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A brief intervention administered in the emergency room can deter suicidal patients from making future attempts to end their lives.
The intervention included developing a personalized safety plan—concrete steps to take if the patient felt suicidal—and follow-up phone calls. People who received it were nearly half as likely to attempt suicide again and twice as likely to attend a mental health appointment in the next six months compared to patients in a control group. The findings, published in the journal JAMA Psychiatry, highlight a relatively fast and inexpensive strategy for hospitals to reduce suicides.
“Very simple, very targeted, very brief interventions are remarkably potent,” says Craig Bryan, an assistant professor of clinical psychology at the University of Utah, who was not involved in the study. “We can easily transport these simple strategies to a lot of settings and potentially move the needle on suicide prevention.”
Prevention has become increasingly critical in recent years. The suicide rate rose 28 percent between 1999 and 2016, according to the National Institute of Mental Health. In 2016, nearly 45,000 people died by suicide.
The researchers collected information on 1,640 people admitted to Veterans Health Administration emergency departments for a suicide-related reason between 2010 and 2015. They compared patients who received the intervention to those who did not for six months after they were discharged, a period when patients have an elevated risk of suicide.
The goal of safety planning, part of the intervention in this study, is to guide someone through an acute period of crisis, a stage that is dangerous but often temporary, says the report’s lead author Barbara Stanley, who developed the intervention and is a professor of psychiatry at Columbia University Medical Center. A clinician, such as a doctor, psychologist, or social worker, collaborates with the patient to develop coping strategies. First, they identify distracting activities that the person should try in a suicidal crisis, such as watching cartoons, knitting, or playing video games. Second, they list helpful distractors in the person’s social environment, such as going to a coffee shop to be around others. Third, the person notes family or friends they should call for support. If all else fails, the person is instructed to call a mental health professional or go to the hospital. The clinician also discusses limiting access to potential means of suicide and provides education about suicide.
“Every time we get on a plane, we hear about what to do when the cabin pressure drops—you do this, this, and this—because we don’t think clearly in an emergency. When we are suicidal, it’s an emergency, and we want somebody to just have a plan to get them through the crisis,” Stanley says.
Patients in the intervention group also received brief follow-up phone calls within 72 hours of leaving the hospital. Staff members checked to make sure the patient was safe, asked whether the patient remembered or used their safety plan, and encouraged patients to attend mental health appointments.
People given the intervention showed 45 percent fewer suicidal behaviors—which include deaths, attempts, and serious suicidal ideation—than a group who received typical care in the emergency room. They were also twice as likely to visit a mental health professional in the next six months.
An important limitation is that the data didn’t capture suicide attempts that did not result in a hospital visit. Even so, experts believe the results are compelling. “Very brief and simple strategies with someone in crisis can reduce the likelihood that they try to kill themselves by nearly 50 percent. Think about that for a minute. That’s a stunning finding,” Bryan says.
Strategies like safety planning represent a significant shift in suicide prevention, he explains. In the past, people were instructed to leverage external sources, such as calling the police, going to the hospital, or signing “no-suicide contracts” (which studies have shown are ineffective and potentially harmful). This approach is deeply flawed because it implies that people are incompetent and incapable of managing their lives, Bryan argues.
In contrast, safety planning provides concrete solutions that people can carry out themselves. “It’s a much more empowering approach, and that’s what I consistently hear from my patients,” Bryans says. “We’ve really flipped on its head the traditional ways of approaching suicide prevention.”
Safety planning began to permeate the field in the late 2000s, says Stephen O’Connor, an assistant professor of psychiatry at the University of Louisville, who was not involved in the study. Collecting thorough data on large groups of people took time, so there had been a lack of evidence to support the trend. But now, Stanley’s findings join a few other large projects proving the approach is effective, including one recent study by Craig Bryan’s team and another by a team at Brown University. “Safety planning just makes so much sense that it became the (best) standard before the data caught up with it,” O’Connor says. “I’m excited that the data supports what people believe is an effective way to help people manage a really risky period between emergency department treatment and follow up.”
In addition to reducing suicides, the intervention may also cut hospital hosts, Stanley says. The 45-minute program is short and relatively inexpensive, and emergency rooms could save money by curbing readmission rates. For example, a 2017 study by Bryans and colleagues showed crisis response planning (which is similar to safety planning) led patients to spend fewer days readmitted in psychiatric units.
Nevertheless, a few obstacles prevent safety planning and similar interventions from being implemented more widely. It requires more time from clinicians, and changing emergency department policies is difficult given the busy, intense, and demanding workflow.
Adoption also involves a shift in the way emergency rooms approach mental health care, Stanley says. Emergency departments focus on diagnosing and stabilizing patients. But stabilization following an injury doesn’t solve the underlying problem for suicide as it normally does for physical injuries.
Stanley’s team hopes to turn the safety plan into a concrete, critical solution. Although a piece of paper seems an unlikely candidate, Stanley has observed its powerful effect. “Anecdotally, it’s been pretty astounding to me,” Stanley says. “I’ve been doing suicide research for many years, and we’ve had patient after patient say, ‘This intervention saved my life.’”
For immediate help 24/7, call the National Suicide Prevention Lifeline, 1-800-273-TALK, or text TALK to 741741 for the Crisis Text Line.
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