Lifeline: Penn Medicine Mental Health Experts Work to Expand Suicide Prevention Strategies in the Emergency Department
Approximately 12 million Americans are seen in U.S. emergency departments each year for mental health-related symptoms. Of those patients, around 650,000 are evaluated for suicide attempts. For many of these people, it’s a frightening stop on the long and painful road of suffering that results from depression, anxiety, and substance abuse.
The usual care for these suicidal patients seen in the ED and other emergency settings is to assess their level of risk in terms of how likely they are to actually harm themselves and then refer them to the appropriate level of care. Typically, when suicidal patients are evaluated in the ED and hospitalization is not determined to be necessary, they are provided with information for outpatient mental health treatment and sent home. But that approach doesn’t necessarily meet the needs of patients or their physicians, who may worry about discharging patients in the midst of a crisis.
“This ‘assess and refer’ approach can be disconcerting to patients and their families,” says Gregory K. Brown, PhD, research associate professor of Clinical Psychology in Psychiatry in the Perelman School of Medicine. “It can also leave clinicians feeling like they didn’t do enough due to the dire consequences associated with suicidal thoughts in patients.”
Another problem is that very few patients who receive a referral to an outpatient treatment facility ever actually get the help they need. Dr. Brown says that up to 50 percent of suicidal individuals refuse outpatient treatment altogether.
And the patients that actually do reach out for additional help will likely hit many roadblocks before getting the care they desperately need. A 2009 study by Penn Emergency Medicine researchers found that two-thirds of patients referred for psychiatric services following an emergency room visit are likely to reach only an answering machine when they call for help. Only 10 percent of all calls placed to mental health clinics in nine U.S. cities during the study resulted in an appointment scheduled within two weeks.
These troubling facts leave clinicians and researchers alike looking for more immediate solutions to help these patients when they come into an ED. “Treatment of any other acute medical problem in the ED most often includes some form of direct intervention,” Brown says. “So it only makes sense to look for a brief treatment option when a suicidal patient presents in the ED.”
Brown, who is also a co-principal investigator for the Center for the Prevention of Suicide (CPS) at Penn, has focused his research on developing, evaluating, and disseminating targeted, psychotherapy interventions for these individuals. Now, in a recent paper published in the journal Cognitive and Behavioral Practice, Brown and his colleague, Barbara Stanley, PhD, director of the Suicide Intervention Center at the New York State Psychiatric Institute, propose a novel method for treatment of suicidal patients in the ED known as a Safety Planning Intervention (SPI).
The SPI, a very brief intervention that takes approximately 20 to 45 minutes to complete, provides patients with a prioritized and specific set of coping strategies and sources of support that can be used should suicidal thoughts reemerge. The intent of the safety plan (see the example below) is to help individuals lower their imminent risk for suicidal behavior by consulting a predetermined set of potential coping strategies and a list of individuals or agencies they may contact.
“The SPI is a therapeutic technique that provides patients with more than just a referral at the completion of the suicide risk assessment during an emergency evaluation,” Brown says. “By following a predetermined set of internal coping strategies, social support activities, and help seeking behaviors, patients have the opportunity to evaluate those strategies that are most effective.”
Other safety plans have been utilized as a supplement to treatments such as cognitive behavioral therapy and not as a stand-alone intervention, Brown says, while “the SPI that we have developed can be used independently and places greater emphasis on the warning signs and internal coping strategies to distract oneself from a suicidal crisis.” He also notes that safety plans are different from "no suicide contracts" which ask the patient to promise not to kill themselves, without giving them detailed instructions for dealing with a suicidal crisis other than to contact emergency services.
The SPI may also help patients far beyond those who come to emergency rooms. The researchers say nurses, psychologists, primary care physicians, psychiatrists and social workers in many other settings can also be trained to implement this intervention. It can be be easily adapted for use in the military, since it involves a detailed and easy-to-use protocol for helping soldiers avert a crisis. Self-help strategies for mitigating a suicidal crisis may be especially useful for service members who don’t have easy access to or are are reluctant to seek psychiatric care.
Brown, and colleagues from Columbia and the Department of Veterans Affairs, are currently investigating the effectiveness of their SPI in two studies, funded by the Army's Military Operational Medicine Research Program. The first study, Suicide Assessment Follow-up Engagement: Veteran Emergency Tracking (SAFE VET) project , is also funded by the Department of Veterans Affairs, and it examines the effectiveness of the SPI plus follow-up telephone contact. The second study examines the effectiveness of the tool for high risk, active duty service members who are being treated on a psychiatric inpatient unit at the Walter Reed National Military Medical Center.
Dr. Brown says the SPI is currently being utilized in Penn Medicine’s emergency departments, and is a standard of care for patients who are treated within the VA system and who are deemed to be at high risk for suicide. In addition, the SPI has been recognized as a best practice by the Suicide Prevention Resource Center (www.afsp.org) and the American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention (www.sprc.org). The researchers are hopeful that with additional validated studies, the SPI will be viewed as viable option for a variety of patients, offering a critical lifeline for when they need it most.