Suicide Assessment and Prevention During and After Emergency Commitment
The purpose of this study was to address two primary issues within the context of emergency commitment: (a) the suicide-prevention measures implemented at receiving facilities where emergency commitments occur and (b) the perceptions of key stakeholders about access to community services post-discharge. One hundred seventy-eight respondents who worked in receiving facilities, where emergency commitments occur, responded to an online survey or were interviewed. Respondents indicated the use of suicide-prevention measures such as suicide assessment tools used at intake and discharge and strategies utilized to maintain client safety when the issue of suicidality had been determined at intake. Almost half of respondents (46.6%) described the availability of community mental health treatment at discharge from emergency commitment as being “less than adequate.” Emerging themes about community service availability are discussed and include long waiting periods and funding issues.
KeywordsMental health Community services Substance abuse Baker Act Suicide risk
Suicide is the eleventh leading cause of death across all ages in the United States, claiming 34,598 lives in 2007 (Centers for Disease Control and Prevention (CDC) 2010), such that suicide is a serious public health concern. People who have received inpatient psychiatric treatment are at an increased risk for suicide, especially during the initial weeks following hospital discharge, where people may feel a sudden loss of support, renewed exposure to the problems in their home environment, and remain vulnerable to the distress caused by their psychological and emotional symptoms (Appleby et al. 1999; Deisenhammer et al. 2007; Goldacre et al. 1993; Meehan et al. 2006).
A history of mental health treatment is related to increased risk of suicide (Harris and Barraclough 1997; Pirkis et al. 1999). Emergency commitment is one way that people access inpatient mental health assessment and treatment. All states have involuntary treatment laws, with the objective of assessing “likelihood of serious harm” (Feldman and Finguerra 2001, p. 27). Florida’s mental health statute, the “Baker Act,” is similar to other states in that it allows for emergency commitments if there is evidence of a) mental illness and b) harm to self, harm to others, and/or self neglect (F. S. 394 2010). Emergency commitments may be initiated by law enforcement, mental health professionals, or judges, may last up to 72 h and take place in one of 105 Florida Department of Children and Families designated Baker Act receiving facilities (see Christy et al. 2006 for additional details). From 2004 through 2006, 1,147 (16.09%) of the 7,128 people who died by suicide in Florida had experienced at least one emergency commitment in the 4 years before their death (Roggenbaum et al. 2008). Further, 169 of these people died by suicide within 30 days of an emergency commitment, with 81 dying <2 weeks after their emergency commitment (Roggenbaum et al. 2008). In sum, those subject to emergency commitment constitute a subset of people with inpatient treatment whose issues of suicide risk need to be addressed.
Given concerns about risk for people post-release from inpatient care, including emergency commitments, it is important to understand the process of risk assessment, especially for individuals identified as having suicidal behaviors or ideation (Bongar 2002; Sullivan and Bongar 2006). The importance of integrating psychological assessment tools within a comprehensive approach to identifying associated risk factors of suicidality has been demonstrated (Bongar 2002; Jacobs et al. 1999) and is an important issue to explore within the context of emergency commitment. Examples of assessment tools that may be included in comprehensive assessment are the Beck Depression Inventory (Beck et al. 1988), Suicide Ideation Survey (Reynolds 1988), and the Scale for Suicide Ideation (Beck et al. 1979). The period immediately post- discharge from a mental health facility, such as following an emergency commitment, is a period of vulnerability, with further engagement with mental health and substance abuse services critically important (Deisenhammer et al. 2007; Meehan et al. 2006), highlighting the need for a focus on risk assessment. The purpose of this study was to address these issues within the context of emergency commitment by (a) examining the suicide-prevention measures implemented at receiving facilities where emergency commitments occur and (b) investigating the perceptions of key stakeholders about access to community supports and services post-discharge from receiving facilities.
The research team developed a questionnaire with the aid of two senior level mental health professionals associated with different Baker Act receiving facilities. The survey questions covered areas such as employment status, demographics, general procedural issues related to suicide, suicidality assessment tools used by receiving facilities, opinions about treatment availability in the community during the period immediately following discharge from a receiving facility, and educational opportunities related to suicide and suicide prevention for employees and the public. The survey included both closed and open-ended questions. This study was approved by the University of South Florida’s Institutional Review Board (IRB).
The questionnaire was developed for use as an online survey and for on-site face-to-face interviews. A waiver of documentation of informed consent was obtained for the online survey, with signed consent obtained for the interviews. Participants were informed of the voluntary nature of their participation and the confidentiality of their responses. The online survey invitation was sent to mental health professionals identified through previous attendance at trainings related to Florida’s involuntary commitment law and/or who had information in a database of Baker Act receiving facility staff maintained by the Baker Act Reporting Center, which has received statewide emergency commitment data since 1998. Invitations to participate with a link to the online survey were sent to 480 e-mail addresses, with people encouraged to forward the e-mail to other professionals they knew who worked at Baker Act receiving facilities. The design and implementation procedures for the online survey were guided by a modified version of the Dillman (2007) tailored-design method, and included three waves of contacts through e-mail over a 5-week period. In addition, the study team conducted face-to-face interviews with mental health professionals at four Baker Act receiving facilities to elicit more in-depth responses to the survey questions. The four facilities were selected to represent Florida’s east coast, central peninsula, southwest, and panhandle geographic areas. A total of 178 individuals participated in the study (156 online respondents and 22 interviewees).
