Peer Specialists Can Aid in Suicide Prevention

In 2013, emergency physician Michael Wilson, M.D., Ph.D., had what seemed like a routine encounter treating an older patient with a toe injury during a night shift. However, the next day he was informed that the patient had died by suicide following discharge.

“That experience was both life and research changing,” said Wilson, who is an associate professor of emergency medicine with a secondary appointment in psychiatry at the University of Arkansas for Medical Sciences (UAMS). He told Psychiatric News that since then, he has looked for ways for emergency departments to become more involved in suicide prevention.

One evidence-based way to reduce suicide among emergency patients who might be at risk is to have them complete suicide safety plans while in the emergency department, Wilson said. At UAMS, social workers or mental health specialists commonly work with patients on these plans, but these staff are busy and may not be available 24 hours a day. Additionally, the time pressures on emergency physicians can make it difficult to engage with patients for the 20 to 45 minutes needed for safety planning, he explained. Wilson believes trained peer specialists could help to fill this gap.

“Peers have a wealth of personal experience, and by acting more as friends and supports, peer specialists can develop a bond with patients that might engage them more in the safety planning process,” he said.

Along with UAMS research colleagues Ron Thompson, Ph.D., and Angie Waliski, Ph.D., Wilson compared how well peer specialists performed at safety planning relative to current UAMS practice. The study involved 31 patients aged 18 to 89 years who were admitted to the ED for suicidal ideation or suicide attempt; 15 completed a safety plan with the assistance of a mental health nurse or social worker, and 16 did so with the assistance of a trained peer specialist.

“Because peers had lived through personal trauma and had never held a similar role within the [emergency department], debriefing and supervision were paramount,” Wilson and colleagues wrote in the Psychiatric Services article describing their findings. “Peers received biweekly feedback by the study team on the quality and completeness of the plans and adherence to study protocol. … The peers also received a weekly debriefing by a licensed clinical counselor throughout the study.”

The researchers found that patient safety plans completed with help from peer specialists were more complete and of higher quality on average than those completed with help from mental health professionals. There was even some evidence to suggest that the patients who worked with peer specialists were less likely to return to the emergency department in the three months after creating a safety plan, but Wilson cautioned that the sample size of the study was small.

Still, the study suggests that peer specialists can fulfill this important role in the emergency department. “The specialists who participated all felt empowered and grateful that they could use their own life story to help another person in need,” Wilson said.

Wilson hopes to now expand his work to determine if peer specialists can also help to follow up with patients.

“In rural settings like ours, it’s vital to follow people after discharge because outpatient services are limited,” Wilson noted.

Paul Pfeiffer, M.D., M.S., the Susan Crumpacker Brown Research Professor of Depression at the University of Michigan Medicine, has worked with peer specialists for many years and, like Wilson, believes they are well suited to engage with suicidal patients.

The interpersonal theory of suicide—a model developed by Thomas Joiner, Ph.D., of Florida State University—posits that suicidal ideation arises when people perceive themselves as a burden to others and not belonging anywhere, particularly when they have a sense of hopelessness, Pfeiffer said. A peer, who has experienced and overcome suicidal ideation, is in a unique position to provide social connection and hope to these patients.

Pfeiffer and colleagues developed and tested an intervention called PREVAIL (Peers for Valued Living). This intervention connects trained peer specialists with patients hospitalized following suicidal ideation or attempt multiple times over the course of 12 weeks (peers connect with patients one or two times at the hospital and follow up with the patients at postdischarge check-ins). During check-ins, the peers go over various suicide prevention strategies, such as reviewing the patients’ safety plans, setting goals, and helping patients strengthen their social networks. Pfeiffer said that although there is a set of topics that peers are asked to cover, he wanted PREVAIL to offer enough flexibility so they could make use of their skills, such as active listening and being able to share their story of suicidal recovery.

“The peer specialists we have worked with have a range of opinions,” Pfeiffer said. “Some wanted even more of a structured approach, while others wanted the freedom to do their thing.” In the end, Pfeiffer noted this middle ground allowed for enough structure to ensure evidence-based suicide prevention skills are being taught while enabling peer specialists to be true to themselves as they offer support and hope.

In a pilot study involving 70 psychiatric inpatients with documented suicidal ideation or attempt at admission, Pfeiffer and his colleagues showed that peer specialists could reliably administer the PREVAIL intervention and were able to retain patients over the 12-week follow-up period. The participants also viewed the PREVAIL program favorably.

Pfeiffer and colleagues are now recruiting patients for a larger, multisite trial that will compare outcomes in patients hospitalized for suicidal ideation or attempt who receive 12 weeks of PREVAIL or enhanced usual care (which involves staff sending a brief supportive text a few days after discharge and links to mental health resources for patients who reply). The goal of the study is to both assess the effectiveness of PREVAIL and identify any barriers to implementing the program in hospitals.

Pfeiffer acknowledges that while many of the peer specialists find the work intensely rewarding, not every peer specialist is suited to work in suicide prevention. “Some people can find it too stressful, and there are potential downstream risks to peer specialists if patients experience an adverse outcome [like a suicide attempt],” he said. That’s why it’s important that the specialists be embedded within a clinical team that includes regular support and feedback from other peer specialists and mental health clinicians to help manage difficult or high-risk patient situations.”

Overall, though, the experience of building up PREVAIL has been tremendously positive for all involved, Pfeiffer said. “We had many patients tell us how the specialists brought them hope they didn’t know was possible.” ■

“Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial”

“Development and Pilot Study of a Suicide Prevention Intervention Delivered by Peer Support Specialists”