Opportunities for Suicide Prevention in the Emergency Department

By Shelley N. Barnes

"Suicide is caused by psychache…the hurt, anguish, soreness, aching, and psychological pain…of excessively felt shame, or guilt, or humiliation, or loneliness, or fear, or angst, or dread of growing old or of dying badly, or whatever.… Suicide occurs when psychache is deemed by [an individual] to be unbearable."¹

— Edwin S. Shneidman, Ph.D., Psychologist and Suicidologist

Successfully achieving a reduction in the annual suicide rate has become a major public health concern in the United States. Data from the 2010 National Vital Statistics Reports show that out of a population of 100,000 Americans, about 18 males and 5 females commit suicide each year. In addition, the rate of suicide per age group more than doubles between the ages of 15 to 24 years and from age 65 and onward. The rate of completed suicides, however, does not tell the whole story. Statistics from the U.S. Centers for Disease Control and Prevention Youth Risk Behavior Survey show that 8,500 out of every 100,000 adolescents attempt suicide.

In their suicide prevention efforts, clinicians, public health experts, and mental health professionals, and others have focused their attention on a myriad of suicide risk factors. For example, there are well-established links between suicide and a variety of psychiatric disorders (particularly depression and anxiety disorders) and between suicide and suicidal ideation, social isolation, and recent stressful events. Yet according to Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia University Medical Center and an investigator with the Rutgers Center for Education and Research on Therapeutics (CERT), literature on the epidemiology of suicide indicates that the single strongest known risk factor for suicide is a recent suicide attempt. Olfson’s research has identified a potential point-of-care opportunity to decrease this risk factor: the hospital emergency department (ED).

About 1 percent of all adults and adolescents who visit an ED because of deliberate self-injury will die by suicide within 3 months of this event. Furthermore, about 15 percent of all suicide victims have visited an ED for deliberate self-injury within the year before their suicide. In a recent study, approximately 43 to 53 percent of patients who visited an ED and were diagnosed with deliberate self-injury did not receive a mental health assessment on site, and 47 to 63 percent of these patients were discharged directly back into the community.²   In addition to focusing on high-risk populations, suicide prevention efforts should concentrate on this high-risk time window. As Dr. Olfson describes in his research, some EDs have missed opportunities for suicide prevention, and he is hoping to increase effective suicide risk reduction interventions in this treatment setting.

"We've learned from the epidemiology of suicide that those people who visit the ED following deliberate self-injury represent a high-risk population during a high-risk period," Olfson explains. "This is an area where a greater emphasis on and access to mental health services has a real chance of providing and promoting what may be life-saving care for this patient population."

While organizations such as the American Psychiatric Association (APA) have long recognized the need for conducting thorough psychiatric evaluations in emergency settings—the APA published its Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors as early as 2003—several intrinsic challenges have hindered the successful implementation of their recommendations. In his research with the Rutgers CERT investigators, Dr. Olfson has identified several gaps in the current standard of care and strategies to bridge these gaps to potentially improve suicide prevention efforts nationwide.

The first gap is a shortage of mental health professionals in hospital EDs, particularly in nonteaching hospitals and hospitals in rural locations. This shortage, says Olfson, indicates that there is a subset of suicidal people who are receiving their emergency care entirely from general medical  providers rather than mental health specialists. A principle strategy for addressing this structural weakness is to increase access to mental health specialists—whether on site or on call—who can assist with the emergency management of patients at high risk for suicide.

A second gap concerns the training of emergency medicine physicians in managing psychiatric emergencies. According to some surveys, many emergency medicine residency training programs provide little or no organized instruction in this area. For many patients who visit the ED because of self-injury, their medical care is focused on their physical injury rather than on their underlying and enduring risks posed by their mental health status. Dr. Olfson and other researchers would like to see suicide prevention practices and education in the clinical care of patients who self-harm be incorporated into the  training of physicians and other clinical staff who work in EDs.

A third gap involves the discharge of patients who have received care in an ED following a self-harm event and are sent out into the community rather than a psychiatric hospital. Because these patients are at high short-term risk for suicide, improving and fortifying the relationships between hospitals and rapidly accessible outpatient mental health services will be particularly important, especially if these patients have not previously received outpatient mental health care. Based on epidemiological data from the Centers for Medicare and Medicaid Services (CMS) that examined adults in the Medicaid program who visited an ED for deliberate self-injury, the 30-day risk of repeated deliberate self-injury is significantly reduced among those patients who are discharged from the ED with a mental health diagnosis when compared with those who are discharged without one.³ The same CMS data also revealed that Medicaid patients who visited an ED because of deliberate self-injury were less likely to receive a mental health assessment and were more likely to be discharged than self-insured patients.

Olfson and his colleagues at the Rutgers CERT believe that epidemiological data mining can provide valuable clues, both about practice standards and about strategies to reduce the suicide threat. The Rutgers CERT, which focuses on making a positive impact on the use and management of mental health therapeutics in patient care, has built large claims databases that have recently been linked to the National Medicaid Death Index. As a result of this linkage, the Rutgers CERT investigators will now be able to associate mental and general health services with suicide risk and mortality on a national level. These databases contain extensive information on severe mental health disorders and represent a powerful resource for epidemiological research studies on suicide and suicide prevention.

As more data on practices that improve suicide prevention are generated, we can move toward vitally important policy changes. The ultimate goal of this research, says Dr. Olfson, is to identify clinical practices that are associated with lower risks of repeated self-injury and suicide.

"There is a lot that we do not know," he concludes, "and now we have more tools to inform efforts to improve quality practice."

Resources

These resources can help you learn more about what you can do to help improve suicide prevention efforts in your hospital ED.

• Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran’s Affairs Version: A clinical intervention to help physicians assess risk of suicide and work with Veterans to develop a safety plan during a suicidal crisis. Available at http://www.mentalhealth.va.gov/docs/va_safety_planning_manual.pdf.
• Columbia Suicide Severity Rating Scale (C-SSRS): A tool to help physicians assess suicidal behavior and predict a future suicide attempt. Available at http://cssrs.columbia.edu/.
• Patient Safety Plan Template: Used in conjunction with the Safety Planning Guide, the template is filled out collaboratively by the clinician and the patient and then used independently by the patient to help ensure his or her safety in daily life. Available at http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf.

The Center for Education and Research on Mental Health Therapeutics at Rutgers, The State University of New Jersey, is one of six nationwide CERTs funded by the Agency for Healthcare Research and Quality. The mission of each CERT is to conduct research and provide education that will advance the optimal use of drugs, medical devices, and biological products; increase awareness of the benefits and risks of therapeutics; and improve quality while cutting the costs of health care.

References

1. Shneidman ES. Suicide as psychache. J Nerv Ment Dis. 1993 Mar;181(3):145-7. PMID: 8445372.
2. Olfson M, Marcus SC, Bridge JA. Focusing suicide prevention on periods of high risk. JAMA. 2014 Mar 19;311(11):1107-8. PMID: 24515285.
3. Olfson M, Marcus SC, Bridge JA. Emergency department recognition of mental health disorders and short-term outcome of deliberate self-harm. Am J Psychiatry. 2013 Dec 1;170(12):1442-50. PMID: 23897218.

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