The Emergency Department: Challenges and Opportunities for Suicide Prevention

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Key points

  • Emergency services can offer life-saving suicide prevention care.

  • Brief therapeutic interventions initiated in the emergency department (ED) for youths presenting with suicide/self-harm risk can improve continuity of care and connections with outpatient follow-up treatment, a national suicide prevention objective.

  • A care process model and clinical guidance are offered based on current scientific evidence.

  • Effective treatment strategies for youth suicide/self-harm prevention are emerging from the

The emergency department

EDs provide a safety net in the US health system, owing to federal law (the Emergency Medical Treatment and Labor Act) guaranteeing access to ED care regardless of insurance or ability to pay. Roughly 1.5 million US youth, particularly lower income individuals from underserved populations, receive their primary health care in the ED,3 and the prevalence of ED visits for BH has increased.5 Given this increased need for BH treatment within EDs, integrating BH within ED services has potential for

Models of emergency psychiatric/behavioral health care

Table 1 summarizes models of emergency care. These models have generally been established for adults, with little developmental adaptation, although some applications of the mobile crisis response and intensive community-based treatment models have been developed specifically for youth.8

The traditional ED consultant model is used in many hospitals. In this approach, when suicide and self-harm risk is identified, a BH specialist, who consults to the ED, is called to do an assessment (now

Screening and brief interventions in the emergency department

All of the emergency service models begin with risk screening and evaluation. Owing to high acuity and limited resources, the most feasible and efficient approach is to use brief self-report screeners followed by more extensive evaluation for youths with positive screens. Such screeners, like the Ask Suicide-Screening Questions, have shown predictive validity.25 Adaptive screening algorithms that ask additional questions after positive responses, combined with objective behavioral tasks,26

Current guidelines and practice parameters

Practice guidelines, as a representation of evidenced-based practice, have achieved substantial credibility in medicine, are an integral part of emergency medicine, and combined with training can help to improve the quality of care. Guidelines are available online, and a Committee of the American College of Emergency Physicians develops and reviews published guidelines (available at: http://www.acepnow.com/tag/clinical-guidelines/).

Available clinical guidance emphasizes adults. Consensus

Care process model for youths presenting with a risk for suicide and self-harm

Fig. 1 presents a care process model for youths presenting to ED or emergency services for suicide and self-harm, based on evidence and clinical guidance reviewed. This process begins when patients with suspected suicide and self-harm risk are identified, at which time safety precautions are needed, including close monitoring in a safe setting to prevent suicide and self-harm and/or patients leaving without evaluation. Secondary screening and medical clearance is conducted by ED staff, which

Summary

EDs can offer life-saving suicide prevention care, yet hospital-based ED care is at a breaking point and underresourced to serve as a safety net for youth with BH problems.6 This article reviewed the characteristics of EDs, models of emergency care; ED screening, evaluation, and intervention models; and practice guidelines and parameters. We offered a care process model for youths presenting with suicide and self-harm risk with guidance for clinicians based on current scientific evidence.

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    • Predictors of Traumatic Suicide Attempts in Youth Presenting to Hospitals with Level I Trauma Centers

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      Suicide attempt at ED presentation vs. suicidal ideation alone is a significant predictor of a future suicide attempt. Several brief therapeutic intervention programs initiated in the ED have been shown to lead to increased attendance of mental health service appointments in randomized controlled trials (26). Connecting patients to outpatient services alone did not necessarily improve clinical outcomes.

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    Disclosure Statement: Dr J.R. Asarnow discloses consulting on quality improvement for depression and suicide prevention. Drs K. Babeva and E. Horstmann have nothing to disclose. Work reported in this article was supported by grants from the National Institute of Mental Health (R01MH112147, R34 MH078082), the United States Substance Abuse and Mental Health Services Administration (U79SM080041), the American Foundation for Suicide Prevention, and Centers for Disease Control (CCR921708). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

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