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

The experiences of consumers, clinicians and support persons involved in the safety planning intervention for suicide prevention: a qualitative systematic review and meta-synthesis

Background

The Safety Planning Intervention (SPI) is an efficacious brief intervention for supporting people experiencing suicidal ideation and behavior. However, the subjective experiences of those who have used the SPI have not been systematically evaluated. This systematic review synthesized qualitative evidence regarding the experiences of people involved in the SPI.

Method

Systematic searches of international, peer-reviewed, English language literature were conducted in seven databases (CINAHL, Embase, Emcare, MEDLINE, PsycInfo, Scopus and Web of Science).

Results

A total of 588 articles were screened for eligibility, with screening, data extraction, and critical appraisal conducted in duplicate. Qualitative data were extracted from 10 included studies and synthesized via meta-aggregation. Ninety individual findings were aggregated into 14 unique categories, with categories subsequently combined to produce four synthesized findings: acceptability and positive outcomes associated with the SPI; maximizing the effectiveness of the SPI; navigating the involvement of support persons in the SPI process; barriers and limitations associated with the SPI.

Discussion

Collectively, findings indicate that the SPI is viewed as beneficial by users and can be enhanced through clinicians' use of a person-centered, collaborative approach, as well as through the inclusion of support persons. Future research should seek lived experience understandings from more diverse stakeholders, particularly regarding consumers' experiences of using the SPI during acute distress. Further research is required to investigate causal pathways between SPI engagement and improved outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022312425, identifier CRD42022312425.

Evidence-Based Youth Suicide Prevention and Intervention in Pediatric Primary Care Settings

Suicide is a leading cause of death in youth. Evidence highlights the importance of identifying youth at risk for suicide in pediatric primary care, and suggests this is a crucial setting for improving youth mental health. The American Academy of Pediatrics recommends primary care providers not only screen and assess for suicide risk, but also become educated on how to better manage certain mental health conditions. This article discusses the epidemiology of youth suicide in the United States and describes evidence-based strategies and innovative practices for suicide prevention in pediatric primary care including suicide risk screening, assessment, intervention, and follow-up care.

Towards a Better Use of Safety Planning in Emergency Departments: An Exploratory Study of Patients and Clinicians' Perspectives

Suicidality frequently leads to emergency department (ED) visits, yet few interventions are offered in EDs to mitigate suicide risk. This study uses a descriptive interpretative design to evaluate the key components for a successful use of such an intervention, the Stanley-Brown safety plan, in EDs. Semi-structured interviews were conducted with patients and ED clinicians and were analyzed using a thematic analysis approach. Participants' perspectives revealed 6 key recommendations for a successful use of the safety plan in EDs: (1) personalize the content of the safety plan, (2) offer a variety of formats, (3) avoid periods of high emotional intensity, (4) engage a broad range of professionals in safety planning, (5) use limited time to make meaningful interventions, (6) propose alternative interventions. A change in the ED culture is needed to ensure that the management of suicidal patients in EDs includes brief therapeutic interventions like safety planning, to mitigate suicide risk.

Recognizing and coping with suicidal thoughts: A mixed-methods investigation of digital safety plan content

OBJECTIVES

Suicide safety plans are a personalized means of documenting how a person at risk of suicide recognizes and intends to cope with emerging suicidal thoughts. This study aimed to understand how users of digital suicide safety plans describe their warning signs, methods of coping and any relationships between these that may emerge.

METHODS

A sample comprising 150 users of the Australian suicide safety planning smartphone app Beyond Now consented to share the content of their safety plans. Reflexive thematic analysis was used to identify themes in overall plan content. Most participants identified as women (61%), had a history of at least one suicide attempt (61%) and completed their plans by themselves (84%).

RESULTS

Three major themes emerged: (1) interpersonal challenges and complexity; (2) matching coping strategies to warning signs; and (3) helpful and harmful digital technology use. Most plans appeared to demonstrate high self-awareness of warning signs and available supports.

