by Steven D. Targum, MD; Frank Friedman, MD; and Manuel N. Pacheco, MD, FAPM, DFAPA
Steven D. Targum, MD, is the scientific director at Clintara LLC, the chief medical officer at Methylation Sciences Inc., BrainCells Inc., and Functional Neuromodulation Inc., the chief medical advisor at Prana Biotechnology Ltd., and a consultant in psychiatry at the Massachusetts General Hospital, Boston, Massachusetts. Dr. Frank Friedman is an Assistant Professor of Emergency Medicine at Tufts University School of Medicine and the Director of Prehospital Care and Emergency Preparedness at Tufts Medical Center in Boston, Massachusetts. Dr. Manuel N. Pacheco is an Assistant Professor of Psychiatry at Tufts University School of Medicine and Chief of the Consultation/Liaison Service and of the Emergency Service, Department of Psychiatry at the Tufts Medical Center in Boston, Massachusetts.
Innov Clin Neurosci. 2014;10(9–10):194–200
Funding: There was no funding for the development and writing of this article.
Financial disclosures: Dr. Targum has received consultation fees, retainers, or vendor grants from the following sponsors within the past three years: Acadia Pharmaceuticals, Acumen, Alcobra, Alkermes Inc., AstraZeneca, BioMarin, BrainCells Inc., Civitas, Eli Lilly and Company, EnVivo (Forum) Pharmaceuticals, Euthymics, Functional Neuromodulation Inc, Intracellular Therapies Inc., Ironwood Pharmaceuticals, Johnson & Johnson PRD, Methylation Sciences Inc., Mitsubishi Tanabe, NeoSync, Novartis Pharmaceuticals, Nupathe, Pfizer Inc., Prana Biotechnology Ltd., ReViva, Roche Labs, Sophiris, Sunovion, Targacept, Theravance, Transcept. Drs. Friedman and Pacheco have no conflicts of interests related to the writing of this paper.
Introduction
Dr. Targum: Hospital emergency departments see a lot of people who are seriously thinking about suicide or have made suicide attempts. In fact, emergency departments (ED) in the United States treat over 500,000 people annually for suicide-related issues.[1,2] Within many healthcare systems, the ED has become a critical thoroughfare (the default option) for acute and chronically suicidal patients.[1] Mills et al[3] found that the ED had the second highest number of reported completed suicides and attempts within the Veterans Affairs (VA) healthcare system and was second only to inpatient psychiatric units.[3]
Suicide attempts leading to ED visits are not restricted to any age group, ethnicity, or socio-economic status and are not always associated with psychiatric comorbidity like depression, conduct disorder, or substance abuse. Suicide attempts leading to ED visits occur in adolescents as well as the elderly, may be impulsive or deliberate, may follow alcohol intoxication, and vary widely in the actual intent to die.[4–7]
The obvious high risk of a repeat suicide attempt generates an urgency to make an accurate assessment and create a safe, yet plausible treatment plan. ED physicians need to quickly assess the potential lethality of suicidal patients and determine whether to retain them (hospital admission) or discharge them. The majority of suicide attempt patients seen in the ED are discharged without hospitalization after medical stabilization and psychosocial evaluation.[6] Yet, these patients still have a high risk for repeated attempts. Up to 25 percent of these suicide attempters return to the ED after another attempt, and 5 to 10 percent eventually die by suicide.[1] Given this context, it is intriguing that hospitalization rates following suicide attempt-related ED visits actually decreased from 49 percent to 32 percent during the same time period (1992–2001) that ED visits for suicide attempts had increased by 47 percent.[6]
Clearly, the ED is a vital setting for suicide prevention and may be the only access to healthcare available for some patients. Of course, the busy ED has to deal with cardiac arrests, gun shot wounds, sick babies, and every other conceivable medical emergency at the same time that they assess a suicidal patient. For this column, I discuss the assessment of suicidal patients with two physicians who work at the very busy ED at Tufts Medical Center in downtown Boston, Massachusetts. Their views go beyond the theoretical and reflect the experience and wisdom of physicians who work on the front line of healthcare. Dr. Frank Friedman is an Assistant Professor of Emergency Medicine at Tufts University School of Medicine and the Director of Prehospital Care and Emergency Preparedness at Tufts Medical Center. Dr. Manuel N. Pacheco is an Assistant Professor of Psychiatry at Tufts University School of Medicine, Chief of the Consultation/Liaison Service and of the Emergency Service, Department of Psychiatry at the Tufts Medical Center.
