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

Abstract

With more than 12 million emergency department visits annu- ally 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 classi – cation, 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.

May 2019 Volume 21, Number 5

Authors

Bernard P. Chang, MD, PhD, FACEP

Assistant Professor of Emergency Medicine, Columbia University Medical Center, New York, NY

Katherine Tezanos, BA

Doctoral Student, Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY

Ilana Gratch, BA

Department of Psychiatry, Columbia University Medical Center, New York, NY

Christine Cha, PhD

Assistant Professor, Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY

Peer Reviewers

Nicholas Schwartz, MD

Assistant Clinical Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Attending Emergency Physician, Maimonides Medical Center, Brooklyn, NY and Elmhurst Hospital Center, Queens, NY

Scott Zeller, MD

Clinical Assistant Professor of Psychiatry, University of California- Riverside, Riverside, CA; Vice-President, Acute Psychiatry, Vituity

Prior to beginning this activity, see “CME Information” on the back page.

Editor-In-Chief

Andy Jagoda, MD, FACEP

Professor and Interim Chair, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY

Associate Editor-In-Chief

Kaushal Shah, MD, FACEP

Associate Professor, Vice Chair
for Education, Department of Emergency Medicine, Weill Cornell School of Medicine, New York, NY

Editorial Board

Saadia Akhtar, MD, FACEP

Associate Professor, Department of Emergency Medicine, Associate Dean for Graduate Medical Education, Program Director, Emergency Medicine Residency, Mount Sinai Beth Israel, New York, NY

William J. Brady, MD

Professor of Emergency Medicine and Medicine; Medical Director, Emergency Management, UVA Medical Center; Operational Medical Director, Albemarle County Fire Rescue, Charlottesville, VA

Calvin A. Brown III, MD
Director of Physician Compliance, Credentialing and Urgent Care Services, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

Peter DeBlieux, MD

Professor of Clinical Medicine, Louisiana State University School of Medicine; Chief Experience Of cer, University Medical Center, New Orleans, LA

Daniel J. Egan, MD

Associate Professor, Vice Chair of Education, Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY

Nicholas Genes, MD, PhD

Associate Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Michael A. Gibbs, MD, FACEP

Professor and Chair, Department
of Emergency Medicine, Carolinas Medical Center, University of North Carolina School of Medicine, Chapel Hill, NC

Steven A. Godwin, MD, FACEP

Professor and Chair, Department of Emergency Medicine, Assistant Dean, Simulation Education, University of Florida COM- Jacksonville, Jacksonville, FL

Joseph Habboushe, MD MBA

Assistant Professor of Emergency Medicine, NYU/Langone and Bellevue Medical Centers, New York, NY; CEO, MD Aware LLC

Gregory L. Henry, MD, FACEP

Clinical Professor, Department of Emergency Medicine, University
of Michigan Medical School; CEO, Medical Practice Risk Assessment, Inc., Ann Arbor, MI

John M. Howell, MD, FACEP

Clinical Professor of Emergency Medicine, George Washington University, Washington, DC; Director of Academic Affairs, Best Practices, Inc, Inova Fairfax Hospital, Falls Church, VA

Shkelzen Hoxhaj, MD, MPH, MBA

Chief Medical Of cer, Jackson Memorial Hospital, Miami, FL

Eric Legome, MD

Chair, Emergency Medicine, Mount Sinai West & Mount Sinai St. Luke’s; Vice Chair, Academic Affairs for Emergency Medicine, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY

Keith A. Marill, MD, MS

Associate Professor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

Charles V. Pollack Jr., MA, MD, FACEP, FAAEM, FAHA, FESC Professor & Senior Advisor for Interdisciplinary Research and Clinical Trials, Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA

Michael S. Radeos, MD, MPH

Associate Professor of Emergency Medicine, Weill Medical College
of Cornell University, New York; Research Director, Department of Emergency Medicine, New York Hospital Queens, Flushing, NY

Ali S. Raja, MD, MBA, MPH

Executive Vice Chair, Emergency Medicine, Massachusetts General Hospital; Associate Professor of Emergency Medicine and Radiology, Harvard Medical School, Boston, MA

Robert L. Rogers, MD, FACEP, FAAEM, FACP
Assistant Professor of Emergency Medicine, The University of Maryland School of Medicine, Baltimore, MD

Alfred Sacchetti, MD, FACEP

Assistant Clinical Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA

Robert Schiller, MD

Chair, Department of Family Medicine, Beth Israel Medical Center; Senior Faculty, Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY

Scott Silvers, MD, FACEP

Associate Professor of Emergency Medicine, Chair of Facilities and Planning, Mayo Clinic, Jacksonville, FL

Corey M. Slovis, MD, FACP, FACEP

Professor and Chair, Department
of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

Ron M. Walls, MD

Professor and COO, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Critical Care Editors

William A. Knight IV, MD, FACEP, FNCS

Associate Professor of Emergency Medicine and Neurosurgery, Medical Director, EM Advanced Practice Provider Program; Associate Medical Director, Neuroscience ICU, University of Cincinnati, Cincinnati, OH

Scott D. Weingart, MD, FCCM

Professor of Emergency Medicine; Chief, EM Critical Care, Stony Brook Medicine, Stony Brook, NY

Research Editors

Aimee Mishler, PharmD, BCPS

Emergency Medicine Pharmacist, Program Director, PGY2 EM

Pharmacy Residency, Maricopa Medical Center, Phoenix, AZ

Joseph D. Toscano, MD

Chief, Department of Emergency Medicine, San Ramon Regional Medical Center, San Ramon, CA

International Editors

Peter Cameron, MD

Academic Director, The Alfred Emergency and Trauma Centre, Monash University, Melbourne, Australia

Andrea Duca, MD

Attending Emergency Physician, Ospedale Papa Giovanni XXIII, Bergamo, Italy

Suzanne Y.G. Peeters, MD

Attending Emergency Physician, Flevo Teaching Hospital, Almere, The Netherlands

Edgardo Menendez, MD, FIFEM

Professor in Medicine and Emergency Medicine; Director of EM, Churruca Hospital of Buenos Aires University, Buenos Aires, Argentina

Dhanadol Rojanasarntikul, MD

Attending Physician, Emergency Medicine, King Chulalongkorn Memorial Hospital; Faculty of Medicine, Chulalongkorn University, Thailand

Stephen H. Thomas, MD, MPH

Professor & Chair, Emergency Medicine, Hamad Medical Corp., Weill Cornell Medical College, Qatar; Emergency Physician-in-Chief, Hamad General Hospital,
Doha, Qatar

Edin Zelihic, MD

Head, Department of Emergency Medicine, Leopoldina Hospital, Schweinfurt, Germany

Case Presentations

Between managing a septic patient and another with an acute stroke, you note 3 patients waiting to be seen: a 30-year-old apparently healthy man with an upper respi- ratory infection, an elderly man with a sprained ankle, and a woman needing a medication re ll. The young man has a URI, but you also nd 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 speci c 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 noncompli- ance, hence the medication re ll. You wonder whether the clinical presentation could be due to her thyroid disease, and if there is anything that needs to be done in the ED…

Introduction

Mental-health-related chief complaints, including substance abuse, account for nearly 12.5% of emer- gency 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 com- plaints, 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 differ- ences among ethnic groups may cause symptoms of depression to manifest in different ways, making recognition dif cult. 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 pro- vides an ED-focused approach to assessing depres- sion and suicide risk. Background information is provided regarding the classi cation, epidemiology, and known pathology of depression, as well as suicide risk within depression. Best-practice recom- mendations are made regarding evaluation and cur- rent management strategies along with cutting-edge interventions and approaches.

Critical Appraisal of the Literature

The primary references and articles for this review were collected from Ovid MEDLINE®, Web of Sci- ence, 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, psychiat- ric emergencies, biology of depression, depression treat- ment, suicide attempt treatment, suicide, and emergency department. A guideline search identi ed 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 excel- lent narrative review papers on suicide and depres- sion in the ED.10,11

Etiology and Pathophysiology

Nomenclature and Classi cation

In the acute care setting, speci c diagnosis of a psy- chiatric disorder is often not necessary and should not delay primary evaluation and assessment. Psy- chiatric diagnoses are often determined via thorough and extensive evaluations, making arrival at a spe- ci c psychiatric diagnosis neither feasible nor realis- tic in the ED. Instead, the emphasis in the ED should be on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. For information on managing behavioral health emergencies in children, see the January 2018 issue of Pediatric Emergency Medicine Practice, “Best Practices in Managing Child and Adolescent Behavioral Health Emergencies,” at http://www.ebmedicine.net/PedBehavioral.

The following sections present some of the di- agnostic criteria for common psychiatric conditions seen in the ED, noting that the list is not exhaustive for the full range of psychiatric conditions.

2 Reprints: http://www.ebmedicine.net/empissues

Depression

In the United States, classi cation of psychiatric conditions has been based largely on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).12 Table 1 summarizes the 9 symptoms included in the DSM-5 Diagnostic Criterion A for major depressive disorder (MDD). Other diagnostic criteria from the DSM-5 (Criterion B, C, D, and E) include additional factors for other mental illnesses. The diagnosis of MDD must include factors from:

• Criterion A: 5 or more symptoms lasting most of the day, nearly every day, for a minimum of
2 consecutive weeks, with at least 1 symptom being either depressed mood or loss of interest/ pleasure

• Criterion B: Clinically signi cant distress or impairment across multiple areas of functioning (eg, social settings, work)
The diagnosis of MDD does not include factors from:

• Criterion C: Substance use or a medical condi- tion

• Criterion D: Psychotic disorders

• Criterion E: History of manic episodes
Although MDD is the most common depressive disorder, there are additional diagnoses to consider. The factors of Criterion C are particularly relevant, as MDD may not be an appropriate diagnosis if

1. Depressed mood (ie, “sad,” “empty,” “hopeless”) for most of the day, nearly every day. Can be from self-reports or reports of others.*

2. Decreased interest or pleasure in most activities, most of the day, nearly every day. Can be from self-reports or reports of others.*

3. Body weight change (increase or decrease) of > 5% when not dieting.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation, restlessness, or slowing of physical
movement that is apparent on observation.

6. Fatigue or loss of energy, nearly every day.

7. Feelings of worthlessness or guilt that is excessive or
inappropriate, nearly every day.

8. Diminished ability to think or concentrate, or indecisiveness,
nearly every day. Can be from self-reports or reports of others.

9. Recurrent thoughts of death and/or suicide, with or without a
speci c plan.

*For diagnosis of major depressive disorder, at least 1 of these symptoms is required. These symptoms must last most of the day, nearly every day, for a minimum of 2 weeks.

Abbreviation: DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

depressive symptoms are related to involvement of substance or medication use (ie, potential sub- stance/medication-induced depressive disorder or depressive disorder due to another medical condi- tion). Regarding Criterion D, if symptoms co-occur with psychosis, they may be better explained by

a psychotic disorder (eg, schizoaffective disorder, schizophrenia, schizophreniform disorder) or at least require a speci er (eg, depressive disorder with mood-congruent/mood-incongruent psychotic features). Regarding Criterion E, MDD may not be an appropriate diagnosis if a patient has a history

of manic episodes (ie, potential bipolar disorder). An MDD diagnosis may also not be appropriate

if symptoms have been experienced continuously across 2 years with little to no interruption (ie, po- tential persistent depressive disorder), or repeatedly co-occurring with menses (ie, potential premenstrual dysphoric disorder). Even in the context of MDD, exploration of seasonal patterns, anxious distress, melancholic features, peripartum onset, atypical features (eg, mood reactivity, rejection sensitivity), or catatonia should be considered as additional speci- ers of depressive disorders.

While an awareness of the breadth and variety of mood disorders and related conditions is im- portant for emergency clinicians, a speci c DSM-5 diagnosis may not be necessary or even possible when evaluating a depressed patient in the acute care setting, so emphasis should be placed on col- lecting important information regarding symptoms and treatment.

Suicide

Suicidal thoughts and behaviors are diverse, and range from thinking about killing oneself, to actual suicide death. For instance, suicidal ideation is
the consideration or desire to kill oneself, and is formally listed as a symptom of depression in the DSM-5. The content of suicidal thoughts can vary from being passive (“I want to disappear,” or “I don’t want to be alive”) to active (“I want to kill myself”). Other suicidal thoughts and behaviors that may accompany depressive symptoms include the suicide plan, which features some consideration of how, where, or when a person may kill himself; and suicide attempt, when an action is taken toward ending one’s life. Finally, suicide death is the lethal outcome of a suicide attempt.

