Largest analysis of lethal means assessments outlines opportunities for suicide prevention and safety planning
Suicide is one of the leading causes of death in the United States. Lethal means safety, in which providers assess patients’ access to harmful means such as medications and firearms, has the potential to save lives as a critical component in suicide prevention. A new study published in Archives of Suicide Research provides important insights into individual-level uptake of lethal means assessment.
With funding from the UW Population Health Initiative, researchers from the University of Washington (UW) Department of Epidemiology, along with an interdisciplinary team of co-investigators,[1] analyzed 32,658 electronic health records (EHR) from patients who were seen within Psychiatric Emergency Services (PES) over a six-year period at a busy urban medical center in the Pacific Northwest. The research team assessed the frequency of documented lethal means assessments, and evaluated characteristics of patient visits, to help inform recommendations for lethal means safety implementation in clinical settings.
“To our knowledge, this investigation is fifteen times larger than previous comparable studies, and it also took place in a novel setting. Whereas most previous studies were conducted in general emergency departments and among patients at high risk of suicide only, we included all patients who were evaluated in the Psychiatric Emergency Services.” Anne Massey, MPH, a UW Epidemiology doctoral student who led this study as part of her master’s thesis in the Department.
Each of the 15,652 patients included in the study received a Suicide Risk Assessment (SRA). Using the SRA, clinicians assess suicidality, access to lethal means (including firearms and/or pills), and suicide risk factors. Individuals’ responses are recorded using a standardized template in the EHR. The research team developed an algorithm to analyze six data elements within these templates and determine access and availability of lethal means, as well as the level of documentation recorded during patient visits.
The study found that nearly 70% of visits had documentation of some lethal means assessment, wherein a response was recorded for at least one of the six data elements included in the algorithm. While these results are higher than previous observations, this finding indicates that even in a PES, frequency of lethal means assessment documentation was suboptimal. Additionally, the proportion of documentation did not vary significantly based on individuals’ suicide risk nor for most demographic factors. These results indicate that the issue of under-documentation was consistent across relevant patient subpopulations.
“The fact that we were able to identify a persistent pattern of under-documentation is consistent with what seems to be happening across the country in different types of clinical settings,” Massey explains. “Even in settings that have implemented best practices, like the use of a standardized template for Suicide Risk Assessment, we’re still seeing this pattern. Therefore, it seems that having structured template language alone is not enough to ensure comprehensive documentation.”
The study also identified opportunities to improve documentation frequency and detail. For example, adding or adapting SRA form fields could allow providers to gather more precise information regarding specific means available other than firearms or pills, and to indicate when information cannot be ascertained.
“Lethal means safety relies on creating time and distance between lethal means and a person at high risk of suicide,” said Dr. Ali Rowhani-Rahbar, associate professor of epidemiology and the study’s senior author. “This study highlights opportunities for improving the documentation of access to lethal means to aid in patients’ immediate safety planning and to provide data to optimize and scale suicide prevention strategies going forward.”
[1]Contributing authors of the study were Paul Borghesani, Associate Professor in UW Department of Psychiatry and Behavioral Sciences; Jennifer Stuber, Associate Professor, UW School of Social Work; Anna Ratzliff, Associate Professor, UW Department of Psychiatry and Behavioral Sciences; Frederick Rivara, Professor in UW Department of Pediatrics; and Ali Rowhani-Rahbar, the Bartley Dobb Professor for the Study and Prevention of Violence and Associate Professor in the UW Department of Epidemiology. This study was funded by the University of Washington’s Population Health Initiative.