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Approximately 500鈥�000 patients in the United States present to emergency departments (EDs) annually after deliberate self-harm¹ and are at high short-term risk for repeat self-harm² and suicide.³ Improving their emergency care is a key focus of national strategies to reduce the suicide rate,⁴ yet little is known about ED management of deliberate self-harm. We provide the first national estimates, to our knowledge, of how frequently evidence-based management practices are used by EDs when treating patients who present for self-harm.

Between May 2017 and January 2018, we mailed a survey about ED management of self-harm to a random sample of 665 ED nursing directors at hospitals that were selected from 2228 hospitals with 5 or more self-harm visits in the prior year identified within national Medicaid claims data. Respondents received $100, and the response rate was 77.1% (n鈥�=鈥�513). Using a 4-point Likert-type scale, the survey assessed the availability of key mental health services that were provided to ED patients after an episode of deliberate self-harm, which refers to nonfatal self-poisoning or self-injury with or without suicidal intent.³ Responses were dichotomized as: 鈥渙n a routine basis鈥� or 鈥渘ot on a routine basis鈥� (never or rarely, sometimes, or usually but not routine). Emergency departments were characterized according to their patient volume, teaching status, location, and staffing. Emergency departments with high mental health staffing were defined by having continuous availability of a mental health specialist or by having continuous availability of a social worker with mental health specialist at least part time. The University of Pennsylvania institutional review board approved the study. A waiver of written consent for the survey was provided given the study presented no more than minimal risk of harm to participants.

Means and frequencies were tabulated overall and stratified by hospital characteristics. t Tests and 蠂² tests were performed (P鈥�<鈥�.05, 2-tailed) using survey weights to accommodate the sampling design that selected hospitals with probability proportional to their volume of patients presenting with self-harm and to produce estimates of the 2228 hospitals (weighted N). To control for multiple comparisons, we used false discovery rate correction.⁵

Most EDs sampled were urban (1669 [75.4%]), nonteaching hospitals (1276 [57.6%]) and had high mental health staffing (1299 [58.3%]). Overall, EDs routinely provided a mean (SE) of 5.44 (0.14) of 10 specified self-harm management practices. Emergency departments most commonly assessed patients who present with self-harm for current suicidal intent/plans (2156 [97.6%]), past suicidal thoughts/behaviors (1989 [90.6%]), and access to lethal means (1708 [77.7%]) (Figure). Provision of individual safety planning elements ranged from 24.8% (n鈥�=鈥�492) to 79.2% (n鈥�=鈥�1710), with 2 of 6 elements being routinely provided more than 50% of the time: lists of professionals or agencies to contact in a crisis (1710 [79.2%]) and helping patients to recognize warning signs of suicide (1075 [52.2%]). Only 15.3% (n鈥�=鈥�342) routinely provided all recommended safety planning elements. There were no significant differences in emergency self-harm management practices by urban/rural status, mental health staff availability, or hospital volume. However, EDs associated with teaching hospitals were significantly more likely than EDs affiliated with nonteaching hospitals to provide professional contact lists (791 [86.5%] vs 909 [73.7%]; P鈥�=鈥�.004) (Table).

Most EDs in the United States routinely assess patients who present with deliberate self-harm for suicidal thoughts/behaviors and access to lethal means, but relatively few routinely act to provide basic aspects of safety planning, such as creating individualized plans to restrict access to lethal means, helping patients to use internal coping strategies, or accessing available social supports/activities. Emerging research indicates that safety planning in combination with structured telephone follow-up can significantly reduce suicidal behaviors after ED discharge compared with usual care.⁶ Because provision of these services in our study was largely independent of ED characteristics, there are widespread opportunities for improvement.

Study limitations include use of self-report rather than an audit, the possibility that our ED sample may not generalize to all US EDs, and an inability to know whether social workers have mental health specialty training or which professionals provide the services. The study also was not designed to assess the effect of severity of the self-harm incident or recognition of a mental disorder in the ED on self-harm management practices. Future research should evaluate whether specific aspects of emergency management of deliberate self-harm lower the risk of repeat self-harm and suicide.

Corresponding Author: Jeffrey A. Bridge, PhD, Center for Suicide Prevention and Research, The Research Institute at Nationwide Children鈥檚 Hospital, 700 Children鈥檚 Dr, Columbus, OH 43205 (jeff.bridge@nationwidechildrens.org).

Accepted for Publication: December 11, 2018.

Published Online: March 13, 2019. doi:10.1001/jamapsychiatry.2019.0063

Author Contributions: Dr Marcus had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Bridge, Olfson, Marcus.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Bridge, Diana, Marcus.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Bridge, Diana, Frankel, Marcus.

Obtained funding: Olfson, Marcus.

Administrative, technical, or material support: Cullen, Diana, Marcus.

Conflict of Interest Disclosures: Dr Caterino reports grants from National Institutes of Health during the conduct of the study. Dr Marcus reports personal fees from Allergan, Alkermes, Johnson & Johnson, Sage Therapeutics, and Sunovion outside the submitted work. No other disclosures were reported. No other disclosures were reported.

Funding/Support: This research was supported by the National Institute of Mental Health, National Institutes of Health (grant 5R01-MH107452 to Drs Marcus and Olfson).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.