CONCLUSIONS

Safety plan content provides a window into the thought process underlying the recognition of suicidal thoughts and the attempts to manage them. An opportunity exists for practitioners and support persons to use this content when collaboratively supporting a safety plan user to improve their coping strategies and support networks.

The Components and Characteristics of Safety Management Plans Used to Reduce the Risk of Self Harm: A PRISMA Scoping Review

BACKGROUND

The term "safety management planning" can be thought of as having evolved to constitute a number of different intervention types and components used across various clinical settings with various populations. This poses a challenge for effective communication between clinicians and likely variability in the clinical effectiveness of these interventions.

AIM

This PRISMA Scoping Review aims to review the literature to ascertain which intervention components and characteristics currently fall under this umbrella term as well as in which contexts the plans are delivered and who is involved in the process.

METHOD

Published research studies in PsycINFO, CINAHL Plus, MEDLINE, Science Direct and Web of Science were reviewed. Grey literature was searched using the databases Base and OpenGrey as well as through the search engine Google.

RESULTS

2853 abstracts were initially identified for screening and 74 pieces of literature informed the final review, with 54 derived from the published academic literature and 20 from the grey literature. Results indicated that the safety plans are used with a wide variety of populations and often include components related to identifying warning signs, internal coping strategies, accessing social professional support amongst other components.

CONCLUSION

Although most safety management plans described appeared to be based on specific interventions, there was a large amount of heterogeneity of components and characteristics observed. This was particularly the case with regards to safety management planning within the grey literature.

Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use

OBJECTIVE

The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients' receipt of recent mental health care.

METHODS

Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined.

RESULTS

During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission.

CONCLUSIONS

Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol

BACKGROUND

The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth.

METHOD

This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys.

CONCLUSION

If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review

BACKGROUND

Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps.

OBJECTIVE

This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps.

RESULTS

Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies.

CONCLUSIONS

Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use.

Pre-implementation adaptation of suicide safety planning intervention using peer support in rural areas

Introduction

Currently, seventeen veterans die by suicide daily in the United States (U.S.). There are disparities in suicide behavior and access to preventative treatment. One disparity is the suicide rate in rural areas, including the state of Arkansas-suicide deaths among rural veterans increased 48% in the last 2 decades, double that of urban veterans. One major challenge for veterans in rural areas is the lack of healthcare providers to provide Safety Planning Intervention, which is an effective intervention to reduce suicide attempts in the general adult population and among veterans. One solution is more broadly implementing Safety Planning Intervention, by using peers to deliver the intervention in rural communities. Before implementation, the intervention needs to be adapted for peer-to-peer delivery, and barriers and facilitators identified.

Methods

Since January 2021, using community-based participatory research, we collaboratively developed and executed a 1 year study to adapt Safety Planning Intervention for peer-to-peer delivery in rural communities and identified implementation barriers and facilitators prior to spread. From July 2022 to February 2023, we conducted group interviews with 12 participants: rural veterans with prior suicidal thoughts or attempts in one U.S. state, their support persons, and healthcare professionals with expertise in veteran suicide prevention, Safety Planning Intervention, and/or peer delivery. We collected qualitative data through interviews during nine, 2 h meetings, and quantitative data from one anonymous survey and real-time anonymous voting-all on the topic of core and adaptable components of Safety Planning Intervention and implementation barriers and facilitators for peer delivery in rural communities. Questions about adaptation were designed according to processes in the ENGAGED for CHANGE community-engaged intervention framework and questions about facilitators and barriers were designed according to the Health Equity Implementation Framework. Participants categorized which Safety Planning Intervention components were core or adaptable, and how freely they could be adapted, using the metaphor of a traffic light in red (do not change), yellow (change with caution), and green (change freely) categories.

Results

Participants made few actual adaptations (categorized according to the FRAME modification system), but strongly recommended robust training for peers. Participants identified 27 implementation facilitators and 47 barriers, organized using the Health Equity Implementation Framework. Two example facilitators were (1) peer-to-peer safety planning intervention was highly acceptable to rural veterans; and (2) some state counties already had veteran crisis programs that could embed this intervention for spread. Two example barriers were (1) some community organizations that might spread the intervention have been motivated initially, wanting to help right away, yet not able to sustain interventions; and (2) uncertainty about how to reach veterans at moderate suicide risk, as many crisis programs identified them when suicide risk was higher.

