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Individuals with severe mental illness (SMI), including bipolar disorder (BD) and schizophrenia-spectrum disorders (SSD), are at high risk for suicide. However, suicide research often excludes individuals with SMI. The current research examined differences in suicide outcomes (i.e., suicide attempt or death) for adults with and without BD and SSD diagnoses following an emergency department (ED) visit and investigated the efficacy of the Coping Long Term with Active Suicide Program (CLASP) intervention in reducing suicide outcomes among people with SMI. 1235 adults presenting with recent suicidality were recruited from 8 different EDs across the United States. Using a quasi-experimental, stepped wedge series design, participants were followed for 52-weeks with or without subsequent provision of CLASP. Participants in the SSD group and the BD group had significantly shorter time to and higher rate of suicide outcomes than participants with other psychiatric diagnoses in all study phases and in non-CLASP phases, respectively. Participants with BD receiving the CLASP intervention had significantly longer time to suicide outcomes than those not receiving CLASP; these differences were not observed among those with SSD. Study limitations include self-reported psychiatric diagnosis, exclusion of homeless participants, and small sample size of participants with SSD. Participants with SMI were at higher risk for suicide outcomes than participants with other psychiatric diagnoses. CLASP was efficacious among those participants with BD. Psychiatric diagnosis may be a key indicator of prospective suicide risk. More intensive and specialized follow-up mental health treatment may be necessary for those with SSD. • Those with severe mental illness had highest rate of lifetime suicide attempts. • During the study, those with severe mental illness had shortest time to suicide. • During the study, those with severe mental illness had the highest rate of suicide. • The suicide intervention was efficacious for participants with bipolar disorder. • Additional research is needed on suicide intervention for those with schizophrenia. [ABSTRACT FROM AUTHOR]

Background: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. Methods: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. Conclusions: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. Trial registration: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023. [ABSTRACT FROM AUTHOR]

To compare Emergency Department (ED) care of suicidal patients with and without documented acute alcohol use. Retrospective chart review of randomly sampled patient visits (n = 800; January 2014 to December 2015) at an urban ED with universal screening for suicide risk. Eligible visits were by adults (18+ years) who screened positive for suicide risk at the ED visit (i.e., suicidal ideation in past two weeks or suicide attempt in past six months). Analyses compared those with and without documentation of acute alcohol use. Among these patients with suicide risk, 19% had documented acute alcohol use (versus 43% with no use and 38% without documentation); individuals with acute alcohol use were more often male and aged 35–59 years. Overall, 62% were evaluated by a mental health professional in the ED. Individuals with acute alcohol use were significantly less likely (vs those without use) to be evaluated by a mental health professional in the ED (odds ratio 0.49, 95%CI 0.28–0.87) after adjustment for age, recent suicide ideation, current suicide plan, self-harm as a chief complaint, contact with family, and ED disposition. Although alcohol use can increase suicide risk, ED patients with acute use appear to receive less thorough suicide risk assessments. [ABSTRACT FROM AUTHOR]

Background/Objective We described characteristics and treatment received for older (≥60 years) vs younger (<60 years) adult emergency department ( ED) patients with suicide risk. Design Retrospective chart review. Setting An ED with universal screening for suicide risk. Participants Eligible charts included a random sample of adults (≥18 years) who screened positive for suicidal ideation ( SI) in past 2 weeks and/or a suicide attempt ( SA) within the past 6 months. Visit dates were from May 2014 to September 2016. Results A total of 800 charts were reviewed, with oversampling of older adults. Of the 200 older adults sampled, fewer older adults compared to younger adults (n = 600) had a chief complaint involving psychiatric behavior (53% vs 70%) or self-harm behavior (26% vs 36%). Although a higher number of older adults (93%) had documentation of current SI compared to younger adults (79%), fewer older adults (17%) reported SA in the past 2 weeks compared to younger adults (23%). Of those with a positive suicide screen who were discharged home, less than half of older adults received a mental health evaluation during their visit (42%, 95% CI 34-52) compared to 66% (95% CI 61-70) of younger adults who met the same criteria. Similarly, fewer older, than younger, adult patients with current SI/ SA received referral resources (34%; 95% CI 26-43; vs 60%; 95% CI 55-65). Conclusions Significantly fewer suicidal older adult patients who were discharged home received a mental health evaluation when compared to similar younger adults. These findings highlight an important area for improvement in the treatment of older adults at risk for suicide. [ABSTRACT FROM AUTHOR]

