Edwin Boudreaux, PhD
A new study finds that a combination of brief interventions administered during and after an emergency department visit can decrease suicidal behavior among at-risk patients following the emergency room visit. The findings, published in JAMA Psychiatry, are the result of a clinical trial conducted in eight hospitals by the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study. Co-led by principal investigators Edwin Boudreaux, PhD, of UMass Medical School; Ivan Miller, PhD, of Brown University; and Carlos Camargo Jr, MD, DrPH, of Harvard University, ED-SAFE is a multisite study funded by the National Institutes of Mental Health aimed at improving suicide prevention in hospital emergency department patients.
“The field has not had many brief interventions that have shown promise for reducing suicidal behavior, so any intervention that shows a significant effect is a very important finding,” said Dr. Boudreaux, vice chair and professor of emergency medicine and professor of psychiatry and quantitative health sciences. “We asked two main questions: Does universal screening increase the detection of suicidality? And, can care for patients be improved to reduce attempted and completed suicides?”
The five-year, $12 million study was conducted in three phases, with 1,400 patients identified as being at high risk of suicide via a brief screening questionnaire administered while they were at the hospital, in which they said they had engaged in suicidal ideation or had made an attempt within a week before their ED visit.
The first phase assessed “treatment as usual” for patients who have psychiatric risk factors such as depression, suicidal thoughts or behavior, or substance abuse. While many of these patients are evaluated by a mental health provider in the ED and some may be referred for counseling outside the hospital, few receive adequate follow-up care after they are discharged.
The second phase tested a universal screening process in which all patients, regardless of whether they exhibit typical risk factors for suicide, were screened for thoughts of suicide. Published in April 2016, this phase found that universal suicide risk screening in emergency departments nearly doubled the number of patients who were positively identified as thinking about or having attempted suicide.
The third and final phase now detailed in JAMA Psychiatry implemented a more intensive intervention including receiving suicide prevention resources and follow-up telephone counseling after the ED visit. Patients were followed for 52 weeks.
Participants in the intervention phase showed small but meaningful reductions in suicide risk, with 30 percent fewer total suicide attempts than participants in the treatment as usual or screening phases.
“Our data show that screening alone does not impact outcomes; the screening has to be accompanied by an intervention,” said Boudreaux. “Specifically, in this case, it was an intervention that transcended the ED visit and followed the patient into the community through engaging with trained telephone advisors.”
Authors of an accompanying editorial in JAMA Psychiatry note that there are more than 460,000 emergency department visits related to self-harm each year, and that up to 40 percent of individuals who die by suicide visited an ED in the year before death.
“The ED-SAFE study provides a long-overdue opportunity to reflect on the potential public health benefits of raising expectations for care delivered to high-risk suicidal individuals presenting in the typical ED,” they wrote. “We applaud the ED-SAFE investigators for conducting a rigorous test of an innovative screening and intervention strategy to help reduce suicide risk in adult ED patients.”
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