Mobile crisis team intervention to enhance linkage of discharged suicidal emergency department patients to outpatient psychiatric services: a randomized controlled trial.
OBJECTIVE
Many suicidal patients treated and released from emergency departments (ED) fail to follow through with subsequent outpatient psychiatric appointments, often presenting back for repeat ED services. Thus, the authors sought to determine whether a mobile crisis team (MCT) intervention would be more effective than standard referral to a hospital-based clinic as a means of establishing near-term clinical contact after ED discharge. This objective was based on the premise that increased attendance at the first outpatient mental health appointment would initiate an ongoing treatment course, with subsequent differential improvements in psychiatric symptoms and functioning for patients successfully linked to care.


METHODS
In a rater-blinded, randomized controlled trial, 120 participants who were evaluated for suicidal thoughts, plans, or behaviors, and who were subsequently discharged from an urban ED, were randomized to follow-up either in the community via a MCT or at an outpatient mental health clinic (OPC). Both MCTs and OPCs offered the same structured array of clinical services and referral options.


RESULTS
Successful first clinical contact after ED discharge (here described as "linkage" to care) occurred in 39 of 56 (69.6%) participants randomized to the MCT versus 19 of 64 (29.6%) to the OPC (relative risk = 2.35, 95% CI = 1.55-3.56, p < 0.001). However, we detected no significant differences between groups using intention-to-treat analyses in symptom or functional outcome measures, at either 2 weeks or 3 months after enrollment. We also found no significant differences in outcomes between participants who did attend their first prescribed appointment via MCT or OPC versus those who did not. However divided (MCT vs. OPC, present at first appointment vs. no show), groups showed significant improvements but maintained clinically significant levels of dysfunction and continued to rely on ED services at a similar rate in the 6 months after study enrollment.


CONCLUSIONS
Community-based mobile outreach was a highly effective method of contacting suicidal patients who were discharged from the ED. However, establishing initial postdischarge contact in the community versus the clinic did not prove more effective at enhancing symptomatic or functional outcomes, nor did successful linkage with outpatient psychiatric care. Overall, participants showed some improvement shortly after ED discharge regardless of outpatient clinical contact, but nonetheless remained significantly symptomatic and at risk for repeated ED presentations.
Currier
Glenn W
GW
Center for Public Health and Population Interventions for Preventing Suicide, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA. glenn_currier@urmc.rochester.edu
Fisher
Susan G
SG
Caine
Eric D
ED
D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D003156:Community Mental Health Services / Q000379:methods* / Q000706:statistics & numerical data; D003419:Crisis Intervention / Q000379:methods* / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital; D004637:Emergency Services, Psychiatric / Q000379:methods*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000628:therapy*; D008875:Middle Aged; D008952:Mobile Health Units; D011567:Psychiatric Department, Hospital; D011569:Psychiatric Status Rating Scales; D013405:Suicide / Q000523:psychology; D016896:Treatment Outcome; D055815:Young Adult; D000092864:Suicide Prevention