State of Suicide Prevention in Emergency Care

NIMH convened a meeting with federal and private stakeholders to review the current state of knowledge and the scope of the suicide problem in the U.S emergency departments.

In 2015, more than 44,000 people in the U.S. lost their lives to suicide. To reduce this number, the Action Alliance for Suicide Prevention  has joined with the American Foundation for Suicide Prevention  to focus on particular settings where progress in reducing suicide is most likely. The emergency care setting (ED) is a place where society expects high risk individuals to receive help for suicidal crises, in addition to treatment for injuries. It is estimated that 1 in 5 suicide fatalities are seen in an ED  in the month prior to their death, which suggests 9,000 suicide deaths each year could be reduced though improved ED suicide prevention efforts. In 2015, recognizing the importance of the ED setting for suicide prevention, the Substance Abuse and Mental Health Services Administration (SAMHSA) supported Suicide Prevention Resource Center released Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments . Building from this extensive guide, the current meeting considered the following questions:

• What is known about the scope of the suicide problem in U.S. EDs?
• What is the risk for morbidity and mortality after an ED visit?
• What are effective approaches to risk detection that can be practically implemented? What are effective approaches to brief interventions that can be practically implemented?
• What are effective approaches in crisis services that can be used in consort with ED providers for either diversion or additional support?

In each of these areas, policy and practices challenges, as well as research gaps were identified for further strategic efforts.

Scope of the Problem in the US

National surveys of medical encounters and patient self-reports use weighted samples to estimate that over 400,000 individuals visit the ED annually for a suicide attempt. These U.S. survey data are not longitudinal; they do not allow for follow-back or follow-up analyses to determine post visit survival, nor how specific health care practices might affect post visit survival. However, our ability to examine health care patterns before (in a predictive way) and after health care “attempt events” (later morbidity and mortality risk) is improving. Large, ‘contained’ health care systems across the U.S. that provide both care and insurance, can reveal characteristics of patients who seek care for suicide attempts, their later morbidity, service utilization, and mortality risk. Particular states that have mandatory International Classification of Diseases (ICD) coding of external cause of morbidity typically have the best quality health care system attempt data, and there are ongoing efforts  to link attempt, other morbidity and death records. An approach to tracking the incidence of suicide attempts in near real time, which could be used for identifying potential patterns of suicide behavior “contagion” among other surveillance priorities, is the National Syndromic Surveillance Program ; it has 24-hour reports uploaded daily, currently involves 65-70% of all EDs in the U.S.

‘Expected’ ED Suicide Prevention Practices in the US and Current Challenges

Multiple stakeholder viewpoints were presented on their expectations for suicide prevention care in the ED. Before receiving suicide prevention training, both nurse and physician providers are less likely to believe that suicide is preventable. While survey data show that emergency care nurses are generally willing to be trained to conduct screening for suicide risk, limitations in ED mental health resources for consultation and behavior health referrals raise challenges for the ED work flow. The presence of written protocols improves the likelihood that suicide preventive care will take place. However, ED physician providers are particularly concerned about excessive boarding times when waiting for an inpatient psychiatry bed; and the degree to which suicide risk detection practice methods result in ‘false positive’ cases that could further contribute to boarding volume and time. Research surveys of providers’ motivation to engage in suicide prevention care is driven primary by hospital legal/risk management, reflecting the high stakes outcomes of appropriate ED care. Social workers play multiple roles in the ED, including screening, provision of brief treatment, and facilitation of referrals and follow-up care, but are not typically present 24/7 in the majority of EDs.

Individuals who have ‘lived experience,’ who have histories of their own suicidal thoughts and/or behaviors, recommend that provider respect for patients, collaboration with the patient and inspiring hope and meaning, and facilitation of support after discharge (e.g., follow-up phone calls; family and peer support in transition to community care) would improve the quality of ED care, and in turn, patient outcomes. Many workshop participants agreed that excessive boarding time, while life-saving at that point in time, diminishes the respect and support aspects of care, and may reduce later patient help-seeking behaviors. Including those with lived experience in suicide prevention research studies  is critical for quality improvement efforts in the ED.

