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.
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...
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.
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
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.
|Table 6. Resources for Assisting Patients With Depression and at Risk for Suicide|
|ED-SAFE (PSS-3)||Patient Safety Screener||ED-SAFE|
|Columbia-Suicide Severity Rating Scale (C-SSRS)||Suicide rating scales||Columbia C-SSRS|
|ICARE2, American College of Emergency Physicians||Tool for managing suicidal patients in the emergency department||ICARE2|
|Suicide Assessment Five-Step Evaluation and Triage (SAFE-T)||Suicide assessment tool||SAFE-T|
|Suicide Prevention Resource Center: Resource center of Education Development Center, supported by the United States Substance Abuse and Mental Health Services Administration (SAMHSA)|
|National Suicide Prevention Lifeline||Crisis telephone line||1-800-273-8255 [TALK]|
|National Suicide Prevention Lifeline Chat||Online chat line||Lifeline Chat|
|Zero Suicide||Health and behavioral system model||National Action Alliance for Suicide Prevention|
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.
Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry
Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department.
Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression?
Nachi: That would certainly be all of our listeners!
Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval?Show More v
Nachi: Again, just about all of our listeners I’m sure!
Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes?
Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in.
Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University.
Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside.
Jeff: Quite the team, from a variety of backgrounds.
Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt.
Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23%
Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode.
Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable.
Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions.
Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history.
Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest.
Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks.
Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning.
Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes.
Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD.
Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder.
Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself.
Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.”
Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt.
Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan.
Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%.
Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers...
Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients.
Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men.
Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older.
Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression.
Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide.
Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US.
Nachi: That’s an incredible amount and much more than I would have guessed.
Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals.
Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often.
Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods.
Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts
Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another.
Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study.
Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation.
Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality.
Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization.
Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations.
Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions.
Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations.
Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings.
Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise.
Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide.
Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt.
Jeff: In one study, using this tool doubled the number of suicide-risk cases detected.
Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener.
Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit.
Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it?
Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations.
Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical.
Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression.
Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression.
Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here.
Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease.
Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing.
Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility.
Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility.
Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management.
Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion.
Nachi: That wraps up testing. Let’s move on to treatment.
Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable.
Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation.
Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes.
Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do.
Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling).
Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary.
Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do.
Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts.
Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means.
Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend.
Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths.
Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means.
Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time.
Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling.
Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline.
Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations.
Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there.
Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan.
Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though...
Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans.
Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms.
Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population.
Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death.
Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care.
Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed.
Nachi: Let’s talk controversies and cutting-edge topics from this issue.
Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality.
Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting.
Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression.
Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future.
Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition.
Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED.
Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated.
Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide.
Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED.
Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment.
Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines.
Nachi: Moving on to the next topic - let’s discuss post discharge patient contact.
Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%.
Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact.
Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors.
Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance.
Jeff: The last cutting-edge topic to discuss is telepsychiatry.
Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access.
Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated.
Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations.
Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold.
Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches.
Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making.
Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization.
Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed.
Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible.
Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls.
Nachi: So that wraps up Episode 28!
Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%.
Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask.
Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at firstname.lastname@example.org with any comments or suggestions. Talk to you next month!
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)
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book)
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)
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)
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)
Drs. Nachi Gupta and Jeff Nusbaum are practicing emergency physicians in two busy EDs in the US. Join Jeff, a former firefighter, and Nachi, a former mathematician, as they take you through the May 2019 issue of Emergency Medicine Practice: Depressed and Suicidal Patients in the Emergency Department: An Evidence-Based Approach (Behavioral Health CME).
Get quick-hit summaries of hot topics in emergency medicine. EMplify summarizes evidence-based reviews in a monthly podcast. Highlights of the latest research published in EB Medicine's peer-reviewed journals educate and arm you for life in the ED.
Why to Use
The PHQ-9 objectively determines initial symptom severity in depression. It also monitors symptom changes and the effect of treatment over time.
When to Use
The PHQ-9 is a screening tool that is used:
The final diagnosis of depression should be made with a clinical interview and mental status examination, including assessment of the patient’s level of distress and functional impairment.
Ferda Sakman, MD
A suicide risk assessment should be performed for patients who respond positively to item 9 on the PHQ-9 (“Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?”).
Bipolar disorder, normal bereavement, and medical disorders should be ruled out as the causes of depression.
The PHQ-9 was initially developed by Kroenke et al (2001) as a subset of 9 questions from the full Patient Health Questionnaire, which had been derived previously and studied in a cohort of 6000 patients in 8 primary care clinics and 7 obstetrics and gynecology clinics (Spitzer 1999). PHQ-9 scores of ≥ 10 points were found to be 88% sensitive and 88% specific for detecting MDD. Kroenke et al (2001) assessed the criterion validity in a sample of 580 patients.
Arroll et al (2010) validated the PHQ-9 as a screener for MDD in a cohort of 2642 primary care patients and found slightly higher specificity (91%) and lower sensitivity (74%) at the same cutoff of ≥ 10 points.
