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

Emergency Department Evaluation

The presentation of the depressed/suicidal patient varies widely in terms of history, physical examination, and overall clinical impression. At times, a patient may present with depression as the chief complaint; at other times, the symptoms of depression may manifest as physical ailments such as nonspecific body pain, fatigue, or restlessness.48 It is critical to have an efficient – yet systematic and thorough – approach to these patients. Among the immediate interventions for patients presenting with a mood disorder is to ensure safety for the patient and others. Such activities include (but are not limited to) a thorough examination of patient’s clothing and personal belongings for potentially dangerous objects or medications; obtaining 1:1 observation for the patient; and if the patient is at imminent risk to self or others, a medical order to hold the patient against his or her will, using physical or chemical restraints until the workup/evaluation is complete.

History

In evaluating the depressed and/or suicidal patient, it is advisable to approach the interview process with a flexible approach and with the goal of assessing the degree of imminent risk to the patient and/or others. In addition to information from the patient, the history is aided by information from family and friends, while remaining cognizant of patient confidentiality rights.

It is key to integrate the chronology of the symptoms of depression and their impact on the patient’s functional status (personal/family/professional). Alleviating and aggravating factors are also useful in identifying potentially reversible causes of depression. A review of systems incorporates infectious, toxic-metabolic, and neurologic complaints. Contributing factors can be elicited from recent medical events (eg, myocardial infarction) and a complete list of medications ingested.

A thorough examination of past psychiatric history includes any history of previous psychiatric hospitalizations or treatments, suicide attempts/gestures, and dangerous behavior to oneself. Additionally, the presence of anxiety symptoms and alcohol or other substance abuse have all been shown to be associated with a worsening course and severity of depression and should be taken into consideration when assessing the patient’s potential for harm to self and overall safety. Conversely, individuals presenting with alcohol or substance abuse-related complaints may have depression as an underlying factor driving the abuse.

Assessment of suicide risk is paramount for all patients presenting with depressive symptoms, regardless of overt suicidal statements. The presence of any positive/ambivalent response should be followed up with questions regarding the nature of the ideas as well as intention, plan, and specific action. Additionally, other key aspects of the history for the potentially suicidal patient include a documentation of history of suicide attempts (including date, circumstances, and method), family history of suicide, recent life stressors, and current living situation (ie, social support, safety at home). Some clinicians have been concerned that for the patient not endorsing suicidal ideation, such questioning may somehow  encourage or introduce the idea of suicide; however, the literature has not supported this hypothesis and has demonstrated that direct questioning about suicidal thoughts is not associated with increased  suicidal behavior.61,62 (See Table 9.) Furthermore, it has been found that when asked about suicidal ideation, there is no associated induction of negative affect/mood.63 Taken together, the evidence  suggests that there should be no hesitation for the emergency clinician to perform a thorough suicide evaluation for patients who express depressive symptoms or who may be a suicide risk.

During the physical examination, be aware of possible co-ingestions or medications. Although patients will often readily detail the specific ingestion, at times a patient will be unwilling or unable to acknowledge ingestion of a potentially toxic substance. The reliability of reports from patients with psychiatric complaints who deny ingestions is a common concern among emergency clinicians. This has been studied particularly in intentional acetaminophen (paracetamol) and aspirin ingestion. The overall conclusions from the limited number of studies addressing this question suggest that, in general, patients admitting some aspect of suicidality will often report an accurate ingestion history, but there is a small but significant number of patients who will not.64,65 Additionally, an accurate ingestion history may also be confounded by the concern that patients may present obtunded or otherwise unable or unwilling to detail their ingestion. A high index of suspicion should remain for potential co-ingestion of multiple substances. Additional information may be gathered from the delivering emergency medical services (EMS) staff that was at the scene, regarding medication/bottles seen at the site; other information may be corroborated through family/friends.

