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ED Suicide Intervention Found Effective

Discussion in 'Psychiatry' started by Dr.Scorpiowoman, Jul 13, 2018.

  1. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    Focused on 6-month high-risk period after emergency department visit

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    Enhanced brief intervention services administered to patients presenting with suicidal concerns to emergency departments (ED) helped reduce subsequent suicidal behaviors, a study found.

    Patients who received a safety planning intervention plus telephone follow-up (SPI+) were 45% less likely to demonstrate suicidal behaviors (OR 0.56, 95% CI 0.33-0.95, P =0.03) and more than twice as likely to attend for outpatient mental health treatment (OR 2.06, 95% CI 1.57-2.71, P<0.001) during the high-risk 6 month period following discharge versus those who received standard care, reported Barbara Stanley, PhD, of the New York State Psychiatric Institute at Columbia University, and colleagues in JAMA Psychiatry.

    The large-scale cohort comparison study compared outcomes for 1,186 patients who received SPI+ in five Veterans Affairs (VA) ED intervention sites with 454 matched controls from four VA sites delivering treatment as usual. Patients in the intervention and control groups were mostly male and in middle-age.

    On a secondary analysis, investigators stratified risks of relapse in the intervention and comparison groups as it relates to specific, underlying mental health conditions.

    There was no significant impact on interaction with treatment due to depression (OR 0.62, 95% CI 0.21-1.85, P =0.39), post-traumatic stress disorder (OR 0.37, 95% CI 0.11-1.28, P=0.12) or substance use disorders (OR 2.72, 95% CI 0.87-8.51, P =0.09). However, bipolar disorder had a significant moderating effect on treatment interaction (OR 7.05, 95% CI 1.30-38.18, P =0.02).

    Patients with a baseline diagnosis of bipolar disorder who received SPI+ demonstrated a similar risk of suicidal behavior during the follow-up period to those receiving standard care (OR 2.1, 95% CI 0.28-15.73, P=0.47).

    In email to MedPage Today, Stanley wrote that to buttress support for this sub-group, "we have to look to additional means to reduce suicidal behavior in the bipolar population like careful pharmacological intervention in addition to psychosocial interventions."

    The SPI+ intervention initiative and follow-up criteria included the following six steps:

    • Identify personalized warning signs for an impending suicide crisis
    • Determine internal coping strategies that distract from suicidal thoughts and urges
    • Identify family and friends who are able to distract from suicidal thoughts and urges and social places that provide the opportunity for interaction
    • Identify individuals who can help provide support during a suicidal crisis
    • List mental health professionals and urgent care services to contact during a suicidal crisis
    • Lethal means counselling for making the environment safer


    Stanley touched upon the lethal means criteria, describing the need for such conversations as those concerning gun control as "a natural discussion when talking with suicidal patients because about 50% of all suicides in the U.S. are with firearms." She highlighted that discussions of firearm possession are not necessarily primary, but rather fit into the larger rubric of discussions that must take place, adding, "We talk about temporary removal of weapons, safe storage, etc., in much the same way we discuss access to lethal medications."

    Further to the safety plan, provided prior to ER discharge, SPI+ included sustained follow-up via telephone consultation, by appropriately trained and supervised project staff (social workers or psychologists). Contact was attempted within 72 hours of discharge and included mood check and risk assessment, review of the SPI, and facilitation of treatment engagement.

    Follow-up continued weekly and was generally discontinued after two calls if the patient had at least one behavioral outpatient health appointment in place or if the patient requested no further contact.

    Usual care varied across the control site as it was not protocol driven. It generally consisted of primary assessment by a nurse or social worked followed by ED physician assessment. Medical care was provided as indicated to stabilize the patient, medication initiated or reviewed, and discharge was accompanied by an outpatient appointment or information about how to access psychiatric services. No safety plan or sustained follow-up via telephone were given.


    Asked how SPI+ intervention might fit in at busy EDs, Stanley said a recalibration of the roles of practitioners in these departments would be required. "While the intervention does not take much time to do, it can be seen as another task to do for an already overburdened staff," she noted, but suggested nurses and social workers should see this as part of their role.

    "It ... involves a bit of shift from an orientation of 'Diagnose, Stabilize, Triage' to include Intervention (beyond immediate stabilization) as part of the ED function."

    Regarding the telephone intervention, Stanley explained how "this function does not typically fit neatly into workflow of the ED or even outpatient care. Yet suicidal patients discharged from the ED are at significantly increased risk of suicidal behavior, and the frequent discharge plan is a referral to outpatient care which can involve significant delays to intake."

    Studly limitations included the fact that this was not a randomized trial so there was the potential for confounding. Also, given the study group characteristics, the findings may not be generalizable to civilian settings and women. Wide confidence intervals also suggested the study was underpowered for some of the subgroup analyses.

    "Our findings are promising and indicate that safety planning and active outreach, a set of low-burden strategies, are useful components of effective suicide prevention. Importantly, using the low-burden intervention in this project and others was associated with about the same reduction in suicidal behaviour as more intensive and costly psychosocial interventions," the authors concluded.

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