Safety Planning Intervention Linked to Reduced Suicidal Behavior, Improved Treatment Engagement

Barbara H. Stanley, PhD

According to the findings of a large-scale cohort comparison study, the use of Safety Planning Intervention (SPI) with suicidal patients after discharge from the emergency department (ED) was associated with not only a reduction in suicidal behavior but increased treatment engagement.

The SPI, defined by the authors as “a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies,” which is utilized widely, including with the Veterans Health Administration.

In a comparison with usual care in a total of 1640 patients treated in the EDs at 9 sites, the intervention group included 1186 patients with a mean age of 47.15 (standard deviation [SD], 14.89), while the comparator group included the remaining 454, with a mean age of 49.38 (SD, 14.47). In total, men made up 88.5% (n = 1050) and 88.1% (n = 400) of the intervention and comparator groups, respectively.

Led by Barbara H. Stanley, PhD, a professor of medical psychology at Columbia University Medical Center, the study investigators examined the suicidal behaviors of the 2 groups, with the intervention group receiving the SPI, plus a follow-up component that consists of telephone calls from project staff within 72 hours of discharge. Additional weekly follow-up was continued after, consisting of ≥2 calls. For the usual care group, the patients were given the option of a referral to psychiatric care at discharge.

“What we do not want clinicians to do is to just give patients a piece of paper and say, ‘fill this out,’” Stanley said in a podcast interview on the JAMA network. “They actually have to take a little bit of time and explain to the patient the nature of a suicidal crisis. That these suicidal feelings do not stay with you forever. The urge to act on them subsides over time.”

“The safety plan gives them something to do other than to just white-knuckle it and tough it out,” she added.

The results showed that patients in the SPI group were less likely to engage in suicidal behavior. Only 3.03% (n = 36) of the SPI group reported suicidal behaviors, compared to 5.29% (n = 24) of those receiving usual care during the 6-month follow-up period. In total, use of the SPI was associated with 45% fewer suicidal behaviors—roughly halving the odds of suicidal behavior over 6 months (odds ratio [OR], 0.56; 95% CI, 0.33 to 0.95; P = .03). Patients in the intervention group were also twice as likely to attend ≥1 outpatient mental health visit (OR, 2.06; 95% CI, 1.57 to 2.71; P <.001).

Previously, up to a decade ago, these situations were met with No-Suicide Contracts, in which patients would promise not to kill themselves, signed by both the patient and the clinician. In a 2017 study led by Craig Bryan, PsyD, an intervention similar to SPI—Crisis Response Planning&mdash;was shown to be much more effective in reducing suicide attempts.

“If you think about what a contract is, it’s a document in which 2 parties have skin in the game. Both give, and both get,” Stanley said in the interview. “But with a No-Suicide Contract, the only person that is giving, in a certain sense, is the patient. The clinician isn’t giving anything, and so it’s not a genuine contract. If you talk with patients about this, they will say, ‘Well, I think it helps the institution, or it helps the clinician, feel better, but it doesn’t really help me.’”

The study, “Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department,” was published in JAMA Psychiatry.