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<< The Depressed Patient And Suicidal Patient In The Emergency Department: Evidence-Based Management And Treatment Strategies

Introduction

Mental-health-related chief complaints account for a significant number of ED visits. In 2007, there
were 12 million ED visits in the United States involving a diagnosis related to a mental health/substance abuse issue.1 Among the broad spectrum of mental illness complaints managed in the ED, mood disorder was the most common (42.7%), followed by anxiety disorders (26.1%), and alcoholrelated conditions (22.9%). Often presenting in conjunction with depressive symptoms, suicidal ideation is another common chief complaint in the ED. Suicide is a leading cause of death, and attempted suicide is a leading cause of economic and personal disability. Data from the United States Public Health Service shows that annually nearly 650,000 individuals are evaluated in EDs for suicide attempts.2 Despite the large numbers of mood-disorder-related presentations and suicidal ideation, there are few standardized guidelines or strategies outlined for ED diagnosis and management, so there is a large variation in the quality of care provided to these patients. Complicating the care provided in the ED to patients with mood disorders are the challenges in recognition of depression in either the primary or secondary complaint—a
challenge exacerbated by the volume and acuity of patients being seen in the ED. Often, depression
is manifested in seemingly unrelated somatic complaints, such as unexplained abdominal pain or chest pain.3 Additionally, sociocultural differences among ethnic groups in the manifestation of depression may make the diagnosis of depression symptoms difficult. Among the elderly, signs of depression can be misinterpreted as early dementia, and vice versa, which may lead to an erroneous management strategy and disposition.2

Despite the challenges of recognizing a mood disorder, depression exists as a frequent presentation to the ED. Work by Kroenke found that among outpatient medical visits in a busy urban center, approximately 20% to 25% of patients had somatic complaints that were unexplained, and within that
group, measures of depression and anxiety were significantly higher compared to the general population.
4 Meldon et al have also noted the challenges of detecting depression in the ED, finding that recognition
of depression by emergency physicians in a group of geriatric patients was poor, with a sensitivity of 27%.5 Added to this is the concern that many external resources such as mental health programs and community resource centers are often stretched to their resource limits, and patients may look to the ED in desperation for help with acute and subacute psychiatric concerns. Taken together, the disease burden of depression is a critical condition that emergency clinicians must be aware of.

The goal of this issue of Emergency Medicine Practice is to examine the broad literature base on depression and depression with suicidal ideation as it pertains to the practice of emergency medicine. Risk factors associated with depression and suicide are reviewed as well as validated screening measures that may be useful for identifying depressed patients in the ED. Current management strategies and recommendations regarding acute care of the depressed patient and the depressed suicidal patient in the ED are provided.

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Last Modified: 12/11/2017
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