H. Chen et al.: Mob ile Telepho ne Message Interventions with Suicide AttemptersPublishing Crisis 2010; Vol.

31(2):109112 2010 Hogrefe in China

Short Report

A Pilot Study of Mobile Telephone Message Interventions with Suicide Attempters in China
Hui Chen1,2, Brian L. Mishara1, and Xiao Xian Liu2
1

Centre for Research and Intervention on Suicide and Euthanasia, Universit du Qubec Montral, Canada 2 School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, China
Abstract. Background: In China, where follow-up with hospitalized attempters is generally lacking, there is a great need for inexpensive and effective means of maintaining contact and decreasing recidivism. Aims: Our objective was to test whether mobile telephone message contacts after discharge would be feasible and acceptable to suicide attempters in China. Methods: Fifteen participants were recruited from suicide attempters seen in the Emergency Department in Wuhan, China, to participate in a pilot study to receive mobile telephone messages after discharge. All participants have access to a mobile telephone, and there is no charge for the user to receive text messages. Results: Most participants (12) considered the text message contacts an acceptable and useful form of help and would like to continue to receive them for a longer period of time. Conclusions: This suggests that, as a low-cost and quick method of intervention in areas where more intensive follow-up is not practical or available, telephone messages contacts are accessible, feasible, and acceptable to suicide attempters. We hope that this will inspire future research on regular and long-term message interventions to prevent recidivism in suicide attempters. Keywords: suicide attempt, text message, intervention, prevention, recidivism

Suicide is the fifth leading cause of death in China. The annual suicide mortality rate is 23 per 100,000 population (Phillips, Li, & Zhang, 2002). In addition, it is estimated that 2 million suicide attempts occur per year (Phillips, Li et al., 2002). A national case-control psychological autopsy study revealed that having made a previous suicide attempt is an independent risk factor for suicide, with an adjusted odds ratio of 21.5 (Phillips, Yang et al., 2002). However, no systematic aftercare is provided to suicide attempters after they are discharged from emergency departments or inpatient settings (Phillips, Yang et al., 2002). The WHO multisite intervention study on suicidal behaviors (SUPREMISS) reported that practically no referral to any professional service was made for suicide attempters in Yuncheng, the selected research site in China, which reflects the nonexistence of referral services there (Fleischmann et al., 2005). This multisite research also demonstrated that a brief intervention and contact, which included an individual information session combined with systematic longterm contacts after discharge (phone calls or visits), can have a positive influence on preventing subsequent deaths from suicide up to 18 months (Fleischmann et al., 2008). Systematic follow-up contacts enhanced a feeling of connectedness and gave the patient a feeling of being seen and heard by someone (Wolk-Wasserman, 1986).
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An important target population for the prevention of repetition of suicidal behaviors is suicide attempters who either decline traditional postdischarge treatment or do not having access to aftercare assistance (Hawton & Fagg, 1988). In China, systematic aftercare for suicide attempters is generally not available. To date, there have been no randomized controlled studies of interventions with suicide attempters who do not have access to any formal postdischarge treatment (Bertolote et al., 2005; Fleischmann et al., 2005; Phillips, Yang et al., 2002). There is, however, evidence from the United States and Australia that minimal contact programs in the form of short letters or postcards may decrease the risk of repeated attempts (Motto & Bostrom, 2001). Long-term contact using these minimal interventions was associated with a significant reduction in some suicidal attempts. The postcards from the Edge project (Carter, Clover, Whyte, Dawson, & DEste, 2005) reduced repetitions of deliberate self-poisoning, but did not significantly decrease the proportion of individual attempters. These programs have been thought to prevent repeated suicide attempts by decreasing peoples sense of isolation and increasing feelings of connectedness. These programs have the advantage of using limited resources in terms of costs, equipment, and personnel (Carter et al., 2005, 2007; Motto & Bostrom, 2001; Wolk-Wasserman, 1986).
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Since mobile telephones and wireless local telephones are commonly used as the primary electronic communication method in China (Monthly report from Ministry of Information Industry of PRC, 2007), mobile phone text messages might be a feasible, effective, and economical method of assisting high-risk patients after their having been discharged from hospitals. This may help prevent recidivism in the developing world where continued outpatient treatment for suicide attempters is simply not available because of the costs in terms of personnel time involved. This pilot study tests the accessibility, acceptance, and feasibility of mobile telephone message interventions with suicide attempters. Our specific objectives were to determine whether a mobile telephone message intervention would be acceptable to suicide attempters, to explore the operational procedures of this intervention in order to help determine the appropriate content of supportive messages, and to test the feasibility of cell-phone message interventions.