Discussion

Our results provide one of the more comprehensive pre-implementation assessments to date for Safety Planning Intervention in any setting, especially for peer delivery (also referred to as task shifting) outside healthcare or clinical settings. One important next step will be mapping these barriers and facilitators to implementation strategies for peer-to-peer delivery. One finding surprised our research team-despite worse societal context in rural communities leading to disproportionate suicide deaths-participants identified several positive facilitators specifically about rural communities that can be leveraged during implementation.

A Suicide Prevention Intervention for Emerging Adult Sexual and Gender Minority Groups: Protocol for a Pilot Hybrid Effectiveness Randomized Controlled Trial

BACKGROUND

Suicide attempts and suicide death disproportionately affect sexual and gender minority emerging adults (age 18-24 years). However, suicide prevention strategies tailored for emerging adult sexual and gender minority (EA-SGM) groups are not widely available. The Safety Planning Intervention (SPI) has strong evidence for reducing the risk for suicide in the general population, but it is unclear how best to support EA-SGM groups in their use of a safety plan. Our intervention (Supporting Transitions to Adulthood and Reducing Suicide [STARS]) builds on content from an existing life skills mobile app for adolescent men who have sex with men (iREACH) and seeks to target core risk factors for suicide among EA-SGM groups, namely, positive affect, discrimination, and social disconnection. The mobile app is delivered to participants randomized to STARS alongside 6 peer mentoring sessions to support the use of the safety plan and other life skills from the app to ultimately reduce suicide risk.

OBJECTIVE

We will pilot-test the combination of peer mentoring alongside an app-based intervention (STARS) designed to reduce suicidal ideation and behaviors. STARS will include suicide prevention content and will target positive affect, discrimination, and social support. After an in-person SPI with a clinician, STARS users can access content and activities to increase their intention to use SPI and overcome obstacles to its use. EA-SGM groups will be randomized to receive either SPI alone or STARS and will be assessed for 6 months.

METHODS

Guided by the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework, we will recruit and enroll a racially and ethnically diverse sample of 60 EA-SGM individuals reporting past-month suicidal ideation. Using a type-1 effectiveness-implementation hybrid design, participants will be randomized to receive SPI (control arm) or to receive SPI alongside STARS (intervention arm). We will follow the participants for 6 months, with evaluations at 2, 4, and 6 months. Preliminary effectiveness outcomes (suicidal ideation and behavior) and hypothesized mechanisms of change (positive affect, coping with discrimination, and social support) will serve as our primary outcomes. Secondary outcomes include key implementation indicators, including participants' willingness and adoption of SPI and STARS and staff's experiences with delivering the program.

RESULTS

Study activities began in September 2021 and are ongoing. The study was approved by the institutional review board of the University of Pennsylvania (protocol number 849500). Study recruitment began on October 14, 2022.

CONCLUSIONS

This project will be among the first tailored, mobile-based interventions for EA-SGM groups at risk for suicide. This project is responsive to the documented gaps for this population: approaches that address chosen family, focus on a life-course perspective, web approaches, and focus on health equity and provision of additional services relevant to sexual and gender minority youth.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05018143; https://classic.clinicaltrials.gov/ct2/show/NCT05018143.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48177.

Using a Safety Planning Mobile App to Address Suicidality in Young People Attending Community Mental Health Services in Ireland: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Over 700,000 people die by suicide annually, making it the fourth leading cause of death among those aged 15-29 years globally. Safety planning is recommended best practice when individuals at risk of suicide present to health services. A safety plan, developed in collaboration with a health care practitioner, details the steps to be taken in an emotional crisis. SafePlan, a safety planning mobile app, was designed to support young people experiencing suicidal thoughts and behaviors and to record their plan in a way that is accessible immediately and in situ.

