This article reports results of a study on the effectiveness of the Safety Planning Intervention (SPI), a simple intervention conducted by staff in emergency departments when a patient has been treated for an attempted suicide. The intervention involves creating a safety plan for each patient and following up with phone calls after discharge.
The story — and the study that it’s based on — both tout that SPI reduced the risk of short-term suicidal behavior in half. That’s a misleading way to frame the results. More precisely, 3.03% of the patients who received the SPI intervention engaged in suicidal behavior within six months of discharge, compared to 5.29% of those receiving usual care. This is a key example of why news stories should report the absolute risk reduction.
Suicide is one of the top ten leading causes of death in the United States. Almost 45,000 people died as a result of suicide in 2016. Many of these people are treated in emergency departments. Unfortunately, nearly half of suicide patients do not attend treatment afterward, or discontinue treatment quickly. Yet risk for repeated suicidal behavior is greatest during the first 6 months following a suicidal crisis. Thus, emergency department personnel may be the only point of mental health care at a critical time in these patients’ lives.
A brief SPI intervention that helps patients and their families plan how to deal with suicidal thoughts and provides follow-up care could make a critical difference. But news stories must be careful to explain the study–and its limitations–so that people come away understanding what it couldn’t measure (see evidence quality, below).
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.
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.
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.
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.
Suicide is the 10th leading cause of death in the United States overall and suicide rates have increased by more than 30% in half of U.S. states since 1999. Suicide rates are especially high among middle-aged men and veterans. This story doesn’t inflate the prevalence.
Two expert sources not involved with the study are cited, and we didn’t detect any conflicts of interest that should have been disclosed.
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.
We’re told that the SPI approach is becoming increasingly more available in hospitals across the country.
This is the first large-scale test of the SPI intervention, so even though it is already being used in many emergency departments, the evidence for effectiveness is new.
The story did not appear to rely on the news release.