The PHQ-9 has also been validated in several additional subpopulations, including in psychiatry patients (Beard 2016), patients with medical comor-bidities such as multiple sclerosis (Ferrando 2007) and Parkinson disease (Chagas 2013), pregnant patients (Sidebottom 2012), and in an occupational health setting (Volker 2016).
Kurt Kroenke, MD
Why to Use
Suicide risk assessment is complex; the C-SSRS can assist clinicians in evaluation of patients in the emergency department to predict overall suicide risk and the need for admission. The C-SSRS has been extensively validated in several subpopulations, including children and adolescents, military veterans with concomitant posttraumatic stress disorder, and psychiatry outpatients.
The C-SSRS is recommended by the United States Food and Drug Administration for clinical trials (United States Food and Drug Administration 2012), and has been adopted by the Centers for Disease Control and Prevention to define and stratify suicidal ideation and behavior (Crosby 2011).
When to Use
The C-SSRS should be used in patients in the emergency department for whom there is a concern for suicidality.
Protocols vary by institution, but most recommend a complete assessment by a psychiatrist and inpatient admission for patients identified as high risk (Level 4 or 5). Patients at low to moderate risk should be reassessed by a trained clinician and may not require admission.
Joshua Salvi, MD, PhD
The C-SSRS should not replace a complete clinical evaluation. It may be employed as an initial screening to guide a clinician in suicide risk assessment and to help stratify patients into categories of low, moderate, or high risk.
The C-SSRS was originally derived by researchers at Columbia University, the University of Pennsylvania, and the University of Pittsburgh (Posner 2011).
While suicidal ideation and behavior had previously been understood as one-dimensional, with passive ideation progressing to active intent and then to suicidal behavior, the C-SSRS attempted to separate ideation and behavior by using 4 constructs (severity of ideation, intensity of ideation, behavior, and lethality), based on factors identified in previous studies as predictive of suicide attempts and completed suicide.
In a study of 3776 patients who had a baseline C-SSRS screening and at least 1 follow-up, positive reports had 67% sensitivity and 76% specificity for identifying suicidal behaviors (Mundt 2013).
Similar findings have been reproduced by others. In a longitudinal study of 1055 adults admitted to a psychiatric hospital, the C-SSRS was found to have excellent internal consistency (alpha = 0.95), with the summary score and total score revealing adequate classification for suicide-related behavior within 6 months (sensitivity 69%; specificity 65%- 67%) (Madan 2016).
The C-SSRS has been used in numerous trials and has been extensively validated in several sub-populations, including children as young as 5 years of age (Glennon 2014); military veterans with concomitant posttraumatic stress disorder (Legarreta 2015); and outpatients in a psychiatry clinic (Viguera 2015). It has been translated for use in more than 30 languages (Gratalup 2013).
Kelly Posner, PhD
Why to Use
Among patients presenting to the ED with nonpsychiatric chief complaints, 3% to 12% also have suicidal ideation (Boudreaux 2013). Identification of these at-risk patients is an important first step in implementing an intervention to prevent the sequelae of suicidal behavior. Traditional suicide-risk measures are lengthy and complex, but the PSS-3 is a short, efficient screening tool that can be integrated easily into an existing clinical workflow in the ED.
When to Use
The PSS-3 should be used to screen for suicide risk in patients presenting to the ED for any complaint, including nonpsychiatric complaints.
A patient with a positive screening result on the PSS-3 should be further assessed by the treating clinician to determine whether a mental health professional should be consulted. The provision of a safety plan should also be considered.
Hyunjoo Lee, MD
The PSS-3 is meant to be a universal screening tool. All patients presenting to the emergency department (ED) can be screened with this tool, even when the primary complaint is nonpsychiatric.
The PSS-3 is a screening tool and not an endpoint. A positive screening result should prompt the clinician to assess the patient further for suicidality and to consider consulting a mental health professional.
More in-depth screening and assessments tools for suicide risk include the BSSI and the Columbia- Suicide Severity Rating Scale (C-SSRS). Patients for whom there is high concern for suicidality should be assessed by a mental health specialist.
Boudreaux et al (2013) designed the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study to determine whether universal screening of ED patients could improve detection of patients with suicide risk, and whether an intervention initiated from the ED visit can improve outcomes related to suicidality. Given the high-risk nature of suicidality, the ED-SAFE investigators used a quasi-experimental multiphase design instead of a randomized control trial.
Eight EDs in 7 states participated in the study, including large academic centers as well as small community hospitals. The objective of Phase 1 of the study, “Treatment as Usual,” was to obtain baseline data. Research assistants prospectively collected data from chart documentations of intentional self-harm ideation or behavior, and patients received the usual care. In Phase 2, “Universal Screening,” screening was implemented with the PSS-3 being administrated by the primary treating nurse. In Phase 3, “Universal Screening Plus Intervention,” patients with a positive screening had secondary screening administered by a physician to determine whether to consult a mental health specialist. Patients also received a safety plan and up to 7 follow-up phone calls over the next year as part of the intervention. Outcomes were assessed by phone interviews or medical record reviews at 6, 12, 24, 36, and 52 weeks.
