Journal Article Annotations
2023, 3rd Quarter
Annotations by Scott A. Simpson, MD, MPH
The investigators describe a continuation of the landmark, multi-state ED-SAFE trial. That prior trialdemonstrated the effectiveness of a suicide safety-planning and follow-up intervention for reducing self-harm. Here, the investigators randomized 8 emergency departments (EDs) to implement process improvements primarily aimed at training staff in safety planning and providing lean process improvement around suicide prevention care. Randomization determined the timing of implementation. During implementation, the incidence of suicide or a suicide-related healthcare visit decreased from 21% to 15% among a random sample of 2761 discharged ED patients.
Strength and weaknesses:
The stepped implementation and multisite design is innovative and an ethical way to study effectiveness without compromising care quality. That these improvements build on previously impressive results from ED-SAFE are impression. The study could better describe specific interventions that were the target of lean process improvement. The most significant weaknesses are the study’s ascertain of outcomes: a random sample of patient charts were reviewed for a composite outcome of suicide-related clinical visits or suicide. Patients who were admitted from their ED visit were excluded; the chart-review methodology may well have missed many outcomes occurring outside of available records; and only patients who screened positive for suicide risk in the ED were included. Yet most patients who die by suicide after ED discharge likely screen negative due to the insensitivity of suicidal ideation alone as a risk screener.
Suicide prevention care in the ED saves lives and reduces self-harm. The effect size is likely proportional to the intensity of the intervention, its cultural impact in a local ED, and investment in sustaining improved processes. C-L psychiatrists must take an active leadership role in championing high reliability and supporting evidence-based suicide care delivery in hospital EDs.
In a systematic review, the authors identified and described 8 clinical trials of single-session psychotherapy in the emergency department (ED). These interventions primarily involve crisis (safety) planning and family-focused therapies. Even brief therapy in the ED appears to reduce the frequency of suicidal behaviors, intensity of suicidal ideation, and subsequent ED and hospital utilization. Brief therapy may also increase the likelihood of patients receiving outpatient follow-up care. The risk of bias was high.
Strength and weaknesses:
Although this is the largest review—to this writer’s knowledge—of single-session ED-based psychotherapies, there were only 8 identified studies. A full meta-analysis was not completed, and the quality of included studies is not well-described although a risk of bias assessment was completed. Most studies were limited to adolescent and military subjects.
Psychotherapy is an efficacious and safe treatment for most psychiatric conditions. Designing brief psychotherapy suitable for ED settings can not only improve the treatment of behavioral health crises but also make higher quality psychiatric care accessible to diverse and underserved communities who depend on EDs for psychiatric treatment. C-L psychiatrists should consider how these brief interventions can be incorporated into their own general hospital practice—and whether there are opportunities to train colleagues in emergency medicine in their use as well.