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Experts point to insufficient mental healthcare resources in the United States as one of the key drivers in the rising suicide rate. However, these experts emphasize that emergency providers have a front-row seat to the problem, and can play an important role in prevention. To address the issue, a growing number of EDs are implementing universal screening to identify patients at risk for suicide. Such steps must be paired with effective protocols to connect at-risk patients with appropriate interventions.
With suicide rates rising, there is a new focus on what frontline providers can do to address the problem. It is well-known that patients at risk for suicide often present to the ED, so developing an effective way to take advantage of this opportunity could prevent many patients from taking their own lives.
However, with EDs already overwhelmed with other tasks, taking on suicide prevention can be challenging, especially when there is a dearth of mental health resources in the community. But the urgency of this problem — reflected in newly released data from the CDC, showing that suicide rates are up in every state with the exception of Nevada, where rates already were elevated — suggests that it is an issue that clearly requires more attention and new solutions. (Editor’s Note: Read more about the new CDC data later in this issue.)
What’s pushing the suicide rates higher in this country? Edwin Boudreaux, PhD, a professor in the departments of emergency medicine, psychiatry, and quantitative health sciences at the University of Massachusetts Medical School, has been working on the issue for many years, and he suggests one of the biggest contributing factors is plain to see.
“The mental health treatment system in the United States is broken, so we have really poor access to high-quality behavioral healthcare,” he says.
Thus, Boudreaux notes psychiatric patients who come to the ED often are boarded or “hung up” there at a much higher rate and for a much longer period than medical patients. “If you come into the ED, and you have a medical problem that requires hospital admission, you get into the hospital relatively quickly compared to psychiatric patients,” he says. “The reason for that is there is no place to send psychiatric patients.”
In fact, the scarcity of mental health resources extends from outpatient care to intensive inpatient care.
“If people can’t readily access high-quality behavioral healthcare, then their behavioral health disorders go untreated ... and [they] are more likely to die by suicide,” Boudreaux laments. “There is a clear problem with getting access to high-quality care that leaves people in the lurch, so they have no safety net and because of this, they end up dying by suicide.”
Boudreaux acknowledges that it is difficult to prove this link, but he notes there are different bits of data that are revealing.
“We see the suicide rate increasing, but we also see the boarding rate in EDs increasing, and we see other data that suggest access to behavioral healthcare is problematic, with long delays and insufficient coverage,” he says.
Another potential contributing factor to the rising suicide rate is the growing isolation of the modern tech era, Boudreaux offers.
“When all your friends are online, and there is an actual breakdown in community connectedness ... people become isolated, and they feel lonely and disconnected; they feel their lives have less meaning,” he says. “When you have lonely, disconnected lives, people tend to resort to suicide more frequently.”
Suicide prevention advocates also are concerned about the increasingly available access to information about highly lethal suicide methods.
“What we have seen is that when you can access on the internet information around exactly how [to commit suicide], including ways that are relatively painless and highly likely to be effective, then that information translates into action,” Boudreaux says. “Where people may not have understood how to [commit suicide] in the past, and they have taken overdoses or used other non-lethal means and didn’t die, now they are more often dying through their attempts because they are getting this information.”
Indeed, in his own region, Boudreaux has observed people using different suicide methods than in the past, and the new methods tend to be more lethal. This is unfortunate because many people who get through a suicide crisis without dying will recover and be just fine, he says.
“A low-lethal suicide attempt doesn’t mean the person will inevitably die by suicide, but if you have available lethal means, you don’t get past it.”
Emergency providers must be particularly attuned to the issue when high-profile instances of suicide are widely publicized, as they have been recently with the suicide deaths of designer Kate Spade and celebrity chef Anthony Bourdain.
“We know that high-profile suicide cases lead to other suicides,” Boudreaux says. “Suicide contagion is a pretty well-studied phenomenon.”
When news coverage of these cases goes viral and is shared repeatedly via social media in ways that were not available before, it becomes an omnipresent type of reminder and stimulus, Boudreaux adds.
“If a person is already feeling suicidal, and now they are not only seeing it on the news, but they are seeing it on Facebook and seeing it in tweets, and it is retweeted and reposted and emailed ... it becomes a stimulus that is difficult to avoid in the way that in the past it could be avoided by just turning off the TV.”
Marian Betz, MD, MPH, an associate professor in the department of emergency medicine at the University of Colorado’s Anschutz Medical Campus, notes that many aspects of the suicide problem are beyond the immediate control of emergency providers. These aspects include not maintaining enough psychiatric beds or not employing enough outpatient mental health providers. However, Betz recommends emergency providers advocate for additional resources in these areas, stressing that this is just a start.
