The Hippo


Jul 21, 2019








Suicide Prevention Lifeline

If you or a loved one are experiencing thoughts of suicide, call the National Suicide Prevention Lifeline: 1-800-273-8255.

Unasked questions
How ERs help suicidal patients, and how they can do better

By Ryan Lessard

 Suicide is the No. 2 cause of death among young people ages 10 to 34 in New Hampshire, and the state’s emergency departments are one of the first lines of defense in finding help for those in crisis. Ken Norton, the executive director of the National Alliance on Mental Illness New Hampshire (NAMI-NH), said prevention efforts make a big difference, and it’s a myth that if someone wants to end his life there isn’t anything that can be done to stop it.

“The statistic that I like to focus on is that 90 percent of the people who attempt suicide don’t go on to die by suicide,” Norton said.
While the systems have improved in recent years, emergency department workers and advocates agree there’s room for improvement.
The process
In the past five years, the number of emergency department patients in Manchester who are receiving psychiatric evaluations has doubled and more people are getting directed to community services. But screening for mental health issues or suicidal thoughts for unrelated medical ER visits isn’t standard.
“There’s always a lot of opportunities for improvement, but [we’re] doing the best we can with the resources,” said Ann Berthiaume, a social worker who provides supportive counseling to ER patients at Catholic Medical Center in Manchester.
Berthiaume talks with patients to try to address some of their immediate concerns and hooks them up with the right community services.
“We may have a patient that’s coming in because they’re feeling very overwhelmed about their social situation and expressing some thoughts of wishing that they weren’t here anymore,” Berthiaume said. “And if we can address some of the immediate concerns they have, like ‘I don’t have insurance’ or ‘I can’t take my medications’ or ‘my other health-related issues,’ I can help to address those right away.”
The Mental Health Center of Greater Manchester partners with both CMC and Elliot Hospital in Manchester to do all the psychiatric evaluations in their respective emergency departments. When patients go to an ER and tell the staff they’re having thoughts of suicide, area hospitals say they have a procedure to follow.
A medical triage nurse asks about the reason for their visit and tries to get some additional details before seeing a physician, according to Dr. Joe Guarnaccia, the medical director of the Elliot emergency department. They check the patient’s vitals and do routine blood tests and urine tests for drugs and alcohol.
The physician will do a more focused exam to make sure the patient is cleared medically. Sometimes, he said, they can have an infection or an electrolyte imbalance that can cause symptoms similar to depression.
“When patients come through, we need to make sure not only are they medically stable but they don’t have any behavioral health issue that’s going to put them in harm’s way,” Guarnaccia said.
If patients are under the influence of drugs or alcohol when they come in, and they’ve expressed suicidal thoughts, they will be admitted to the hospital, according to both Berthiaume at CMC and Heidi St. Hilaire, the clinical nurse manager of Adult Behavioral Services at Elliot. A psychiatric evaluation will be done after the patient is no longer intoxicated.
“Sometimes people say things when they’re intoxicated and then they sober up and they’re no longer suicidal,” St. Hilaire said.
When a mental health issue is identified, counselors from Manchester Mental Health will come in and perform an assessment. Based on the risk factors they identify, they may refer the patient to anything from a next-day visit with a therapist at the Manchester Mental Health offices to voluntary or involuntary admission to a designated receiving facility such as the state mental hospital.
St. Hilaire said Elliot has a 14-bed psychiatric unit called Pathways, and a geriatric psychiatric unit. And Manchester Mental Health has its own designated receiving facility for acute inpatient care called the Cypress Center. Some hospitals have specialized psychiatric emergency departments. At Elliot, it’s called PEP (Psychiatric Evaluation Program), and St. Hilaire said they staffed it with behavioral health nurses about three years ago. 
Sheila Caron, spokesperson for St. Joseph Hospital in Nashua, said their emergency department has three rooms reserved for mental health patients awaiting inpatient care called the psychiatric holding area.
According to Norton of NAMI-NH, Concord Hospital has a section of its emergency department called Yellow Pod, which is staffed by mental health clinicians from Riverbend Community Mental Health. Norton said demand for Yellow Pod far exceeds its capacity.
