Family-Based Crisis Intervention with Suicidal Adolescents in the Emergency Room: A Pilot Study

By Wharff, Elizabeth A.; Ginnis, Katherine M. et al. | Social Work, April 2012 | Go to article overview

Family-Based Crisis Intervention with Suicidal Adolescents in the Emergency Room: A Pilot Study


Wharff, Elizabeth A., Ginnis, Katherine M., Ross, Abigail M., Social Work


As the adolescent suicide rate has been increasing over the last several decades (Centers for Disease Control and Prevention, 1998, 2007a, 2007b, 2008; Office of Disease Prevention and Health Promotion, 2000), there has been a parallel increase (as high as 59 percent) in pediatric emergency room (ER) usage rates by adolescents in need of mental health evaluations in the United States (Breslow, Erickson, & Cavanaugh, 2000; Ellison, Hughes, & White, 1989; Hughes, 1993; Page, 2000; Sills & Bland, 2002; Stewart, Spicer, & Babl, 2006). Suicidality in adolescents has been the most significant factor in the majority of ER visits for behavioral health concerns (Stewart et al., 2006) and the most common presenting problem for adolescents subsequently admitted to an inpatient psychiatric unit (Brooker, Ricketts, Bennett, & Lemme, 2007).

Although the number of psychiatric ER visits has increased substantially (Bruffaerts, Sabbe, & Demyttenaere, 2004; Hughes, 1993; Larkin, Claassen, Emond, Pelletier, & Camargo, 2005), child mental health service availability has not kept pace, resulting in longer ER wait times and stays for patients (American College of Emergency Physicians, 2008), likely contributing to a phenomenon termed psychiatric "boarding" (Mansbach, Wharff, Austin, Ginnis, & Woods, 2003) that has gained notoriety in the popular press (Holmberg, 2007; Katz, 2006; Kowalczyk, 2007; Trafford, 2000). Boarding describes a patient who is in psychiatric crisis and requires inpatient hospitalization but for whom there is no available inpatient psychiatric bed (Mansbach et al., 2003). In a recent survey of ER medical directors, over 70 percent reported boarding psychiatric patients as a routine practice, with nearly 40 percent doing so a minimum of once a week (American College of Emergency Physicians, 2008).

In current practice, the standard of care in emergency psychiatry is evaluation and disposition with little or no treatment provided at the time of presentation (Bruffaerts, Sabbe, & Demyttenaere, 2008). Psychiatric ER protocol is a noteworthy deviation from triage practice in standard emergency care, in which the most acute patients are prioritized and receive the most rapid and intensive care. Historically, there has been little focus on psychiatric treatment within the emergency setting, often due to time pressures to move patients through the ER and the prevailing treatment philosophy that psychiatric treatment of suicidal patients requires admission to a locked inpatient facility.

A number of studies evaluating specialized interventions occurring within the context of the ER have yielded significant increases in after-care treatment compliance among psychiatric patients (Rotheram-Borus et al., 1996; Spooren, Van Heeringen, & Jannes, 1998) and reductions in depressive symptomology (Rotheram-Borus, Piacentini, Cantwell, Belin, & Song, 2000) and suicide attempts (Huey et al., 2004). None, however, have piloted or evaluated a single-session intervention that occurs exclusively within the ER.

Though limited data on the cost-effectiveness of alternatives to inpatient hospitalization are available (Lamb, 2009; Shepperd et al., 2009), community-based interventions like multisystemic therapy (MST) show promising results; specifically, in a randomized controlled trial of 116 adolescents meeting criteria for inpatient hospitalization receiving either home-based MST or inpatient hospitalization, higher levels of patient satisfaction, improvement in family functioning, and reductions in externalizing symptoms were reported in the MST group than in the group receiving inpatient hospitalization (Henggeler et al., 1999). Because the ER is frequently a critical point of contact for suicidal adolescents to receive access to services, we developed a family-based crisis intervention (FBCI) for use exclusively in the ER, with the explicit goal of decreasing acute symptoms and sending more suicidal adolescents home safely with their families. …

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