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Weekly UpdatesSAN FRANCISCO -- Many new strategies are being tested to improve identification and treatment of people who are suicidal when they come to emergency departments, where most suicidality currently falls through the cracks.
Studies repeatedly show the need. About 441,000 people arrived in emergency departments (EDs) in 2002 because of suicide attempts, and many who come for non-mental health reasons also have suicidal ideation, federal data show.
"In 2001, when the National Strategy for Suicide Prevention was released" by the US. Department of Health and Human Services, "there was quite a bit of attention given to emergency departments as a point of intervention for suicide. In the 7 years since then, our thinking has advanced a fair amount about what can be done in an emergency department," said David Litts, O.D., the director of science and policy for the Suicide Prevention Resource Center in Newton, Mass., who moderated the session.
One study of 1,590 people in EDs for non-mental health reasons found 31 with definite plans for suicide, yet suicidal ideation went undetected by ED staff in 25 of these 31 patients at the index visit, and 4 returned to the ED within 45 days after attempting suicide (Br. J. Psychiatry 2005;186:352-3).
In another study, 165 patients self-identified as having suicidal ideation on a computer screening in EDs. A physician and nurse were informed, and the patients were told that they were informed. At a 6-month follow-up, however, only 25% had any notation in their chart about suicide risk; four patients (2%) who had been seen for non-mental health problems returned after suicide attempts, and 10% of patients had been transferred to psychiatric services (Am. J. Emerg. Med. 2008;26:701-5).
Separate data from South Carolina show that 10% of people who committed suicide had been in an ED within 2 months of their death.
To improve detection and intervention, new strategies include teams of mental health workers who hover in EDs to catch suicidal adolescents; family-focused, on-the-spot counseling; pocket guides for ED clinicians; and 1-hour cognitive-behavioral therapy sessions.
A panel of experts described their ongoing studies of leading-edge practices in a session at the annual conference of the American Association of Suicidology
Most of the studies include these common components, in various forms:
* Hear what patients have to say; listen to their stories.
* Challenge their entrenched thoughts.
* Help patients know what they can do differently next time they feel suicidal.
* Link them to follow-up care.
Cheryl King, Ph.D., described a pilot study of the Teen Options for Change program, which screened 298 adolescents (aged 13-17 years) in a Michigan ED for suicide risk. Of the 49 teens (16%) who screened positive, 13 (27%) had come to the ED for nonsuicide reasons. At-risk teens underwent individual or family-based adapted motivational interviews and on-the-spot counseling.
"It's highly feasible to screen teens in the ED and to do brief interventions," said Dr. King, chief psychologist in the department of psychiatry and psychology at the University of Michigan, Ann Arbor.
Although two-thirds of suicidal teens seen in mental health practices are girls, "the boys who are suicidal do not come into the mental health setting. Going to the emergency department was our attempt to find the boys," Dr. King said. A refined version of the program will be tested in a randomized, controlled pilot study of 1,100 adolescents in the ED.
A pocket card listing a quick guide for clinicians is being used in a suicide prevention program in the Veterans Affairs medical system, said Gregory K. Brown, Ph.D., of the department of psychiatry at the University of Pennsylvania, Philadelphia.
Similar to the SBIRT (Screening, Brief Intervention, and Referral to Treatment) model that is used to train ED staff to quickly assess for the presence and extent of hazardous substance use and to deliver brief interventions, the guide reminds clinicians to help potentially suicidal patients develop their own safety plans.
The steps include recognizing warning signs of suicidality, using internal coping strategies, turning to family members or others if internal strategies don't resolve the crisis, contacting professionals and agencies if needed, and reducing access to lethal means.
Two pilot studies hope to increase the likelihood that suicidal patients in the ED will engage in treatment after leaving the ED, adhere to treatment in the 3 months after the ED visit, and decrease their risk of suicidal ideation and behavior in that time period. The studies employ separate interventions: a problem-solving interview, and a brief motivational interview, said Barbara Stanley, Ph.D., professor of clinical psychology at Columbia University, New York.
"The ability to maintain suicidal individuals in treatment has eluded practitioners," she said. Previous data suggest that 38% of suicide attempters who are hospitalized for 3 months do not engage in outpatient treatment after discharge, and that 73% of attempters are not in treatment at 1 year after their suicide attempt, she noted.
A family-focused intervention for suicide prevention is the basis of the SAFETY (Safe Alternatives for Teens and Youth) program being tested by Joan Asarnow, Ph.D., and her associates. One important element seems to be the development of an "expert leader" team in the ED, including security guards and others who help identify suicidal visitors, said Dr. Asarnow, professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles.
The intervention includes assessing imminent danger in ED visitors aged 10-18 years, helping them identify feelings and high-risk emotional states, developing a plan for coping with trigger situations, and facilitating positive family interactions and support. Having the young patients write down three steps in a safety plan helps. "You have to practice with the kids" in the session, with the parents there, for best effect, she noted.
Dr. David Knesper and associates have taken a 1 -hour cognitive-behavioral therapy intervention that was developed on medical-surgical units after suicide attempts by patients, and have transplanted the program to the ED.
"I tell patients, "We have 1 hour.' It's comforting to them to know there's a beginning and an end," said Dr. Knesper, director of hospital and community psychiatry at the University of Michigan, Ann Arbor. "Hopefully, in 1 hour we develop a rapport, and I say, 'Now, can we spend a little more time in a follow-up appointment?'"
Mental health workers need to take the lead in improving suicide detection and interventions in EDs, Dr. Knesper said. "In mental health, we get shortchanged" in the emergency department, he said. "If you have a heart attack, they make all kinds of room" for cardiac specialists. "We have to fight for that mental health."
The Suicide Prevention Resource Center offers a "Best Practices Registry" for ED clinicians, Dr. Litts said, and produces a poster, printed guide, and handouts in English and Spanish that are available on the group's Web site (www.sprc.org) or through the U.S. Substance Abuse and Mental Health Services Administration or the Emergency Nurses Association.
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