“More people show up in the emergency room in Concord Hospital for mental health reasons than anywhere else in the state,” Norton said.
He said about 40 percent of those patients are not from Concord’s catchment area, which could be due to Concord’s centralized location, it’s proximity to New Hampshire Hospital, the fact that it has a specialized mental health unit and a dearth of psychiatric services in smaller community hospitals in the region and the North Country.
But what happens when someone comes to the ER for something else, like abdominal pains? Norton said it’s possible many of those folks, if they are also depressed or suicidal, will fall through the cracks.
Front lines
Norton said most people who consider suicide are actually ambivalent about dying, which means there’s an opportunity to prevent it. 
“A lot of times [potentially suicidal patients] don’t get asked questions about their mental health or they don’t get asked directly about suicide,” Norton said.
Primary care offices are starting to do this more in their regular screening process, according to Norton.
“Personally, this year, for the first time ever, my primary care provider, as part of the routine screening that I went through, asked me about my mental health or if I had thoughts of suicide,” Norton said.
This is part of a more recent push for mental health screenings and broader integration of mental health in primary care settings. The state Department of Health and Human Services is spending $150 million from a five-year federal grant to do just that across the state, Norton said.
But emergency rooms might not be screening for mental health as uniformly as other clinics now do.
Guarnaccia said the Elliot emergency department staff are trained to ask everyone a question related to domestic abuse, which he hopes may lead some patients to open up about thoughts of suicide.
“During the triage process, the emergency department triage nurse is asking them, ‘Do you feel safe at home?’ That triggers a cascade of questions for the nurse if they say they don’t feel safe,” Guarnaccia said.
CMC spokesperson Lauren Collins-Cline said suicidal thoughts and a history of suicide attempts are among the things providers screen for in the ER, but there isn’t a standard list of questions everybody gets asked.
Still, Norton thinks every staff member in emergency departments, from receptionists to triage nurses and beyond, needs to be trained to detect the more subtle signs of suicide ideation. Some patients may not express these thoughts to a triage nurse who is, in theory, better trained to pick up on those cues, but they’ll drop a hint later with a lab technician who might brush off a comment as a joke.
Broad strategy
In the grand scheme of things, the state has been doing better at recognizing people in crisis, according to Mark Bodwell, the coordinator for emergency services at Manchester Mental Health.
Over the past 25 years, he said, the state and country have made important steps in the right direction so that now more school staff and employers are able to pick up on the signs.
Norton said the first national strategy for suicide prevention came out around 2000 and was revised in 2012. The state came out with its own strategy in 2004, though he said it put very little funding toward prevention.
The New Hampshire suicide death rate grew from 11.5 per 100,000 population in 2006 to 16.9 in 2015, according to the state 2017-2020 suicide prevention plan released last year. The numbers peaked in 2014, with 18.6 per 100,000. The causes for the increase are difficult to pin down, but Norton said some drug overdoses are counted as suicides by the medical examiner. Kim Fallon at the ME’s office said about 10 percent of the overdoses in 2016 were counted as suicides.
Norton said it’s a real public health problem and there’s still a long ways to go toward fixing it.
Goal No. 1 in the state plan is to build awareness of this public health problem and the fact that it is preventable. 
The state plan builds on the directions laid out in the national plan, and it promotes a key component to the 2012 plan, which is called Zero Suicide. According to the Zero Suicide website, it’s a programmatic approach “based on the realization that suicidal individuals often fall through the cracks in a sometimes fragmented and distracted health care system.” So it takes a system-wide approach to prevention, rather than working on an individual, case-by-case basis.
Part of that is training medical staff. Norton said Exeter Hospital is hosting a Zero Suicide Academy on Nov. 29 and Nov. 30.
Ultimately, Norton said, everyone has a role to play in preventing suicide.
“Offering people hope is really key,” Norton said. 

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