Safety planning by peers is feasible and acceptable to patients, might result in decreased ED visits, and may represent a way of implementing safety plans in rural EDs.
SPECIAL REPORT: EMERGENCY PSYCHIATRY
Suicide is now the 11th leading cause of death in the United States.1 Suicide rates rose by 33% from 1999 to 2017,2 and by 2019, an estimated 3.5 million individuals had thoughts of suicide, 1.4 million made suicide attempts (SAs), and 47,511 died by suicide. Many of these patients presented first to an emergency department (ED). Even though evidence-based best practices such as safety planning have been identified in previous systematic reviews,3,4 most EDs in the United States do not currently provide these best practices to patients with suicidal ideation (SI) or who present after an SA. In results from one survey, only 13% to 17% of EDs reported providing all elements of safety planning to their patients.5
There are multiple reasons why EDs are unable to provide this care to patients with SI, but the most common culprit is too many unscheduled visits compared with available staff.6 Patients with SI are common in the ED and, according to the latest data from the Centers from Disease Control and Prevention, present to the ED more often than patients with back problems.7 As such, EDs face challenges in delivering interventions such as safety planning, which can often take 20 to 45 minutes to perform.8 This may be even more true in a rural environment where trained staff may be more difficult to recruit.
Despite this, patients with SI continue to present to US EDs in record numbers. This might be because EDs are open 24 hours a day and now provide nearly half of all medical care in the United States.9 Whatever the reason, implementing more effective suicide prevention strategies in the ED is vital. Unfortunately, ED medical and mental health staff have limited time and training to maintain the fidelity of suicide interventions. In addition, there are numerous post–COVID-19 difficulties in recruiting and paying for additional clinicians.
One almost universally recommended suicide prevention strategy in the ED is safety planning. There are 2 versions of safety plans, including the Stanley-Brown Safety Plan and Emergency Department Safety Assessment and Follow-up Evaluation (Table). Notably, in the Stanley-Brown Safety Plan,8,10,11 individuals are prompted to list the single most important thing that is worth living for.
Regardless of version, safety planning is typically conducted by medical and mental health providers in the ED. It is not overwhelmingly considered to be within the scope of peer practice, but nonetheless, many of the skills employed in a safety planning intervention (SPI; eg, person-centered services, trauma-informed care, collaborative relationships) are similar to the core competencies of peers as defined by the Substance Abuse and Mental Health Services Administration and other organizations.12,13 The term peer is sometimes vaguely defined but is used here to refer to an individual who has had severe suicidal thoughts and plans in their lifetime, has been able to manage impulses without an SA for at least the past 2 years, and is currently state certified as a peer recovery support specialist to deliver behavioral interventions to others in crisis. No matter how they are defined, peers are likely to have more time to spend with patients than medical or mental health providers.
Given the time required to develop a complete and quality safety plan and the typical salaries of trained providers, the delivery of safety planning by peers might be less expensive but just as efficacious to implement than delivery of such planning by busy providers. Furthermore, patients often perceive peers to be more empathetic and caring than busy clinical staff.14-16
Peer-delivered interventions are especially popular in the United Kingdom, where peers provide services in many mental health facilities.17 In the United States, more than 30 states have some level of Medicaid reimbursement for peers.18 Findings from studies outside the ED comparing the delivery of services by trained peer specialists with that of trained mental health providers performing similar services have shown that peer specialists are as efficacious as providers.
Consequently, we asked these questions: Could nonclinical peers, who have lived experience of suicide but are not clinicians themselves, be taught to perform safety planning in the ED setting? More importantly, would there be any harm to the patient, who is having one of the worst days of their life, or to the peer themselves, who might be emotionally harmed by working in the ED?
To answer these questions, we conducted a pilot randomized controlled trial (RCT) at the University of Arkansas for Medical Sciences in Little Rock in which patients in the ED with SI received safety planning using the Stanley-Brown Safety Plan from a mental health provider or from a peer with lived experience of suicide but no medical training.19 Compared with provider-delivered safety planning, participants with peer-delivered safety planning in this RCT had similar lengths of stay but higher safety plan completeness and quality. Patients in both groups found safety planning similarly acceptable. Furthermore, patients in the peer-delivered group had fewer ED visits in the subsequent 3 months.