OBJECTIVE

The aim of this study is to assess the feasibility and acceptability of the SafePlan mobile app for patients experiencing suicidal thoughts and behaviors and their clinicians within Irish community mental health services, examine the feasibility of study procedures for both patients and clinicians, and determine if the SafePlan condition yields superior outcomes when compared with the control condition.

METHODS

A total of 80 participants aged 16-35 years accessing Irish mental health services will be randomized (1:1) to receive the SafePlan app plus treatment as usual or treatment as usual plus a paper-based safety plan. The feasibility and acceptability of the SafePlan app and study procedures will be evaluated using both qualitative and quantitative methodologies. The primary outcomes are feasibility outcomes and include the acceptability of the app to participants and clinicians, the feasibility of delivery in this setting, recruitment, retention, and app use. The feasibility and acceptability of the following measures in a full randomized controlled trial will also be assessed: the Beck Scale for Suicide Ideation, Columbia Suicide Severity Rating Scale, Coping Self-Efficacy Scale, Interpersonal Needs Questionnaire, and Client Service Receipt Inventory. A repeated measures design with outcome data collected at baseline, post intervention (8 weeks), and at 6-month follow-up will be used to compare changes in suicidal ideation for the intervention condition relative to the waitlist control condition. A cost-outcome description will also be undertaken. Thematic analyses will be used to analyze the qualitative data gathered through semistructured interviews with patients and clinicians.

RESULTS

As of January 2023, funding and ethics approval have been acquired, and clinician champions across mental health service sites have been established. Data collection is expected to commence by April 2023. The submission of completed manuscript is expected by April 2025.

CONCLUSIONS

The framework for Decision-making after Pilot and feasibility Trials will inform the decision to progress to a full trial. The results will inform patients, researchers, clinicians, and health services of the feasibility and acceptability of the SafePlan app in community mental health services. The findings will have implications for further research and policy regarding the broader integration of safety planning apps.

TRIAL REGISTRATION

OSF Registries osf.io/3y54m; https://osf.io/3y54m.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44205.

The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review

The safety planning intervention (SPI) is gaining momentum in suicide prevention practice and research. This systematic review sought to determine the effectiveness of the SPI for adults experiencing suicide-related distress. Systematic searches of international, peer-reviewed literature were conducted in six databases (Cochrane Trials, Embase, Emcare, Medline, PsycINFO and Web of Science), including terms for safety planning, suicide, and suicide-related outcomes. A total of 565 results were included for screening. Result screening (title/abstract and full-text), data extraction and critical appraisal were conducted in duplicate. Twenty-six studies met the inclusion criteria. Studies were primarily quantitative (n = 20), largely with general adult or veteran samples; a small number of studies explored the perspectives of staff and significant others. Half of the studies included the SPI as a standalone intervention, while the other half examined the SPI in combination with other interventions. Most interventions were delivered in-person, with a hard-copy safety plan created, while a smaller number explored internet-based interventions. Primary measures included: suicidality (ideation, behavior, deaths; 10 studies), suicide-related outcomes (depression, hopelessness; 5 studies) and treatment outcomes (hospitalizations, treatment engagement; 7 studies). The evidence supports improvements in each of these domains, with complementary findings from the remaining quantitative and qualitative studies suggesting that the SPI is a feasible and acceptable intervention. While positive, these findings are limited by the heterogeneity of interventions and study designs, making the specific impact of the SPI difficult to both determine and generalize. Conversely, this also points to the flexibility of the SPI.HighlightsThe Safety Planning Intervention (SPI) is a valuable indicated intervention for general adult and veteran populations experiencing suicide-related distress, primarily in face-to-face, clinical settings.Quantitative findings indicate associations between the SPI and improvements in suicidal ideation and behavior, decreases in depression and hopelessness, along with reductions in hospitalizations and improvements in treatment attendance.Qualitative studies suggest the SPI is acceptable and feasible, with areas for development.SPIs have been shown to be adaptable to the clinical area in its modality (digital or paper-based), delivery (face-to-face or online), facilitation (clinician or self-administered) and multiplicity (as stand-alone or combined intervention).