The Joint Commission  (JC), which accredits and certifies nearly 21,000 health care organizations and programs in the United States, is a critical stakeholder in ED care. In 2007, the JC issued the National Patient Safety Goal (NPSG) 15.01.01 (Goal 15), to improve detection of patients at risk for suicide in psychiatric hospitals as well as among patients being treatment for behavioral health issues in general hospitals. In 2016, an advisory Sentinel Event Alert 56  highlighted the benefits of detecting and treating suicide ideation in all healthcare settings. The expansion of the NPSG to additional health care settings and types of patients, particularly including adolescent and adult patients presenting to EDs, is being discussed.

State of ED Suicide Prevention Practice Research

Risk Identification. Workshop participants considered the state of evidence for ED suicide prevention research. With regard to screening and/or risk identification, the ED SAFE study  found that use of a brief, universal screening approach with all adults in ED could double the usual rate of suicide risk detection (from 3% to 6%). Youth suicide screening efforts that provide ED providers clinical pathways, depending on level of risk, are being fielded and tested. The ED STARS  study is examining ways to identify the fewest screening items with the greatest sensitivity and specificity for youth. Fidelity of screening for youth is likely to be improved through computer assisted screening approaches. Multiple health care settings are currently fielding various ED screening approaches, and evaluation of their feasibility and effectiveness  and sustainability are in progress.

Brief Interventions in the ED. Once individuals are considered at elevated risk, most suicide prevention experts agree that a brief intervention in the ED, such as motivational interviewing and collaborative safety planning (reducing access to lethal means; identifying crisis supports and plans; developing problem solving approaches) are appropriate and promising for reducing later suicidal behavior. The degree to which these practices are currently being used were surveyed in the mountain west states , which have the highest suicide rates. How ED suicide prevention practices are associated with later adult patient outcomes are being examined in claims data from Medicaid, Medicare and Optum ; another study is examining health service claims among youth who have visited EDs in the state of California . There are multiple studies testing the benefits of these approaches across many health care systems, including those in the Mental Health Research Network ; UMass Memorial Health Care system ; and in several Colorado hospital EDs .

Interventions that Extend Post ED Visit. A systematic review   found multiple psychosocial interventions effective for reducing re-attempts post ED visit for a suicide attempt. However, many of these interventions are resource intensive and may not be widely available. Recent efforts have considered opportunities using resources more readily available, and brief interventions that facilitate patient engagement in outpatient care before ED discharge to enhance continuity of care. The Emergency Care/Family Intervention for Suicide Prevention (FISP) study examined the benefits of providing brief family crisis counseling in the ED, followed by several telephone contacts, and reported improved linkage to outpatient follow-up treatment. The ED SAFE study found that the provision of multiple telephone support contacts after ED discharge reduced suicide attempts among adults by 30% over 12 months. A Colorado program supported by the state legislature, linked high-risk patients to a state crisis line counselor before discharge, with the counselor then following-up patients post discharge with additional calls. ¹

A recent NIMH-led economic model  that considered benefits and costs of 3 types of post ED interventions for adult patients (under varying levels of screening quality and implementation conditions) concluded that all interventions were beneficial for preventing re-attempts and deaths. An economic analysis  of South Carolina’s statewide ED telepsychiatry program that provides around-the-clock telehealth coverage for consultation in ED found that this approach had multiple benefits: it halved the rates of inpatient admissions from the ED in the 30 days after the index encounter; resulted in 25% shorter lengths of stay in hospital, and resulted in a 3-fold increase in referred 30-day outpatient follow-up. Determining the benefits of the addition of peer supports  compared to professional case managers in the ED to this telepsychiatry model is currently under way. There are an estimated 24,000 peer specialists in the U.S., and a recent pilot study  found suicide prevention-specific training safe and feasible as an adjunct suicide prevention approach appropriate for further testing.

