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


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology
and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available.

  1. Owens, P, Mutter, R, Stocks, C. Mental health and substance abuse-related emergency department visits among adults 2007; 2010. Statistical Briefs Agency for Health Care Policy and Research. (Epidemiologic data)
  2. Spicer, RS, Miller, T.R. Suicide acts in 8 states: incidence and case fatality rates by demographics and method. Am J Public Health. 200:90:1885 (Epidemiologic data)
  3. Simms L, Prisciandaro J, Krueger R, et al. The structure of depression, anxiety, and somatic symptoms in primary care. Psychol Med. 2011;20:1-14. (Review article)
  4. Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management. Int J Methods Psychiatric Res. 2003; 12(1): 34-43. (Review article)
  5. Meldon S, Emerman C, Schubert D. Recognition of depression in geriatric ED patients by emergency physicians. Ann Emerg Med. 1997; 30(4); 442-447. (Observational study; 101 subjects)
  6. Williams JW, Jr, Pignone, M, Ramirez, G, Perez Stellato, C. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry. 2002; 24:225. (Meta analysis; 38 studies)
  7. No authors listed. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision, American Psychiatric Association, Washington, DC 2000. (Texbook)
  8. Bradvik L, Berglund M. Repetition of suicide attempts across episodes of severe depression. Behavioural sensitisation found in suicide group but not in controls. BMC Psychiatry. 2011;11:5. (Retrospective)
  9. Grant B, Stinson F, Dawson D, et al. Prevalence and cooccurence of substance abuse disorders and independent mood and anxiety disorders. Arch Gen Psych. 2004;61(8);807-816 (Survey data; 49,093 patients)
  10. Centers for Disease Control and Prevention. Current depression among adults--United States, 2006 and 2008. MMWR. 2010;59(38):1229-1235. (Survey; 235,067 subjects)
  11. No authors listed. Centers for Disease Control and Prevention (CDC). Homicides and suicides--National Violent Death Reporting System, United States, 2003-2004. MMWR. 2006;55:721. (Epidemiologic data)
  12. Corso PS, Mercy JA, Simon TR, et al. Medical costs and productivity losses due to interpersonal and self-directed violence in the United States. Am J Prev Med. 2007:32:474-482. (Survey data)
  13. Moscicki, E. Epidemiology of suicide. In: Goldsmith, S, ed. Suicide Prevention and Intervention. National Academy Press, Washington, DC; 2001. (Textbook chapter)
  14. Haukka J, Suominen K, Partonen T, et al. Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996-2003. Am J Epidemiol. 2008;167:1155. (Epidemiologic data)
  15. Seedat S, Scott KM, Angermeyer MC, et al. Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry. 2009;66:785. (Face-to-face household survey; 72,933 subjects)
  16. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617. (Survey; 9282 subjects)
  17. Williams DR, González HM, Neighbors H, et al. Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Arch Gen Psychiatry. 2007;64:305. (Retrospective study; 6082 subjects)
  18. Kessler RC, Birnbaum H, Bromet E, et al. Age differences in major depression: results from the National Comorbidity Survey Replication (NCS-R). Psychol Med. 2010;40:225. (Survey; 9282 subjects)
  19. Lyness JM, Niculescu A, Tu X, et al. The relationship of medical comorbidity and depression in older, primary care patients. Psychosomatics. 2006;47:435. (Retrospective; 546 subjects)
  20. Lebowitz, BD, Pearson, JL, Schneider, LS, et al. Diagnosis and treatment of depression in late life. Consensus statement update. JAMA 1997; 278:1186. (Review)
  21. Pokorny, AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry 1983; 40:249. (Prospective study; 4800 subjects)
  22. Hawton, K. Suicide and attempted suicide. In: Handbook of Affective Disorders, 2nd ed, Pankel, ES (Ed), Guilford, New York 1992. p.635. (Textbook)
  23. O’Connell, H, Chin, AV, Cunningham, C, Lawlor, BA. Recent developments: suicide in older people. BMJ 2004; 329:895. (Review article)
  24. Hirschfeld, RM, Russell, JM. Assessment and treatment of suicidal patients. N Engl J Med 1997; 337:910. (Review article)
  25. Evenson, RC, Wood, JB, Nuttall, EA, Cho, DW. Suicide rates among public mental health patients. Acta Psychiatr Scand 1982; 66:254. (Epidemiologic data)
  26. Bostwick, JM, Pankratz, VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry 2000; 157:1925. (Metaanalysis)
