Factors Associated With Suicide Outcomes 12 Months After Screening Positive for Suicide Risk in the Emergency Department

The Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) was a quasi-experimental, eight-center study designed to test an approach to universal screening for suicide risk and postvisit telephone intervention among ED patients (4). ED-SAFE consisted of three phases of data collection: treatment as usual (phase 1), universal screening (phase 2), and universal screening and use of an intervention (phase 3). ED-SAFE was conducted from August 2, 2010, through November 8, 2013. Our study analyzed data from the first two phases of ED-SAFE because no study-related interventions for suicidal patients were implemented in these phases, thus maximizing the applicability of our study findings to general U.S. EDs.

ED-SAFE participants were selected by first determining whether the individual’s chart documented any screening for self-harm ideation or behavior. If documentation indicated positive self-harm (self-harm ideation or behavior was documented as present), the patient was approached for further eligibility screening. If the patient confirmed either active suicidal ideation or a suicide attempt within the past week and agreed to participate, then he or she went through the consent process and enrolled in the ED-SAFE study.

The participants completed a baseline assessment and were then followed postdischarge (from ED or from inpatient services, if admitted) with a multimethod approach involving telephone assessments and chart reviews. After the index ED visit, each participant was telephoned by a trained interviewer at 6, 12, 24, 36, and 52 weeks for an outcome assessment. In addition, chart reviews were conducted by a trained chart abstractor at the site at six and 12 months. The first three chart reviews were independently reviewed by the site principal investigator for accuracy. For the major predictor variables, kappas between the research assistant and the site principal investigator were very strong, ranging from .96 to 1.00.

Institutional review boards at each site approved all study procedures and protocols; overall study oversight and monitoring were conducted by the National Institute of Mental Health Data and Safety Monitoring Board.

In the sample of 874 participants, the median age was 37 years (interquartile range 27–47) 56% (N=488) were female, 74% (N=649) were white, and 13% (N=113) were Hispanic. At baseline, 577 (66%, CI=62%–70%) reported suicidal ideation alone, whereas 297 (34%, CI=29%–40%) reported a suicide attempt in the past week. Of the 297 with a suicide attempt in the past week, 227 (76%) presented to the ED as a result of a suicide attempt; the remaining presented with suicide-related complaints (N=28, 9%), mood disorders (N=3, 1%), substance use (N=2, 1%), concerns for nonsuicidal self-harm (N=1, <1%), or general medical issues (such as chest pain, N=8, 3%) or were missing data on the presenting complaint (N=28, 9%).

There were 782 participants (90%) with data available at any of the follow-up assessment time points to determine whether the participant experienced one of the constituents of the traditionally reported suicide outcome. Of those 782 individuals, all of them were followed through chart review, 707 completed at least one of the five telephone follow-up assessments, and 405 completed all of the telephone follow-up assessments. Of the 782 participants, 264 (34%) screened positive for current suicidal ideation or behavior, of which 239 (91%) received a mental health evaluation at the index ED visit. In the 12 months after the index ED visit, 195 (25%) had documentation of at least one suicide attempt or suicide (Table 1).

One important goal of the ED-SAFE was to identify factors associated with future suicide risk among ED patients presenting with active suicidal ideation or behavior. In this high-risk population, outcome data were ascertained for 90% (N=782) of the cases, where 195 (25%) study participants attempted suicide or died by suicide in the 12 months after the index ED visit. Participants were more likely to have suicidal behavior if, at the index ED visit, they reported that their highest level of education was high school or less. From a health history standpoint, increased future suicidal behavior was associated with a history of nonsuicidal self-injury, current alcohol misuse, and reports of an ED visit within the past six months. Finally, individuals indicating suicidal ideation with intent or intent with a plan were more likely than others to engage in future suicidal behavior.

A large percentage of the traditionally reported outcome was reported within six weeks of the initial visit. The most notable differences between the six-week and broader time frame were that high school education or less, alcohol misuse, and a history of nonsuicidal self-injury were not predictive, but high scores on the BSI somatization measure became a significant predictor. This finding suggests that the presence of serious health issues may be important for predicting short-term suicide outcomes among ED patients. This finding also aligns with previous literature linking chronic health conditions and functional limitations with greater suicide risk (12,13).