Interventions to change clinicians' behavior related to suicide prevention care in the emergency department: a scoping review

OBJECTIVE

The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine the functional mechanisms of interventions and how these characteristics can influence emergency department clinicians' behaviors related to suicide prevention care.

INCLUSION CRITERIA

This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude.

METHODS

This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behaviour Change Wheel's intervention functions. Reported outcome measures were categorized. Findings were tabulated and synthesized narratively.

RESULTS

This review included a total of 70 sources, describing 66 different interventions. Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivization (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches.

CONCLUSIONS

Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and organization-level barriers for a given context. The ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors; however, current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

Safety planning-type interventions for suicide prevention: meta-analysis

BACKGROUND

Safety planning-type interventions (SPTIs) for patients at risk of suicide are often used in clinical practice, but it is unclear whether these interventions are effective.

AIMS

This article reports on a meta-analysis of studies that have evaluated the effectiveness of SPTIs in reducing suicidal behaviour and ideation.

METHOD

We searched Medline, EMBASE, PsycINFO, Web of Science and Scopus from their inception to 9 December 2019, for studies that compared an SPTI with a control condition and had suicidal behaviour or ideation as outcomes. Two researchers independently extracted the data. To assess suicidal behaviour, we used a random-effects model of relative risk based on a pooled measure of suicidal behaviour. For suicidal ideation, we calculated effect sizes with Hedges' g. The study was registered at PROSPERO (registration number CRD42020129185).

RESULTS

Of 1816 unique abstracts screened, 6 studies with 3536 participants were eligible for analysis. The relative risk of suicidal behaviour among patients who received an SPTI compared with control was 0.570 (95% CI 0.408-0.795, P = 0.001; number needed to treat, 16). No significant effect was found for suicidal ideation.

CONCLUSIONS

To our knowledge, this is the first study to report a meta-analysis on SPTIs for suicide prevention. Results support the use of SPTIs to help preventing suicidal behaviour and the inclusion of SPTIs in clinical guidelines for suicide prevention. We found no evidence for an effect of SPTIs on suicidal ideation, and other interventions may be needed for this purpose.

Staff Perspectives of Safety Planning as a Suicide Prevention Intervention for People of Refugee and Asylum-Seeker Background

Background: Safety planning involves the co-development of a personalized list of coping strategies to prevent a suicide crisis. Aims: We explored the perspectives of workers regarding safety planning as a suicide prevention strategy for people of refugee background and those seeking asylum in Australia. Method: Participants attended suicide prevention training, specific to refugees and asylum seekers, at which safety planning was a key component. Semistructured, posttraining interviews (n = 12) were analyzed thematically. Results: Four key themes were identified: safety planning as a co-created, personalized activity for the client; therapeutic benefits of developing a safety plan; barriers to engaging in safety planning; strategies to enhance safety planning engagement. Limitations: First-hand refugee and asylum-seeker experiences were not included. Conclusion: As a relatively low-cost, flexible intervention, safety planning may be valuable and effective for these groups.

C-SSRS performance in emergency department patients at high risk for suicide

OBJECTIVE

To evaluate the psychometric and predictive performance of the Columbia-Suicide Severity Rating Scale (C-SSRS) in emergency department (ED) patients with suicidal ideation or attempts (SI/SA).

METHODS

Participants (n = 1,376, mean age 36.8, 55% female, 76.8% white) completed the C-SSRS during the ED visit and were followed for one year. Reliability analyses, exploratory structural equation modeling, and prediction of future SA were explored.

