Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

The association between adolescent suicide rates and socioeconomic indicators in Brazil: a 10-year retrospective ecological study

OBJECTIVE

To examine suicide rates among adolescents from six large cities in Brazil and to analyze the relationship between adolescent suicide rates and socioeconomic indicators between 2006 and 2015.

METHODS

Generalized estimating equation models were used to assess the impact of socioeconomic factors - including social inequality and unemployment rates - on adolescent suicide rates.

RESULTS

The rate of adolescent suicide increased by 24% over the course of the study period. Social inequality (assessed using the Gini index), was positively associated with overall adolescent suicide rates (β = 10.68; 95%CI = 2.32-19.05; p ≤ 0.012). After disaggregating the findings by age (10-14 and 15-19 years), social inequality was associated with suicide rate only for adolescents aged 15-19 years (β = 9.63; 95%CI = 2.31-16.96; p ≤ 0.005). Disaggregating these findings by sex, the association with economic variables became significant only among females. Males had a higher overall suicide rate than females, and the highest rate was observed in male adolescents aged 15-19 years. Higher levels of unemployment were associated with higher suicide rates.

CONCLUSION

Our findings suggest that socioeconomic indicators, particularly unemployment and social inequality, are relevant social determinants of suicide in adolescence.

Directionality of change in obsessive compulsive disorder (OCD) and suicidal ideation over six years in a naturalistic clinical sample✰

BACKGROUND

Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study.

METHODS

Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported.

RESULTS

The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts.

LIMITATIONS

The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study.

DISCUSSION

OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Posttraumatic stress disorder clusters and suicidal ideation

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and behavior. However, less is known about how the PTSD symptom clusters, namely alterations in arousal and reactivity (AAR), negative alterations in cognitions and mood (NACM), avoidance, and intrusion, uniquely relate to suicidal ideation. This study aimed to characterize the associations among suicidal ideation and these symptom clusters.

METHODS

Study 1 (n = 346) and Study 2 (n = 194) included community members and treatment-seeking adults at an anxiety specialty clinic, respectively. Participants completed measures of trauma exposure, PTSD symptoms, and suicidal ideation.

RESULTS

In both studies, suicidal ideation significantly and positively correlated with all PTSD factors. In Study 1, Wald tests of parameter constraints indicated that NACM and AAR had the strongest associations with suicidal ideation, followed by intrusion and avoidance. Results were replicated when restricting the sample to individuals with probable PTSD. In Study 2, suicidal ideation significantly and positively correlated with all PTSD factors; there were no differences in the strength of the suicidal ideation-PTSD factors relations.

LIMITATIONS

The studies were cross-sectional and relied on a single-item measure of suicidal ideation.

DISCUSSION

All PTSD factors significantly and positively correlated with suicidal ideation, and the NACM and AAR PTSD clusters were most strongly associated with suicidal ideation in Study 1. Therefore, clinicians should be cautious to thoroughly screen patients with elevations on these PTSD cluster scores for suicide risk.

Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department

Importance

Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care.

Objective

To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period.

Design, Setting, and Participants

Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018.

Interventions

The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement.

Main Outcomes and Measures

Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge.

Results

Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P < .001).

Conclusions and Relevance

This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.

Motivational Interviewing-Enhanced Safety Planning for Adolescents at High Suicide Risk: A Pilot Randomized Controlled Trial

