Depressed and Suicidal Patients in the Emergency Department: An Evidence-Based Approach

Table of Contents

 

Though there is growing evidence that shows that ED patients present with high rates of depression and suicidal ideation, there are some novel strategies that emergency clinicians can use to quickly identify patients most at risk:

What are the DSM-5 symptoms for major depressive disorder (MDD)?

Is it necessary to diagnose MDD in the ED?

What are the differences between suicidal thoughts, ideation, gestures, and plans? How can you tell?

Are all suicidal patients “depressed?”

When is it appropriate to ask a patient whether they’ve been thinking about suicide?

What are the uses and validation evidence for PHQ-9, ED-SAFE PSS-3, C-SSRS, SAFE-T, ICARE2?

What are the 7 things that emergency clinicians are recommended to do when assessing patients with exacerbating psychiatric complaints?

Lethal-means counseling, no-suicide contracts, safety planning, zero suicide: what works, and how are they administered?

Do intoxicated patients need to sober up before evaluating them for suicidality?

What is the status of using inhaled ketamine (esketamine) in the ED?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Nomenclature and Classification
   2. Depression
   3. Suicide
6. Epidemiology
   1. Depression
   2. Suicide Risk Within Depression
      1. Prevalence
      2. Demographics
      3. Risk Factors
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Key Historical Questions
   2. Screening for Depression and Suicide
   3. Physical Examination
10. Diagnostic Studies
11. Treatment
    1. Maintaining a Safe Environment
    2. Safety Planning
    3. (Lack of) No-Suicide Contracts
    4. Lethal-Means Counseling
    5. Connecting With Follow-up Resources
    6. Pharmacotherapy
12. Special Populations
    1. Military Veterans
13. Controversies and Cutting Edge
    1. Ketamine and Treatment-Resistant Depression and Suicidality
    2. The Zero Suicide Model
    3. Alcohol Intoxication and Suicide Risk in the Emergency Department
    4. Postdischarge Patient Contact
    5. Enhancing Clinical Decision-Making
    6. Telepsychiatry
14. Disposition
    1. Suicide Risk Assessment Tools in Disposition Decisions
    2. Coordination of Follow-Up Care
       1. Involuntary Confinement
       2. Discharge and Referral
15. Summary
16. Risk Management Pitfalls for Evaluating Depression and Suicide Risk in the Emergency Department
17. Time and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway For Assessing Depression in the Emergency Department
20. Tables and Figures
    1. Table 1. Summary of DSM-5 Diagnostic Criterion A for Major Depression: Symptoms
    2. Table 2. Risk Factors for Major Depression
    3. Table 3. Medical Conditions Associated With Mood Disorder Symptoms
    4. Table 4. Patient Health Questionnaire-9 (PHQ-9)
    5. Table 5. Key Aspects of the Mental Status Evaluation on Physical Examination
    6. Table 6. Resources for Assisting Patients With Depression and at Risk for Suicide
    7. Figure 1. Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) Tool
21. References

Abstract

With more than 12 million emergency department visits annually related to substance abuse and mental health crises, and approximately 650,000 patients evaluated for suicide attempts, the ED is a critical clinical setting for intervention. This review presents an ED-focused approach to assessing depression and suicide risk, including background information on the classification, epidemiology, and known pathology of depression, as well as the assessment of suicide risk within depression. Best-practice recommendations are made regarding current mental status evaluation and management strategies. Cutting-edge interventions and approaches, including the use of assessment and screening tools, implementation of safety planning, the Zero Suicide model, continuing postdischarge contact, lethal-means counseling, and novel pharmacotherapy approaches are also reviewed.

Case Presentations

Between managing a septic patient and another with an acute stroke, you note 3 patients waiting to be seen: a 30-year-old apparently healthy man with an upper respiratory infection, an elderly man with a sprained ankle, and a woman needing a medication refill. The young man has a URI, but you also find out that he recently moved to the city and states that he is feeling “overwhelmed” and “sad;” at times thinking of ending his life because he “would be better off dead.” He has never seen a psychiatrist and has never been told by his primary care provider that he has any psychiatric illness. You wonder whether this patient meets criteria for a major depressive episode and whether there are screening tools that could be helpful in deciding whether a psychiatric consultation is indicated...

