Experiences of substance-using suicidal males who present frequently to the emergency department

Help-Seeking Needs Related to Suicide Prevention for Individuals in Contact With Mental Health Services: A Rapid Scoping Review

INTRODUCTION

Prior mental healthcare utilisation presents an important window of opportunity for providing suicide prevention interventions. To date, no reviews have consolidated the help-seeking needs of individuals in contact with mental health services. This warrants further attention given this group may have different needs for interventions compared with the general population who have not sought help previously.

AIM

The purpose of this rapid scoping review was to summarise the available literature on help-seeking needs related to suicide prevention among individuals in contact with mental health services from healthcare settings.

METHOD

Cochrane rapid review and Joanna Briggs Institute scoping review methodologies were adapted, and databases, including MEDLINE, Scopus, CINAHL, PsycInfo and EMBASE, were searched.

RESULTS

A total of 42 primary studies were included in analysis. Reported barriers and facilitators to help-seeking behaviours identified within studies were mapped onto the socio-ecological model. Barriers and facilitators identified included knowledge and attitudes towards healthcare utilisation, family and peer support, interactions with healthcare professionals, provision of holistic care, and the creation of a supportive atmosphere and safe space to promote open discussions of suicide-related concerns.

DISCUSSION

The findings of this review offer valuable insights into areas for improvement in addressing help-seeking needs for individuals who are in contact with health services related to suicide prevention.

IMPLICATION FOR RESEARCH

The findings serve as a foundation for shaping mental health initiatives informing approaches and care delivery tailored towards individuals who are in contact with health services. The reported barriers and facilitators offer insights to inform the development of mental health support tools to enhance care and considerations for evaluations.

Experiences of consumers, carers and clinicians during borderline personality disorder presentations to the emergency department-An integrative review

INTRODUCTION

People with a borderline personality disorder (BPD) diagnosis or symptoms may experience emotional crises which necessitate use of the emergency department (ED). No existing reviews focus specifically on experiences of consumersa, carersb and clinicians in relation to ED presentations by people diagnosed with BPD.

AIM/QUESTION

The aim of this study was to synthesise knowledge on consumer, carer and clinician experiences of BPD in the ED.

METHOD

An integrative review methodology was chosen as it best captures the complexity of varied perspectives and emergent phenomena from diverse literature sources. EMBASE, CINAHL, PsycInfo and Medline were searched for papers published before 16 February 2022.

RESULTS

Nine papers met the inclusion criteria (five qualitative, one quantitative, one mixed methods and two letters to the editor). Key themes were barriers to timely and adequate care, and stigmatising attitudes and practices towards people diagnosed with BPD. Negative attitudes were perceived to perpetuate harmful outcomes and further ED visits.

DISCUSSION

Predominantly negative ED experiences were expressed by clinicians, consumers and carers. Further work is needed in ED models of care and staff education to improve the experience of care for consumers, carers and clinicians alike.

IMPLICATIONS FOR PRACTICE

Opportunities for change will exist through co-designed innovation, education, advocacy and leadership.

Racial disparities in emergency department utilization among patients with newly diagnosed depression

OBJECTIVE

To test the hypothesis that racial and ethnic minorities have increased emergency department visit rates, despite being established with a primary care provider.

METHODS

In this retrospective cohort study, ED visits without hospital admission in a 12-month period among patients with a new primary care provider-issued diagnosis of depression were assessed. Electronic medical record (EMR) data was obtained from 47 family medicine clinics in a large Michigan-based healthcare system. General linear regression models with Poisson distribution were used to predict frequency of ED visits.

RESULTS

A total of 4159 patients were included in the analyses. In multivariable analyses, Black / African American race was associated with an additional 0.90 (95% CI 0.64, 1.16) ED visits and American Indian or Alaska Native race was associated with an additional 1.39 (95% CI 0.92, 1.87) ED visits compared to White or Caucasians (null value 0). These risks were only exceeded by patients who received a prescription for a typical antipsychotic drug agent.

CONCLUSION

Despite being established patients at primary care providers and having follow-up encounters, Black / African American and American Indian or Alaska Native patients with depression were considerably more likely to seek ED treatment compared to White/Caucasian patients with depression.

"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors

OBJECTIVES

Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018.

RESULTS

After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies).

CONCLUSIONS

The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Mental Health and Addiction Related Emergency Department Visits: A Systematic Review of Qualitative Studies

Mental health and addiction (MHA) related Emergency Department (ED) visits have increased significantly in recent years. Studies identified that a small subgroup of patients constitutes a disproportionally large number of visits. However, there is limited qualitative research exploring the phenomenon from the perspectives of patients who visited ED frequently for MHA reasons, and healthcare providers who provide care to the patients since the overwhelming majority of studies were quantitative based on clinical records. Without input from patients and healthcare providers, policymakers have inadequate information for designing and implementing programs. The purpose of this study was to systematically review the literature of qualitative research on frequent MHA related ED visits. The findings of the review revealed that a lack of community resources and existing community resources not meeting the needs of patients were critical contributing factors for frequent MHA related ED visits.

