Suicide Risk Assessment and Prevention in the Acute Care General Hospital Setting

Suicide is a nationwide problem. According to data from the Centers for Disease Control and Prevention, 44,193 suicides occurred in the United States in 2015, making it the 10th leading cause of death overall. This is an average of 121 deaths by suicide per day, or one every 12 minutes. Suicide is the second leading cause of death among individuals age 15 to 24 years, the third leading cause of death among children age 5 to 14 years, and the fourth leading cause of death among adults age 25 to 44 years. (CDC) The data on suicidal behavior are even more striking. According to 2008–2009 statistics, 8.3 million individuals in the United States reported having suicidal thoughts and more than 1 million Americans reported attempting suicide. (Crosby et al.)

A dearth of need-appropriate, accessible resources for patients with behavioral health needs, including suicidality, causes great difficulties for patients and healthcare organizations across the continuum of care. Historical efforts moved many people with behavioral health conditions out of institutions and into less restrictive settings. However, some people still need inpatient beds but cannot get them because the demand exceeds the supply. (Raphelson) In 2016, fewer than 12 state psychiatric beds were available per 100,000 population—the lowest number per capita since the United States stopped considering mental illness a crime in the 1850s (Fuller et al.). In some areas, outpatient services exist but have months-long waiting lists. Costs to patients and social determinants of health (e.g., transportation difficulties) are other potential barriers to access.

All of this has had a tremendous effect on healthcare delivery. Acute care hospitals and in particular the emergency department (ED) have become the de facto provider of behavioral healthcare for many patients, causing an increase in the numbers of patients with psychiatric needs presenting to EDs. One study found that in a nationwide comparison of visits by four-year groupings, rates for suicide attempt and self-injury ED visits more than doubled from 1993–1996 to 2005–2008 (Ting et al.). The trend continues to escalate; the number of ED visits for suicidal ideation increased by 415% from 2006 to 2014 (Moore et al.).

Patients who seek care in an ED or general hospital primarily because of suicidal ideation or injuries from a suicide attempt may volunteer this information. Others may seek care for injuries sustained in a suicide attempt without disclosing that the injuries resulted from a suicide attempt (e.g., a broken limb from jumping). Yet others may present for unrelated physical or behavioral health reasons but may also be at risk for suicide. In a study of nearly 6,000 people who died by suicide, 83% received healthcare services in the year before death, but most such contacts with the healthcare system were not associated with a mental health diagnosis code (Ahmedani et al.).

When the patient's reason for presenting does not obviously relate to suicide, suicide risk may go unrecognized, particularly if providers do not ask screening questions. Researchers sent surveys to all level I and level II trauma centers in the United States, asking about their screening procedures and interventions. Only 49% of respondents routinely screened patients for suicide risk. (Love and Zatzick) This represents a lost opportunity to intervene, whether or not the patient's reason for presenting relates to suicidality. Even when suicide risk is recognized, it is often challenging to determine which disposition is most appropriate or how to plan effectively to keep the patient safe.

The relatively recent influx of patients with psychiatric needs into the acute care setting, regardless of how they present, revealed a system that was ill prepared for the challenges it faces. For example, EDs often have insufficient resources to invest in capital redesigns to make the spaces safer and to provide additional training to staff. Since most providers do not have a behavioral health background, they believe they lack the knowledge and expertise to best provide care for the psychiatric patient population. In addition, some of these providers have negative attitudes toward psychiatric patients in general and express frustration with patients who repeatedly present with suicidal behavior. Overall, staff exhibit frustration with the organization and a feeling of helplessness at the perceived failure of the mental health system. ...