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Nugent SM, Anderson J, Young SK. Behavioural mental health interventions delivered in the emergency department for suicide, overdose and psychosis: a scoping review. BMJ Open 2024; 14:e080023. [PMID: 38531581 DOI: 10.1136/bmjopen-2023-080023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE To identify and describe evidence on brief emergency department (ED)-delivered behavioural and care process interventions among patients presenting with suicide attempt or acute ideation, substance overdose or psychosis. DESIGN We employed a scoping review design and searched multiple data sources, clinical trial registries and references lists through March 2023. We included English-language trials and rigorously designed observational studies. In alignment with scoping review guidelines, we did not assess the quality of included studies or rate the strength of evidence of intervention effectiveness. POPULATION Our population of interest was adults presenting to the ED with suicidality (eg, attempt or acute ideation), any substance overdose or acute psychosis from a primary mental health condition. INTERVENTION We included studies of brief behavioural or care process interventions delivered in the ED. OUTCOME MEASURES Health outcomes (eg, symptom reduction), healthcare utilisation and harms. RESULTS Our search identified 2034 potentially relevant articles. We included 40 studies: 3 systematic reviews and 39 primary studies. Most studies (n=34) examined ED interventions in patients with suicide attempt or suicidal ideation, while eight studies examined interventions in patients with opioid overdose. No studies examined ED interventions in patients with acute psychosis. Most suicide prevention studies reported that brief psychological, psychosocial or screening and triage interventions reduce suicide and suicide attempt following an ED visit. Most clinical trial interventions were multicomponent and included at least one follow-up. All substance overdose studies focused on opioids. These studies often contained medication and referral or consultation components. Multiple studies reported increases in substance use disorder treatment utilisation; evidence on repeat overdose events was limited. CONCLUSIONS A wide range of multicomponent ED-delivered behavioural health interventions for suicidality and opioid use disorder show short-term improvement on primary outcomes such as suicide reattempt. Few studies on non-opioid substances and psychosis are available.
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Affiliation(s)
- Shannon M Nugent
- Center to Improve Veteran Involvement in Care, Portland VA Medical Center, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Johanna Anderson
- Evidence Synthesis Program, Portland VA Medical Center, Portland, Oregon, USA
| | - Sarah K Young
- Evidence Synthesis Program, Portland VA Medical Center, Portland, Oregon, USA
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Khazanov GK, Keddem S, Hoskins K, Wortzel HS, Simonetti JA. Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts. J Psychiatr Pract 2024; 30:139-146. [PMID: 38526402 DOI: 10.1097/pra.0000000000000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, previous studies have shown that clinicians may hesitate to deliver this evidence-based intervention, in part because of concerns that patients might not find such discussions acceptable. Based on a published review of 18 qualitative studies examining diverse perspectives on LMSC, we discuss strategies that may help clinicians increase the acceptability of LMSC among their patients and present supporting scripts, rationales, and resources. The studies included in the review examined the perspectives of clinicians, patients, firearm owners, and other relevant groups across a wide range of clinical settings on LMSC for firearms. The authors of these studies recommend that clinicians approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patients' lives, and adapt LMSC to patients' previous experiences with firearms, safety, and injury. Clinicians may also want to contextualize and provide a rationale for LMSC, decide whether or not to directly ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or discount coupons for purchasing such devices may increase the acceptability and efficacy of these discussions. The strategies recommended in this paper are the first to be based on a comprehensive set of relevant studies. Future research is needed to examine whether these strategies do in fact increase the acceptability of LMSC and promote other outcomes such as increased feasibility and efficacy.