How many patients visit the Tufts Medical Center ED each year? How many of these patients have suicide-related issues?
Dr. Friedman: We saw 40,669 patients in the ED last year. Although only 704 of these patients actually listed “suicidal” as their entering chief complaint, it is clear that many more patients were evaluated for this possibility.
Dr. Pacheco: I get called to the Tufts ED several times a day for suicide evaluations. So the “real” number has to be higher than the listed chief complaint.
How do you determine that patients are “suicidal” if they don’t acknowledge it?
Dr. Friedman: Some patients may say, “I want to see a psychiatrist,” or describe “depression,” or ”anxiety” as their chief symptom, or arrive intoxicated after a suicide gesture and initially say nothing at all. Ultimately, during the course of our evaluation, it becomes clear when a patient is feeling suicidal.
Do you think that the number of ED visits for suicide attempts has increased?
Dr. Pacheco: It has notably increased. I think that increased drug abuse, fewer psychiatric beds, the move to treat more patients in the community, and the mere cost to simply see a doctor has contributed to increased ED visits by suicidal patients. Of course, there are many differences among the types of suicidal patients we see in the ED.
Can you describe the different types of suicidal patients that you see in the ED?
Dr. Friedman: First of all, we see a lot of patients who have made serious suicide attempts. But we also see patients who have just expressed some suicidal ideation and may have been referred to the ED because they said something of concern to somebody (their doctor, a psychiatrist, or a family member). Some patients present following relatively trivial gestures such as, “I took 10 Advils” or with very superficial cuts of the wrist (with many other old scars present), and a lot of patients with suicidal behavior are brought to the ED after a substance abuse binge.
As the first physician to evaluate the patient, I recognize five broad categories of suicidal patients ranging from the most severe who are at the highest risk to those with the least risk: 1) the highest risk are those patients who have just made a serious gesture or attempt prior to arriving in the ED; 2) patients in a traditionally high-risk group (like the elderly) who are particularly despondent or voicing suicidal ideation; 3) patients with significant chronic psychiatric illnesses or substance use and current suicidal ideation with a plan; 4) patients with significant substance utilization who say “I’m suicidal” but seem to have no particular plan; and 5) patients who simply announce that they are requesting psychiatric (or dual-diagnosis) hospitalization. This last group may just want a place to sleep.
We see children much more often than we used to for all sorts of psychiatric complaints. It seems that nearly any child who acts out in school is now sent for an evaluation rather than in-school disciplinary action. Any off-hand remark that can be interpreted as a musing about suicide will result in a trip to the ED too. I have occasionally seen children as young as five years old sent in for an evaluation because they said something like “I wish I was dead.”
Dr. Pacheco: A lot of patients are seen with ethanol intoxication and suicidal ideation. I divide them into two groups as either intoxicated or sober because the suicidal ideation is best assessed when they are sober. A good rule of thumb is “no one is suicidal until they are sober and suicidal.” Unfortunately, it may take several hours for some patients to “sleep it off” to achieve sobriety. For instance, a seasoned alcoholic may not appear clinically intoxicated even with a blood alcohol level over 300. Incidentally, that level could be lethal in most ethanol-naive cases.
We also see suicidal patients who have taken multiple substances as well. In Boston, as is other eastern United States cities, crack is notably prevalent in our homeless population and methamphetamine abuse in the gay male population.
Otherwise, suicidal adult patients present during periods of new homelessness or joblessness, or related to marital strife, divorce, or breakup. One other group, newly released prisoners, are a frequent occurrence in our ED if they have alienated family and/or spouses/partners and are being banned from the family.
