A 2008 report by the National Association of State Mental Health Program Directors argues that “…lapses in continuity of care, especially after discharge from emergency department and inpatient psychiatry units, contribute to significant suicide-related morbidity and mortality”. The report recommends improving continuity of care following discharge. At least in the NYC area and probably elsewhere, many psychiatric facilities already have in place a follow up system for people discharged from inpatient units to verify that initial post-discharge outpatient appointments are kept (personal communication, 2008). What is not well established is a service follow up model applied to people who visit a psychiatric emergency room with suicidal ideation but who are not admitted to inpatient care. There is some research evidence to suggest that, for people with suicidal ideation, telephonic follow up with to the point that they have connected with an appropriate treatment resource (rather than simply being referred to such a resource), is an appropriate, cost-effective service model that can increase the probability that the person remains safe and will eventually begin or continue treatment. When combined with development of a “safe plan,” such a call-out follow up service may be an important potential suicide prevention service model for higher risk individuals.
The published research data on the effectiveness of telephone follow up as a suicide prevention strategy is limited but promising. Vaiva et al conducted a study in France to determine the effects over one year of contacting patients by telephone one month or three months after being discharged from an emergency department following suicidal behavior, compared with usual treatment. The authors conclude that: “Contacting people by telephone one month after being discharged from an emergency department … may help reduce the number of reattempted suicides over one year.”
There is also evidence that development of a “safe plan” with people at risk may be a useful component of such a telephonic follow up model. A “safe plan” is different from a “no suicide contract.” The former is logically more sound than a simple “no suicide contract”, adding as it does the extra dimension of providing specific contingency methods and steps for the individual to use to help cope with suicidal thoughts and feelings. An evaluation of the Lifeline Australia program found that telephonic follow up with suicidal callers to the helpline, coupled with development of a safe plan resulted in a reduction in the frequency and strength of suicidal thoughts and self-reports of marked improvement in coping ability. The safe plan now in use by LifeNet, the MHA of NYC’s behavioral health crisis and information and referral call center, is based on the ASIST model of suicide intervention, developed by Living Works. In general terms, such a safe plan is a collaborative undertaking between the client and the provider and consists of:
- Agreement to keep safe
- Safe or no use of drugs or alcohol
- Establishing a specific list of safety contacts
- Linking the individual to additional supportive resources
- Identifying and supporting specific past survival skills
- Working with the client to disable any current suicidal plans
We believe that the model lends itself to evaluation, is relatively inexpensive to establish and operate, and if implemented, can be an important step toward addressing the finding in the NASMHPD report regarding the lack of continuity of care and suicide-related morbidity and mortality following discharge from emergency departments.