Public Health Policy Analysis (PHPA) Paper

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AJPH.2015.302656.pdf

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement Barbara Stanley, PhD, Gregory K. Brown, PhD, Glenn W. Currier, MD, MPH, Chelsea Lyons, MS, Megan Chesin, PhD, and Kerry L. Knox, PhD

We implemented an innovative,

brief, easy-to-administer 2-part in-

tervention to enhance coping and

treatment engagement. The inter-

vention consisted of safety plan-

ning and structured telephone

follow-up postdischarge with 95

veterans who had 2 or more emer-

gency department (ED) visits

within 6 months for suicide-related

concerns (i.e., suicide ideation or

behavior). The intervention signifi-

cantly increased behavioral health

treatment attendance 3 months

after intervention, compared with

treatment attendance in the 3

months after a previous ED visit

without intervention. The trend

was for a decreasing hospitaliza-

tion rate. (Am J Public Health. 2015;

105:1570–1572. doi:10.2105/AJPH.

2015.302656)

Approximately 400 000 to 500 000 US emergency department (ED) visits occur an- nually for suicide attempts.1,2 The ED is a pri- mary site for the treatment of suicide attempts, and for many patients, ED interventions are the only treatment they receive.3 As many as 60% of suicidal ED patients are stabilized and dis- charged directly to outpatient care.1,2 Unfortu- nately, only 50% of these patients follow up on their referrals and attend 1 or more out- patient behavioral health sessions.3 Conse- quently, costly repeat ED visits and additional suicidal behavior are frequent. As many as 30% of patients presenting to the ED for

a suicide-related concern return to the ED for another suicide-related concern within 1 year,4

and 2-year follow-up suicide mortality rates among suicide attempters are estimated at 2%.5 Recurrent suicidal behavior and limited outpatient treatment engagement are similarly significant problems among veterans,6---8 who may be at greater risk for suicide than civilians despite more recent reductions.9,10 Given that the ED is the only place where many suicidal individuals receive care, it could be an impor- tant intervention site to increase outpatient treatment engagement and reduce repeat sui- cidal behavior, ED visits, and hospitalizations.11

METHODS

In a clinical demonstration initiative, titled the Suicide Assessment and Follow-up En- gagement: Veteran Emergency Treatment project and implemented by the US Depart- ment of Veterans Affairs (VA), we sought to increase treatment engagement. We imple- mented a 2-stage behavioral intervention that included (1) development of a safety plan intervention (SPI)12 in the ED, which helps patients identify personal warning signs of a developing suicide crisis, strategies to cope with subsequent suicidal feelings through identification of coping skills, professional and personal supports to seek during a suicidal crisis, and ways to reduce access to lethal means, and (2) brief structured telephone follow-up calls after ED discharge (structured follow-up; SFU)13 to provide support, facilitate treatment engagement, and mitigate risk. Dur- ing SPI, VA patients presenting to the ED for suicide-related concerns (i.e., suicidal ideation or a recent suicide attempt) who were clinically determined not to require admission for in- patient care were offered enrollment.

Five VA EDs participated in the demonstra- tion project. Details of the project and the SPI-SFU intervention are described elsewhere.13

The VA is an excellent system in which to conduct this type of project because it has a comprehensive electronic record system, and patients tend to receive all their care within the VA. Therefore, data on treatments received tend to be complete. Here, we report on the effectiveness of SPI-SFU for increasing outpa- tient treatment attendance and decreasing ED visits and inpatient utilization among the

subsample of veterans seen in the demon- stration project who had repeat ED visits for suicide-related concerns over a 6-month period.

RESULTS

SPI-SFU was implemented from 2009 to 2012 with a total of 1102 VA patients who presented to the ED for suicide-related con- cerns (i.e., suicide attempt or ideation but not nonsuicidal self-injury), were determined to not need inpatient admission, and were discharged with outpatient referrals. We examined a sub- sample of 96 intervention patients who had 2 or more suicide-related ED visits in a 6-month period, 1 at the index visit at which the in- tervention was initiated and 1 during the pre- ceding 3- to 6-month time frame. We then examined follow-up treatment engagement for the 3 months after each ED visit.

Patients were predominantly White (66%), male (86%), and aged 35 years or older (75%). Most did not have a college degree (87%) and were unemployed (76%). Thirty-four percent were diagnosed with posttraumatic stress dis- order. Forty percent had a mental health service---connected disability of 10% or greater. Sixty percent had a lifetime history of 1 or more suicide attempts, and a similar proportion had a history of alcohol abuse. With a few exceptions, the subsample was demographi- cally and clinically similar to the patients who received SPI-SFU but did not have repeat ED visits for suicide-related concerns within the 6-month time frame.

