• Bibtex: @skopp2023
  • Bibliography: 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

Example citation

The evidence to support reductions in suicide from Caring Contacts is inconclusive

Caring Contacts seems to reduce the rate of suicide attempts at one year follow-up

My notes

  • TO READ:
    • Hunt, 2009
  • k = 6, n = 6218
  • They discuss “optimal dose” of eight contacts in a year.
  • Only Comtois 2019 used text messages
  • 3 studies in US, 1 Australia, 1 New Zealand, 1 Iran
  • Five studies report data on death by suicide, the number of events were 1-10 in the groups.
  • Three studies report data on suicide attempt, number of events are 21-55.
    • RR for suicide attempts at 1 year was 0.57 (0.40 to 0.80).
  • A methodological limitation is retrospective self-report, and the authors argue that we should use medical records instead.
  • They don’t really discuss whether the CC is given to everyone after discharge or only those who refuse other treatment. In the original motto1976 study and in the hassanian-moghaddam2011 evaluation in Iran, it was either those who refused treatment or very little TAU. In other studies TAU has included more things. Perhaps this can explain the varying results.

The intervention entails sending a series of periodic and personalized text-based communications that express interest and concern for the recipient’s well-being without placing any demands for a response or action

Mechanisms of action? From Motto, 1976:

  • The forces that bind us willingly to life are mostly those exerted by our relationships with other people, whether they be intimately involved in our lives or influence us by other psychological processes.
  • A suicidal person can be encouraged to retain an interest in continued living, by regular and long-term contact with another person who expresses caring and concern about the former’s well-being.
  • The contact must be initiated by the concerned person and must put no demands or expectations on the other, in order to be experienced as an expression of unconditional concern and to have potential for reducing feelings of isolation and helplessness.
  • Such a program of continuing contact can exert a long-term suicide prevention influence on high-risk persons who cannot accept the established health care system

So reducing isolation and showing that there is another person that cares for you. Is something perhaps lost if we send text messages instead of postcards? In the meta-analysis they really emphasize the non-demanding form, e.g., not encouraging patients to engage with treatment or health-care in any way.

Meta-analysis results

Very few suicide events. Basically it’s only the Motto & Bostrom 2001 study that reports a reduction, but the total number of events are very small for suicide.

Small protective effect for repeat suicide attempt and hospitalization.


Caring Contacts (CC), a low-cost intervention originally designed and tested by Jerome Motto in 1976, remains one of the few strategies to demonstrate efficacy in the prevention of suicide deaths. Interest in CC has increased steadily over the last several years in tandem with rising U.S. suicide rates and the acceleration of suicide prevention initiatives. There have been several efforts to design interventions modeled after Motto’s strategy, and the recent publication of additional large-scale randomized controlled trials (RCTs) in alignment with the intent of Motto’s original model afford an opportunity to systematically review efficacy findings. The current systematic review provides an updated and focused analysis of the evidence supporting the efficacy of CC. A systematic literature search of MEDLINE, EMBASE, PsycINFO, Cochrane Library, and ClinicalTrials.gov was conducted, and PRISMA, Cochrane, and GRADE guidelines were followed. Of 2,746 abstracts reviewed, 13 publications, comprising six randomized controlled trials (RCTs) met inclusion criteria. The studies encompassed 6,218 participants across four countries and military, veteran, and civilian health care systems. The primary outcome was suicide mortality; secondary outcomes were suicide attempts and emergency department (ED) presentations/hospitalizations. The DerSimonian-Laird random-effects univariate meta-analysis was used to estimate summary effect sizes and evaluate statistical heterogeneity. Summary risk ratio estimates ranged from 0.57 to 1.29 across outcomes and time points; most estimates indicated a protective effect. For suicide deaths and ED presentations/hospitalization, interval estimates at 1-year postrandomization were consistent with either an increase or a decrease in risk. A protective effect was observed for suicide attempts at 1-year postrandomization. Implications and methodological recommendations for future work in this area reviewed and discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved). PDF: skopp_2023_caring_contacts_for_suicide_prevention_-_a_systematic_review_and_meta-analysis.pdf