Exploring Facilitators and Barriers to Dual Intervention In Suicidal Ideation and Intimate Partner Violence In an Emergency Care Setting: A Qualitative Study

Background and Purpose: Intimate partner violence (IPV) victimization increases the risk of suicidal ideation (SI), yet few interventions exist that address their comorbidity. Emergency Departments (ED) are vital intervention points for both SI and IPV and could serve as a site for a dual intervention. It is estimated that 2-8% of ED patients present with SI. Over half of women seeking care in urban EDs reported lifetime IPV, and 84-93% of female survivor-patients report co-occurring SI, compared to 7-16% of patients without IPV. Attending to comorbid IPV-SI is critical to disrupting their combined lethal risks. We sought to describe the care landscape for patients experiencing SI and/or IPV within a university hospital system.

Methods: We interviewed ED providers (n=17) from a university hospital system and its associated children’s hospital, including social workers, clinicians, nurses, and psychiatry staff. Virtual interviews lasted 30-60 minutes and covered their current responses to patients experiencing SI and/or IPV, provider perceptions of screening, and barriers to and facilitators of treatment. Thematic analysis was used to identify patterns of meaning (i.e., themes) across interviews.

Results: Findings indicated that IPV and SI were treated separately, even when co-occurring. Perceptions of, barriers to, and facilitators of triage, treatment, and referrals varied among providers, likely due to differences in IPV and SI responses. The primary barrier during triage was inconsistent screening, particularly for IPV. There were robust SI protocols, which increased provider confidence and consistent implementation. IPV protocols, by contrast, were described as underdeveloped, and often, as something not yet implemented. The main barriers to treatment were an over-taxed ED system and practitioners’ training to prioritize the patient's medical care over social and mental health issues. The primary barrier for discharge was a lack of knowledge about available and effective resources, particularly for IPV resources, which, when known, were seen as ineffective. Providers noted several facilitators of treatment and referrals at systemic and individual levels. A primary facilitator was the accessibility of the ED, particularly in a community with limited access to primary care. Where clear protocols and providers who cared about these issues intersected, multidisciplinary team collaborations facilitated SI and IPV care delivery. While all participants noted that the ED was a key intervention site to identify and treat crises, they disagreed on whether this made it appropriate for SI and IPV intervention.

Conclusions and Implications: Although the high co-occurrence of IPV and SI is indicated in prior research, this study found that IPV and SI were treated separately within the ED and that provider perceptions of care varied due to differences in the hospitals’ approaches to IPV and SI. It is imperative to offer training on IPV, its intersections with SI, and avenues for referrals and treatment to prepare providers to intervene in this high-risk population. A dual intervention should aim to provide stabilization, brief treatment, and referral to community resources. Individuals experiencing IPV and SI are a doubly vulnerable population, and it is critical to develop interventions that attend to their co-occurring lethality and injury risk.