This pilot randomized controlled trial examined the feasibility and acceptability of a motivational interview (MI)-enhanced safety planning intervention (MI-SafeCope) for teens hospitalized due to suicide risk and explored proximal outcomes (possible mechanisms of change). Participants were 36 hospitalized adolescents (ages 13-17; 78.8% female) with last-week suicidal ideation and/or past-month suicide attempts. Adolescents were randomized to MI-SafeCope, a three-component intervention (individual and family sessions, postdischarge call), or to treatment as usual. Primary outcomes were feasibility and acceptability. We also explored differences in proximal outcomes assessed at 2 weeks, 1 month, and 3 months (family connectedness, motivation for safety plan use, parental motivation to encourage safety plan use), as well as daily for 4 weeks (self-efficacy, coping behavior, safety plan use). Participation and retention rates and intervention satisfaction ratings indicate feasibility and acceptability. Mixed-effects models of daily assessments indicated, for the MI-SafeCope group, significantly higher self-efficacy to refrain from suicidal action (B = 1.15, p = .030), greater reliance on self to cope with suicidal ideation (B = 1.56, p = .042), and higher likelihood of safety plan use to manage suicidal thoughts (B = 0.25, p = .004). Parents in the MI-SafeCope group reported higher motivation to encourage safety plan use (B = 1.04, p = .031). Safety planning incorporating MI is feasible and acceptable with hospitalized teens. Preliminary findings suggest that MI strategies may be promising in maintaining adherence to safety plans, increasing self-efficacy and coping, and in fostering parents' motivation to encourage safety plan use. Our study also highlights the benefit of daily-level assessment of individuals' response to suicide-specific interventions.

Occult Suicidality and Psychiatric Disease Among Emergency Department Patients with Low-acuity Chief Complaints

Introduction

Patients presenting to emergency departments (ED) are often screened for suicidality, even when their chief complaint does not involve mental health concerns. Patient receptiveness to ED-based mental health screening and intervention is unknown, particularly among patients with low-acuity chief complaints, who often prioritize rapid evaluation and discharge.

Methods

This cross-sectional study included adults with low-acuity chief complaints presenting to an urban, academic ED in the Northeastern United States during daytime and evening hours, from 2015 to 2016. Participants completed validated mental health screening instruments, including the Suicide Behaviors Questionnaire-Revised and the Patient Health Questionnaire-4. Participants were also asked to rate the importance of addressing mental health concerns during their ED visit.

Results

We approached 1,688 patients, and 816 (48.4%) consented to participate in the study. Of these, 27% screened positive for anxiety and 25% screened positive for depression. Even among patients with no prior depression history, 17% were at high risk of depression. Eleven percent of participants were at high risk for suicidal behavior, including 5% of those with no reported history of depression or bipolar disorder. Thirty-five percent of patients at risk for suicide and 53% of those at high risk of depression thought it was important or very important to address these issues during the ED visit.

Conclusion

Symptoms of mental health disorders were common among this group of ED patients presenting with low-acuity chief complaints. Patients often desired to address these mental health concerns as part of their ED visit.

Factors Influencing Suicidal Tendencies of Patients with Diagnosis of Attempted Suicide in Medical History and Potential Prevention of Relapse Prevention

OBJECTIVE

The authors researched the incidence of suicidal thoughts and related factors in 123 patients of the psychiatric ward of the Hospital of České Budějovice with diagnosed attempted suicide in their medical history for the period from January 2013 – June 2015.

METHODS

The research was carried out in two stages. At the beginning of the hospitalization, quantitative data collection was implemented using a semi-structured questionnaire, followed by qualitative research conducted with semi-structured phone conversation, based on previous patient's written consent. The research data were statistically processed to obtain information about the character of relations among individual characteristics. To quantify them, the Bayesian Network (BN) was constructed, and to identify relations among individual characteristics, the Hill-Climbing algorithm was used. Before deriving the network, variables were discretized. The network parameters were set based on a data matrix using the maximal plausibility method.

RESULTS

The results of analysed set show that the probability of suicidal thoughts is high, achieving a value of 0.750 (0.781 for women and 0.724 for men). If the patient visits a contact centre for drug-addicted persons, the probability of suicidal thoughts decreases to 0.683. If the patient visits a psychotherapist, the values of 0.736 are achieved. If a daily care centre is visited, the estimated risk rises to 0.832 and the probability of the patient repetitively attempting suicide is 0.606. If the interviewed person regularly consumes alcohol, the probable relapse amounts to 0.616. But if the person consumes alcohol from time to time, the probability rises to 0.701. In case of abstinence, the probable relapse decreases to 0.565.