Do you think that adolescent suicide attempts create a unique situation?
Dr. Friedman: Yes. Adolescents are different. Suicide is the third leading cause of death in adolescents Although the ratio of attempted to completed suicides in adolescents has been estimated to be about 200 to 1 in contrast to approximately 20 to 1 in the general population, every suicidal adolescent patient I see in the ED represents a special risk in my opinion.
Sadly, in the Boston area we have witnessed a near epidemic of adolescent suicides in the past several years: three in suburban Newton in 2011 and six in South Boston in 1997, among others. We tend to have a very low threshold to obtain a psychiatric consult in an adolescent with either suicidal ideation or after a gesture, and most of these patients are either hospitalized or are discharged to home only after a lengthy and comprehensive evaluation assuring a competent social environment to which to return the individual.
Dr. Pacheco: Adolescent patients come to the ED during periods of new stressors. For instance, in Boston we often see adolescents and young adult students at the beginning of the school year or during exam periods. Exam time can be especially stressful if the student has been failing but has not shared their dire academic straits with their family.
If a patient is a minor there may be an additional consent wrinkle. If the parents/guardians disagree with any recommended treatment plan, the physicians need to consult with the hospital risk management staff on how to proceed.
On the other end of the age dimension, the suicide rate for people over 65 years of age is 50 percent higher than for the rest of the nation as a whole.[5] How do you manage suicidal geriatric patients?
Dr. Friedman: As long as the older adult is not someone who comes into the ED frequently (we have a few well-known older patients), being older than 60 or so and verbalizing suicidal thoughts or despondency are taken as a major red flag and will often result in hospitalization.
Dr. Pacheco: We see older, geriatric patients presenting with suicidal ideation following a new terminal diagnosis or advancing serious illness. Occasionally, we’ll see caregivers who are simply burned out and are no longer able to cope with taking care of a totally dependent loved one at home.
What happens when a suicidal patient is brought to the ED?
Dr. Friedman: The first role of the ED is to determine if the suicidal patient is “medically clear” for a psychiatric evaluation. If someone has made a serious gesture—a significant medication overdose or self-injury—hospital admission is indicated and psychiatry is not involved until the patient’s condition has been stabilized.
“Medical clearance” involves simply being a good doctor—taking a good history and physical exam for any other conditions or concerns besides the psychiatric complaint. In a young and otherwise healthy person, no further testing might be required other than a toxicology screen for drugs of abuse. For an older individual with several chronic illnesses, a full set of routine blood and other ancillary testing may be required. The reason for this is two-fold: We want to exclude an organic explanation for a patient’s condition and because many psychiatric hospitals are free-standing with few healthcare resources to address medical complaints. Many psychiatric hospitals will not even consider a patient for hospitalization unless certain tests have been performed and were normal.
The literature describes three lethality factors that need to be assessed in suicidal patients: predisposing factors, risk factors, and protective factors.[5] Predisposing factors are usually long-standing conditions (like chronic illness), whereas risk factors are generally more acute symptoms, stressors, or conditions that could trigger the suicidal act. Alternatively, the presence or absence of protective factors, such as a strong social support network, also affects a person’s risk level. Dr. Friedman, How do you determine lethality?
Dr. Friedman: I always ask about what an individual has actually done or contemplated doing to harm him- or herself. But, I also like to ask two probing questions to someone who overtly claims to be suicidal: 1) Why didn’t you kill yourself? And 2) “What do you see yourself doing in a year?” Patients are often shocked by my first question, but their response can be very informative about their true intent. Some patients say, “I’m here because I want help,” or “I was afraid of what I might do,” which suggests an urgent need for help. Patients who are reactive and just get angry at me about my question actually worry me less. A positive response to my second question about goals for the future generally indicates that the person plans to be alive and hasn’t already given up on life. Someone once said that the only truly justifiable reason for suicide is if one hates oneself, so I will sometimes ask about self-loathing as well.
How do you decide whether to admit a patient or discharge him or her?
