intervention for those at imminent risk for the expression of suicidal behaviors … and in referring their patients for expert assessment and treatment” (PHS, 2001).

Barriers in Emergency Care

Suicidal patients are frequently encountered in the emergency department (ED). These patients present for care in four situations: (1) patients who mask their suicidal intent by complaining of other health problems; (2) overtly suicidal patients coming in on their own, or with the help of others; (3) patients who have already attempted suicide; and (4) patients pronounced dead in the ED from a suicide attempt and whose bereaved family must be consulted (Buzan and Weissberg, 1992).

Several barriers to care occur in the ED, all of which have been highlighted previously in the context of primary care. The first barrier is that patients with covert symptoms are not recognized. Another barrier is the lack of guidelines for suicide assessment by professional organizations. This prompted the Surgeon General to set as a national objective the development of guidelines expressly for the ED (PHS, 2001). Yet another barrier is the lack of training for ED staff. Seventy percent of emergency physician training programs in a 1990 survey reported not offering any training in the management of psychiatric emergencies (Weissberg, 1990).

Once diagnosed in the ED, suicide attempts are important to treat promptly, to admit to a psychiatric unit, and/or to arrange for effective care after discharge (Buzan and Weissberg, 1992). Suicide attempters are at risk of re-attempt or completed suicide (Chapter 3). However, they often do not receive follow-up care. For instance, up to half of all suicide attempts among adolescents did not receive subsequent care after an ED visit (Spirito et al., 1989). The need for effective linkages with follow-up care was set as a national objective by the Surgeon General (PHS, 2001). Yet barriers persist even with good linkage to care because many—more than 40 percent of adolescent attempters (Piacentini et al., 1995)—are nonadherent with treatment.

Barriers in Specialty Mental Health Care

A significant percentage of suicide completers make recent contact with specialty mental health care, either in the community or in the hospital. A review of the published literature found that about 41 percent of those who die by suicide have contact with inpatient care in the year before death. Up to 9 percent of them complete suicide within a day of discharge from inpatient care. The figures are slightly lower for commu-

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