Medical records data were coded by master’s-level staff to ascertain outpatient (mental health and substance abuse treatment appointment attendance; mental health and substance abuse visits were coded separately) and acute (psychiatric ED visits and hospitali- zations for suicide risk) service use in the 3 months after the ED visits. We used v2 analysis and the paired t test to compare the prevalence and incidence of outpatient and acute service use among subsample members in the 3 months after both ED visits.

In the 3 months after they received SPI-SFU, suicidal veterans presenting to and discharged directly from VA EDs were more likely to attend outpatient behavioral health appoint- ments (either mental health or substance abuse

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treatment) than they had during the 3 months after a previous ED visit when they did not receive the intervention. In particular, they attended more outpatient mental health treat- ment appointments after SPI-SFU than they had after an earlier ED visit. ED visits in the 3 months after ED discharge did not change with SPI-SFU. Hospitalizations for suicide-related concerns were lower in 3 months after the SPI-SFU intervention, although this difference was not statistically significant (Tables 1 and 2). No suicides occurred during this study.

DISCUSSION

Attending outpatient care is critical because the period after ED presentation for suicide- related concerns (i.e., suicidal ideation or behavior) is associated with elevated risk for further suicidal behavior, including completed suicide.5 By comparing rates of outpatient treatment attendance among patients who presented to the ED and received SPI-SFU with rates of treatment attendance among the same

participants after an earlier ED visit when SPI-SFU was not provided, we found that SPI-SFU was effective in increasing rates of outpatient behavioral health treatment atten- dance. Although SPI-SFU did not significantly reduce rates of hospitalization for suicide- related concerns, we found a trend toward a lower incidence of suicide-related hospitali- zations after SPI-SFU. A statistically significant inverse relationship between receiving SPI-SFU in the ED and future hospitalization may be detected in a larger sample.

A major limitation of this study is that it was uncontrolled, and elements of the quality of care in the ED during both the index visit and the previous visit were not well characterized and thus could not be considered in the analyses. In general, standard care for suicidal individuals in the Veterans Affairs Medical Center system is extensive and includes evidence-based screening, assessment, and treatment at all levels of care. Furthermore, every Veterans Affairs Medical Center has at least 1 staff member, a suicide prevention

coordinator, who is dedicated to providing enhanced case management and follow-up to veterans at high risk for suicide. In addition, length of stay on inpatient units in the VA is typically longer than in community hospi- tals.14,15 It is possible that, given the differences between the VA and non-VA facilities, the results may not be completely generalizable to community hospitals.

It is interesting that, despite the VA’s heavy attention to suicidal veterans, our results sug- gest that the additional care provided in this intervention may be needed to engage suicidal veterans in care. We do not know whether the effects of the intervention we tested would be weaker or stronger in community systems in which care is not as intense and integrated. Moreover, the sample consisted mostly of young, White men, which reflects the demo- graphic composition of the veteran population but limits the generalizability of the findings to patients of other ages and races. Patients could also have received different (more intensive or coordinated) ED care during their second visit

TABLE 1—Prevalence of Outpatient and Acute Service Utilization Before and After SPI-SFU: Suicide Assessment and Follow-Up Engagement:

Veteran Emergency Treatment Project, United States, 2009–2012

Service Type

3 Mo After Non–SPI-SFU ED

Visit (‡ 1 Visit), No. (%) 3 Mo After SPI-SFU ED

Visit (‡ 1 Visit), No. (%) v2 (McNemar) P

Mental health and substance abuse combined 66 (68.8) 81 (84.4) 8.33 .004

Mental health visit 61 (63.5) 74 (77.1) 5.12 .02

Substance abuse visit 27 (28.1) 29 (30.2) 0.17 .68

ED visits 41 (42.7) 42 (43.8) 0.03 .87

Hospitalizations for suicide risk 25 (26.0) 16 (16.7) 3.24 .07

Note. ED = emergency department; SPI-SFU = safety plan intervention–structured follow-up.

TABLE 2—Incidence of Outpatient and Acute Service Utilization Before and After SPI-SFU: Suicide Assessment and Follow-Up Engagement:

Veteran Emergency Treatment Project, United States, 2009–2012

3 Mo After ED Visit Without SPI-SFU 3 Mo After ED Visit With SPI-SFU

Service Type Mean (95% CI) Total, No. Max, No. Mean (95% CI) Total, No. Max, No. s (Wilcoxon rank-sum) P

Mental health and substance abuse visits combined 6.88 (4.28, 9.48) 660 57 10.79 (6.53, 15.06) 1036 130 523 .02

Mental health visits 4.52 (2.63, 6.41) 434 54 5.57 (3.33, 7.81) 535 80 471 .02

Substance abuse visits 2.35 (0.78, 3.92) 227 44 5.21 (1.65, 8.77) 501 100 75 .26

ED visits 0.84 (0.57, 1.11) 81 6 0.66 (0.47, 0.85) 63 4 –107 .32

Hospitalizations for suicide risk 0.33 (0.21, 0.45) 32 2 0.23 (0.11, 0.36) 22 4 –60 .15

Note. ED = emergency department; SPI-SFU = safety plan intervention–structured follow-up.