Although there is no established universal approach for predicting future suicidal behavior after an ED visit, this study found that current suicidal ideation severity, current alcohol misuse, and documentation of an ED visit within the past six months had a strong association with predicting suicide outcomes for ED patients presenting with suicidal ideation or behavior. However, prior suicide attempt severity and a history of mental health problems were not found to be significant predictors. As in previous research, socioeconomic factors appear to be important for assessing risk in the general population (14–16). One explanation may be that these individuals are hospitalized more frequently, which has been identified as a risk factor for suicide (17). Our findings also align with findings of Posner and colleagues (10), in that individuals with suicidal ideation with suicidal intent or stronger inclinations had higher odds of attempting suicide within 24 weeks of the initial assessment.

Our model was based on the traditionally reported outcomes of suicide attempts and suicides. However, it has been suggested that suicide outcomes include a broader range of variables, such as preparatory acts and interrupted and aborted suicide attempts. Our study briefly touched on this expanded model and determined that using it resulted in some additional predictors, including unemployment, a history of chronic health condition(s), and a history of depression. Future research on this model is needed and may benefit from comparisons to existing prediction rules, such as the ReACT self-harm rule (18).

Findings such as these are useful for meeting the demands of improved screening, interventions, treatment, and follow-up with suicidal ED patients (19). Using empirically supported variables to improve guidelines targeting patients presenting with suicide risk may help clinicians choose appropriate treatment and improve long-term suicide management for these patients.

Although several variables associated with 12-month suicide outcomes were identified, our model accounted for only 10% of the variance in the traditionally reported suicide outcome. Although this is lower than found in other studies (20), our findings provide additional support for variables associated with suicide outcomes for an ED population at risk of suicide. In addition, some of the variables included in our model were readily available in the patient’s medical record.

Another limitation was the small sample size for completed suicides (N=2). From a health standpoint, the low mortality rate is positive; however, from a statistical standpoint it does not provide enough power to draw conclusions about factors influencing completed suicides. Additional research is needed to identify risk factors for completed suicides in an ED population.

We did not directly follow patients with no suicidal ideation; however, we conducted random chart reviews to account for times when research staff were not providing coverage in the ED, and we conducted fidelity assessments to ensure that suicide screenings were being appropriately completed. Although these chart reviews did not directly track the nonsuicidal patients, they did provide a means for verifying the accuracy of the ED-SAFE data.

The large number of variables examined in this study allowed for a broad comparison of several relevant factors associated with longitudinal suicide outcomes. However, the large number of variables also limited the extent to which each variable or category of variables could be examined. The goal of this study was to identify a comprehensive group of predictors for identifying ED patients at risk of engaging in suicidal behavior. Future research may want to further delve into the individual implications for each of the findings from the larger grouping of variables.

Finally, it should be noted that some of our significant findings had odds ratios with confidence intervals close to 1.00. These findings point to clinical and statistical significance but should be interpreted cautiously. Future research is needed to replicate and confirm these findings. However, the results provide an initial framework on which to build future studies.

Among participants in ED-SAFE—a unique, prospectively recruited and tracked cohort of ED patients from multiple, geographically diverse sites—both psychiatric and nonpsychiatric characteristics were associated with engaging in future suicidal behavior. In addition, ED-SAFE was the first study to track preparatory acts and interrupted and aborted suicide attempts over a 12-month time frame, which allowed for initial investigation into expanding the traditionally reported suicide outcome measure. The findings that individuals who did not complete high school, who had an ED visit within the past six months, who were misusing alcohol, and who had a high C-SSRS suicidal ideation severity score (current) and a history of nonsuicidal self-injury were more likely than others to attempt or complete suicide within 12 months after the index ED visit all add to the extant research on risk factors for future suicidal behavior in an adult ED population and contribute to the goal of facilitating identification of ED patients at risk of future suicidal behaviors.