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Salhi C, Beatriz E, Berrigan J, Azrael D, Houston A, Runyan C, Barber C, Betz M, Miller M. "Your son needs help … and we're gonna help him": A qualitative study of the experiences of gun-owning caregivers of adolescents receiving lethal means counseling in the emergency department. Soc Sci Med 2023; 335:116218. [PMID: 37738913 DOI: 10.1016/j.socscimed.2023.116218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/17/2023] [Accepted: 09/01/2023] [Indexed: 09/24/2023]
Abstract
Suicide attempts in adolescents are often transient and unpredictable, making preventative approaches crucial in reducing suicide deaths. One important approach is lethal means counseling (LMC), in which clinicians counsel caregivers to reduce access to methods used in suicide, specifically firearms and medications. Research on LMC has increasingly encouraged the use of the shared decision-making (SDM) model, which emphasizes information exchange, collaborative deliberation, and joint planning between caregivers and clinicians. We examine caregivers' experiences with LMC, using the SDM model as our analytic framework. We conducted qualitative interviews with 21 firearm-owning caregivers of adolescents who came to emergency departments (EDs) in Colorado for a behavioral health complaint. The implementation of LMC at these institutions had three central components: training for clinicians, materials (e.g., lockboxes and pamphlets) to support LMC, and the protocolization of LMC at the institution. Our semi-structured, hour-long interviews examined participants' reflections on and reactions to LMC provided in the ED and how that related to changes in their understanding of their medication and gun storage practices. We analyzed interviews using a phenomenological approach, focusing on experiences with LMC and informed by the tenets of the SDM model. Our analysis revealed that caregivers were receptive to the idea of LMC in the pediatric emergency care setting. Caregivers' engagement in LMC was reinforced by experiences with clinicians who sought to understand the circumstances of their household, shared the motivation behind LMC, and facilitated conversation around a shared concern for the child's safety. In contrast, counseling delivered mechanically and without considering the household context was tied to caregivers' confusion and alienation, both for LMC and their consideration of changes to home storage practices. These findings provide insight into adolescent caregivers' experiences with LMC implemented in EDs and how LMC may best be approached.
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Affiliation(s)
- Carmel Salhi
- Department of Health Sciences, Northeastern University, Boston, MA, USA; Institute of Health Equity and Social Justice Research, Northeastern University, Boston, USA.
| | | | - John Berrigan
- University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, KS, USA; Harvard Injury Control Research Center, Harvard Chan School of Public Health, Boston, MA, USA.
| | - Deb Azrael
- Harvard Injury Control Research Center, Harvard Chan School of Public Health, Boston, MA, USA.
| | - Ashley Houston
- Institute of Health Equity and Social Justice Research, Northeastern University, Boston, USA.
| | - Carol Runyan
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
| | - Catherine Barber
- Harvard Injury Control Research Center, Harvard Chan School of Public Health, Boston, MA, USA.
| | - Marian Betz
- Injury and Violence Prevention Center, Colorado School of Public Health, Aurora, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Matthew Miller
- Department of Health Sciences, Northeastern University, Boston, MA, USA; Harvard Injury Control Research Center, Harvard Chan School of Public Health, Boston, MA, USA.
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Mueller KL, Blomkalns AL, Ranney ML. Taking Aim at the Injury Prevention Curriculum: Educating Residents on Talking to Patients About Firearm Injury. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1433-1437. [PMID: 35442908 DOI: 10.1097/acm.0000000000004707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The medical community recognizes that firearm injury is a public health problem. Yet we lack both the tools for and the implementation of evidence-based firearm injury screening and counseling techniques. One reason for these deficits is the lack of clinical training related to engaging patients in firearm injury risk reduction. In this issue, Rickert et al describe a pre-post evaluation of a 2-part firearm injury prevention training curriculum for first-year medical residents at a single academic medical center. Their manuscript serves an important, but still preliminary, step forward for the field of postgraduate medical education on firearm injury and its prevention. Important elements of this project and paper consist of the inclusion of multiple medical disciplines and the use of standardized patients to evaluate participants' learning. This project also points to the need for further growth. We must commit to consistently and conscientiously framing injuries from guns not as "gun violence" but rather as "firearm injuries" to ensure that they are considered squarely in both the public health space and the clinical space. An ideal curriculum would also highlight the importance of trauma-informed care, cultural competency, and antiracist medical practice while countering implicit biases (e.g., toward gun owners, victims of firearm violence, perpetrators of violence). It should address barriers, as well as facilitators, to change. And most importantly, future educational work must evaluate the effect of these trainings on actual clinical practice-and, even better, the efficacy of education in changing behavior and patient-level outcomes.