Summary

In the next few years, empirical evidence for various ED suicide prevention approaches will be available. Addition research gaps that are priorities to be addressed include the following:

• Obtain more timely data from state and national data on ED visits for suicide injury and ideation, determine the care provided, and examine the morbidity and mortality risk post ED visit. This is necessary to improve national estimates for modeling  the benefits of suicide prevention in the ED.
• The increasing use of ‘big data’ to predict behavior will likely result in ED providers having access to actuarial risk information on ED patients that does not have to rely on self-report. Optimal ways of using this information in triage and referral remains to be tested.
• The many feasibility questions regarding ED suicidal patient risk identification and management would also benefit from research that examines various clinical work flow patterns, and how efficient and effective flow patterns can be sustained.
• The degree to which brief interventions in the ED can reduce acute risk, and thus reduce the need for inpatient care and boarding if beds are not available, is of high interest.
• Given the challenges that ED providers face in attempting to adequately identify those at risk, assess and address the multitude of problems they face, research that tests approaches to ED diversion, particularly for at-risk suicidal individuals who do not have injuries, would be a priority. The role of community crisis support (crisis telephone lines; peer support; drop in centers) as ED diversions, as well as post-ED visit support value, should be evaluated.

¹ Warm Handoff of ED Patients with Suicide Risk to Telephonic Follow-Up by a State Crisis Line. Allen MH, Betz M, Skelding C, Tvrdy C and Brummett S.  DoD/VA Suicide Prevention Conference, Denver, CO, August 2, 2017.

Meeting Participants

Brian Ahmedani, Ph.D. LMSW

Henry Ford Health System

Michael H. Allen, M.D.

University of Colorado School of Medicine; Rocky Mountain Crisis Partners

Joan Asarnow, Ph.D.

University of California, Los Angeles

Shelli Avenevoli, Ph.D.

National Institute of Mental Health

David Baker, M.D., M.P.H., FACP (remote)

The Joint Commission

Emmy Betz, M.D., M.P.H.

University of Colorado School of Medicine

Edwin Boudreaux, Ph.D.

University of Massachusetts Medical School

Stuart Buttlaire, Ph.D., M.B.A

Kaiser Permanente Northern California

James Churchill, Ph.D.

National Institute of Mental Health

Cynthia (Cindy) Claassen, Ph.D.

JPS Behavioral Health Service

Lisa Colpe, Ph.D., M.P.H.

National Institute of Mental Health

Carol DeFrances, Ph.D. (remote)

CDC, National Center for Health Statistics

Sidra Goldman-Mellor, Ph.D., M.P.H.

University of California, Merced

Julie Goldstein Grumet, Ph.D.

Suicide Prevention Resource Center

Jacqueline Grupp-Phelan, M.D., M.P.H.

Cincinnati Children's Hospital

Jill Harkavy-Friedman, Ph.D.

American Foundation for Suicide Prevention

Kristin Holland, Ph.D., M.P.H.

CDC, Division of Violence Prevention

Lisa Horowitz, Ph.D., M.P.H.

National Institute of Mental Health

Celeste Johnson, DNP, APRN, PMH CNS

Parkland Health & Hospital System

Cheryl King, Ph.D.

University of Michigan Medical School

DeQuincy Lezine, Ph.D.

Prevention Communities

Steven Marcus, Ph.D.

University of Pennsylvania

Angelo McClain, Ph.D., LICSW

National Association of Social Workers

Richard McKeon, Ph.D., M.P.H.

Substance Abuse and Mental Health Services Administration

Ivan Miller, Ph.D.

Brown Medical School, Butler Hospital

Gillian Murphy, Ph.D.

National Suicide Prevention Lifeline

Meera Narasimhan, M.D., DFAPA

University of South Carolina

Jane Pearson, Ph.D.

National Institute of Mental Health

Paul Pfeiffer, M.D., M.S.

University of Michigan

Loren Rives, MNA

American College of Emergency Physicians

Carol Runyan, M.P.H., Ph.D.

Colorado School of Public Health

Michael Schoenbaum, Ph.D.

National Institute of Mental Health

Barbara Stanley, Ph.D.

Columbia University

Holly Wilcox, Ph.D.

Johns Hopkins School of Medicine

Michael Wilson, M.D., Ph.D., FAAEM, FACEP

University of Arkansas for Medical Sciences

Lisa Wolf, RN, Ph.D., CEN, FAEN

Institute for Emergency Nursing Research, Emergency Nurses Association

Leslie Zun, M.D., M.B.A

Chicago Medical School, Mount Sinai Hospital