  27. Sareen, J, Cox, BJ, Afifi, TO, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a populationbased longitudinal study of adults. Arch Gen Psychiatry 2005; 62:1249. (Retrospective study; 4796 subjects)
  28. Palmer, BA, Pankratz, VS, Bostwick, JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 2005; 62:247. (Meta-analysis; 61 studies)
  29. Heikkinen, ME, Isometsä, ET, Marttunen, MJ, et al. Social factors in suicide. Br J Psychiatry 1995; 167:747. (Retrospective study; 1067 subjects)
  30. Platt, S. Unemployment and suicidal behaviour: a review of the literature. Soc Sci Med 1984; 19:93. (Review article)
  31. Dube, SR, Anda, RF, Felitti, VJ, et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 2001; 286:3089. (Retrospective cohort study; 17,337 subjects)
  32. Qin, P, Agerbo, E, Mortensen, PB. Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers. Lancet 2002; 360:1126. (Case control series; 4262 subjects)
  33. Dunlop BW, Nemeroff CB. The role of dopamine in the pathophysiology of depression. Arch Gen Psychiatry. 2007;64:327. (Theory paper)
  34. Hasler G, van der Veen JW, Tumonis T, et al. Reduced prefrontal glutamate/glutamine and gamma-aminobutyric acid levels in major depression determined using proton magnetic resonance spectroscopy. Arch Gen Psychiatry. 2007;64:193. (Cross-sectional study; 20 subjects, 20 controls)
  35. Sanacora, G, Mason GF, Rothman DL, et al. Reduced cortical gamma-aminobutyric acid levels in depressed patients determined by proton magnetic resonance spectroscopy. Arch Gen Psychiatry. 1999;56:1043. (Cross-sectional study; 14 subjects, 18 controls)
  36. Wankerl M, Wust S, Otte C. 2010 current developments and controversies: does the does the serotonin transporter genelinked polymorphic region (5-HTTLPR) modulate the association between stress and depression? Curr Opin Psychiatry. 23(6):582-587. (Meta-analysis; 19 studies reviewed)
  37. Price JL, Drevets WC. Neurocircuitry of mood disorders. Neuropsychopharmacology. 2010; 35:192. (Review article)
  38. Davidson RJ, Shackman AJ, Maxwell JS. Asymmetries in face and brain related to emotion. Trends in Cognitive Science. 2004;8(9):389-391 (Review article)
  39. Henriques J, Davidson R. Left frontal hypoactivation. J Abnor Psychol. 1991;100(4):533-545. (Review article)
  40. Zasler N, Katz D, Zafonte R. Brain Injury Medicine. 2006. Ed: Demos Medical. (Textbook)
  41. Heller AS, Johnstone T, Shackman AJ, et al. Reduced capacity to sustain positive emotion in major depression reflects diminished maintenance of fronto-striatal brain. Proc Natl Acad Sciences USA. 2009;106(52):22445–22450 (Prospective study;subjects)
  42. Stanley B, Molcho A, Stanley M, et al. Association of aggressive behavior with altered serotonergic function in patients who are not suicidal. Am J Psychiatry. 2000;157(4):609-614. (Prospective, comparative; 64 patients)
  43. Coccaro EF, Siever LJ, Klar HM, et al. Serotonergic studies in patients with affective and personality disorders. Correlates with suicidal and impulsive aggressive behavior. Arch Gen Psychiatry. 1989;46(7):587-599. (Prospective; 63 patients)
  44. Arango V, Huang Y, Underwood D, et al. Genetics of the serotenergic system in suicidal behavior. J Psychiatr Res. 2003;37(5):375-386. (Review article)
  45. Kendler KS, Gatz M, Gardner CO, et al. A Swedish national twin study of lifetime major depression. Am J Psychiatry. 2006;163:109 (Retrospective; 15,493 twin pairs)
  46. Sullivan PF, de Geus EJ, Willemsen G, et al. Genome-wide association for major depressive disorder: a possible role for the presynaptic protein piccolo. Mol Psychiatry. 2009;14:359. (Retrospective; 6079 MDD cases, 5893 controls)
  47. Shi J, Potash JB, Knowles JA, et al. Genome-wide association study of recurrent early-onset major depressive disorder. Mol Psychiatry. 2010;16(2);193-201. (Case review; 1020 case subjects, 1636 controls)
  48. Shim R, Baltrus P, Ye J et al. Prevalence, treatment, and control of depressive symptoms in the United States: results from the national health and nutrition examination survey (NHANES), 2005-2008. Journal Am Board Fam Med. 2011;24(1):33-38. (Epidemiologic data)
  49. Roy A, Segal N. Suicidal behavior in twins: a replication. Journal of Affective Disorders. 2001. 66(1): 71-74. (Case series; 28 twin pairs)
  50. Beck AT. Cognitive models of depression. J Cogn. Psychother. 1987;1:5-37 (Theory paper)
  51. Clark D, Beck A. Cogntive therapy and therapy of anxiety and depression: convergence with neurobiological findings. Trends in Cognitive Sciences. 2010;14(9):418-424. (Review article)
