How to evaluate and care for the suicidal patient in the ED

Authors: Noah Rohrer, MD (EM Resident Physician, UVM Medical Center) and Maxine Dudek, MD (Psychiatry Resident Physician, UVM Medical Center) // Reviewed by: Courtney Cassella, MD (EM Attending Physician, Reading Hospital Tower Health); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Cases

Case 1: A 64-year-old male with a past medical history of hypertension and major depressive disorder arrives with a chief complaint of abdominal pain. His vital signs are within normal limits and his medical workup is deemed to be benign, but on nursing screening is positive for suicidal thoughts, so further history is obtained. He says he has had thoughts of suicide for years which he describes as “maybe this life isn’t worth living anymore”, and that these have intensified over the last few months due to a recent divorce. He denies having a specific plan in place and dismisses further questions with “I don’t want to talk about this anymore”. How do you proceed?

Case 2: A 27-year-old female with a past medical history of major depressive disorder arrives with a chief complaint of suicidality. Her vital signs are normal except for tachycardia to 108. She endorses chronic suicidality for the last several years, and that today she felt that her feelings had intensified without any apparent trigger. She denies any plan, and has never attempted suicide before. She spoke to her sister regarding her worsening despair today who suggested that she come to the emergency department for help. How do you proceed?

Priority is to avoid missing a dangerously suicidal patient

The COVID-19 pandemic has stretched our medical system in many ways, and psychiatric emergencies are no exception. While formal data are still being studied, it is expected that there will be a significant increase in deaths by suicide in the aftermath of the pandemic. This is thought to be due to numerous factors, including worsening substance abuse, worsening despair, many patients with chronic medical and psychiatric conditions going untreated, and loss of social support systems. This brings new importance to being ready to address behavioral emergencies in your emergency department.¹

Suicidality ideation is a common complaint in the emergency department (ED) with an estimated prevalence of 8% of all ED visits, yet many Emergency Physicians (EPs) report low comfort with how to appropriately work up and disposition these patients.² This figure may be due to high subjectivity in the topic area, fear of litigation, and lack of validated, reliable, and generalizable clinical decision rules on this subject. Like any other medical complaint, suicidality has a wide range of acuity. In men with depression, bipolar, or schizophrenia, suicide risk is especially high. For example, 10% of people with schizophrenia die by suicide.³ Because of the difficulty in identifying which patients will progress to completion of suicide, it is generally agreed that screening and treatment should be geared towards a high sensitivity at the price of low specificity, so as to prioritize avoiding “missing” a dangerously suicidal patient.

The work-up: know your high-risk elements

First, evaluate for and treat any other acute medical issues, and be sure to order a one-to-one observation when there is any question of self-injurious behavior. Additionally, order a temporary emergency hold to ensure that the patient is not able to leave until there is opportunity to evaluate for suicidality and homicidality. Depending on your country and state, the legalities and logistics of this vary widely, and we recommend clarifying your own local legal environment.

Obtaining vital signs, obtaining a history of present illness, and performing a focused physical and neurological exam should be performed in every patient with a psychiatric complaint. With regards to whether or not to obtain a set of basic screening labs, the data are mixed. In general, if a young patient (less than 65 years old) presents with symptoms consistent with an exacerbation of a known psychiatric illness, most studies recommend against the utility of obtaining laboratory testing (including a urine drug screen).² If this is a case of new psychiatric complaint, or the patient is older or with other medical conditions, there may be utility to obtaining such testing.4 Lastly, be sure to communicate with your mental health colleagues to make sure your approaches are congruent, because in some cases their workflow will require early testing (such as a urine drug screen).⁴

Assuming the patient does not have an immediate medical reason for hospitalization, the next step is to dive deeper into his or her behavioral history and current mental state. There is no perfect clinical decision tool to predict future self-harm, but the fundamental process involves identifying high-risk features and then making a clinical decision accordingly. The one obvious complaint to trigger an involuntary hold and psychiatry consultation is active suicidal ideation with a lethal plan in place. If this is not the case, it is essential for the EP to consider other high-risk elements, including access to lethal means (such as firearms), a history of prior suicide attempt, recent psychosocial stressor, older age, Caucasian race, previous psychiatric illness, and chronic alcohol or drug use.^5,6 While it may be tempting to assign different weights on risk factors, expert consensus suggests taking each factor into consideration with the larger clinical context, as each patient presents a unique set of circumstances. ⁷ Presence of any of these high-risk features with suicidal thinking should prompt consideration of psychiatric consultation and involuntary hold.