Beyond suicidal thoughts and behaviors, other clinical presentations, such as a suicide gesture/threat or nonsuicidal self-injury, may be encountered in
the ED. A suicide gesture or threat is an action (eg, expressed statements and/or behavior) intended to make others believe the person wants to kill himself when, in fact, he may not have clear suicidal intent. This may be in the form of expressed statements and/or behavior. Additionally, nonsuicidal self-

Table 1. Summary of DSM-5 Diagnostic Criterion A for Major Depression: Symptoms12

May 2019 • http://www.ebmedicine.net

injury involves self-injurious behavior(s) speci cally for the purpose of hurting oneself, in the absence
of intent to die. This behavior is distinct from the suicide attempt. While there is an important dif- ference between these entities, it is necessary for

the emergency clinician to take all such complaints seriously and further clarify intent by gathering additional history and collateral information and initiating other means of investigation. In the case of drug overdoses, emergency clinicians are simi- larly encouraged to practice caution and thoroughly assess for suicidal intent, because suicidal behavior and drug overdose share risk factors.13

Epidemiology

Depression

Mood disorders are among the most common psychiatric disorders in the United States, with MDD being the most prevalent.14 Based on the 2005 National Epidemiologic Survey of Alcoholism and Related Conditions, the prevalence in the United States of 1-month MDD was 5.28%, with an overall lifetime prevalence of major depression at 13.23%.15 Another large survey carried out by the Behavioral Risk Factor Surveillance System (BRFSS) study and analyzed by the Centers for Disease Control and Prevention (CDC) found that, among 235,067 adults in the general population surveyed from 2006-2008, 9% met the criteria for major depression.16

Evidence suggests that prevalence rates of MDD may be even higher in ED settings. In a prospective cohort study of 182 adult patients presenting to an urban ED over the course of 1 week, approximately one-third screened positive for depression.17 Mood disorders account for approximately 23% of mental- health-related visits to United States EDs, with MDD being the most prevalent disorder.18 Importantly, from 2002-2008, visits to the ED for depression
and suicide-related reasons remained stable, while outpatient visits for the same decreased. This trend suggests that EDs remain a critical entry point and clinical setting for the evaluation of depression and suicide-related thoughts and behaviors.19

Evidence suggests that differences exist for depression risk with regard to gender, ethnicity, and age. In a survey of nearly 73,000 adults from
15 countries, the reported prevalence of MDD was nearly 2 times as high in women compared to men, and a lifetime prevalence of MDD and dysthymia was 1.7 times higher in women.20,21 Published risk factors for depression are summarized in Table
2. In the United States, the prevalence of MDD in men was 3% to 5%, compared with 8% to 10% in women.22 The BRFSS study noted that the incidence of major depression in women was 4%, versus 2.7% in men.16 Within the ED speci cally, those reporting past-year depression were more likely to be female,

middle-aged, smokers, complaining of physical pain or asthma, and of lower socioeconomic status.23

In general, MDD is more common in younger adults than it is in elder adults living in the same community.24 A survey of nearly 10,000 adults found that, while the prevalence of MDD was 19% to 23% among adults aged < 65 years, the prevalence was 10% in adults aged ≥ 65 years.25 However, some studies report that older adults presenting to the ED have depression rates comparable to younger adults living in the same community. In a study of patients aged ≥ 65 years presenting to the ED for a nonpsy- chiatric chief complaint, a brief depression screen identi ed approximately 30% as depressed. Among these adults, depression was more common in adults living in nursing facilities and in those reporting poor physical health.8 A second component of this study was to detect recognition rates of depression by ED physicians. The authors found that ED physi- cians were unable to identify any of the depression cases, suggesting that depression among the elderly may go largely undetected.8

Differences in the prevalence and incidence
of depression among different racial groups in the United States have also been noted. A survey pub- lished in 2007 of adults living in the United States who were matched for age and gender, found life- time prevalence rates of black individuals to be 10%, compared to white individuals at 18%.24 However, the more-recent BRFSS study noted that Hispanic in- dividuals and non-Hispanic black individuals were signi cantly more likely to report major depression (4.3% and 4%, respectively) compared to non-His- panic white individuals (3.1%).16

Suicide Risk Within Depression

Prevalence

Suicidal thoughts and behaviors frequently emerge among depressed patients, so initial detection of de- pressive symptoms warrants thorough consideration of the patient’s suicide risk. Nearly one-half (45.5%) of depressed adults in community-based samples have reported that they felt that they wanted to

die, and approximately one-third (36.4%) had ever thought about suicide.26 Among adults presenting to an urban ED for non–suicide-related care, recent thoughts of suicide were detected in 8% of patients,

Table 2. Risk Factors for Major Depression

• • • • • • •

Female gender
Young age or older age in a nursing facility Never-married, widowed, or divorced Black or Hispanic ethnicity
Major life event
Poor social support
Substance abuse

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and this was especially common in those with higher levels of depressive symptoms.27 Beyond this, 14% to 31% of depressed adults have ever attempted suicide.28 An epidemiological study of ED visits for attempted suicide and self-in icted injury found comorbid depression in 34% of patients.29 Depres- sive episodes may also have a time-dependent effect on suicide risk, with adults at higher risk toward the onset and in the early course of depression, as well as during any active depressive episode.30 Roughly
1 in 10 (3.4%-17.5%) depressed adults ultimately die by suicide.31 Beyond being the most extreme and tragic outcome of depression, suicide death among depressed adults has an estimated economic burden in the United States of $5.4 billion per year.32

Demographics

While emergency clinicians should take seriously and treat the presence of suicidal ideation or behav- iors brought forward by any patient, regardless of age, sex, socioeconomic status, race/ethnicity, and sexual minority status, demographic trends do exist. Regarding suicide death, white men aged ≥ 80 years have the highest suicide rate in the United States among those recorded (51.6/year per 100,000).16,33 While rates of completed suicide are highest in older adults, younger adults attempt suicide more often.3,34 Similarly, rates of suicide-attempt-related ED visits are highest among youth aged < 30 years, and are signi cantly heightened among adolescents aged < 15 years.18 Although women attempt suicide nearly 4 times more frequently than men, men are nearly 3 times more likely to die by suicide. These differences are thought to be related to the method by which men and women choose to engage in the act.3

Self-reported lesbian, gay, and bisexual status
is related to heightened risk for suicidal thoughts and behaviors. Lesbian, gay, and bisexual men and women are 2 times as likely to experience suicidal ideation compared to heterosexual peers.35 Men who identify as sexual minorities (ie, gay, bisexual, or transgender) are between 4 to 6 times more likely to attempt suicide across their lifetime compared to heterosexual men.36,37 Sexual minority women are approximately 2 times more likely to attempt suicide than heterosexual women.35,36

Risk Factors

Regarding clinical risk factors, the strongest single predictor for suicide-related outcomes is prior his- tory of suicidal ideation or attempt.38 For example, an individual who has made a previous suicide at- tempt is nearly 6 times more likely to make another attempt.39 One in 100 people who have attempted suicide will ultimately die of suicide within 1 year of the initial suicide attempt.40

It has also been found that more than 90% of individuals attempting suicide meet criteria for 1

or more major psychiatric disorder,34 with another study nding that patients with a psychiatric diag- nosis have suicide rates nearly 3 to 12 times higher than other patients.41 Among individuals with co- morbid psychiatric conditions, individuals who have had symptoms severe enough to warrant psychiatric admission have been found to have an increased lifetime risk of suicide (8.6% compared to 0.5% for the general population).42 Among the psychiatric conditions most associated with suicide risk, MDD was the most common, followed by schizophrenia, personality disorders, borderline personality dis- order, bipolar disorder, and posttraumatic stress disorder (PTSD).43,44

Differential Diagnosis

A crucial aspect in the evaluation of the patient
with depressive symptoms is identifying potential secondary causes of depressive symptoms, as mani- festation of depressive symptoms is often driven by medical etiologies that require different manage- ment strategies and treatment. The approach to the differential should be standard for all patients in
the ED presenting with depressive symptoms and should be systematic. An excellent overview of such an approach to evaluating behavioral chief com- plaints (such as agitation) is presented by Nordstrom et al, with many principles applicable to the evalua- tion of acutely depressed or suicidal patients.45

Speci cally, the behavioral evaluation involves a thorough history, assessment of vital signs, and
a focused physical examination. A review of sys- tems, incorporating infectious, toxic-metabolic, and neurologic complaints may help point to medical etiologies of the presentation. Contributing factors can be elicited from recent medical events (eg, myo- cardial infarction) and a complete list of medications ingested. A list of potential medical causes that may manifest as mood disorder symptoms is provided in Table 3, page 6.

Prehospital Care

Many depressed patients are referred to the ED by their primary care providers and outpatient psy- chologists. In cases of active and imminent suicidal ideation, transfer to the ED may be made with either professional emergency medical services or with a clinician accompanying the patient. Scene assess- ment for possible signs of overdose may give critical information for both the initial evaluation and subsequent treatment. Home assessment by initial providers for the presence of rearms should also be considered, given their lethality and use as a poten- tial means of self-injury. In the setting of any inges- tions or suicide attempt using lethal means (such as rearms), emphasis should be placed on the acute

May 2019 • http://www.ebmedicine.net 5

medical stabilization of the patient prior to transfer. Advance communication with the ED in these set- tings is ideal, with consideration of transportation to facilities with full psychiatric services for patients with active and imminent suicidal ideation.

Emergency Department Evaluation

Key Historical Questions

Eliciting intimate details of a patient’s psychiatric background is a challenging endeavor, but is even more challenging for emergency clinicians, given the minimally established clinician-patient relationship, time constraints, and emergent nature of the visit. When possible, maximize the patient’s privacy by avoiding interviewing in hallways or on stretchers, and use a patient, nonjudgmental approach. Begin- ning with open-ended questions such as, “What brought you here today?” versus closed-ended questions such as, “Did you mean to kill yourself today with these pills?” may elicit more detailed and helpful information and a better understanding of the patient.46 An initial discussion to map the chronology of depressive symptoms, the impact on the patient’s functional status (personal, family, and professional), and psychiatric history (prior hospitalizations, treat- ments, and any behaviors placing self or others at risk), will provide some context in which screener results can be interpreted and a differential diagnosis can be made.

Screening for Depression and Suicide

A patient’s suicide risk may go undetected unless it
is assessed deliberately, so screening is critical for all patients presenting with depressive symptoms, regard-

Secondary Causes of Depression

Endocrine disorders: hypothyroidism, Cushing disease, hyperparathyroidism, Addison disease

Central nervous system disorders: space-occupying lesion, Alzheimer disease, multiple sclerosis, seizure disorders, microangiopathic lesions

Infectious process: meningitis, encephalitis, Lyme disease, HIV encephalopathy

Medication side effects: common medications include antihypertensives (beta blockers, calcium-channel blockers), corticosteroids, hormone therapy (progesterone, testosterone, gonadotropin-releasing hormone)

Nutritional de ciency (commonly B12, B6/pyridoxine, thiamine) Obstructive sleep apnea

less of whether suicidal statements are made overtly. Depression is a known risk factor for suicidal thoughts and behaviors, and the period of time after hospital discharge marks one of the highest-risk periods for engaging in suicidal thoughts and behaviors.47

Screening tools typically consist of brief ques- tions that have been shown to be easy to administer and acceptable to patients.48 Although not broadly adopted in many EDs, the use of standardized screen- ing/assessment tools may be useful in evaluating patients with mood disorder-related complaints, allowing quantitative assessment of potentially high- risk patients in a quick, structured format. Several screening questionnaires have been developed for depression in the outpatient and primary care setting. http://www.MDCalc.com has online tools for rating the severity of suicide risk, including the PHQ-9, the ED- SAFE PSS-3, and the C-SSRS.

Online tools for assessing suicide risk are available from http://www.MDCalc.com:

• PHQ-9: http://www.mdcalc.com/phq- 9-patient-health-questionnaire-9

• ED-SAFE: http://www.mdcalc.com/ed-safe-patient- safety-screener-pss-3

• C-SSRS: http://www.mdcalc.com/columbia-suicide- severity-rating-scale-c-ssrs

For more information on the use of screening tools in patient disposition decision-making, see the “Disposition” section, page 14.

