Rapid-Response Team Critical When Teens Attempt Suicide

A rapidly responding outpatient treatment team can reduce hospitalizations of teenagers who have thought about or attempted suicide, according to the results of a new study.

When 286 suicidal adolescents aged 12 to 17 were randomly assigned to two treatment modalities—treatment as usual or an experimental, rapid-response outpatient team—researchers at McGill University in Montreal, Canada, found that those who received treatment as usual ended up being hospitalized more than twice as often.

The results of the study appeared in the December 2002 issue of Psychiatric Services.

Two months after an initial emergency room visit sometime between December 1996 and October 1998 when researchers first assessed the adolescents, just 17 percent of the 158 teens who had contact with the rapid-response outpatient team had been hospitalized, whereas 41 percent of the 131 assigned to treatment as usual had.

At the six-month marker, these differences held. Just 18 percent of the teens in the outpatient group had been hospitalized, compared with 43 percent of those who received treatment as usual.

When teenagers in the sample came to the emergency room at Montreal Children’s Hospital, their placement into one of the two groups—experimental or control—was determined by which psychiatrist was working in the emergency room at the time of the visit.

According to Brian Greenfield, M.D., an assistant professor of psychiatry and pediatrics at McGill University Health Center and study leader, when adolescents think about, express, or act upon a desire to kill themselves and land in the emergency room, some can be stabilized and sent home. “When the child leaves the emergency room,” said Greenfield, “the crisis is resolved, and the clinician is sufficiently reassured that the patient will live until the next appointment.”

However, most suicidal adolescents who leave the emergency room need follow-up treatment, and researchers found that “treatment as usual” meant they had to wait 10 days before receiving follow-up care in the community.

In the seemingly interminable period between the emergency room visit and follow-up with a mental health professional in the community, many clinicians may hospitalize the patients out of fear that the patients may not be able to tolerate the wait, Greenfield said.

Psychiatrists working with the teenagers in the control group had several options—they could hospitalize them, follow them on an outpatient basis, or refer them to a mental health professional in the community for treatment.

As a result, more than half of the control sample—43 percent—were hospitalized. In contrast, the rapid-response outpatient team contacted the adolescent and his or her family within one to two days after the emergency room visit. In the study design, the team consisted of a psychiatrist and psychiatric nurse, but outside of the study, the team could be adapted to include any number of health professionals from a variety of backgrounds, Greenfield said.

While working with the suicidal adolescent, the rapid-response team “did whatever it could to get the child out of crisis,” explained Greenfield.

The team first assessed the adolescent and his or her family to identify the nature of the crisis, precipitating events, and strengths and weaknesses of the adolescent’s support system and used a combination of cognitive, behavioral, interpersonal, psychodynamic, and pharmacologic therapy to reduce maladaptive behaviors and reframe misconceptions between family members.

“That may mean explaining to the child that ‘Mother’s depression can cause her to become agitated and angry, and when she behaves this way toward you, it isn’t because you’re bad’—that can be enlightening for the child,” Greenfield said. “We often function as family therapists.”

The needs of the adolescent and his or her family drove the frequency with which the rapid-response team worked with the adolescent and family. Some received treatment a few times a week, while others needed it only once every couple of weeks.

The researchers also measured clinical outcomes between the two groups using the Children’s Global Assessment Scale and the Spectrum of Suicidal Behavior Scale and found no significant differences.

While acknowledging that hospitalization, when necessary, can be “lifesaving,” Greenfield also commented on the stress associated with a psychiatric hospitalization. “It can disrupt family functioning, schooling, and socialization and can stigmatize the child,” he said.

Greenfield also noted that the rapid-response model was much less costly than hospitalization. ▪