RESULTS

Reliability of the Suicidal Ideation subscale was adequate, but was poor for the Intensity of Ideation and Suicidal Behavior subscales. Three empirically derived factors characterized the C-SSRS. Only Factor 1 (Suicidal Ideation and Attempts) was a reliable predictor of subsequent SA, though odds ratios were small (ORs: 1.09-1.10, CI95% : 1.04, 1.15). The original C-SSRS Suicidal Ideation and Suicidal Behavior subscales and the C-SSRS ED screen predicted subsequent SA, again with small odds ratios (ORs: 1.07-1.19, CI95% : 1.01, 1.29). In participants without a SA history, no C-SSRS subscale predicted subsequent SA. History of any SA (OR: 1.98, CI95% : 1.43, 2.75) was the strongest predictor of subsequent SA.

CONCLUSIONS

The psychometric evidence for the C-SSRS was mixed. History of a prior SA, as measured by the C-SSRS, provided the most parsimonious and powerful assessment for predicting future SA.

Safety Planning Intervention for Adolescents: Provider Attitudes and Response to Training in the Emergency Services Setting

OBJECTIVE

This study aimed to describe the implementation of the empirically supported Safety Planning Intervention (SPI) for adolescent suicidality in emergency services (ES) settings.

METHODS

Using an implementation science framework, the authors collaboratively evaluated the needs of ES providers; developed a plan; and trained ES psychiatrists, social workers, and mental health specialists for SPI implementation. The health care and social workers put the safety plan into practice in ES settings and, after involving stakeholders in addressing challenges during implementation, fully integrated the program into ES practice. This study examined providers' attitudes toward the structured SPI before and after training in this evidence-based intervention.

RESULTS

Providers reported a desire to learn evidence-based interventions for safety planning before the training. The effect of time from pre- to posttraining on provider attitudes and knowledge about the SPI was statistically significant (F=4.19, df=2 and 22, p=0.030), indicating that providers' attitudes toward using the structured SPI in their work improved after completing the training.

CONCLUSIONS

These findings are relevant for health care settings that seek to comply with new standards for hospital accreditation and improve overall patient care for suicidal youths. The results suggest that stakeholder collaboration and brief training in SPI may be effective for incorporating structured safety planning practices into pediatric ES settings.

Development of a Clinical Pathway for the Assessment and Management of Suicidality on a Pediatric Psychiatric Inpatient Unit

Purpose

This article describes steps taken by a mental health inpatient multidisciplinary team to develop a clinical pathway for the assessment and management of suicidality in a pediatric psychiatric inpatient unit.

Patients and Methods

The setting for this project is a 19-bed inpatient psychiatry unit providing care for children and adolescents (6-17 years of age) in a tertiary care pediatric hospital in Ontario, Canada. Three Lean methodologies were used: 1) The A3 process was used to articulate a problem statement and help clarify expectations, determine goals, and uncover, address and encourage discussion of potential issues; 2) Process mapping was used to show how work process activities are sequenced from the time of the patient's admission to discharge; and 3) Standard work, where consideration was given to the breakdown of the work into categories which are sequenced, organized and repeatedly followed. Generally accepted methodologies for developing clinical pathways were used to create a framework and algorithm for the assessment and management of suicidality in psychiatrically hospitalized children and adolescents.

Results

The clinical pathway development resulted in six steps from admission to discharge: intake process, inclusion/exclusion criteria, data integration and treatment formulation, interventions, determination of readiness for discharge, and the discharge process.

Conclusion

This framework, developed with the aim to standardize care for psychiatrically admitted suicidal children and adolescents, may serve as a flexible template for use in similar settings and could be adapted according to local realities and resources.

Suicide Safety Planning: Clinician Training, Comfort, and Safety Plan Utilization

Extant literature has demonstrated that suicide safety planning is an efficacious intervention for reducing patient risk for suicide-related behaviors. However, little is known about factors that may impact the effectiveness of the intervention, such as provider training and comfort, use of specific safety plan elements, circumstances under which providers choose to use safety planning, and personal factors which influence a provider’s decision to use safety planning. Participants were (N = 119) safety plan providers who responded to an anonymous web-based survey. Results indicated that most providers had received training in safety planning and were comfortable with the intervention. Providers reported that skills such as identifying warning signs and means safety strategies were routinely used. Providers who reported exposure to suicide were more likely to complete safety plans with patients regardless of risk factors. In addition, almost 70% of providers indicated a need for further training. These data provide important considerations for safety plan implementation and training.