Importance: Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped.Objective: To determine whether an ED-initiated intervention reduces subsequent suicidal behavior.Design, Setting, and Participants: This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013.Interventions: Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk.Main Outcomes and Measures: The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed.Results: A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99).Conclusions and Relevance: Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior. [ABSTRACT FROM AUTHOR]

Objectives To estimate the prevalence of self-harm, suicidal ideation ( SI), and suicide attempts ( SA) in older adults in the emergency department ( ED), including differences according to age, sex, and race and ethnicity. Design Quasi-experimental, multiphase, eight-center study with prospective review of consecutive charts during enrollment shifts (November 2011-December 2014). Setting Eight EDs in seven states, all with protocols for nurses to screen every patient for suicide risk (universal screening). Participants Adults (≥18 years) registered in the ED. Measurements Demographic characteristics; documented screening for self-harm, SI, or SA; and positive self-harm, SI, or SA in those with screening performed. Results Of 142,534 visits, 23.3% were of individuals aged 60 and older. Documented screening for self-harm, SI, or SA declined with age, from approximately 81% in younger age groups to a low of 68% in those aged 85 and older. The prevalence of positive screens for self-harm, SI, or SA also declined with age, with peaks in young and middle-age (9.0%) and reaching the lowest point after the age of 75 (1.2%). Conclusion Documented screening for suicide risk declined with age in this large sample of individuals in the ED. Although the reason for this finding is unclear, at least part of the decline may be related to increasing rates of altered mentation or other individual-level barriers to screening in the older population. These findings support the need for more-detailed examination of the best methods for identifying-and treating-suicide risk in older adults. [ABSTRACT FROM AUTHOR]

Objective: The main objective was to identify which patient characteristics have the strongest association with suicide outcomes in the 12 months after an index emergency department (ED) visit. Methods: Data were analyzed from the first two phases of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE). The ED-SAFE study, a quasi-experimental, interrupted time-series design, involved participation from eight general medical EDs across the United States. Participants included adults presenting to the ED with active suicidal ideation or an attempt in the past week. Data collection included baseline interview; six- and 12-month chart reviews; and six-, 12-, 24-, 36-, and 52-week telephone follow-up assessments. Regression analyses were conducted. Results: Among 874 participants, the median age was 37 years (interquartile range 27-47), with 56% of the sample being female (N=488), 74% white (N=649), and 13% Hispanic (N=113). At baseline, 577 (66%) participants had suicidal ideation only, whereas 297 (34%) had a suicide attempt in the past week. Data sufficient to determine outcomes were available for 782 (90%). In the 12 months after the index ED visit, 195 (25%) had documentation of at least one suicide attempt or suicide. High school education or less, an ED visit in the preceding six months, prior nonsuicidal self-injury, current alcohol misuse, and suicidal intent or plan were predictive of future suicidal behavior. Conclusions: Continuing to build an understanding of the factors associated with future suicidal behaviors for this population will help guide design and implementation of improved suicide screening and interventions in the ED and better allocation of scarce resources. [ABSTRACT FROM AUTHOR]

Background Although research suggests that crisis hotlines are an effective means of mitigating suicide risk, lack of empirical evidence may limit the use of this method as a research safety protocol. Purpose This study describes the use of a crisis hotline to provide clinical backup for research assessments. Methods Data were analyzed from participants in the Emergency Department Safety and Follow-up Evaluation (ED-SAFE) study (n = 874). Socio-demographics, call completion data, and data available on suicide attempts occurring in relation to the crisis counseling call were analyzed. Pearson chi-squared statistic for differences in proportions were conducted to compare characteristics of patients receiving versus not receiving crisis counseling. P < 0.05 was considered statistically significant. Results Overall, there were 163 counseling calls (6% of total assessment calls) from 135 (16%) of the enrolled subjects who were transferred to the crisis line because of suicide risk identified during the research assessment. For those transferred to the crisis line, the median age was 40 years (interquartile range 27–48) with 67% female, 80% white, and 11% Hispanic. Conclusions Increasing demand for suicide interventions in diverse healthcare settings warrants consideration of crisis hotlines as a safety protocol mechanism. Our findings provide background on how a crisis hotline was implemented as a safety measure, as well as the type of patients who may utilize this safety protocol. [ABSTRACT FROM AUTHOR]

