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How Emergency Physicians Can Detect Suicide Risk and Save Lives

By Debra Wood, RN, contributor

Patients presenting at an emergency department (ED) with deliberate self-harm or suicidal ideation experienced significantly higher death rates in the following year than demographically similar people, according to a new study supported by the National Institutes of Health and published in the JAMA Network Online in December 2019.

But emergency physicians can use screening tools and interventions to reduce suicide risk.

“We can move the needle,” said the study’s lead author Sidra Goldman-Mellor, PhD, an assistant professor of public health at the University of California, Merced. 

Goldman-Mellor and colleagues found that people who presented to an ED with deliberate self-harm, which could include cutting or other actions in addition to suicide attempts, had a suicide rate in the year after their visit 56.8 times higher than those of demographically similar people, and those with suicidal ideation had suicide rates 31.4 times higher than those of demographically similar Californians in the year after discharge.

“It’s pretty astounding,” Goldman-Mellor said. “Even though we put a number on it in a way that had not been done before, it wasn’t exactly a surprise.”

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The study on patient suicide risk and mortality

More than 500,000 people present to emergency departments each year with deliberate self-harm—which could be cutting, an intentional drug overdose or a nonfatal firearm injury—or suicidal ideation, both risks for suicide in the future. Many of the patients have serious mental health issues, Goldman-Mellor said. 

“Difficulties people are facing in their lives do not go away,” Goldman-Mellor said. “It’s a challenge to figure out what the patient’s intent was.”

Goldman-Mellor and colleagues sought to understand patterns of suicide and other mortality in the year after an ED presentation. The researchers also found that the risk for death due to unintentional injury was markedly elevated for patients who presented with self-harm or suicidal ideation. 

“Our results also highlight the fact that patients with suicidal ideation or self-harming behaviors are at high risk not only for death by suicide, but also for death by accidents, homicide, and natural causes,” Goldman-Mellor said in a statement. “We think this shows the importance of addressing the full spectrum of their health and social needs in follow-up care.”

ED physicians and providers can make a difference

Here’s a sobering statistic: nearly 4 out of every 10 people who die by suicide (around 39 percent) had visited an ED in the year prior to their death, researchers found. Yet, emergency physicians and other professionals engaged in the care of patients can take steps and make a difference in decreasing suicide risk. 

“The stigma around taking care of people with mental illness and the time involved is a challenge for a clinician,” said Goldman-Miller, adding that the effort is worth it. 

Emergency physician intervention requires two parts, according to Emmy Betz, MD, MPH, associate professor of emergency medicine at the University of Colorado School of Medicine in Aurora and deputy director of the Program for Injury Prevention, Education and Research at Colorado School of Public Health in Denver. 

The two essential elements are:

  • Identifying the patient at risk of suicide, and then
  • Acting on that information, which includes evaluating suicide risk, connecting with resources and helping the person remain safe until stabilized.

A suicide intervention tool for emergency physicians

The American Foundation for Suicide Prevention and the American College of Emergency Physicians (ACEP) teamed up to reduce the number of suicides by focusing on prevention in the emergency department. They developed a rapid suicide screening and intervention tool called ICAR2E and have made it available for free. 

The ICAR2E acronym stands for:

  • Identify suicide risk
  • Communicate
  • Assess for life threats and ensure safety
  • Risk assessment
  • Reduce the risk
  • Extend care beyond the emergency department visit   

“Often providers might be afraid to open a Pandora’s Box or they don’t know what they can offer the patient or do,” said Betz, who helped develop the ICAR2E tool. “The tool helps explain what are the next steps.”

Other interventions that are making an impact

A 2017 study in JAMA Psychiatry found screening in EDs, followed by safety planning guidance and periodic phone check-ins led to a 30 percent decrease in suicide attempts during a 52-week period as compared to standard ED care. 

“There are new interventions being developed, including in emergency departments, that seem to be successful at reducing future suicidal behavior among patients who get the intervention,” Goldman-Miller said. Some of the interventions “are not time intensive.” 

As an example, Goldman-Miller described the Postcard intervention, which entails simply sending follow-up postcards from hospital staff to patients who presented with self-harm or suicidal ideation. It requires no time by emergency physicians. The postcard says something like “We are thinking of you and hope you are doing well” and offers to connect the patient with outpatient services. 

“A lot of what is missing from the lives of people going through a suicidal crisis is a feeling of connection with other people, that someone cares about them,” Goldman-Miller said. “This is a way of showing that.”

Additional interventions mentioned in the JAMA study include universal screening, managing transitions, and calling patients, offering support.

Safety Planning, a specific suicide intervention, incorporates home safety, firearms, giving the patient the crisis hotline number, and identifying family and friends to help, said Betz, who reminded fellow emergency medicine physicians that these interventions are worth the time and effort. 

“There are things we can do that are not all that complicated,” Betz said. “Perhaps the most important thing we can do for a patient is to give them hope. Things do get better.”

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