Edwin Boudreaux, professor of Emergency Medicine, Psychiatry, and Quantitative Health Sciences at the University of Massachusetts Medical School, advocates for universal suicide risk screening for patients entering a hospital emergency department.
The emergency department (ED), he said in “Zero Suicide Work in Emergency Departments: Opening Pandora’s Box,” his presentation to Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, presents an opportunity to identify and provide support for individuals at risk for taking their own lives.
He cited research indicating that some 40 percent of people who died by suicide had made an ED visit within the year, and mostly for reasons other than a personal mental health crisis. “A substantial proportion of them are being seen for a psychiatric crisis, but many of them aren’t and then they’re dying by suicide in the weeks or months after that visit,” he explained. “Is there something better we could do to try to detect that suicide risk prior to the person dying?”
Boudreaux also cited research showing that when ED patients were systematically screened, a larger than expected percentage indicated an elevated suicide risk due to recent suicidal ideation or a past suicide attempt.
Part 6 in a Series about the Zero Suicide Model for Healthcare
Bourdreaux himself led a universal screening study covering eight EDs across the United States. That study found that use of universal screening was feasible to implement, and that it detected suicide risk in 5.7 percent of patients compared to 2.9 percent in “treatment as usual” settings.
“The emergency department is a suicide risk environment, but we’re missing most of the patients who have suicide risk by using our existing approaches of just screening patients who are presenting with frank psychiatric symptoms,” Boudreaux said. “We demonstrated that it was feasible to do the [universal] screening and that when we did this improved screening we actually improved detection.”
Boudreaux called universal screening a “Pandora’s Box” because of a common fear among healthcare administrators that such screening could challenge workloads and “break” the ED system. He said they worry about the lack of behavioral health providers, at-risk patient observers, boarding capacity, training for handling suicidal patients, and time required for making assessments. In addition, he said, administrators are concerned about creating patient dissatisfaction among individuals seeking ED services for non-mental health conditions.
“The biggest fear people have is, ‘What if I ask the question about suicide and they say yes. Then what do I do?’” he said. “The objection is it’s simply not feasible. There’s no way you can implement universal screening because it’s going to break the emergency department.”
For making the screening itself more feasible, Boudreaux pointed to Computerized Adaptive Tests, or CATS, a research-tested technological innovation in screening, and a CATS tool for youth known as the Computerized Adaptive Screen for Adolescents, or CASSY. He noted that traditional mono-dimensional quick-screen instruments like the C-SSRS Baseline Screening focus only on suicidal ideation and behavior. He said that CATS conducts screens quickly and with improved fidelity and efficiency, and also addresses multiple dimensions (such as depression, PTSD, suicidal ideation/behavior, and trauma history) yielding a spectrum analysis with more precise results and allowing a more complex risk formulation.
Boudreaux acknowledged the challenges of implementing universal screening in hectic EDs. He said that his study found that sometimes clinicians go through the motions of screening and mark a patient negative for suicidal thoughts without actually asking them the question.
Boudreaux argued that opening Pandora’s Box is do-able if EDs use their Clinical Decision Rules with the support of the CATS tool, and follow the Zero Suicide Model of efficient and appropriate pathways for suicide care.
“You have to establish a very clear protocol,” he said. “People can’t be confused or vague about what they do when they ask the screener and if they get a yes, or if they get a mild, moderate, or high risk. There can be no ambiguity. Your institution has to have very clear policies and procedures around the stratification of those patients and what happens. You can’t treat all risks the same. It’s a huge resource burden.”
He said for example, many patients screening positive for suicidal ideation do not need full psychiatric examinations or intensive safety precautions such as observation or boarding. He said that patients screening for mild risk could be given a referral to a behavioral health provider and educational materials to review.
Boudreaux highlighted the imperative that EDs understand the need for compassionate and evidence-based intervention that takes into account the patient’s values and preferences.
“They want respect,” he said. “Their idea of safety is treating is them with compassion. They want to feel like they can trust the clinicians who are working with them and not to overreact if they share that they’re suicidal and get the security guard involved and have to strip search them and admit them to an inpatient unit. It’s going to make them feel vulnerable. It’s going to make them feel traumatized, not safe.”
READ MORE: The Zero Suicide Model in Tompkins County
If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.