SAN FRANCISCO – A simple, low-cost intervention reduces the rate of suicide intent by about one-third among veterans at moderate risk who are discharged from the emergency department, according to a study presented at the annual meeting of the American Psychiatric Association.
The two-part intervention – known as the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment project (SAFE VET) – consists of a safety plan developed in the emergency department plus structured weekly follow-up monitoring post discharge.
Among the 124 veterans included in an interim analysis, about 15% of those in the intervention group had suicide intent at 1 month after discharge, compared with 22% of those in a risk-matched group receiving usual care, reported lead investigator Barbara Stanley, Ph.D., professor and research scientist at Columbia University, New York.
Nearly two-thirds of the veterans in the intervention group reported that they had used their safety plan to avert a suicidal crisis. Furthermore, in comments, the veterans described the intervention as life saving.
"Does SAFE VET ultimately prevent suicide? That question, of course, is out. Do people think this is very, very helpful to them? Very much so," Dr. Stanley commented. "And if you think about this, overall, the expenditure of time is, maximum, 3 hours."
One person attending the session questioned the level of training needed for professionals who help develop the safety plans. "You made it sound pretty easy, and I just wondered, when you are talking about moderate suicide risk patients who are seen cross sectionally, that’s very complicated," he said.
Dr. Stanley responded that doing a safety plan is far easier than conducting a good risk assessment "because you train in it and follow a particular pattern. We have trained people from the level of volunteers answering hotlines up to psychiatrists. If somebody has judged the person is okay to be let go [from the hospital], once you go from that point on, it does not require a lot of professional expertise to do it."
Another attendee asked, "Did you stratify effectiveness by diagnosis or impairment? For example, I could see that cognitively impaired people would do better with a program that reaches out to them, rather than wait for them to come to us."
"No, we kind of took an effectiveness approach in this study; we just took all comers. So if the staff had decided that this person is moderate risk and doesn’t need to be hospitalized, we would include them, period," Dr. Stanley said. "I’m not saying that there won’t be a difference [by diagnosis], because there could be."
SAFE VET intervention
There is good rationale for using ED-based suicide interventions, as the ED is often suicidal patients’ main or only contact with the health care system and many will not follow through with or will have a wait in accessing care after discharge, according to Dr. Stanley.
She contrasted the typical ED approach to suicidal patients and patients with obvious fractures, noting that the latter would never be sent on their way for treatment of the problem at a later time.
"We should figure out a way to have time enough in the ED to do an intervention for our suicidal veterans or suicidal patients, the equivalent of applying a cast in the ED," she maintained.
The safety plan component of SAFE VET is a short prioritized list of coping strategies and resources for use before or during a suicidal crisis that is crafted jointly by the patient and clinician in the ED, but in the patient’s own words (Am. J. Public Health 2012;102[Suppl. 1]:S33-7). It aims to reduce risk, enhance coping, increase treatment motivation, and promote linkages.
The plan has six steps: recognize warning signs, use internal coping strategies, socialize with others who can offer support and distraction, contact family members or friends who can help, contact a mental health agency or professional, and reduce the potential for use of lethal means such as firearms.
The plan has been adopted nationwide at Veterans Affairs Medical Centers in the United States, where a template is used.
With a safety plan in place, "patients feel like they don’t have to ‘white knuckle’ their suicidal episodes anymore because, in the past, what they just did was try to survive it, knowing that time in a certain sense is their friend because the suicidal feelings eventually go away," Dr. Stanley explained. "This gives them something they can do in order to help them through that period of time."
The other component of SAFE VET is structured follow-up monitoring after the patient leaves the ED, typically in the form of weekly telephone calls.