Safety Planning on Crisis Lines: Feasibility, Acceptability, and Perceived Helpfulness of a Brief Intervention to Mitigate Future Suicide Risk

BACKGROUND

The role of crisis hotlines traditionally was limited to de-escalation and service linkage. However, hotlines are increasingly recruited to provide outreach and follow-up to suicidal individuals. Hotlines have the opportunity to not just defuse current crises but also provide brief interventions to mitigate future risk. The Safety Planning Intervention (SPI) is a brief intervention designed to help manage suicidal crises, but its feasibility and effectiveness on hotlines are not established.

AIMS

This study examined feasibility and perceived effectiveness of SPI, as reported by 271 crisis counselors at five centers in the National Suicide Prevention Lifeline network.

METHOD

Counselors were trained to use SPI. Self-report surveys were completed immediately after training (time 1) and at the end of the study, approximately 9 months later (time 2).

RESULTS

Counselors reported that SPI was feasible and helpful, and was used on both incoming and follow-up calls. Utilization and perceived effectiveness at time 2 were predicted by self-efficacy, feasibility, and helpfulness at time 1.

LIMITATIONS

Results are preliminary and limited to counselors' perceptions. Future RCTs should establish efficacy of SPI for crisis callers.

CONCLUSION

The Safety Planning Intervention is a promising approach to reduce crisis callers' future suicide risk that hotline counselors report is both feasible and helpful.

Dissemination of the Safety Planning Intervention (SPI) to University Counseling Center Clinicians to Reduce Suicide Risk Among College Students

Suicide risk on college campuses remains a pervasive problem. Structural deficits in current clinical care models often result in sub-optimal treatment for suicidal students. This study reports on the feasibility, acceptability, and utility of the Safety Planning Intervention (SPI), a brief, empirically validated, clinician-administered suicide prevention intervention, in a university counseling center (UCC) setting. A group of 12 university counseling center direct service staff completed a 2-hour training in SPI. Participants reported on suicide intervention practices, training needs, and confidence at baseline and 10 weeks post-training. Acceptability, utility, and frequency of SPI use were assessed at follow-up. All clinical staff attended the training and found it useful, reporting that confidence in managing suicide risk increased as a result. Two-thirds of staff implemented SPI least once. Results suggest that SPI is a feasible, acceptable, and useful suicide intervention tool for UCCs.

Evaluating the Feasibility and Effectiveness of an Australian Safety Planning Smartphone Application: A Pilot Study Within a Tertiary Mental Health Service

OBJECTIVE

The purpose of this study was to examine the feasibility and effectiveness of a suicide prevention smartphone application.

METHOD

Thirty-six non-Aboriginal Australians aged between 16 and 42 years (67% female) were recruited from a tertiary mental health service where they were receiving treatment for suicide risk. Participants were asked to use the BeyondNow safety planning smartphone application to manage their suicide safety plan during a 2-month trial, as an adjunct to treatment as usual. A survey battery designed to measure feasibility and effectiveness of the smartphone app plus treatment as usual intervention was completed at baseline and follow-up.

RESULTS

A vast majority of participants used the app to view and edit their safety plans and reported that the app was easy to use. A reduction was observed in participant severity and intensity of suicide ideation, and suicide-related coping increased significantly. No significant changes were observed in suicide resilience.

CONCLUSIONS

The BeyondNow safety planning smartphone application was shown to be feasible and effective as an adjunct to mental health treatment among patients at risk of suicide.

Suicide Prevention Experiences, Knowledge, and Training among School-based Counselors and Nurses in King County, Washington - 2016

Objective

Few studies have assessed the suicide-specific perceptions and awareness of school-based nurses and counselors. This project assessed the self-reported training, beliefs, and professional experiences of school counselors and nurses towards suicide prevention, and identified areas for enhancing efforts to respond to student suicidality.

