How to decrease suicide rates by 30%

Suicidal behavior, both attempts and ideation, are a common ER complaint, accounting for 4% of all visits. One million people in the US attempt suicide each year, and 1.2% of all US deaths are due to suicide. As the holidays are coming soon, I felt this would be a good time to review how we can ensure a safe discharge for those who may not meet inpatient criteria.

TL;DR: ER interventions can decrease suicide attempts by 30%. Use the below dotphrase to improve your documentation in patients who are being discharged.

A study published this July in JAMA Psychiatry found the implementing an ER intervention can prevent future suicidal behavior, with a number needed to treat between 13 and 22. The study utilized a primary (universal) and a secondary screening tool administered by the nurse and provider, followed by discharge resources and a follow-up phone call.

The first step is similar to the current triage safety questions, asking patients about suicidal thoughts or attempts. Those who screen positive are identified and a secondary screening form (PDF) was completed by the physician. This form uses known risk factors for suicide to determine if there should be a psychiatric consultation (plan for suicide, intent, prior inpt treatment, and substance abuse). The third step of their intervention consisted of a safety plan which identified triggers for suicidal thoughts, how to get help, and what followup steps need to happen. All patients received a followup phone call after discharge. The study found that the intervention group had a 30% decrease in total suicide attempts than those receiving typical treatment.

The study is interesting, but YOU DON’T NEED THESE FORMS TO HELP SAVE LIVES. Most of us are probably already incorporating most of this into our treatment of those patients being discharged with outpatient followup!

• Take a good history, including medical problems, available medications at home, social situation and support at home, who they live with, availability of firearms, prior suicide attempts or inpatient admissions, and any prior family history of suicide.
• Examine your patient, including for signs of self-harm and IV drug abuse.
• Ensure the patient has good judgement by asking questions such as “What could you do if you felt like hurting yourself?” to ensure they realize they could call a friend, return to the ER, or other alternative to hurting themselves.
• Document, using the dotphrase below, in your MDM/R&R.

​After initial evaluation, the patient endorses _ depressive symptoms. The patient has _ prior suicide attempts, currently _ abusing medications or drugs, and _ family history of suicide. The patient has _  judgement as evidenced by _, and displays _ insight into their symptoms. Although the patient is _ not currently endorsing active suicidal or homicidal ideation, and appears to have a good plan for follow up, I will consult psychiatry to provide outpatient resources and ensure a safe discharge plan prior to disposition.

jamapsychiatry_miller_2017_oi_170023.pdf
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