The intoxicated patient endorsing suicidal ideation presents an especially challenging scenario for EPs. While it has been shown that alcohol use is strongly associated with completed suicide, it is also the case that those who make suicidal statements in the emergency department are more likely to be discharged home.^8,9 Anecdotal evidence seems to suggest this is because as alcohol intoxication dissipates, so does intoxication-related suicidal ideation.¹⁰ Intoxicated patients who endorse suicidal ideation should be held until clinically sober and then reevaluated. The most conservative approach to these patients that deny suicidal ideation upon sobering is to hold them for specialty evaluation, though this topic would benefit from further research.⁵

High Risk Features of Suicidality, evidence drawn from Betz et al.

“Managing Suicidal Patients in the Emergency Department”.⁵

A structured approach

In some cases, the presence or absence of specific risk factors may not be sufficient to articulate the unique circumstances in which a patient presents. Unfortunately, there are no “Gold-Standard” assessment tools to quantify risk, but thankfully there are many resources to help you methodically structure your approach. Among these include the ED-SAFE, Columbia Suicide Severity Rating Scale (CSSRS), ICARE2, and SAFE-T. Below is one algorithm proposed by Betz. et al.⁵

Framework for care and evaluation of suicidal patients in the ED, as described by Betz. et al. in “Managing Suicidal Patients in the Emergency Department”.5

If you are less familiar with each of these elements of suicide assessment, or prefer a more detailed approach, the CSSRS may be more useful for risk assessment. This is an evidence-based, validated study in the emergency department and has been shown to have high sensitivity for suicidal behavior.[1] There are multiple training opportunities both online and in person available for CME credit to become more fluent with this screening tool, but they are not required for its use. Rather than prescribing artificial numeric value to low, medium, or high risk patients, this tool describes your patient’s protective and risk factors to assist in making that judgement. Your clinical judgement and rationale are essential in using the CSSRA to evaluate the patient. This tool also provides an excellent template for documenting your clinical reasoning in your MDM.

The full CSSRS includes instructions for how to frame and phrase each question. Shorter versions such as the Screening CSSRS exist, but are insufficient for full medical decision-making and documentation (www.cssrs.columbia.edu)

After obtaining a history, an excellent resource for corroborating a patient’s story is their family members or other close friends. Provided that the patient does not object, calling and asking for clarifying details about a patient’s history can provide strong support for your decision either to hold or discharge. In the circumstance that the patient does object, or if the patient is incapacitated, there is an allowance made in HIPAA for reaching out to family and friends, if under clinical judgement it would decrease the imminent risk of harm to the patient or someone else.¹²

Disposition

If after your assessment, you deem the patient is “low-risk” and has a safe discharge plan, you should document accordingly. This is not the time to be stingy with words – articulate what protective factors justify your discharge.

Contracts avoiding suicide and self-harm have been shown to be ineffective and offer no protection from litigation.² It is essential to articulate your discussion with the patient as well as your thought process in your free-text MDM. Creating a template (or “smart-phrase”) in your EMR may be helpful to organize your thoughts in such cases. ACEP provides an excellent discharge instructions template as well to remind patients of their resources (https://www.acep.org/patient-care/smart-phrases/suicide-prevention/).

If the patient at any time qualifies for anything higher than “low-risk”, he or she is rarely appropriate for discharge from the emergency department prior to a psychiatric consultation. An emergency hold should be placed, and you should notify the patient. It is important to note that state requirements, durations, and indications for an emergency hold vary widely, and this should be clarified with your practice environment. In general, if a moderate or high-risk patient does not opt for voluntary hospitalization, or at any point withdraws their voluntary status, he or she should be held under an emergency hold (assuming they are determined to pose a danger to themselves or others) until a comprehensive evaluation can be completed.¹⁴

In some institutions, delays to psychiatric evaluation can be considerable. Don’t neglect the patient who is medically stable but mentally suffering. Afford them safe entertainment, a diet order, and assistance with sleeping (pharmacological, if appropriate). This is the humane thing to do and may also prevent a dangerous crisis in your department. Choosing a medication for agitation can be a complicated decision, and for details on this we recommend reading more here (http://www.emdocs.net/emdocs-cases-ed-approach-agitation/), or, when in doubt or concerned regarding medication interactions, discuss with your local pharmacist.

