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

Risk Management Pitfalls For Depression In The Emergency Department

  1. “The patient is a frequent flyer and often comes to our ED intoxicated and leaves when sober. I thought he was just drunk and wanted to sleep.”
    Patients who make frequent visits to the ED often get broadly overlooked for an acute change in their presentation. There is an increased incidence and prevalence of suicide and depression among individuals with substance abuse issues; it is critical to review the vital signs and perform a safety assessment for these patients and a reevaluation when sober.
  2. “I was afraid that if I asked the patient if he had a specific plan it might give him an idea and encourage him to do it.”
    Multiple reports have found that direct questioning about suicide does not result in an increase in suicidal ideation; for many patients, it is only through direct questioning that the emergency clinician is able to ascertain safety risk.
  3. “She said she only took a few dipenhydramine pills to get some attention.”
    Patients who have made a suicide attempt are often unreliable and uncertain about the amount
    and type of medication/pills they have ingested. In cases of intentional ingestion, it is prudent to
    obtain a full toxicology screen and anticipate a possible decline in clinical status while awaiting
    for initial studies; in this situation, it is prudent to assume the worst.
  4. “I thought he was just looking for attention when he told his girlfriend that he was thinking of jumping off the bridge.”
    All statements of suicide or self-harm, however casual the context or tone, warrant serious
    investigation and questioning. Not all patients who make such statements ultimately require
    a psychiatric hospitalization. However, it is the responsibility of the emergency clinician to evaluate the patient’s ability to maintain safety for themselves as well as others and to involve psychiatry expertise when necessary.
  5. “She kept on talking about how her chest hurt, and she never mentioned anything about being depressed or suicidal.”
    Depression is a complex condition that often manifests in both cognitive as well as physical/
    psychomotor symptoms. Physical ailments such as chest pain and abdominal pain have been found to be among the most common symptoms endorsed by depressed patients when presenting to their healthcare providers. Keep a high index of suspicion for depression.
  6. “We thought grandma was just feeling sad and that her leg pain and fatigue were due to her feeling down.”
    Conversely, be sure to always do a full physical examination and evaluation for patients with
    psychiatric complaints; other medical conditions can be missed by not doing a full examination.
  7. “I didn’t think she needed 1:1 observation; she looked so calm and was so cooperative despite saying she wanted to kill herself.”
    Patients with active suicidal ideation often require 1:1 observation to prevent any occurrence of self-inflicted harm while in the ED.
  8. “He didn’t look like the type who would get violent in the ED.”
    Patients endorsing active suicidal ideation should have all of their belongings searched by hospital staff for any potentially dangerous materials that could be used on themselves and
    others.
  9. “The patient just wanted a prescription for a few anxiolytics to calm down.”
    Prescribing large amounts of anxiolytics for patients with acute depressive symptoms is challenging, given the risk for intoxication as well as poor follow-up. Ideally, prescriptions should be done in collaboration with the patient’s outpatient psychiatrist/primary care provider to ensure follow-up as well as appropriateness.
  10. “The patient just got diagnosed with metastatic lung cancer and said she felt life was over and she wanted to die. I thought it was normal to feel like that after getting such a diagnosis.”
    Patients with tremendous life stressors such as the case mentioned above will often present
    with acute depressive symptoms and passive or even active suicidal ideation. The emphasis
    should always be on safety of the patient, and a full psychiatric and safety evaluation should be
    made by the emergency clinician when seeing these patients.

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Last Modified: 10/19/2017
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