Request for Information (RFI): Building an Evidence Base for Effective Psychiatric Inpatient Care and Alternative Services for Suicide Prevention

Notice Number: NOT-MH-15-019

Key Dates
Release Date:  May 8, 2015
Response Date: August 1, 2015

Related Announcements
None    

Issued by
National Institute of Mental Health (NIMH)
National Institute on Drug Abuse (NIDA)
Substance Abuse and Mental Health Services Administration (SAMHSA)
American Foundation for Suicide Prevention (AFSP)

Purpose

The National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the American Foundation for Suicide Prevention (AFSP) are seeking information on approaches to better understand 1) what components of inpatient care are safe and effective in reducing suicide risk for various populations; 2) what are effective alternatives to inpatient care (e.g., telephone counseling; home visits; intensive day/residential treatment; types of respite care) and how can they be broadly implemented; and 3) what type of research designs could compare inpatient interventions with alternative approaches in a safe, acceptable and fair manner.  While a number of interventions for suicide attempters have been effective and even replicated, the effectiveness of inpatient care interventions or alternative approaches in reducing later morbidity (e.g., suicide attempts) and mortality (e.g., suicide deaths) remains a question for many U.S. health care systems.  Testing the effectiveness of inpatient or alternative approaches is critical for suicidal patients, as few empirically-based practices exist for acute care interventions and their follow-up care.

This request for information (RFI) is intended to seek information about current practices and solicit perspectives on the need for empirical research from stakeholders who are associated with relevant systems of care (e.g., state commissioners, health care administrators; insurers; providers; patients; suicide attempt survivors; family members) and who play a role in the provision of interventions for individuals at acute risk for suicide, as well as researchers focused on such interventions and services research. Seeking this information is consistent with the 2012 National Strategy for Suicide Prevention’s (NSSP) Goal 8.2, Develop and implement protocols for delivering services of individuals with suicide risk in the most collaborative, responsive, and least restrictive settings.  It is aligned with the 2014 Prioritized Research Agenda for Suicide Prevention (Agenda), Key Questions 3 (optimal interventions) and 4 (optimal care services); and the NIMH Strategic Plan for Research Objective 3 (strive for prevention and cures) and Objective 4 (strengthen the public health impact of NIMH-supported research).  It is consistent with AFSP’s priority area addressing the high suicide risk period following discharge from an inpatient hospital. 

Background
In 2010, the National Mental Health Services Survey reported that on any given day, there were approximately 100,000 patients receiving inpatient mental health care.  Analyses of the 2008-2012 National Survey on Drug Use and Health found 29% of adults who attempted suicide in the past year (an estimated 1.3 million Americans) received at least one night of inpatient mental health care within the same year.  A recent report from the Agency for Healthcare Research and Quality (AHRQ), reviewing the 2006 to 2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample, found inpatient visits for suicide, suicidal ideation, and self-injury increased by 104% for children ages 1 to 17 years, and by 151% for children ages 10 to 14 years . 

Inpatient care, as one of the most resource intensive treatments for acutely suicidal individuals, has a very limited evidence base.  Current guidance for inpatient care is largely limited to the focus on risk reduction in these inpatient settings.  The Joint Commission has long emphasized how inpatient environment hazards, such as access to ligature points and poisons must be reduced.  AHRQ patient safety efforts encourage surveillance efforts that link health care system data to vital statistic surveillance to examine care patterns associated with risk, as well as intervention benefits. In a systematic effort to mitigate environmental hazards, the VA has developed an environmental checklist to improve safety on inpatient units.  SAMHSA’s TIP 45 recommends enhanced monitoring and environmental safety during inpatient detoxification for patients who may be suicidal, but few evidence-based practices for detoxification exist with regard to efficacy or cost/benefit for inpatient care.  In terms of inpatient therapeutic interventions, there are few published pharmacologic or psychotherapeutic studies that can provide an evidence base for practice. Two recent examples include intervention with the N-methyl-D-aspartate receptor antagonist ketamine for treatment resistant depression and suicide ideation, and Safety Planning added to usual care in a military psychiatric inpatient unit. 

In contrast, there is a growing evidence base that psychotherapy interventions offered to adult suicide attempters post ED or inpatient discharge are effective in preventing reattempts. What is not clear is whether these protective interventions are effective with all types of suicide attempters (e.g., patients with substance abuse or addiction), or at all stages of their care (i.e., more severe patients earlier in their treatment). SAMHSA’s Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (TIP 50) provides guidance for monitoring and management of suicidal ideation and behaviors for substance abuse treatment counselors across addiction treatment settings.  Examination of various substance abuse (SA) treatment programs suggest longer treatment may be needed for those with suicidal ideation or attempts, but more work is needed to understand how SA treatment is modified to address suicidal concerns. The longer term success of inpatient interventions are often dependent on the quality of such outpatient programs that individuals are referred to for less intensive care. A Suicide Prevention Resource Center review of research on suicide risk associated with the lack of continuity of care within and across systems, highlights many research needs around care transitions. 

