Three previously studied suicide prevention strategies not only decrease risk for suicide in patients after they leave emergency departments (EDs), the interventions are also “highly” cost-effective, suggests new research from the National Institutes of Health.
Modeled analysis showed that follow-up telephone calls after an ED visit improved outcomes at a mean cost of $4300 per life-year saved compared with usual care, which consisted of receiving a list of mental health resources. Suicide-focused cognitive-behavioral therapy (CBT) improved outcomes at a mean cost of $18,800 per life-year saved.
On the basis of the common assumption that societal willingness to pay (WTP) is around $50,000 per additional life-year for a healthcare procedure, these two methods are considered to be effective.
In addition, sending out “caring communications” decreased costs compared with usual care.
“The surprising part wasn’t the positive findings, it was how robust the findings were,” corresponding author Michael Schoenbaum, PhD, a senior advisor, economist, and epidemiologist at the National Institute of Mental Health (NIMH), told Medscape Medical News.
Dr Michael Schoenbaum
Even after adjustments, “the value proposition for all three strategies is really strong,” said Dr Schoenbaum. He added that he was particularly struck by the finding that “caring letters saves lives and actually reduce costs. That’s the ‘holy grail’ in terms of healthcare.”
The findings were published online September 15 in Psychiatric Services.
Urgent Need
“In the face of a gradually rising suicide rate, the need for effective prevention strategies is urgent,” Joshua Gordon, MD, PhD, director of the NIMH, said in a press release.
“And if we want to improve outcomes nationally, one critical place where we need to do better is the hospital emergency department,” added Dr Schoenbaum.
According to the Centers for Disease Control and Prevention, more than 500,000 people are treated in EDs for self-harm injuries each year.
Although previous research has shown that several ED-based strategies to prevent future suicide attempts are effective, “none has been widely disseminated or adopted yet,” the NIMH noted in the release. So its researchers wanted to examine the cost-effectiveness of three methods.
Telephone outreach entails hospital staff calling patients identified as being at risk 1 to 3 months post discharge to offer support and encourage follow-up treatment.
The “postcards” were in fact caring letters sent via a variety of methods, including traditional mail, email, or text, noted Dr Schoenbaum. Four messages of encouragement were sent out monthly, after which four additional messages were sent out bimonthly.
With suicide-focused CBT, hospital staff steered at-risk patients toward suitable programs.
“In each of these interventions, the ED has responsibility for initiating follow-up engagement with the patient,” write the investigators.
They created a Markov state-transition model to evaluate cost-effectiveness, and they used Monte Carlo simulation (1000 repetitions) to evaluate possible consequences 1 year after a patient’s ED visit.
Better Outcomes, Cost-effective
“We found that all three interventions improved outcomes compared with usual care,” said Dr Schoenbaum.
The mean cost for usual care was almost $1962 per patient. The mean costs were .07% lower with postcards and .05% higher with telephone outreach. The mean cost for CBT was .25% higher than for usual care.
Table. Costs for Suicide-Prevention Strategies Studied
| Intervention | Treatment Cost ($ per Person) | Incremental Cost-effectiveness ($ per Life-Year) |
|---|---|---|
| Usual care | 1961.81 | ― |
| Postcards | 1960.45 | (Cost/life savings) |
| Telephone | 1962.86 | 4300 |
| CBT | 1966.77 | 18,800 |
At a WTP of $50,000 per life-year saved, “postcards and CBT improved outcomes…with certainty” compared with usual care, report the investigators. The probability of improved outcomes at this threshold was 99.5% for telephone outreach.
When the simulation lowered the WTP to $20,000 per life-year, there was a 96% probability that telephone outreach was cost-effective; there was an 80% probability when the amount was lowered to $10,000 per life-year.
The probability was 67% for CBT at a WTP of $20,000 per life-year, but only 1.6% at a WTP of $10,000 per life-year.
Interestingly, the probability of better outcomes with postcards over usual care was cost-effective even at a WTP of $0 per life-year.
“The highly favorable cost-effectiveness found for each outpatient intervention provides a strong basis for widespread implementation,” write the investigators.
“Importantly, the [findings] also make a strong case for expanding screening, which would allow us to reach more of those at risk,” added Dr Gordon.
Speaking for himself and not for his organization, Dr Schoenbaum noted that on the basis of this cost analysis, he would recommend that practice be changed.
“Caring communication for sure should be adopted as part of the standard of care, and I think one could make a really strong argument to justify widespread use of follow-up phone calls and this type of psychotherapy,” he said. “Any of these three would improve outcomes at an affordable price.”
“Key Tool” in National Conversations
Asked for comment, Christine Moutier, MD, chief medical officer at the American Foundation for Suicide Prevention (AFSP), said that the study provides important information.
Dr Christine Moutier
“It was a new way of doing this cost analysis, rather than just looking at effectiveness of an intervention,” Dr Moutier told Medscape Medical News.
She added that the results were “very much in line” with the work and vision of the AFSP. “We know that by scaling up effective interventions, lives can be saved that would have otherwise been lost to suicide.”
Dr Moutier noted that her organization has created Project 2025, which has conducted a similar type of analysis. “Through the project, we hope to reduce the national suicide rate by 20% by the year 2025.” One of the pathways to achieving that is through EDs.
“It’s not a question of whether these interventions work. It’s now more a question of willingness and overcoming inertia in the healthcare system to make changes that will implement these simple interventions across the board,” she said.
“Any change in a system across several states is a heavy lift in overcoming the status quo. But I think this [study] will be a key tool in conversations that are already ongoing at national, state, and local levels.”
The study was supported under professional services contracts with the National Institute for Mental Health. The study authors and Dr Moutier report no relevant financial relationships.
Psych Serv. Published online September 15, 2017. Abstract
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