“I think sometimes people get frustrated, thinking there is nothing they can do,” she says. “But there is a lot that we can be doing within the ED to identify and then [intervene] with people who are at risk for suicide.”
For example, Betz’s ED, and a growing number of EDs across the country, have begun to implement universal screening for suicide risk. Typically, such screening takes place at triage or during the initial nursing assessment. The process involves asking patients a few questions regarding their thoughts about suicide or whether they have made any suicide attempts in the past. Such questions are embedded with queries about other risk factors such as domestic violence, smoking, and the like.
“The rationale for [suicide risk screening] is that prior estimates suggest that there is a decent proportion of people who are at risk for suicide who are seen in EDs and won’t say anything unless you ask them about it,” Betz says. “You don’t pick up [the signs] unless you ask.” While some EDs opt for targeted screening, which means they only screen patients in other high-risk groups such as those with substance use disorders or mental health conditions, that approach misses a group of patients at risk who have no presenting symptoms or obvious risk factors.
“That is why a lot of EDs have decided they will just screen everybody,” Betz notes. “It is easier, and it has been estimated from prior research that about 10% of all adults in the ED have had recent suicide ideation or behaviors, but a lot of those people won’t say anything unless you ask about it.”
Of course, there is no point in screening for suicide risk unless there are protocols in place for addressing next steps if a patient is found to be at risk. “We do know some people feel some relief at being asked about the pain they are in, but certainly there should be a follow-up step to figure out what the person needs,” Betz advises. “That is where it can get a little more difficult because we as emergency physicians practice in such varied locations. There are small, community, often rural EDs that don’t have mental health specialists available, whereas I work in an urban, tertiary care center where we have 24/7 access to social workers within our ED to do our [follow-up] evaluations.”
In Betz’s ED, if a patient screens positive for suicide risk or presents with a complaint of feeling suicidal, the emergency physician will conduct an initial assessment. Many of these patients then will be seen by a licensed social worker, referred to as a behavioral health evaluator, for a more comprehensive assessment. “It is really helpful to have those specialists because of their training, but also because they have more time to sit with the patient and really talk through all of the risks and protective factors, and to formulate a more detailed evaluation,” Betz shares. For smaller hospitals or EDs that do not have access to such specialists, the follow-up piece is a bigger lift. However, Betz says these facilities can contract with an outside group that can send a specialist to the ED, or through a tele-psychiatry solution. “I also think it is important to point out that we as emergency providers should develop a skill base to be able to care for at least the lowest-risk individuals without behavioral health specialists,” she says, noting that it is analogous to caring for patients with chest pain. “We don’t call a cardiologist for everybody who has chest pain. As emergency providers, we know how to do the initial risk stratification and decide who needs further testing or who needs to see a specialist.”
Similarly, Betz notes that emergency providers should learn the skills to care for a patient who has had some suicidal thoughts, but demonstrates no other risk factors. “We should be empowered to be able to care for those types of patients sometimes, even without a specialist,” she says. “That is important because at places where behavioral health specialists are not available, you are faced with transferring patients or keeping them for hours in the ED, which is tricky.”
The array of skills Betz would like to see emergency providers acquire includes knowing what questions to ask and how to risk-stratify someone with suicide risk. “In my own training, and what I have seen since then, it often seems as though with psychiatric complaints, we hand off as opposed to owning some of that risk stratification,” she says. “Some of this training should [be provided through] the development of better residency curricula and continuing medical education curricula.”
Betz also would like to see guidance on how to help ED staff find ways to show empathy and connect with these patients. This can be difficult because, unfortunately, patients with suicide risk often get lumped with patients who have other behavioral disturbances that may make them very difficult to care for. Such patients may be intoxicated, violent, or verbally abusive to staff, Betz explains.
“Such behaviors can make providers feel angry, upset, or jaded ... so I think they need to learn to recognize the spectrum of emotional and mental health disorders, and recognize that when someone is in the ED with suicide risk, that person is feeling very real pain too,” Betz stresses. “It is emotional pain, but in the same way that we feel compassion for physical pain, we need to get better at knowing how to heal [these patients].”
Sometimes, this is as simple as helping people find hope, Betz observes. “Being able to connect [with people] and [help them] think about something worth living for, whether that is a child or a pet or something that is coming up that the patient is looking forward to,” she says. “Emergency departments are not set up to be the most soothing or therapeutic places physically, so that is an added challenge.”
Safety planning with patients found to be at risk for suicide is part of the equation, too. “This involves helping a patient develop problem-solving skills in identifying people they can turn to and activities that make them feel better,” Betz explains. “They actually write these things down.”