Evaluation

Obtain TSH levels, cortisol levels

Consider advanced imaging (eg, head CT, MRI)

Obtain lumbar puncture; consider advanced imaging

Initiate discussion with outpatient provider regarding close follow-up with regard to discontinuing or changing medication

Obtain B12, CBC levels for anemia; outpatient follow-up

Consider home CPAP in discussion with outpatient provider

Table 3. Medical Conditions Associated With Mood Disorder Symptoms

Clinical Findings

Psychomotor retardation

Focal neurologic de cits, de cits in memory

Fever, headache, focal neurologic de cits, altered level of consciousness

Thorou

gh review of medications used

Review of systems: fatigue, dietary history, travel

Review of medical history, sleep history

Abbreviations: CBC, complete blood cell count; CPAP, continuous positive airway pressure; CT, computed tomography; HIV, human immunode ciency virus; MRI, magnetic resonance imaging; TSH, thyroid-stimulating hormone. http://www.ebmedicine.net

One common questionnaire, the Patient Health Questionnaire (PHQ) is a 9-question, self-adminis- tered depression questionnaire based on the Primary Care Evaluation of Mental Disorders (PRIME-MD) di- agnostic instrument for detection of common mental disorders.49 The PHQ-9 has been validated in various outpatient clinical settings, including the ED.27,49-53 (See Table 4.) It has been studied extensively and has been found to be reliable across genders and different cultural contexts.54-57

The PHQ-9 offers a single-item screener for suicide through its question about recent suicidal thoughts and behaviors (item 9). Item 9 consists of the question, “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?,” with response options ranging from “not at all” to “nearly every day.”58 Patients’ responses to this single item can predict subsequent suicide attempt and death, such that 1 in 250 who respond “not at all” are likely to attempt suicide, whereas 1 in 25 who respond “nearly every day” are likely to attempt suicide.

An increasingly studied multi-item measure
is the ED-SAFE Patient Safety Screener (PSS-3), available at: http://emnet-usa.org/wp-content/ uploads/2019/02/K_PtSafetyScreen.pdf. The PSS-3 assesses for depression/hopelessness in the prior 2 weeks, suicidal ideation in the prior 2 weeks, and lifetime history of suicide attempt.59 The PSS-3 is part of the ED-SAFE public health outreach pro- gram, coordinated through Massachusetts General Hospital (www.emnet-usa.org). It has been shown to

Patient is asked “Over the last 2 weeks, have you had the following problems?” The patient is asked to respond “not at all” (0 points), “several days” (1 point), “more than half the days” (2 points), “nearly every day” (3 points).

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling asleep or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself or that you are a failure or have let
yourself/family down

7. Trouble concentrating on things like reading the newspaper or
watching TV

8. Moving or speaking so slowly that other people have noticed;
or the opposite: being so dgety or restless that you have been
moving around a lot more

9. Thoughts that you would be better off dead or of hurting yourself

Points are added for score:

1-4 = minimal depression
5-9 = mild depression
10-14 = moderate depression
15-19 = moderately severe depression

20-27 = severe depression
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be feasible across multiple emergency settings in the United States, and has also been shown to double the number of suicide-risk cases detected.61 Another well-known screener with similar questions is the Columbia-Suicide Severity Rating Scale (C-SSRS), available at http://cssrs.columbia.edu/60

If a patient reports recent suicidal ideation or
a prior suicide attempt when asked these initial questions, further screening through a secondary screener that assesses additional characteristics (eg, current suicide plan, recent suicidal intent, prior hospitalizations, excessive substance use, current irritability/agitation) should be conducted in order to determine whether a mental health consultation is needed. This approach has been shown to decrease the total number of suicide attempts by 30% follow- ing an ED visit.62 Nonetheless, the ultimate impact of screening on preventing actual suicide death remains unknown.

Some clinicians have expressed concern that questioning a patient about suicidal ideation could encourage or introduce the idea of suicide in pa- tients who had not previously considered it; howev- er, the literature does not support this assumption.63 It has been found that there is no associated induc- tion of negative affect/mood when a patient is asked about suicidal ideation.64 Taken together, the evi- dence suggests that asking about suicidal ideation is not the same thing as suggesting it. Fear or concerns around iatrogenic effects should not prevent such evaluations.

Physical Examination

There are 2 components to the physical examina- tion in a patient with depression: (1) the physical examination that includes vital signs and the cogni- tive assessment that focuses on identifying medical conditions (including drug toxicity and physical harm from prior or acute suicide attempts); and (2) the behavioral mental health status examination that focuses on identifying the presence and degree of depression. (See Table 5, page 8.) A review of sys- tems incorporating infectious, toxic-metabolic, and neurologic complaints may help point to medical etiologies of the presentation. Contributing factors can be elicited from recent medical events and a complete list of medications ingested.

Diagnostic Studies

A large body of work has attempted to examine the utility of medical screening in the context of psychiat- ric emergencies in the ED. A systematic review of 60 studies by Chennapan et al examined medical screen- ing of adult ED patients with psychiatric complaints, which led to 7 recommendations for emergency clinicians assessing patients with psychiatric emer- gencies (not limited to mood disorder complaints).66

Table 4. Patient Health Questionnaire-9 (PHQ-9)

Patients with a known psychiatric disease present- ing with exacerbating psychiatric complaints in the ED should:

1. Undergo a medical screening that includes a full
medical and psychiatric history; and

2. A focused physical examination; and

3. A mental status examination.

4. Routine serum and urine toxicology screening is
not recommended.

5. Additional screening tests should be considered
for new-onset psychiatric symptoms in individ-
uals aged ≥ 65 years; and

6. Immunosuppressed patients; or

7. Patients with concomitant medical disease.66
A 2017 Clinical Policy by the American Col-

lege of Emergency Physicians regarding diagnosis and management of the adult psychiatric patient in the ED also recommends against the routine order- ing of laboratory testing for the patient with acute

psychiatric symptoms, and instead calls for the use of medical history, previous psychiatric diagnoses, and physical examination to guide testing (Level C recommendation).9 Similarly, a Level C recommen- dation was made against the routine use of a urine drug screen in the evaluation of alert, cooperative psychiatric patients, and urine toxicology screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility.

While laboratory studies are not routinely indi- cated, laboratory studies may help in speci c cases, such as in patients with advanced age, medical co- morbidities, or a new psychiatric presentation that is different from previous psychiatric episodes. In the case of patients taking certain psychotropic medi- cations with known toxic effects (such as lithium), serum levels may aid management.67

Imaging studies of the brain, such as computed tomography (CT) or magnetic resonance imaging (MRI), should not be ordered routinely for patients with depression or suicidality unless there is a high degree of suspicion for an anatomical lesion or history of traumatic injury, or possibly in cases with patients who are older, have medical comorbidities, new-onset psychiatric symptoms, etc. The focus of diagnostic studies for these patients should be driven by their clinical presentation66,68 and examination.

Treatment

Interventions targeting depression and suicide risk can take place across settings ranging from the ED to outpatient care. Key steps taken in the ED can help optimize patient well-being and subsequent out- comes. Given the often imminent nature of suicide risk, the following interventions primarily target suicidal patients in the ED.

Maintaining a Safe Environment

Patients can be at risk for self-harm and/or elope- ment during their stay in the ED. Effective precau- tions should include mechanisms to alert medical and nursing staff to the potential safety risk and,
if applicable, an appropriate search of the patient and his belongings should be performed so that dangerous items (medications, weapons, etc) can be removed. The patient’s physical environment in the ED should be assessed to minimize risk, including removal of tubing and needles. Patients who are at acute safety risk may also warrant continuous obser- vation, as suicidal behavior may be impulsive.

Safety Planning

An increasingly widespread practice with poten- tially suicidal patients is safety planning, which is a brief intervention designed to reduce short-term suicide risk. Safety planning can be completed col- laboratively by the patient and emergency clini-

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Table 5. Key Aspects of the Mental Status Evaluation on Physical Examination

Examination Component

General appearance

Orientation

Speech

Motor activity

Affect

Mood

Thought process

Thought content

Perceptual disturbances

Description

Observe the patient’s general appearance during the interview/ examination, such as overall grooming, clothing, and posture.

Ask the patient his or her full name, the full date (day, month, year), and place where the patient is currently located.

Make note of the patient’s speech, including volume, rate, articulation, coherence, and spontaneity.

Include comment on the patient’s motor behavior, including gait, gesture, overall general body movement, and tics.

Affect, de ned as a patient’s outwardly demonstrated emotional state, should be noted on the examination.65 Descriptive terms such as blunted or at affect, sullen, or agitated can be used.

Ask the patient to report his subjective mood for the past few days/weeks. When possible, note words used directly by the patient (ie, “I have felt terrible and depressed over the last week”).

Observe whether the patient’s thinking is logical, tangential, goal-directed, or shows a loosening of associations or ight of ideas (ie, ideas not logically connected to each other).

Note any general/repetitive themes or the presence or absence of delusion as well as suicidal/homicidal thoughts.

Note whether the patient is experiencing
any disturbances in perception such as auditory, visual, olfactory, or somatosensory disturbances.

cian in approximately 20 to 45 minutes, and it has strong acceptability among both patients and staff in ED settings.69,70 While safety planning interven- tions have been led primarily by psychiatrists or psychologists in the ED setting, we describe such procedures here for emergency clinicians to increase awareness of such treatments and their potential utility in the ED.

The clinician begins the intervention by conduct- ing a brief interview, eliciting the nature of the current suicidal crisis to help the patient identify personal- ized warning signs. The safety planning intervention involves establishing a list of personalized, prioritized steps intended to keep the patient safe in subsequent suicidal crises. The steps, outlined in a worksheet, typically include the following:71

1. Warning signs: behaviors, feelings, or thoughts
that precede suicidal crises and indicate that the patient should invoke the safety plan (eg, feeling angry, isolating myself, thinking about things I wish I had handled differently).

2. Internal coping strategies: distractions that do not require contacting another person (eg, watch television at home, play guitar).

3. People and social settings that provide distrac- tion: individuals, as well as accessible places that can provide distraction (eg, call a coworker, visit a bookstore, go to a coffee shop).

4. People whom I can ask for help: trusted indi- viduals who can provide support in a crisis (eg, mother/father, friend, spiritual advisor).

5. Professionals or agencies I can contact during a crisis: clinician(s), the National Suicide Preven- tion Lifeline, and the address of local emergency services.

6. Making the environment safe: lethal-means counseling to ensure a safe home environment postdischarge (see description following).
The clinician then provides an overview of

how the plan should be used (ie, as soon as the patient notices that he is experiencing those warning signs, he moves from step to step until the suicidal thoughts subside). The patient should be told to
feel free to seek professional help immediately if necessary or desired. While completing the remain- ing steps of the safety plan with the patient, clini- cians are encouraged to help problem-solve against potential obstacles that may prevent the patient from using the safety plan effectively.71

Safety planning has been proposed as a stand- alone intervention, although the majority of evi- dence demonstrating its effectiveness involves safety planning combined with other interventions, such
as a follow-up telephone call after leaving the ED. Research suggests that safety planning may help enhance outpatient treatment engagement after an ED visit72 and reduce the total number of subse-

quent suicide attempts by approximately 30% to 50%, compared to usual emergency care.62,73 A study of the combined safety planning and follow-up telephone call approach suggests high acceptability and feasibility among ED staff,70 and safety planning has been endorsed by the Best Practices Registry for Suicide Prevention.74

(Lack of) No-Suicide Contracts

No-suicide contracts, also referred to as “no-harm” contracts or “contracting for safety” are verbal/ written agreements between the patient and the emergency clinician, and are intended to have the patient articulate that he will not attempt to hurt himself. Initially developed within psychiatry,75
this technique has been used in a wide range of contexts, from psychiatrists to primary care physi- cians, in inpatient, outpatient, and ED settings.75,76 Studies examining the clinical utility of no-suicide contracts are mixed, at best; one study found that 41% of psychiatrists who had used such contracts still had patients who went on to attempt or die by suicide.77 In a randomized clinical trial of no-suicide contracts versus crisis safety planning among active- duty soldiers with an emergency behavioral health appointment, suicide attempts were reduced for those with safety planning intervention compared to those with contracts.76 Beyond the lack of evidence, no-suicide contracts do not offer any legal protection and may, in fact, result in reduced vigilance of the at-risk patient.78

Lethal-Means Counseling

A potentially helpful suicide prevention strategy is to assess and offer brief counseling around suicidal patients’ access to lethal means. Lethal-means coun- seling is thought to be effective due to the relatively short-lived nature of many suicidal crises. Because suicidal thoughts are often eeting, the longer it takes to access lethal means, the more likely it is
that the suicidal thoughts will have subsided before means are obtained.79 Reducing access to lethal means has been shown to reduce suicide attempts and deaths, and is also endorsed as a best practice by the Suicide Prevention Resource Center.80 Despite this, very few patients have been asked about their access to lethal means during an ED visit.81,82

Lethal-means counseling typically begins with the clinician explaining the rationale behind means restriction. The clinician asks about the lethal means available to the patient, and provides options for restricting access, such as disposal, locking up the means and giving the key to a spouse, enlisting a family member to administer medication, or tempo- rarily giving the means to a friend. The clinician and patient select an option, develop a detailed plan, and the clinician uses motivational interviewing strategies to increase the patient’s compliance with the plan.79

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Working collaboratively with the patient’s ac- companying friends and/or family may further increase the likelihood of reduced access during
a crisis period (eg, having a friend and/or family member lock medications in a secure location or store rearms).82 A study conducted in a pediatric psychiatric emergency service suggests that lethal- means counseling with parents of suicidal youth
is both feasible and well-received.83 Lethal-means counseling may be achieved as a component of the safety planning process or as a separate discussion.

