Emergency Department Intervention May Reduce Suicide Attempts in At-Risk Patients

Suicide attempts fell significantly in at-risk patients seen in several U.S. emergency departments after the sites began offering a multifaceted intervention program, according to a study published April 29 in JAMA Psychiatry. The findings suggest that it may be possible to reduce the risk of suicidal behaviors in at-risk patients without overburdening emergency settings.

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The emergency department (ED) has long been recognized as a place where people at high risk of suicide interact with the health care system. (One study estimated that up to 40 percent of all people who die by suicide visit the ED in the year before death, including 15 percent due to self-harm.) While this makes EDs a prime location for identifying and treating those at greatest risk of suicide, most departments lack the resources needed to effectively manage these patients.

Ivan Miller, Ph.D., a professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, set out to see if a brief in-ED intervention and a series of telephone calls after ED discharge could make a difference in the lives of at-risk patients. Compared with usual ED treatment, the number of patients who attempted suicide dropped by about 20 percent and the total number of suicide attempts dropped by about 30 percent.

The clinical trial, known as the Emergency Department Safety Assessment and Follow Up Evaluation (ED-SAFE) took place in eight EDs in the United States. The participating sites ranged from small community hospitals to large academic centers, and none had an on-site or adjacent psychiatric center, in an effort to make the study more generalizable to any ED in the U.S. The study was the largest suicide intervention trial to date, Miller told Psychiatric News.

For the three-phase study, Miller and colleagues enrolled 1,376 adults with a recent suicide attempt or ideation who presented at one of the eight emergency departments. During the first phase, all patients who enrolled received treatment according to the customary care at each ED; patients enrolled during the second phase received usual care plus a universal suicide risk screening assessment (the Patient Safety Screener); and patients in the third phase received a three-part intervention plan.

The intervention featured a secondary suicide risk screening designed for emergency department physicians, a self-administered safety plan provided by nursing staff, and weekly check-ins with the patient and/or a significant other by a trained coping advisor for one year after discharge. In addition to these calls, all participants received periodic follow-up phone interviews to assess their status and to refer them to a suicide hotline if necessary.

There were 548 suicide attempts during the study period, with 288 participants making at least one suicide attempt (53 patients had two attempts and 67 had three or more).

There were no significant differences in the number of patients who made an attempt between the usual-care and universal-screening groups (23 percent versus 22 percent) or total number of attempts (0.45 per participant versus 0.44 per participant). These numbers did drop during the intervention phase, however, which saw only 18 percent of participants attempt suicide and 0.31 attempts per participant.

The study authors estimated that this reduction translated to a number needed to treat (NNT) of 22. “This level of risk reduction compares favorably with other interventions to prevent major health issues, including statins to prevent heart attack (NNT=104), antiplatelet therapy for acute ischemic stroke (NNT=143), and vaccines to prevent influenza in elderly individuals (NNT=20),” Miller and colleagues wrote.

“Given that our study design had many limitations that are a fact of suicide prevention research, these results are impressive and encouraging,” Miller said. For example, Miller highlighted that every participant received follow-up to assess risk, and this safety measure may have decreased suicide rates in the non-intervention groups.

And though the intervention was designed to be readily implemented in EDs without strong mental health resources, Miller believes it can be also useful in places with a strong psychiatric presence. “The telephone follow-up by trained coping specialists we included is not routinely done in psychiatric emergency settings, for example, so that is something that could be incorporated into existing strategies,” he said.

Miller added that more research is needed to understand whether each of the three components of the intervention—the secondary screen, safety plan, or follow-up calls—contributed equally to reducing suicidal behaviors in at-risk patients.

“We applaud the investigators for conducting a rigorous test of an innovative screening and intervention strategy to help reduce suicide risk in adult ED patients,” wrote Jeffrey Bridge, Ph.D., of Ohio State University and colleagues in an accompanying editorial. “Now, we must ensure that the implicit message to patients at risk for suicide is that they are as welcomed in the ED as patients with chest pain or broken bones and are equally deserving recipients of standardized, algorithm-driven care.”

The ED-SAFE study was supported by an award from the National Institute of Mental Health. ■