A 50% reduction in suicide risk? NPR story overstates the benefits of ‘Safety Planning Intervention’

Does the story adequately discuss the costs of the intervention?

Not Satisfactory

We’re told the intervention takes a few minutes up to two hours for nurses or social workers to administer when a patient comes to the emergency room after a suicide attempt. We assume this counseling is provided at no additional cost, but we’d like to know for certain. One possible additional cost is having a delegated staff person in the ED at all times to accommodate these patients. Also, there may be cost savings in not having these patients wait for a full psychiatric evaluation by a psychiatrist or a psychiatric social worker or nurse.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Not Satisfactory

The story explains that people who received the Safety Planning Intervention cut their odds of repeated suicidal behavior in the next six months by nearly half. But that what’s known as the relative risk reduction, and it’s not the full picture.

More precisely, 3.03% of the patients who received the SPI intervention engaged in suicidal behavior compared to 5.29% of those receiving usual care. This is a key example of why news stories should report the absolute risk reduction.

Does the story adequately explain/quantify the harms of the intervention?

Not Satisfactory

Patients could be potentially harmed if a hospital relies too heavily on the SPI instead of more thorough and immediate psychiatric care. For example, if a patient with a serious mental illness isn’t diagnosed and treated promptly.

Does the story seem to grasp the quality of the evidence?

Not Satisfactory

The story informs us that the study involved 1,200 patients at 5 VA hospitals around the country who were given the treatment, compared to patients at 4 hospitals who were just sent home, and therefore served as a comparison group.

But the full picture is more complicated. The story doesn’t note that this wasn’t actually a randomized controlled trial — medical records were used for the control group instead of actively enrolling patients. Also, patients who were admitted to inpatient care directly from the emergency room were excluded from the trial–so the data may only reflect lower-risk patients–and not all patients with suicidal ideation. As the study authors note, this also may explain in part why the number of suicide attempts post-hospital were low in both groups. We just don’t how this intervention helps higher-risk patients.

Lastly, the patients were all mostly middle-aged military men, so we don’t know if the intervention will have similar results for other groups.

Does the story compare the new approach with existing alternatives?

Not Satisfactory

The story doesn’t adequately explain what the alternatives are–if a hospital doesn’t have this protocol in place, what normally happens with suicidal patients?

There’s some history of alternative approaches that could have put this intervention into context. Up until 10 years ago “no-suicide contracts” were commonly used after emergency department visits, but they were repeatedly shown to be ineffective. Around that time, safety plans were recommended as an alternative, and clinical trials among active duty military found them to lower suicide risks. Post-discharge follow-up by in-person visit or phone calls was also shown to lower suicidal behavior by up to 30%. The authors of this study, then, developed and evaluated a combination of the two approaches.