From the Editor
He presents to the Emergency Department a few days after a suicide attempt. What can we do to help keep this man safe today – and moving forward?
Emergency Departments: noisy, busy, and an opportunity for suicide prevention?
It’s a scenario that repeats itself at EDs across the country with regularity. This week, in our first selection, we consider a new JAMA Psychiatry paper that has just been published looking at suicide prevention in the ED population. The authors claim “this study is the largest suicide intervention trial ever conducted in the United States,” and they show that, with an intervention, they can reduce suicides and suicide attempts.
And, in the other selection, we look at a short New York Times essay in which economist Austin Frakt argues that substance programs pay for themselves in crime reduction.
ED and Suicide Prevention
“Suicide Prevention in an Emergency Department Population: The ED-SAFE Study”
Ivan W. Miller, Carlos A. Camargo Jr, Sarah A. Arias, Ashley F. Sullivan, Michael H. Allen, Amy B. Goldstein, Anne P. Manton, Janice A. Espinola, Richard Jones, Kohei Hasegawa, Edwin D. Boudreaux
JAMA Psychiatry, 29 April 2017 Online First
Suicidal behavior is a significant public health issue. In 2015, there were 44 193 deaths by suicide in the United States. Suicide accounts for 1.2% of all deaths and is the tenth leading cause of death in the United States. Attempted suicide is an even more common event, with more than 1 million people per year attempting suicide.
Despite its significance, to our knowledge, few intervention trials have targeted and/or reduced suicidal behavior. Some psychotherapies have been found to reduce rates of suicide attempts, although there are concerns about publication bias. Additionally, these interventions require substantial training and are lengthy and costly to administer. Briefer, less intensive interventions (eg, follow-up letters and reminder postcards) have had mixed results. New interventions specifically developed to prevent suicidal behavior are clearly needed.
Because emergency departments (EDs) treat many patients who are at risk for suicidal behavior, they are particularly important locations for suicide prevention. More than 4% of all ED visits are attributable to psychiatric conditions, and there are approximately 420 000 visits every year for intentional self-harm. These high-risk individuals are susceptible to suicide attempts after their ED visit. Also, a significant proportion of those who die by suicide received care in an ED in the period prior to death.
To address these ongoing public health issues, we conducted a multicenter study of adult ED patients who screened positive for suicide attempts or ideation. In this article, we focus on the hypothesis that a multifaceted intervention delivered during and after the ED visit would decrease subsequent suicidal behaviors compared with usual care.
Ivan W. Miller
Here’s what they did:
- “Participants with suicidal ideation or recent attempt were recruited from 8 EDs across 7 states in the United States, ranging from small community hospitals to large academic centers.”
- Participants had a suicide attempt or ideation within a week of the ED visit. Exclusion criteria included language and cognitive problems.
- There were three phases: (1) the treatment as usual (TAU) phase, (2) the universal screening phase, and (3) the universal screening plus intervention phase. Participants were enrolled in (1), (1) and (2), or all three phases.
- The intervention phase consisted of further suicide risk screening (designed for ED physicians to evaluate suicide risk), the provision of a self-administered safety plan combined with information to patients by nursing, and a series of telephone calls to the participant, with the option of involving their significant other, for 52 weeks following the ED visit.
- “For all phases, following the index ED visit, enrolled participants were observed for 1 year using telephone assessments and medical record reviews…”
- Several statistical analyses were done.
Here’s what they found:
- “Of 1636 patients who met the study inclusion criteria, we enrolled 1376 participants, including 497 in the TAU phase, 377 in the screening phase, and 502 in the intervention phase…”
- Demographically: the median age was 37 years; participants tended to be female (55.9%) and white (67.4%). Most had past suicide attempts (71.7%); the majority (87.4%) had a psychiatric disorder and most also had a coexisting medical disorder (69.2%).
- “Overall, of 1376 participants, 288 (20.9%) made at least 1 suicide attempt during the 12-month period. In the TAU phase, 114 of 497 participants (22.9%) made a suicide attempt, compared with 81 of 377 participants (21.5%) in the screening phase and 92 of 502 participants (18.3%) in the intervention phase. Five attempts were fatal, with fatalities observed in the TAU phase (n = 2) and intervention phase (n = 3).”