Interviewing Strategies

Eliciting intimate details of a patient’s psychiatric background is a challenging endeavor but is even more so for the emergency clinician, given the limited established relationship, time constraints, and emergent nature of the visit. The emergency clinician should attempt to maximize the patient’s privacy, when possible (ie, avoiding interviewing in hallways or stretchers), and should use a patient, nonjudgmental approach. Open-ended questions (eg, “What brought you here today?”) versus closed-ended questions (eg, “Did you mean to kill yourself today with these pills?”) may help elicit more detailed and helpful information and thus a better understanding of the patient and their ability to contract for safety.

Screening Tools

While not widely adopted in many EDs, the use of standardized screening/assessment tools may be useful in evaluating patients with mood-disorderrelated complaints, allowing the emergency clinician to quantitatively assess for potentially high-risk patients in a quick, structured format. Several screening questionnaires have been developed for depression; among the most-used in the primary care setting include the Geriatric Depression Scale, the Beck Depression Inventory for Primary Care (BDIPC), and the Patient Health Questionnaire (PHQ-9). The scales have shown wide variability in sensitivity and specificity, with sensitivities ranging from 50% to 97% (median 85%) and specificities from 51% to 98% (median 74%).6 While many of these tools have been validated in controlled settings, the ED poses challenges that may be difficult to overcome. In attempting to address this, several of these screening tools have been abbreviated.

Another potentially useful tool that may help emergency clinicians structure the interview of patients with depressive symptomatology is to use the modified SAD PERSONS scale, which has been validated and used in the ED in the assessment of depression and suicide risk.66 (See Table 10.)

Geriatric Depression Scale

The Geriatric Depression Scale was originally a 30-item questionnaire that was designed to identify depression risk in geriatric (aged 65 and older) patients,67 and it has been validated in a large sample of geriatric patients as well as in younger adults (despite its name).68 A 15-item form has been validated and is now widely used, as well as a 5-question geriatric depression version, which have been shown to be as sensitive in detecting depression in multiple clinical settings (hospital, outpatient clinic, and nursing home).69 (See Table 11.)

Beck Depression Inventory For Primary Care

The BDI-PC is a 7-item scale adapted from the larger 21-item Beck Depression Inventory (BDI) that has
been used as a depression screening tool. The original BDI has been extensively studied and validated
across gender, age, and multiple specific medical populations.70-72 A BDI-PC score of 4 or greater has
been found to have a sensitivity of 95% and specificity of 99% in a group of primary care outpatients, though this study was limited by a small sample size (60 men and 60 women).73 While this tool has been used infrequently in the ED, the full BDI has been used in previous ED-based screening studies looking at the incidence of depression among depressed adults and adolescents.74

PHQ-9 And PHQ-2

The Patient Health Questionnaire (PHQ) is a selfadministered questionnaire which is based on the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic instrument for detection of common mental disorders.75 The PHQ-9 is a 9-question depression scale that has been found to be a valid and reliable measure of depression.75,76 (See Table 12.) Unlike other tools, the PHQ-9 is not a screening tool but involves all elements of the depression diagnosis; thus, it establishes the clinical diagnosis of depression and does not need further confirmation. It has been studied extensively and has been found to be reliable and valid while screening for depression severity across gender and different culture contexts, including Southeast Asia, eastern Africa/Kenya, and western Africa/Ghana.77-80 Another feature of the PHQ-9 is the ability to gauge and follow clinical severity of depression.81

An even briefer version of the PHQ-9, the 2-item PHQ-2, has also begun to be used in several underclinical settings. (See Table 13.) A study by Kroenke et al found that among 6000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics, the PHQ-2 had a sensitivity of 83% and specificity of 92% for major depression compared to the standardized structured patient interview.81 Other work carried out by Corson et al found that a PHQ-2 score greater than 3 was 97% sensitive and 92% specific for detecting major depression and suicidality in patients,82 although a recent study by Arroll et al looking at 2642 patients in a busy primary care setting found that the PHQ-2 sensitivity and specificity for detecting major depression was 86% and 78%, respectively, compared to a PHQ-9 sensitivity and
specificity of 74% and 91%.83