Procedure
After the patient was medically stabilized in the emergency department or medical ward, an interview was conducted by a psychologist hired by the researchers, using an open-ended questionnaire focusing on precrisis treatment and postdischarge health care, which included questions on the patients accessibility to mobile telephone messages, their acceptance of long-term message interventions, the preferred content and form of the messages, and the support they may need after discharge. Sociodemographic information and the history of the current episode were obtained from clinical medical records. Mobile telephone messages began to be sent to patients in the first week after discharge and once a week during the first month, for a total of four contacts. The text messages were sent to the participants by one of the researchers (H.C.). At the end of 4 weeks the psychologist who conducted the original interview contacted all participants by telephone and interviewed them on their reactions to the mobile telephone messages.

Method
Study Participants and Setting
Wuhan is a metropolis with approximately 10 million inhabitants in central China, where the two major mobile telecom operators, China Mobile Communications Corporation and China Union Communications Corporation, have 7 million users. In addition, there are 1.5 million wireless local telephone users. The total number of mobile telephone users in Wuhan at the end of 2006 was 8.5 million of the 10 million inhabitants, and these population statistics include children who would not be expected to have a mobile phone (Wuhan Government, 2007). All these mobile telephones can receive text messages, and there is no charge to the user for text messages received. Participants were recruited from suicide attempters who had presented in the emergency departments of two general hospitals, Tongji Hospital and Union Hospital, in Wuhan, China. All persons who were seen in the emergency departments for a suicide attempts were invited to participate, the only exclusion criteria being of less than 18 years of age. Suicide attempt was defined using the WHO definition as nonfatal acts in which an individual deliberately causes selfinjury or ingests a substance in excess of any prescribed or generally recognized therapeutic dosage. Thus, all patients aged 18 and over seen at the two hospitals for a suicide attempt from October 1, 2007, to October 31, 2007, were invited to participate on a voluntary basis by a nurse in the emergency room. Those who agreed to participate were invited to sign an informed consent form. Of the 19 attempters during that month, 15 agreed to participate. Since there is no ethics committee at the participating hospitals, the study was submitted to the ethics committee of one of the coauthors and was approved by the Ethics Committee of the University of Quebec at Montreal, as well as by the directors of the emergency departments at the respective hospitals.
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Interview Questions
During the initial interview participants were asked about their history of seeking help and treatment for their problems, their knowledge of sources of help, and their expectations for support or help after discharge. They were also asked what they thought about receiving cell phone message contacts and for how long they would like to receive messages. They they were also invited to add any other information about aftercare they thought would be useful for the researchers to know. During the final interview 1 month later they were asked about the aftercare they had received, whether they had attempted suicide again, had considered suicide, and whether they thought they would attempt suicide again. They were asked to confirm that they had received all the messages, how they felt about the messages, whether they would like to receive the messages for a longer period of time. Finally, they were asked for suggestions about the messages and any other comments.

Mobile Telephone Messages

The same mobile telephone messages were sent to each participant, with different messages being sent each week for 4 weeks, beginning 1 week after discharge. The messages were standard supportive messages simple expressions of concern about whether the person was getting along well. The intent was to let the person know that the researchers were aware of his or her existence, to express positive feelings toward him or her, and to offer encouragement. The participants were invited to respond if they
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wished to. The first text message was: It has been about a week since you were here at the hospital, and we hope everything is going well for you. We would be glad to hear from you if you would like to do so. The second text message was: Compliance with doctors suggestion would be good for your health. Do not give up. We are always with you. The third text message was: If you have any problem in treatment, please dont hesitate to contact us, maybe we can help. The fourth text message was: It would be great to hear from you and let us share your feelings. Please keep contact with us.

