel engagement of suicidality in the emergency department: Virtual collaborative assessment and management of suicidality. General Hospital Psychiatry, 63, 119-126. https://doi.org/10.1016/j.genhosppsych.2018.05.005
Ehret, B. C., Chalker, S. A., Pozun, C. T., & Martinez-Ceren, C. S. (2022). A peer approach to suicide prevention and recovery: Study protocol for a feasibility and acceptability trial of caring cards for veterans. Contemporary Clinical Trials Communications, 29. https://doi.org/10.1016/j.conctc.2022.100974
Ehret, B. C., Treichler, E. B., Ehret, P. J., Chalker, S. A., Depp, C. A., & Perivoliotis, D. (2021). Designed and created for a veteran by a veteran: a pilot study of caring cards for suicide prevention. Suicide and Life‐Threatening Behavior, 51(5), 872-881.
Evans, M. O., Morgan, H. G., Hayward, A., & Gunnell, D. J. (1999). Crisis telephone consultation for deliberate self-harm patients: Effects on repetition. British Journal of Psychiatry, 175(1), 23-27. https://doi.org/10.1192/bjp.175.1.23
Hebert, L. E., Fruhbauerova, M., Evanson, A., Bogic, M., Petras, A., Shaw, J., … Comtois, K. A. (2022). Caring texts, a strength-based, suicide prevention trial in 5 native communities: Research design and methods. Contemporary Clinical Trials, 123. https://doi.org/10.1016/j.cct.2022.106966
Houtsma, C., Raines, A. M., Kerbrat, A. H., & True, G. (2024). Feasibility and acceptability of caring contacts texts for suicide prevention among veterans recently separated from military service. Psychological Services, https://doi.org/10.1037/ser0000859
Jansen, K. J., Shaw, J. L., Comtois, K. A., Elliott-Groves, E., Slaney, T., Avey, J. P., … The CARE Phase 1 Study Team. (2023). Culturally adapting caring contacts for suicide prevention in four Alaska Native and American Indian communities. Archives of Suicide Research, 27(1), 89-106. https://doi.org/10.1080/13811118.2021.1967820
Kolade, L., Shere, L., Gill, S., Saini, G., Macrae, F., Kuppuswamy, M., ... Luxton, D. D. (2015). 77 Post-hospitalisation caring contacts for suicide prevention provide active crisis intervention benefit at VA PALO ALTO. Injury Prevention, 21(Suppl 2), A28. https://doi.org/10.1136/injuryprev-2015-041654.77
Landes, S. J., Abraham, T. H., Woods, J. A., Curtis, N. D., Lauver, M., Manchester, C., ... & Reger, M. A. (2023). Qualitative evaluation of a caring letters suicide prevention intervention for the Veterans Crisis Line. Psychiatric services, 74(12), 1234-1239.
Landes, S. J., Jegley, S. M., Kirchner, J. E., Areno, J. P., Pitcock, J. A., Abraham, T. H., … Comtois, K. A. (2021). Adapting caring contacts for veterans in a Department of Veterans Affairs emergency department: Results from a type 2 hybrid effectiveness-implementation pilot study. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.746805
Landes, S. J., Kirchner, J. E., Areno, J. P., Reger, M. A., Abraham, T. H., Pitcock, J. A., ... Comtois, K. A. (2019). Adapting and implementing caring contacts in a Department of Veterans Affairs emergency department: A pilot study protocol. Pilot and Feasibility Studies, 5(1), 115. https://doi.org/10.1186/s40814-019-0503-9
Law, Y. W., Lok, R. H. T., Chiang, B., Lai, C. C. S., Tsui, S. H. M., Chung, P. Y. J., & Leung, S. C. (2023). Effects of community-based caring contact in reducing thwarted belongingness among postdischarge young adults with self-harm: Randomized controlled trial. JMIR Formative Research, 7. https://doi.org/10.2196/43526
Livingston, W. S., Carter, S. P., Leitner, R., Ton, A. T., Gebhardt, H., Zoellner, L. A., … Reger, M. A. (2024). A peer veteran approach to the caring letters suicide prevention program: Preliminary data. Psychological Services, 21(1), 1-12. https://doi.org/10.1037/ser0000760
Luxton, D. D., June, J. D., & Comtois, K. A. (2013). Can postdischarge follow-up contacts prevent suicide and suicidal behavior?: A review of the evidence. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 34(1), 32-41. https://doi.org/10.1027/0227-5910/a000158