Connecting With Follow-up Resources

Helping depressed and suicidal patients connect with follow-up resources is critical. Example re- sources include outpatient providers (psychiatrist, psychologist) and crisis call/chat line National Suicide Prevention Lifeline, 1-800-273-8255 [TALK]; Lifeline Chat via https://suicidepreventionlifeline. org/chat/). Depressed patients presenting to the ED are more likely to experience negative short-term outcomes, such as suicidal thoughts and suicide at- tempts, which are often the result of poor treatment compliance. As such, patients may require more pro- active steps to follow through with ED recommen- dations.84 This can be achieved ef ciently through 5 steps that can be taken in the ED74:

1. Provide a standard handout pamphlet that in- cludes addresses, contact numbers, and informa- tion about insurance coverage of local outpatient providers.

2. Inform the patient of 24-hour crisis lines.

3. Ask the patient to indicate which of the afore-
mentioned resources seem most viable, whether the patient anticipates any barriers to accessing those preferred resources, and what alternative solutions to such barriers may be available to

Pharmacotherapy

The administration of psychotropic medication to treat depression is not routinely initiated in the ED, although evidence now exists for the use of medica- tions, such as ketamine, in conjunction with oral antidepressant medications in the management of acute depressive episodes.85 (See the “Controversies and Cutting Edge” section, page 11.) Commonly pre- scribed antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), can take as long as 6 to 8 weeks before showing clinical effect.

There have been multiple studies examining the overall ef cacy of the available SSRIs (eg, citalo- pram, escitalopram, uoxetine, uvoxamine, parox- etine, sertraline) compared to selective norepineph- rine reuptake inhibitors (SNRIs) (eg, desvenlafaxine, duloxetine, venlafaxine), and other second-genera- tion antidepressants (eg, bupropion, nefazodone). Three multicenter randomized double-blind studies examined the differences in effectiveness of various SSRI antidepressants, such as sertraline, citalopram, paroxetine, and uoxetine, and all 3 studies noted no signi cant differences in the effectiveness of the medications toward management of depressive symptoms.86-88 The ultimate choice of which speci c antidepressant to use for patients should ideally be made in coordination with a psychiatry provider or primary care team following the patient, as ongoing follow-up is essential for monitoring the ef cacy and impact of any intervention.

Special Populations

Military Veterans

There has been a growing interest in the effects of traumatic events and the incidence of psychiatric complications such as PTSD, depression, and suicide

them. among members of the armed forces.89,90 Recent

4. Schedule a follow-up appointment with a preferred outpatient provider (ideally within 1 week of discharge).

5. Document the patient’s preferred follow-up resources and steps taken to connect them with such resources.
At times, it may not be possible to immediately

arrange a follow-up appointment, such as when a patient presents to the ED during off-hours or there is a lack of care coordination in the ED. In such cas- es, identify departmental or hospital administrative support staff who may be able to help make such an appointment during regular business hours and, if needed, identify an alternative provider (eg, primary care provider). Alternatively, it may not be feasible to schedule an outpatient appointment if the patient will be hospitalized following the ED presentation. In such cases, it is encouraged to take steps 1-3 and pass along documentation from step 5.

evidence has supported an association between ex- posure to blast/concussive injuries and subsequent depressive and anxiety symptoms.91 The underly- ing pathophysiology of such association between blast/concussive injuries and affective disorder symptoms may hinge on a complex interrelation- ship between neuropathological and neurophysi- ologic pathways.92 Numerous emergency facilities within the United States Veterans Administration (VA) medical system have noted increased rates of depressive symptoms among returning military vet- erans.93 Among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideation in the prior week, with about 40% indicating active suicidal ideation at presentation; 70% reported current depressive symptoms; and 76% reported intense anxiety.94 Among depressed veterans with a health-related VA visit shortly before death by suicide, approximately 10% had visited

a VA ED in the 30 days prior to their death.95 The

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rami cations for the emergency clinician are broad, whether or not one practices in a military-af liated hospital. As with many other mental disorders, the downstream effects of conditions such as depression, suicide, and PTSD affect not just the patient, but also family, friends, and other contacts. Care must be taken to inquire about the patient’s adjustment back to civilian life and to pursue further questioning/ workup when concerning history is elicited. When evaluating recent military veterans, a high degree of concern should be maintained to ensure that such patients have adequate social and professional sup- port in place. This may be done in conjunction with social work services in the ED or with the patient’s primary care team.

Despite a surge of interest in this area, there are multiple unanswered questions, from the actual dis- ease burden noted in military groups to the possible differential vulnerability of veterans based on age, military experience, gender, or race. It is incumbent upon emergency clinicians in both military and civil- ian EDs to be aware of this potential association and remain vigilant with these patients to ensure they receive appropriate evaluations and support.

Controversies and Cutting Edge

Ketamine and Treatment-Resistant Depression and Suicidality
While current treatment of patients with acute suicidality has infrequently used acute pharmaco- logical treatments or interventions, recent research has explored the use of ketamine in the treatment of treatment-resistant depression and acute suicidal- ity. A number of clinical trials including random- ized controlled studies have found that low doses
of ketamine, administered via a number of routes, from intravenous to intranasal, may have a signi – cant therapeutic effect toward reducing suicidality in patients evaluated in the acute setting.51,85,96-100 Esketamine, an intranasally administered ketamine derivative medication, was recently approved by the United States Food and Drug Administration (FDA) for management of depression that has not respond- ed to at least 2 antidepressant treatments (ie, treat- ment-resistant depression).101 Because of the poten- tial for abuse, the FDA has mandated that the drug be available through a restricted distribution system and administered only in a certi ed medical of ce where the patient can be monitored for sedation and dissociation for at least 2 hours after administration. While further research, including larger sample sizes and longer-term follow-up, is needed before wide- spread adoption of such interventions, such inter- ventions may hold promise in the acute-care setting management of depression.

The Zero Suicide Model

The Zero Suicide model is an innovative program developed by the National Action Alliance for Suicide Prevention. It is a multipronged approach to reducing suicide based on the premise that death by suicide is a preventable outcome under the auspices of health and behavioral health systems.102 Based, in part, on previous integrated approaches to suicide reduction such as the United States Air Force Suicide Program and the Perfect Depression Care Mod- el,103,104 Zero Suicide incorporates a combination of educating clinicians on best practices, identifying available screening and assessment tools for use in the ED, engagement, treatment, and disposition. Beginning in 2017, it has been implemented in the outpatient setting in approximately 170 free-stand- ing outpatient clinics serving over 80,000 patients. Application of the Zero Suicide model in the ED may offer a novel management approach to patients with psychiatric emergencies and may be associated with improved health outcomes.105

Alcohol Intoxication and Suicide Risk in the Emergency Department
Patients with depression are at signi cantly in- creased risk for alcohol abuse and dependence.
Data suggest that this relationship is bidirectional. Depressive illness often fosters hopelessness, social isolation, and dysphoria, all of which can lead to the use of alcohol. Conversely, the impact of alcohol on mood is generally in the direction of worsening de- pression. Furthermore, alcohol has the general effect of disinhibition of brain function, which may lead to worsening suicidal thoughts and decreased ability to control suicidal behavior. As a result, alcohol abuse is a major lifetime risk factor for completed sui- cide.106 In addition, individuals who make suicide attempts or present with suicidal ideation are more likely to be acutely intoxicated.107,108

Alcohol intoxication can complicate the ap- proach to the ED patient who expresses thoughts
to harm himself or others. These patients may
deny such thoughts or intentions when sober. This change in verbalized intent may impact disposi- tion, which explains why many mental health pro- viders will insist that the patient be “sober” before they perform an assessment. Thus, the emergency clinician and consulting mental health provid-
ers are faced with a paradox: Population-based studies clearly indicate that such patients have an increased lifetime risk of death due to suicide; how- ever, there are no data to support that patients who are no longer suicidal when sober are at increased acute safety risk. Therefore, the decision regard-
ing whether to seek psychiatric hospitalization for these patients is a dif cult one.

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Clinical Pathway For Assessing Depression in the Emergency Department

• Ask about depressive symptoms: sleep, interest, guilt, energy, suicidality, concentration, appetite, psychomotor, emotion [depressed mood])

• Assess for suicidal ideation

• Review medical history and medication for secondary causes
of depressive symptoms (Class I)

• Conduct complete physical examination, including a cognitive assessment

• Obtain diagnostic studies based on history and physical examination
(Class I)

Does the patient express suicidal ideation?

YES

Are there signs of secondary causes of depression?

YES

PHQ-9 score ≥ 15

• Suggestive of major depressive episode

• Obtain psychiatric consult (where available) (may involve
transfer by ambulance to facility with psychiatrist) (Class II)

• Initiate 1:1 observation

• Search patient’s belongings for objects potentially
dangerous to patient or others

• Obtain psychiatry consult; patient may not leave the ED
without formal psychiatric evaluation

Administer PHQ-9 (Class II) Pursue relevant medical workup

PHQ-9 score < 15

• Use clinical judgment regarding patient’s safety/functional status for discharge home

• If safe for discharge home, arrange outpatient psychiatric follow-up

• Discuss plan with patient’s primary care provider

• Document patient’s contact information and additional
emergency information (Class II)

Abbreviations: ED, emergency department; PHQ-9, 9-item Patient Health Questionnaire.

Class of Evidence De nitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following de nitions.

Ask directly about:

• Intent, plan, and available means

• Recent life stressors

Class I

• Always acceptable, safe
• De nitely useful
• Proven in both efficacy and effectiveness

Level of Evidence:
• One or more large prospective studies

are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and

compelling

Class II

• Safe, acceptable • Probably useful

Level of Evidence:
• Generally higher levels of evidence
• Nonrandomized or retrospective studies:

historic, cohort, or case control studies • Less robust randomized controlled trials • Results consistently positive

Class III

• May be acceptable
• Possibly useful
• Considered optional or alternative treat-

ments

Level of Evidence:
• Generally lower or intermediate levels of

evidence
• Case series, animal studies,

consensus panels
• Occasionally positive results

Indeterminate

• Continuing area of research
• No recommendations until further

research

Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory • Results not compelling

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

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Emergency clinicians are advised to develop a consistent and thoughtful approach to the assess- ment of intoxicated suicidal patients, which should involve the following concepts:

• Before completing the evaluation, clinicians should observe the patient until the patient has reached a reasonable level of sobriety. Sober in- dividuals are more likely to be organized in their thinking and more accurate in their assessment of their own safety.

• Guidelines for establishing when the patient has achieved an effective level of sobriety should
be based on clinical assessment and not blood alcohol levels. Chronically alcohol-dependent individuals may be sober despite a signi cant blood alcohol level.