  52. Seligman ME, Maier SF. Failure to escape traumatic shock. J Exp Psychol. 1967;74:1-9. (Prospective study; 30 subjects)
  53. Peterson C, Seligman M. Causal explanations as a risk factor for depression: Theory and evidence. Psychol Rev. 1984;91:347-374. (Review paper)
  54. Hiroto DS, Seligman M. Generality of learned helplessness in man. Journal of Personality and Social Psychology. 1975;31:311- 327. (Randomized controlled study; 96 subjects)
  55. Cuijipers P, Van Straten A, Andersson G, et al. Psychotherapy for depression in adults: a meta-analysis. J Consult Clin Pyschol. 2008;76(6): 909-922. (Meta-analysis; 53 studies)
  56. Paykel ES. Life events and affective disorders. Acta Psychiatr Scand. Suppl 2003;61. (Review)
  57. Rosenquist JN, Fowler JH, Christakis NA. Social network determinants of depression. Mol Psychiatry. 2010;16:273-281. (Retrospective study; 12,067 subjects)
  58. Hayhurst H, Cooper Z, Paykel ES, et al. Expressed emotion and depression. A longitudinal study. Br J Psychiatry. 1997;171:439. (Prospective, longitudinal study; 39 subjects)
  59. Klein DN, Shankman SA, Rose S. Ten-year prospective follow-up study of the naturalistic course of dysthymic disorder and double depression. Am J Psychiatry. 2006;163(5):872-880. (Prospective longitudinal; 142 subjects)
  60. Klein DN, Schwartz JE, Rose S, et al. Five-year course and outcome of dysthymic disorder: A prospective, naturalistic follow-up study. Am J Psychiatry. 2000;157(6):931-939. (Prospective longitudinal; 125 subjects)
  61. Williams J, Rost K, Dietrich A, et al. Primary care physicans’approach to depressive disorder. Effects of physician specialty and practice structure. Arch Fam Med. 1999; 8(1):58-67. (Questionnaire; 3375 physicians)
  62. Pary R, Lippmann S, Tobias C. A preventive approach to the suicidal patient. J Fam Pract. 1988;26(2):185-189. (Review article)
  63. Deeley S, Love AW. Does asking adolescents about suicidal ideation induce negative mood state? Violence Vict. 2010;25(5):677-688. (Randomized control study; 129 subjects, 71 controls)
  64. Sporer K, Khayam-Bashi H. Acetaminophen and salycilate serum levels in patients with suicidal ingestion or altered mental status. Am J Emerg Med. 1996;14(5):443-446. (Retrospective chart review; 1820 subjects)
  65. Bentur Y, Lurie Y, Tamir A, et al. Reliability of history of acetaminophen ingestion in intentional overdose patients. Hum Exp Toxicol. 2011;30(1):44-50. (Retrospective chart review; 154 patients)
  66. Hockberger RS, Rothstein R. Assessment of suicide potential by non-psychiatrists using the SAD PERSONS scale. J Emerg Med. 1998;6:99-107. (Survey data; 100 subjects)
  67. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165. (Review)
  68. Rule BG, Harvey HZ, Dobbs AR. Reliability of the Geriatric Depression Scale in younger adults. Clin Gerontol. 1989;9:37. (Cross-sectional study; 585 subjects)
  69. Rinaldi P, Meocci P, Benedetti C, et al. Validation of the five-item geriatric depression scale in elderly subjects in three different settings. J Am Geriatr Soc. 2003;51(5):694-698. (Cross-sectional study; 181 subjects)
  70. Richter P, Werner A, Heerlein Kraus, et al. On the validity of the Beck Depression Inventory. A review. Psychopathology. 1998; 31(3):160-168. (Review)
  71. Storch EA, Roberti JW, Roth DA. Factor structure, concurrent validity, and internal consistency of the Beck Depression Inventory-Second Edition in a sample of college students. Depress Anxiety. 2004;19(3):187-189. (Cross-sectional study; 440 subjects)
  72. Lipps G, Lowe G, De La Haye W, et al. Validation of the Beck Depression Inventory II in HIV-positive patients. West Indian Med. 2010;59(4):374-349. (Cross-sectional study; 191 subjects)
  73. Steer R, Cavalieri T, Leonard D, et al. Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders. Gen Hosp Psychiatry. 1999;21(2):106-111. (Cross-sectional study; 120 subjects)
  74. Biros M, Mann J, Hanson R, et al. Unsuspected or unacknowledged depressive symptoms in young adult emergency department patients. Acad Emerg Med. 2009;16(4):288-294. (Survey data; 1264 subjects)
  75. Kroenke K, Spitzer L, Williams B. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. (Psychometric/methods paper)
  76. Gilbody S, Richards D, Brealey S, et al. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22:1596. (Meta-analysis)
