Emergency department–initiated intervention aids secondary prevention of suicide

Emergency department (ED)–initiated safety planning intervention (SPI) significantly reduces subsequent suicide behaviours in the 12 months following patients’ initial ED visit, the ED-SAFE 2 trial has shown.

Suicide is one of the leading causes of death worldwide. According to the WHO, one in every 100 deaths is caused by suicide. Additionally, 25 percent of patients who visit EDs following suicide attempts make another attempt, and 40 percent of patients who die by suicide visited EDs in the year before death. [www.who.int/news/item/17-06-2021-one-in-100-deaths-is-by-suicide; Br J Psychiatry 2003;183:28-33]

“Although the ED is an opportune setting, ED-initiated suicide prevention interventions remain underdeveloped and understudied,” said the researchers. [JAMA Psychiatry 2023;doi:10.1001/jamapsychiatry.2023.1304]

ED-SAFE is a stepped-wedge cluster randomized clinical trial aiming to examine whether an ED-initiated SPI could reduce the suicide composite outcome of death by suicide or suicide-related acute care, including ED visits and hospitalizations, within 6 months of the index ED visit. The SPI involved a trained clinician creating a safety plan to help at-risk patients manage suicidal crises, coaching other clinicians through role-playing, and overseeing continuous quality intervention (CQI). Data were collected across three 12-month phases: baseline, implementation and maintenance.

A total of 2,761 ED-discharged patients who screened positive for suicide risk (mean age, 37.4 years; male, 50.4 percent) were included in the study. “Most patients had a depression diagnosis [89.4 percent] and had suicidal ideation in the past 2 weeks before the index visit [83.8 percent],” pointed out the researchers.

During the 6-month follow-up period, 546 patients (19.8 percent) had one suicide-related event, including 538 patients (19.5 percent) with an ED visit due to suicidal ideation or attempt, and 9 patients (0.3 percent) who died by suicide. A significant difference in the suicide composite outcome was observed between the three phases (baseline, 20.9 percent; implementation, 22.0 percent; maintenance, 15.3 percent; p=0.001), which was driven largely by differences in suicide-related ED visits as the number of deaths across the three phases was small.

During the maintenance phase, the adjusted odds ratio (OR) of the suicide composite outcome was 0.57 (95 percent confidence interval [CI], 0.43–0.74) vs baseline and 0.61 vs the implementation phase (95 percent CI, 0.46–0.79), reflecting a 43 percent and 39 percent reduction in suicide behaviours, respectively. The SPI’s number needed to treat to prevent future suicidal behaviour was 25.

“Interestingly, during the implementation phase, an overall steady decrease in rate of the suicide composite outcome was observed over time,” noted the researchers. Although the finding did not reach statistical significance in the early stage of the implementation phase, the decreased OR became statistically significant in later stages of the implementation phase through the early stage of the maintenance phase.

“This is important because it suggests that the impact of the SPI may be delayed, and the effect [on suicide prevention] may be incremental and extended over a long timeline,” commented the researchers.