Jill M. Harkavy-Friedman, PhD, Vice President of Research
American Foundation for Suicide Prevention
Roughly 40 percent of people who die by suicide were seen in an emergency room in the year prior to their death. Yet less than 50 percent would have received a mental health diagnosis there. Imagine you went to the emergency room for an unexplained fall. Before being directed to a specialist, you would immediately have your vital signs measured: blood pressure, heart rate, temperature, height, and weight. The emergency department staff’s immediate goal would be to make sure you are stable, then recommend appropriate care within the hospital or on an outpatient basis.
Think of your mental health as your sixth vital sign. We know that about 90 percent of people who die by suicide have a diagnosable and potentially treatable mental health condition, yet this often goes undetected. Mental health symptoms provide information for physical diagnosis as well. Conducting a mental health assessment as standard emergency room protocol – asking about your mood, thoughts, and recent behavior, as well as family mental health history – takes just a few minutes. When asked about their mental health, about 12 percent of people in the emergency room for non-psychiatric reasons are revealed to have been thinking about suicide. By standardizing a simple mental health assessment as part of emergency department procedure, those experiencing mental health challenges can get the help they need before it’s too late.
It’s time for a whole health approach
A whole health approach means that mental and physical health are considered equal partners and of equal importance to your well-being. A person’s mental health can provide clues to a person’s physical health. For example, asking about changes in anxiety, mood, and sociability might be clues for a thyroid imbalance. A few simple questions can make all the difference.
But not all emergency department training programs require personnel to receive education about mental health, leaving staff unequipped and probably uncomfortable formally assessing mental health. This may explain their reluctance to assess mental health as part of a whole person exam. But all they need to do is learn the basics and how to determine when a fuller consultation is needed.
Sensitivity training is just as important as protocol training since bias can present itself in many forms. For example, it is not uncommon for patients’ physical conditions to be dismissed when it is learned they live with a mental health condition. Many patients, aware of this bias, choose not to disclose their mental health condition when presenting at the ED with a physical condition because they have experienced this discrimination in the past.
Helping patients connect to mental health care
There are brief interventions that can be conducted in the ED to help a person who is experiencing a mental health challenge engage in outpatient care when immediate hospitalization is not necessary, which is often the case. These interventions include educating and motivating the person to seek mental health care and attend their first appointment. Providing an actual appointment is optimal; however, even providing the link to the SAMHSA locator service and recommending the patient see their primary care physician is better than nothing. A written personalized safety plan can be developed in about 15 minutes to equip a suicidal person with tools for managing periods of distress and suicidal ideation. Follow-up contact in the form of telephone calls or postcards can help in the short-run, though they are not a substitute for ongoing care. All of these interventions combined can be conducted in about an hour — far less than the long wait for a psychiatric consultation — and much more cost-effective.
Standard of care for mental health is on the rise in EDs
The Joint Commission that accredits hospitals published an alert on February 24, 2016 with suggestions on actions an ED can take to screen all patients for suicide risks, including the following.
- Review each patient’s personal and family medical history for suicide risk factors
- Screen all patients for suicide ideation using a brief standardized, evidence-based screening tool
- Review screening questionnaires before the patient leaves the appointment or is discharged
- Take actions using assessment results to inform the level of safety measures needed
- Establish a collaborative, ongoing, and systemic assessment and treatment process with the patient, involving other providers, family, and friends as appropriate
- Improve outcomes for at-risk patients by developing treatment and discharge plans that directly target suicidal ideation and behavior
- Educate all staff in patient care settings about how to identify and respond to patients with suicidal ideation.
The Joint Commission recommends several publications for further information, including Suicide Prevention and the Clinical Workforce: Guidelines for Training and Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments.
Whole health integration has seen positive results when implemented. Much can be learned from the Henry Ford Health System. The Behavioral Health Services Division embarked on an ambitious project to reduce deaths by suicides to zero; many of the strategies of this program can be implemented within the ED. Key to the success of the initiative was the buy-in and acceptance of the staff — clinicians, administration, and supportive services — that the goal was realistic and achievable. Successful screening tools to evaluate the level of risk for suicide, creating a patient-centered culture, and providing appropriate staff training have all contributed to a 71 percent annual reduction in suicides within the first three years of the program.
Changing the delivery of health care in the ED to a patient-centered environment that focuses on whole health may require an investment in resources and the enthusiastic support of hospital administration. Given that suicide is the tenth leading cause of death in the United States, we can’t afford to wait. Treating the whole health of patients presenting at the ED may save lives.
- How would you change the delivery of care in emergency departments so that capturing mental health vital signs is the norm?
More reading on Care for Your Mind
- How Can We Improve Emergency Department Psychiatric Care?
- The Hospital Failed My Father – And Our Family
- Are There Alternatives to Emergency Departments when Facing a Psychiatric Emergency?
- American Foundation for Suicide Prevention: Thoughtful public policies can reduce the number of suicides
- Joint Commission, “Detecting and treating suicide ideation in all settings” (download .pdf)
- Zero Suicide website
- E. Boudreaux et al., “Improving Suicide Risk Screening and Detection in the Emergency Department”
Dr. Jill Harkavy-Friedman leads the American Foundation for Suicide Prevention’s research grant program, working with more than 150 scientific advisors to advance the field of suicide prevention. With 30 years of experience as a clinician and a researcher, she is passionate about translating research into practice, publishing over 100 articles. She assists with AFSP’s development of programs and messages that reflect best practices and current research.
Harkavy-Friedman earned her BA in Psychology at the University of Pennsylvania and her PhD in Clinical Psychology at the University of Florida. In 1984, she joined Montefiore Medical Center/Albert Einstein College of Medicine as an assistant professor, establishing the Adolescent Depression and Suicide Program. In 1989, she moved to Columbia University/New York State Psychiatric Institute, first as an assistant professor and later an associate professor of clinical psychology in psychiatry. She maintains a clinical practice in Manhattan.
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