This post presents the “number crunching” used to make the points given in the final part of the series on peer support.
I thought it might make sense to look at the numbers to see an alternative perspective. I’m a stats guy. I have fun with numbers, and wanted to run through this exercise to guesstimate the size of the impact for clinical intervention given the many holes that exist before a person reaches care. Again, it’s an exercise, but it’s illustrative.
- National Suicide Prevention Lifeline (the Lifeline) takes about 1,200,000 calls each year. [Allowance #1: Assume that each call is from a different person].
- About 25% (1,200,000 x 0.25 = 300,000) of the calls (based on Kalafat et al 2007 & Gould et al 2007; and Lifeline internal reports) involve ‘serious’ suicidal thinking. This makes the network one of the most far-reaching and sustained interventions we have in suicide prevention, and well worth funding.
- [Allowance #2: Assume every suicidal caller that gets this intervention would have attempted suicide otherwise]. Through this intervention we may reach 12% of those who would attempt (300,000 / 2,500,000 = 0.12).
- Note: This is a very large allowance being used in the calculations. The call numbers are actually based on “suicidal thinking” and thus the more strict comparison would be to the number who “seriously consider suicide” – therefore reaching just 2.6% (300,000 / 11,500,000 = 0.026) of suicidal individuals.
- Of the 300,000 suicidal callers, 46.7% receive a referral to new mental health care (300,000 x 0.47 = 140,100) and 10.7% are referred back to existing mental health care (300,000 x 0.107 = 32,100) mental health care (ref Gould, 2007). Altogether, 57.4% received some type of mental health referral.
- Using this figure, 6.9% of suicidal individuals would get referred to a mental health professional through the Lifeline (172,200 / 2,500,000 = 0.069).
- About 35% of those with a new referral go to the appointment (140,100 x 0.35 = 49,035), and assume that all of those with existing care go back (32,100) – Total = 81,135. (ref Gould, 2012)
- This is 47% of callers referred (81,135 / 172,200 = 0.47).
- This is 27% of all suicidal callers (81,135 / 300,000 = 0.27)
- This is 3.2% of those who would attempt suicide (81,135 / 2,500,000 = 0.032)
- A survey of behavioral health providers found that approximately 50% feel confident about addressing suicidal behavior. This figure matches estimates in the literature about numbers who have received some form of training on the topic (see Schmitz et al, 2012).
- [Allowance #3: Assume that the training and/or confidence is the same as competence] Thus, 50% of the individuals who reach a mental health professional this way (81,135 x 0.5 = 40,568) will get competent care.
- This is 1.6% of those who would attempt suicide (40, 568 / 2,500,000)
- The second intervention pathway that will be added is referral through the emergency department (ED).
- According to CDC data from 2010 there were 713,000 ED visits for self-injury [Allowance #4: Assume all “self-injury” cases involved suicidal intent] and [Allowance #5: Assume every visit is by a unique individual] and [Allowance #6: Assume every individual seen and referred through the ED has not been counted in the numbers used above for the Lifeline pathway]
- Note: These are large allowances. For example, the SPRC / SAMHSA / AAS report on continuity of care noted that some individuals visit the ED thirty times a year, and mental / behavioral health issues are among the most likely reasons for repeat visits.
- In a US survey cited in the Continuity of Care Report, ED Directors said that 77% of suicidal patients get a mental health consultation. [Allowance #6: Assume each consultation leads to a referral]. Thus, 549,100 suicidal individuals would get a mental health referral through the ED (713,000 x 0.77 = 549,100).
- This would be 21.9% of suicidal individuals (549,100 / 2,500,000 = 0.219)
- Note: One report from the UK found that only 41% of patients left the ED with a mental health assessment (Hickey et al, 2001). However, I am using the more generous 77% in this exercise.
- An estimated 50% of patients referred to mental health care through the ED make it to the first appointment (549,100 x 0.5 = 274,550).
- Note: As reported in the Continuity of Care report, some estimates are as low as 30% of patients making it to the first appointment. However, I am again using the more generous estimate by using 50%.
- Again, we would say that 50% of patients who make it to care would see a confident / competent professional (274,550 x 0.5 = 137,275).
- This would be 5.5% of suicidal individuals (137,275 / 2,500,000 = 0.055).
- Adding together the number reaching good care through Lifeline referral (40,568) and those reaching good care through ED referral (137,275) there would be 177,843 suicidal individuals helped in this way.
- This would be 7.1% of suicidal individuals (177,843 / 2,500,000 = 0.071).
- Achieving perfect clinical care would mean that 100% of suicidal individuals who reach a mental health professional receive good care (double the 50% receiving good care in this exercise) making it 14.2% of suicidal individuals helped.
- Achieving perfect follow-through with referrals, even without improving clinical care would also double the number helped, making it 14.2% of suicidal individuals helped.
The limitations to these calculations will be likely be noted by many – they are oversimplified, they don’t account for X or Y, etc. However, I’ll ask them to keep in mind the six or more allowances included here, some of which are quite sizeable, that were used to grant considerable room for additional inputs or interventions to add to the ‘true’ figures and not radically change the estimates that are reached at the end.