Methods

A self-report needs assessment survey was conducted with school-based nurses and counselors in King County, Washington. Group comparisons and descriptive statistics were calculated to characterize providers' perceptions and experiences.

Results

Most training experiences reported by counselors and nurses corresponded with greater perceptions of comfort in applying suicide prevention knowledge and skills. Fewer respondents endorsed means safety and safety planning as regularly implemented interventions for at-risk students compared to other interventions.

Conclusion

Means safety and safety planning appeared to be areas for enhancing existing suicide prevention efforts.

Clinician Experience and Attitudes Toward Safety Planning with Adolescents at Risk for Suicide

This study examined clinician experiences and attitudes toward safety planning in a large urban pediatric psychiatry department serving primarily Latino youth. A total of 46 clinicians completed a survey assessing their experience with and attitudes toward safety planning with adolescents at-risk for suicide. The majority of clinicians were female (78%), non-Latino White (54%), and aged 30-39 (52%). Clinicians' attitudes were largely positive (M = 3.69 SD = 0.47, Range = 2.42-4.42). However, many clinicians (n = 24) were not convinced that safety planning reduces the imminent risk of suicidal behavior in patients. This study provides more depth to our understanding of the way in which safety planning is perceived by clinicians.

Perceptions of Adjunctive Mindfulness-Based Cognitive Therapy to Prevent Suicidal Behavior Among High Suicide-Risk Outpatient Participants

Abstract. Background: Few investigations of patient perceptions of suicide prevention interventions exist, limiting our understanding of the processes and components of treatment that may be engaging and effective for high suicide-risk patients. Aims: Building on promising quantitative data that showed that adjunct mindfulness-based cognitive therapy to prevent suicidal behavior (MBCT-S) reduced suicidal thinking and depression among high suicide-risk patients, we subjected MBCT-S to qualitative inspection by patient participants. Method: Data were provided by 15 patients who completed MBCT-S during a focus group and/or via a survey. Qualitative data were coded using thematic analysis. Themes were summarized using descriptive analysis. Results: Most patients viewed the intervention as acceptable and feasible. Patients attributed MBCT-S treatment engagement and clinical improvement to improved emotion regulation. A minority of patients indicated that factors related to the group treatment modality were helpful. A small percentage of patients found that aspects of the treatment increased emotional distress and triggered suicidal thinking. These experiences, however, were described as fleeting and were not linked to suicidal behavior. Limitations: The sample size was small. Conclusion: Information gathered from this study may assist in refining MBCT-S and treatments to prevent suicidal behavior among high suicide-risk patients generally.

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.

The Zero Suicide Model: Applying Evidence-Based Suicide Prevention Practices to Clinical Care

Suicide is reaching epidemic proportions, with over 44,000 deaths by suicide in the US, and 800,000 worldwide in 2015. This, despite research and development of evidence-based interventions that target suicidal behavior directly. Suicide prevention efforts need a comprehensive approach, and research must lead to effective implementation across public and mental health systems. A 10-year systematic review of evidence-based findings in suicide prevention summarized the areas necessary for translating research into practice. These include risk assessment, means restriction, evidence-based treatments, population screening combined with chain of care, monitoring, and follow-up. In this article, we review how suicide prevention research informs implementation in clinical settings where those most at risk present for care. Evidence-based and best practices address the fluctuating nature of suicide risk, which requires ongoing risk assessment, direct intervention and monitoring. In the US, the National Action Alliance for Suicide Prevention has put forth the Zero Suicide (ZS) Model, a framework to coordinate a multilevel approach to implementing evidence-based practices. We present the Assess, Intervene and Monitor for Suicide Prevention model (AIM-SP) as a guide for implementation of ZS evidence-based and best practices in clinical settings. Ten basic steps for clinical management model will be described and illustrated through case vignette. These steps are designed to be easily incorporated into standard clinical practice to enhance suicide risk assessment, brief interventions to increase safety and teach coping strategies and to improve ongoing contact and monitoring of high-risk individuals during transitions in care and high risk periods.

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.

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.