• Patients in active withdrawal should be treated throughout their stay in the ED.
Past guidelines by organizations such as the American College of Emergency Physicians and the American Association for Emergency Psychiatry have supported this type of approach, recommend- ing a personalized approach to intoxicated psychiat- ric patients.9,109,110 These guidelines emphasize eval- uating the patient’s cognitive abilities rather than the speci c blood alcohol level as the guiding factor in deciding whether emergency clinicians should pursue a formal psychiatric assessment. Future research in this area may explore the correlation of blood alcohol level with decision-making capability, but it is currently recommended to evaluate patients as a function of their individual presentation as well as initiating a period of observation for intoxicated patients who have psychiatric symptoms, to evalu- ate for possible resolution of psychiatric symptoms as the patient sobers. For patients without evidence of acute ongoing safety risk, acute but voluntary treatments may still be indicated. This may include outpatient substance abuse treatment, referral to a detoxi cation center, or referral to a combined sub- stance abuse/psychiatric hospital unit (often known as a dual diagnosis unit).
Postdischarge Patient Contact
In addition to providing patients with follow-up re- sources, in collaboration with mental health special- ists, emergency clinicians may consider implement- ing continuing patient contact, an evidence-based intervention that involves following up directly with suicidal patients after discharge.111 In the months following discharge, mental health providers make telephone calls to check in on the patient’s treatment and adjust treatment plans as needed, or they may send a simple postcard with a caring note signed by the patient’s attending physician. For instance, the note may read: “Dear [Patient Name], It has been
a short time since you were here at the [Hospital

Name], and we hope things are going well for you. If you wish to drop us a note, we would be happy
to hear from you.”112 A randomized controlled trial compared the effects of usual treatment alone with usual treatment plus 1 such postcard mailed 9 times over the course of the year after discharge among patients presenting to an ED with deliberate self- poisoning. There was a 50% reduction of repeat self-poisoning events per individual in the group that received the caring postcards.113 A review of several studies that utilized outreach methods such as telephone calls, postcards, letters, in-person visits, emails, and text messages following ED visits and inpatient hospitalizations revealed mixed, but over- all promising effects of continuing patient contact on postdischarge suicidal behavior-related outcomes.114 While these interventions occur post-ED evaluation and are outside the scope of the acute treatment plan, an awareness of such strategies by emergency clinicians may help when crafting disposition and follow-up plans in conjunction with other mental health specialists.

Enhancing Clinical Decision-Making

Despite the aforementioned screening recommenda- tions, clinical decision-making around suicide may still be limited. This may be due to 2 factors: First, many of the screening tools currently rely on explicit self-reporting and are only as accurate as patients’ ability or willingness to acknowledge certain risk factors (eg, current ideation, history of suicide at- tempt). Some of these screening tools have been shown to only modestly predict near-term adverse events in the ED or disposition from the ED.115,116 One alternative is the use of screening tools that do not rely on self-report, such as brief behavioral tasks that assess suicide-related cognitions. As an exam- ple, implicit association tests (IATs) are brief reac- tion-time computer tasks that can be completed in less than 5 minutes. Death/self-harm IATs can yield a score that indicates how closely the patient identi- es with death- and suicide-related concepts. These IAT scores have been shown to predict subsequent suicidal thoughts and behaviors; in some cases, above and beyond clinician prediction, the patient’s own prediction, and well-known risk factors.117,118

A second reason why screening tools may still be limited is their consideration of relatively few risk factors. Suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. To help address this, research is being conducted to explore whether complex computa- tional approaches, such as machine learning, may
be applied to electronic medical health records to help inform clinical decision-making.119 Preliminary research is promising, and may yield practical tools that more comprehensively guide the determination of low to imminent suicide risk.120

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Telepsychiatry

Novel tools, such as telepsychiatry, may also im- prove access to mental health providers in a wide setting of ED practices and allow remote assess- ment and management care in collaboration with the ED.86 Such tools may provide expanded access to psychiatric management and consultation via remote methods and may offer potential improve- ments in the cost-effectiveness of mental-health-care management in the ED.121

Disposition

Emergency clinicians in the past have relied on
a combination of clinical judgment (and, where available, local protocols) when determining which patients should be kept for observation, discharged, or admitted to an inpatient unit. Determining the appropriate disposition is often fraught with legal, ethical, and psychological considerations, coupled with the knowledge that patients with suicidal ideation tend to have longer overall lengths of stay compared to other patients on involuntary mental health hold.122

Suicide Risk Assessment Tools in Disposition Decisions
While no universally accepted guidelines currently exist for disposition management of depressed or suicidal patients in the ED, tools such as the C-SSRS, the SAFE-T tool, and the ICARE2 tool, alongside
the broad framework of programs such as the Zero Suicide model, may serve as important tools to aid physician decision-making in management of these patients, but they do not guide disposition.60,105,123 Two assessments that have been explored in the
ED setting (within the context of the Zero Suicide model) are the C-SSRS and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T).11

The C-SSRS is a series of questions that assess the quality of suicidal ideation (eg, wish to be dead, thoughts about killing self), suicide plan, and intent to act on thoughts. The C-SSRS has been shown to be sensitive to change over time and has been used at multiple levels of care, including the ED.60

The SAFE-T is a 5-step evaluation and triage tool that walks the clinician through the assessment of risk and protective factors, current and past history of suicidal thoughts and behaviors, and then offers treatment recommendations based on the patient’s responses (See Figure 1, page 15.)

Another potentially useful instrument for emergency clinicians is the ICARE2 tool. Provided by the American College of Emergency Physicians, it is the result of an iterative literature review and expert consensus panel.123 The online tool can be ac- cessed at: http://www.acep.org/patient-care/iCar2e/ The ICARE2 tool integrates many of the risk factors and

treatment approaches discussed in this paper, and provides clinicians with a tool that is easy to refer- ence to help with assessment.

It is important to note that while these tools hold promise, the use of these tools (eg, C-SSRS, SAFE-T, ICARE2) for disposition decisions is not currently supported by the literature, and no single suicide risk assessment tool, to date, has been found to be suf ciently predictive of high-risk cases.116,124 Thus, these innovative assessment tools should not be used by themselves for disposition and risk strati cation. Rather, they should be used to complement other existing resources and col- laboration with psychiatric consultation, as needed, to assist clinical judgment.

Coordination of Follow-Up Care

For patients who do not acknowledge active suicidal ideation but who do acknowledge signi cant depres- sive symptoms, it is prudent to involve a mental health clinician to facilitate the development of an acute treatment plan. These patients likely do not require inpatient psychiatric hospitalization but would bene t from an integrated effort to coordinate the follow-up care required to facilitate outpatient management. Care may include referral to outpatient psychiatric treat- ment, partial hospitalization, or voluntary hospitaliza- tion programs. Typically, these dispositions and care plans will be facilitated by consultation with mental health professionals in the ED, where available.

Patients who are deemed to be at moderate to high or imminent risk of harming themselves may require further evaluation in the ED, transfer to a hospital-based psychiatric ED, psychiatric observa- tion unit/crisis stabilization unit (where available), or inpatient hospitalization. Potential bene ts to hospitalization include crisis stabilization, keeping the patient in a safe and monitored environment, and beginning or changing medications.

Involuntary Con nement

Involuntary con nement or hospitalization may be necessary for patients who are at imminent risk of harming themselves but refuse to stay in the ED or be hospitalized, or for suspected suicidal patients who refuse evaluation. In these cases, it may be necessary to hold patients involuntarily in the ED until a com- plete psychiatric and safety evaluation is performed and appropriate disposition planning has taken place.

The decision to hold a patient involuntarily should be accompanied by several key consider- ations. First, before making the decision to hold a patient involuntarily, there must be knowledge of
the state and federal laws concerning involuntary holding of patients. Statutes governing such involun- tary holds are governed by county and state law, and procedures vary from state to state. The United States Supreme Court has ruled, across several landmark

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cases, that involuntary hospitalization and/or treat- ment without “clear, unequivocal, and convincing” evidence of risk violates an individual’s civil rights, and some states have changed their statutes to re ect this principle (Addington v Texas, 1979; O’Connor v Donaldson, 1975; Jackson v Indiana, 1972). In general, an individual must be exhibiting behavior that is an imminent danger to himself or others, the hold must be for an evaluation only, and a court order must be received for more than a very short-term hospitaliza- tion (in many states, this is 72 hours).

Second, physicians must document their reasons supporting the decision to hold a patient involun- tarily. Concerns for the patient’s safety should be explicitly documented, and/or potential to harm himself and/or others. While the actual process

of involuntary (or “civil”) commitment is a legal process that occurs outside of the ED, such commit-

ment proceedings may follow a period of emergency hospitalization begun in the ED.

Third, potential risks are associated with hos- pitalizing patients, even voluntarily. Recent work found evidence to suggest that crisis-service utiliza- tion (eg, ED visits) may uniquely increase suicide risk during the already heightened risk period fol- lowing ED and hospital discharge.125

When involuntary con nement is deemed nec- essary, it should be for as brief a duration as possible in an effort to minimize the patient’s stay in the ED and minimize the time spent waiting for appropriate treatment, which may include inpatient treatment or crisis stabilization. Psychiatric patients, and suicidal patients in particular, experience longer lengths of stay in the ED compared to nonpsychiatric pa- tients.126 Long lengths of stay in the ED are associ- ated with negative patient and hospital outcomes,

Figure 1. Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) Tool11

Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge.

1. RISK FACTORS

Suicidal behavior: history of prior suicide attempts, aborted suicide attempts or self-injurious behavior
Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD,

Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity).

Co-morbidity and recent onset of illness increase risk
Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, insomnia, command hallucinations
Family history: of suicide, attempts or Axis 1 psychiatric disorders requiring hospitalization
Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame or despair (e.g., loss of relationship, financial or

health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of

physical or sexual abuse. Social isolation.
Change in treatment: discharge from psychiatric hospital, provider or treatment change Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk Internal: ability to cope with stress, religious beliefs, frustration tolerance
External: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent
Ideation: frequency, intensity, duration–in last 48 hours, past month and worst ever
Plan: timing, location, lethality, availability, preparatory acts
Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun), vs. non-suicidal self injurious actions Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious;
Explore ambivalence: reasons to die vs. reasons to live
* For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors or disposition
* Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above.

4. RISK LEVEL/INTERVENTION
Assessment of risk level is based on clinical judgment, after completing steps 1-3 Reassess as patient or environmental circumstances change
(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., setting, medication, psychotherapy, E.C.T., contact with significant others, consultation); firearm instructions, if relevant; follow up plan. For youths, treatment plan should include roles for parent/guardian.

RISK LEVEL

RISK / PROTECTIVE FACTOR

SUICIDALITY

POSSIBLE INTERVENTIONS

High

Psychiatric disorders with severe symptoms, or acute precipitating event; protective factors not relevant

Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal

Admission generally indicated unless a significant change reduces risk. Suicide precautions

Moderate

Multiple risk factors, few protective factors

Suicidal ideation with plan, but no intent or behavior

Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers

Low

Modifiable risk factors, strong protective factors

Thoughts of death, no plan, intent or behavior

Outpatient referral, symptom reduction. Give emergency/crisis numbers

Source: https://www.integration.samhsa.gov/images/res/SAFE_T.pdf

May 2019 • http://www.ebmedicine.net

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

1. “The patient often comes to our ED intoxicated and leaves when he’s sober. I thought he was just drunk and wanted to sleep.”
Patients who make frequent visits to the ED often get broadly overlooked. There is an increased incidence and prevalence of suicide and depression among individuals with substance abuse issues; it is critical to review
the vital signs and perform a safety assessment for these patients and re-evaluate when they are sober.

2. “I was afraid that if I asked the patient if he had a speci c plan, it might give him an idea and encourage him to do it.”
Multiple reports have found that direct questioning about suicide does not result
in an increase in suicidal ideation; for many patients, it is only through direct questioning that the emergency clinician is able to ascertain imminent suicide risk.

3. “She said she only took a few diphenhydra- mine pills to get some attention.”
Patients who have made a suicide attempt are often uncertain about the amount and type of medication/pills they have ingested. In cases
of intentional ingestion, it is prudent to obtain a full toxicology screen and anticipate a possible decline in clinical status while waiting for initial studies to result.

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.

5. “We thought grandma was just feeling sad, and that her leg pain and fatigue were due to her feeling down.”
Be sure to always do a full physical examination and evaluation for patients with psychiatric complaints; other medical conditions can be missed by not doing a full examination.

“I didn’t think she needed close observation; she looked so calm and was so cooperative despite saying she wanted to kill herself.” Patients with current suicidal ideation may require 1:1 observation to prevent occurrence of self-in icted harm while in the ED.

“He didn’t look like the type who would get violent in the ED.”
Patients expressing active suicidal ideation should have their belongings searched by hospital staff for any potentially dangerous materials that could be used on themselves and others.

“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.

“The patient just got diagnosed with metastatic lung cancer and said she felt life was over and she wanted to die. I thought it was normal for patients to feel like that after getting such a diagnosis.”

Patients with tremendous life stressors will often present with acute depressive symptoms and passive or even active suicidal ideation. The emphasis should always be on safety of the patient, and a full psychiatric and safety evaluation should be made by the emergency clinician when seeing these patients.

“I thought he was just looking for attention when he told his girlfriend that he was think- ing of jumping off the bridge.”
All statements of suicide or self-harm, however casual the context or tone, warrant serious investigation and questioning. Not all patients who make such statements ultimately require

a psychiatric hospitalization. However, it is the responsibility of the emergency clinician to evaluate the patient’s ability to maintain safety for themselves as well as others and to involve psychiatry expertise when necessary.