You enter the next bay to manage the elderly man with the ankle sprain. As you enter, you are met by a woman stating that she is concerned that her father, who twisted his ankle, has been increasingly depressed and has said to her on several occasions, “Maybe I’d be better off dead.” When talking to the patient, he states that he does occasionally have thoughts of wishing he was dead, but he has not had any specific plan. The ankle ends up being less concerning, and you now wonder: “Is this patient safe to go home?” You consider what steps you should take to ensure his safety...

The third patient is an 82-year-old woman whose family is concerned that she is depressed. When asking her about her mood, she states that she feels “really sad.” She has a history of hypothyroidism and medication noncompliance, hence the medication refill. You wonder whether the clinical presentation could be due to her thyroid disease, and if there is anything that needs to be done in the ED...

Introduction

Mental-health-related chief complaints, including substance abuse, account for nearly 12.5% of emergency department (ED) visits.¹ Emergency clinicians see a broad range of mental health complaints and play a critical role in the management of psychiatric emergencies, with mood disorders being the most common (42.7%), followed by anxiety disorders (26.1%), and alcohol-related conditions (22.9%).¹ Data from the United States Public Health Service show that, annually, nearly 650,000 individuals are evaluated in EDs for suicide attempts, with a population-based annual rate ranging from 163.¹ to 173.8 per 100,000.^2,3

Evaluating and treating depression in the acute care setting presents numerous challenges for providers. For example, in the ED, depression may manifest in seemingly unrelated somatic complaints, such as unexplained chest pain.^4,5 Research has shown that, among adults presenting to an urban ED for acute, unexplained chest and somatic complaints, approximately 23% met criteria for a major depressive episode.⁶ Sociocultural differences among ethnic groups may cause symptoms of depression to manifest in different ways, making recognition difficult. Similarly, among the elderly, signs of depression can be misinterpreted as early dementia (and vice versa), making the detection of depression challenging.^7,8

This issue of Emergency Medicine Practice provides an ED-focused approach to assessing depression and suicide risk. Background information is provided regarding the classification, epidemiology, and known pathology of depression, as well as suicide risk within depression. Best-practice recommendations are made regarding evaluation and current management strategies along with cutting-edge interventions and approaches.

Critical Appraisal of the Literature

The primary references and articles for this review were collected from Ovid MEDLINE^®, Web of Science, Cochrane Database of Systematic Reviews, Google Scholar, and PubMed. A search of PubMed was performed through March 2019 using the terms depression, suicide, suicidal ideation, depression in the emergency department, behavioral emergencies, psychiatric emergencies, biology of depression, depression treatment, suicide attempt treatment, suicide, and emergency department. A guideline search identified a recent clinical policy on the evaluation of the psychiatric patient in the ED.⁹ A Cochrane review of depression revealed nearly 572 review summaries, 87 of which were relevant to this article. There are also 2 excellent narrative review papers on suicide and depression in the ED.^10,11

Risk Management Pitfalls for Evaluating Depression and Suicide Risk in the Emergency Department

1. “The patient often comes to our ED intoxicated and leaves when he's sober. I thought he was just drunk and wanted to sleep.”

Patients who make frequent visits to the ED often get broadly overlooked. 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 re-evaluate when they are sober.

4. “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 reported by depressed patients when presenting to their healthcare providers. Maintain a high index of suspicion for depression.

8. “The patient said he 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, medications should be prescribed in collaboration with the patient’s outpatient psychiatrist/primary care provider to ensure follow-up as well as appropriateness. 