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August 2015, Vol 105, No. 8 | American Journal of Public Health Stanley et al. | Peer Reviewed | Research and Practice | 1571

to the ED for suicide-related concerns in short time frame than they had during their previous visit. Thus, definitive conclusions regarding the effectiveness of SPI-SFU for increasing outpa- tient treatment engagement await a controlled trial comparing SPI-SFU with usual care. Despite these limitations, findings from this evaluation suggest that SPI-SFU holds promise with respect to engaging patients at high risk for suicide presenting to EDs in outpatient follow-up treat- ment. This approach could be adapted for EDs across various settings in the general population, including urgent care facilities. j

About the Authors Barbara Stanley and Megan Chesin are with the Depart- ment of Psychiatry, Columbia University, New York, NY, and the New York State Psychiatric Institute, New York. Gregory K. Brown is with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Glenn W. Currier and Kerry L. Knox are with the Department of Psychiatry, University of Rochester, Rochester, NY. Chelsea Lyons is with Health Services Research and Policy, University of Rochester. Correspondence should be sent to Barbara Stanley, PhD,

Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 42, New York, NY 10032 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted February 24, 2015.

Contributors B. Stanley, G. K. Brown, G. W. Currier, and K. L. Knox planned and designed the project and oversaw data acquisition. All authors were involved in analysis and interpretation of the data and drafting and revising the article. All authors approved the final article.

Acknowledgments The Safety Plan Intervention---Structured Follow-Up (SPI- SFU) demonstration project was supported by Mental Health Services in the US Department of Veterans Affairs (VA) and the VA Healthcare Upstate New York (VISN 2) Center of Excellence for Suicide Prevention. The Execu- tive Committee for the project was Kerry L. Knox, PhD (Chair), Gregory K. Brown, PhD, Glenn W. Currier, MD, and Barbara Stanley, PhD. Ira Katz, MD, PhD, and Jan Kemp, RN, PhD, provided valuable insight into the design of the project. The VA’s Office of Mental Health, specifically Caitlin Thompson, PhD, and David Carroll, PhD, reviewed the article. Heather Elder, research assistant for the Center of Excellence for Suicide Pre- vention, assisted with the analysis. Coordination of the project was provided by the VISN 2 Center of Excellence for Suicide Prevention, site leads (Lisa Brenner, PhD, Joan Chips, LCSW, Joshua Hooberman, PhD, Christine Jackson, PhD, Mitchel Kling, MD, and Keith Rogers, MD) and acute services coordinators (Patricia Alexander, PhD, Laura Blandy, PsyD, Aimee Coughlin, MSW, John Dennis, PhD, Michael Miello, PhD, Katherine Mostkoff, LCSW, and Jarrod Reisweber, PsyD). Key individuals who facilitated implementation of SPI-SFU and provided essential guidance and support were Lauren Denneson, PhD, Steven Dobscha, MD, Ashley Bush, MMH, Walter

Matweychuk, PhD, Gerd Naydock, MSW, Keith Rogers, MD, Donald Tavakoli, MD, and Adam Wolkin, MD.

Human Participant Protection Institutional review board approval, as required by the individual institutions participating in this project, was obtained for medical records review. Permission for a waiver of consent was obtained.

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Effect of Depression on Risky Drinking and Response to a Screening, Brief Intervention, and Referral to Treatment Intervention Annika C. Montag, PhD, Stephanie K. Brodine, MD, John E. Alcaraz, PhD, John D. Clapp, MSW, PhD, Matthew A. Allison, MD, Dan J. Calac, MD, Andrew D. Hull, MD, Jessica R. Gorman, PhD, MPH, Kenneth Lyons Jones, MD, and Christina D. Chambers, PhD, MPH

We assessed alcohol consump-

tion and depression in 234 Ameri-

can Indian/Alaska Native women

(aged 18–45 years) in Southern

California. Women were random-

ized to intervention or assessment

alone and followed for 6 months

(2011–2013). Depression was asso-

ciated with risk factors for alcohol-

exposed pregnancy (AEP). Both

treatment groups reduced drinking

(P < .001). Depressed, but not non-

depressed, women reduced drink-

ing in response to SBIRT above the

reduction in response to assess-

ment alone. Screening for depres-

sion may assist in allocating women

to specific AEP prevention inter-

ventions. (Am J Public Health. 2015;

105:1572–1576. doi:10.2105/AJPH.

2015.302688)

Women who consume alcohol and do not practice effective contraception are at risk for an alcohol-exposed pregnancy (AEP). AEPs can lead to fetal alcohol spectrum disorders, the leading known cause of developmental disabilities.1---3 Prepregnancy drinking, partic- ularly heavy episodic or binge drinking, is

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1572 | Research and Practice | Peer Reviewed | Montag et al. American Journal of Public Health | August 2015, Vol 105, No. 8