Dr. Friedman: There is no blood test or single screening tool that determines the risk of an individual repeating a suicide attempt. We look at the whole picture—Does the person belong to an established higher risk group? Has a serious attempt or concerning plan been described? What is the previous psychiatric history? Is the person currently intoxicated? What is the social support? Saying “I’m suicidal” is probably one of the least likely reasons, in and of itself, that will lead to a patient being hospitalized.
Our records show that last year 108 of the 704 patients (15.3%) that presented with an initial chief complaint of “suicidal” were admitted to our institution and 105 other patients (14.9%) were transferred to an inpatient psychiatric facility elsewhere—so about 30 percent were admitted. Most patients are discharged after several different clinicians have evaluated them, and are discharged to the care of someone they know.
How do you determine if a potentially suicidal patient simply wants a place to sleep for the night and really has no genuine suicidal intent?
Dr. Friedman: Some patients will actually admit that they just want a safe, warm place to sleep if you ask them bluntly, especially if they’ve already alluded to the fact that they are undomeciled and don’t like where they’ve been staying. For most patients though, it is a matter of inference—a lack of firm suicidal plan or even a gesture, and they seem more interested in a meal and a blanket immediately upon arrival.
Dr. Pacheco, as the psychiatric consultant to the ED, how do you decide whether to admit a suicidal patient or discharge him or her?
Dr. Pacheco: The assessment of suicide risk ranges from low to high and that affects our decision. Some factors that increase suicide risk include the following:
• Chronic, untreated, or poorly treated mental illness
• Chronic housing problems or new homelessness
• Uncontrolled substance use placing them or others in dangerous potentially fatal situations
• Recent diagnosis of a terminal illness
• Advancing medical disease burden
• Alienation or lack of the usual support systems (e.g., family, physicians)
• Previous suicide attempts
• Recent divorce or ending of a valued relationship
• Previous successful suicide attempts in close friends or family
• Possession of a viable plan and means to kill him- or herself (e.g., firearm or medication)
• Patients from ethnic cultural groups that disdain or don’t accept mental illness.
How any ED physician, nurse, or physician assistant in the end gauges any patient’s risk stratification is based on experience and individual judgement. However, once a critical mass of these factors are reached, most of us will either hold the patient for further evaluation or transfer the patient to a locked psychiatric unit.
Dr. Friedman, how often do you ask for a psychiatric consultation? How do you make that decision?
Dr. Friedman: There are no hard and fast rules for which suicidal patients will get a psychiatric evaluation. Everyone presenting to the ED receives a “medical screening examination” to evaluate and stabilize their condition. Every potentially suicidal patient coming to the ED is evaluated by an attending emergency physician (EP). We serve as gatekeepers for all sorts of medical utilization. Asking to see a psychiatrist (by the patient) is no more of a guarantee of a consult than asking to see someone from any other specialty or asking for a test like a magnetic resonance imaging scan. The EP has to believe that it is medically warranted as part of an emergency evaluation (some might be given outpatient follow-up information and asked to make an appointment).
Dr. Pacheco, as a psychiatrist, what procedures and questions do you routinely apply when you evaluate a suicidal patient in the ED?
Dr. Pacheco: First, we begin with safety. We always place people with a one-to-one sitter until they sober up, are in adequate behavioral control, or state that they are no longer contemplating suicide.
Once we believe that the patient is safe, we review our electronic medical records to see if we have seen the patient before. My emergency consultation service documents each visit, including past psychiatric history and contact information from caregivers, physicians, caseworkers, and group home/shelter staff that have had contact with the patient. We take a lot of time to get enough information so as not to reinvent the wheel on cases we have seen before. We also check the Massachusetts Prescription Drug Monitoring Program to detect cases of doctor shopping for patients seeking benzodiazepines, opiates, or stimulants. It is important to caution that the information in these databases is often incomplete and for now limited only to the state where you are licensed.