CONCLUSIONS

The incidence of suicidal thoughts in observed patients was high, and the amount of risk was influenced by gender, by visiting follow-up care facilities, psychotherapy, and particularly by the frequency of alcohol consumption. Intermittent alcohol consumption is the highest-risk factor in connection with relapsing suicide. In case of psychiatric patients with attempted suicide in their medical history, all verified preventive and therapeutic procedures that can contribute to prevention of relapses should be used within follow-up professional care. Specific approach of the closest social environment, medical literacy of the population and state safety measures are important.

Improving patient care after a suicide attempt

OBJECTIVES

Improving the care that patients receive after a suicide attempt will reduce the risk of a subsequent suicide attempt. We described how care for these patients can be improved and identified the available guidelines.

METHODS

We reviewed the literature on crisis and aftercare, psychosocial assessment, risk assessment, brief contact interventions, and brief interventions.

RESULTS

People who have made a suicide attempt are at increased risk of suicide, and the period immediately after discharge from hospital is particularly risky. Patients require an empathic response at their first point of contact, comprehensive psychosocial assessment, effective discharge planning, rapid and assertive follow-up, and coordinated care in the subsequent months.

CONCLUSIONS

Empathic and effective care that begins in the emergency department and extends through to community care is imperative. Enough is known about the risks of inadequate care and the key ingredients of effective care to proceed with changes to Australia's healthcare response to a suicide attempt.

Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk

Suicide is the tenth leading cause of death in the United States, accounting for more than 42,000 deaths in 2014. Although this tragedy cuts across groups defined by age, gender, race/ethnicity, and geographic location, it is striking that nearly four times as many males as females die by suicide in the U.S. We describe the current regulations and recommendations for suicide risk screening in healthcare systems and also describe the aspirational goal of "Zero Suicide," put forth by the National Action Alliance for Suicide Prevention. We then provide information about suicide risk screening tools and steps to take when a patient screens positive for suicide risk. Given the substantially higher suicide rate among males than females, we argue that it is important to consider how we could optimize suicide risk screening strategies to identify males at risk and females at risk. Further research is needed to accomplish this goal. It is recommended that we consider multi-factorial suicide risk screens that incorporate risk factors known to be particularly important for males as well as computerized, adaptive screens that are tailored for the specific risk considerations of the individual patient, male or female. These strategies are not mutually exclusive. Finally, universal suicide risk screening in healthcare settings, especially primary care, specialty medical care, and emergency department settings, is recommended.

The Impact of Safety Plans in an Outpatient Clinic

BACKGROUND

Safety plans are recommended as tools to mitigate suicide risk; however, their effectiveness remains unclear.

AIM

To evaluate the impact of safety plans on patient care at an outpatient mental health clinic.

METHOD

In this retrospective chart review, patients' treatment engagement, health-care utilization, and risk behaviors were measured. Patients served as their own historical controls, and we compared outcomes in the 6 months before and 6 months after creation of safety plans.

RESULTS

In all, 48 patient charts were identified. Hospitalizations were significantly reduced and use of crisis calls significantly increased after implementation of safety plans. There were five suicide attempts before safety plan completion and one after, representing a trend toward statistical significance. Outpatient encounters increased by 18%, missed appointments increased by 34%, psychiatric emergency room visits decreased by 47%, and a 69% reduction in inpatient hospital days was observed, all trending toward statistical significance. No differences were seen in episodes of violence or self-injurious behavior.

LIMITATIONS

The study sample was small and there was a lack of randomization.

CONCLUSION

Results suggest that safety plans can lead to improvements in utilization of care and patient engagement. Further research is needed to better understand the clinical impact of safety plans on high-risk patients.

