[Suicidal behavior in light of COVID-19 outbreak: Clinical challenges and treatment perspectives]. / Épidémie de COVID-19 et prise en charge des conduites suicidaires : challenge et perspectives.

OBJECTIVE: The COVID-19 pandemic affected today more than 3,000,000 worldwide, and more than half of humanity has been placed in quarantine. The scientific community and the political authorities fear an epidemic of suicide secondary to this crisis. The aim of this review is to analyze the impact of the COVID-19 pandemic on the dimensions of the suicidal process and its interaction with the various risk factors. We also propose innovative strategies to manage suicidal behavior in the context of pandemic. METHODS: We carried out a narrative review of international publications dealing with major pandemics (COVID-19, SARS) and their influence on suicidal vulnerability. RESULTS: Many factors are likely to increase the emergence of suicidal ideation and suicide attempts during this crisis. Social distancing and quarantine could increase the feeling of disconnection and the perception of social pain in vulnerable individuals. Some populations at high suicidal risk could be further impacted by the current pandemic: the elderly, medical staff and individuals exposed to economic insecurity. Several innovative tools adapted to the constraints of social distancing and quarantine may prevent suicide risk: e-health, VigilanS, buddhist-derived practices and art engagement. CONCLUSIONS: This unprecedented crisis may interact with certain dimensions of the suicidal process. However, it is time to innovate. Several suicide prevention tools all have their place in new modes of care and should be tested on a large scale.

[An example of post-discharge monitoring after a suicide attempt: VigilanS]. / Un exemple de système de veille post-hospitalière des suicidants : VigilanS.

BACKGROUND: Attempted suicide is a major risk factor of further re-attempts and death. Self-harm behaviors are related to multiple causes explaining why it is ineffective to have a single and simple strategy to offer after the clinical assessment in reducing morbidity and mortality. Furthermore, treatment adherence is known to be especially poor in a context where social connection seems compromised and a source of pain. Effective interventions can be divided into two categories: intensive intervention programs (care at home, supported by a series of brief psychotherapy interventions) and case management programs that rely on a "stay in contact" dimension. These programs, initiated by Jerome Motto and its short letters may consist of: (1) sending letters or postcards after discharge of the ER; (2) giving a crisis card that offers a crisis telephone line and a crisis unit for hospitalization if needed, and; (3) placing a phone call at some time distance after the discharge. The aim is to enhance a "connectedness feeling" with the patient. These different strategies have proven to be even more effective in some specific subgroups, highlighting the heterogeneity of this population. Each modality of contact was well accepted and generated a positive involvement of the patients. METHOD: It led to the idea of combining these different strategies in an algorithm built on the specificity of identified subgroups. A randomized controlled trial, named ALGOS was carried out in France to test this algorithm in 2011. The algorithm consisted of: (1) delivering a crisis card for first attempters; (2) giving a phone call for re-attempters to re-assess their situation between the 10th and 21st day after their discharge, and to propose a new intervention if needed, and; (3) in case of an unsuccessful call or a refusal of proposed care, sending personalized postcards for 6 months. All of this was supported with shared information to the general practitioner of the patient. This study was further adapted to routine care in 2015 in the northern departments of France, Nord and Pas-de-Calais (4.3 million people), taking the name of VigilanS. The inclusion consists of sending a form for every patient assessed after a suicide attempt in the two departments to the medical staff of VigilanS in order to provide information about the patient and the context of his suicide attempt. The algorithm has been modified in giving the crisis card to all the patients whether it is a first attempt or not. An information letter, explaining the aim of the monitoring is also given to the patient, and to his general practitioner. The calling staff is composed of 4 nurses and 4 psychologists, all trained in suicidal crisis management. They use a phone platform located in the Emergency Medical Assistance Service (SAMU) of the Nord department on a halftime basis and manage the incoming calls from the patients as well as the outgoing calls towards the patients, their relatives and their medical contacts. A set of 4 postcards (1 per month) can be sent if needed in case of an inconclusive or a failed phone call. CONCLUSION: Built on a monitoring philosophy, VigilanS has further developed a real crisis case management dimension requiring enough time to insure an effective medical supervision and strong networking abilities. A specific time is also needed to take care of all the technical aspects of the organization. This program expertise, designed by Northern departments to prevent suicide, can be shared with other French or even foreign territories.