Tables and Figures

References

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 is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report)
2. Canner J, Giuliano K, Selvarajah S, et al. Emergency department visits for attempted suicide and self harm in the USA: 2006–2013. Epidemiol Psychiatr Sci. 2018;27(1):94-102. (Epidemiologic study)
3. Spicer RS, Miller TR. Suicide acts in 8 states: incidence and case fatality rates by demographics and method. Am J Public Health. 2000;90(12):1885-1891. (Epidemiologic data)
4. Simms LJ, Prisciandaro JJ, Krueger RF, et al. The structure of depression, anxiety and somatic symptoms in primary care. Psychol Med. 2012;42(1):15-28. (Review article)
5. Kuijpers PM, Denollet J, Wellens HJ, et al. Noncardiac chest pain in the emergency department: the role of cardiac history, anxiety or depression and type D personality. Eur J Cardiovasc Prev Rehabil. 2007;14(2):273-279. (Prospective observational cohort; 304 patients)
6. Yingling KW, Wulsin LR, Arnold LM, et al. Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain. J Gen Intern Med. 1993;8(5):231-235. (Prospective observational cohort; 342 patients)
7. Meldon SW, Emerman CL, Schubert DS. Recognition of depression in geriatric ED patients by emergency physicians. Ann Emerg Med. 1997;30(4):442-447. (Observational study; 101 subjects)
8. Meldon SW, Emerman CL, Schubert DS, et al. Depression in geriatric ED patients: prevalence and recognition. Ann Emerg Med. 1997;30(2):141-145. (Prospective observational cohort; 259 patients)
9. Brown MD, Byyny R, Diercks DB, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2017;69(4):480-498. (Clinical policy)
10. Petrik ML, Betz ME, Olson-Madden JH, et al. Identification, assessment, and management of suicide risk in emergency departments: significant updates in research and practice. Curr Emerg Hosp Med Rep. 2017;5(2):94-102. (Review article)
11. Betz ME, Boudreaux ED. Managing suicidal patients in the emergency department. Ann Emerg Med. 2016;67(2):276-282. (Review article)
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book)
13. Bohnert ASB, Ilgen MA. Understanding links among opioid use, overdose, and suicide. N Engl J Med. 2019;380(1):71-79. (Review article)
14. Kessler RC, Petukhova M, Sampson NA, et al. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169-184. (Epidemiologica study; 5295 patients)
15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients)
16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects)
17. Boudreaux ED, Cagande C, Kilgannon H, et al. A prospective study of depression among adult patients in an urban emergency department. Prim Care Companion J Clin Psychiatry. 2006;8(2):66-70. (Prospective cohort convenience sample; 182 patients)
18. Larkin GL, Claassen CA, Emond JA, et al. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677. (Epidemiologic study)
19. Chakravarthy B, Toohey S, Rezaimehr Y, et al. National differences between ED and ambulatory visits for suicidal ideation and attempts and depression. Am J Emerg Med. 2014;32(5):443-447. (Epidemiologic study)
20. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575-1586. (Epidemiologic study)
21. 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(7):785-795. (Face-to-face household survey; 72,933 subjects)
22. 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(6):617-627. (Survey; 9282 subjects)
23. Kumar A, Clark S, Boudreaux ED, et al. A multicenter study of depression among emergency department patients. Acad Emerg Med. 2004;11(12):1284-1289. (Cross-sectional study; 752 patients)
24. Williams DR, Gonzalez 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(3):305-315. (Retrospective study; 6082 subjects)
25. 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(2):225-237. (Survey; 9282 subjects)
26. Hasin DS, Goodwin RD, Stinson FS, et al. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62(10):1097-1106. (Epidemiologic study)
27. Ilgen MA, Walton MA, Cunningham RM, et al. Recent suicidal ideation among patients in an inner city emergency department. Suicide Life Threat Behav. 2009;39(5):508-517. (Retrospective case review; 5641 patients)
28. Hasin DS, Sarvet AL, Meyers JL, et al. Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry. 2018;75(4):336-346. (Epidemiologic study; 36,309 patients)