The study team analyzed quantitative and descriptive data from the surveys. Quantiative descriptive analyses were conducted in Microsoft Access. The team also conducted a qualitative analysis of the responses for key words, phrases, and concepts using QSR NVivo (2010). Several themes emerged from the content of responses to survey questions.
The vast majority of respondents (91.0%) were employed full time at a Baker Act receiving facility in the following positions: psychiatric nurses (30.8%), licensed mental health counselors (17.9%), and licensed clinical social workers (17.9%). Over one quarter of respondents (28.6%) identified themselves as other mental health professionals, and “other” responses included; intake specialists, care coordinators, and Baker Act coordinators. All respondents had been employed at their current place of employment for at least 1 year, with 29.1% having worked at the same facility for 6–10 years, and 15.5% of respondents continuously employed at the same facility for over 20 years.
Use of Suicide Assessment Tools at Intake
Respondents were asked to select suicide assessment tool(s) used at intake and discharge from a list, with an “other” option also included. There were 117 (65.73%) respondents who indicated the use of one or more assessments at intake and 75 (42.12%) who indicated the use of one or more assessments at discharge. The Beck Depression Inventory (BDI/BDI-II) was the most commonly used assessment at intake (25.0%) and discharge (10.1%). Also used were the Suicide Ideation Survey (SIQ: intake 12.4%; discharge 7.8%), the Adult Suicide Ideation Survey (ASIQ: intake 8.4%; discharge: 4.0%), the Scale for Suicide Ideation (SSI: intake 7.3%; discharge 6.2%), Suicide Intent Scale (SIS: intake 7.3%; discharge 5.0%), Beck Hopeless Scale (BHS: intake 3.4%; discharge 0.6%), and the Linehan Reasons for Living Inventory (LRFL: intake 1.1%; discharge 0.6%). Sites also used their own facility-generated assessment (intake 8.9%; discharge 6.2%), or indicated using an assessment but did not name the assessment (intake 7.8%; discharge 4.0%). A variety of “other” assessments were used at intake (15.7%) and discharge (5.0%). These included the Question, Persuade, Respond (Refer) or QPR, Pierce Suicide Intent Scale; Family Risk Assessment; Health Suicide Assessment Scale; CAGE Questionnaire; Geriatric Depression Scale; Zung Depression Scale and Buspar Anxiety Scale.
Respondents provided information about a number of important strategies and procedures utilized to maintain client safety when the issue of suicidality had been determined for people at intake for emergency commitments. The majority of staff (79%) indicated that there were baseline and 15-min checks on each client, at which time the client had to be in the sight of a staff member. In addition to the baseline checks, respondents pointed out that the facilities were locked, as is required of all Baker Act receiving facilities. Staff members also reported that no “sharps” were allowed in facilities and that environmental safety assessment and personal searches were conducted to confiscate items such as strings, shoelaces, and belts from the unit or prior to unit admission. Because some clients required an “extra eye,” some facility policies put people on “open seclusion,” where the client was required to be within sight at all times.
Including family members in a client’s discharge planning was seen as critical by some respondents, who noted that family members should be included in a dialogue about stressors that may exist for a client at home, including his/her access to weapons. Staff members saw the home and family as a potential site for both danger and support for the client. One facility mandated that some form of a support system be utilized in the discharge of a client. Several respondents mentioned turning to family members for information regarding weapons, particularly guns, in the client’s home, and took the family members’ assessment of the home environment into consideration when planning for discharge.
Availability of Community Resources
Respondents were asked to choose the phrase corresponding to a five-point scale that best described the availability of both mental health and substance abuse community treatment services for consumers being discharged or referred by their facility (Excellent, Good, Adequate, Less than Adequate, Not Adequate). Almost half of the respondents (46.6%) described the availability of community mental health treatment at discharge as being “less than adequate” (n = 63; 35.4%) or “not adequate,” (n = 20; 11.2%), while 25.8% (n = 46) described it as “adequate.” One quarter of these respondents (24.7%) rated the availabilityof community mental health services as “excellent” (n = 14; 7.9%) or “good” (n = 31; 17.4%). Availability ofsubstance abuse services at discharge was described by the majority of respondents (65.2%) as “less than adequate” (n = 87; 48.9%) or “not adequate,” (n = 29; 16.3%), while the remainder of respondents described the availability as “adequate” (n = 36; 20.2%), “good” (n = 18; 10.1%), or “excellent” (n = 5; 2.8%).
Two additional themes emerged from the qualitative analysis of the responses about community service availability: long waiting periods and funding issues. Notably, respondents reported long waiting periods for follow-up appointments once a client was discharged into the community. While several respondents noted that mental health facilities and services existed in their respective communities, many indicated that long waits hindered clients’ follow-up care. One respondent highlighted particular concern for individuals who had drug and alcohol addiction issues and who were in need of detoxification services. Individuals who were discharged and waiting for detoxification services may relapse or change their mind about pursuing treatment.