Because of the resource intensive nature of inpatient care, (and because patients sometimes refuse to be admitted for inpatient care) health care systems have explored alternative care approaches (and their combinations), such as outpatient day/residential treatment, crisis hotlines, crisis response teams, and peer respite support. As a part of the SAMHSA Assessing the Evidence Base Series, a literature review of the effectiveness of substance abuse intensive outpatient programs concluded they are beneficial when medical detoxification is not required. If alternatives to inpatient care are being implemented for subgroups who do not need medical care yet are acutely suicidal, little is known about the evidence base for such services.  Moreover, it is not known how care decisions to use inpatient or alternative approaches are influenced by patient characteristics (e.g., those with different disorders [e.g., substance abuse; bipolar disorder; psychosis]; those who differ in terms of their estimated potential for lethality for harm to self or others; insurance status), and bed availability.  There is a need for empirical validation of which practices and care system structures lead to success in decreasing suicide attempts and deaths.
This request for information seeks to determine whether stakeholders who play a role in the reduction of acute suicide risk have recommendations for research that would provide empirical support for interventions/ approaches to acute care that reduce the morbidity and mortality of suicidal behavior. Examples of stakeholders include state mental health commissioners, health care administrators, insurers, providers, peer supports, patients, suicide attempt survivors, family members, and suicide prevention researchers, among others. 

Information Requested

Information is particularly sought on but not limited to the following 4 topics:

1) The lack of evidence supporting inpatient care for suicidal persons, including the goals of inpatient care, and patient status attained prior to discharge.  Examples could include:

  • Defining  health systems approaches to defining patient  eligibility for psychiatric inpatient care, outcome goals, and/or quality indicators of inpatient care for acutely suicidal patients. For example, detoxification, rapid reduction of suicidal thoughts and plans; keeping at risk patients safe while mitigating contextual dangers (homelessness; domestic violence/abuse contexts).
  • Care systems'  specific treatment approaches to decrease putative patient risk factors (e.g., cognitive biases, affective l ability, impulsivity), and environmental factors contributing to patient risk.
  • Strategies used to ensure continuity of care and bridge transitions to outpatient care.
  • Strategies used to prepare patients for post-discharge protection against suicidal behavior (e.g., safety planning).

2) The type of inpatient care, or alternatives to inpatient interventions that will provide benefits to individuals at acute risk for suicide.  Examples could include:

  • Approaches used to stratify risk and match to patient treatment needs, (e.g., algorithms derived from EHR data; detailed patient needs assessments),
  • Factors that might be examined as potential intervention moderators (e.g., patient age; prior suicidal history and experience with care systems; comorbid conditions [e.g., addiction, agitation, insomnia, etc.])

3) Experiences with alternative approaches to inpatient care for individuals at acute risk for suicidal behavior (e.g., telephone counseling; home visits; intensive day treatment; types of respite care). Examples could include:

  • Components of  alternative care that appear essential to their successes (e.g., provider training; peer training; crisis management; collaborative care; continuity of care) 
  • Challenges to implementing alternative care practices (e.g., reimbursement, liability, licensing, policy barriers)

4) Examples of research designs/infrastructure that could be used to examine the utility of specific components (or combinations of components) of inpatient interventions, as well as research designs that could be used to compare inpatient intervention approaches with less restrictive, alternative community-based approaches, in a safe and fair manner.  Examples could include suggestions for:

  • Research designs to test quality improvement approaches within systems
  • The type of system data that are needed to determine the effectiveness of inpatient care alternatives and/or sequential care
  • Study designs and particular analytic approaches (e.g., propensity scoring to equate illness severity) that could be used to compare approaches
  • Technology enhanced monitoring and support that could be used to maintain or enhance intervention gains over time
  • Research that considers the potential involuntary nature of some inpatient care provision, and best approaches to studying this care process.  Relatedly, describe what might be research design considerations that are relevant for examining psychiatric advance directives.

Submitting a Response

Responses to this RFI Notice are voluntary. Submitted information will not be considered confidential. Responses are welcome from associations and professional organizations as well as individual stakeholders. This request is for information and planning purposes and should not be construed as a solicitation or as an obligation of the Federal Government or NIMH. No awards will be made based on responses to this RFI. The information submitted will be analyzed and may be used for planning purposes. You will receive an electronic confirmation acknowledging receipt of your response, but will not receive individualized feedback on your submission. No proprietary, classified, confidential and/or sensitive information should be included in your response. The NIH and the government reserve the right to use any non-proprietary technical information in any future solicitation(s).

Responses will be accepted through August 1, 2015.  Electronic responses are preferred and may be addressed to RBSuicideResearch@nih.gov (Please include the Notice number NOT-MH-15-019 in the subject line).  Responses may also be sent by letter or fax to the following address:

NIMH Suicide Prevention
Division of Services and Intervention Research
6001 Executive Boulevard, Room 7133, MSC 9629
Rockville, MD  20852-9629
Fax:  (301) 443-4045

Inquiries

Please direct all inquiries to:

NIMH Suicide Prevention
Division of Services and Intervention Research
Email: RBSuicideResearch@nih.gov