10.

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including increased mortality, healthcare-acquired conditions, and increased nancial burden for both the patient and the hospital.127

Discharge and Referral

Not every patient who reports suicidal ideation should be held in the ED or admitted for inpatient services. In cases where suicide risk is deemed low or not imminent, referrals to outpatient mental health services, such as day/partial hospital ser- vices or outpatient therapy, should be made so that continuity of care can be assured. Appointments should be scheduled for as soon as possible follow- ing discharge; guidelines from the Suicide Preven- tion Resource Center recommend appointments

be scheduled for within 24 to 72 hours following discharge.74 Unfortunately, up to 70% of suicidal in- dividuals do not follow up with their recommended treatment following discharge from the hospital,128 so it is important to discuss attitudes towards treat- ment as well as barriers to treatment while review- ing disposition plans with the patient.

For a summary of the resources discussed in this issue, see Table 6.

Summary

Depression with and without suicidal features is a common presentation in the ED and presents many challenging aspects of management and care. The evaluation of such patients requires emergency clinicians to maintain a exible and compassionate approach to the patient with a focus on safety. While many of these patients may be managed safely on
an outpatient basis, some patients present with such debilitating symptoms that they warrant hospitaliza-

tion. A multispecialty collaborative approach with psychiatry is crucial. The long-term mental health of these patients is based on many factors, and the emergency clinician can play a critical role in the overall well-being of such patients in the ED.

Case Conclusions

After a detailed psychiatric history and examination, you discovered that the 30-year-old man with the URI has been feeling worse over the last 3 weeks, with thoughts of “drinking myself to death.” With this concerning history for a possible major depressive episode and suicidal ide- ation, you formally consulted psychiatry and the patient was placed for psychiatric hospitalization after current suicidal intent and plan was detected.

After discussing with the elderly patient with the sprained ankle his expression of “maybe I’d be better
off dead,” you evaluated his comments. It appeared that he did not wish himself dead at this time. There was no plan, he had not had a history of suicide attempts in the past, and he had no known comorbid psychiatric illness. While you were not concerned that he was actively sui- cidal, because of his presenting symptoms and his lack of psychiatric follow-up, you formally consulted psychiatry. They evaluated him and agreed that he did not require an involuntary hold; however, he was placed in a voluntary outpatient partial hospitalization program.

While the lady seeking the thyroid medication re ll stated that she felt depressed, she was not suicidal and had no thoughts of hurting herself or others. You sent a complete metabolic panel, including TSH levels, to the lab. The results showed a TSH level nearly 3 times higher than previously recorded for her 45 days ago. You con- tacted her primary care provider and restarted her home regimen of levothyroxine and planned 24-hour follow-up.

Table 6. Resources for Assisting Patients With Depression and at Risk for Suicide

Resource

ED-SAFE (PSS-3)

Columbia-Suicide Severity Rating Scale (C-SSRS)

ICARE2, American College of Emergency Physicians

Suicide Assessment Five- Step Evaluation and Triage (SAFE-T)

Contact Information Screening Tools

http://emnet-usa.org/wp-content/uploads/2019/02/K_PtSafetyScreen.pdf http://cssrs.columbia.edu/

https://www.acep.org/patient-care/iCar2e/ https://www.integration.samhsa.gov/images/res/SAFE_T.pdf

Description

Patient Safety Screener

Suicide rating scales

Tool for managing suicidal patients in the emergency department

Suicide assessment tool

Suicide Prevention Resource Center: Resource center of Education Development Center, supported by the United States Substance Abuse and Mental Health Services Administration (SAMHSA)

Crisis telephone line

Online chat line

Health and behavioral system model

National Suicide Prevention Lifeline

National Suicide Prevention Lifeline Chat

Zero Suicide

May 2019 • http://www.ebmedicine.net

1-800-273-8255 [TALK] https://suicidepreventionlifeline.org/chat/ http://zerosuicide.sprc.org/

Time and Cost-Effectiveness Strategies

• Not all depressed patients need routine labora- tory screening or imaging prior to discussing the case with the behavioral health team. Consider the history and physical examination in guiding the decision to pursue any imaging.

• Identifying underlying depressive symptoms may result in redirecting a medical workup to an underlying psychiatric disorder with signi – cant disposition differences (eg, admission for chest pain workup vs evaluation for outpatient psychology).

• Early identi cation and treatment of depression can result in long-term health improvement and overall reduced healthcare utilization for patients.
References
Evidence-based medicine requires a critical ap- praisal of the literature based upon study methodol- ogy and number of subjects. Not all references are equally robust. The ndings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
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Garvey KA, Penn JV, Campbell AL, et al. Contracting for safety with patients: clinical practice and forensic implications. J Am Acad Psychiatry Law. 2009;37(3):363-370. (Review article) Barber CW, Miller MJ. Reducing a suicidal person’s access to lethal means of suicide: a research agenda. Am J Prev Med. 2014;47(3 Suppl 2):S264-S272. (Review article/concepts paper)

Suicide Prevention Resource Center. Suicide prevention
fact sheets. Available at: https://www.sprc.org/resources- programs. Accessed April 10, 2019. (Online resource)
Betz ME, Miller M, Barber C, et al. Lethal means access and assessment among suicidal emergency department patients. Depress Anxiety. 2016;33(6):502-511. (Retrospective study; 1358 charts)
Runyan CW, Brooks-Russell A, Tung G, et al. Hospital emergency department lethal means counseling for suicidal patients. Am J Prev Med. 2017. (Retrospective chart review; 363 institutions)
Runyan CW, Becker A, Brandspigel S, et al. Lethal means counseling for parents of youth seeking emergency care for suicidality. West J Emerg Med. 2016;17(1):8-14. (Prospective cohort; 236 patients)
Cremniter D, Payan C, Meidinger A, et al. Predictors of short-term deterioration and compliance in psychiatric emer- gency patients: a prospective study of 457 patients referred to the emergency room of a general hospital. Psychiatry Res. 2001;104(1):49-59. (Prospective cohort study; 457 patients) Daly EJ, Singh JB, Fedgchin M, et al. Ef cacy and safety
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of paroxetine, uoxetine, and sertraline in primary care: a randomized trial. JAMA. 2001;286(23):2947-2955. (Random- ized controlled study; 573 subjects)
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ing, and following deployment to Iraq. J Abnorm Psychol. 2011;120(4):807-818. (Survey data; 445 subjects)
Marx BP, Brailey K, Proctor SP, et al. Association of time since deployment, combat intensity, and posttraumatic stress symptoms with neuropsychological outcomes following Iraq war deployment. Arch Gen Psychiatry. 2009;66(9):996-1004. (Prospective cohort study; 268 subjects)
Rosenfeld JV, Ford NL. Bomb blast, mild traumatic
brain injury and psychiatric morbidity: a review. Injury. 2010;41(5):437-443. (Review article)
Shively SB, Horkayne-Szakaly I, Jones RV, et al. Characteri- sation of interface astroglial scarring in the human brain after blast exposure: a post-mortem case series. Lancet Neurol. 2016;15(9):944-953. (Retrospective case series; 15 subjects) Jakupcak M, Hoerster KD, Varra A, et al. Hopelessness and suicidal ideation in Iraq and Afghanistan War Veterans reporting subthreshold and threshold posttraumatic stress disorder. J Nerv Ment Dis. 2011;199(4):272-275. (Survey data; 275 patients)

Reprints: http://www.ebmedicine.net/empissues

94. McClure JR, Criqui MH, Macera CA, et al. Prevalence of suicidal ideation and other suicide warning signs in veterans attending an urgent care psychiatric clinic. Compr Psychiatry. 2015;60:149-155. (Prospective cohort study; 473 patients)

95. Smith EG, Craig TJ, Ganoczy D, et al. Treatment of veterans with depression who died by suicide: timing and quality of care at last Veterans Health Administration visit. J Clin Psy- chiatry. 2011;72(5):622-629. (Retrospective case study; 1843 patients)

96. Wan L-B, Levitch CF, Perez AM, et al. Ketamine safety and tolerability in clinical trials for treatment-resistant depres- sion. J Clin Psychiatry. 2015;76(3):247-252. (Prospective observational study; 205 participants)

97.* Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized con- trolled trial; 24 participants)

98. Ballard ED, Ionescu DF, Voort JLV, et al. Improvement in sui- cidal ideation after ketamine infusion: relationship to reduc- tions in depression and anxiety. J Psychiatr Res. 2014;58:161- 166. (Prospective observational study; 133 participants)

99. Price RB, Iosifescu DV, Murrough JW, et al. Effects of ket- amine on explicit and implicit suicidal cognition: a ran- domized controlled trial in treatment-resistant depression. Depress Anxiety. 2014;31(4):335-343. (Randomized controlled trial; 57 participants)

100.* Grif ths JJ, Zarate CA, Rasimas J. Existing and novel bio- logical therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

101. United States Food and Drug Administration. FDA approves new nasal spray medication for treatment-resistant depres- sion; available only at a certi ed doctor’s of ce or clinic. Available at: https://www.fda.gov/NewsEvents/News- room/PressAnnouncements/ucm632761.htm. Accessed April 10, 2019. (FDA news release)

102. Suicide Prevention Resource Center. Zero Suicide. Available at: http://zerosuicide.sprc.org/. Accessed April 10, 2019. (Online resource)

103. Coffey CE. Building a system of perfect depression care in behavioral health. Jt Comm J Qual Patient Saf. 2007;33(4):193- 199. (Concept paper)

104. Knox KL, P anz S, Talcott GW, et al. The US Air Force suicide prevention program: implications for public health policy. Am J Public Health. 2010;100(12):2457-2463. (Model/ concepts paper)

105. Labouliere CD, Vasan P, Kramer A, et al. “Zero suicide” – a model for reducing suicide in United States behavioral healthcare. Suicidologi. 2018;23(1):22-30. (Model/theory paper)

106. Heikkinen ME, Isometsa ET, Marttunen MJ, et al. Social fac- tors in suicide. Br J Psychiatry. 1995;167(6):747-753. (Retro- spective study; 1067 subjects)

107. Borges G, Rosovsky H. Suicide attempts and alcohol consumption in an emergency room sample. J Stud Alcohol. 1996;57(5):543-548. (Prospective cohort study; 40 patients)

108. Ting SA, Sullivan AF, Boudreaux ED, et al. Trends in US emergency department visits for attempted suicide and self-in icted injury, 1993-2008. Gen Hosp Psychiatry. 2012;34(5):557-565. (Epidemiologic study)

109. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychi- atric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99. (Evidence-based guideline)

110. Allen MH, Currier GW, Hughes DH, et al. The expert con- sensus guideline series. Treatment of behavioral emergen- cies. Postgrad Med. 2001(Spec No):1-88. (Evidence-based guideline)

111. Vaiva G, Vaiva G, Ducrocq F, et al. Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study. BMJ.

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2006;332(7552):1241-1245. (Multicenter randomized con- trolled trial; 605 patients)
Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv. 2001;52(6):828- 833. (Randomized controlled trial; 843 patients)

Carter GL, Clover K, Whyte IM, et al. Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated delib- erate self poisoning. BMJ. 2005;331(7520):805. (Randomized controlled trial; 772 patients)
Luxton DD, June JD, Comtois KA. Can postdischarge follow- up contacts prevent suicide and suicidal behavior? A review of the evidence. Crisis. 2013;34(1):32-41. (Narrative review) Chang BP, Tan TM. Suicide screening tools and their associa- tion with near-term adverse events in the ED. Am J Emerg Med. 2015;33(11):1680-1683. (Prospective observational study; 50 participants)
Mullinax S, Chalmers CE, Brennan J, et al. Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department. Am J Emerg Med. 2018. (Prospective observational study; 276 participants) Cha CB, O’Connor RC, Kirtley O, et al. Testing mood-acti- vated psychological markers for suicidal ideation. J Abnorm Psychol. 2018. (Prospective observational study; 157 partici- pants)
Nock MK, Park JM, Finn CT, et al. Measuring the suicidal mind: implicit cognition predicts suicidal behavior. Psychol Sci. 2010;21(4):511-517. (Prospective observational study; 157 participants)
Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clin Psychol Sci. 2017;5(3):457-469. (Retrospective study; 5167 participants) Heravian A, Chang BP. Mental health and telemedicine in the acute care setting: applications of telepsychiatry in the ED. Am J Emerg Med. 2018;36(6):1118-1119. (Concepts paper/ narrative review)
Williams MP, M.; Boyle, J. Telepsychiatry in the emergency department: overview and case studies. 2009. Available
at: https://www.chcf.org/publication/telepsychiatry-in- the-emergency-department-overview-and-case-studies/. Accessed April 10, 2019. (Website)
Wilson MP, Brennan JJ, Modesti L, et al. Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use. Am J Emerg Med. 2015;33(4):527-530. (Retrospective cohort study; 640 patients)
American College of Emegency Physicians. ICARE2: a
tool for managing suicidal patients in the ED. Available at: https://www.acep.org/patient-care/iCar2e/. Accessed April 10, 2019. (Website)
Carter G, Milner A, McGill K, et al. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.
Br J Psychiatry. 2017;210(6):387-395. (Systematic review and meta-analysis)
Coyle TN, Shaver JA, Linehan MM. On the potential for iatrogenic effects of psychiatric crisis services: the example
of dialectical behavior therapy for adult women with borderline personality disorder. J Consult Clin Psychol. 2018;86(2):116. (Prospective observational study; 101 par- ticipants)
Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(1 Suppl):49-59. (Case controlled study; 153 participants)
García-Gigorro R, de la Cruz Vigo F, Andrés-Esteban E, et al. Impact on patient outcome of emergency department length of stay prior to ICU admission. Medicina Intensiva (English Edition). 2017;41(4):201-208. (Prospective observational cohort study; 269 participants)

May 2019 • http://www.ebmedicine.net 21

128. Knesper DJ. Suicide Prevention Resource Center. Continuity of care for suicide prevention and research: suicide attempts and suicide deaths subsequent to discharge from an emer- gency department or an inpatient psychiatry unit. Available at: http://www.sprc.org/resources-programs/continuity- care-suicide-prevention-research. Accessed April 10, 2019. (Online resource)

CME Questions

Take This Test Online!