Respondents reported a lack of available funding, whether systemic or client level, for community mental health and substance abuse treatment as an issue. Some respondents reported that while community mental health services may be available, access could be challenging. Seven respondents pointed out how the presence of a co-occurring disorder posed an additional barrier to services, such as because of the lack of coordination of services across providers. Respondents also noted how lack of funds hindered their clients’ ability to make appointments to get medication prescriptions and their ability to refill the medications. Related to the availability of substance abuse services at discharge, respondents emphasized the limitations of insurance coverage for substance abuse services. Additionally, several respondents indicated the availability of follow-up substance abuse treatment appointments and inpatient substance abuse treatment was dependent on an individual’s insurance status.
Suicide continues to be a public health concern, with over 2,500 deaths by suicide in Florida in 2007, with an increase in suicide deaths nationally from 2006 to 2007 (from 33,300 to 34,598) (CDC 2010). This study has described staff perceptions for those working in facilities where emergency commitments take place about how issues related to assessment and management of suicide risk are handled during and after emergency commitment, as well as the use of screening tools.
The process of risk assessment within both inpatient and outpatient settings is an important aspect of any treatment regimen, especially for individuals identified as having suicidal behaviors or ideation (Bongar 2002; Sullivan and Bongar 2006). Assessment tools (e.g., Beck Depression Scale, Beck Hopelessness Scale, Scale for Suicide Ideation, Suicide Intent Scale, the Thematic Apperception Test) have commonly been used by clinicians to assess risk of suicide (Sullivan and Bongar 2006). Though assessment instruments are a valuable resource in helping to identify potential risk factors, face-to-face clinician interview should be at the core of any comprehensive assessment protocol (Bryan and Rudd 2006), while data collected via the use of actuarial instruments should also be integrated into the assessment process. Sullivan and Bongar (2006) recommend taking a comprehensive approach to risk assessment that includes the use of routine psychological testing, the utilization of reliable and valid suicide risk assessment measures, comprehensive psychodiagnostic evaluation, a complete psychobiosocial history, and documentation of suicide risk assessment, in conjunction with an ongoing assessment of suicide that overlays the entire process of treatment. The information from this study helps inform risk assessments and safety measures implemented with individuals in emergency assessment facilities.
The process of risk assessment is an important aspect of any treatment regimen, especially for individuals identified as having suicidal behaviors or ideation. Respondents reported routine assessments especially just prior to discharge, although the use of assessment tools/standardized assessments was not known by over half (57.9%) with the reported use of such assessments at intake and discharge being quite low. Because the period immediately post-discharge from a mental health facility is a period of vulnerability, further engagement with mental health and/or substance abuse services if appropriate (Caplan 2001), is critical (Deisenhammer et al. 2007; Meehan et al. 2006). As such, scheduling follow-up mental health care appointments is essential. However, respondents reported that long waiting periods and funding were a challenge in obtaining follow-up treatment (Roggenbaum et al. 2008). Roggenbaum et al. (2008) found that during a 3-year period 169 Floridians died by suicide within 1 month of an emergency commitment. Together, these findings indicate a need for community services to be available immediately following discharge after an emergency commitment. This population is not only the most vulnerable (Deisenhammer et al. 2007), but these deaths are also often preventable with immediate and effective continuity of care (Burgess et al. 2000).
This study was subject to some limitations. With a response rate of about 33% for the online survey, it is possible that our respondents differed in their experiences and perspectives of mental health and substance abuse services than did those who did not choose to respond. Additionally, our surveys and interviews were conducted within Florida Baker Act receiving facilitates, which may differ from facilities in other regions of the country, limiting the generalizability of our study. Respondents may have answered questions as they relate to all clients in their crisis units, including those who seek treatment on a voluntary basis, although the risk assessment and post-discharge planning and service access issues are similar for those who seek voluntary care versus those who are committed, these issues may differ and this study did not allow us to discern those differences. Data were of reported use of assessments, which may not the be a completely accurate account of actual assessment use.
Examples of community-level actions that could lead to improvement in access to needed services include: conducting an inventory of available services and wait lists, facilitating needs assessments and data gathering, strategic planning, visioning, intra-agency memorandum of agreements, and informal collaborations. Funding for new services or even expansion of existing services is often not an option. Therefore creative strategies such as creation of a warm line (Pudlinski 2001) or follow-up phone calls to stay in touch with individuals and monitor for further crises until they can get more formal services may help provide bridges during waiting periods for available services, and most importantly, possibly prevent a tragic death by suicide.
Suicide continues to be a critical issue in Florida and throughout the nation. The identification of issues related to access and utilization of mental health and substance abuse services may contribute to our understanding of the provider and system level reforms that are needed to reduce and prevent suicides.
Funding for this research was provided by Florida’s Agency for Health Care Administration under Contract MED078, PI Roger Boothroyd, Ph.D. The authors greatly appreciate comments from our reviewers, Drs. Mary Armstrong and Norín Dollard and the contribution from Mark McCranie, M.A. our Research Specialist.
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