We determine if the patient is able to engage in an interview. The patient may be acutely intoxicated or too psychotic to interview. We’ll use involuntary medication or restraint only as a last resort for agitated patients. When patients can be interviewed, we ask about their current state and the events or triggers that precipitated the suicidal behavior. We ask about prescription bottles and where they fill their prescriptions so we can find out who their prescribers are. We check their belongings for recent discharge summaries from outside hospitals or prisons. We also ask for contact information about family members, roommates, spouses/partners, or treaters/clinicians that know the patient. Often patients are reluctant to provide contact information, but non-confrontational approach can often work.
We coordinate with our emergency medicine colleagues to assure that all necessary lab studies have been ordered. Labs should include a urine and serum toxicology screen to elucidate if any suicidal statements or behaviors are taking place in an intoxicated state. If any case involves someone never having being seen by medical/psychiatric personnel then a more comprehensive investigation takes place to uncover any medical causes of behavioral, affective, or cognitive changes. If there has been an abrupt change in behavior in a previously healthy individual then neuroimaging is ordered—usually a head computed tomography scan to start. Other labs are ordered depending on clinical suspicion or differential diagnoses. We usually order a complete blood count with differential and Chemistry 10 panel especially if there is a good chance that the patient will end up being transferred to a locked psychiatric unit.
If neuroleptics are necessary to control violent or uncontrolled behavior, then a 12 lead electrocardiogram at some point is warranted to assess their QTc interval or to elucidate any occult cardiac disease.
It has been reported that the risk of suicide is 20 times greater in persons with a diagnosis of major depressive disorder (MDD) than it is in the general population.[5] How often do you diagnosis untreated MDD among suicidal patients in the ED?
Dr. Pacheco: It is difficult to diagnosis MDD in a patient seen for the first time in the ED setting because it is a diagnosis of exclusion, especially in patients new to the system. If after collateral information gathering, warranted physical examination, history, and lab/imaging studies have been done and there is no other plausible explanation for the suicidal behavior and expression of depression, we will make a diagnosis of depressive disorder not otherwise specified (NOS) or mood NOS. Some of these patients may actually be in the depressed phase of bipolar or schizoaffective disorder.
Psychosis is also strongly linked to suicidal ideation. In addition to occurring with illnesses like schizophrenia or during alcohol withdrawal, psychotic symptoms can be associated with mood disorders, such as depression or bipolar disorders.[5] Dr. Pacheco, how do you manage these types of psychotic patients?
Dr. Pacheco: Many suicidal patients seen in the ED are psychotic. The severity and implications of psychotic symptoms vary from patient to patient. Command auditory hallucinations telling patients to kill themselves or harm others are extremely dangerous and require immediate intervention. Psychotic symptoms may include delusions of persecution such that patients firmly believe that someone is out to harm them or someone they care about will be harmed. There may also be an element of hyper-religiosity in psychotic, suicidal patients as well.
We manage these patients by asking if they have been off their antipsychotics, mood stabilizers, or antidepressant medications. As mentioned before, we also inquire if they have used substances such as cocaine, amphetamines, or cannabis recently as they can exacerbate an existing psychotic disorder or bring about new psychosis.
Many psychotic patients have stopped taking their prescribed medication. Administering the prescribed antipsychotic or judicious administration of a novel one can often resolve the acute psychotic episode. Often, the suicidal ideation dissipates when the patient is no longer acutely psychotic. The clinical treatment may require larger or repeated doses of antipsychotic medications to achieve benefit. Physical restraint or parenteral administration of an antipsychotic may also be warranted in agitated patients as a last resort. One should always be prepared for this contingency in new patients unknown to the system or intoxicated patients. It is far better to be prepared for the worst than have to deal with serious injuries after a patient becomes assaultive.
Is it common or uncommon for psychiatric patients to take an overdose of their own medications?
Dr. Pacheco: It is common. Overdose of their own medication is especially common in patients with comorbid substance use issues or personality disorders. The attempts often happen during a period of intoxication where there is decreased inhibition. Patients with personality disorders often overdose on their medications and then text or phone their families or spouses/partners to inform them of their actions.
How important is a support system? Can you send someone home without a support system?
Dr. Pacheco: A support system is crucial. Desperate and lonely people do desperate things, including killing themselves.
