Role of postcards in reducing suicidal behaviour

The article by Hassanian-Moghaddam et al ¹ provides useful insights into the potential utility of postcard intervention in reducing suicidal behaviour. The authors by virtue of this study have found that among participants who had self-poisoned, nine postcards sent sequentially over a period of 12 months produced reduction in suicidal ideation and suicide attempts. The study deserves accolades for various reasons, including a large sample from a non-Western population and a randomised control design, ensuring an over 90% retention rate and nearly equal rates of loss to follow-up in both groups. The results of the study are illuminating but their generalisability and applicability in day-to-day clinical practice needs to be analysed against the backdrop of following limitations.

1. (a) The study provided for assessment of outcomes only at 12 months. It would have been better if the assessments were performed more frequently such as once in 2 or 3 months.

2. (b) The study at no point assessed suicidal intent among participants.

3. (c) Instead of employing any standard sampling technique, the participants of the study included consecutive individuals with poisoning, admitted from March to June 2006 in the Loghman-Hakim Poison Hospital.

4. (d) Baseline assessment did not include a comprehensive psychiatric evaluation that could have ascertained the specific psychiatric diagnosis of the participants and permitted subgrouping of the participants based on psychiatric diagnosis, thereby providing a valuable opportunity to study the differential impact of postcard intervention in reducing suicidal ideation and suicidal attempt among the participants with different psychiatric disorders.

5. (e) There is no mention in the article of whether the delivery of the postcards was confirmed by the recipients.

6. (f) The participants were masked to study outcomes but the research psychologist was not masked to allocation, and this could have inadvertently influenced responses at follow-up.

7. (g) Individuals may have got some clue about the study outcomes from the questions asked of them and this could have influenced the final results of the study.

8. (h) A small minority of participants withdrew from the postcard intervention but the specific reasons for the same were not assessed.

To make the postcard intervention more acceptable and effective, one needs to ascertain the specific reasons which made the participants withdraw from this intervention.