Table 1. Demographic and clinical characteristics of the participants

Characteristics Gender Female Male Age (years) 1834 3564 Method of suicide attempt 9 6 12 3 No.

Results
Nineteen suicide attempters aged over 18 were seen in the emergency department in the month studied, 15 of whom agreed to participate in this study. The first four attempters we approached had their parents in the room at the time we asked for participation. In each of these four instances the parents interjected that their adult child would not participate in the study. It is not unusual in China for adult attempters to have their parents visiting them for extended periods during their hospitalization. After these initial negative experiences, we changed the procedure and asked for participation only when the parents were not in the room and then obtained 100% acceptance of participation from the remaining 15 attempters. The participants consisted of 12 females and 3 males, ranging from 18 to 56 years. Twelve of the participants had intentionally used self-poisoning with medications, agricultural poisons, or alcohol. Three of the participants had intentionally self-harmed by cutting themselves with sharp objects. Regarding the type of care received in the hospital, nine patients stayed under observation and treatment in the emergency department and were discharged directly from the emergency department, whereas six were transferred to the intensive care unit for further medical care before being discharged. The explanations given by the participants for their suicidal behaviors can be categorized into three groups: Eight patients told us they mainly hoped to manipulate others; they had had conflicts with relatives immediately before their selfharm behaviors, and somebody was nearby or in telephone contact when they tried to harm themselves. Five patients told us they hoped to die. Two patients hoped to have a temporary rest. Detailed demographic data are summarized in Table 1. None of the participants had sought any medical or psychosocial help from other persons before their suicide attempt. None of them knew of any other existing services or resources that could help. Ten participants thought there is no need to receive any follow-up treatment even if the physician would refer them. Five told us they would like to receive follow-up treatment if the physician would refer them. Regarding the mobile message contacts, all of the participants had cell phones and could receive text messages for free. All of the participants were willing to
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Self-poisoning with medications, agricultural poisons, or alcohol Self-harmed by cutting with sharp objects Type of care Stayed under observation/treatment in emergency department and discharged Transferred to the intensive care unit for further medical care before discharge

12 3

9 6

receive some supportive text messages after leaving the hospital. None of the participants responded to the weekly text message interventions after being discharged. After 4 weeks, we called each subjects to obtain their comments. At the time when we called them, none of them had ever been referred to professional services or received any aftercare assistance. Each of them said they had received all four text messages and had read them. Most of them (12) expressed appreciation for the concern about their well-being. They thought the text message contacts were acceptable and said they would like to receive them for a longer time. When asked about suggestions for the development of the text messages, they said it was fine and they had no specific suggestions. The other three participants thought it was not helpful for them and refused to receive any further messages. But they said they would keep our telephone number in case they might need our help in the future. When asking what kind of information or follow-up they would like to get, they just said they did not need any information.

Discussion
Suicide attempters rarely receive any professional aftercare services in China since referral systems and follow-up simply do not exist (Fleischmann et al., 2005; Phillips, Yang et al., 2002). They are also unaware of existing services or resources that may be helpful when they feel suicidal. Our pilot research found that mobile telephone text message intervenCrisis 2010; Vol. 31(2):109112

