Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study

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Given that an index suicide attempt is a strong predictor of future suicide, intervening with individuals who have recently attempted suicide is a targeted prevention approach that can be delivered within the public health system and has potential to be scaled up across low-resource settings. Aim To test the implementation and preliminary effectiveness of Contact and Safety Planning (CASP) in reducing suicidal behaviour and symptoms of depression among adults with a recent suicide attempt in Chhattisgarh. Methods We will carry out a non-randomized, controlled pilot study to evaluate the feasibility, acceptability, adoption, reach, implementation (including cost) and preliminary effectiveness of CASP when delivered by health workers – emergency nurses and Community Health Officers – in two districts of Chhattisgarh (n=250). The control group will receive Enhanced Usual Care, consisting of telephonic counselling by trained District Mental Health (n=250) program staff. Data will be collected at baseline and at 6- and 12-month follow- up. Conclusion This study will shed light on the feasibility of CASP and inform its further refinement to address suicide at scale in India. Trial Registration Clinical Trials Registry India (CTRI/2022/12/048087) dated 1 October 2022. Link here. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-279/v2", "name": "Health worker delivered Contact and Safety Planning (CASP) for suicide..." } } ] } Home Browse Health worker delivered Contact and Safety Planning (CASP) for suicide... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Kumar S, Negi S, Tripathy S et al. Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.12688/f1000research.159494.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Revised Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] Sonali Kumar https://orcid.org/0000-0002-8926-8374 1 , Sapna Negi 1 , Snehasish Tripathy 1 , [...] Derek deBeurs 2 , Deepa Pandit 1 , Dr Ben Wijnen 3 , Dr Lakshmi Vijayakumar https://orcid.org/0000-0003-2471-9004 4 , Laura Shields Zeeman 3 , Soumitra Pathare https://orcid.org/0000-0001-9311-9024 1 Sonali Kumar https://orcid.org/0000-0002-8926-8374 1 , Sapna Negi 1 , [...] Snehasish Tripathy 1 , Derek deBeurs 2 , Deepa Pandit 1 , Dr Ben Wijnen 3 , Dr Lakshmi Vijayakumar https://orcid.org/0000-0003-2471-9004 4 , Laura Shields Zeeman 3 , Soumitra Pathare https://orcid.org/0000-0001-9311-9024 1 PUBLISHED 06 Oct 2025 Author details Author details 1 Centre for Mental Health Law & Policy, Indian Law Society, Pune, Maharashtra, 400005, India 2 University of Amsterdam, Amsterdam, The Netherlands 3 Trimbos-instituut, Utrecht, The Netherlands 4 SNEHA, Chennai, India Sonali Kumar Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Sapna Negi Roles: Methodology, Project Administration, Writing – Review & Editing Snehasish Tripathy Roles: Methodology, Project Administration, Writing – Review & Editing Derek deBeurs Roles: Conceptualization, Supervision, Writing – Review & Editing Deepa Pandit Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Dr Ben Wijnen Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Dr Lakshmi Vijayakumar Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Review & Editing Laura Shields Zeeman Roles: Supervision, Writing – Review & Editing Soumitra Pathare Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Global Public Health gateway. This article is included in the Society for Mental Health in Low- and Middle-Income Countries (SoMHiL) gateway. Abstract Background India records the highest number of suicide deaths globally, but suicide prevention efforts are hindered by a lack of trained personnel within the public health system. Given that an index suicide attempt is a strong predictor of future suicide, intervening with individuals who have recently attempted suicide is a targeted prevention approach that can be delivered within the public health system and has potential to be scaled up across low-resource settings. Aim To test the implementation and preliminary effectiveness of Contact and Safety Planning (CASP) in reducing suicidal behaviour and symptoms of depression among adults with a recent suicide attempt in Chhattisgarh. Methods We will carry out a non-randomized, controlled pilot study to evaluate the feasibility, acceptability, adoption, reach, implementation (including cost) and preliminary effectiveness of CASP when delivered by health workers – emergency nurses and Community Health Officers – in two districts of Chhattisgarh (n=250). The control group will receive Enhanced Usual Care, consisting of telephonic counselling by trained District Mental Health (n=250) program staff. Data will be collected at baseline and at 6- and 12-month follow- up. Conclusion This study will shed light on the feasibility of CASP and inform its further refinement to address suicide at scale in India. Trial Registration Clinical Trials Registry India (CTRI/2022/12/048087) dated 1 October 2022. Link here. READ ALL READ LESS Keywords Suicide prevention, India, Safety planning, Brief interventions, Health system Corresponding Author(s) Sonali Kumar ( [email protected] ) Close Corresponding author: Sonali Kumar Competing interests: No competing interests were disclosed. Grant information: Funding for this project is provided by Mariwala Health Initiative (MHI), India, to Indian Law Society, Pune, India. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Kumar S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Kumar S, Negi S, Tripathy S et al. Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.12688/f1000research.159494.2 ) First published: 10 Mar 2025, 14 :279 ( https://doi.org/10.12688/f1000research.159494.1 ) Latest published: 06 Oct 2025, 14 :279 ( https://doi.org/10.12688/f1000research.159494.2 ) Revised Amendments from Version 1 In this revised version, we made changes to improve clarity and transparency in response to reviewer feedback. In the Methods section, we have added descriptions of participant retention strategies (including the number and type of follow-up contact attempts), as well as procedures for participant withdrawal and criteria for loss to follow-up. To improve our description of the setting and context, we expanded upon our descriptions of the control districts, detailing their populations and comparability to the intervention districts. We clarified which measures are applied to both intervention and control groups by revising the Aims section and adding a table specifying measurement by study arm. We further elaborated on the selection process for the cost sub-sample and described recruitment and consent procedures for the cost analysis in control districts. To address long-term implementation concerns, we have clarified how the transition of supervision from the research team to the health system will be explored over the course of the study through formative and outcome interviews, which we describe in the Methods section. Additionally, we revised terminology throughout the manuscript to replace “completed suicide” with “died by suicide” in line with current best practices. In this revised version, we made changes to improve clarity and transparency in response to reviewer feedback. In the Methods section, we have added descriptions of participant retention strategies (including the number and type of follow-up contact attempts), as well as procedures for participant withdrawal and criteria for loss to follow-up. To improve our description of the setting and context, we expanded upon our descriptions of the control districts, detailing their populations and comparability to the intervention districts. We clarified which measures are applied to both intervention and control groups by revising the Aims section and adding a table specifying measurement by study arm. We further elaborated on the selection process for the cost sub-sample and described recruitment and consent procedures for the cost analysis in control districts. To address long-term implementation concerns, we have clarified how the transition of supervision from the research team to the health system will be explored over the course of the study through formative and outcome interviews, which we describe in the Methods section. Additionally, we revised terminology throughout the manuscript to replace “completed suicide” with “died by suicide” in line with current best practices. See the authors' detailed response to the review by Nikki Lyka van Eijk See the authors' detailed response to the review by Seonaid Cleare READ REVIEWER RESPONSES Introduction Suicide is a leading threat to the well-being of communities globally, and particularly in India which reports the highest number of suicide deaths in the world. 1 Although Indians make up 18% of the world’s population, India accounts for 26.6% of suicides globally. 2 Since 2017, suicide rates in India have increased steadily with suicide ranking as the first and second leading cause of death among young women and men aged 18-39 respectively. 3 , 4 Data from the National Crime Records Bureau (NCRB) indicates an upward trajectory, with a national suicide rate of 12.4 per 100,000 individuals in 2022 up from 12 in 2021, marking the highest rate in NCRB history. 4 This is despite a recognized under-reporting of suicides in India by as much as 30-100%. 3 , 5 Chhattisgarh, a central Indian state, has a suicide rate of 28.2 per 100,000 (2022), the fourth highest among states in India and more than double the national suicide rate of 12.4 per 100,000. 4 The Chhattisgarh District Mental Health Program (DMHP) was designed to offer telephonic and in-person follow-up counselling for individuals who have attempted suicide; however, most DMHP clinics are unable to implement the intended program due to a dearth of specialized providers, such as psychiatrists, psychologists or counsellors trained to respond to suicide. Consequently, in many districts, there is no follow-up by a professional after a suicide attempt, despite prior research demonstrating that a previous suicide attempt is one of the strongest predictors of future attempts. 6 , 7 Although the State Government of Chhattisgarh is drafting a State Suicide Prevention Strategy (not yet published); the lack of human resources is a significant constraint in the state which necessitates the mobilization of public health resources to implement suicide response and prevention measures. Contact and Safety Planning (CASP) is an adaptation of brief intervention and contact (BIC) and safety planning interventions, methods which have been effective in reducing suicidal behavior among high-risk individuals worldwide. 7 – 10 CASP was developed and adapted from evidence-based safety interventions for the Indian context by SNEHA, Chennai and showed to be effective, feasible and acceptable when delivered among a refugee population in Tamil Nadu. 8 BIC has been effective in reducing repeat suicides in a 5-country study 11 , 12 and is recommended by the World Health Organisation (WHO) as an effective intervention to reduce suicides and attempted suicides in the general population. 13 Safety planning interventions have been found to reduce fatal and non-fatal suicide attempts in a recent meta- analysis 9 and when tested in conjunction with brief contact among veterans in the US. 14 Leveraging the public health system to deliver CASP may be a promising solution to address the treatment gap for suicide in Chhattisgarh and similarly low-resourced settings, however, the feasibility and acceptability of a health-systems approach for CASP is yet to be determined. This study will integrate CASP into the public health system by training non-specialist health workers to identify and follow up with adults who have recently attempted suicide in two districts where the DMHP is not providing any response to suicide attempts (due to personnel shortages). We will train two groups of health workers: (1) nurses in emergency wards of health centres to identify and recruit adults who have attempted suicide from emergency wards, and (2) Community Health Officers (CHOs) at community-based Health and Wellness Centers (HWCs) to deliver the CASP intervention in the community over an 11-week follow-up period. Follow ups by CHOs will include suicide risk assessments, provision of emotional support and empathetic listening, and collaborative safety planning to identify steps a participant can follow if they are in distress. Steps include identifying symptoms of distress, recognizing coping mechanisms and planning for future use of coping strategies, activating support networks, referrals for professional care and sharing details of the nearest emergency services. The first follow up visit will occur within one week of discharge from a healthcare facility post-attempt, and then continue periodically over the immediate 11-week period afterward. Protocol Aims The primary aims of this study are to assess the feasibility, acceptability, reach, adoption and implementation (including cost) of delivering the CASP intervention within the public health system in Chhattisgarh. The secondary aim is to assess: • Difference in rate of suicide re-attempt at 6 and 12 month follow up between intervention and control groups, • Preliminary impact on suicidal behaviour and symptoms of depression at 6 and 12 month follow up within the intervention group only. For the purposes of this study, suicidal behaviour is defined as inclusive of suicidal intention, ideation, planning and fatal or non-fatal suicide attempt. Study design The CASP intervention will be tested in the form of a 1:1 non-randomized, controlled pilot study. The pilot study will consist of two arms, comparing the CASP intervention in the two districts of Balod and Rajnandgaon against Enhanced Usual Care in the two districts of Mungeli and Balodabazar. Setting The Central Indian state of Chhattisgarh, formerly a part of Madhya Pradesh, was granted statehood in 2000 and is the ninth largest state in India (estimated population 25.5 million). 