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The study
Stanley et al. (2018) asked whether the Safety Planning Intervention (SPI), given in emergency departments with telephone follow-up, was associated with less suicidal behavior and better engagement in outpatient treatment in the 6 months after discharge, a known high-risk period.
Design
The study used a cohort comparison design at nine Veterans Health Administration emergency departments: five intervention sites and four control sites. Adults with a suicide-related visit who did not need inpatient admission were included. At intervention sites, patients received the SPI, a brief intervention combining strategies into a prioritized list of coping skills and supports, and at least two follow-up phone calls to monitor risk, review the safety plan and support treatment engagement. Control sites provided usual care. Outcomes were taken from medical records for 6 months.
Results
Of 1,640 patients, 1,186 were in the intervention group and 454 in the comparison group. Suicidal behavior occurred in 3.03% of intervention patients and 5.29% of comparison patients, which the authors described as 45% fewer suicidal behaviors (odds ratio 0.56; 95% CI 0.33–0.95). Intervention patients had more than double the odds of attending at least one outpatient mental health visit (odds ratio 2.06).
Strengths
- A real-world setting at multiple emergency departments, which supports applicability to busy clinical practice.
- An intervention that is brief and clearly described, so it could be reproduced.
- A clinically important outcome during a well-known period of high risk.
- Objective outcome data from medical records rather than self-report alone.
Threats to validity
Because patients were not randomized, the groups may have differed in ways that affected outcomes. Shadish et al. (2002) describe selection as the main threat to internal validity in nonrandomized comparisons.
| Threat | How it applies |
|---|---|
| Selection | Intervention and control sites were different hospitals, with different patients, staff and local services |
| History | Other changes at the intervention sites during the study, such as new outpatient programs, could explain the results |
| Detection | Suicidal behavior was taken from medical records, so behavior that didn't lead to contact with VA care may have been missed, possibly differently at each site |
| Imprecision | The confidence interval for the main outcome is wide (0.33–0.95), with an upper limit close to no effect |
The authors adjusted for some differences, but unmeasured confounding can't be ruled out.
External validity. About 88% of participants were men and all were veterans, so results may not apply equally to women, civilians or adolescents.
Level of evidence
As a nonrandomized cohort comparison, the study sits below randomized trials in the evidence hierarchy. Its findings are promising, consistent with the theory behind safety planning, and the intervention carries little risk.
Implications for advanced practice
The evidence supports offering safety planning with follow-up contact to suicidal patients discharged from emergency settings, while recognizing that a randomized trial would give stronger evidence. An advanced practice nurse could introduce it with a standard template, staff training and a follow-up call schedule, and evaluate outcomes locally.
References
Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental designs for generalized causal inference. Houghton Mifflin.
Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. https://doi.org/10.1001/jamapsychiatry.2018.1776