Experiences of crisis care among service users with complex emotional needs or a diagnosis of 'personality disorder', and other stakeholders: systematic review and meta-synthesis of the qualitative literature

BACKGROUND

Mental health crises are common in people with complex emotional needs (our preferred working term for people diagnosed with a 'personality disorder'), yet this population is often dissatisfied with the crisis care they receive. Exploring their experiences and views on what could be improved, and those of carers and healthcare staff, is key to developing better services.

AIMS

We aimed to synthesise the relevant qualitative literature.

METHOD

Five databases were searched. Eligible studies included service users with a diagnosis of personality disorder and their carers or relevant staff, focused on crisis responses and used a qualitative design. Data were analysed with thematic synthesis.

RESULTS

Eleven studies were included, most focusing on emergency departments. Four meta-themes emerged: (a) acceptance and rejection when presenting to crisis care: limited options and lack of involvement of carers; (b) interpersonal processes: importance of the therapeutic relationship and establishing a framework for treatment; (c) managing recovery from a crisis: clear recovery plan and negotiating collaboration; and (d) equipping and supporting staff: training and emotional support.

CONCLUSIONS

Our findings suggest that emergency departments have major limitations as settings to provide crisis care for people with complex emotional needs, but there is a lack of research exploring alternatives. The quality of the therapeutic relationship was central to how care was experienced, with collaborative and optimistic staff highly valued. Staff reported feeling poorly supported in responding to the needs of this population. Research looking at experiences of a range of care options and how to improve these is needed.

"A Sustained, Productive, Constructive Relationship with Someone Who Can Help"-A Qualitative Exploration of the Experiences of Help Seekers and Support Persons Using the Emergency Department during a Suicide Crisis

For Australians experiencing a suicide crisis, the emergency department (ED) is the recommended point of contact for intervention and to ensure personal safety. However, negative ED experiences can deter individuals from returning, thus impacting future suicide risk. In order to improve the ED environment for individuals in suicidal crisis, an in-depth understanding of this experience is needed. In-depth semi-structured interviews with 17 help seekers and 16 support persons were conducted. A grounded theory approach uncovered a core organising concept—all participants wanted a “a sustained, productive, constructive relationship with someone who can help” during the ED visit—which guided analysis. Thematic analysis resulted in two themes and four subthemes exploring the systemic and interpersonal aspects of the ED visit and the roadblocks and pathways to development of the relationship. Interpersonal factors included aspects of staff interaction and presence of a support person. Systemic factors related to aspects controlled by the physical space and internal policies and procedures and included aspects such as the chaotic environment, long waiting times, and access to staff. Overwhelmingly, there were more roadblocks than pathways reported by participants. Improving the ED environment, increasing staff training and encouraging the presence of support persons may help mitigate some of these roadblocks.

Adult frequent presentation to emergency departments and adverse childhood experiences: a scoping review

BACKGROUND

Extensive literature reports the influence of childhood adversity on adult health, however few studies have explored these life antecedents in people who frequently present to the emergency department. This review synthesizes literature exploring childhood adversity influences on emergency department presentations, if and how it is identified, and interventions addressing the health care needs of this group.

METHODS

Eight electronic databases were searched. Arksey and O'Malley's framework guided this review, and a quality appraisal was undertaken. Searches included all published studies until August 2020.

RESULTS

Twenty-one articles were included in this review. They revealed that childhood adversity is common among adults who frequently attend the emergency department. It impacts physical and psychological health into adulthood and there is no standardized approach described to documenting childhood adversity, nor any consistent intervention reported by emergency departments to address its sequelae in adulthood.

CONCLUSIONS

Several studies call for screening, intervention, and education to identify and address impacts of childhood adversity for patients who frequently present to the emergency department. However, reliable high-level studies exploring these topics specific to the emergency department are uncommon. Consequently, definitive interventions to address the healthcare needs of this group is lacking and warrants further research.

Experience of being a frequent user of primary care and emergency department services: a qualitative systematic review and thematic synthesis

BACKGROUND

Frequent users of healthcare services are often categorised as 'heavy-cost patients'. In the recent years, many jurisdictions have attempted to implement different public policies to optimise the use of health services by frequent users. However, throughout this process, little attention has been paid to their experience as patients.

OBJECTIVE

To thematically synthesise qualitative studies that explore the experience of frequent users of primary care and emergency department services.

DESIGN

Qualitative systematic review and thematic synthesis.

SETTING

Primary care and emergency department.

PARTICIPANTS

Frequent users of primary care and emergency department services.

METHODS

A qualitative systematic review was conducted using three online databases (MEDLINE with full text, CINAHL with full text and PsycINFO). This search was combined to an extensive manual search of reference lists and related citations. A thematic synthesis was performed to develop descriptive themes and analytical constructs.

STUDY SELECTION

Twelve studies were included. All included studies met the following inclusion criteria: qualitative design; published in English; discussed frequent users' experiences from their own perspectives and users' experiences occurred in primary care and/or emergency departments.