Introduction: The Emergency Department Safety Assessment and Follow-up Evaluation Screening Outcome Evaluation examined whether universal suicide risk screening is feasible and effective at improving suicide risk detection in the emergency department (ED).Methods: A three-phase interrupted time series design was used: Treatment as Usual (Phase 1), Universal Screening (Phase 2), and Universal Screening + Intervention (Phase 3). Eight EDs from seven states participated from 2009 through 2014. Data collection spanned peak hours and 7 days of the week. Chart reviews established if screening for intentional self-harm ideation/behavior (screening) was documented in the medical record and whether the individual endorsed intentional self-harm ideation/behavior (detection). Patient interviews determined if the documented intentional self-harm was suicidal. In Phase 2, universal suicide risk screening was implemented during routine care. In Phase 3, improvements were made to increase screening rates and fidelity. Chi-square tests and generalized estimating equations were calculated. Data were analyzed in 2014.Results: Across the three phases (N=236,791 ED visit records), documented screenings rose from 26% (Phase 1) to 84% (Phase 3) (χ(2) [2, n=236,789]=71,000, p<0.001). Detection rose from 2.9% to 5.7% (χ(2) [2, n=236,789]=902, p<0.001). The majority of detected intentional self-harm was confirmed as recent suicidal ideation or behavior by patient interview.Conclusions: Universal suicide risk screening in the ED was feasible and led to a nearly twofold increase in risk detection. If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.Trial Registration: Emergency Department Safety Assessmentand Follow-up Evaluation (ED-SAFE) ClinicalTrials.gov: (NCT01150994). https://clinicaltrials.gov/ct2/show/NCT01150994?term=ED-SAFE&rank=1. [ABSTRACT FROM AUTHOR]

It is essential that investigators in clinical research settings follow ethical guidelines for monitoring, assessing, and responding to suicide risk. Given the unique considerations associated with suicide risk assessment in a research context, resources informing the development of research-specific suicide risk management procedures are needed. With decades of collective experience across heterogeneous contexts, we discuss approaches to monitoring, assessing, and responding to suicide risk as a function of study sample (e.g., students, psychiatric inpatients), data collection methodologies (e.g., interview, self-report, or ecological momentary assessment), and study design (e.g., treatment research). Additional considerations include training and supervision of staff to identify suicide risk, coordination of others to respond to risk, and documentation of procedures. Finally, we attend to the impact of these procedures on the external validity of outcome data. (PsycINFO Database Record (c) 2019 APA, all rights reserved). [ABSTRACT FROM AUTHOR]

Prior work from surveys and limited populations suggests many emergency department (ED) patients with suicide risk do not have documented lethal means assessments (e.g., being asked about home firearms). The specific objectives of this study were to, in an ED with universal screening for suicide risk: (1) estimate how often ED providers documented lethal means assessment for suicidal patients, and (2) compare patients with and without documented lethal means assessments. We reviewed 800 total charts from a random sample of adults in three a priori age groups (18–34 years; 35–59 years; ≥ 60 years) with a positive suicide risk screen from 8/2014 to 12/2015. Only 18% ( n = 145) had documentation by ≥ 1 provider of assessment of lethal means access. Among these 145, only 8% ( n = 11) had documentation that someone discussed an action plan to reduce access (most commonly changing home storage or moving objects out of the home). Among 545 suicidal patients discharged home from the ED, 85% had no documentation that any provider assessed access to lethal means. Our findings highlight an important area for improving care: routine, documented lethal means assessment and counseling for patients with suicide risk. There is an urgent need for further exploration of barriers and facilitators. [ABSTRACT FROM AUTHOR]

Abstract: Background: Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention. Purpose: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes. Methods: This paper summarizes the ED-SAFE's study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1440 suicidal individuals, from 8 general ED's nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment. Conclusions: While ‘classic’ randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multi-phase, quasi-experimental design embedded in ‘real world’ clinical settings. [Copyright &y& Elsevier]