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

Disposition

Patients presenting with depressive symptoms in the ED often represent challenging disposition dilemmas. Of paramount concern is patient safety and their ability to care for themselves. Based on this concept, the present standard of care for the depressed patient presenting with active suicidal ideation is to have the patient remain in the ED, both voluntarily and involuntarily, for a formal psychiatric assessment and likely inpatient psychiatric hospitalization. Additionally, depressed patients who present with psychotic symptoms also warrant a psychiatric inpatient hospitalization after ruling out acute medical causes. Patients with severe depressive symptoms (ie, depression with melancholic features) who may endorse passive suicidal ideation and who have significant deficits in functional status in social/occupational contexts also warrant an inpatient psychiatric hospitalization in consultation with psychiatric colleagues. Finally, individuals with severe depression without suicidal ideation but with social/occupational impairment may benefit from a voluntary inpatient hospitalization. This group of patients may differ from the depressed patient with psychotic features or the actively suicidal patient in that such patients may be admitted voluntarily, unlike the previous groups mentioned.

Once the decision has been made to arrange for an inpatient hospitalization, discussion with the patient requires a nonjudgmental and supportive manner. Emphasis on the genuine interest of the patient and his overall well-being must be stressed (ie, “We really want the best for you, and we are worried that since you are saying you want to hurt yourself that it’s not safe for you to go home”) rather than a tone that may be interpreted as punitive (ie, “You can’t leave now because you said you wanted to kill yourself”). Keeping patients active participants in their care helps to maintain a sense of collaboration as well as focus on their welfare. However, if a high-risk patient refuses to cooperate or is unwilling to be admitted, then it is necessary to begin the procedures for involuntary commitment as applicable to the specific civil law. Extreme care should be made not to escalate the situation unless necessary. In the setting of an involuntary admission, some patients may react in verbal or physical outbursts. It is critical for the emergency clinician to maintain an emphasis on safety for both the patient and staff. Maintaining 1:1 observation, verbal de-escalation, pharmacologic interventions, and, if necessary, physical restraint with the aid of hospital security all fall within the realm of acceptable practice within the proper context.

While the severely depressed patient with active suicidal ideation may appear to have a clearly laid-out disposition, in many ways, it is the patient who endorses some elements of severe depression as well as passive suicidal ideation that presents the most challenging disposition dilemma. It is in these contexts that an evaluation of the patient’s social support and resources as well as healthcare support is paramount in deciding whether or not a person is safe for discharge. For the patient with moderate depression (determined either subjectively or quantitatively with screening methods such as the PHQ-9) or passive suicidal ideation, a discussion with a mental health provider is warranted. If a patient has an existing psychiatrist who could provide timely follow-up, then discharge may be possible. One scenario would be an ED evaluation by the psychiatry team followed by a discharge home with an intensive outpatient psychiatric day program in conjunction with the existing primary psychiatrist. In this setting, the evaluation of the patient’s existing social support structure (family, friends) is crucial, as frequent surveillance is important. Furthermore, as discussed earlier, while the ED administration of long-term antidepressant medications is usually not indicated without coordination by psychiatry, in certain cases outpatient therapy in conjunction with the patient’s psychiatrist or ED psychiatry team may be planned post-discharge.

Follow-up is essential for patients discharged from the ED with depressive symptoms or suicidal ideation. Patients who no longer express suicidal ideation and have been evaluated by a psychiatrist and deemed safe for discharge should have explicit instructions for immediate return to the ED for worsening suicidal ideation or other concerning psychiatric or behavioral symptoms. These precautions must be clearly discussed and written for the patient. Additionally, if possible, provide a list of potential resources for the patient regarding mental health support structures. Document thoroughly the interaction between the patient as well as the thought process and discussion with psychiatry when discharging these patients. Tools used in the outpatient setting such as a “suicide contract” offer no medical-legal protection for emergency clinicians, so a clearly written and well-documented note is of great importance.

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Last Modified: 10/19/2017
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