29. Doshi A, Boudreaux ED, Wang N, et al. National study of US emergency department visits for attempted suicide and self-inflicted injury, 1997-2001. Ann Emerg Med. 2005;46(4):369-375. (Epidemiologic study)
30. Holma KM, Melartin TK, Haukka J, et al. Incidence and predictors of suicide attempts in DSM–IV major depressive disorder: a five-year prospective study. Am J Psychiatry. 2010;167(7):801-808. (Epidemiologic study)
31. Blair-West GW, Cantor CH, Mellsop GW, et al. Lifetime suicide risk in major depression: sex and age determinants. J Affect Disord. 1999;55(2):171-178. (Epidemiologic study)
32. Greenberg PE, Fournier A-A, Sisitsky T, et al. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). J Clin Psychiatry. 2015;76(2):155-162. (Epidemiologic study)
33. Centers for Disease Control and Prevention. Homicides and suicides--national violent death reporting system, United States, 2003-2004. MMWR Morb Mortal Wkly Rep. 2006;55(26):721-724. (Government statistical report from 13 states)
34. Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med. 1997;337(13):910-915. (Review article)
35. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70. (Systematic review and meta-analysis; 476 papers, 28 studies; 214,344 heterosexual people, 11,971 nonheterosexual people)
36. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations. J Homosex. 2011;58(1):10-51. (Expert panel review)
37. Herrell R, Goldberg J, True WR, et al. Sexual orientation and suicidality: a co-twin control study in adult men. Arch Gen Psychiatry. 1999;56(10):867-874. (Twin study; 103 pairs of male twins)
38. Franklin JC, Ribeiro JD, Fox KR, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187-232. (Meta-analysis; 365 studies)
39. Pokorny AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry. 1983;40(3):249-257. (Prospective study; 4800 subjects)
40. Hawton K. Suicide and attempted suicide. In: Pankel E, ed. Handbook of Affective Disorders. 2nd ed. Guilford, New York;1992:635. (Textbook)
41. Evenson RC, Wood JB, Nuttall EA, et al. Suicide rates among public mental health patients. Acta Psychiatr Scand. 1982;66(3):254-264. (Epidemiologic data)
42. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry. 2000;157(12):1925-1932. (Meta-analysis; 30 studies)
43. Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry. 2005;62(11):1249-1257. (Retrospective study; 4796 subjects)
44. Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 2005;62(3):247-253. (Meta-analysis; 61 studies)
45. Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project Beta Medical Evaluation Workgroup. West J Emerg Med. 2012;13(1):3-10. (Concept paper/consensus statement)
46. Chu C, Van Orden KA, Ribeiro JD, et al. Does the timing of suicide risk assessments influence ratings of risk severity? Prof Psychol Res Pr. 2017;48(2):107-114. (Prospective observational; 169 patients)
47. Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(7):694-702. (Systematic review; 100 studies, 183 patients)
48. Roaten K, Johnson C, Genzel R, et al. Development and implementation of a universal suicide risk screening program in a safety-net hospital system. Jt Comm J Qual Patient Saf. 2017. (Survey instrument design, retrospective; 328,064 participants)
49. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. (Psychometric/methods paper)
50. 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(11):1596-1602. (Meta-analysis; 14 studies, 5026 patients)
51. Burger J, Capobianco M, Lovern R, et al. A double-blinded, randomized, placebo-controlled sub-dissociative dose ketamine pilot study in the treatment of acute depression and suicidality in a military emergency department setting. Mil Med. 2016;181(10):1195-1199. (Randomized controlled trial; 10 patients)
52. Hyphantis T, Kotsis K, Kroenke K, et al. Lower PHQ-9 cutpoint accurately diagnosed depression in people with long-term conditions attending the accident and emergency department. J Affect Disord. 2015;176:155-163. (Prospective cohort; 349 patients)
53. Barbic S, MacEwan WG, Leon A, et al. LO60: Validation of the PHQ-9 as a screen for depression in the emergency department. CJEM. 2017;19(S1):S48-S48. (Prospective cohort; 200 patients)
54. Zuithoff NP, 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 Pract. 2010;11:98. (Cross-sectional study; 1338 subjects)
55. Lotrakul M, Sumrithe S, Saipanish R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry. 2008;8:46. (Cross-sectional study; 1000 subjects)
