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Effect of Augmenting Standard Care for Military Personnel With Brief Caring Text Messages for Suicide Prevention: A Randomized Clinical Trial

Open access
Comtois, Katherine Anne, Kerbrat, Amanda H., DeCou, Christopher R., Atkins, David C., Majeres, Justine J., Baker, Justin C., Ries, Richard K.·2019·JAMA Psychiatry
DOI 10.1001/jamapsychiatry.2018.4530PMC PMC6495345
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Abstract

Importance: Accessible and cost-effective interventions for suicidality are needed to address high rates of suicidal behavior among military service members. Caring Contacts are brief periodic messages that express unconditional care and concern and have been previously shown to prevent suicide deaths, attempts, ideation, and hospitalizations. Objective: To test the effectiveness of augmenting standard military health care with Caring Contacts delivered via text message to reduce suicidal thoughts and behaviors over 12 months. Design, Setting, and Participants: This randomized clinical trial was conducted at 3 military installations in the southern and western United States. Soldiers and Marines identified as being at risk of suicide were recruited between April 2013 and September 2016. The final follow-up was in September 2017. Interventions: Both groups received standard care, and the Caring Contacts group also received consisted of 11 text messages delivered on day 1, at week 1, at months 1, 2, 3, 4, 6, 8, 10, and 12, and on participants' birthdays. Main Outcomes and Measures: Primary outcomes were current suicidal ideation and suicide risk incidents (hospitalization or medical evacuation). Secondary outcomes were worst-point suicidal ideation, emergency department visits, and suicide attempts. Suicidal ideation was measured by the Scale for Suicide Ideation, suicide risk incidents, and emergency department visits by the Treatment History Interview; attempted suicide was measured by the Suicide Attempt Self-Injury Count. Results: Among 658 randomized participants (329 randomizely assigned to each group), data were analyzed for 657 individuals (mean [SD] age, 25.2 [6.1] years; 539 men [82.0%]). All participants reported suicidal ideation at baseline, and 291 (44.3%) had previously attempted suicide. Of the 657 participants, 461 (70.2%) were assessed at 12 months. Primary outcomes were nonsignificant. There was no significant effect on likelihood or severity of current suicidal ideation or likelihood of a suicide risk incident; there was also no effect on emergency department visits. However, participants who received Caring Contacts (172 of 216 participants [79.6%]) had lower odds than those receiving standard care alone (179 of 204 participants [87.7%]) of experiencing any suicidal ideation between baseline and follow-up (odds ratio, 0.56 [95% CI, 0.33-0.95]; P = .03) and fewer had attempted suicide since baseline (21 of 233 [9.0%] in the group receiving Caring Contacts vs 34 of 228 [14.9%] in the standard-care group; odds ratio, 0.52 [95% CI, 0.29-0.92]; P = .03). Conclusions and Relevance: This trial provides inconsistent results on the effectiveness of caring text messages between primary and secondary outcomes, but this inexpensive and scalable intervention offers promise for preventing suicide attempts and ideation in military personnel. Additional research is needed. Trial Registration: ClinicalTrials.gov identifier: NCT01829620.

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  • Sending caring text messages over one year to active military personnel who had reported a suicide attempt or suicidal ideation lowered subsequent suicide attempts by almost half.

    “Another study used a similar approach by sending caring text messages over one year to active military personnel who had reported a suicide attempt (50%) or suicidal ideation, but not in the context of discharge from hospital or ED. The intervention lowered subsequent suicide attempts by almost half.(114)”

    From Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review (2021) · cites this paper as [114]

    The Primary Outcomes section (page unavailable) reports 48% lower odds of at least one suicide attempt during follow-up with caring texts (9.0% vs 14.9%), supporting the main finding. The Participant Characteristics section reports that 44.3%, not 50%, had a lifetime suicide attempt and that 53.0% were referred from an inpatient unit. The paper does not establish the citing sentence’s categorical description that the intervention was outside the context of hospital discharge. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • A recent RCT with suicidal military personnel found that those receiving caring contacts via text message were less likely to have any suicidal ideation and fewer attempts from baseline to 12 months.

    “The investigators found that those receiving caring contacts via text message were less likely to have any suicidal ideation and fewer attempts from baseline to 12 months.”

    From One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths (2019) · cites this paper as [36]

  • In the same RCT, the likelihood or severity of suicidal ideation and the number of suicide risk incidents were not significantly different between groups.

    “However, the likelihood or severity of suicidal ideation and the number of suicide risk incidents (i.e., hospitalization or medical evacuation) were not significantly different between groups.”

    From One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths (2019) · cites this paper as [36]

  • Tests for small-study effects are known to risk false-positive detection when fewer than 10 studies are included or between-study heterogeneity is substantial.

    “Although these tests are a widely used method for estimating small study effects, there is known risk of false-positive detection of small study effects when fewer than 10 studies are included in the analysis or there is substantial between-study heterogeneity.13,14”

    From Association of Suicide Prevention Interventions With Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systematic Review and Meta-analysis (2020) · cites this paper as [13]

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Authors
Comtois, K. A., Kerbrat, A. H., DeCou, C. R., Atkins, D. C., Majeres, J. J., Baker, J. C., & Ries, R. K.
Affiliations
  • University of Washington (US)
  • Womack Army Medical Center (US)
  • Naval Medical Center Camp Lejeune, Camp Lejeune, North Carolina
Corresponding author
Kerbrat, Amanda H.
ORCID
Venue
JAMA Psychiatry
Publisher
American Medical Association (AMA)
Published
2019-05-01
Volume
76
Issue
5
Pages
474
ISSN
2168-622X (ISSN-L)
DOI
10.1001/jamapsychiatry.2018.4530
PMC
PMC6495345
OpenAlex
W2911417286
Cited by
144
References
33
Citations by year
2026: 15 · 2025: 21 · 2024: 16 · 2023: 15 · 2022: 20 · 2021: 32 · 2020: 11 · 2019: 13
FWCI
22.02
Type
journal article
Language
en
Open access
Locations
  • JAMA Psychiatry (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institutes of Health (2t32hd057822-16)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (T32, HD057822)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Social Psychology › Mental Health via Writing
Keywords
suicide prevention, suicidal ideation, suicide attempts, military personnel, text messaging intervention, suicide prevention funding, suicide prevention education
MeSH terms
Military Health, Suicide Prevention, Adult, Female, Humans, Male, Military Personnel, Suicide, Suicide, Attempted, Young Adult, Suicidal Ideation, Text Messaging

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