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Suicide Attempts and Suicide Deaths Subsequent to Discharge from an Emergency Department or an Inpatient Psychiatry Unit Continuity of Care for Suicide Prevention and Research 2011 This report was commissioned by the Suicide Prevention Resource Center (SPRC) in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA).• David Litts, SPRC Director of Science and Policy, provided overall direction. Alan L. Berman, Executive Director of the American Association of Suicidology (AAS), led the administration of the project. David J. Knesper, M.D., Department of Psychiatry, University of Michigan, is the author. Continuity of Care for Suicide Prevention and Research This material is based upon work supported by the Substance Abuse and Mental Health Services Administration under Grant Number 6U79SM7392. Additional support came from the University of Michigan, Department of Psychiatry. Any opinions, findings, and conclusions or recommenda- tions expressed in this material are those of the author and do not necessarily reflect the views of the Substance Abuse and Mental Health Service Administration or the University of Michigan. This publication supports Goal 7 of the National Strategy for Suicide Prevention: Develop and promote effective clinical and professional practices, and, in particular, Objective 7.4: Develop guidelines for aftercare treatment programs for individuals exhibiting suicidal behavior, including those discharged from inpatient facilities. Cite as: Knesper, D. J., American Association of Suicidology, & Suicide Prevention Resource Center. (2010) Continuity of care for suicide prevention and research: Suicide attempts and sui- cide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, MA: Education Development Center, Inc. This document may be found in the online library of the Suicide Prevention Resource Center: www.sprc.org 2 Continuity of Care for Suicide Prevention and Research Foreword he American Association of Suicidology and the Suicide Prevention Resource Center have provided a valuable service to the nation in preparing this comprehensive report on suicide attempts and suicide deaths subsequent to discharge from Emergency Departments or TInpatient Psychiatric Units. The report, entitled, “Continuity of Care for Suicide Prevention and Research” is grounded in an extensive review and analysis of the current literature, conducted by David Knesper, M.D. Dr. Knesper’s scholarly work on the Report was aided through generous support provided by the University of Michigan while he prepared the monograph. It highlights a critical area for suicide prevention efforts, one that holds promise for reducing the number of suicides in America. The accumulating research in suicide had made it increasingly clear that for those who experience suicidal crises and receive acute care interventions in hospitals and Emer- gency Rooms, suicide risk does not end at the moment of discharge. Rather, their elevated risk continues or is easily rekindled in the days and weeks that follow, leading to heightened rates of suicide during this post acute care period. However, as is noted in the National Strategy for Suicide Prevention, “All too often the assump- tion is that individuals are no longer at risk for suicide once they are discharged from inpatient hospital or institutional settings.” (DHHS, 2001) Yet, despite the fact that those who attempt suicide and others experiencing a suicidal crisis who are seen in the health care system are a high risk population going through a clear high risk period, there have been few systematic suicide prevention efforts in the United States that have focused on this population during this time pe- riod. Elevated post discharge rates of death by suicide, suicide attempts, and readmissions to acute care services have been repeatedly documented, but this has not been matched by proportionate prevention efforts. Moreover, as this report makes clear, not only has the need been shown to be unmistakable, but there are also promising interventions that can be utilized. In fact, the only two randomized controlled trials in the suicide prevention literature that have shown a reduction in the number of deaths by suicide have both involved following up with high risk populations after discharge from acute care services (Motto and Bostrom, 2001; Fleischmann et al., 2008). The report makes a large number of recommendations for both practice and research. While not everyone may agree with every recommendation, there are core recommendations that are key for behavioral health systems if they are to be designed in a way to optimize their suicide prevention potential and maximize the number of lives that can be saved. These include the establishment of standards for the provision of prompt outpatient care for those who attempt suicide and oth- ers at high risk who are discharged from acute care settings. Here the Veterans Administration is providing national leadership. A second is the need for active outreach and/or case management following discharge. Here the report highlights a number of promising practices ranging from the use of Apache community workers to reach out to those at high risk after discharge, to the use of community crisis centers through the National Suicide Prevention Lifeline to provide phone and text-based outreach, to the VA’s use of “caring letters” and the utilization of facility based suicide prevention coordinators. We have known for many years that Assertive Community Treatment was an evidence-based practice that could improve outcomes and prevent readmissions through 3 Continuity of Care for Suicide Prevention and Research assertive post discharge outreach. The adaptation of similar principles to high suicide risk popula- tions could also be of great benefit. Other nations have also begun to focus efforts in their national strategies for suicide prevention on exactly these high risk populations. Norway’s Chain of Care model is highlighted in this report. In Denmark, they have identified four areas where reductions in the number of deaths by suicide could have the greatest impact on their suicide rates. Two of those populations, suicide attempt- ers and those discharged from inpatient units, are very much the subject of this paper, and a third, substance abusers, could also benefit from an extension of these continuity of care principles given the high frequency with which those who are both substance abusers and suicidal are seen in emergency departments and inpatient units for detoxification and other needs. In England, the British National Clinical Study was able to calibrate, by day, week, and month, the degree of post discharge suicide risk, with the greatest risk occurring during the time closest to discharge, lead- ing to recommended standards for prompt follow up within seven days of those discharged from inpatient units (Crawford, 2004). In the United States, this period of high risk and the need for intervention during this time were recognized in the National Strategy for Suicide Prevention. Objective 7.1 focuses on the need for follow up after emergency room discharge while Objective 7.4 focuses on the need for aftercare following inpatient discharge. The American Association for Suicidology, the Suicide Prevention Resource Center, and Dr. David Knesper have provided an extremely valuable service through this comprehensive review and set of recommendations that have the promise, if acted upon, for constructing a critical safety net during these periods of heightened risk. Richard McKeon, PhD, MPH Chief, Suicide Prevention Branch Substance Abuse and Mental Health Services Administration References Crawford, M.J. (2004), Suicide following discharge from in-patient psychiatric care, Advances in Psychiatic Treatment, 10, 434–438. Fleischman, A., Bertolote, J., Wasserman, D., DeLeo, D., Bolhari, J., Botega, N., et al. (2008). Ef- fectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86, 703–709. Motto, J.A., Bostrom, A. G. A randomized controlled trial of postcrisis suicide prevention. Psychi- atr Serv. Jun 2001;52(6):828–833. U.S. Department of Health and Human Services. National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Department of Health and Human Services, Pub- lic Health Service; 2001. 4 Continuity of Care for Suicide Prevention and Research Contents List of Exhibits ................................................................................................................................. 6 Executive Summary ......................................................................................................................... 7 Abstract .............................................................................................................................................................7 Parts One through Eight ....................................................................................................................................8 Part Nine .........................................................................................................................................................12 Part One - Suicide Attempts and Risk for Suicide Deaths ........................................................... 20 Definitions: The Language of Suicide ............................................................................................................22
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