Implementing psychological care in emergency departments for suicide prevention

Table 1 Comparative analysis of evidence-based psychological interventions for suicide attempters in emergency department settings

Intervention type	Core components	Target population	Duration/format	Key efficacy findings	Implementation considerations
SPI	Collaborative development of personalized crisis response plan; means restriction counseling; identification of warning signs and coping strategies	All suicide attempters presenting to ED	Single session (20-45 minutes); often combined with follow-up contacts	Odds ratio: 0.51 for suicide attempts vs usual care[4]; 43%-86% reduction in suicide-related ED visits in DBT programs[29]	Can be delivered by trained nurses, social workers, or peers; requires standardized training and fidelity monitoring
Cognitive behavioral therapy	Cognitive restructuring; problem-solving skills; emotion regulation; behavioral activation	High-risk patients with recurrent attempts or severe ideation	6-12 sessions (individual or group); may be initiated in ED with community referral	Odds ratio: 0.54 for repeat attempts[5]; 41% reduced risk via telehealth delivery[27]	Requires specialized therapists; may involve task-shifting with supervision; telehealth adaptations show promise[20]
DBT	Mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness skills	Patients with borderline personality traits, chronic suicidality, or emotion dysregulation	Comprehensive program (individual therapy, skills group, phone coaching, team consultation)	Significant reductions in suicide attempts and self-harm[33]; digital DBT shows feasibility[15]	Resource-intensive; requires specialized training; digital adaptations may increase accessibility[33]
Brief contact interventions	Postcards, letters, phone calls, text messages; caring contacts; systematic follow-up	All suicide attempters post-discharge	Multiple contacts over 6-12 months (e.g., 24-48 hours, 1 week, 1 month, 3 months, 6 months)	24% reduced risk of relapse with early appointment scheduling[31]; active contact reduces repeat attempts within 6 months[30]	Low-cost; can be automated or delivered by non-specialists; requires systematic tracking system[56,57]
Attempted Suicide Short Intervention Program	Therapeutic alliance building; narrative reconstruction; safety planning; follow-up letters	First-time and repeat suicide attempters	3-4 sessions plus follow-up letters over 24 months	Reduced suicide reattempts by 80% at 24-month follow-up[55]	Brief format (3 sessions); manualized; requires therapist training[55]

SPI: Safety planning intervention; ED: Emergency department; DBT: Dialectical behavior therapy.

Table 2 Implementation barriers and evidence-based solutions for emergency department suicide prevention programs

Barrier category	Specific barriers	Evidence-based solutions	Supporting evidence
Workforce and training	Limited mental health specialists in ED; inadequate suicide risk assessment training; high staff turnover	Task-shifting with protocolized interventions; standardized training programs; telehealth consultation models	Nurse-led SPI implementation[20]; ED-SAFE training protocols[11]; SPCC telehealth model[40]
Workflow and resources	Time constraints; competing clinical priorities; lack of dedicated space for interventions	Integration into nursing discharge process; electronic health record prompts; dedicated “suicide prevention coordinator” role	SPI embedded in discharge workflow[29]; EHR clinical decision support[36]; follow-up coordinator models[45]
Assessment and documentation	Inconsistent risk assessment; lack of standardized tools; poor documentation	Mandatory use of validated tools (Columbia-Suicide Severity Rating Scale); structured documentation templates; automated risk scoring	Columbia-Suicide Severity Rating Scale validation in ED settings[44]; standardized assessment protocols[11]
Care coordination	Fragmented post-ED care; poor communication with outpatient providers; lost to follow-up	Warm hand-offs; shared EHR alerts; fixed appointment timelines (≤ 7 days); centralized follow-up systems	Integrated care pathways[49]; formal community partnerships[12]; systematic contact protocols[31]
Cultural and systemic	Stigma; organizational resistance; lack of leadership support; funding constraints	Implementation science frameworks (RE-AIM, CFIR); leadership engagement; quality improvement initiatives	Zero suicide framework implementation[36]; organizational readiness assessment[13]
Technology and access	Digital divide; privacy concerns; interoperability issues	Hybrid models (in-person + digital); app-based safety planning; telehealth follow-up	Digital DBT interventions[15]; SPI apps[23]; telehealth service models[40]

ED: Emergency department; SPI: Safety planning intervention; SAFE: Suicide assessment follow-up and engagement; SPCC: Suicide Prevention and Crisis Center; HER: Electronic health record; RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance; CFIR: Consolidated Framework for Implementation Research; DBT: Dialectical behavior therapy.

Table 3 Cost-effectiveness analysis of emergency department-based suicide prevention interventions

Intervention	Incremental cost per patient	Effectiveness (suicide attempts averted)	Cost per life-year saved	Population impact	Key studies
Universal screening + telephone intervention	$500 more than screening alone	10% reduction in attempts/deaths at 12 months	$4300 per life-year saved	Potential savings of $840M annually if 25% of attempts averted	ED-SAFE cost analysis[11]
Postcard/caring letters	Cost-saving compared to usual care	Significant reduction in repeat attempts	Dominant strategy (improves outcomes, reduces costs)	Low-cost, scalable population-level intervention	Modeling studies[60,61]
Safety planning intervention	$1063 per month per patient (telehealth model)	Reduced suicidal behavior and healthcare utilization	To be determined in ongoing trials	Potential for system-wide cost offsets through reduced acute care	SPCC trial protocol[40]
Cognitive behavioral therapy	$18800 per life-year saved	41%-54% reduction in repeat attempts	Cost-effective at WTP ≥ $50000 per life-year	Targeted approach for high-risk populations	Economic evaluation[26,27]
Brief contact interventions	Minimal incremental cost	24% reduced relapse risk with early appointment	Highly cost-effective	Can be integrated into existing follow-up systems	Observational studies[31]

ED: Emergency department; SAFE: Suicide assessment follow-up and engagement; SPCC: Suicide Prevention and Crisis Center; WTP: Willingness to pay.