Current subscribers receive CME credit absolutely free by completing the following test. Each issue includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP

Instruments such as the PHQ-9 can:

a. Be used to disposition depressed patients from the ED.

b. Along with a focused history and physical examination, provide information regarding symptom severity.

c. Can be used for screening psychosis.

d. Is validated only in the inpatient setting.

Directly questioning a depressed patient about suicidal thoughts:

a. Should only be done if there is a high
degree of suspicion, because asking about suicidal ideation may encourage a patient to entertain suicide.

b. Is appropriate and indicated for all depressed patients.

c. Should be done in consultation with the psychiatry team.

d. Should be done following a medical evaluation to rule out other causes of depression.

The approach to the physical examination for depressed patients:

a. Should be focused on the psychiatric
examination, with a brief overall physical
examination.

b. Is not indicated unless the patient shows
other systemic symptoms or signs on history
or psychiatric examination.

c. Is indicated in all patients with psychiatric
chief complaints.

d. Is indicated in the setting of trauma or other
historical ags concerning for secondary causes of depression.

Lethal-means counseling:

Category I credits, 4 AAFP Prescribed credits, or

Take This Test Online!

4 AOA Category 2-A or 2-B credits. Online testing is available for current and archived issues. To receive your free CME credits for this issue, scan the QR code below with your smartphone or visit http://www.ebmedicine.net/E0519.

1. The single strongest predictor of suicide is:

a. History of never being married.

b. Prior history of suicidal ideation or attempt.

c. History of depression or other mental
illness.

d. History of recent unemployment.

2. You are caring for a 23-year-old man with no psychiatric history who was brought in by his friends for “crying and saying he is seeing dead people.” On examination, he has a tem- perature of 103°F, and appears confused. In ad- dition to evaluating his behavioral complaint:

a. He needs a full medical evaluation,
including potential ingestion and infectious
workup.

b. He needs a full psychiatric evaluation prior
to initiating any medical evaluation or
workup.

c. He may be discharged without full medical
evaluation, given his age and lack of any
psychiatric history.

d. New-onset mania or depression is low on
the differential for this patient, since most patients with mania or depression show their rst symptoms much later in life.

a. b. c. d.

Should be used only in older patients with poor social follow-up.
Is recommended for all patients expressing suicidal ideation.

Should be used only with the assistance of a psychiatrist.
Is inappropriate to undertake the ED.

Reprints: http://www.ebmedicine.net/empissues

7. Starting a new psychotropic medication for an acutely depressed patient:

a. Should be done in consultation with the
patient’s outpatient physician/therapist to
ensure proper follow-up.

b. Should never be done in the ED.

c. Should be routinely started in the ED with
or without psychiatry input.

d. Can be done only for patients who are on an
involuntary hold.

8. Emerging evidence suggests that ketamine may be:

a. A useful therapeutic agent for management of suicidality in the acute setting.

b. Used for the treatment of acute mania or schizophrenia.

c. A treatment for depression limited to younger patients.

d. Used only in geriatric patients.

10.

With patients who are intoxicated and express- ing suicidal ideation, one should:

a. Ignore the behavioral chief complaints.

b. Plan careful observation and re-evaluation
for when the patient is sober.

c. Discharge immediately.

d. Use blood alcohol level to determine
sobriety before evaluation.

Patients who acknowledge suicidal ideation:

a. Must be held involuntarily in the ED under all cases and admitted to a psychiatric facility.

b. Must have a physical examination and suicide history, including discussion with a behavioral health specialist, if possible.

c. May be discharged without evaluation if they have an established outpatient mental health provider.

d. Should be immediately evaluated by a psychiatrist before the emergency clinician’s evaluation.

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May 2019 • http://www.ebmedicine.net 23

In uenza: Diagnosis

December 2018 Volume 20, Number 12

and Management in the

Authors
AL Giwa MD, MBA, FACEP, FAAEM
Assistant Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Chinwe Ogedegbe, MD, MPH, FACEP
Associate Professor of Emergency Medicine, Hackensack Meridian

Emergency Department

Abstract

HAsesaoltchiaStechPorolfeosfsMoredoifcEinmeeartgSenectoynMHeadllicUineiv, eRrusittgye, rNsu-Ntleyw, NJeJr;sey Medical School, Newark, NJ
Charles G. Murphy, MD
Department of Emergency Medicine, Metrowest Medical Center, Framingham, MA

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for in uenza and the avail- able resources to guide management. This comprehensive review outlines the classi cation of in uenza viruses, in uenza pathophysiology, the identi cation of high-risk patients, and the importance of vaccination. Seasonal variations of in uenza are discussed, as well as the rationale for limiting testing during pe- riods of high prevalence. Differences between strains of in uen- za are discussed, as well as the challenges in achieving optimal vaccine effectiveness. Recommendations for use of the currently available oral, intranasal, and intravenous antiviral treatments are provided, as well as utilizing shared decision-making with patients regarding risks and bene ts of treatment.

Peer Reviewers
Michael K. Abraham, MD
BCalinlticmaolrAes,sMisDtant Professor, University of Maryland School of Medicine,

Editor-In-Chief

Daniel J. Egan, MD

Shkelzen Hoxhaj, MD, MPH, MBA

Alfred Sacchetti, MD, FACEP

Pharmacy Residency, Maricopa Medical Center, Phoenix, AZ Joseph D. Toscano, MD

Andy Jagoda, MD, FACEP

AEdssuoccaitaioten,PDroefpeasrstomr,eVnitcoefCEhmaeirgoefncy Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY

MCheimefoMriaeldHicoaslpOitfa lc,eMr,iaJmaci,kFsoLn

ADsespiastratmnteCntlinoifcEaml PerrogfenscsyorM, edicine, Thomas Jefferson University, Philadelphia, PA

Professor and Interim Chair, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY

Eric Legome, MD

Chief, Department of Emergency Medicine, San Ramon Regional Medical Center, San Ramon, CA

Kaushal Shah, MD, FACEP

Associate Professor, Department of York, NY

Keith A. Marill, MD, MS

Medicine at Mount Sinai, New York, NY

PeAtceardCeammiceDroirne,cMtoDr,TheAlfred Emergency and Trauma Centre, Monash University, Melbourne, Australia

Associate Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Michael A. Gibbs, MD, FACEP

Associate Professor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

Scott Silvers, MD, FACEP

Editorial Board

Corey M. Slovis, MD, FACP, FACEP

Attending Emergency Physician, Ospedale Papa Giovanni XXIII, Bergamo, Italy

Saadia Akhtar, MD, FACEP

Professor and Chair, Department
of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

Associate Professor, Department of Emergency Medicine, Associate Dean for Graduate Medical Education, Program Director, Emergency Medicine Residency, Mount Sinai Beth Israel, New York, NY

Steven A. Godwin, MD, FACEP

Suzanne Y.G. Peeters, MD

WilliamJ.Brady,MD

JosephHabboushe,MDMBA

MAicshsaoecliaSte.RParodfeosso,rMoDf,EMmPerHgency School,Boston,MA

Chair of Emergency Services, HospitalItaliano,BuenosAires, Argentina

Professor of Emergency Medicine and Medicine; Medical Director, Emergency Management, UVA Medical Center; Operational Medical Director, Albemarle County Fire Rescue, Charlottesville, VA

Assistant Professor of Emergency Medicine, NYU/Langone and Bellevue Medical Centers, New York, NY; CEO, MD Aware LLC

Medicine, Weill Medical College of Cornell University, New York; Research Director, Department of Emergency Medicine, New York Hospital Queens, Flushing, NY

Critical Care Editors

Dhanadol Rojanasarntikul, MD

Calvin A. Brown III, MD
Director of Physician Compliance, Credentialing and Urgent Care Services, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

Clinical Professor, Department of Emergency Medicine, University
of Michigan Medical School; CEO, Medical Practice Risk Assessment, Inc., Ann Arbor, MI

AlEi xSe.cRuatijvae, VMicDe, CMhBaAir, EMmPeHrgency Medicine, Massachusetts General Hospital; Associate Professor of Emergency Medicine and Radiology, Harvard Medical School, Boston, MA

Peter DeBlieux, MD

Clinical Professor of Emergency UMneidveicrisniety,,GWeaosrghiengWtoansh, iDnCgt;oDnirector of Academic Affairs, Best Practices, Inc, Inova Fairfax Hospital, Falls Church, VA

RoFAbeArEtML.,RFAoCgePrs,MD,FACEP,

Professor of Emergency Medicine; CMheideifc, iEnMe, SCtroitnicyaBl Croaorek, SNtYony Brook

Doha, Qatar

Professor of Clinical Medicine, Louisiana State University School of Medicine; Chief Experience Of cer, University Medical Center, New Orleans, LA

Assistant Professor of Emergency Medicine, The University of Maryland School of Medicine, Baltimore, MD

Research Editors

Edin Zelihic, MD

Nicholas Genes, MD, PhD

Chair, Department of Family Medicine,

International Editors

Beth Israel Medical Center; Senior AssociateEditor-In-Chief EofmMeregdeicnicnyeMateMdiociunnet,SIcinaahin,NSecwhool HMeadlitchinSeyasteMmo,uInctaShinaSi,cNhoewolYoofrk,NY CFaocmumltyu,nFiatymHilyeaMltehd,IicianhenaSncdhoolof

Professor and Chair, Department
of Emergency Medicine, Carolinas Medical Center, University of North Carolina School of Medicine, Chapel Hill, NC

Associate Professor of Emergency Medicine, Chair of Facilities and Planning, Mayo Clinic, Jacksonville, FL

Andrea Duca, MD

Professor and Chair, Department of Emergency Medicine, Assistant Dean, Simulation Education, University of Florida COM- Jacksonville, Jacksonville, FL

Ron M. Walls, MD

Attending Emergency Physician, Flevo Teaching Hospital, Almere, The Netherlands

Gregory L. Henry, MD, FACEP

Associate Professor of Emergency Medicine and Neurosurgery, Medical DPriroevcidtoerr, EPMrogArdamva;nAcsesdoPciratcetiMcedical Director, Neuroscience ICU, University of Cincinnati, Cincinnati, OH

John M. Howell, MD, FACEP

Scott D. Weingart, MD, FCCM

Chair, Emergency Medicine, Mount Sinai West & Mount Sinai St. Luke’s; Vice Chair, Academic Affairs for Emergency Medicine, Mount Sinai

Robert Schiller, MD

Daniel J. Egan, MD

Associate Professor, Vice Chair of Education, Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY

Prior to beginning this activity, see “Physician CME Information” on the back page.

