EMPOWERING PHYSICIANS WITH EVIDENCE-BASED CONTENT
 

Home > Browse Topics

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

Treatment

Patient Safety And Involuntary Containment In The Emergency Department

The acute management of the depressed patient in the ED requires a multifaceted approach. One central concern is assessment of the safety of the patient as well as others. Patients who endorse active suicidal thoughts or thoughts of hurting other individuals are usually not safe for discharge and need emergency psychiatric evaluation. For patients who refuse such an evaluation, it may be necessary to involuntarily hold them in the ED until a complete psychiatric and safety evaluation is performed. Statutes governing such involuntary holds are governed by state law, and procedures vary from state to state. The United States Supreme Court has ruled that involuntary hospitalization/and or treatment without evidence of risk violated an individual’s civil rights and subsequently, individual states have changed their statutes to reflect this principal. In general, an individual must be exhibiting behavior that is an imminent danger to himself or others, the hold must be for an evaluation only, and a court order must be received for more than a very shortterm treatment/hospitalization (in many states, this is 72 hours). Emergency clinicians must be cognizant of the laws and document explicitly their concern for the patient’s safety for himself and/or potential to harm himself and/or others. While the actual process of involuntary (or “civil”) commitment is a legal process that occurs outside of the ED, such commitment proceedings may follow a period of emergency hospitalization begun in the ED, and as such it is crucial for the emergency clinician to be knowledgeable about the applicable state and federal laws governing initial involuntary holds.

For patients who do not endorse active suicidal or homicidal ideation but endorse strong depressive symptoms, it is prudent to involve a mental health clinician to facilitate the development of an acute treatment plan. These patients may not require a mandatory inpatient psychiatric hospitalization but would benefit tremendously from an integrated effort to coordinate the follow-up care required to facilitate outpatient management. Care may include referral to outpatient psychiatric treatment, partial hospitalization, or voluntary hospitalization programs. Typically, these dispositions and care plans will be facilitated by either consultation with the psychiatric service or with other mental health professionals in the ED.

Depression Treatment: Pharmacotherapy

The administration of psychotropic medications typically used to treat depression is not routinely initiated in the ED. Because the clinical effects of many antidepressants are usually not seen for at least 2 weeks after starting treatment, from an ED standpoint this does not reflect prudent clinical practice, given lack of follow-up and the risk for serious adverse side effects.86 However, because many depressed patients in the ED may be currently using these types of medication, Table 16 lists the most commonly used antidepressants, their presumed mechanism of action, and their side effects. If antidepressant medications are prescribed in the ED, it is best done in consultation with psychiatry. In some depressed patients with significant anxious features, a short course of anxiolytics pending follow-up with psychiatry may help bridge therapy; however, a literature search through 2011 identified no studies discussing the implications/effectiveness of such strategies, so no specific recommendations can be made at this time regarding this practice. There have been multiple studies examining the various overall efficacy of the available SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine) compared to selective norepinephrine reuptake inhibitors (SNRIs) (mirtazapine, venlafaxine), serotonin-norepinephrine reuptake inhibitors (SSNRIs) (duloxetine), and other secondgeneration antidepressants (bupropion, nefazodone). Three multicenter randomized double-blind studies examined the differences in effectiveness of various second-generation antidepressants such as setraline, citalopram, paroxetine, and fluoxetine, and all 3 studies noted no significant differences in the effectiveness of the medications towards management of depressive symptoms.87-89

The choice of which specific antidepressant to be used for patients should ideally be made in consultation with a psychiatry provider or primary care team following the patient, as ongoing follow-up is essential for monitoring efficacy and impact of any intervention.

Management Of Suicide Risk

Patients with suicidal ideation, suicidal behavior, or risk factors that increase their potential for suicide are the most common psychiatric emergency seen in hospital EDs. It is important that every ED develop a policy and procedure for assessing and managing patients who are a suicide risk. Those who present with overt suicidal statements or behaviors are readily identifiable, but screening mechanisms for the assessment of suicidal ideation should occur with patients who present with high-risk conditions including depression, psychosis, severe anxiety, acute substance abuse, and serious medical illness with recent exacerbation. Screening should include directly asking if patients have recently thought about harming themselves and, if so, whether they have a specific plan.

Individuals with active suicidal risk warrant an emergent psychiatric evaluation. Patients may be unwilling to cooperate with such an assessment, and prevention of the patient leaving the ED may be necessary until such an evaluation can be completed. Patients are at increased risk of self-harm and/or elopement during this period. Effective suicide precautions should include mechanisms to alert medical and nursing staff to the potential safety risk and appropriate search of the patient and his belongings so that dangerous items (medications, weapons, etc.) can be removed. The physical environment of the patient’s room should be assessed to minimize potential risk, including removal of tubing and needles. Patients at acute safety risk may also warrant constant observation, as suicidal behavior may be impulsive in nature. Emergency departments would be wise to develop policies and protocols regarding suicide precautions, patient searches, and constant observation.

Some controversy exists as to whether patients assessed to be at risk of harm to themselves should be disrobed. In general, it is best to encourage the patient to change into a hospital gown, but forced disrobing should only occur when the risk is felt to be significant. Again, the development of disrobing policies in the ED can help minimize conflicts and inconsistent behavior on the part of staff. Training in de-escalation approaches and restraint techniques for ED staff can help avert unnecessary physical confrontations or, when necessary, help minimize the risk to staff and patient. Where security officers exist as part of the ED staffing, they should participate in such training.

The acute management of the patient who has made a suicide attempt is often focused on the method of self-harm that the patient utilized. General strategies for the most common methods are outlined below. The assessment and management of ingestions begins in parallel to the underlying psychiatric evaluation; early involvement of a local poison center is advisable. Administration of charcoal, gastric lavage, and other measures may be indicated depending on the time to presentation and the substance ingested. While most patients with ingestions remain cooperative and alert, the emergency clinician must always be vigilant in case the airway needs to be secured.

Suicide contracts have at times been utilized in the ED in the acute management of patients presenting with suicidal ideation.90 These verbal/written agreements between the patient and the emergency clinician (also known as a “no-harm” contract) are intended to have the patient articulate that they will not attempt to hurt themselves. Initially developed in the realm of psychiatry,91 this technique has been used variably in a wide range of contexts from the psychiatry treatment setting to primary care physicians in both inpatient and outpatient settings.91 Studies examining the clinical utility of the no-harm contract are mixed; one study found that 41% of psychiatrists who had used such contracts still had patients who went on to commit suicide or suicide attempts92 and a review by Lewis93 found that suicide contracts were not associated with a significant reduction in later suicide attempts; thus, the current data are equivocal at best on the use of such contracts within the scope of acute management for the emergency clinician and should be done with discussion with the psychiatry consulting service.

Related Links:

Emergency Stroke Care, Advances and Controversies

 

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 12/11/2017
© EB Medicine