The 3-item PSS-3 was used for universal screening in the ED-SAFE Study. The original Patient Safety Screener, called the PSS-5, consisted of 5 items derived from the Patient Health Questionnaire-9 (PHQ-9) and the C-SSRS. The PSS-5 assessed for anhedonia, depressed mood, passive suicidal ideation, active suicidal ideation, and lifetime suicide attempt.
The validation study by Boudreaux et al (2015) compared 2-item and 3-item versions of the Patient Safety Screener (PSS-2 and PSS-3, respectively) with the well-validated but much lengthier BSSI. The PSS-3 assessed for depression, active suicidal ideation, and prior lifetime suicide attempt, while the PSS-2 omitted the question related to depression. Patients who were unable to engage in conversation were excluded. Patients had a positive screening result if there was active suicidal ideation in the previous 2 weeks or if there was a lifetime history of suicide attempt. The study enrolled 951 participants across 3 EDs, with 459 participants randomized into the PSS-2 group versus 492 participants in the PSS-3 group. Overall, 15.2% of the patients had a positive screening re-sult. A strong agreement with the BSSI was demonstrated for both the PSS-2 (kappa = 0.94) and the PSS-3 (kappa = 0.95); however, the agreement on active suicidal ideation was stronger for the PSS-3 (kappa = 0.61) than for the PSS-2 (kappa = 0.34).
Caterino et al (2013) summarized the baseline suicide risk screening rate by reviewing 94,354 charts in a prospective observational cohort study, which was the first phase in the larger ED-SAFE study. One of the study sites was an outlier, as it included a version of universal screening as part of “treatment as usual.” Overall, 26% of the patients in the study were assessed for self-harm, with that proportion dropping to 12% when excluding the data from the outlier site. In this Phase 1 study, only 2.7% of patients were documented as having current self-harm ideation. The study also found that men, in general, and younger men, in particular, were more likely to be assessed for self-harm, while older adults (aged ≥ 65 years) were less likely to be assessed.
Boudreaux et al (2016) reviewed 236,791 charts to analyze the effect of universal screening. Docu-mentation of screening for suicide risk increased across the phases of the ED-SAFE study (26% in Phase 1, 73% in Phase 2, and 84% in Phase 3 [P < .001]). With increases in screening, there were also increases in the detection of intentional self-harm ideation or behavior (2.9% in Phase 1, 5.2% in Phase 2, 5.7% in Phase 3 [P < .001]).
Miller et al (2017) analyzed the effects of implementing an ED-initiated intervention for patients who were positive on the universal screening. The intervention consisted of a secondary suicide risk screening conducted by the treating ED physician, the provision of a safety plan that was reviewed with the patient by nursing staff, and follow-up phone calls from advisors trained on the Coping Long Term with Active Suicide Program (CLASP) protocol to reduce suicide risk. The study enrolled 1376 patients in 3 phases: 497 in the treatment-as-usual phase, 377 in the universal-screening (“screening”) phase, and 502 in the universal-screening-plus-intervention (“intervention”) phase.
While 89.4% of the patients in the intervention phase received a secondary suicide risk assessment, only 3.9% of those patients were assessed using the ED-SAFE–designated secondary screening tool. Among the intervention-phase patients, 60.8% completed at least 1 CLASP protocol phone call, with 37.4% of those patients reporting that they received a written safety plan during the ED visit. During the 1-year study period, 20.9% of all study participants made at least 1 suicide attempt (22.9% of the treatment-as-usual phase patients, 21.5% of the screening-phase patients, and 18.3% of the intervention-phase patients).
There was a reduction in all suicidal behaviors (suicide preparation, interrupted or aborted suicide attempt, suicide attempt, death by suicide) among the intervention-phase patients. Overall, 46.3% of the study participants experienced at least 1 of the suicidal behaviors during the study period: 48.9% of the treatment-as-usual phase patients, 49.6% of the screening-phase patients, and 41.4% of the intervention-phase patients. The intervention-phase patients also showed a small reduction in suicide risk and overall suicidal behaviors compared to the treatment-as-usual phase patients, with numbers needed to treat of 22 and 13, respectively.
Edwin D. Boudreaux, PhD
Bernard P. Chang, MD, PhD, FACEP; Katherine Tezanos, BA; Ilana Gratch, BA; Christine Cha, PhD
Nicholas Schwartz, MD; Scott Zeller, MD
May 1, 2019
May 31, 2022
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Behavioral Health CME credits
Date of Original Release: May 1, 2019. Date of most recent review: April 10, 2019. Termination date: May 1, 2022.
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