Every day, suicidal individuals are sent home from the emergency room with little to no follow up. I believe this to be one of the greatest threats to effective suicide prevention.
Today is World Suicide Prevention Day. I feel the need to add to this important conversation, not only because of my personal relationship with suicide but also because suicide often fails to be recognized for the serious health issue it is. The World Health Organization estimates that about 800,000 people worldwide die by suicide every year. In Canada every day 10 people die by suicide and 200 attempt suicide. In Ontario alone 1327 people died by suicide in 2014. In short, we need to talk about suicide prevention.
Discussions about suicide prevention are not complete without looking at necessary improvements to our hospital mental health systems. While hospitals, doctors and other mental health professionals work tirelessly to support their at-risk patients, there remain major flaws in the availability, accessibility and adequacy of services provided. Not the least of these problems occurs when suicidal patients are denied care in hospital emergency departments.
Imagine for a moment that you feel there is no reason to live. You feel that you can’t stand to go on any longer and have made plans of how to kill yourself. Imagine you reluctantly make it to the hospital, perhaps of your own will or perhaps at the urging of someone who cares. With one last shred of hope, you think maybe the hospital will help you, and what do you have to lose? You wait for hours, growing more jaded as time goes on. After sitting in the hospital all night in high emotional distress receiving only cursory information from busy ER nurses, you finally see a doctor. You describe to them that you plan to kill yourself, you explain your plans, describe your hopelessness and pain. Imagine that doctor, after only spending a few minutes with you, sending you home without offering help. Imagine feeling even more worthless and hopeless, because even the system that is in place to save lives turns you away. Imagine feeling as though doctors are telling you that you are not worthy of being saved. You return home, emotions heightened, even more certain than before that your life has no value.
This happens every day. Every day people who have decided to end it all are turned away from the very systems there to protect them. While my experiences with the ER have often been positive, this has happened to me. It is one of the worst feelings imaginable, to be at the end of your rope and have your attempt to access care rejected. Few things have made me feel less worthy of living than being sent home from the emergency room when I am a threat to myself. To add insult to injury there is often no follow up even when follow up is promised. While this is certainly not the intention of the hardworking emergency department medical staff, the message I internalize from these events is loud and clear, “Your life is not important and you do not deserve to be saved.” When in the depths of a suicidal episode even the act of being assessed by a doctor for my risk of suicide feels stigmatizing. Being asked questions with the obvious motive of trying to uncover whether I am “suicidal enough” is humiliating. Shouldn’t it be enough that we are asking for help?
Suicidal patients like myself and our caregivers have been placed in the position of having to advocate for our need for care during crisis. As a suicidal person, it isn’t easy when you do not believe you should live to present yourself to the hospital and advocate for care to keep you alive. In fact, it’s one of the hardest things I have ever done. Caregivers too are placed in difficult positions, often having to advocate for care they feel is desperately needed, sometimes against the wishes of their loved one. My husband has had to advocate me, and I know it hasn’t been easy for him to simultaneously convince me to accept treatment and convince doctors of my need for treatment. I am forever grateful that he has endured that stress, it has saved my life. These self-advocacy measures should not be necessary. We shouldn’t have to convince doctors of our honesty, our intent and our need for treatment, out of fear of being sent home with no answers.
I believe the result of these interactions with hospital emergency departments can foster a distrust of mental health systems. It is dangerous, I believe, to contribute to a person’s feeling that their suicidal ideation, plans and actions will not be taken seriously. I know many people, myself included, who have at one time or another refused to go to the hospital due to the belief that they will not receive care and their time there will only make things worse. Surely, contributing to that belief is not what hospitals should be doing for suicidal individuals. Emergency departments have a key role in suicide prevention and sadly they are not always up to the task.
Why I Think This Happens
There are, of course, many reasons why doctors might choose not to admit a suicidal patient to the hospital. A hospital admission isn’t always in the best interest of the patient. For one, there is a broad range of what qualifies as “suicidal” and not everyone who has thoughts of suicide is an immediate risk to their own safety. According to The Suicide Risk Assessment Guide by the Ontario Hospital Association (pg. 25), doctors in emergency settings should assess the risk of suicide by determining the patient’s actual level of intent to die by suicide and evaluating whether the patient is telling the truth about wanting/not wanting to die by suicide. Based on the assessment of risk of suicide, doctors determine the level of care needed and should, ideally, help connect the patient to the appropriate level of care. In Ontario we have a shortage of psychiatrists, hospitals are frequently operating over capacity, wait times for mental health services are long. I imagine that those constraints add an additional level of difficulty in pairing suicidal patients with the treatments they require. However, sending suicidal patients home without follow up care or even a safety plan is irresponsible.
Solving this issue isn’t straight forward. This is not about a few stigmatizing doctors who believe their suicidal patients are just attention-seeking (though that is sometimes the case). Often, the capacity to offer timely help to every person who needs it is simply not there. In many places, hospitals don’t have enough rooms or enough beds or enough staff or enough funding to offer immediate support to every suicidal person who comes looking for it. In an ideal world, everyone who has plans to end their life would have a place in the hospital until they are truly safe to go home. Fixing this problem isn’t as simple as admitting every patient who may be at risk to the hospital. As it stands, at least here in Ontario, that just isn’t possible.
There are ways that I believe the emergency departments can contribute to suicide prevention. Information about free community services with low wait lists should be shared. Peer support groups, for example, can be helpful in suicide prevention and often do not have waitlists. Helping the patient create a safety plan can also be beneficial. Follow up from the hospital (calls or appointments) is another way to not only check that patients are okay, but also to reassure patients that they are a priority and have not been forgotten. Doctors should make sure the patient has a mental health professional or family doctor they can follow up with soon. You would think that all of these practices would already be used consistently, but that is not the truth of my experience or the experience of many of the people I have interacted with. The result of a hospital visit due to a suicide attempt or suicidal plans should never be nothing. No suicidal patient wants to feel that they are met with apathy at the hospital. We are failing to prevent suicides by letting suicidal individuals slip through the cracks. When all else fails, compassion from the emergency department medical team can save a life. I should know, it has saved mine.
My own personal experiences with visiting the emergency department when I am suicidal have varied. At times, I am treated with compassion and a level of concern appropriate to the severity of my condition. At other times, I have been sent home without any help, care or follow up. At the worst, I have felt stigmatized and humiliated by the words and actions doctors. My experience is not unique. There are many people who are turned away from the hospital when they truly need help. If you need any evidence of that, I suggest you start looking at the mental health community on Twitter. I see stories every day of people turned away from the emergency room without help, even when they have no other supports in place.
With all that said, I am deeply grateful to the doctors, nurses and administrators at hospital emergency departments who have helped me in the past. I have had some very positive outcomes from ER visits.
Suicide prevention is something I can’t help but care about deeply. Once you have been suicidal, you understand how big the discrepancy is between the need for effective emergency care to help suicidal individuals and what is actually available. We are told to report to our nearest hospital emergency room when we are in crisis, we should be able to expect to receive real help when we do.