  77. Zuithoff N, Vergouwe Y, King M, et al. The Patient Health Questionnaire-9 for detection of major depressive disorder in primary care: consequences of current thresholds in a crosssectional study. BMC Fam Prac. 2010;13(11):98. (Crosssectional study; 1338 subjects)
  78. Lotrakul M, Sumrithe S, Saipanish R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry. 2008;20(8):46. (Cross-sectional study; 1000 subjects)
  79. Coyne J, Thombs B, Mitchell A. 2009. PHQ-9 and PHQ-2 in Western Kenya. J Gen Intern Med. 2009.24(7):890. (Observational; 347 subjects)
  80. Weobong B, Akpalu B, Doku V, et al. The comparative validity of screening scales for postnatal common mental disorders in Kintampo, Ghana. J Affect Disord. 2009.113(1-2):109-117. (Cross-sectional study; 160 subjects)
  81. Kroenke K, Spitzer R, Williams J. The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care. 2009;41(11):1284-1292. (Questionnaire/psychometric study; 6000 subjects)
  82. Corson K, Gerrity M, Dobscha S. Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item. Am J Manag Care. 2004;10(11 Pt 2):839-854. (Prospective; 1211 subjects)
  83. Arroll B, Goodyear-Smith F, Gunn J, et al. Validation of PHQ-22 and PHQ-9 to screen for major depression in the primary care population Ann Fam Med. 2009.8(4):348-353. (Prospective; 2642 subjects)
  84. Folstein M, Folstein S, McHugh P. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198. (Methods paper)
  85. Lukkens T, Wolf S, Edlow J, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99. (Clinical policy)
  86. Hetrick S, Merry S, McKenzie J, et al. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrance Database Syst Rev. 2007;18(3):CD004851. (Review; 12 trials)
  87. Kroenke K, West SL, Swindle R, et al. Similar effectiveness of paroxetine, fluoxetine, and sertraline in primary care: a randomized trial. JAMA. 2001;286:2947-2955. (Randomized control study; 573 subjects)
  88. Sechter D, Troy S, Paternetti S, et al. A double-blind comparison of sertraline and fluoxetine in the treatment of major depressive episode in outpatients. Eur Psychiatry. 1999;14:41-48. (Randomized control study; 240 subjects)
  89. Ekselius L, von Knorring L, Eberhard G. A double-blind multicenter trial comparing sertraline and citalopram in patients with major depression treated in general practice. Int Clin Psychopharmacol. 1997;12:323-331. (Randomized control study; 400 subjects)
  90. Farrow TL. “No suicide contracts” in community crisis situations: a conceptual analysis. J Psychiatr Ment Health Nurs. 2003;10(2):199-202. (Review)
  91. Stanford EJ, Goetz RR, Bloom JD. The no-harm contract in the emergency assessment of suicidal risk. J Clin Psychiatry. 1994;55(8):344-348. (Review of 14 case reports)
  92. Kroll J. Use of no-suicide contracts by psychiatrists in Minnesota. Am J Psychiatry. 2000;157(10):1684-1686. (Questionnaire; 267 psychiatrists)
  93. Lewis LM. No-harm contracts: a review of what we know. Suicide and Life-Threatening Behavior. 2007;37(1):50-57.
  94. Lukens TW, Wolf SW, Edlow JA, et al. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on critical issues in the diagnosis and management of the psychiatric patient in the emergency department. Ann Emerg Med. 2006;47:79-99. (Evidence-based guideline)
  95. Allen M, Currier G, Hughes D, et al. The expert consensus guideline series: treatment of behavioral emergencies. Postgrad Med Special Report. 2001:1-90. (Evidence-based guideline)
  96. Stone M, Jones M. Clinical review: relationship between antidepressant drugs and suicidal behavior in adults. Overview for December 13 meeting of psychopharmacologic drugs advisory committee (PDAC). US Food and Drug Administration. 2006.11-74. (Review study)
  97. Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ. 2009;180(3): 291-297. (Metaanalysis)
  98. Meis L, Erbes C, Kaler M, et al. The structure of PTSD among two cohorts of returning soldiers: before and after deployment to Iraq. J Abnorm Psychol. 2011;293-301. (Survey data; 445 subjects)
  99. Marx B, Brailey K, Proctor S, et al. Association of time since deployment, combat intensity, and posttraumatic stress symptoms with neuropsychological outcomes following Iraq war deployment. Arch Gen Psychiatry. 2009;66(9):996-1004. (Prospective cohort study; 268 subjects)
  100. Jakupcak M, Horester K, Varra A, et al. Hopelessness and suicidal ideation in Iraq and Afghanistan war veterans reporting subthreshold and threshold posttraumatic stress disorder. J Nerv Ment Dis. 2011;199(4):272-275. (Survey data; 275 patients)

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