Suicide Means among Decedents Aged 50+ Years, 2005-2014: Trends and Associations with Sociodemographic and Precipitating Factors

OBJECTIVE

To examine 1) temporal trends between 2005 and 2014 in the three most frequently used suicide means (firearms, hanging/suffocation, alcohol/drug/medicine overdose) by decedents aged 50+ years and 2) associations of suicide means with sociodemographic and precipitating factors.

METHODS

The National Violent Death Reporting System, 2005-2014, provided data (N = 46,857). Suicide means were identified from ICD-10 codes for underlying cause of death and coroner/medical examiner (CME) reports. Precipitating factors are based on either CME or law enforcement report. Age-group (50-64 and 65+ years) and gender-separate logistic regression analyses were used to examine study questions.

RESULTS

In the 50-64 years age group, each advancing year (i.e., from 2005 to 2014) was associated with a 1% decrease in the odds of firearm use and a 6% increase in the odds of hanging/suffocation among men; a 9% increase in the odds of hanging/suffocation among women; and a 4% decrease in the odds of overdose among each gender. In the 65+ years age group, each advancing year was associated with a 4% increase in the odds of overdose among men. Physical health was a significant factor for firearm use among men (adjusted odds ratio: 1.47; 95% CI: 1.39-1.55) only. Regardless of gender and age, mental health and substance abuse problems and prior suicide attempts were associated with hanging/suffocation and overdose.

CONCLUSIONS

Firearm use decreased among men aged 50-64 years between 2005 and 2014, but its use did not change among the other gender by age groups. With rapidly growing numbers of older adults, routine suicide risk assessments, firearm safety monitoring, and interventions to improve quality of life are needed.

Computer Administered Safety Planning for Individuals at Risk for Suicide: Development and Usability Testing

BACKGROUND

Safety planning is a brief intervention that has become an accepted practice in many clinical settings to help prevent suicide. Even though it is quick compared to other approaches, it frequently requires 20 min or more to complete, which can impede adoption. A self-administered, Web-based safety planning application could potentially reduce clinician time, help promote standardization and quality, and provide enhanced ability to share the created plan.

OBJECTIVE

The aim of this study was to design, build, and test the usability of a Web-based, self-administered safety planning application.

METHODS

We employed a user-centered software design strategy led by a multidisciplinary team. The application was tested for usability with a target sample of suicidal patients. Detailed observations, structured usability ratings, and Think Aloud procedures were used. Suicidal ideation intensity and perceived ability to cope were assessed pre-post engagement with the Web application.

RESULTS

A total of 30 participants were enrolled. Usability ratings were generally strong, and all patients successfully built a safety plan. However, the completeness of the safety plan varied. The mean number of steps completed was 5.5 (SD 0.9) out of 6, with 90% (27/30) of participants completing at least 5 steps and 67% (20/30) completing all 6 steps. Some safety planning steps were viewed as inapplicable to some individuals. Some confusion in instructions led to modifications to improve understandability of each step. Ratings of suicide intensity after completion of the application were significantly lower than preratings, pre: mean 5.11 (SD 2.9) versus post: mean 4.46 (SD 3.0), t27=2.49, P=.02. Ratings of ability to cope with suicidal thoughts after completion of the application were higher than preratings, with the difference approaching statistical significance, pre: mean 5.93 (SD 2.9), post: mean 6.64 (SD 2.4), t27=-2.03, P=.05.

CONCLUSIONS

We have taken the first step toward identifying the components needed to maximize usability of a self-administered, Web-based safety planning application. Results support initial consideration of the application as an adjunct to clinical contact. This allows for the clinician or other personnel to provide clarification, when needed, to help the patient build the plan, and to help review and revise the draft.

