Suicidal Patients: ED Docs Miss Opportunities to Intervene

Megan Brooks

March 24, 2016

National guidelines encourage emergency department (ED) physicians to ask suicidal patients whether they have access to guns or other lethal means of ending their lives, but only about half do ask, according to a new study.

"That means there is a large group of patients we are missing a chance to intervene for," lead investigator Marian Emmy Betz, MD, MPH, from the University of Colorado Anschutz Medical Campus, in Aurora, said in a statement.

"There is evidence that reducing access to lethal means (including by building barriers on bridges and reducing access to things like firearms) can prevent suicide. And there have been studies suggesting that physician counseling can affect how patients/families store lethal methods of suicide (like medications and firearms)," Dr Betz told Medscape Medical News.

The study was published online March 17 in Depression and Anxiety.

Surprising, Concerning

The research team interviewed 1358 patients from eight EDs in seven states. All patients had experienced suicidal ideation or had attempted suicide. The median age of the patients was 36 years, and 56% were women. The investigators asked the patients about access to firearms, and they reviewed the patients' ED medical records.

Dr Marian Betz

Overall, 11% of the patients said they had at least one firearm at home; 25% reported keeping a gun loaded and unlocked in the home; and 54% said they had easy access to guns.

Of these suicidal patients, 91% had presented to the ED with a psychiatric problem, and 13% were intoxicated. Most (88%) were evaluated by a mental health professional during the ED visit; 66% were admitted to a psychiatric facility, and 25% were discharged to home. For only 37% of those patients discharged to home was there evidence in the medical record that a safety plan had been created.

For only 50% of patients was there documentation in the ED record that the patient was asked about access to guns. For more than half (55%) of the patients who were discharged to home after the ED visit, there was no documentation of "lethal means assessment" in the ED. Patient intoxication and being evaluated by an ED provider only (not a mental health professional) were two factors associated with a decreased likelihood of lethal means assessment in the ED.

The ED is a "key setting" for suicide prevention, inasmuch as up to 8% of all ED patients are actively experiencing suicidal ideation or have recently experienced it. Multiple ED visits appear to be a risk factor for suicide, and many suicide victims are seen in the ED shortly before death, the researchers note. "Based on models using national suicide statistics, ED-based interventions might help decrease suicide deaths by 20% annually," they report.

The results of this report are "surprising and very concerning," Sergey Motov, MD, from the Department of Emergency Medicine, Maimonides Medical Center, New York City, told Medscape Medical News. "I don't think it is a routine practice in the ED to ask patients with suicidal ideations about access to firearms," he said. "Since all patients with suicidal ideations are routinely seen by a psychiatrist in the ED, the psychiatrists usually inquire about access to firearms."

Dr Betz said it is likely that a "mix of factors" account for suboptimal rates of lethal means assessment in the ED, including "ignorance/inadequate training, fear of alienating the patient (given the sensitivity of firearms as a political topic, although research suggests patients are okay with nonjudgmental education), inadequate resources (like brochures to give patients/family, unfamiliarity with local resources for temporary storage of firearms, or places to buy storage options). Time pressure is also probably a factor."

What is needed, she said, is "better training (many physicians may not have heard about this concept before) and ways to integrate this questioning into typical work-flows (this might be a checklist or prompts in an electronic medical record system, or easy access to local resources)."

No-brainer

Dr Betz also thinks a "broader public dialogue and collaboration with firearm advocates (including owners of ranges/shops and organizations) to educate people about the risk factors for and warning signs of suicide, as well as to tailor the messages we give patients" would be helpful.

In an interview with Medscape Medical News, Paul Gionfriddo, president and CEO, Mental Health America, a community-based nonprofit organization, noted, "There is a strong undercurrent around the country that if you ask about access to firearms, you are stepping on the toes of peoples' Second Amendment rights, even though health providers absolutely see this as a public health issue.

"The NRA [National Rifle Association] and others believe strongly that these are questions that should not be asked and should not be permitted to be asked," Gionfriddo added. "For me, a public health guy and mental health advocate, it's absolutely reasonable to ask a person with suicidal ideation what they have access to, such as guns or poisons, before you release them. It continues to surprise me that there is strong undercurrent of opposition to asking these kinds of questions.

"From the perspective of the health delivery system, it's really a no-brainer; patients should be sent home with an adequate after-care plan, and for some people, that involves a safety plan, at least until the suicidal ideation has passed and they are stabilized," Gionfriddo added.

Funding for the study was provided by the National Institute of Mental Health. The authors have disclosed no relevant financial relationships.

Depress Anxiety. Published online March 17, 2016. Abstract

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