15 , 16 75% of the population live in rural areas and the state has the highest tribal population among large states in India with one-third of its population belonging to tribal communities. 16 , 17 Chhattisgarh is divided into 32 districts as of 2021, 28 of which are covered by the Government’s District Mental Health Program (DMHP). 18 In 2022, Chhattisgarh contributed 4.9% of India’s suicide burden, with a rate of 28.2 per 100,000 people, more than twice the national average (12.0). 4 According to the National Mental Health Survey (2016), approximately 0.28% of the population in Chhattisgarh is at high risk of suicide, with the highest risk group being 18–29-year-olds. 15 As per the NCRB, factors which contribute to suicide in Chhattisgarh include financial difficulties among men such as bankruptcy or indebtedness, and marriage related problems among both men and women. 4 The mental health treatment gap is also high in Chhattisgarh, ranging from 54.5 % (for psychosis) to 80.1% (for common mental disorders). 19 Intervention district selection 16 Rajnandgaon is home to an estimated 1.8 million people, with 82.27% residing in rural areas. The population includes 26% Scheduled Tribe (ST) and 10% Scheduled Caste (SC) communities and shows a 52% work participation rate. As a larger district, Rajnandgaon consists of 6.02% of the state’s population. It comprises 9 blocks with 1 district hospital, 1 medical college, 10 community health centres, and 47 primary health centres. Balod district is home to approximately 0.8 million people, with 88% living in rural areas. 31% of the population belong to ST communities, and 8% to SC communities. The district’s work participation rate is 51%, and it is divided into 5 blocks and 704 villages. The healthcare infrastructure includes 1 district hospital, 5 community health centres, and 30 primary health centres. Both districts lack follow-up care for attempted suicide cases in healthcare facilities, a gap this study aims to address by training health workers placed at multiple levels of the health system in these districts. Control district selection Balodabazar and Mungeli are two predominantly rural districts in Chhattisgarh. Balodabazar has a total population of approximately 1.31 million, with 87.25% residing in rural areas. The district’s population includes 23.37% Scheduled Castes (SC) and 12.8% Scheduled Tribes (ST). The district is administratively divided into six blocks and is served by one district hospital, six community health centres (CHCs), and 31 primary health centres (PHCs). Mungeli has a smaller population of approximately 0.70 million, with an even higher rural proportion (90.67%). Its population comprises 27.76% SC and 10.37% ST. Mungeli consists of three blocks and is served by one district hospital, three CHCs, and 28 PHCs. Like Balod and Rajnandgaon, Balodabazar and Mungeli are characterized by a predominantly rural, socially disadvantaged population and limited health infrastructure. Participants We will recruit adults (≥18 years of age), who present to emergency public health facilities (district hospitals, primary or community health centers) in Balod and Rajnandgaon districts with attempted suicide or are already admitted for attempted suicide within one week of the study start date. We will exclude individuals who are unable to communicate clearly due to medical conditions or speech/hearing disabilities despite reasonable accommodations, those unable to comprehend one of the local languages used by CHOs to deliver the intervention, and individuals who do not reside within the catchment area of Balod and Rajnandgaon Health and Wellness Centers (where trained CHOs are placed). Study interventions CASP was developed specifically for individuals at risk of suicide by SNEHA Suicide Prevention Center (Chennai, India) 8 and incorporates two evidence-based components: brief contact 7 , 11 and safety planning. 9 Its core focus revolves around establishing periodic connections with individuals who have recently survived suicide attempts, alongside a collaborative effort to create and track progress using personalized safety planning cards intended for distressing as well as crisis situations. Within this framework, emergency nurses will report details (name of health facility, age and gender of participant) to the project team who communicate this to Community Health Officers (CHOs) from that locality. A nearby CHO will then follow up with and visit the consenting individual at a time and place of their choosing, within the upcoming week. The timing of these visits will adhere to the contact schedule outlined in the multi-site WHO suicide study, SUPRE-MISS (1, 2, 4, 7, and 11 weeks after the attempt). 10 , 12 During these visits, CHOs will extend emotional support, gauge the level of risk, and jointly work with the individual to identify personal warning signs, coping strategies, and available support mechanisms (safety planning). Safety planning 8 , 9 will be carried out by the CHO with the participant in a quiet and confidential setting after each participant has received their own safety planning card. Safety planning will be a collaborative exercise wherein the CHO will guide the participant through each step involved in safety planning and help the participant to fill in the card. Participants will be encouraged to refer to their safety planning card when they are distressed, and their use will be monitored during visits. The primary objective of the safety planning card is to support participants when they experience suicidal thoughts and urges by reminding them of coping mechanisms that make them feel better, people they can reach out to and actions they can take to make their environment safer. Referrals to social benefits: Many suicides occur spontaneously in periods of crisis where there is a breakdown in coping mechanisms for life stressors, such as financial difficulties, sudden illness or managing a chronic illness, relationship difficulties, etc. According to the National Crime Records Bureau (2022), family issues and illness are the main contributors to suicide in India, accounting for 32% and 18% of all suicides in 2022 respectively, while ‘Unemployment’ accounted for 1.9% and ‘Bankruptcy or indebtedness’ accounts for 4.1% suicides. 4 Thus, increasing access to state provided social benefits and schemes which focus on unemployment and livelihood support can help address some of these risk factors. CHOs will be trained to refer individuals in need of social security and support (e.g., government-provided employment or pension benefits, disability schemes, etc.) to the appropriate government workers, and all CHOs will have a list of locally available schemes and programs which they can use to match people to schemes and provide further information during visits. Control condition: Enhanced Usual Care (EUC) In Chhattisgarh, usual care under the DMHP includes a telephonic follow-up, where a social worker or a clinical psychologist at the DMHP clinic provides counselling for an individual who has recently attempted suicide, and invites them to visit the DMHP clinic in person to receive continued support. However, some clinics (such as in as our intervention districts) do not have any existing follow up care for suicide due to staff shortages, and so the CASP pathway will serve as the primary follow-up response in these districts. In the control districts, participants will receive Enhanced Usual Care (EUC). EUC will consist of the usual care provided by the District Mental Health Plan (DMHP) in Balodabazar and Mungeli, which have an active DMHP program staffed by a social worker, a nurse as well as a psychiatric nurse, a clinical psychologist and a Medical Officer (MO) (a medical professional based in primary and community care clinics). DMHP personnel in control districts are trained in telephonic counselling for mental health and suicide which they apply while carrying out follow-up calls for suicide attempts. Moreover, the DMHP in the control districts carry out monthly mental health awareness raising camps in the community to increase awareness around mental health and their services (this is not occurring in the intervention districts). The CASP team will also provide a brief training with DMHP staff in control districts covering suicide, its prevalence and associated risk factors, and myth busting around suicide prevention. Recruitment & Retention Individuals presenting at district hospitals, Primary Health Centres (PHCs), or Community Health Centres (CHCs) following a suicide attempt will be identified by casualty nurses, who will screen for eligibility and invite those meeting the criteria to participate in the study. After providing a brief explanation of the study, the nurses will obtain verbal consent from interested individuals and notify the research team via telephone, sharing details such as the participant’s village of residence and hospital discharge date. The research team will then assign a Community Health Officer (CHO) from the nearest Health and Wellness Center to follow up with the participant at a time and place of their convenience. Within one week of discharge, the CHO will meet the participant, obtain written informed consent, and initiate follow-up care as per the CASP intervention protocol. During the informed consent process, the CHO will explain the study’s purpose, procedures, and the potential risks and benefits of participation, emphasizing that involvement is entirely voluntary. Participants will receive a consent form and an information sheet detailing the study objectives, procedures, and the contact information of CASP research team members, enabling them to seek clarifications or address concerns at any point during the study. To support participant retention in the study, we will make up to five contact attempts over a two-week period following each scheduled follow-up appointment. These attempts will include a combination of telephone calls and in-person home visits (where feasible and safe). If a participant misses a follow-up but can be contacted later, they will still be approached for subsequent follow-ups at later time points. For participants who actively request to discontinue follow-ups, the study team will first explore and address any concerns to encourage continued participation. However, if the participant continues to decline, they will be formally withdrawn from the intervention and no further contact will be made. Sample size Since the present study is a pilot study (focused primarily on understanding feasibility and refining processes in anticipation of a full-scale trial), the sample size calculation is based on a conservative assumed rate of the secondary outcome (change in suicide attempts) of 10% at the end of 12 months in the control group. Thus, a minimum enrolment of 500 participants (250 control; 250 intervention) has a power of 80% (at a 2-sided alpha level of 0.05) to detect an absolute risk reduction of 10 percent points (minimal detectable difference of 10% between the groups (intervention and control), while allowing for an expected 20% loss to follow-up over the 12 months follow-up period. Training All emergency nurses and Community Health Officers (CHOs) in the selected districts will be required to undergo CASP training, organized by the state government. The training sessions will be conducted by Master Trainers, a cadre of Rural Medical Assistants (RMAs) who will first receive a three-day training led by the study’s Principal Investigators (SP and LV). RMAs, trained under the Chhattisgarh RMA scheme, are formally qualified medical personnel working across Health and Wellness Centres in the state. CHOs will participate in a two-day training program covering key topics such as understanding suicide and associated risk factors, empathetic communication, safety planning, suicide risk assessment, contact procedures, data recording, privacy and confidentiality, emergency response protocols, and self-care strategies to mitigate burnout. Emergency nurses from all Primary Health Centres (PHCs), Community Health Centres (CHCs), and District Hospitals will undergo a one-day training delivered by Master Trainers. This training will focus on understanding suicide and its risk factors, empathetic communication, and obtaining verbal consent for study participation. Additionally, a one-day refresher training will be provided to all health workers six months after the initial training to reinforce key concepts. Training materials will also be made available to health workers throughout the study to support their ongoing learning and implementation of CASP protocols. Supervision In-person supervision will occur once a month in the districts and will be carried out by the research team. At supervision meetings, CHOs who are conducting follow-ups and nurses at the hospitals will be invited to meet with the research team and discuss challenges in implementation and carrying out of project tasks. Implementation of the project activities will be supported by the Master Trainers who are based in health facilities in the chosen districts, as well as by the District Coordinators who oversee CHOs in the districts. Outcomes As this is a pilot study, the primary outcomes of interest are related to its implementation, specifically: reach, adoption, implementation (including cost), feasibility and acceptability, as summarized in Table 1 . The RE-AIM framework will serve as the guiding conceptual framework for the primary outcomes in this study. 