56. Coyne JC, Thombs BD, Mitchell AJ. PHQ-9 and PHQ-2 in Western Kenya. J Gen Intern Med. 2009;24(7):890-890. (Observational; 347 subjects)
57. Weobong B, Akpalu B, Doku V, et al. The comparative validity of screening scales for postnatal common mental disorder in Kintampo, Ghana. J Affect Disord. 2009;113(1-2):109-117. (Cross-sectional study; 160 subjects)
58. Martin-Subero M, Kroenke K, Diez-Quevedo C, et al. Depression as measured by PHQ-9 versus clinical diagnosis as an independent predictor of long-term mortality in a prospective cohort of medical inpatients. Psychosom Med. 2017;79(3):273-282. (Prospective cohort; 803 participants)
59. Boudreaux ED, Jaques ML, Brady KM, et al. The patient safety screener: validation of a brief suicide risk screener for emergency department settings. Arch Suicide Res. 2015;19(2):151-160. (Psychometric study)
60. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266-1277. (Psychometric study, prospective cohort; 673 patients)
61. Boudreaux ED, Camargo CA, Arias SA, et al. Improving suicide risk screening and detection in the emergency department. Am J Prev Med. 2016;50(4):445-453. (Prospective observational cohort; 236,791 patients)
62. Miller IW, Camargo CA, Arias SA, et al. Suicide prevention in an emergency department population: the ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570. (Prospective observational cohort; 1376 participants)
63. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005;293(13):1635-1643. (Randomized controlled trial; 2342 participants)
64. DeCou CR, Schumann ME. On the iatrogenic risk of assessing suicidality: a meta-analysis. Suicide Life Threat Behav. 2017. (Meta-analysis; 13 studies)
65. Henriques JB, Davidson RJ. Left frontal hypoactivation in depression. J Abnorm Psychol. 1991;100(4):535-545. (Review article)
66. Chennapan K, Mullinax S, Anderson E, et al. Medical screening of mental health patients in the emergency department: a systematic review. J Emerg Med. 2018;55(6):799-812. (Systematic review; 60 studies)
67. Anderson EL, Nordstrom K, Wilson MP, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults part I: introduction, review and evidence-based guidelines. West J Emerg Med. 2017;18(2):235-242. (Review/concepts paper)
68. Wilson MP, Nordstrom K, Anderson EL, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. part II: controversies over medical assessment, and consensus recommendations. West J Emerg Med. 2017;18(4):640-646. (Review/concept paper)
69. Stanley B, Chaudhury SR, Chesin M, et al. An emergency department intervention and follow-up to reduce suicide risk in the VA: acceptability and effectiveness. Psychiatr Serv. 2016;67(6):680-683. (Semistructured interview; 100 patients)
70. Chesin MS, Stanley B, Haigh EA, et al. Staff views of an emergency department intervention using safety planning and structured follow-up with suicidal veterans. Arch Suicide Res. 2017;21(1):127-137. (Prospective survey; 50 patients)
71. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256-264. (Review article)
72. Stanley B, Brown GK, Currier GW, et al. Brief intervention and follow-up for suicidal patients with repeat emergency department visits enhances treatment engagement. Am J Public Health. 2015;105(8):1570-1572. (Prospective observational cohort;1102 participants)
73. Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75(9):894-900. (Prospective cohort comparison design; 1186 patients with intervention; 454 patients comparison/control)
74. Suicide Prevention Resource Center. Caring for adult patients with suicide risk: a consensus-based guide for emergency departments. Accessed April 10, 2019. (Online resource)
75. 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)
76. Bryan CJ, Mintz J, Clemans TA, et al. Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial. J Affect Disord. 2017;212:64-72. (Randomized controlled trial; 97 patients)
77. Kroll J. Use of no-suicide contracts by psychiatrists in Minnesota. Am J Psychiatry. 2000;157(10):1684-1686. (Questionnaire; 267 psychiatrists)
78. Garvey KA, Penn JV, Campbell AL, et al. Contracting for safety with patients: clinical practice and forensic implications. J Am Acad Psychiatry Law. 2009;37(3):363-370. (Review article)
79. Barber CW, Miller MJ. Reducing a suicidal person’s access to lethal means of suicide: a research agenda. Am J Prev Med. 2014;47(3 Suppl 2):S264-S272. (Review article/concepts paper)
