Changing the channel on 13 Reasons Why

Everybody is talking about 13 Reasons Why — a new television series on Netflix — for the wrong reasons.  The series is adapted from the novel by Jay Asher.  The central character of the series is a teenager who commits suicide.  The girl leaves behind a tape addressed to a person in her life who she says contributed to her decision to end her life.  

The program has the community of mental health professionals beside themselves and for good reason.  It normalizes suicide — going so far as to treat it as a rational response to an appropriate set of circumstances.  it shifts the blame onto the people to whom the teen addresses the tapes.  In my view, the more people labeled as causing or contributing to a suicide, the less likely it is that any of them is in any way responsible.  

The series floats a notion as dubious as it is twisted: that there is something fair and just about a long list of people bearing a lifetime of guilt for one person's decision to end their lives.  

I intend to give the show a wide berth.  I'd rather talk about a new program in the U.S. that makes ERs better at helping patients prevent suicide attempts. Each year, close to 4,000 Canadians die by suicide. Twenty times that number makes the attempt.  Many end up in the ER. 

The intervention comes from a study called ED-SAFE – which stands for Emergency Department Safety Assessment and Follow-up Evaluation.  All patients who visited the ER were screened for suicide risk.  They targeted patients who had attempted suicide or who thought of suicide in the preceding week.  Patients identified as high risk got further assessment by the ER physician on duty.  Nurses in the ER gave patients information on suicide prevention, and encouraged them to complete a personal safety plan that they could put into action should they have suicidal thoughts again.  When patients left the ER, they received further counseling and case management by phone for a full year.  If agreed to, the patient's significant other could also participate in the intervention by phone.

The intervention had a significant impact.  The study, by researchers at Brown and Harvard Universities, recruited patients at eight emergency departments across seven states in the U.S. – everything from small community hospitals to university-affiliated centres in major cities. Nearly 1,400 high-risk patients entered the study.  Compared to treatment as usual, universal screening plus the intervention in person in the ER and on the phone afterwards resulted in a five per cent decrease in the number of patients who subsequently attempted suicide, and a 30 per cent decrease in the total number of suicide attempts.  This is the quite likely the largest suicide intervention study ever conducted in the U.S. 

The study is important because suicide is a growing public health problem in the U.S.  In a 16-year period ending in 2015, the rate of suicide in that country rose from 10.5 to 13.3 per 100,000.  The epidemic of opioid addiction plays a part in this.  Between 1999 and 2014, the U.S. National Center for Health Statistics reported that opioid-related suicides rose from two to four per cent.  Close to half a million people a year visit emergency departments south of the border for treatment following self-harm.  Studies show that a single visit to the ER for that reason increases the risk of suicide nearly six-fold.  As well, 40 per cent of those of who die visited an ER the year before.  You can see why an editorial also published in JAMA Psychiatry says it's important to intervene during the ER visit.

As with the U.S., ERs in Canada are dealing a growing number of patients with mental health crises.  A 2016 study in Ontario found that ER visits for patients with emotional illness age 10 to 24 rose by 33% in just five years.  On almost every shift I work, I see patients who attempt or contemplate suicide.  I see lots of patients who cut themselves, and a smaller number who have taken potentially lethal doses of acetaminophen, antidepressants and other medications.  

The biggest difference between the U.S. and Canada is that many ERs south of the border have no psychiatric services. My hospital provides 24-hour access to a psychiatrist. Colleagues who work in rural and remote parts of Canada would call that a luxury.  Even so, hospital-based psychiatrists provide emergency care during a crisis. Patients need a community psychiatrist to provide on-going care, but the chances of finding one taking patients is between slim and none.

I see the ED-SAFE approach helping in three tangible ways.  First, it focuses people like me on prevention.  Most of the time, we're preoccupied with treating the aftermath of a suicide attempt.  ED-SAFE allows us to use the suicide attempt as a golden opportunity to make a substantial difference in a patient's life.  Second, we don't like it when we don't know how to intervene, and we don't like seeing patients who remind us that we lack knowledge. ED-SAFE addresses both by providing emergency physicians and nurses with new skill at assessing people with suicidal thoughts.  Third, I think it takes the stigma out of assessing patients with emotional issues.  

For all of those reasons, I'm all for it.