After struggling with depression and self-harm through most of her teenage years, Alyse Ruriani attempted suicide at age 17. While her parents and a hospital stay saved her life that day, she said she has survived ever since with therapy and also by using a so-called safety plan — a step-by-step tool she can turn to in crisis.
Ruriani, now a 23-year-old Chicago graduate student studying art therapy at the School of the Art Institute of Chicago, has used her safety plan to identify when she’s headed into a depression and how to keep suicidal thoughts at bay.
As she moves through the steps of the plan, “usually that intense feeling subsides,” Ruriani said. “I’m still depressed … but I’m not in a crisis mode that I’m afraid I might attempt (suicide).”
Research shows this type of safety planning, combined with prompt follow-up from medical professionals, can help save lives, particularly for those who come to the emergency room after suicide attempts or expressing suicidal thoughts. But while many local hospitals have procedures in place to address the needs of suicidal patients who come to the ER, administrators acknowledged that consistent follow-up can be difficult.
As public health officials continue to grapple with how to address rising suicide rates in Illinois and across the country, experts say emergency departments should be well-equipped to handle mental health crises. Not only do patients visit emergency rooms after a suicide attempt, but the time period immediately following hospital discharge is a dangerous one, when those with suicidal thoughts are more at risk for a second attempt.
“One of the problems is, when people go to the emergency department, they get a slip of paper that tells them where to go next,” said Jill Harkavy-Friedman, vice president of research for the American Foundation for Suicide Prevention. But “the follow-up on that is very low.”
Reaching out to patients after they leave the hospital, even if it’s simply a letter, “can go a long way,” Harkavy-Friedman said. This, along with safety planning, can create a better outcome for patients seen in the emergency department, she said.
Suicide rates in Illinois increased by 22.8 percent from 1999 to 2016, according to a report released last June by the Centers for Disease Control and Prevention. That trend was seen in almost every state, according to the report, with a more than 25 percent increase nationally.
Although outlines for a safety plan were suggested in Ruriani’s hospital discharge paperwork when she was a teenager living in Pennsylvania, she said it wasn’t until she was actively engaged in creating one with her therapist that she started using it as part of her ongoing treatment.
The plan is “personalized,” she said. “What helps me could be useless to someone else.”
In Ruriani’s plan, which she accesses on her phone, she can identify triggers that could send her down a dark path, as well as people she can turn to and activities and crisis hotlines that will help her get through tough times.
Barbara Stanley, professor of psychology at Columbia University, has studied safety plan use in emergency departments. Her most recent work, published in July in JAMA Psychiatry, showed patients who were given safety plans and also received follow-up phone calls upon discharge from the emergency room, were less likely to attempt suicide and more likely to engage in follow-up treatment.
“We know that if someone has made an attempt, and even if they are correctly determined not to need hospitalization, they are at risk for at least the next three to six months for another attempt,” she said. “And we are not doing anything for them except giving them a referral.”
To fill the gaps between follow-up appointments, hospitals should discharge patients with safety plans, which typically help people identify when they’re headed into a depression, list professional and social support they can call upon, as well activities or people that can serve as a distraction to help get through periods of suicidal thoughts.
“It’s such a simple idea, and it seems like it can’t possibly work, but I can tell you it does,” Stanley said. “The idea is a suicide crisis doesn’t last a very long time, so time is your friend.”
The plans also offer ways to make a person’s environment safer, like securing guns or medications to eliminate access. But because the safety plan is a tool to get through an immediate crisis, and doesn’t get “to the root of the problem,” follow-up with mental health professionals upon discharge from the hospital is important, Stanley added.
In her study, Stanley examined emergency departments at nine Veterans Health Administration hospitals. The results showed that among the 1,186 vets who received safety planning help plus follow-up phone calls, there was a 50 percent reduction in suicidal behavior over a six-month period, and more than twice as many of those patients followed through with treatment referrals, compared with the control group who received more typical care, according to the study.
While safety planning has become commonplace in the past decade, follow-up phone calls can be unrealistic at large, urban emergency departments, Chicago area hospital administrators said.
Most patients who come to the ER after a suicide attempt are hospitalized, and not discharged from the emergency department, said Patricia Madden, director of patient care services in the emergency department at the University of Illinois Medical Center at Chicago.
“If we don’t admit them to this facility, we find somewhere to admit them,” Madden said. She added that her hospital also has a challenge with its homeless patients — it’s hard to follow up at all.
At Edward Hines, Jr. VA Hospital near Maywood, there are a number of protocols in place for veterans struggling with suicidal thoughts. As soon as a veteran comes to Hines, or any hospital, the VA’s suicide prevention team is alerted, said Suicide Prevention Coordinator Anita Carmona-Caravelli.
That starts a 90-day period when the veteran receives care, including safety plans and weekly follow-up calls for at least the first month, Carmona-Caravelli said.
Dr. Leslie Zun, president of the American Association for Emergency Psychiatry and professor of emergency medicine at Chicago Medical School at Rosalind Franklin University in North Chicago, said the VA system has a strong behavioral health component with the ability to provide comprehensive care to their patients.
But at community hospitals, “there’s maybe not as many resources,” Zun said. “It’s much tougher to apply these kinds of guidelines.”
Although emergency departments are also often overwhelmed with responsibilities, emergency physicians need more training in emergency psychiatry, Zun said.
At Northwestern Memorial Hospital, patients have access to mental health experts, including a separate psychiatry emergency department, said Dr. Pedro Dago, medical director of the department.
Most patients in the midst of a suicide crisis are admitted for inpatient care, Dago said, but those who are safe to leave from the emergency department are provided with safety plans, crisis numbers, and a follow-up, outpatient appointment within days. Although the department does not make follow-up calls, the staff shores up support for the patient before discharge, including contacting family members who can help ensure the patient receives outpatient care.
All emergency departments in DuPage County can refer suicidal patients who meet certain criteria to the DuPage County Health Department’s Behavioral Health Services, which contacts patients within 24 hours to connect them with a variety of services, said Lori Carnahan, the county’s director of behavioral health.
“This is really geared toward those folks who do not have that high level of need where they need a (hospital) stay, but they are struggling,” she said. “A lot of times people don’t know what to do or where to go.”
Through a federal grant, Northwestern Medicine Central DuPage County Hospital in Winfield extends the referral program to all patients.
“The program puts patients on a fast track … so that we know they’ll be seen promptly upon discharge, whereas previously we were not able to guarantee that,” said Dan Doebler, manager of behavioral health social work at the hospital.
At several Advocate hospitals in the region, patients are provided with on-the-spot video chat sessions with a psychiatrist while in the emergency department. The Behavioral Health Hub includes mental health staff who are located at Christ Medical Center in Oak Lawn but able to see patients at other hospitals, including two downstate, using a video chat system that is wheeled around the hospital, said Renee Donaldson, executive director of the behavioral health service line.
From that conversation, doctors can write prescriptions and develop treatment plans just like a regular visit, she said. “It really affords the opportunity to bring levels of expertise and a skill set where that professional may not be in a hospital setting.”
It also helps with patient engagement, said Dr. David Kemp, psychiatrist and medical director of the behavioral health service line. If patients can actually see the psychiatrist in the emergency department, they’re more likely to follow through with suggested care afterward, he said.
Along with the health hub, all Advocate ER patients 65 and older receive a depression and anxiety screening. This could extend to other age groups in the future, Kemp said.
“It’s looking at all depression and anxiety that may be under-recognized or inadequately treated,” he said. “Because the ER may be the only time a patient may be able to have an interaction with a behavioral-health provider.”
The National Suicide Prevention Lifeline number is 800-273-TALK(8255).