Research Corner: Suicide Treatment

Suicide is currently the 10th cause of death in the US (Data & Statistics Fatal Injury Report, CDC, 2014). In 2012 alone, over 1 million adults attempted suicide in the United States, and rates of suicide have increased 30% over just 10 years (1999-2010), so that suicide deaths now surpass deaths from car accidents (http://www.nytimes.com/2013/05/03/health/suicide-rate-rises-sharply-in-us.html). Yet, only 83 RCTs have been conducted on suicidality, with 58% not operationally defining how they measured the construct. This is in stark contrast with the 12th and 13th leading causes of death, who count on 1092 (liver disease) and 1049 (hypertension) RCTs respectively. Shockingly, most (58%) of these RCTs on suicidal behavior did not even operationally define how they measure the construct, and several did not use reliable measures or blind raters, and even went so far as to EXCLUDE people with acute suicidality (Linehan, 2015, APS Annual Convention).

Considering current practices in treatment is also not encouraging. First, there is no evidence that hospitalizing suicidal people helps prevent suicide in the long run (Linehan, 2015, APS Annual Convention). Each year 1500 people die from suicide while staying at inpatient units in hospitals (APA, 2003). Patients with Borderline Personality Disorder admitted to a hospital are 44.3 times more likely to die by suicide, and even having been in the Emergency Department for any reason increases the odds of dying by suicide by 27.9 times (Hjorthoj et al., 2014). Once a psychiatric patient is at the Emergency Department, the situation is also often bleak: two recent retrospective studies examining data from the National Hospital Ambulatory Medical Care Survey found that compared to medical patients, nearly three times more psychiatric patients will end up waiting longer than 12 or 24 hours at the ED (Lippert, ACEP16 Annual Scientific Assembly, Las Vegas). The crisis of EDs lack of capacity to handle suicidal patients has gone so far that the president of the American College of Emergency Physicians recently declared that "The Emergency Department has become the dumping ground for these vulnerable patients who have been abandoned by every other part of the health care system" (Rebecca B. Parker, ACEP16 Annual Scientific Assembly, Las Vegas).

The conundrum does not end after discharge; rates of post-discharge suicide are hundreds of times larger than among the general population (Qin & Nordentoft, 2006; Large et al., 2011). Most suicides happen within one day of release (Linehan, 2006), with another 5% within a week (Pirkola et al., 2005), and 20% within a year (Desai et al, 2005). When considering that only half of psychology trainees report ever receiving training in suicide risk assessment and management (Dexter-Mazza & Freeman, 2013) this is not surprising.

Researchers' call to action to improve this situation includes: a more robust cadre of suicide researchers, examining possibly iatrogenic effects of hospitalizing suicidal people, no longer fragilizing graduate students and instead teaching them how to treat suicidality, and addressing IRB and institutional fears (Linehan, 2015, APS Annual Convention).

EBPI has joined the struggle for better assessment and treatment of suicidal folks. CAMS-RAS (the Collaborative Assessment and Treatment of Suicidal Patients - Relational Agent System) is an innovative, NIMH-funded grant co-led by Drs. Linda Dimeff (EBPI) and David Jobes (Catholic University of America) that is developing a tablet app to deliver parts of CAMS, an evidence-based program for assessing and treating suicidality, directly to patients while they are waiting to be seen in Emergency Departments. To do this, we are creating a "virtual" version of the developer of CAMS himself, Dr. David Jobes. Our hope is that "Dr. Dave" will offer suicidal patients a supportive and empathic experience while they wait to see a live professional, giving them something therapeutic to do while they are idle and supporting resource-tapped ED professionals. Boston University has set a precedent for this technology with "Louise", their virtual discharge nurse, who was perceived by patients as caring and patient, and whose use resulted in reduced readmissions to hospitals (Berkowitz et al., 2013). If effective, in addition to lowering distress and offering hope, "Dr. Dave" may also help prepare suicidal patients to communicate with the medical team, and to self-advocate, increasing their chances of having their treatment needs met. Stay tuned to hear more about CAMS-RAS!