RESULTS

The predominant aspects of frequent users' experiences were: (1) the experience of being ill and (2) the healthcare experience. The experience of being ill encompassed four central themes: physical limitations, mental suffering, impact on relationships and the role of self-management. The healthcare experience embraced the experience of accessing healthcare and the global experience of receiving care.

CONCLUSION

This synthesis sheds light on potential changes to healthcare delivery in order to improve frequent users' experiences: individualised care plans or case management interventions to support self-management of symptoms and reduce psychological distress; and giving greater importance on the patient-providers relationship as a central facet of healthcare delivery. This synthesis also highlights future research directions that would benefit frequent users.

Frequent use of emergency departments for mental and substance use disorders

Objectives

We described the population of people who frequently use ED for mental disorders, delineating differences by the number of visits for substance use disorders (SUDs), and predicted the receipt of follow-up services and 2-year mortality by the level of ED use for SUD.

Methods

This retrospective observational study included all Ontario residents 15 years and older who had five or more ED visits during any 12-month period from 2010 to 2012 (n=263 346). The study involved a secondary analysis of administrative health databases capturing emergency, hospital and ambulatory care. Frequent ED users for mental disorders (n=5416) were grouped into nested categories based on the number of ED visits for SUD. Logistic regression was used to examine group differences in the receipt of follow-up services and mortality, controlling for sociodemographics, comorbidities and past service use.

Results

The majority of frequent ED users for mental disorders had at least one ED visit for SUD, most commonly involving alcohol. Relative to people with no visits for SUD, those with ED visits for SUD were older and more likely to be men (Ps <0.001). As the number of ED visits for SUD increased, the likelihood of receiving follow-up care, particularly specialist mental healthcare, declined while 2-year mortality steadily increased (Ps <0.001). These associations remained after controlling for comorbidities and past service use.

Conclusions

Findings highlight disparities in the receipt of specialist care based on use of ED services for SUD, coupled with a greater mortality risk. There is a need for policies and procedures to help address unmet needs for care and to connect members of this vulnerable subgroup with services that are better able to support recovery and improve survival.

Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts

OBJECTIVE

This qualitative study aimed to capture the experience of living in the ambivalent space between life and death for adults with recurrent suicide attempts (RSA). It sought to expand upon an earlier study that explored the processes involved in transitioning away from RSA among adults, which revealed that occupying this ambivalent space is a crucial part of this process.

DESIGN

Interpretive phenomenological analysis (IPA) was used. This methodology was designed to explore the lived experiences and meaning making and enabled interpretation of the multidimensional subjective experiences of RSA participants.

METHODS

In-depth semi-structured interviews were conducted with eight adult women with a history of RSA who had participated in a therapeutic intervention at the research site (Skills for Safer Living: A Psychosocial/Psychoeducational Intervention for People with Recurrent Suicide Attempts [SfSL/PISA]). The six stages of IPA were followed to analyse the interview data.

RESULTS

Analysis revealed the superordinate theme, 'surviving moment to moment', which refers to a precarious state of making decisions about one's life and destiny on a moment-to-moment basis without clear commitment to either life or death. Two subordinate themes were identified: 'deciding not to die in the moment' when the participants were more invested in dying than living and 'deciding to live in the moment' when they were more invested in living than dying.

CONCLUSION

The study illuminated the complex process of making decisions about ones' destiny on a moment-to-moment basis. It revealed the torment experienced when occupying this state, while paradoxically, also revealing how indecision about life and death provided a lifeline opportunity for those with RSA. Clinicians who recognize the subtle distinctions associated with this in-between state can tailor their interventions accordingly.

PRACTITIONER POINTS

Surviving moment to moment is characterized by a state of emotional flux and uncertainty about one's destiny, where the person has not fully committed to either life or death. Within this state, there are two interlinked subprocesses, whereby the person is leaning more towards death or life. A critical feature in working with this client group is to recognize their ambiguity and the fragility and temporality of their decisions about their destiny. The practitioner has an opportunity to be a catalyst in the momentum towards life by demonstrating understanding of this survival struggle and tailoring intervention to fit with the nuanced processes within this state.

Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada

Aims

Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision.

Methods

EDs and shelters were conceptualized as ‘micro environments’ with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada.

Findings

The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges.

Conclusions

Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.

Shame behind the masks: the parents' perspective on their sons' suicide

Suicides are more frequent among boys than girls. A tentative, conceptual model of processes behind suicide among boys and young men (aged 12-25), grounded in their parents' views, is presented. Extensive interviews with parents in 33 cases of suicide were analyzed using grounded-theory methodology. Family alliances, coalitions, and secrets interacted with the boy concealing problems and "hiding behind a mask," while the professionals did not understand the emergency. Four interwoven paths to suicide were found: the boy was hunted and haunted, addicted, depressed, or psychotic. Different forms of shame were hidden behind the masks of "the clown," "the warrior," and "the prince." Future preventive programs need to address barriers to communication among all parties involved.

Literature-based recommendations for suicide assessment in the emergency department: a review

BACKGROUND

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

OBJECTIVES

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

METHODS

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

RESULTS

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

CONCLUSION

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.