20 , 21 Secondary outcomes include suicidal behaviour (including intention, ideation, planning and fatal or non-fatal suicide attempt) and symptoms of depression over a 6- and 12-month follow-up period. Table 1. Implementation outcomes, indicators and timepoints of data collection. Outcome Indicator Data source Data collection Reach 1) Absolute number and proportion of people who agreed to join the study Study data (Nurses records) Process data (during study period) 2) Participant attrition/retention rate at endline (5 sessions) Study data (CHOs records) 3) Demographic characteristics of participants compared to non-participants (Refusals and Lost to Follow up cases 1 ) Study records Adoption Nurses: Number and % of health centres where participants were identified and recruited Study records Process data (during study period) CHOs: Number and % of trained CHOs who deliver the CASP intervention Implementation Of intervention: Proportion of CASP sessions which were delivered as per CASP intervention delivery schedule (on time) CHO records Process data (during study period) Of training: Change in knowledge, attitudes and skills of delivery agents (CHOs) Pre-post survey of knowledge, skills and attitudes Pre-pilot and at 18 months (sustained impact) Intervention costs, costs of (healthcare) resource use and quality of life TiC-P and EQ-5D-5L with random sub-sample of 50 participants per condition (n=100) Baseline and 6 months follow up Feasibility Extent to which health workers felt CASP is feasible to deliver Semi-structured interviews with a purposive sample of health workers (n=20) After concluding participant recruitment Acceptability Extent to which participants felt CASP is acceptable In-depth interviews with a random sample of n=20 participants per district (total n=40) After final contact point 1 Lost to Follow Up refers to individuals who have provided verbal consent to nurses in emergency wards, but with whom we have not been able to make subsequent contact and so therefore have not been formally recruited into the study. Primary outcome measures A brief survey collecting data on age, gender, education, marital status, employment status, caste/tribal background and income will be used to collect participant demographic information. Reach will be measured by the absolute number, proportion, and representativeness of individuals who participate in CASP and how representative participants are compared to the target population. Adoption will be measured by the absolute number and proportion of health facilities and intervention agents who are willing to initiate and carry out CASP. Feasibility will be measured using semi-structured interviews exploring the perceptions of health workers and supervisors on the extent to which CASP is viable as a suicide prevention response within the health system. Within these interviews, we will also explore the feasibility of health system adoption beyond the study, e.g. what supervision pathways can be established for maintenance and scale-up of the programme (as during the pilot, supervision will be carried out by the research team). Acceptability of intervention delivery will be measured qualitatively via the same interviews with health workers and supervisors specifically to assess comfort with the CASP training and intervention content. Acceptability for participants will be measured qualitatively via in-depth interviews with a random sample of n=20 participants per district (total n=40) after their last session of CASP which will explore participant comfort with CASP session content and structure and to solicit feedback for adaptations to the intervention. Implementation is defined as 1) the intervention agents’ adherence to the CASP schedule of session delivery (1, 2-, 4-, 7- and 11-weeks contact points), 2) the impact of the CASP training program and 3) the costs of the intervention. Timeliness of CASP sessions as delivered by CHOs will be measured via program data, specifically CHO records. Knowledge and skills improvement due to the CASP training will be measured by a pre-post knowledge and skills assessment with nurses and CHOs. Cost will be assessed from the health system (costs required to run the program), patient (healthcare expenses, quality of life), and societal (e.g. productivity losses) perspectives with a sub-sample of participants from the main participant pool in both arms. The sub-sample will be selected using a simple random number generator, ensuring every participant in the main sample has an equal probability of inclusion and minimizing selection bias. If a participant has been selected as part of the cost sub-sample, the cost data will be collected along with the rest of the study data that is relevant at that timepoint. The health system costs will be stratified based on the agencies incurring the cost and the nature of the cost (start-up capital cost and recurrent costs). The random sub-sample of participants in the intervention and control groups (n=100, 25 per district) will be asked about their medical costs and productivity losses in the previous four weeks using a modified Treatment Inventory of Costs in Patients (TIC-P) (Hindi) 22 at baseline and at 6 months follow up. The TiC-P is a reliable instrument for collecting data on healthcare utilization and productivity loss in patients with mental health problems. 22 Quality of life will be assessed using the Hindi EuroQol-5D-5L (EQ-5D-5L) at baseline and at 6 months follow up. The EQ-5D-5L is a quality-of-life measure which has been widely used in India. 23 It measures quality of life via five dimensions, namely mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension is measured by a Likert scale containing five levels spanning from a no problem to an extreme problem level. Secondary outcome measures 1. Suicidal behavior A modified Hindi version of the Columbia Suicide Severity Rating Scale (C-SSRS) Modified Screener Version 24 will measure suicidal behavior (suicidal intention, ideation, planning and fatal and non-fatal suicide attempt) at baseline and 6- and 12- month follow up. The Modified C- SSRS Screener is a semi-structured tool which measures the risk of suicide by inquiring about suicidal behaviour in the person’s lifetime (baseline) and since the last contact point (follow up). The screener consists of 6 questions and can be completed in a few minutes. For the purposes of this study, a lifetime measure was added to the screener to collect data on previous history of suicide ideation and behaviour at baseline. Specifically, the tool explores: 1. The presence of thoughts about suicide (suicidal ideation), 2. Actions taken by the individual, in relation to preparing for suicide, 3. Instances when the person has either attempted suicide or initiated a suicide attempt that was interrupted by another person or halted voluntarily, and the timing of this (lifetime, since last contact). The C-SSRS has been translated in over 60 countries (including Hindi, and in India) and takes approximately 5 minutes to complete when administered as a clinical interview. The scale can be used by non-specialists across a range of settings, including healthcare settings. 2. Symptoms of depression The Hindi Patient Health Questionnaire (PHQ-9) 25 assessment can be used as a screening tool as well as measures of symptom severity for depression. The nine-item PHQ-9 uses a 4- point Likert-scale with items ranging from 0 (not at all) to 3 (nearly every day). The PHQ-9 has been validated, widely used, and found to be suitable for use in India. 26 Data collection Baseline demographic data—including age, gender, education, marital status, employment status, caste/tribal background, income, and contact details—will be collected by Community Health Officers (CHOs) from consenting participants. Study records will include the following: (1) record books maintained by nurses at health facilities, documenting the date, age, gender, method of attempt, verbal consent status, and, if applicable, reasons for refusal; and (2) CHO records detailing the dates and locations of participant visits to monitor adherence to the CASP intervention schedule (at 1, 2, 4, 7, and 11 weeks post-attempt). For outcome assessments, the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Patient Health Questionnaire-9 (PHQ-9) will be administered to participants in the intervention group at baseline and during follow-ups at 6 and 12 months. Within the control arm, a brief follow up survey will be administered that captures suicide re-attempt at 6 and 12 month follow up points. Data collection will be conducted by trained data collectors, who are local Master’s graduates in mental health or related fields with prior experience in the health system. To support the cost analysis and economic evaluation, a brief cost survey (Modified TiC-P) and the EuroQol-5D-5L will be administered to a random sample of 50 participants in both the intervention and control groups at baseline and at the 6-month follow-up. Data collection will be conducted using paper-and-pencil assessments or self-administered forms, based on participant preference. Qualitative follow-up data will be collected through in-depth and semi-structured interviews, lasting approximately one hour each. These interviews will be conducted by research team members and audio recorded with prior informed consent for transcription purposes. Acceptability interviews with participants will include a random sample selected independently of intervention completion status, ensuring the inclusion of individuals who may have dropped out of the study. See Figure 1 for research and data collection procedures. Figure 1. Flowchart of research procedures. Data analysis Implementation outcomes Descriptive statistics (means, medians and standard deviations) of the reach, adoption and implementation metrics will be calculated. Qualitative thematic analysis 27 of the in-depth interviews exploring feasibility and acceptability will be carried out using a mix of inductive and deductive approaches. Two coders will independently review transcripts, generate initial codes, and collaboratively develop a comprehensive codebook (initial coding). This will be followed by a pilot coding phase to ensure procedural consistency before independent coding of the remaining transcripts, with discrepancies resolved through consensus or third-rater consultation. Researchers will then interpret and refine final themes. Coding will be done using NVivo 1.4.1. Clinical outcomes 1. Difference in percentage of re-attempted suicide and death by suicide We will analyze the difference between the intervention and control group in the percentage of participants who, after initial visit in the hospital for a suicide attempt, have re-attempted suicide (including deaths by suicide) at 6 and 12 months of follow-up. For statistical analysis, we will use Bayesian binominal testing as implemented in the open software program JASP. 28 Bayesian analysis allows us to not only test whether the null hypothesis is true or false, but also to test how likely the alternative hypothesis (that the change in suicide rates between intervention and control) is given the data. 29 , 30 2. Change in depression, suicide risk and TiC-P scores The mean change in depression and suicidal behavior scores between baseline and 6- and 12- months follow-up within the intervention group will be calculated using Bayesian linear mixed models as implemented in JASP. Models will be estimated both with and without a random effect for location, to see if it is needed to control for any clustering effect. 