Luxton, D. D., Thomas, E. K., Chipps, J., Relova, R. M., Brown, D., McLay, R., ... Smolenski, D. J. (2014). Caring letters for suicide prevention: Implementation of a multi-site randomized clinical trial in the U.S. military and Veteran Affairs healthcare systems. Contemporary Clinical Trials, 37(2), 252-260. https://doi.org/10.1016/j.cct.2014.01.007
Motto, J. A., & Bostrom, A. G. (2001). Follow-up for parasuicidal patients. Psychiatric Services, 52(9). https://doi.org/10.1176/appi.ps.52.9.1254-a
Osilla, K. C., Meredith, L. S., Griffin, B. A., Martineau, M., Hindmarch, G., & Watkins, K. E. (2023). Design of CLARO+ (collaboration leading to addiction treatment and recovery from other stresses, plus): A randomized trial of collaborative care to decrease overdose and suicide risk among patients with co-occurring disorders. Contemporary Clinical Trials, 132. https://doi.org/10.1016/j.cct.2023.107294
Radin, A. K., Shaw, J., Brown, S. P., Flint, H., Fouts, T., McCue, E., … Comtois, K. A. (2023). Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial. Contemporary Clinical Trials, 131. https://doi.org/10.1016/j.cct.2023.107268
Radin, A. K., Shaw, J., Brown, S. P., Torres, J., Harper, M., Flint, H., ... Comtois, K. A. (2023). Comparative effectiveness of two versions of a Caring Contacts intervention in healthcare providers, staff, and patients for reducing loneliness and mental distress: A randomized controlled trial. Journal of Affective Disorders, 331, 442-451. https://doi.org/10.1016/j.jad.2023.03.029
Reger, M. A., Gebhardt, H. M., Lee, J. M., Ammerman, B. A., Tucker, R. P., Matarazzo, B. B., ... Ruskin, D. A. (2019). Veteran preferences for the caring contacts suicide prevention intervention. Suicide & Life-Threatening Behavior, 49(5), 1439-1451. https://doi.org/10.1111/sltb.12528
Reger, M. A., Jegley, S. M., Porter, S. A., Woods, J. A., Liu, L., Markman, J. D., & Landes, S. J. (2023). Implementation strategy to increase clinicians’ use of the caring letters suicide prevention intervention. Psychological Services, 20, 44-50. https://doi.org/10.1037/ser0000637
Reger, M. A., Luxton, D. D., Tucker, R. P., Comtois, K. A., Keen, A. D., Landes, S. J., ... Thompson, C. (2017). Implementation methods for the caring contacts suicide prevention intervention. Professional Psychology, Research and Practice, 48(5), 369-377. https://doi.org/10.1037/pro0000134
Schalley, S., Goldenstein, Kristi M., Graeve, T., Timmons, Z., Elshami, N., Beidas, R. S., & Hoffmann, Jennifer A. (2024). Retrospective evaluation of implementation of caring contacts for youth suicide prevention in an emergency department. Journal of the American College of Emergency Physicians Open, 5(5). https://doi.org/10.1002/emp2.13322
Skopp, N. A., Smolenski, D. J., Bush, N. E., Beech, E. H., Workman, D. E., Edwards-Stewart, A., & Belsher, B. E. (2023). Caring contacts for suicide prevention: A systematic review and meta-analysis. Psychological Services, 20(1), 74-83. https://doi.org/10.1037/ser0000645
Sorrell, J. M. (2020). Suicide in older adults. Journal of Psychosocial Nursing and Mental Health Services, 58(1), 17-20. https://doi.org/10.3928/02793695-20191218-04
Steinberg, R., Amini, J., Sinyor, M., Mitchell, R. H. B., & Schaffer, A. (2024). Implementation of caring contacts using patient feedback to reduce suicide‐related outcomes following psychiatric hospitalization. Suicide and Life-Threatening Behavior, https://doi.org/10.1111/sltb.13108
Termansen, P. E., & Bywater, C. (1975). S.A.F.E.R.: A follow-up service for attempted suicide in Vancouver. Canadian Psychiatric Association Journal, 20(1), 29-34. https://doi.org/10.1177/070674377502000106
Thomas, G. V., Camacho, E., Masood, F. A., Huang, Y., Valleru, J., Bridge, J. A., & Ackerman, J. (2024). Development and implementation of postdischarge text messages to adolescents with suicidal thoughts and behaviors through caring contacts: Implementation study. JMIR Pediatrics and Parenting, 7. https://doi.org/10.2196/51570
