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Clinical Trial
. 2017 Jun 1;74(6):563-570.
doi: 10.1001/jamapsychiatry.2017.0678.

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study

Free PMC article
Clinical Trial

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study

Ivan W Miller et al. JAMA Psychiatry. .
Free PMC article


Importance: Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped.

Objective: To determine whether an ED-initiated intervention reduces subsequent suicidal behavior.

Design, setting, and participants: This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013.

Interventions: Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk.

Main outcomes and measures: The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed.

Results: A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99).

Conclusions and relevance: Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.


Figure 1.
Figure 1.. CONSORT Diagram
Figure 2.
Figure 2.. Total Suicide Attempts per Participant by Phase
TAU indicates treatment as usual.
Figure 3.
Figure 3.. Proportion of Participants Who Did Not Make a Suicide Attempt Over Time
The screening phase (phase 2) vs the treatment as usual phase (phase 1): P = .56 by log-rank test. The intervention phase (phase 3) vs the treatment as usual phase (phase 1): P = .08 by log-rank test.

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