Pediatric patients presenting to the ED with suicidal ideation, single or repeat suicide attempts fall along a continuum of increasing risk8
making appropriate care and disposition decisions essential. While most clinical practice guidelines and literature reviews for this field7,14–21
have emphasized limitations in the available evidence base, these papers have not accounted for several ED-based trials or been updated with recently published data. This systematic review identified several promising interventions that could significantly impact patient and system outcomes if additional research is conducted and more consistent approaches to this field of study are applied.
Few ED interventions have been shown to reduce subsequent suicide-related behaviors and related hospitalizations. Interventions that initiate care in the ED and/or extended this care past ED discharge have shown impact on suicide-related outcomes compared to interventions initiated only after ED discharge. Findings should be interpreted with caution, however, given the studies’ noted limitations. Greenfield’s examination of a community outreach program was shown to decrease subsequent suicide-related hospitalizations for pediatric patients who presented to the ED with suicidal ideation, a group that is far less likely to be admitted to hospital than patients with behavioral intent.36
This study’s use of a quasi-experimental (non-randomized) design may have increased study feasibility (and possibly ethical conduct), but the role of confounding variables in hospitalization (e.g., comorbidity, behavioral intent, health care provider care) is still unclear. While the well-conducted Fleishmann trial31
suggested that brief intervention with ongoing supportive contact can reduce rates of death by suicide, conclusions were directed towards middle- to low-income countries and the intervention was evaluated with a predominantly young adult population. Both factors do limit the degree of study generalizability. Further, no perspective was offered on the intervention’s impact on rates of re-attempt and suicidal re-ideation, which are far more prevalent behaviors preceding death by suicide. Given that the Fleishmann trial demonstrated significant impact on a less frequently occurring outcome than other studies on a high risk clinical population (those with suicide attempt), the role of transition (ED + post-ED) care on suicide-related outcomes is important to thoroughly investigate. Although this approach to ED management would create a shift in how acute (and complex) conditions are treated, the care continuity in this approach is an important issue to evaluate. The failure of other studies to demonstrate a significant effect may be based on the nature of the intervention. For example, if interventions are disjointed from the critical clinical moment for the patient (such as post-ED interventions) they may fail to capitalize on motivation and opportunities to tailor treatment. However, it is impossible to address this, given current study designs. The introduction of ‘process evaluations’ to determine the effectiveness of individual intervention elements (rather than the collective intervention) would help address this gap. Of the studies that reported no significant effect of specialized interventions or standard care on suicide-related outcomes, current study limitations make firm conclusions difficult, and further evaluation using rigorous study design would allow for a more conclusive evaluation of the impact of ED, post-ED, and transition (ED + post-ED) care on suicide-related outcomes.
Strikingly absent from our review was the evaluation of the use of safety planning with patients. These plans are distinct from ‘no-harm contracts,’ which are not empirically supported.47–50
No studies with this intervention were screened during the initial stages of the review. The primary purpose of these safety planning contracts is to problem-solve with the patient and create a plan they will utilize during times of suicidal crisis. There may be utility in evaluating the impact of this form of planning on short-term and long-term patient outcomes given the lack of observed effect with both standard care and novel interventions.
Based on this review, it appears that re-attempts continue after an 18 to 24 month treatment period despite some reduction in suicidal ideation. As past suicide-related behaviors are strong indicators of later ones,4,19–20,51–52
it is critical that emergency and post-emergency based research improve the study and understanding of the role of clinical care in relation to these behaviors. Including known moderating and/or confounding relationships between ideation and attempts such as family environment, parental monitoring, co-morbidities, and risk-taking behaviors (i.e., substance use, smoking) is an important methodological step and one that was largely unaccounted for by the studies included in this review.
