Annotated Abstracts of Journal Articles
2015, 4th Quarter
Annotations by Scott Simpson, MD, MPH
of the APM Emergency Psychiatry SIG
January 2016
Petrik ML, Gutierrez PM, Berlin JS, Saunders SM
Gen Hosp Psychiatry 2015; 37(6):581-586
ANNOTATION (Scott Simpson)
The Finding: This qualitative study describes barriers to suicide risk assessment reported by emergency department (ED) attendings, residents and fellows, nurses, and social workers. Six identified themes were (1) lack of time to conduct an appropriate assessment, (2) lack of privacy, (3) patients’ inability or unwillingness to participate, (4) challenges communicating suicide risk across shifts or disciplines, (5) lack of a standard screening protocol, and (6) challenges collaborating with other providers or community resources (e.g., police). This sixth theme included ED providers describing how a lack of treatment options on discharge decreased the value to screening. The authors recommend several potential interventions, including improved access to mental health consultation and training ED providers in basic risk stratification (e.g., high versus low).
Strength and Weaknesses: The rigorous qualitative analysis of themes enables the authors to emphasize several core barriers to suicide risk evaluation in the ED. The study benefits by including a range of different ED clinicians from both an academic medical center and also a community hospital. That these themes emerged across multiple systems enhances the study’s generalizability.
Relevance: Soliciting emergency providers’ perceptions on barriers to risk assessment is crucial for implementing practical clinical strategies for addressing suicidal ideation in the ED. Future studies can work on improving these identified barriers and linking those improvements with clinical outcomes.
Objectives: To understand emergency department (ED) providers’ perspectives regarding the barriers and facilitators of suicide risk assessment and to use these perspectives to inform recommendations for best practices in ED suicide risk assessment.
Methods: Ninety-two ED providers from two hospital systems in a Midwestern state responded to open-ended questions via an online survey that assessed their perspectives on the barriers and facilitators to assess suicide risk as well as their preferred assessment methods. Responses were analyzed using an inductive thematic analysis approach.
Results: Qualitative analysis yielded six themes that impact suicide risk assessment. Time, privacy, collaboration and consultation with other professionals and integration of a standard screening protocol in routine care exemplified environmental and systemic themes. Patient engagement/participation in assessment and providers’ approach to communicating with patients and other providers also impacted the effectiveness of suicide risk assessment efforts.
Conclusions: The findings inform feasible suicide risk assessment practices in EDs. Appropriately utilizing a collaborative, multidisciplinary approach to assess suicide-related concerns appears to be a promising approach to ameliorate the burden placed on ED providers and facilitate optimal patient care. Recommendations for clinical care, education, quality improvement and research are offered.
ANNOTATION (Scott Simpson)
The Finding: ED-SAFE is a multicenter study of suicidal patients in the emergency department (ED). This report describes 12-month outcomes for 782 patients enrolled before the study’s intervention phase. Twenty-five percent of patients had a suicide attempt or completed suicide within 12 months after their ED visit. In multivariate analysis, risk factors were a history of non-suicidal self-injury, high school education or less, alcohol misuse, or high suicidal ideation on the Columbia-Suicide Severity Rating Scale. Forty percent of suicide attempts or completions occurred within six weeks of the ED visit. Additionally, there were even higher rates of interrupted suicide attempts, aborted attempts, and preparatory acts in the follow-up period.
Strength and Weaknesses: ED-SAFE offers a rich clinical description of this high-risk cohort over a full year. Baseline data included medical and psychiatric history, ED utilization history, demographics, and clinical severity scales. The high retention rate (90% at one year) minimizes bias and allows multivariate analysis of risk factors. The inclusion of a range of suicidal behaviors as both risk factors and outcomes is unique and helpful to clinicians who must often consider the risks of these behaviors in addition to the risk of completed suicide.
ED-SAFE did not follow patients who screened negative for suicidal ideation at the initial ED visit. It is not clear how these subjects compare to patients who deny suicidal ideation in the ED (who are probably also at elevated risk, particularly for less dangerous suicidal behaviors). Only 2 patients completed suicide, a number too small for statistical analysis.
Relevance: Patients who receive a psychiatric evaluation in the emergency department are at high risk for engaging in a range of suicidal behaviors. In the future, ED-SAFE will evaluate the benefit of a brief intervention that involves safety planning in the ED and a brief follow-up contact.
Objective: The main objective was to identify which patient characteristics have the strongest association with suicide outcomes in the 12 months after an index emergency department (ED) visit.
Methods: Data were analyzed from the first two phases of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE). The ED-SAFE study, a quasi-experimental, interrupted time-series design, involved participation from eight general medical EDs across the United States. Participants included adults presenting to the ED with active suicidal ideation or an attempt in the past week. Data collection included baseline interview; six- and 12-month chart reviews; and six-, 12-, 24-, 36-, and 52-week telephone follow-up assessments. Regression analyses were conducted.
Results: Among 874 participants, the median age was 37 years (interquartile range 27-47), with 56% of the sample being female (N=488), 74% white (N=649), and 13% Hispanic (N=113). At baseline, 577 (66%) participants had suicidal ideation only, whereas 297 (34%) had a suicide attempt in the past week. Data sufficient to determine outcomes were available for 782 (90%). In the 12 months after the index ED visit, 195 (25%) had documentation of at least one suicide attempt or suicide. High school education or less, an ED visit in the preceding six months, prior nonsuicidal self-injury, current alcohol misuse, and suicidal intent or plan were predictive of future suicidal behavior.
Conclusions: Continuing to build an understanding of the factors associated with future suicidal behaviors for this population will help guide design and implementation of improved suicide screening and interventions in the ED and better allocation of scarce resources.