Treating Suicidal Thoughts and Behaviors Within an Emotional Disorders Framework: Acceptability and Feasibility of the Unified Protocol in an Inpatient Setting

We provide a theoretical rationale for applying a transdiagnostic, shared mechanism treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders [UP]) to suicidal thoughts and behaviors. We also present results from a proof of concept study examining the feasibility and acceptability of adding a modified UP to treatment as usual (TAU) in an inpatient setting for individuals reporting a recent suicide attempt or active suicidal ideation. Participants ( N = 12) were randomly assigned to receive UP + TAU or TAU alone. Findings indicate good feasibility and acceptability of the adjunctive intervention. Among participants who were responsive to contact attempts postdischarge ( n = 6), there were no observable differences in suicidal thoughts or behaviors during a 6-month follow-up. This application represents a promising initial extension of a cognitive-behavioral, emotion-focused treatment to suicidal individuals within an inpatient setting. Future studies adequately powered to speak to efficacy of the modified UP intervention are warranted.

Staff Views of an Emergency Department Intervention Using Safety Planning and Structured Follow-Up with Suicidal Veterans

The objective of this study is to summarize staff perceptions of the acceptability and utility of the safety planning and structured post-discharge follow-up contact intervention (SPI-SFU), a suicide prevention intervention that was implemented and tested in five Veterans Affairs Medical Center emergency departments (EDs). A purposive sampling approach was used to identify 50 staff member key informants. Interviews were transcribed and coded using thematic analysis. Almost all staff perceived the intervention as helpful in connecting SPI-SFU participants to follow-up services. A slight majority of staff believed SPI-SFU increased Veteran safety. Staff members also benefited from the implementation of SPI-SFU. Their comfort discharging Veterans at some suicide risk increased. SPI-SFU provides an appealing option for improving suicide prevention services in acute care settings.

Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment

BACKGROUND

The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation.

METHODS

After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework.

RESULTS

Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training.

CONCLUSIONS

The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.

Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans

BACKGROUND

Although suicide ranks 10th as a cause of death in the United States, and 1st among active military personnel, there are surprisingly few evidence-based therapies addressing suicidality, and development of new treatments is limited. This paper describes a clinical trial testing a novel therapy for reducing suicide risk in military veterans. The intervention, Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S), is a 10-week group intervention adapted from an existing treatment for depression (Mindfulness-Based Cognitive Therapy - MBCT). MBCT-S incorporates the Safety Planning Intervention, which is currently implemented throughout the Veterans Health Administration (VHA) for veterans at high suicide risk.

METHODS

MBCT-S is being tested in a VHA setting using an intention-to-treat, two-group randomized trial design in which 164 high suicide risk veterans are randomized to either VHA Treatment As Usual (TAU; n=82) or TAU+MBCT-S (n=82). Our primary outcome measure, suicide-related event, defined to include suicide preparatory behaviors, self-harm behavior with suicidal or indeterminate intent, suicide-related hospitalizations and Emergency Department (ED) visits, will be measured through five assessments administered by blinded assessors between baseline and 12months post-baseline. We will measure suicide attempts and suicide deaths as a secondary outcome, because of their anticipated low incidence during the study period. Secondary outcomes also include severity of suicidal ideation, hopelessness and depression.

SIGNIFICANCE

This study has the potential to significantly enhance the quality and efficiency of VHA care for veterans at suicide risk and to substantially improve the quality of life for veterans and their families.

Perspectives of Suicidal Veterans on Safety Planning

Abstract. Aims: Individual interviews were conducted and analyzed to learn about the engagement of suicidal veterans in safety planning. Method: Twenty suicidal veterans who had recently constructed safety plans were recruited at two VA hospitals. In semistructured interviews, they discussed how they felt about constructing and using the plan and suggested changes in plan content and format that might increase engagement. Results: The veterans’ experiences varied widely, from reviewing plans often and noting symptom improvement to not using them at all and doubting that they would think of doing so when deeply depressed. Conclusion: The veterans suggested ways to enrich safety planning encounters and identified barriers to plan use. Their ideas were specific and practical. Safety planning was most meaningful and helpful to them when they experienced the clinician as a partner in exploring their concerns (e.g., fear of discussing and attending to warning signs) and collaborating with them to devise solutions.