Case Conclusions

Case 1: A 64-year-old male with a past medical history of hypertension and major depressive disorder arrives with a chief complaint of abdominal pain. His vital signs are within normal limits and his medical workup is deemed to be benign, but on nursing screening is positive for suicidal thoughts, so further history is obtained. He says he has had thoughts of suicide for years which he describes as “maybe this life isn’t worth living anymore”, and that these have intensified over the last few months due to a recent divorce. He denies having a specific plan in place and dismisses further questions with “I don’t want to talk about this anymore”. How do you proceed?

After obtaining permission from the patient, you call his brother who reveals that the patient has a history of a suicide attempt via hanging five years ago but aborted due to being interrupted by a family member. His alcohol use has risen significantly and feels estranged from his family and isolated from his friends. He has no outpatient mental health support. He reacts with frustration when you notify him he will need to meet with the psychiatry team, and an involuntary hold order is placed.

Case 2: A 27-year-old female with a past medical history of major depressive disorder arrives with a chief complaint of suicidality. Her vital signs are normal except for tachycardia to 108. She endorses chronic suicidality for the last several years, and that today she felt that her feelings had intensified without any apparent trigger. She denies any plan and has never attempted suicide before. She spoke to her sister regarding her worsening despair today who suggested that she come to the emergency department for help. How do you proceed?

Her heart rate normalizes with observation. Her medical workup is negative. On further questioning, she has a follow-up appointment scheduled with her counselor already in place within 24 hours from now. She lives with her sister with whom she feels very close and reports she would never act on her suicidal thoughts, but was simply frustrated by them and wanted to discuss them with her sister. In the opinion of the clinician, she is ultimately deemed to be low-risk, and is discharged with instructions to return for any worsening of her mood.

Take-home Points

• Suicidal ideation is common, dangerous, and requires appropriate clinical assessment.
• Presence of suicidal thinking with any high-risk factor including a history of prior suicide attempt, recent psychosocial stressor, older age, Caucasian race, psychiatric illness, or substance abuse likely qualifies an individual as at least moderate risk and should prompt consideration of involuntary hold and psychiatry consultation.
• For a structured and comprehensive approach toward suicide risk assessment, we recommend using the Columbia Suicide Severity Rating Scale.
• Document in your note the protective factors and risk factors that justify your determination of risk and decision to either involuntarily hold for psychiatric consultation or discharge home.

References/Further Reading:

1. Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712.
2. Boudreaux ED, Camargo CA Jr, Arias SA, et al. Improving Suicide Risk Screening And Detection In The Emergency Department. Am J Prev Med. 2016;50(4):445.
3. Sher L, Kahn RS. Suicide in Schizophrenia: An Educational Overview. Medicina (Kaunas). 2019;55(7):361. Published 2019 Jul 10.
4. Krithika C, Mullinax S, Anderson E, et al, Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review. Journ Emerg Med. 2018:55(6):799-812.
5. Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282.
6. 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.
7. Bryan CJ, Rudd MD. Advances in the assessment of suicide risk. J Clin Psychol. 2006;62(2):185-200.
8. Bowden B, John A, Trefan L, et al. Risk of suicide following an alcohol-related emergency hospital admission: An electronic cohort study of 2.8 million people. PLoS One. 2018;13(4):e0194772.
9. Urban C, Arias SA, Segal DL, et al. Emergency Department patients with suicide risk: Differences in care by acute alcohol use. Gen Hosp Psychiatry. 2020;63:83-88.
10. Kalk NJ, Kelleher MJ, Curtis V, et al. Addressing substance misuse: a missed opportunity in suicide prevention. Addiction. 2019;114(3):387-388.
11. 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.
12. U.S. Department of Health and Human Services Office for Civil Rights. HIPAA Privacy Rule and Sharing Information Related to Mental Health. Accessed January 2022 at https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf
13. 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.
14. Council on Psychiatry and Law, Position Statement on Voluntary and Involuntary Hospitalization of Adults with Mental Illness. American Psychiatric Association. Accessed January 2022 at https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Voluntary-Involuntary-Hospitalization-Adults.pdf