The purpose of this Funding Opportunity Announcement (FOA) is to solicit research to develop, optimize and test mental health telehealth methods to help evaluate and treat emergency department (ED) patients with suicide risk, compared to usual care of such patients in emergency departments without adequate on-site mental health specialty consultation. Primary research questions include whether the use of telehealth methods (i.e., without involving in-person interaction between a mental health clinician and the patient or ED staff) affects the proportion of ED patients who: (1) are considered at imminent risk for suicide, (2) are boarded in the ED due to suicide risk, and/or (3) are required to be hospitalized for suicide risk. Other questions address: whether use of telehealth methods affects the rate of within-encounter provision of evidence-based suicide prevention interventions; and whether use of telehealth methods affects the rates of suicide ideation, suicide attempts and deaths, as well as health care use and costs in the year after an “index” ED visit in which a patient was identified with suicide risk. To inform future implementation of telehealth enabled suicide prevention practices in the ED, this FOA encourages research on patient-, provider- and setting- level factors that may facilitate or impede telehealth provision and outcomes, as well as patient and provider views of telehealth provision of suicide prevention practices (feasibility and acceptability of clinical decision making; clinical workflows; ease of use of technology). NIMH intends to commit a total of $7 million in FY 2020, to fund up to 2 awards.
The continuing rise in rates of suicide deaths and nonlethal suicide attempts remain pressing public health challenges. Nearly half of suicide decedents visit emergency care in the year before death, and around one-fifth in the month before death. These rates are substantially higher than for the general population and help underscore the importance and potential value of improving identification and treatment of suicide risk in emergency departments (EDs). A growing body of evidence documents the feasibility and effectiveness of ED-based suicide prevention practices, including universal suicide risk screening; brief within-encounter interventions such as safety planning; and post-discharge interventions such as written caring contacts, telephone follow-up, and referral to indicated psychotherapy. Universal screening of ED patients for suicide risk can double the number of individuals identified as warranting treatment for suicide risk, versus usual ED practices. At-risk patients seen in VA EDs, who received the Safety Planning Intervention with follow-up telephone contact were half as likely to exhibit suicidal behavior and more than twice as likely to attend mental health treatment during the 6-month follow-up period, versus usual care. ED patients who screened positive for suicide risk were provided with further screening, a safety plan intervention, and a series of supportive phone calls upon discharge, which resulted in 30% fewer suicide attempts in the following year, versus usual care. ED-initiated follow-up of patients identified with suicide risk, via telephone or via written caring contacts, has also been found to be highly cost-effective and in some cases cost-saving. However, uptake of these practices remains insufficient, and none of them are a part of standard ED practice.
One key barrier consistently identified by the emergency medicine community to implementing universal suicide screening—which would increase the identification of known suicidal patients—is that many ED settings have limited access to mental health specialty consultation. Patients who screen positive should be further evaluated, be provided a brief safety intervention, and appropriate triage and discharge. Absent such access, many EDs report a default care path of hospitalizing individuals with suicide risk, due to a combination of limited clinical expertise and a related concern about potential legal liability. Yet the clinical benefits of such hospitalization are unclear, and the economic and logistical burdens–often including ED boarding until an appropriate hospital bed becomes available–are considerable. Moreover, some patients fear hospitalization as the default treatment, and it has been reported that fear of this limited treatment option deters patients’ reporting of suicidal ideation and/or help seeking altogether. As such, methods to provide mental health specialty consultation to EDs may benefit patients who are identified with suicide risk under current practice. Moreover, mental health specialty consultation could also enable EDs to expand suicide risk identification efforts and provide intervention options that are less restrictive.
Given widespread shortages of local mental health specialty clinicians, telehealth represents a promising way to increase access for EDs to mental health and suicide prevention consultation. Use of telehealth is expanding in many areas, including in EDs. For example, the Emergency Medicine Network conducted a 2017 survey of all (N=5,375) US EDs with 4,507 EDs responding to questions about their use of telehealth (https://doi.org/10.1177/1357633X18816112). Nearly half (48%) of responding EDs reported using telehealth, most commonly for stroke/neurology (77% of telehealth-using EDs, or 38% of responding EDs overall) The next most common use was “psychiatry” (38% of users, or 18% overall), but the study did not assess whether or how telehealth for psychiatry addressed suicide risk.
In this context, NIMH partnered with several other Institutes and agencies in a request for information on the use of telehealth consultation in the ED for suicide prevention (NOT-MH-19-030, Request for Information [RFI]: Guidance on Current Clinical Experience in the Use of Telemental Health for Suicide Prevention in Emergency Department Settings). Responses to the RFI indicated that, overall, there was general provider satisfaction with telehealth use for mental health issues, but less experience with suicide risk consultation. ED providers also saw the potential of telehealth benefits for suicide risk consultation, specifically with regard to reductions in patient boarding (keeping patients in the ED until an inpatient bed is available). These responses indicated that research should examine whether telehealth-enabled suicide prevention practices in the ED do indeed enable EDs to strengthen suicide risk identification and treatment, and improve patient outcomes.
Thus, the primary research questions for this initiative are to determine if ED access to telehealth mental health services affects the proportion of ED patients who: (1) are considered at imminent risk for suicide (2) are boarded in the ED due to suicide risk, and/or (3) are required to be hospitalized for suicide risk. Other questions address whether use of telehealth methods affects the rate of within-encounter provision of evidence-based suicide prevention interventions; and whether use of telehealth methods affects the rates of suicide ideation, suicide attempts and deaths, as well as health care use and costs in the year after an “index” ED visit in which a patient was identified with suicide risk. To inform future implementation of telehealth enabled suicide prevention practices in the ED, this FOA encourages attention to patient-, provider- and setting- level factors that may facilitate or impede telehealth provision and outcomes, as well as patient and provider views of telehealth provision of suicide prevention practices (feasibility and acceptability of clinical decision making; clinical workflows; ease of use of technology).
Filed Under: Funding Opportunities