80. Suicide Prevention Resource Center. Suicide prevention fact sheets. Accessed April 10, 2019. (Online resource)
81. Betz ME, Miller M, Barber C, et al. Lethal means access and assessment among suicidal emergency department patients. Depress Anxiety. 2016;33(6):502-511. (Retrospective study; 1358 charts)
82. Runyan CW, Brooks-Russell A, Tung G, et al. Hospital emergency department lethal means counseling for suicidal patients. Am J Prev Med. 2017. (Retrospective chart review; 363 institutions)
83. Runyan CW, Becker A, Brandspigel S, et al. Lethal means counseling for parents of youth seeking emergency care for suicidality. West J Emerg Med. 2016;17(1):8-14. (Prospective cohort; 236 patients)
84. Cremniter D, Payan C, Meidinger A, et al. Predictors of short-term deterioration and compliance in psychiatric emergency patients: a prospective study of 457 patients referred to the emergency room of a general hospital. Psychiatry Res. 2001;104(1):49-59. (Prospective cohort study; 457 patients)
85. Daly EJ, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine adjunctive to oral antidepressant therapy in treatment-resistant depression: a randomized clinical trial. JAMA Psychiatry. 2018;75(2):139-148. (Randomized controlled trial; 67 patients)
86. Kroenke K, West SL, Swindle R, et al. Similar effectiveness of paroxetine, fluoxetine, and sertraline in primary care: a randomized trial. JAMA. 2001;286(23):2947-2955. (Randomized controlled study; 573 subjects)
87. 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(1):41-48. (Randomized controlled study; 240 subjects)
88. 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(6):323-331. (Randomized controlled study; 400 subjects)
89. Meis LA, Erbes CR, Kaler ME, et al. The structure of PTSD among two cohorts of returning soldiers: before, during, and following deployment to Iraq. J Abnorm Psychol. 2011;120(4):807-818. (Survey data; 445 subjects)
90. Marx BP, Brailey K, Proctor SP, 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)
91. Rosenfeld JV, Ford NL. Bomb blast, mild traumatic brain injury and psychiatric morbidity: a review. Injury. 2010;41(5):437-443. (Review article)
92. Shively SB, Horkayne-Szakaly I, Jones RV, et al. Characterisation of interface astroglial scarring in the human brain after blast exposure: a post-mortem case series. Lancet Neurol. 2016;15(9):944-953. (Retrospective case series; 15 subjects)
93. Jakupcak M, Hoerster KD, 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)
94. McClure JR, Criqui MH, Macera CA, et al. Prevalence of suicidal ideation and other suicide warning signs in veterans attending an urgent care psychiatric clinic. Compr Psychiatry. 2015;60:149-155. (Prospective cohort study; 473 patients)
95. Smith EG, Craig TJ, Ganoczy D, et al. Treatment of veterans with depression who died by suicide: timing and quality of care at last Veterans Health Administration visit. J Clin Psychiatry. 2011;72(5):622-629. (Retrospective case study; 1843 patients)
96. Wan L-B, Levitch CF, Perez AM, et al. Ketamine safety and tolerability in clinical trials for treatment-resistant depression. J Clin Psychiatry. 2015;76(3):247-252. (Prospective observational study; 205 participants)
97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants)
98. Ballard ED, Ionescu DF, Voort JLV, et al. Improvement in suicidal ideation after ketamine infusion: relationship to reductions in depression and anxiety. J Psychiatr Res. 2014;58:161-166. (Prospective observational study; 133 participants)
99. Price RB, Iosifescu DV, Murrough JW, et al. Effects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant depression. Depress Anxiety. 2014;31(4):335-343. (Randomized controlled trial; 57participants)
100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)
101. United States Food and Drug Administration. FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor’s office or clinic. Accessed April 10, 2019. (FDA news release)
102. Suicide Prevention Resource Center. Zero Suicide. Accessed April 10, 2019. (Online resource)
103. Coffey CE. Building a system of perfect depression care in behavioral health. Jt Comm J Qual Patient Saf. 2007;33(4):193-199. (Concept paper)
