Intervention Curbs New Suicide Attempts in At-Risk ED Patients

Pam Harrison

May 01, 2017

Results of a new study show that an intervention for suicidal patients in the emergency department (ED) administered during and after an index ED visit reduced postsuicidal behaviors.

The multicenter study, which included nearly 1400 suicidal patients who presented to a hospital ED, showed that these interventions lowered the relative risk of new suicide attempts by 20% compared to treatment as usual (TAU).

ED patients who received the intervention, which included specialized screening, safety planning guidance, and periodic follow-up telephone check-ins, made 30% fewer total suicide attempts compared to those who received standard ED care.

"We were happy that we were able to find these results," lead author Ivan Miller, PhD, the study's lead author, who is a professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, Providence, Rhode Island, said in a statement.

"We would like to have had an even stronger effect, but the fact that we were able to impact attempts with this population and with a relatively limited intervention is encouraging," Dr Miller added.

The study was published online April 29 in JAMA Psychiatry.

Largest Suicide Intervention Trial to Date

The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study compared the impact of screening plus the novel intervention vs screening alone or TAU among patients who presented to the ED following a suicide attempt or suicidal ideation.

The study included 1376 patients with suicidal ideation or recent attempt from eight EDs in seven states in the United States. Healthcare facilities ranged from small community hospitals to large academic centers.

The trial took place in three phases with three comparison groups. In the first phase, conducted from August 2010 to December 2011, 497 patients received usual treatment in an ED as a control group. In the second phase, conducted from September 2011 to December 2012, 377 patients received additional suicide screening. In the third phase, conducted from July 2012 to November 2013, 502 patients received the experimental intervention.

Patients in the intervention group received additional suicide screening from ED physicians, as well as suicide prevention information from nurses and a personal safety plan that they could opt to fill out to be better prepared for times when they might begin to harbor suicidal thoughts.

During the subsequent year, they also received brief, periodic telephone calls from trained healthcare providers at Butler Hospital, in Providene, Rhode Island. These providers would discuss suicide risk factors, personal values and goals, safety and future planning, treatment engagement, and problem solving.

The intervention was designed to directly involve a designated loved one whenever feasible.

Telephone calls followed the Coping Long Term with Active Suicide Program (CLASP) protocol, an intervention designed to reduce suicide risk.

Patients were observed for 1 year following their index ED visit.

At 12-month follow-up, 20.9% of the study cohort had made at least one suicide attempt.

Suicide attempt rates were 22.9% in the TAU group vs 21.5% in the suicide screening group and 18.3% in the intervention group. Five attempts were fatal, two in the TAU group and three in the intervention group.

Of those who attempted suicide during the 12-month follow-up, 56.9% made one attempt; 18.4% made two attempts; and 23.3% made three or more attempts.

The investigators note that 71.7% of the overall sample had a history of suicide and that approximately one third of the cohort had attempted suicide in the week prior to their index ED visit.

"There were no meaningful differences in risk reduction between the TAU and screening phases," the researchers report.

However, the investigators found a relative risk reduction of 20% in suicide risk among those enrolled in the intervention phase compared with the control phase.

In addition, total suicide attempts were 30% lower among those involved in the intervention phase compared with those involved in either the TAU phase or the screening for suicide risk phase.

The number needed to treat to prevent future suicidal behavior with the intervention strategy ranged from 13 to 22, a level of risk reduction that "compares favorably with other interventions to prevent major health issues," the authors note.

"To our knowledge, this study is the largest suicide intervention trial ever conducted in the United States," the investigators write.

"Results indicated that the provision of universal screening, while successful in identifying more participants, did not significantly affect subsequent suicidal behavior compared with that experienced by participants in the TAU phase," they add.

"By contrast, those participants who received the intervention had lower rates of suicide attempts and behaviors and fewer total suicide attempts over a 52-week period," they conclude.

Lack of ED Mental Health Resources

In an accompanying editorial, Jeffrey Bridge, PhD, Center for Suicide Prevention and Research, the Research Institute at Nationwide Children's Hospital in Columbus, Ohio, and colleagues note that each year in the United States, more than 460,000 ED visits occur following self-harm and that a single ED visit due to self-harm increases future suicide risk by almost sixfold.

Although EDs have been identified as key sites where patients at high risk for suicide can be treated, "the troubling reality is that mental health resources are not available in most American EDs, and few universally screen for suicide risk," Dr Bridge and colleagues write.

Although ED-SAFE was not a randomized trial, the editorialists suggest that the "modest positive outcomes" from the study help boost evidence that efforts to identify and intervene among patients at high risk for suicide can save lives.

"We applaud the ED-SAFE investigators for conducting a rigorous test of an innovative screening and intervention strategy to help reduce suicide risk in adult ED patients," the editorialists write.

"Now, we must ensure that the implicit message to patients at risk for suicide is that they are as welcome in the ED as patients with chest pain or broken bones and are equally deserving recipients of standard, algorithm-driven care," they conclude.

The study was supported by the National Institute of Mental Health. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online April 29, 2017. Full text, Editorial

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