31 3. Quality of life Analyses using EQ-5D-5L data will be presented in various ways. A basic subdivision will be made according to the structure of the EQ-5D-5L: 1) Presenting results from the EQ-5D-5L descriptive system as a health profile for each dimension; 2) Presenting results of the EQ VAS (visual analog scale) as a measure of overall self-rated health status, and 3) Presenting results from the EQ-5D-5L index values. The index values, presented in country specific value sets, are a major feature of the EQ-5D-5L instrument, facilitating the calculation of quality-adjusted life years (QALYs) that are used to inform economic evaluations of health care interventions. Mean change in QOL from baseline to end of follow-up will be presented separately in both control and intervention arms. An appropriate Bayesian linear mixed model using logit link and ordinal family will be employed depending on the data. 4. Economic evaluation The cost analysis will evaluate the CASP program from health system (program implementation costs), patient (e.g., healthcare expenses, quality of life), and societal (e.g., productivity losses) perspectives. Healthcare expenses and productivity losses will be measured using the TiC-P, and quality of life will be assessed with the EQ-5D-5L. Implementation costs will be calculated by the research team based on start-up and recurring costs. Patient costs will be calculated using a bottom-up (micro-costing) approach: each item in the TiC-p will be multiplied by an appropriate unit cost and summed to provide an overall total cost. Given that references’ prices do not exists for India, unit prices will be determined based on previous studies 32 and international recommendations. 33 All cost prices will be converted to the 2024 price levels. Using EQ-5D-5L utilities, the area under the curve method will be used to compute quality-adjusted life years (QALYs) by using the utilities at baseline and 6 months follow-up (i.e. linear interpolation). The economic evaluation will constitute a cost-utility analysis with QALYs as central outcome. To simultaneously evaluate both costs and outcomes, baseline-adjusted seemingly unrelated regression equations (SURE) models will be used. Given that costs are usually non-normally distributed the SURE models will be bootstrapped (2,500 times). To allow for intention to treat analysis, single imputation (based on predictive mean matching) nested in each bootstrap simulation will be used, as recommended by Brand and colleagues. 34 For each bootstrap simulation, incremental cost-effectiveness ratios (ICERs) will be calculated by dividing the incremental costs by the incremental QALYs, resulting in the costs per QALY gained. Next, ICERs will be plotted on a cost-effectiveness plane and a cost effectiveness acceptability curve (CEAC) will be constructed to determine the probabilities that the new intervention is cost-effective given a range of WTP values for a QALY. 35 Given the lack of formal WTP thresholds, a WTP ceiling of three times the national annual gross domestic product (GDP) per capita has been recommended. 36 Sensitivity analyses will be directed towards the main drivers of costs and QALYs. Data management and confidentiality All participants will be identified by a Participant ID which is a code assigned to them when they enroll in the study. The only document which will contain both their name and their ID will be the Informed Consent Form. Signed informed consent forms will be kept in a locked cupboard in the Chief Medical Health Officer’s office in each district. After participants sign informed consent, all further forms will only contain their ID, not their name. A master sheet with all participant names and the corresponding IDs will be saved on a password-protected sheet which is only accessible by the research associates, project manager and PIs. Data entry will be done by research associates of the project. Potential harms Any untoward medical occurrence, and/or (b) serious adverse events: suicide attempt, death due to suicide, death due to other causes, violence experienced by the participant, violence experienced by any other family member, and unplanned hospitalization will be reported. Although suicide attempt and death by suicides are outcome variables, we will also monitor them as if they are serious adverse events to ensure that the intervention is not associated with increase in suicide/attempted suicides. Protocol amendments In the event of significant protocol modifications, our research team will promptly communicate changes in eligibility criteria, outcomes, analyses, and other vital aspects to the Indian Law Society Ethical Review Board in India, CTRI trial registry and Utrecht University, Netherlands Ethical Approval Board. Progression criteria To determine if this study will proceed to a randomized controlled trial, we have developed progression criteria based on recommendations put forth by Mellor et al. (2023). 37 The progression criteria is focused on assessing the feasibility of the study design and the feasibility and appropriateness of the intervention, indicated in Table 2 below. Table 2. Progression criteria for primary outcomes. Outcome Progression criteria Feasibility of participant recruitment Minimum recruitment rate of 50% of eligible participants Feasibility of intervention design • Retention of participants: <30% loss to follow up at 6-month data collection • Retention of CHOs: <20% of CHOs discontinue delivery of CASP sessions Intervention implementation Delivery of the intervention judged as highly feasible and acceptable by health workers and participants through qualitative data These criteria have been selected considering practical limitations and contextual factors that may challenge the feasibility of integrating CASP into the existing health system, for e.g. lack of government resources to incentivize new tasks for health workers, significant distances to be travelled between facilities and participant homes (without adequate travel compensation) for CHOs, and stigma around suicide. As this is the first integration of CASP within the existing health system, one key focus of this study is to assess the impact of practical and contextual limitations and identify where and how we can adapt the study processes to better suit low resourced public health settings (where the scope for scale-up is largest). Red Amber Green traffic light approach 37 : Keeping the abovementioned contextual factors in mind, if after the completion of the pilot study the progression criteria are not met by more than 20% as per quantitative data, and the study is not found to be feasible as per qualitative data, this will be considered under the Red threshold and further exploration of this approach will not be considered. If the criteria are within a 20% range (lower than indicated), this will be considered within the Amber threshold and a reassessment will be carried out by the steering committee and relevant stakeholders, and appropriate adaptations of the intervention and trial processes will be made. If the criteria are met or exceeded by study data, then the intervention will be considered feasible and further assessment in a definitive trial may be explored. Dissemination Dissemination of study findings will be done via the following channels: a) academic publications in peer reviewed, open access journals; b) development and dissemination of an easy-to-understand policy brief that highlights the study’s key findings and recommendations, geared towards policy-makers and stakeholders of the continued implementation or scale-up of CASP within the health system; and c) dissemination meetings within the districts in Chhattisgarh where the research was carried out, as well as among academic networks, healthcare professionals and relevant suicide prevention stakeholders. Study status Participant recruitment and follow-up data collection for the CASP study is ongoing; data collection will conclude in November 2025. Discussion This pilot study evaluates the implementation and preliminary effectiveness of a contact and safety planning (CASP) intervention delivered by trained health workers for suicide prevention in Chhattisgarh, India. While CASP has been previously tested among a refugee population in South India, 8 this study is the first to adapt and integrate CASP for an at-risk population within the public health system. By assessing the intervention’s feasibility, reach, acceptability, adoption, and early indications of effectiveness and cost, this study seeks to generate critical evidence for suicide prevention within the health system in low-resource settings. Conducted in collaboration with the Chhattisgarh Department of Health and Family Welfare, CASP aims to address systemic challenges felt within the health system for suicide prevention in Chhattisgarh. For example, in the control districts of Mungeli and Balodabazar, while DMHP staff provide brief follow-ups and counseling for individuals who attempt suicide and present to emergency wards in district health centres, most other districts lack adequate personnel to fulfil these roles. As a result, attempted suicides often go unattended to. Additionally, nurses in emergency wards are not trained to identify and sensitively respond to attempted suicides, which can influence the care provided and medical decision-making in emergency settings. 38 Training emergency nurses and Community Health Officers (CHOs) as a key link between emergency departments—a common point of contact for individuals at risk—and the community provides a promising pathway to address these gaps. We anticipate challenges when implementing this study. The unexpected doubling of the CHO trainee pool due to the placement of over 200 additional CHOs in district Health and Wellness Centres poses logistical difficulties for keeping to the study timeline and carrying out supervision and coordination with CHOs. Stigma around suicide within families and communities may hinder follow-ups and which are central to this model. Additionally, the lack of systematic data collection on suicide attempts and follow-ups in control districts complicates the evaluation. To mitigate this, data collectors will conduct weekly visits to engage with primary and community health centres and support in improving the consistency and quality of data collection and reporting at this level. This study is timely and essential, given the growing global public health burden of suicide, particularly in low- and middle-income countries (LMICs). It addresses critical gaps in the literature regarding effective suicide prevention interventions in community settings and explores barriers and facilitators to implementation in under-resourced contexts. 39 Furthermore, it provides a practical perspective on the potential of health worker training at multiple levels to enhance suicide prevention efforts, and explores the ability for this programme to be scalable within and by the health system. Findings from this study will contribute to the definitive testing of CASP as a scalable intervention and inform strategies for integrating suicide prevention programs within public health systems in LMICs. Conclusion The knowledge generated through this study will inform the future testing and scale-up of CASP across Chhattisgarh and other regions in India where specialist care and targeted suicide prevention initiatives are minimal. By examining factors influencing the successful implementation of CASP in public health systems, this study will support researchers, health professionals, and policymakers in addressing the suicide prevention gap in low-resource settings. It offers a crucial step toward reducing repeat suicide attempts and enhancing community-level responses to suicide in LMICs. Ethics and consent Ethical approval has been obtained from Indian Law Society’s Institutional review board (ILS/173B/2022) dated 26 September 2022, the University of Utrecht Ethical Review Board, Netherlands (#23-0003) dated 1 October 2022 and the Clinical Trials Registry India (CTRI) (CTRI/2022/12/048087) for this study. All procedures will be done in adherence to guidelines outlined in the Declaration of Helsinki, including obtaining written informed consent from participants, ensuring confidentiality, and protecting participants’ rights, privacy and well-being. Written consent will be collected by Community Health Officers in the intervention districts and by data collectors in the control districts. Authorship of any publications which emerge from this project will be agreed upon by all authors based on individual contribution to the manuscript, project implementation, concept, steering, and evaluation. Author contributions SK and SN drafted the manuscript. LV conceptualized the original intervention, SP and SK with guidance of LV designed the present intervention. SN, ST, LSZ, DdB, BW, LV and SP reviewed the manuscript, provided multiple rounds of edits and feedback, and approved the manuscript for submission. DP developed the plans for sampling and data analysis. Data availability Data collected as part of the study outlined in this protocol: Study data, after de-identification, can be shared with researchers whose proposed use of the data has been approved by an independent review committee. Data will be available 12 months after end of trial for up to 5 years and all requests for data must be directed to the Principal Investigators of the study. Reporting guidelines This protocol followed the SPIRIT guidelines. A completed SPIRIT checklist is attached in the Supplementary Materials along with this manuscript, and a SPIRIT figure can be found in the Zenodo depository. DOI: https://doi.org/10.5281/zenodo.14507570 . 