104. Knox KL, Pflanz S, Talcott GW, et al. The US Air Force suicide prevention program: implications for public health policy. Am J Public Health. 2010;100(12):2457-2463. (Model/concepts paper)
105. Labouliere CD, Vasan P, Kramer A, et al. “Zero suicide” - a model for reducing suicide in United States behavioral healthcare. Suicidologi. 2018;23(1):22-30. (Model/theory paper)
106. Heikkinen ME, Isometsa ET, Marttunen MJ, et al. Social factors in suicide. Br J Psychiatry. 1995;167(6):747-753. (Retrospective study; 1067 subjects)
107. Borges G, Rosovsky H. Suicide attempts and alcohol consumption in an emergency room sample. J Stud Alcohol. 1996;57(5):543-548. (Prospective cohort study; 40 patients)
108. Ting SA, Sullivan AF, Boudreaux ED, et al. Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008. Gen Hosp Psychiatry. 2012;34(5):557-565. (Epidemiologic study)
109. Lukens TW, Wolf SJ, Edlow JA, 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. (Evidence-based guideline)
110. Allen MH, Currier GW, Hughes DH, et al. The expert consensus guideline series. Treatment of behavioral emergencies. Postgrad Med. 2001(Spec No):1-88. (Evidence-based guideline)
111. Vaiva G, Vaiva G, Ducrocq F, et al. Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study. BMJ. 2006;332(7552):1241-1245. (Multicenterrandomized controlled trial; 605 patients)
112. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv. 2001;52(6):828-833. (Randomized controlled trial; 843 patients)
113. Carter GL, Clover K, Whyte IM, et al. Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. BMJ. 2005;331(7520):805.(Randomized controlledtrial;772patients)
114. Luxton DD, June JD, Comtois KA. Can postdischarge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. Crisis. 2013;34(1):32-41. (Narrative review)
115. Chang BP, Tan TM. Suicide screening tools and their association with near-term adverse events in the ED. Am J Emerg Med. 2015;33(11):1680-1683. (Prospective observational study; 50 participants)
116. Mullinax S, Chalmers CE, Brennan J, et al. Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department. Am J Emerg Med. 2018. (Prospective observational study; 276participants)
117. Cha CB, O’Connor RC, Kirtley O, et al. Testing mood-activated psychological markers for suicidal ideation. J Abnorm Psychol. 2018. (Prospective observational study; 157 participants)
118. Nock MK, Park JM, Finn CT, et al. Measuring the suicidal mind: implicit cognition predicts suicidal behavior. Psychol Sci. 2010;21(4):511-517. (Prospective observational study; 157 participants)
119. Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clin Psychol Sci. 2017;5(3):457-469. (Retrospective study; 5167 participants)
120. Heravian A, Chang BP. Mental health and telemedicine in the acute care setting: applications of telepsychiatry in the ED. Am J Emerg Med. 2018;36(6):1118-1119. (Concepts paper/narrative review)
121. Williams MP, M.; Boyle, J. Telepsychiatry in the emergency department: overview and case studies. 2009. Accessed April 10, 2019. (Website)
122. Wilson MP, Brennan JJ, Modesti L, et al. Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use. Am J Emerg Med. 2015;33(4):527-530. (Retrospective cohort study; 640 patients)
123. American College of Emegency Physicians. ICARE2: a tool for managing suicidal patients in the ED. Accessed April 10, 2019. (Website)
124. Carter G, Milner A, McGill K, et al. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387-395. (Systematic review and meta-analysis)
125. Coyle TN, Shaver JA, Linehan MM. On the potential for iatrogenic effects of psychiatric crisis services: the example of dialectical behavior therapy for adult women with borderline personality disorder. J Consult Clin Psychol.2018;86(2):116. (Prospectiveobservational study; 101 participants)
126. Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(1 Suppl):49-59. (Case controlled study; 153 participants)
127. García-Gigorro R, de la Cruz Vigo F, Andrés-Esteban E, et al. Impact on patient outcome of emergency department length of stay prior to ICU admission. Medicina Intensiva (English Edition). 2017;41(4):201-208. (Prospective observationalcohortstudy; 269 participants)
128. Knesper DJ. Suicide Prevention Resource Center. Continuity of care for suicide prevention and research: suicide attempts and suicide deaths subsequent to discharge from an emergency department or an inpatient psychiatry unit. Accessed April 10, 2019. (Online resource)