Screening Tools Summary And Recommendations

With various screening tools now available for potential use in the ED, there are multiple options for their implementation in practice. The use of such psychiatric tools has not been extensively studied in the ED. However, based on the authors’ review on the existing literature and practice, we recommend use of scales such as the PHQ-9 and, to a lesser extent, the PHQ-2. The PHQ-9 has been used to identify high-risk patients for depression in multiple inpatient and outpatient contexts77-80 by both physicians and nurses84 and across different age groups.85 Taken together, with its ease of use and clear scoring system, the PHQ-9 represents a rapid tool that may aid the emergency clinician in practice. The creation of an even more focused scale, the PHQ-2, while promising, has yet to be shown to be as effective and valid in such a broad group of settings.

Physical Examination

Approaching the physical examination in a person presenting with depressive symptoms is a twofold task. In addition to identifying clues that would suggest an underlying medical or organic cause to the symptom presentation, data from the physical examination can help guide the emergency clinician towards understanding the severity and scope of the depression. Additionally, the physical examination should collect the requisite information in a systematic manner, allowing an efficient and information-rich communication with a psychiatrist, should a consultation with one be needed. Beginning with a review of the vital signs, assess for evidence of reversible causes of altered mental status such as fever, hypoxia, hypotension, or hypoglycemia. In the setting of a suspected ingestion, note evidence of a toxic syndrome, “toxidromes.” If there is anything in the history to raise the suspicion of trauma, a comprehensive evaluation, with the patient completely undressed, should be conducted to identify any injuries. General appearance is critical. Note the patient’s eye contact, speech, and overall motor activity. Depressed patients may have a blunted affect and avoid eye contact; conversely, manic episodes may be manifested by pressured speech and increased psychomotor activity. The neurologic examination, with a focus on cranial nerves II, III, IV, and VI, identifies focal neurologic deficits that may clue the emergency clinician to an intracranial mass. Evidence of any endocrine abnormalities (ie, enlarged thyroid) alerts the emergency clinician to potential reversible causes of depression. The skin examination looks for evidence of drug use, signs of self-injury, or soft tissue lesions.

Evaluation of the patient’s psychiatric/mental status is a critical portion of the physical examination.
It is imperative to have a systematic approach such that information may be collected to assist understanding of the patient and to guide workup and management. Furthermore, the physical examination should be collected in such a way that identifies and addresses key information to be conveyed to consulting psychiatry service should they be involved in the management of the patient in the ED. See Table 14 for a summary of the recommended examination.

General Appearance

The emergency clinician should make note of the patient’s general appearance during the interview/examination. Items such as a patient’s overall grooming, clothing, and posture may illustrate normal variants or a particular abnormality (ie, patient is disheveled, poorly groomed, wearing winter clothing in summer, etc.)

Orientation

During the examination, a formal attempt should be made to assess the patient’s orientation. This may
be accomplished by asking the patient his or her full name, the full date (day, month, year), and place
where the patient is currently located. Such information is useful towards helping evaluate the patient’s
cognitive status and impairment.

Speech

The psychiatric examination should make note of the patient’s speech, including volume, rate, articulation, coherence, and spontaneity. Such commentary is useful, as many Axis I disorders are associated with speech disturbances. For example, slowed speech may be present in patients with depression while pressured speech may be present with patients with bipolar disorder.

Motor Activity

The assessment should include comment on the patient’s motor behavior, including gait, gesture, overall general body movement, and tics. Certain Axis I disorders may manifest themselves with exaggerated
movements (ie, bipolar affective disorders) while other conditions such as MDD may be associated with marked psychomotor retardation. Of note, extrapyramidal movement may be present as a result of psychotropic medication.