It is important to ask about firearms because they are the most lethal method of suicide, Betz notes. “Sure, you can ask about medications or access to hanging supplies. That may make people feel like you are not singling out guns, but it is really important that we talk about whether people have access to firearms, and if they do, how they can reduce that access at least temporarily,” she says. “Some people say what does it matter? People [at risk of suicide] will just find another way. Some people, if they want to attempt suicide with a method that is not available, will substitute with something else, but actually most don’t. Even if they substitute something else, it is less likely to kill them than a firearm.”
Providers may ask: If a patient is suicidal, and they own a gun, does that mean the patient should be hospitalized? “The answer is no,” Betz adds. “You need to problem-solve with them, but just having a gun at home is not the thing that determines the risk assessment.”
Policymakers need to acknowledge that emergency providers have liability concerns, especially when they are performing tasks that they have not handled traditionally in a high-risk area, Betz says. “That’s why we need guidelines, tools, and policies from our national organizations that we can cite and say that we are sending a person home because that is in line with specific criteria and policies,” she says. “That will make providers feel more comfortable that they are not out on a limb.”
The Suicide Prevention Resource Center was developed to address some of these concerns. Funded by the Substance Abuse and Mental Health Services Administration, it includes a range of tools and guidance for emergency providers on how to assess for suicide risk as well as how to intervene when a patient is found to be at risk. (Editor’s Note: Readers can learn more information about these tools online at: ).
The site includes tools such as the Patient Safety Screener (PSS-3), a three-item instrument designed for use in the ED to assess for suicide risk (). There also is a safety planning guide that provides details about how to develop a safety plan for patients who are found to be at risk. ().
Boudreaux, who worked with colleagues to develop many of these resources, explains that the idea behind the site is to make it easy for EDs to access information and training materials so that they can actively deploy the tools and strategies. “All of our resources related to the [PSS-3] and how to use it are all in one place now, which we didn’t have before,” Boudreaux notes.
In fact, Boudreaux says that his own ED has programmed the screening tool into the electronic medical record (EMR), and staff are working with several EMR providers to make the tool part of their standard systems. “We have made some progress with that, but we are not quite there yet,” he says. Also in development is a second screening tool that could be used to risk-stratify patients further and gather more information about risk factors on patients who have screened positive on the PSS-3. “We are working on further building out decision support related to using the two tools together,” Boudreaux reports.
In addition to these resources, Betz is working with a group within the American College of Emergency Physicians to develop a reference tool geared especially for emergency physicians who are working in a setting without access to mental health practitioners. “It will help them think through all the steps,” she says, referring to the many issues that need to be addressed when managing a patient at risk for suicide. “We need tools like that to help providers because they can’t remember everything. They need to have a resource to go to, and something to be able to cite to justify what they are doing,” she says. The reference tool should be available later this year.
While new tools and guidance on dealing with suicide risk in the ED are released often, Boudreaux acknowledges that many emergency physicians are resistant to taking on additional tasks.
“It comes from a real place. Emergency physicians aren’t trained to do this, and they are busy and have other priorities,” he says. “That said, though, with suicide, we think we can train clinicians to do a better job of managing patients with lower-level risks. In fact, it is required because if we do a good job of screening, there is no way that we will have sufficient mental health resources to see and treat all of those patients. It’s impossible.”
When it comes to providing this training to emergency providers, the biggest obstacle that Boudreaux faces is logistics. “When clinicians are working, they can’t be trained, and when they are not working, they don’t want to come in on their off hours to get trained. There is no time to do it,” he explains. “Coming up with innovative ways to train people and to reinforce those skills over time is really important, and right now we just don’t have very good options. We do the best we can, but this is still an area that is evolving.”
Emergency staff members need to be reminded continually that they can play an important role in preventing suicides, Betz explains.
“We know from some recent surveys that emergency physicians and nurses, just like the public, may be skeptical that suicide is even preventable. That is another challenge,” she says. “We see people who are in crisis, but we don’t necessarily hear about the successes. We don’t hear about people getting better.”
The nature of emergency personnel is such that providers miss the positive reinforcement of seeing patients whom they treated, and who got better, Betz notes.
“Now, it is two years later, and such patients may be thriving,” she says. “We don’t ever get that feedback.”
Financial Disclosure: Physician Editor Robert Bitterman, MD, JD, FACEP, Nurse Planner Nicole Huff, MBA, MSN, RN, CEN, Author Dorothy Brooks, Editor Jonathan Springston, Editor Jill Drachenberg, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.