40 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements We would like to acknowledge Dr. Sumi Jain and her team at the Department of Health and Family Welfare, Chhattisgarh, for their substantial contributions to the implementation and development of this project. References 1. Institute for Health Metrics and Evaluation: Global Health Data Exchange.2021. (Accessed Feb 1, 2023). Reference Source 2. Amudhan S, Gururaj G, Varghese M, et al. : A population-based analysis of suicidality and its correlates: findings from the National Mental Health Survey of India, 2015–16. Lancet Psychiatry. 2020; 7 (1): 41–51. PubMed Abstract | Publisher Full Text 3. Dandona R, Kumar GA, Dhaliwal RS, et al. : Gender differentials and state variations in suicide deaths in India: The Global Burden of Disease Study 1990–2016. Lancet Public Health. 2018; 3 (10): e478–e489. PubMed Abstract | Publisher Full Text | Free Full Text 4. National Crime Records Bureau: Accidental deaths and suicides in India. New Delhi: Ministry of Home Affairs, Government of India; 2022. 5. Patel V, Ramasundarahettige C, Vijayakumar L, et al. : Suicide mortality in India: a nationally representative survey. Lancet. 2012; 379 (9834): 2343–2351. PubMed Abstract | Publisher Full Text | Free Full Text 6. World Health Organization: Suicide - India. Reference Source [cited 2023 Sept 8]. 7. Inagaki M, Kawashima Y, Yonemoto N, et al. : Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis. BMC Psychiatry. 2019; 19 (1): 1–1. Publisher Full Text 8. Ijayakumar L, Mohanraj R, Kumar S, et al. : CASP – An intervention by community volunteers to reduce suicidal behaviour among refugees. Int. J. Soc. Psychiatry. 2017; 63 (7): 589–597. 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Bouwmans C, De Jong K, Timman R, et al. : Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P). BMC Health Serv. Res. 2013; 13 (1): 1–9. 23. Jyani G, Prinja S, Kar SS, et al. : Valuing health-related quality of life among the Indian population: a protocol for the Development of an EQ-5D Value set for India using an Extended design (DEVINE) Study. BMJ Open. 2020; 10 (11): e039517. PubMed Abstract | Publisher Full Text | Free Full Text 24. The Columbia Lighthouse Project: Guidelines for Triage Using the C-SSRS. [Accessed June 21, 2021]. Reference Source 25. Kroenke K, Spitzer RL, Williams JBW: The PHQ-9. J. Gen. Intern. Med. 2001; 16 (9): 606–613. PubMed Abstract | Publisher Full Text | Free Full Text 26. De Man J, Absetz P, Sathish T, et al. : Are the PHQ-9 and GAD-7 suitable for use in India? A psychometric analysis. Front. Psychol. 2021; 12 : 1688. 27. Braun V, Clarke V: Thematic analysis. Washington, DC: American Psychological Association; 2012. 28. JASP Team: JASP (Version 0.17.3) [Computer software].2023. 29. van Doorn J , van den Bergh D , Böhm U, et al. : The JASP guidelines for conducting and reporting a Bayesian analysis. Psychon. Bull. Rev. 2021; 28 : 813–826. PubMed Abstract | Publisher Full Text | Free Full Text 30. Eylem O, van Straten A , de Wit L , et al. : Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK: the feasibility of a randomized controlled trial of a guided online intervention. Pilot Feasibility Stud. 2021; 7 : 1–8. Publisher Full Text 31. Twisk JWR: Applied multilevel analysis: a practical guide for medical researchers. Cambridge: Cambridge University Press; 2006. 32. Pathare S, Shields-Zeeman L, Vijayakumar L, et al. : Evaluation of the SPIRIT Integrated Suicide Prevention Programme: study protocol for a cluster-randomised controlled trial in rural Gujarat, India. Trials. 2020; 21 : 1–13. Publisher Full Text 33. Mayer S, Berger M, Konnopka A, et al. : In search for comparability: the PECUNIA reference unit costs for health and social care services in Europe. Int. J. Environ. Res. Public Health. 2022; 19 (6): 3500. PubMed Abstract | Publisher Full Text | Free Full Text 34. Brand J, van Buuren S , le Cessie S , et al. : Combining multiple imputation and bootstrap in the analysis of cost-effectiveness trial data. Stat. Med. 2019; 38 (2): 210–220. PubMed Abstract | Publisher Full Text | Free Full Text 35. Drummond MF, Sculpher MJ, Claxton K, et al. : Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2015. 36. Marseille E, Larson B, Kazi DS, et al. : Thresholds for the cost–effectiveness of interventions: alternative approaches. Bull. World Health Organ. 2014; 93 : 118–124. Publisher Full Text 37. Mellor K, Albury C, Dutton SJ, et al. : Recommendations for progression criteria during external randomised pilot trial design, conduct, analysis and reporting. Pilot Feasibility Stud. 2023; 9 (1): 59. PubMed Abstract | Publisher Full Text | Free Full Text 38. McCarthy M, McIntyre J, Nathan R, et al. : Factors influencing emergency department staff decision-making for people attending in suicidal crisis: a systematic review. Arch. Suicide Res. 2024 Jan 2; 28 (1): 35–49. PubMed Abstract | Publisher Full Text 39. Kasal A, Táborská R, Juríková L, et al. : Facilitators and barriers to implementation of suicide prevention interventions: Scoping review. Cambridge Prisms: Glob. Ment. Health. 2023; 10 : e15. Publisher Full Text 40. Zenodo: Supplementary materials to protocol paper. http Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 10 Mar 2025 ADD YOUR COMMENT Comment Author details Author details 1 Centre for Mental Health Law & Policy, Indian Law Society, Pune, Maharashtra, 400005, India 2 University of Amsterdam, Amsterdam, The Netherlands 3 Trimbos-instituut, Utrecht, The Netherlands 4 SNEHA, Chennai, India Sonali Kumar Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Sapna Negi Roles: Methodology, Project Administration, Writing – Review & Editing Snehasish Tripathy Roles: Methodology, Project Administration, Writing – Review & Editing Derek deBeurs Roles: Conceptualization, Supervision, Writing – Review & Editing Deepa Pandit Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Dr Ben Wijnen Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Dr Lakshmi Vijayakumar Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Review & Editing Laura Shields Zeeman Roles: Supervision, Writing – Review & Editing Soumitra Pathare Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Funding for this project is provided by Mariwala Health Initiative (MHI), India, to Indian Law Society, Pune, India. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 06 Oct 2025, 14:279 https://doi.org/10.12688/f1000research.159494.2 version 1 Published: 10 Mar 2025, 14:279 https://doi.org/10.12688/f1000research.159494.1 Copyright © 2025 Kumar S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Kumar S, Negi S, Tripathy S et al. Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.12688/f1000research.159494.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 06 Oct 2025 Revised Views 0 Cite How to cite this report: Eijk NLv. Reviewer Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.188309.r420844 ) The direct URL for this report is: https://f1000research.com/articles/14-279/v2#referee-response-420844 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Oct 2025 Nikki Lyka van Eijk , Leiden University, Leiden, The Netherlands Approved VIEWS 0 https://doi.org/10.5256/f1000research.188309.r420844 I thank the authors for their detailed response and their adaptations to the protocol. ... Continue reading READ ALL I thank the authors for their detailed response and their adaptations to the protocol. I believe the article has improved significantly, with more clarity being provided on key points. Competing Interests: No competing interests were disclosed. Reviewer Expertise: suicide, implementation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Eijk NLv. Reviewer Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.188309.r420844 ) The direct URL for this report is: https://f1000research.com/articles/14-279/v2#referee-response-420844 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 10 Mar 2025 Views 0 Cite How to cite this report: Eijk NLv. Reviewer Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.175227.r397270 ) The direct URL for this report is: https://f1000research.com/articles/14-279/v1#referee-response-397270 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 20 Aug 2025 Nikki Lyka van Eijk , Leiden University, Leiden, The Netherlands Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.175227.r397270 Dear editor, The authors describe a well-written study protocol for a brief intervention targeting suicide attempt survivors in Chhattisgarh, India. The choices made by the authors reflect that this is an initial pilot, with a potential randomized ... Continue reading READ ALL Dear editor, The authors describe a well-written study protocol for a brief intervention targeting suicide attempt survivors in Chhattisgarh, India. The choices made by the authors reflect that this is an initial pilot, with a potential randomized controlled trial following based on their results. The rationale of the study is clear, with high suicide rates in India overall, and the district being the fourth highest in the country. While this district has support in place in theory, the authors describe that logistical problems prevent the DMHP clinics from carrying out these services in several areas. An interventions such as CASP that does not require highly skilled individuals would allow for a more sustainable scale-up than the current system if proven effective. Considering that this is a pilot study, I believe the study design to be appropriate for answering the research questions. An ambitious combination of data sources is planned, including records, surveys, and interviews. The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study. In general, the methodology of the study is well-written and detailed, though mostly on the intervention group. As a reader, I have several questions regarding the control group that remain unanswered in this protocol. I would suggest the following changes: On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population? Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group. Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO. On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation. I also have one minor remark: P.7 word is missing between measured and semi-structured. Overall, this study is relevant and timely. With some clarifications to the methods, I believe this protocol would be improved and a good starting point for future (hybrid) randomized trials. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: suicide, implementation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Eijk NLv. Reviewer Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.175227.r397270 ) The direct URL for this report is: https://f1000research.com/articles/14-279/v1#referee-response-397270 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Oct 2025 Sonali Kumar , Centre for Mental Health Law & Policy, Indian Law Society, Pune, 400005, India 06 Oct 2025 Author Response Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised ... Continue reading Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised the manuscript accordingly. Our detailed responses are: “The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study.” Response: Thank you for pointing this out. To clarify, when calculating the sample size for this study we considered population-level and facility-based data. Chhattisgarh has a suicide rate of 28.2 per 100,000 population, and suicide attempts are generally estimated to occur 20 times more frequently than suicide deaths. Given the combined population of Balod and Rajnandgaon districts is approximately 2.6 million, this corresponds to an estimated 14,600 suicide attempts annually. However, 2020–2021 state-level data from Chhattisgarh (unpublished) indicated that approximately 6,595 suicide attempts were recorded in public health facilities in Balod, suggesting that only a small proportion of attempts are presenting to or being recorded in health facilities. Using this data as a conservative proxy, we estimated that approximately 25–30% of attempts in the two study districts would present to public health facilities, resulting in 3,500–4,000 potentially eligible cases per year. Assuming 15–20% eligibility and consent, we anticipated that recruiting 500 participants over 12 months would be feasible. “On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population?” Response: Thank you; we have now included descriptions of the control districts in the Methods section (p.6). Balodabazar has a population of approximately 1.31 million, with 87.25% residing in rural areas. The population includes 23.37% Scheduled Castes (SC) and 12.8% Scheduled Tribes (ST). The district is administratively divided into six blocks and is served by one district hospital, six community health centres (CHCs), and 31 primary health centres (PHCs). Mungeli has a population of approximately 0.70 million, with 90.67% living in rural areas. Its population comprises 27.76% SC and 10.37% ST. Mungeli consists of three blocks and is served by one district hospital, three CHCs, and 28 PHCs. Like Balod and Rajnandgaon, Balodabazar and Mungeli are predominantly rural, socially disadvantaged districts with limited health infrastructure, making them comparable to the intervention districts. “Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group.” Response: We understand and have clarified in the Aims section (p.5) and have added a table to the manuscript (p.13) that specifies which measures are applied to both intervention and control groups (and vice versa). We hope this helps with clarity of the study design. “Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO.” Response: The cost sub-sample will be selected using a simple random number generator ( https://www.randomizer.org/ ), ensuring every participant in the main sample has an equal probability of inclusion and minimizing selection bias. For recruitment in the control districts, data on hospital admissions for suicide attempts will be obtained from health facilities. Research assistants (RAs) will contact cases telephonically to introduce the project and obtain verbal consent. Data collectors will then follow up with patients at their home (or a preferred location, specified by them) to collect study data. If a participant has been selected as part of the cost sub-sample, the cost data will be collected along with the rest of the study data that is relevant at that timepoint. We have now clarified both processes in the Methods section (p.11). “On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation.” Response: We appreciate this important point and it is a key consideration for us as well. We have now included in the Methods and Discussion section (p.11, p.16) that a key objective of the pilot is to assess the feasibility of transitioning supervision from the research team to Master Trainers who are embedded within the health system. This transition will be explored through formative and follow-up interviews with participants and health system stakeholders to map a supervision pathway that is feasible for the programme’s continued adoption within the health system. We'd like to thank you again for your feedback on this paper and hope our responses have helped strengthen its clarity. Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised the manuscript accordingly. Our detailed responses are: “The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study.” Response: Thank you for pointing this out. To clarify, when calculating the sample size for this study we considered population-level and facility-based data. Chhattisgarh has a suicide rate of 28.2 per 100,000 population, and suicide attempts are generally estimated to occur 20 times more frequently than suicide deaths. Given the combined population of Balod and Rajnandgaon districts is approximately 2.6 million, this corresponds to an estimated 14,600 suicide attempts annually. However, 2020–2021 state-level data from Chhattisgarh (unpublished) indicated that approximately 6,595 suicide attempts were recorded in public health facilities in Balod, suggesting that only a small proportion of attempts are presenting to or being recorded in health facilities. Using this data as a conservative proxy, we estimated that approximately 25–30% of attempts in the two study districts would present to public health facilities, resulting in 3,500–4,000 potentially eligible cases per year. Assuming 15–20% eligibility and consent, we anticipated that recruiting 500 participants over 12 months would be feasible. “On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population?” Response: Thank you; we have now included descriptions of the control districts in the Methods section (p.6). Balodabazar has a population of approximately 1.31 million, with 87.25% residing in rural areas. The population includes 23.37% Scheduled Castes (SC) and 12.8% Scheduled Tribes (ST). The district is administratively divided into six blocks and is served by one district hospital, six community health centres (CHCs), and 31 primary health centres (PHCs). Mungeli has a population of approximately 0.70 million, with 90.67% living in rural areas. Its population comprises 27.76% SC and 10.37% ST. Mungeli consists of three blocks and is served by one district hospital, three CHCs, and 28 PHCs. Like Balod and Rajnandgaon, Balodabazar and Mungeli are predominantly rural, socially disadvantaged districts with limited health infrastructure, making them comparable to the intervention districts. “Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group.” Response: We understand and have clarified in the Aims section (p.5) and have added a table to the manuscript (p.13) that specifies which measures are applied to both intervention and control groups (and vice versa). We hope this helps with clarity of the study design. “Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO.” Response: The cost sub-sample will be selected using a simple random number generator ( https://www.randomizer.org/ ), ensuring every participant in the main sample has an equal probability of inclusion and minimizing selection bias. For recruitment in the control districts, data on hospital admissions for suicide attempts will be obtained from health facilities. Research assistants (RAs) will contact cases telephonically to introduce the project and obtain verbal consent. Data collectors will then follow up with patients at their home (or a preferred location, specified by them) to collect study data. If a participant has been selected as part of the cost sub-sample, the cost data will be collected along with the rest of the study data that is relevant at that timepoint. We have now clarified both processes in the Methods section (p.11). “On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation.” Response: We appreciate this important point and it is a key consideration for us as well. We have now included in the Methods and Discussion section (p.11, p.16) that a key objective of the pilot is to assess the feasibility of transitioning supervision from the research team to Master Trainers who are embedded within the health system. This transition will be explored through formative and follow-up interviews with participants and health system stakeholders to map a supervision pathway that is feasible for the programme’s continued adoption within the health system. We'd like to thank you again for your feedback on this paper and hope our responses have helped strengthen its clarity. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Oct 2025 Sonali Kumar , Centre for Mental Health Law & Policy, Indian Law Society, Pune, 400005, India 06 Oct 2025 Author Response Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised ... Continue reading Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised the manuscript accordingly. Our detailed responses are: “The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study.” Response: Thank you for pointing this out. To clarify, when calculating the sample size for this study we considered population-level and facility-based data. Chhattisgarh has a suicide rate of 28.2 per 100,000 population, and suicide attempts are generally estimated to occur 20 times more frequently than suicide deaths. Given the combined population of Balod and Rajnandgaon districts is approximately 2.6 million, this corresponds to an estimated 14,600 suicide attempts annually. However, 2020–2021 state-level data from Chhattisgarh (unpublished) indicated that approximately 6,595 suicide attempts were recorded in public health facilities in Balod, suggesting that only a small proportion of attempts are presenting to or being recorded in health facilities. Using this data as a conservative proxy, we estimated that approximately 25–30% of attempts in the two study districts would present to public health facilities, resulting in 3,500–4,000 potentially eligible cases per year. Assuming 15–20% eligibility and consent, we anticipated that recruiting 500 participants over 12 months would be feasible. “On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population?” Response: Thank you; we have now included descriptions of the control districts in the Methods section (p.6). Balodabazar has a population of approximately 1.31 million, with 87.25% residing in rural areas. The population includes 23.37% Scheduled Castes (SC) and 12.8% Scheduled Tribes (ST). The district is administratively divided into six blocks and is served by one district hospital, six community health centres (CHCs), and 31 primary health centres (PHCs). Mungeli has a population of approximately 0.70 million, with 90.67% living in rural areas. Its population comprises 27.76% SC and 10.37% ST. Mungeli consists of three blocks and is served by one district hospital, three CHCs, and 28 PHCs. Like Balod and Rajnandgaon, Balodabazar and Mungeli are predominantly rural, socially disadvantaged districts with limited health infrastructure, making them comparable to the intervention districts. “Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group.” Response: We understand and have clarified in the Aims section (p.5) and have added a table to the manuscript (p.13) that specifies which measures are applied to both intervention and control groups (and vice versa). We hope this helps with clarity of the study design. “Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO.” Response: The cost sub-sample will be selected using a simple random number generator ( https://www.randomizer.org/ ), ensuring every participant in the main sample has an equal probability of inclusion and minimizing selection bias. For recruitment in the control districts, data on hospital admissions for suicide attempts will be obtained from health facilities. Research assistants (RAs) will contact cases telephonically to introduce the project and obtain verbal consent. Data collectors will then follow up with patients at their home (or a preferred location, specified by them) to collect study data. If a participant has been selected as part of the cost sub-sample, the cost data will be collected along with the rest of the study data that is relevant at that timepoint. We have now clarified both processes in the Methods section (p.11). “On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation.” Response: We appreciate this important point and it is a key consideration for us as well. We have now included in the Methods and Discussion section (p.11, p.16) that a key objective of the pilot is to assess the feasibility of transitioning supervision from the research team to Master Trainers who are embedded within the health system. This transition will be explored through formative and follow-up interviews with participants and health system stakeholders to map a supervision pathway that is feasible for the programme’s continued adoption within the health system. We'd like to thank you again for your feedback on this paper and hope our responses have helped strengthen its clarity. Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised the manuscript accordingly. Our detailed responses are: “The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study.” Response: Thank you for pointing this out. To clarify, when calculating the sample size for this study we considered population-level and facility-based data. Chhattisgarh has a suicide rate of 28.2 per 100,000 population, and suicide attempts are generally estimated to occur 20 times more frequently than suicide deaths. Given the combined population of Balod and Rajnandgaon districts is approximately 2.6 million, this corresponds to an estimated 14,600 suicide attempts annually. However, 2020–2021 state-level data from Chhattisgarh (unpublished) indicated that approximately 6,595 suicide attempts were recorded in public health facilities in Balod, suggesting that only a small proportion of attempts are presenting to or being recorded in health facilities. Using this data as a conservative proxy, we estimated that approximately 25–30% of attempts in the two study districts would present to public health facilities, resulting in 3,500–4,000 potentially eligible cases per year. Assuming 15–20% eligibility and consent, we anticipated that recruiting 500 participants over 12 months would be feasible. “On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population?” Response: Thank you; we have now included descriptions of the control districts in the Methods section (p.6). Balodabazar has a population of approximately 1.31 million, with 87.25% residing in rural areas. The population includes 23.37% Scheduled Castes (SC) and 12.8% Scheduled Tribes (ST). The district is administratively divided into six blocks and is served by one district hospital, six community health centres (CHCs), and 31 primary health centres (PHCs). Mungeli has a population of approximately 0.70 million, with 90.67% living in rural areas. Its population comprises 27.76% SC and 10.37% ST. Mungeli consists of three blocks and is served by one district hospital, three CHCs, and 28 PHCs. Like Balod and Rajnandgaon, Balodabazar and Mungeli are predominantly rural, socially disadvantaged districts with limited health infrastructure, making them comparable to the intervention districts. “Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group.” Response: We understand and have clarified in the Aims section (p.5) and have added a table to the manuscript (p.13) that specifies which measures are applied to both intervention and control groups (and vice versa). We hope this helps with clarity of the study design. “Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO.” Response: The cost sub-sample will be selected using a simple random number generator ( https://www.randomizer.org/ ), ensuring every participant in the main sample has an equal probability of inclusion and minimizing selection bias. For recruitment in the control districts, data on hospital admissions for suicide attempts will be obtained from health facilities. Research assistants (RAs) will contact cases telephonically to introduce the project and obtain verbal consent. Data collectors will then follow up with patients at their home (or a preferred location, specified by them) to collect study data. If a participant has been selected as part of the cost sub-sample, the cost data will be collected along with the rest of the study data that is relevant at that timepoint. We have now clarified both processes in the Methods section (p.11). “On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation.” Response: We appreciate this important point and it is a key consideration for us as well. We have now included in the Methods and Discussion section (p.11, p.16) that a key objective of the pilot is to assess the feasibility of transitioning supervision from the research team to Master Trainers who are embedded within the health system. This transition will be explored through formative and follow-up interviews with participants and health system stakeholders to map a supervision pathway that is feasible for the programme’s continued adoption within the health system. We'd like to thank you again for your feedback on this paper and hope our responses have helped strengthen its clarity. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Cleare S. Reviewer Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.175227.r391622 ) The direct URL for this report is: https://f1000research.com/articles/14-279/v1#referee-response-391622 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 19 Aug 2025 Seonaid Cleare , University of Glasgow, Glasgow, Scotland, UK Approved VIEWS 0 https://doi.org/10.5256/f1000research.175227.r391622 This is an interesting protocol for a pilot study for a safety planning intervention. I like this study, and think the protocol is well written and detailed. I have a couple of minor pieces of feedback, ... Continue reading READ ALL This is an interesting protocol for a pilot study for a safety planning intervention. I like this study, and think the protocol is well written and detailed. I have a couple of minor pieces of feedback, which I hope will further strengthen the protocol. Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please? Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up? P9. Could the authors avoid using phrases such as “completed suicide” please? I hope the authors find the feedback useful in revising their protocol. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: emotional distress, self-harm and suicide I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cleare S. Reviewer Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.175227.r391622 ) The direct URL for this report is: https://f1000research.com/articles/14-279/v1#referee-response-391622 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Oct 2025 Sonali Kumar , Centre for Mental Health Law & Policy, Indian Law Society, Pune, 400005, India 06 Oct 2025 Author Response Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant ... Continue reading Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please?” Response: Thank you Dr Cleare for this helpful suggestion. We have now included a description of our participant retention strategies in the Methods section (page 8). To clarify, to support participant retention in the study, we will make up to five contact attempts over a two-week period following each scheduled follow-up appointment. These attempts will include a combination of telephone calls and in-person home visits (where feasible and safe). If a participant misses a follow-up but can be contacted later, they will still be approached for subsequent follow-ups at later time points. “Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up?” Thank you for your question; we have now detailed our withdrawal (p.8) and loss-to-follow-up (p.10) procedures in the Methods section. For participants who actively request to discontinue follow-ups, the study team will first explore and address any concerns to encourage continued participation. However, if the participant continues to decline, they will be formally withdrawn from the intervention and no further contact will be made. Participants who cannot be reached despite five contact attempts over two consecutive follow-up periods will be recorded as lost to follow-up. “P9. Could the authors avoid using phrases such as ‘completed suicide’ please?” Thank you for pointing this out; we have revised the manuscript to replace “completed suicide” with the preferred terminology “died by suicide” throughout the text. We hope these revisions address your concerns and strengthen the clarity of our protocol; once again thank you Dr Cleare for your constructive feedback. Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please?” Response: Thank you Dr Cleare for this helpful suggestion. We have now included a description of our participant retention strategies in the Methods section (page 8). To clarify, to support participant retention in the study, we will make up to five contact attempts over a two-week period following each scheduled follow-up appointment. These attempts will include a combination of telephone calls and in-person home visits (where feasible and safe). If a participant misses a follow-up but can be contacted later, they will still be approached for subsequent follow-ups at later time points. “Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up?” Thank you for your question; we have now detailed our withdrawal (p.8) and loss-to-follow-up (p.10) procedures in the Methods section. For participants who actively request to discontinue follow-ups, the study team will first explore and address any concerns to encourage continued participation. However, if the participant continues to decline, they will be formally withdrawn from the intervention and no further contact will be made. Participants who cannot be reached despite five contact attempts over two consecutive follow-up periods will be recorded as lost to follow-up. “P9. Could the authors avoid using phrases such as ‘completed suicide’ please?” Thank you for pointing this out; we have revised the manuscript to replace “completed suicide” with the preferred terminology “died by suicide” throughout the text. We hope these revisions address your concerns and strengthen the clarity of our protocol; once again thank you Dr Cleare for your constructive feedback. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Oct 2025 Sonali Kumar , Centre for Mental Health Law & Policy, Indian Law Society, Pune, 400005, India 06 Oct 2025 Author Response Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant ... Continue reading Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please?” Response: Thank you Dr Cleare for this helpful suggestion. We have now included a description of our participant retention strategies in the Methods section (page 8). To clarify, to support participant retention in the study, we will make up to five contact attempts over a two-week period following each scheduled follow-up appointment. These attempts will include a combination of telephone calls and in-person home visits (where feasible and safe). If a participant misses a follow-up but can be contacted later, they will still be approached for subsequent follow-ups at later time points. “Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up?” Thank you for your question; we have now detailed our withdrawal (p.8) and loss-to-follow-up (p.10) procedures in the Methods section. For participants who actively request to discontinue follow-ups, the study team will first explore and address any concerns to encourage continued participation. However, if the participant continues to decline, they will be formally withdrawn from the intervention and no further contact will be made. Participants who cannot be reached despite five contact attempts over two consecutive follow-up periods will be recorded as lost to follow-up. “P9. Could the authors avoid using phrases such as ‘completed suicide’ please?” Thank you for pointing this out; we have revised the manuscript to replace “completed suicide” with the preferred terminology “died by suicide” throughout the text. We hope these revisions address your concerns and strengthen the clarity of our protocol; once again thank you Dr Cleare for your constructive feedback. Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please?” Response: Thank you Dr Cleare for this helpful suggestion. We have now included a description of our participant retention strategies in the Methods section (page 8). To clarify, to support participant retention in the study, we will make up to five contact attempts over a two-week period following each scheduled follow-up appointment. These attempts will include a combination of telephone calls and in-person home visits (where feasible and safe). If a participant misses a follow-up but can be contacted later, they will still be approached for subsequent follow-ups at later time points. “Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up?” Thank you for your question; we have now detailed our withdrawal (p.8) and loss-to-follow-up (p.10) procedures in the Methods section. For participants who actively request to discontinue follow-ups, the study team will first explore and address any concerns to encourage continued participation. However, if the participant continues to decline, they will be formally withdrawn from the intervention and no further contact will be made. Participants who cannot be reached despite five contact attempts over two consecutive follow-up periods will be recorded as lost to follow-up. “P9. Could the authors avoid using phrases such as ‘completed suicide’ please?” Thank you for pointing this out; we have revised the manuscript to replace “completed suicide” with the preferred terminology “died by suicide” throughout the text. We hope these revisions address your concerns and strengthen the clarity of our protocol; once again thank you Dr Cleare for your constructive feedback. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 10 Mar 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 06 Oct 25 read Version 1 10 Mar 25 read read Seonaid Cleare , University of Glasgow, Glasgow, UK Nikki Lyka van Eijk , Leiden University, Leiden, The Netherlands Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Eijk N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Oct 2025 | for Version 2 Nikki Lyka van Eijk , Leiden University, Leiden, The Netherlands 0 Views copyright © 2025 Eijk N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I thank the authors for their detailed response and their adaptations to the protocol. I believe the article has improved significantly, with more clarity being provided on key points. Competing Interests No competing interests were disclosed. Reviewer Expertise suicide, implementation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Eijk NLv. Peer Review Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.188309.r420844) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-279/v2#referee-response-420844 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Eijk N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 20 Aug 2025 | for Version 1 Nikki Lyka van Eijk , Leiden University, Leiden, The Netherlands 0 Views copyright © 2025 Eijk N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear editor, The authors describe a well-written study protocol for a brief intervention targeting suicide attempt survivors in Chhattisgarh, India. The choices made by the authors reflect that this is an initial pilot, with a potential randomized controlled trial following based on their results. The rationale of the study is clear, with high suicide rates in India overall, and the district being the fourth highest in the country. While this district has support in place in theory, the authors describe that logistical problems prevent the DMHP clinics from carrying out these services in several areas. An interventions such as CASP that does not require highly skilled individuals would allow for a more sustainable scale-up than the current system if proven effective. Considering that this is a pilot study, I believe the study design to be appropriate for answering the research questions. An ambitious combination of data sources is planned, including records, surveys, and interviews. The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study. In general, the methodology of the study is well-written and detailed, though mostly on the intervention group. As a reader, I have several questions regarding the control group that remain unanswered in this protocol. I would suggest the following changes: On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population? Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group. Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO. On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation. I also have one minor remark: P.7 word is missing between measured and semi-structured. Overall, this study is relevant and timely. With some clarifications to the methods, I believe this protocol would be improved and a good starting point for future (hybrid) randomized trials. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise suicide, implementation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 06 Oct 2025 Sonali Kumar, Centre for Mental Health Law & Policy, Indian Law Society, Pune, 400005, India Dear Ms. van Eijk, We'd like to sincerely thank you for your constructive feedback and conditional approval of our manuscript. We have carefully considered your suggestions and have revised the manuscript accordingly. Our detailed responses are: “The authors describe a sample size justification based on the secondary outcome. What is not entirely clear is how feasible this is to achieve within the time period. The authors have not provided data on how many people attend emergency departments in these districts following a suicide attempt. Adding this, as well as an estimate of what percentage of people would then enlist in the study, would help provide clarity on the feasibility of the study.” Response: Thank you for pointing this out. To clarify, when calculating the sample size for this study we considered population-level and facility-based data. Chhattisgarh has a suicide rate of 28.2 per 100,000 population, and suicide attempts are generally estimated to occur 20 times more frequently than suicide deaths. Given the combined population of Balod and Rajnandgaon districts is approximately 2.6 million, this corresponds to an estimated 14,600 suicide attempts annually. However, 2020–2021 state-level data from Chhattisgarh (unpublished) indicated that approximately 6,595 suicide attempts were recorded in public health facilities in Balod, suggesting that only a small proportion of attempts are presenting to or being recorded in health facilities. Using this data as a conservative proxy, we estimated that approximately 25–30% of attempts in the two study districts would present to public health facilities, resulting in 3,500–4,000 potentially eligible cases per year. Assuming 15–20% eligibility and consent, we anticipated that recruiting 500 participants over 12 months would be feasible. “On p.4, a description is given of the two intervention districts. I would add a description of the control districts. Are they comparable in terms of population?” Response: Thank you; we have now included descriptions of the control districts in the Methods section (p.6). Balodabazar has a population of approximately 1.31 million, with 87.25% residing in rural areas. The population includes 23.37% Scheduled Castes (SC) and 12.8% Scheduled Tribes (ST). The district is administratively divided into six blocks and is served by one district hospital, six community health centres (CHCs), and 31 primary health centres (PHCs). Mungeli has a population of approximately 0.70 million, with 90.67% living in rural areas. Its population comprises 27.76% SC and 10.37% ST. Mungeli consists of three blocks and is served by one district hospital, three CHCs, and 28 PHCs. Like Balod and Rajnandgaon, Balodabazar and Mungeli are predominantly rural, socially disadvantaged districts with limited health infrastructure, making them comparable to the intervention districts. “Measures and data collection: it is not entirely clear which measures apply to both the intervention and the control condition. A flowchart of the research procedures could help clear this up. For example, if suicidal behaviour is measured using the CSSRS, and the authors state they wish to compare re-attempted suicide between groups, suicidal behaviour would have to be measured in the control group as well. At the moment, on p.8, the CSSRS is only mentioned for the intervention group.” Response: We understand and have clarified in the Aims section (p.5) and have added a table to the manuscript (p.13) that specifies which measures are applied to both intervention and control groups (and vice versa). We hope this helps with clarity of the study design. “Implementation outcomes: the outcomes that are clearly defined as being assessed in both groups are the TiC-P and the EQ-5D-5L. Here, a random sample of participants in each group will be selected. I would recommend a clarification on the randomization process, as well as the recruitment of participants within the control group, since these participants will not have had the initial screening and informed consent process by a CHO.” Response: The cost sub-sample will be selected using a simple random number generator ( https://www.randomizer.org/ ), ensuring every participant in the main sample has an equal probability of inclusion and minimizing selection bias. For recruitment in the control districts, data on hospital admissions for suicide attempts will be obtained from health facilities. Research assistants (RAs) will contact cases telephonically to introduce the project and obtain verbal consent. Data collectors will then follow up with patients at their home (or a preferred location, specified by them) to collect study data. If a participant has been selected as part of the cost sub-sample, the cost data will be collected along with the rest of the study data that is relevant at that timepoint. We have now clarified both processes in the Methods section (p.11). “On a sustainability and scale-up perspective, I have a concern about the supervision. Supervision is currently being carried out by the research team, which is understandable. However, if this approach shows promising results, districts will have to set up their own supervision structures after the research has ended. I recommend the authors already think about this at an early stage, to prevent a fade-out after the research team is no longer present to support implementation.” Response: We appreciate this important point and it is a key consideration for us as well. We have now included in the Methods and Discussion section (p.11, p.16) that a key objective of the pilot is to assess the feasibility of transitioning supervision from the research team to Master Trainers who are embedded within the health system. This transition will be explored through formative and follow-up interviews with participants and health system stakeholders to map a supervision pathway that is feasible for the programme’s continued adoption within the health system. We'd like to thank you again for your feedback on this paper and hope our responses have helped strengthen its clarity. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Eijk NLv. Peer Review Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.175227.r397270) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-279/v1#referee-response-397270 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Cleare S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 19 Aug 2025 | for Version 1 Seonaid Cleare , University of Glasgow, Glasgow, Scotland, UK 0 Views copyright © 2025 Cleare S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is an interesting protocol for a pilot study for a safety planning intervention. I like this study, and think the protocol is well written and detailed. I have a couple of minor pieces of feedback, which I hope will further strengthen the protocol. Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please? Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up? P9. Could the authors avoid using phrases such as “completed suicide” please? I hope the authors find the feedback useful in revising their protocol. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise emotional distress, self-harm and suicide I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 06 Oct 2025 Sonali Kumar, Centre for Mental Health Law & Policy, Indian Law Society, Pune, 400005, India Dear Dr. Cleare, Thank you for your thoughtful feedback on our protocol. Our responses to your comments are as follows: “Could the authors include a bit around participant retention strategies (e.g. how many attempts to contact the person for follow up will be made; if a person misses one follow-up, would they be contacted at the next time point?) please?” Response: Thank you Dr Cleare for this helpful suggestion. We have now included a description of our participant retention strategies in the Methods section (page 8). To clarify, to support participant retention in the study, we will make up to five contact attempts over a two-week period following each scheduled follow-up appointment. These attempts will include a combination of telephone calls and in-person home visits (where feasible and safe). If a participant misses a follow-up but can be contacted later, they will still be approached for subsequent follow-ups at later time points. “Additionally, it would be good to include details for withdrawal, loss to follow-up procedures. For instance, how many follow-up appointments would need to be missed before a person was recorded as lost to follow-up?” Thank you for your question; we have now detailed our withdrawal (p.8) and loss-to-follow-up (p.10) procedures in the Methods section. For participants who actively request to discontinue follow-ups, the study team will first explore and address any concerns to encourage continued participation. However, if the participant continues to decline, they will be formally withdrawn from the intervention and no further contact will be made. Participants who cannot be reached despite five contact attempts over two consecutive follow-up periods will be recorded as lost to follow-up. “P9. Could the authors avoid using phrases such as ‘completed suicide’ please?” Thank you for pointing this out; we have revised the manuscript to replace “completed suicide” with the preferred terminology “died by suicide” throughout the text. We hope these revisions address your concerns and strengthen the clarity of our protocol; once again thank you Dr Cleare for your constructive feedback. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Cleare S. Peer Review Report For: Health worker delivered Contact and Safety Planning (CASP) for suicide prevention in Chhattisgarh, India: Protocol for a non-randomized, controlled pilot study [version 2; peer review: 2 approved] . F1000Research 2025, 14 :279 ( https://doi.org/10.5256/f1000research.175227.r391622) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-279/v1#referee-response-391622 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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