Affect

Affect, defined as a patient’s expressed emotional state, should be noted on the examination.39 Descriptive terms such as blunted affect, sullen, or agitated can be used. The emergency clinician should note if there is emotional lability during the examination (ie, the patient switches affect rapidly during the examination). Additionally, a comment should be made on whether there is mood congruency during the interview. For example, a mood-incongruent context may arise in the setting of a patient laughing when speaking of his suicide attempt or crying while discussing a recent positive experience.

Mood

Mood is a more historical aspect of the interview, in the sense that the emergency clinician should ask
the patient to report his or her mood for the past few days/weeks. This is a subjective report by the patient, and the emergency clinician must determine what the patient means. When possible, the emergency clinician should use words directly used by the patient (ie, “I have felt terrible and depressed over the last week”). A note should also be made if the patient’s mood and affect are congruent during this phase of the examination (ie, noting the patient’s affect while he is stating he has felt terrible and depressed over the last week). Patients who may use denial or who lack insight into their problems may not realize that their ostensibly nonchalant, cheerful affective expression may not match their reported depressed mood.

Thought Process

The emergency clinician should note during the examination how the patient’s thoughts/ideas are expressed during the interview. This includes an assessment of the patient’s thought production and flow and commentary over whether the patient’s thinking is logical, tangential, goal-directed, or shows a loosening of associations or flight of ideas (ie, the ideas expressed by the patient are not logically connected to each other). Such a lesion in thought process may be evident in certain illnesses such as bipolar disorder, particularly during the manic phase,43 and may be a clue that some toxic-metabolic process may be present and the symptoms expressed may be secondary to an underlying etiology.

Thought Content

The content/material of the patient’s speech should be noted during the interview and examination. In particular, the emergency clinician should pay attention to any general/repetitive themes or the presence
or absence of delusion as well as suicidal/homicidal thoughts. Delusional thinking can be defined as fixed
false beliefs and may present in a multitude of ways, including delusions of persecution, grandiosity, or
somatic complaints. Obsessions are defined as recurrent persistent thoughts that may intrude involuntarily into a person’s thinking and may not be based in reality. Such symptoms may be present in anxiety disorders such as obsessive-compulsive disorder but may also be present in MDD or bipolar disorder.

Perceptual Disturbances

The interviewer should note whether the patient is experiencing any disturbances in perception such as auditory, visual, olfactory, or somatosensory disturbances. Perceptual disturbances in the absence of actual sensory stimuli are defined as hallucinations.3 The emergency clinician should attempt to clarify this with the patient in clear language such as, “Do you ever hear voices talking to you and then realize that no one else is hearing those voices or that you are actually alone?” Such symptoms may be present in depression with psychotic features or schizophrenia. The emergency clinician should make note of the patient responding to such internal stimuli (ie, talking to the voices that are talking to him).

Suicidal And Homicidal Ideation

It is critical to include an assessment of suicidality and homicide thoughts/behavior in patients presenting with psychiatric symptoms. The emergency clinician should, in a nonjudgmental fashion, explore the presence or absence of current suicidal ideation, intent (how much the patient would like to hurt himself), as well as plan (whether the patient has a specific method to kill himself). In a similar fashion, thoughts of hurting another individual or group of individuals should be assessed and studied in a systematic fashion such that intent and plan is clarified. One useful mnemonic/scale that has been developed for ED use in the rapid assessment of patients with suicidal ideation is the SAD PERSONS scale.66 (See Table 10.)

Cognitive Status

Evaluation of cognition begins with assessing orientation to person, place, and time, followed by an assessment of immediate recall (immediately repeating 3 objects) and delayed recall (repeating the 3 objects after 3 minutes). (See Table 15.) If orientation and immediate recall are impaired, delirium must be considered. If the patient cannot store information, they will be unable to recall, in which case the emergency clinician needs to be careful not to misinterpret the impairment in delayed recall as a sign of dementia. In the case that orientation and immediate recall are intact but delayed recall is impaired, the emergency clinician must suspect an underlying dementing process and recommend a more comprehensive evaluation.84

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Last Modified: 12/11/2017
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