Our findings show that safety planning by peers is feasible and acceptable to patients, might result in decreased ED visits, and may represent a way of implementing safety plans in rural EDs. These study findings are consistent with the rapidly growing popularity of peers delivering mental health and substance use interventions worldwide.17 Of course, further study is needed to determine the efficacy and cost-effectiveness of peer-delivered SPI in the ED.
Dr Wilson is an associate professor in the Emergency Medicine and Psychiatry departments at the University of Arkansas for Medical Sciences in Little Rock. Dr Waliski is an assistant professor at the Center for Health Services Research in the Department of Psychiatry at the University of Arkansas for Medical Sciences and in the Department of Health Services Research and Development at the Central Arkansas Veterans Healthcare System in Little Rock. Dr Thompson is an assistant professor at the Center for Health Services Research in the Department of Psychiatry at the University of Arkansas for Medical Sciences.
1. Heron M. Deaths: leading causes for 2019. Natl Vital Stat Rep. 2021;70(9):1-114.
2. Hedegaard H, Curtin SC, Warner M. Suicide mortality in the United States, 1999-2017. NCHS Data Brief. 2018;330:1-8.
3. Wilson MP, Moutier C, Wolf L, et al. ED recommendations for suicide prevention in adults: the ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020;38(5):571-581.
4. Nuij C, van Ballegooijen W, de Beurs D, et al. Safety planning-type interventions for suicide prevention: meta-analysis. Br J Psychiatry. 2021;219(2):419-426.
5. Bridge JA, Olfson M, Caterino JM, et al. Emergency department management of deliberate self-harm: a national survey. JAMA Psychiatry. 2019;76(6):652-654.
6. Petrik ML, Gutierrez PM, Berlin JS, Saunders SM. Barriers and facilitators of suicide risk assessment in emergency departments: a qualitative study of provider perspectives. Gen Hosp Psychiatry. 2015;37(6):581-586.
7. Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2020 Emergency Department Summary Tables. National Center for Health Statistics; 2022. CDC. December 13, 2022. Accessed August 7, 2023. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2020-nhamcs-ed-web-tables-508.pdf
8. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256-264.
9. Marcozzi D, Carr B, Liferidge A, et al. Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. Int J Health Serv. 2018;48(2):267-288.
10. Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75(9):894-900.
11. Stanley B, Chaudhury SR, Chesin M, et al. An emergency department intervention and follow-up to reduce suicide risk in the VA: acceptability and effectiveness. Psychiatr Serv. 2016;67(6):680-683.
12. Core competencies for peer workers. Substance Abuse and Mental Health Services Administration. Accessed August 7, 2023. https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers/core-competencies-peer-workers
13. Brasier C, Roennfeldt H, Hamilton B, et al. Peer support work for people experiencing mental distress attending the emergency department: exploring the potential. Emerg Med Australas. 2022;34(1):78-84.
14. Mullinax S, Wilson MP. The use of peer mentors in behavioral emergencies. In: Zun LS, Wilson MP, Nordstrom K, eds. Behavioral Emergencies for the Healthcare Providers. Springer Publishing; 2021.
15. Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry. 2012;11(2):123-128.
16. Pitt V, Lowe D, Hill S, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database Syst Rev. 2013;2013(3):CD004807.
17. Gillard S, Foster R, Gibson S, et al. Describing a principles-based approach to developing and evaluating peer worker roles as peer support moves into mainstream mental health services. Mental Health and Social Inclusion. 2017;21(3):133-143.
18. Cabassa LJ, Camacho D, Vélez-Grau CM, Stefancic A. Peer-based health interventions for people with serious mental illness: a systematic literature review. J Psychiatr Res. 2017;84:80-89.
19. Wilson MP, Waliski A, Thompson RG Jr. Feasibility of peer-delivered suicide safety planning in the emergency department: results from a pilot trial. Psychiatr Serv. 2022;73(10):1087-1093.