Increasing the inclusion of assessment, disposition planning, and adherence and problem-solving outcomes in ED-based research is also essential. These outcomes will better link research to the roles of clinicians in recognizing risk of suicide-related thoughts and behaviors, connecting young people and their families to necessary mental health services, and promoting continuity of care post-crisis.4,19–20
This review found rigorous evidence suggesting treatment adherence can be increased by addressing treatment barriers, discussing treatment expectations, and negotiating session attendance.27,30,34
Improved problem-solving, although measured as a secondary outcome, was reported by one study.33
Studies tailored to these foci are few, however, and more research is needed in both the ED setting and in referred community-based services with a link to other patient and system outcomes to determine long-term clinical and health utilization impact. Given the numbers needed to treat ranged greatly, linkage to other outcomes is essential.
One notable ED intervention absent from this review was parent means restriction. One observational study was excluded from our review based on design, but suggested that parental education in the ED may effectively improve means restriction in the home environment and may prove promising as a prevention effort.54
Future studies should extend these initial findings by evaluating enhanced parental education in RCTs and also including clinical outcomes to evaluate the effectiveness of means restriction on child/adolescent suicide-related behaviors and risk. Assessing family environment in the ED to gauge parental abilities may also limit means access and encourage monitoring.55–56
Behavioral lethality has received much attention in general treatment literature,4,9,19–20
and by the American Psychiatric Association (APA).59
Lethality assessment during ED history taking has been recommended,59
and scales have been suggested as adjunctive rather than as a rigid replacement to standard history taking,20
given the uniqueness to each child and adolescent’s risk factors and experiences.4
Using scales (e.g., the Beck Scale for Suicide Ideation, or the Beck Suicide Intent Scale60–61
) to augment clinician understanding of risk may help address the concern that ED clinicians can underestimate the seriousness of suicidal intent.20,62
However, our review identified only one study that has used an ED-based population of suicidal patients to evaluate its tool’s psychometric properties.63
As this study did not focus on clinical outcomes, it was excluded in the review. An evaluation of such tools and/or actuarial instruments (which may reveal, more accurately, suicidality because of their self-report nature47
) in the ED setting is needed with a focus on impact on clinical assessment and disposition decision-making.
At present, there is also no high quality research evidence to suggest that the quality
of clinical care can be improved by using a specialized ED team. We think further evaluation is necessary. Within this research agenda, the impact of pediatric emergency- trained physicians versus general emergency practitioners in the ED on clinical care and patient outcomes should be examined. Future studies should also examine systemic factors influencing ED personnel attitudes and readiness to modify practice, and consider how to improve documentation of drug and alcohol use, family history, and co-morbidities given the lack of impact noted in this review, and the demonstrated association between these factors and suicide-related behaviors.64–65
To summarize, robust research evidence to inform current clinical and psychosocial management of pediatric suicide-related ED presentations is emerging but limited. The lack of consistency in methods and outcomes tracked along with the overall limited quality of the studies available suggests that this is an area of research requiring maturation and refinement. A systematic and comprehensive program of research across multiple settings could help to identify the relevant research questions that need to be answered to move this field forward. Multi-setting research efforts with consistent indicators of success in ED management of both children and adolescents will provide more definitive knowledge to guide practice. The dimensions of this research would include: risk assessment, discharge planning, ED capacity and skill set requirements, personnel attitudes and beliefs, crisis interventions, and outcomes tracking. Future studies must address methodological limitations of the reviewed literature and further evaluate already established clinical interventions to establish utility and benefit to patient and family outcomes. This will involve: (1) justifying the level of care to be provided in the ED and appropriate outcomes that should result,65
(2) including ‘process evaluations’ to determine the effectiveness the individual intervention elements of care that are deemed essential to the ED, (3) including well-defined treatment-as-usual control groups which are now considered the standard for conducting suicide-related treatment research,67
(4) distinguishing between short-term and long-term outcome variables that are appropriate for this field,46,68
(5) strict operationalization of the various subtypes of suicidality,44–45
and (6) using multi-site studies to recruit pediatric-only populations to avoid over-generalizing study effects on a broad patient age range. Finally, studies must sample subsets of suicide-related behaviors to increase the likelihood that studies are feasible, ethical and clinically meaningful.46,69
Highly suicidal individuals, for example, have been excluded from clinical trials and measures of certain suicide-related behaviors (i.e., ideation) not included as outcomes. The need to address these shortcomings, particularly in children and youths at risk, is now well recognized.70