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Affiliation(s)
- Kristen L Mueller
- K.L. Mueller is assistant professor, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri; ORCID: https://orcid.org/0000-0001-9799-0861
| | - Andra L Blomkalns
- A.L. Blomkalns is professor and chair, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Megan L Ranney
- M.L. Ranney is professor, Department of Emergency Medicine, Warren Alpert Medical School, and academic dean, School of Public Health, Brown University, Providence, Rhode Island
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Boggs JM, Quintana LM, Beck A, Clinch S, Richardson L, Conley A, Richards JE, Betz ME. “Lock to Live” for firearm and medication safety: Feasibility and acceptability of a suicide prevention tool in a learning healthcare system. Front Digit Health 2022; 4:974153. [PMID: 36148209 PMCID: PMC9485577 DOI: 10.3389/fdgth.2022.974153] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveFew patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications.MethodsPatients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability.ResultsThe population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support.ConclusionDespite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.
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Affiliation(s)
- Jennifer M. Boggs
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, United States
- Correspondence: Jennifer M. Boggs
| | - LeeAnn M. Quintana
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, United States
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, United States
| | - Samuel Clinch
- Kaiser Permanente Colorado Behavioral Health Department, Denver, CO, United States
| | - Laura Richardson
- Kaiser Permanente Colorado Behavioral Health Department, Denver, CO, United States
| | - Amy Conley
- Kaiser Permanente Colorado Behavioral Health Department, Denver, CO, United States
| | - Julie E. Richards
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, United States
| | - Marian E. Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States
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Khazanov GK, Keddem S, Hoskins K, Myhre K, Sullivan S, Mitchell E, Holliman BD, Landes SJ, Simonetti J. Stakeholder perceptions of lethal means safety counseling: A qualitative systematic review. Front Psychiatry 2022; 13:993415. [PMID: 36339871 PMCID: PMC9634731 DOI: 10.3389/fpsyt.2022.993415] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Lethal means safety counseling (LMSC) is an evidence-based suicide prevention intervention during which providers encourage patients to limit their access to lethal means (e.g., firearms, medications). Despite agreement about the importance of LMSC, it is underutilized in clinical practice. METHODS To better understand the individual and contextual factors that influence LMSC and its implementation, we conducted a systematic review of qualitative studies examining stakeholder perceptions of the intervention. PubMed and PsycInfo were searched up to February 2021 using terms related to: (1) LMSC, firearms, or medications; (2) suicide, safety, or injury; and (3) qualitative methodology. Two coders used thematic synthesis to analyze findings from eligible papers, including developing a codebook and coding using an inductive and iterative approach (reliability k > 0.70). Confidence in review findings were evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach. Subthemes were assigned to domains in the Consolidated Framework for Implementation Research. FINDINGS Of the 19 papers identified, 18 discussed LMSC for firearms and 1 focused exclusively on LMSC for medications. The firearm-related studies explored perspectives of a variety of stakeholders (patients, providers, members of the firearms community, healthcare leaders, and family members) across multiple settings (emergency departments, pediatric and adult primary care, and outpatient mental health). Seven overarching themes emerged, including the: (1) importance of firearms to owners' identities and perceptions of ownership as a value and right, which can lead to perceived cultural tensions in clinical settings; (2) importance of patients understanding the context and rationale for LMSC; (3) value of providers showing cultural competency when discussing firearms; (4) influence of safety and risk beliefs on firearm behaviors; (5) need to navigate logistical concerns when implementing LMSC; (6) value of individualizing LMSC; (7) potential for trusted family members and friends to be involved in implementing LMSC. CONCLUSION This synthesis of the qualitative literature informs clinical, operational, and research endeavors aimed at increasing the reach and effectiveness of LMSC. Future research should address the perspectives of individuals underrepresented in the literature (e.g., those from racial/ethnic minority groups) and further examine stakeholders' perceptions of LMSC for medication. [-2pt]. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237515], identifier [CRD42021237515].
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Affiliation(s)
- Gabriela Kattan Khazanov
- Mental Illness Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Shimrit Keddem
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia PA, United States
| | - Katelin Hoskins
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Karoline Myhre
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarah Sullivan
- James J. Peters VA Medical Center, Bronx, NY, United States
| | - Emily Mitchell
- James J. Peters VA Medical Center, Bronx, NY, United States
| | - Brooke Dorsey Holliman
- Department of Family Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Sara J Landes
- Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Joseph Simonetti
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Rocky Mountain Regional VA Medical Center, Aurora, CO, United States.,Division of Hospital Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
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