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tions could be a feasible and acceptable follow-up method with suicide attempters. All of the suicide attempters in our sample who were seen in emergency departments have access to a mobile telephone, and there is no charge for the user to receive text messages. After four message contacts, most of them thought it was acceptable and said they would like to receive the messages for a longer time. Even though three of the participants thought the content of the messages was not helpful, they still kept our telephone number as a useful resource. This suggests that they thought that they might someday seek help by contacting us in case of an emergency. This study has several important limitations, including the small sample size and the short follow-up period. The refusal by four of the participants when the family was present may constitute a source of sampling bias, but this information is quite useful for planning the recruitment methodology of future studies. Although none of the participants repeated a suicide attempt during the study, the evaluation of the effects on suicidal behavior was not an objective of this feasibility study. This was too small a sample to assess the effectiveness of the intervention in comparison with a treatment-as-usual control group. Since this was a small pilot study examining the feasibility of this method of intervention, we only used standard supportive messages expressing our greetings and concerns about their well-being. In future investigations we plan to continue providing text message for an extensive period of time, and we would like to compose individual messages with respect to the patients characteristics, previous text messages, and his or her comments on former messages. It would also be useful in future investigations besides assessing repeated suicidal behaviors to evaluate the effects of receiving text messages on help-seeking behavior, suicidal ideation and psychological distress. We conclude that this is a low-cost brief method of intervention, and that telephone text message contacts are accessible, feasible and acceptable to suicide attempters in China. We hope this will inspire future research using larger samples and randomized controlled trials to assess the effectiveness of long-term text message interventions to prevent recidivism in suicide attempters.

of hospital treated deliberate self poisoning. British Medical Journal, 331, 805809. Fleischmann, A., Bertolote, J. M., De Leo, D., Botega, N., Phillips, M., Sisask, M. et al. (2005). Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight lowand middle-income countries. Psychological Medicine, 35, 14671474. Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J. et al. (2008). Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86, 703709. Hawton, K., & Fagg, J. (1988). Suicide, and other causes of death, following attempted suicide. The British Journal of Psychiatry, 152, 359366. Monthly report from Ministry of Information Industry of Peoples Republic of China. (2007). Retrieved from http://www.mii. gov.cn/art/2007/04/30/art_166_30276.html Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 52, 828833. Phillips, M. R., Li, X., & Zhang, Y. (2002). Suicide rates in China, 199599. Lancet, 359, 835840. Phillips, M. R., Yang, G. H., Zhang, Y. P., Wang, L. J., Ji, H. Y., & Zhou, M. G. (2002). Risk factors for suicide in China: A national case-control psychological autopsy study. Lancet, 360, 17281736. Wolk-Wasserman, D. (1986). Suicidal communication of persons attempting suicide and responses of significant others. Acta Psychiatrica Scandinavica, 73, 481499. Wuhan Government. (2007). Wuhan annual report. Beijing: China Statistics Press.

About the authors Hui Chen, PhD, is Associate Professor in the Department of Maternal and Child Health, Injury Control Research Center, School of Public Health, Yongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China. This study was conducted when Dr. Chen was a Postdoctoral Fellow in the Strategic Transdisciplinary Postdoctoral Training Programme on Research on Suicide and Suicide Prevention at the Centre for Research and Intervention on Suicide and Euthanasia at the Universit du Qubec Montral, funded by the Canadian Institutes for Health Research. Brian L. Mishara, PhD, is Director of the Centre for Research and Intervention on Suicide and Euthanasia and Professor of Psychology at the Universit du Qubec Montral. Xiao Xian Liu is Professor in the Injury Control Research Center, School for Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.

References
Bertolote, J. M., Fleischmann, A., De Leo, D., Bolhari, J., Botega, N., De Silva, D. et al. (2005). Suicide attempts, plans, and ideation in culturally diverse sites: The WHO SUPRE-MISS community survey. Psychological Medicine, 35, 14571465. Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & DEste, C. (2007). Postcards from the EDge: 24-month outcomes of a randomized controlled trial for hospital-treated self-poisoning. British Journal of Psychiatry, 191, 54853. Carter, G. L., Clover, K., Whyte, I. M., Dawson A. H., & DEste C. (2005). Postcards from the EDge project: Randomized controlled trial of an intervention using postcards to reduce repetition
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Brian L. Mishara CRISE UQAM CP 8888, Succ Centre-ville Montral QC H3C 3P8, Canada Tel. +1 514 987-4832, Fax +1 514 987-0350 E-mail mishara.brian@uqam.ca
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