- “There were no meaningful differences in risk reduction between the TAU and screening phases.”
- “In contrast, compared with the TAU phase, participants in the intervention phase showed small but meaningful reductions in suicide risk, with a relative risk reduction of 20% and NNT of 22. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU or screening phases.”
- Using more sophisticated statistical analysis: “Multivariable negative binomial regression analysis also indicated that participants in the intervention phase had fewer total suicide attempts than those in the TAU phase (IRR, 0.75)…”
To our knowledge, this study is the largest suicide intervention trial ever conducted in the United States. More than 1300 participants with significant suicide risk from 8 EDs received either TAU, universal screening, or universal screening plus an intervention consisting of an expanded suicide screening and provision of a self-administered safety plan in the ED followed by a telephone-based intervention delivered over 52 weeks. The results indicated that the provision of universal screening, while successful in identifying more participants, did not significantly affect subsequent suicidal behavior compared with that experienced by participants in the TAU phase. By contrast, those participants who received the intervention had lower rates of suicide attempts and behaviors and fewer total suicide attempts over a 52-week period. These results are consistent with other studies demonstrating the utility of contact following discharge from EDs.
The NNT to prevent future suicidal behavior ranged between 13 and 22. This level of risk reduction compares favorably with other interventions to prevent major health issues, including statins to prevent heart attack (NNT = 104), antiplatelet therapy for acute ischemic stroke (NNT = 143), and vaccines to prevent influenza in elderly individuals (NNT = 20).
A few thoughts:
- This is a good study – it not only recognizes a major issue but points to a way forward in terms of a practical intervention.
- The intervention works, though the outcomes are good, but not incredible.
- The paper raises a larger question: what can be done with an ED contact to increase safety? Often, EDs are about triaging and referring patients with mental health problems, rather than beginning active care.
- The paper runs with an editorial from Ohio State University’s Jeffrey A. Bridge and his co-authors; they make a similar comment:
The ED-SAFE study provides a long-overdue opportunity to reflect on the potential public health benefits of raising expectations for care delivered to high-risk suicidal individuals presenting in the typical ED, challenging the existing dispositional focus (ie, ‘Where to send this suicidal patient?’) by offering a treatment-based perspective (ie, ‘How best to treat this suicidal patient?’).
Drugs and Crime
“Spend a Dollar on Drug Treatment, and Save More on Crime Reduction”
New York Times, 24 April 2017
The burden of substance abuse disorders can fall heavily on the families and friends of those who battle addictions. But society also pays a great deal through increased crime. Treatment programs can reduce those costs.
For at least two decades, we’ve known substance use and crime go hand in hand. More than half of violent offenders and one-third of property offenders say they committed crimes while under the influence of alcohol or drugs.
So begins a short but well-researched essay by economist Austin Frakt. He forwards a simple thesis: treating substance problems reduces crime, and ends up saving money.
He draws from the literature:
- “A study by Emory University scholars found that a 10 percent increase in the treatment rate reduces the robbery and larceny theft rates by about 3 percent and the aggravated assault rate by 4 to 9 percent.”
- “For a dollar spent on treatment, up to three are saved in crime reduction. An earlier study found that interventions to address substance use disorders save more in reduced crime than they save in reduced health care spending.”
- “Several systematic reviews and meta-analyses of therapies for opioid addiction found that methadone therapy reduced criminal activities related to heroin use.”
- “One analysis of more than 8,000 heroin users found that their offending rates were lower while on methadone therapy than when not on it. For every 100 patients on methadone per year, there were 12 fewer robberies, 57 fewer break-and-enters and 56 fewer auto thefts.”
He then considers why more isn’t done with substance treatment, and weighs the influence of stigma.
He closes by quoting the University of Chicago’s Harold Pollack: “Addiction treatment may be the one area of health policy right now in which Democrats and Republicans want to work together to meet an important public health challenge…”
A few thoughts:
- This article is short but thoughtful. He does a nice job of not just espousing an opinion, but tying it to the literature.
- His bipartisan call to action seems fair and reasonable.
- It’s nice to see the public policy debate move past the traditional left-right split, but towards more practical goals.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.