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


Depression is among the most common forms of Axis I psychiatric diseases in the United States. Based on the 2005 National Epidemiologic Survey of Alcoholism and Related Conditions, which surveyed 43,093 individuals, the prevalence of 1-month DSM-IV-TR MDD was 5.28%, with an overall lifetime prevalence of major depression in the United States at 13.23%.9 Another recent large survey carried out by the Behavioral Risk Factor Surveillance System (BRFSS) study and analyzed by the Centers for Disease Control and Prevention (CDC) found that among 235,067 adults surveyed in the general population from 2006-2008, 9% met the criteria for major depression.10

Attempted suicide, defined as injury from self-directed aggression/violence, is a leading cause of death and disability in the United States. Based on data collected in 2007, suicide was the 11th-leading cause of death and accounted for 34,598 deaths.11 Suicide has a tremendous personal and economic impact. In 2000, the estimated cost of self-directed violence (both fatal and nonfatal) was nearly $33 billion ($32 billion in productivity losses and $1 billion in medical costs).12 The most common method of suicide in the United States was by firearms for both men and women (57% overall and 62% of suicides in men)13; the second leading cause was poisoning for women and hanging for men. For every completed suicide, there are an estimated 10 to 40 nonfatal suicide attempts, with an estimated 20% of suicide victims having had a history of previous suicide attempts.14

Published risk factors for depression are summarized in Table 2. Based on a review of previous studies, there appears to be a difference in gender, ethnicity, and age with regard to depression risk. In a survey of nearly 73,000 adults from 15 countries, the reported prevalence of MDD was nearly 2 times as high in females compared to males, and a lifetime prevalence of MDD and dysthymia (so-called “mild depression”) was 1.9 times higher in females.15 Within the United States, the prevalence of MDD in males was 3% to 5%, compared with 8% to 10% in females.16 The BRFSS study noted that the incidence of major depression in women was 4%, versus 2.7% in men.10

In general, MDD is more common in younger than older adults living in the same community.17 A survey of nearly 10,000 adults found that while the prevalence of MDD was 19% to 23% among adults younger than 65, the prevalence was 10% in adults 65 and above.18 The BRFSS study also noted a difference among age groups, with the prevalence of major depression to be 2.8% among individuals aged 18-24, 4.6% among those aged 45-64, and 1.6% in those over 65. However, within the older population, subsets of older adults had higher rates of MDD compared to both older adults and younger population groups; these groups included older adults with multiple medical comorbidities, residents of assisted living or skilled nursing facilities, and widowed older men.19,20

Differences in the prevalence and incidence of depression among different racial groups in the United States have also been noted. A survey of adults living in the United States, matched for age and gender, found lifetime prevalence rates of blacks to be 10%, compared to whites at 18%.6 However, the more-recent BRFSS study noted that Hispanics and non-Hispanic blacks were significantly more likely to report major depression (4.3% and 4% respectively) compared to non-Hispanic whites (3.1%).10


Suicide is associated with multiple risk factors, but the single strongest predictor is prior history of suicide attempts.14 An individual who has made a previous suicide attempt is nearly 6 times more likely to make another attempt.21 One in 100 people who have attempted suicide will ultimately die of suicide within the year of the initial suicide attempt.22 Elderly white men aged 80 and older have the highest suicide rate in the United States (51.6/year per 100,000).10,11 While rates of suicide are highest in older adults, younger adults attempt suicide more often.2,24 Additionally, while females attempt suicide nearly 4 times more frequently than males, males are nearly 3 times as successful in completing suicide; these differences are thought to be related to the method by which males and females choose to commit the act.2

It has been found that more than 90% of individuals attempting suicide meet criteria for 1 or more major psychiatric disorder(s),24 with another study finding that patients with a psychiatric diagnosis have suicide rates nearly 3 to 12 times higher compared to other patients.25 Among individuals with comorbid psychiatric conditions, individuals who have had symptoms severe enough to warrant psychiatric admission have been found to have an increased lifetime risk of suicide (8.6% compared to 0.5% for the general population).26 Among the psychiatric conditions most associated with suicide risk, major depression was the most common, followed by schizophrenia, personality disorders, borderline personality disorder, bipolar disorder, and posttraumatic stress disorder (PTSD).27,28 Other risk factors for suicide are presented in Table 3.29-32

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Last Modified: 12/11/2017
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