Sending a patient home by him- or herself after the patient has presented or vocalized suicidal ideation is risky and should be avoided if at all possible. If someone comes to the ED in the middle of the night, keep them until the morning when family or treaters/clinicians are reachable. Ask family members or roommates, “Do you feel comfortable taking him or her home?’ If they say no, ask “why not?” Often, their answer will provide you with some dimension of the patient of which you have not been aware.
Can you describe any cases that served as “teaching” moments for you or your staff?
Dr. Friedman: I find one of the most useful factors in evaluating the patient with suicidal ideation is getting another perspective. The picture painted by a loved one or coworker, which may be completely different from what the patient is describing, is invaluable. I have evaluated patients whom I thought were safe to be discharged until somebody telephoned in or showed up and described an incredibly risky or dangerous recent event that makes one stop in ones tracks to re-assess the whole situation.
Dr. Pacheco: There have been many teaching moments for me but the most difficult ones have been physicians themselves, mainly because their stories hit close to home. The most important point I’d like to make though is that the majority of suicides happen within one month of any clinical contact, whether it be in the ED or outpatient clinic. Don’t be worried that by merely asking you will trigger suicidal thoughts in any patient. Usually it is the contrary. They are often relieved they have permission to discuss these unthinkable urges and feelings that they have been hiding.
How often do you see the same suicidal patient again? What happens the second time around?
Dr. Friedman: We’ve had patients call 9-1-1 from the ED lobby phone after discharge or go lie down in the street across from the hospital. Generally most of these patients are more likely to carry a diagnosis of personality disorder than truly worry us that they will cause self-harm. However, one of the cardinal rules of residency training in emergency medicine is that any unexpected return of a patient is a red flag. One must force oneself to be as objective as possible in reassessing the patient to make sure that one is really comfortable with one’s original diagnosis.
Has the critical importance of the ED’s role in suicide prevention been recognized on a national level?
Dr. Friedman: Yes it has. The International Association for Suicide Prevention (IASP) has organized a Task Force on Suicide and Emergency Medicine that addresses this challenge.[8]
Where can clinician’s get more information about the assessment and treatment of suicidal patients in the ED?
Dr. Pacheco: Some excellent practice guides have been developed. The American Psychiatric Association published a guide in 2003 and the United States Department of Health and Human Services published one in 2008. Both would probably be good places to start.[9,10]
References
1. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1–6.
2. United States Centers for Disease Control and Prevention (CDC). Fact sheet on suicide, 2011. http://www.cdc.gov/ViolencePrevention/suicide. Accessed October 1, 2014.
3. Mills PD, Watts BV, DeRosier JM, et al. Suicide attempts and completions in the emergency department in Veterans Affairs hospitals. Emergency Med J. 2012;29(5):399–403.
4. Canapary D, Bongar B, Cleary K. Assessing risk for completed suicide in patients with alcohol dependence: clinicians’ views of clinical factors. Professional Psychology: Research and Practice. 2002;33(5):464–469.
5. Mitchell AM, Garand L, Dean D, et al. Suicide assessment in hospital emergency departments: implications for patient satisfaction and compliance Top Emerg Med. 2005;27(4):302–312.
6. Larkin GL, Smith RP, Beautrais AL. Trends in US emergency department visits for suicide attempts, 1992-2001. Crisis. 2008;29(2):73–80.
7. King CA, O’Mara RM, Hayward CN, Cunningham RM. Adolescent suicide risk screening in the emergency department. Acad Emerg Med. 2009;16(11):1234–1241.
8. Larkin GL, Beautrais AL, Spirito A, et al. Mental health and emergency medicine: a research agenda. Acad Emerg Med. 2009;16(11):1110–1119.
9. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(11 Suppl):1–60.
10. Substance Abuse and Mental Health Services Administration. After an Attempt: A Guide for Medical Providers in the Emergency Department Taking Care of Suicide Attempt Survivors. DHHS Pub. No. (SMA) 08-4359, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2006. Reprinted by the Department of Veterans Affairs, Veterans Health Administration, 2008.