Professor and Chair, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical

Hugo Peralta, MD

William A. Knight IV, MD, FACEP, FNCS

Attending Physician, Emergency Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross, Thailand; Faculty of Medicine, Chulalongkorn University, Thailand Stephen H. Thomas, MD, MPH Professor & Chair, Emergency Medicine, Hamad Medical Corp., Weill Cornell Medical College, Qatar; Emergency Physician-in-Chief, Hamad General Hospital,

Aimee Mishler, PharmD, BCPS

Head, Department of Emergency Medicine, Leopoldina Hospital, Schweinfurt, Germany

Emergency Medicine Pharmacist, Program Director, PGY2 EM

First Trimester Pregnancy Emergencies: Recognition and Management
Abstract

January 2019 Volume 21, Number 1

Timely management of patients presenting to the ED while in their rst trimester of pregnancy can improve outcomes for both the patient and the fetus. Common obstetric problems encoun- tered include vaginal bleeding and miscarriage, ectopic preg- nancy and pregnancy of undetermined location, and nausea and vomiting of pregnancy, including hyperemesis gravidarum. Optimal diagnostic approaches and management strategies are covered, including which antiemetics are safe to give in preg- nancy. Common nonobstetric problems include asymptomatic bacteriuria, urinary tract infections including pyelonephritis, and acute appendicitis. This article also reviews the various im- aging modalities available for pregnant patients and reviews the risks of ionizing radiation as well as various contrast media.

Author
Ryan Pedigo, MD
Director of Undergraduate Medical Education, Harbor-UCLA Medical Center, Torrance, CA; Assistant Professor of Emergency Medicine, David Geffen School of Medicine, Los Angeles, CA
Peer Reviewers
Jennifer Beck-Esmay, MD
Assistant Residency Director, Mount Sinai St. Luke’s – Mount Sinai West, New York, NY
Taku Taira, MD, FACEP
Associate Director of Undergraduate Medical Education; Associate Clerkship Director, LAC + USC Department of Emergency Medicine, Keck School of Medicine, Los Angeles, CA

Editor-In-Chief

Daniel J. Egan, MD

Shkelzen Hoxhaj, MD, MPH, MBA

Alfred Sacchetti, MD, FACEP

Pharmacy Residency, Maricopa Medical Center, Phoenix, AZ Joseph D. Toscano, MD

Andy Jagoda, MD, FACEP

AEdssuoccaitaioten,PDroefpeasrstomr,eVnitcoefCEhmaeirgoefncy Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY

CMheimefoMriaeldHicoaslpOitfa lc,eMr,iaJmaci,kFsoLn

ADsespiastratmnteCntlinoifcEaml PerrogfenscsyorM, edicine, Thomas Jefferson University, Philadelphia, PA

Professor and Interim Chair, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY

Eric Legome, MD

Chief, Department of Emergency Medicine, San Ramon Regional Medical Center, San Ramon, CA

Kaushal Shah, MD, FACEP

Associate Professor, Department of York, NY

Keith A. Marill, MD, MS

Medicine at Mount Sinai, New York, NY

PeAtceardCeammiceDroirne,cMtoDr,TheAlfred Emergency and Trauma Centre, Monash University, Melbourne, Australia

Associate Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Michael A. Gibbs, MD, FACEP

Associate Professor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

Scott Silvers, MD, FACEP

Editorial Board

Corey M. Slovis, MD, FACP, FACEP

Attending Emergency Physician, Ospedale Papa Giovanni XXIII, Bergamo, Italy

Saadia Akhtar, MD, FACEP

Professor and Chair, Department
of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

Associate Professor, Department of Emergency Medicine, Associate Dean for Graduate Medical Education, Program Director, Emergency Medicine Residency, Mount Sinai Beth Israel, New York, NY

Steven A. Godwin, MD, FACEP

Suzanne Y.G. Peeters, MD

William J. Brady, MD

Joseph Habboushe, MD MBA

MAicshsaoecliaSte.RParodfeosso,rMoDf,EMmPerHgency School,Boston,MA

Professor in Medicine and Emergency Medicine; Director of EM, Churruca Hospital of Buenos Aires University, Buenos Aires, Argentina

Professor of Emergency Medicine and Medicine; Medical Director, Emergency Management, UVA Medical Center; Operational Medical Director, Albemarle County Fire Rescue, Charlottesville, VA

Assistant Professor of Emergency Medicine, NYU/Langone and Bellevue Medical Centers, New York, NY; CEO, MD Aware LLC

Medicine, Weill Medical College of Cornell University, New York; Research Director, Department of Emergency Medicine, New York Hospital Queens, Flushing, NY

Critical Care Editors

Calvin A. Brown III, MD
Director of Physician Compliance, Credentialing and Urgent Care Services, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

Clinical Professor, Department of Emergency Medicine, University
of Michigan Medical School; CEO, Medical Practice Risk Assessment, Inc., Ann Arbor, MI

AlEi xSe.cRuatijvae, VMicDe, CMhBaAir, EMmPeHrgency Medicine, Massachusetts General Hospital; Associate Professor of Emergency Medicine and Radiology, Harvard Medical School, Boston, MA

Stephen H. Thomas, MD, MPH

Clinical Professor of Emergency PeterDeBlieux,MD MUneidveicrisniety,,GWeaosrghiengWtoansh,iDnCgt;oDnirector

RoFAbeArEtML.,RFAoCgePrs,MD,FACEP,

Professor of Emergency Medicine; CMheideifc, iEnMe, SCtroitnicyaBl Croaorek, SNtYony Brook

Professor of Clinical Medicine, Louisiana State University School of Medicine; Chief Experience Of cer, University Medical Center, New Orleans, LA

of Academic Affairs, Best Practices, Inc, Inova Fairfax Hospital, Falls Church, VA

Assistant Professor of Emergency Medicine, The University of Maryland School of Medicine, Baltimore, MD

Research Editors

Edin Zelihic, MD

Nicholas Genes, MD, PhD

Chair, Department of Family Medicine,

International Editors

Beth Israel Medical Center; Senior AssociateEditor-In-Chief EofmMeregdeicnicnyeMateMdiociunnet,SIcinaahin,NSecwhool HMeadlitchinSeyasteMmo,uInctaShinaSi,cNhoewolYoofrk,NY FCaocmumltyu,nFiatymHilyeaMltehd,IicianhenaSncdhoolof

Professor and Chair, Department
of Emergency Medicine, Carolinas Medical Center, University of North Carolina School of Medicine, Chapel Hill, NC

Associate Professor of Emergency Medicine, Chair of Facilities and Planning, Mayo Clinic, Jacksonville, FL

Andrea Duca, MD

Professor and Chair, Department of Emergency Medicine, Assistant Dean, Simulation Education, University of Florida COM- Jacksonville, Jacksonville, FL

Ron M. Walls, MD

Attending Emergency Physician, Flevo Teaching Hospital, Almere, The Netherlands

Gregory L. Henry, MD, FACEP

Associate Professor of Emergency Medicine and Neurosurgery, Medical DPriroevcidtoerr, EPMrogArdamva;nAcsesdoPciratcetiMcedical Director, Neuroscience ICU, University of Cincinnati, Cincinnati, OH

Attending Physician, Emergency Medicine, King Chulalongkorn Memorial Hospital; Faculty of Medicine, Chulalongkorn University, Thailand

John M. Howell, MD, FACEP

Scott D. Weingart, MD, FCCM

Professor & Chair, Emergency Medicine, Hamad Medical Corp., Weill Cornell Medical College, Qatar; Emergency Physician-in-Chief, Hamad General Hospital,
Doha, Qatar

Chair, Emergency Medicine, Mount Sinai West & Mount Sinai St. Luke’s; Vice Chair, Academic Affairs for Emergency Medicine, Mount Sinai

Robert Schiller, MD

Prior to beginning this activity, see “CME Information” on the back page.
This issue is eligible for 2 Pharmacology CME credits.

Professor and Chair, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical

Edgardo Menendez, MD, FIFEM

William A. Knight IV, MD, FACEP, FNCS

Dhanadol Rojanasarntikul, MD

Aimee Mishler, PharmD, BCPS

Head, Department of Emergency Medicine, Leopoldina Hospital, Schweinfurt, Germany

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CME Information
Date of Original Release: May 1, 2019. Date of most recent review: April 10, 2019. Termination date:

May 1, 2022.

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Patient Health Questionnaire-9 (PHQ-9)

The Patient Health Questionnaire-9 is used to provisionally diagnose depression and stratify the severity of depression symptoms.

Click the thumbnail above to access the calculator.

Points & Pearls

• The Patient Health Questionnaire-9 (PHQ-9) is the major depressive disorder (MDD) module of the full Patient Health Questionnaire.

• The PHQ-9 is used to provisionally diagnose depression and grade the severity of symptoms in general medical and mental health settings.

• The questionnaire scores each of the 9 criteria for MDD as identi ed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi- tion, using a scale of 0 (“not at all”) to 3 (“nearly every day”) and resulting in a severity score of 0 to 27 points.

• The patient’s response to the last question on the PHQ-9 (“How dif cult have these problems made it for you to do your work, take care of things at home, or get along with other peo- ple?”) is not included in the nal score tally, but is an indicator of the patient’s global impairment and can be used to track treatment response.

• Higher PHQ-9 scores are associated with de- creased functional status and increased symp- tom-related dif culties, sick days, and health- care utilization.
Critical Actions
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 bet- ter off dead or of hurting yourself in some way?”). Bipolar disorder, normal bereavement, and medi- cal disorders should be ruled out as the causes of depression.

Evidence Appraisal

The PHQ-9 was initially developed by Kroenke et al (2001) as a subset of 9 questions from the full Pa- tient Health Questionnaire, which had been derived previously and studied in a cohort of 6000 patients in 8 primary care clinics and 7 obstetrics and gyne- cology clinics (Spitzer 1999). PHQ-9 scores of

≥ 10 points were found to be 88% sensitive and

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:

• To assist the clinician in making the
diagnosis of depression.

• To quantify depression symptoms and
monitor depression severity.
Next Steps
The nal 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.

CALCULATOR REVIEW AUTHOR

Ferda Sakman, MD

San Jose Clinic, Veterans Affairs Palo Alto Health Care System, San Jose, CA

CD1

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88% speci c 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 speci city (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).

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Calculator Creator

Kurt Kroenke, MD
Click here to read more about Dr. Kroenke.

References

Original/Primary Reference

• Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. https://www.ncbi.nlm.nih.gov/pubmed/11556941

Validation References

• Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-353. DOI: https://doi.org/10.1370/afm.1139

• Chagas MH, Tumas V, Rodrigues GR, et al. Validation and internal consistency of Patient Health Questionnaire-9
for major depression in Parkinson’s disease. Age Ageing. 2013;42(5):645-649.
DOI: https://doi.org/10.1093/ageing/aft065

• Volker D, Zijlstra-Vlasveld MC, Brouwers EP, et al. Validation of the Patient Health Questionnaire-9 for major depressive disorder in the occupational health setting. J Occup Rehabil. 2016;26(2):237-244.
DOI: https://doi.org/10.1007/s10926-015-9607-0

• Ferrando SJ, Samton J, Mor N, et al. Patient Health Ques- tionnaire-9 to screen for depression in outpatients with multiple sclerosis. Int J MS Care. 2007;9(3):99-103.
DOI: https://doi.org/10.7224/1537-2073-9.3.99

• Beard C, Hsu KJ, Rifkin LS, et al. Validation of the PHQ-9 in a psychiatric sample. J Affect Disord. 2016;193:267-273. DOI: https://doi.org/10.1016/j.jad.2015.12.075

• Sidebottom AC, Harrison PA, Godecker A, et al. Validation of the Patient Health Questionnaire (PHQ)-9 for prena-
tal depression screening. Arch Womens Ment Health. 2012;15(5):367-374.
DOI: https://doi.org/10.1007/s00737-012-0295-x
Other Reference

• Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737-1744. https://www.ncbi.nlm.nih.gov/pubmed/10568646

Emergency Medicine Practice • May 2019

CD2

Columbia-Suicide Severity Rating Scale (C-SSRS)

The Columbia-Suicide Severity Rating Scale (C-SSRS) screens for suicidal ideation and behavior.

Click the thumbnail above to access the calculator.

Points & Pearls

• The Columbia-Suicide Severity Rating Scale (C-SSRS) score is based on the patient’s re- sponses to screening questions, but it also allows for integration of information from other sources (eg, family and friends, healthcare pro- fessionals, hospital records, or coroner’s report).

• The C-SSRS has been validated in emergency settings (ie, to triage patients in the emergency department) but also has some validation in the outpatient psychiatry setting (Viguera 2015).
Critical Actions
The C-SSRS should not replace a complete clinical evaluation. It may be employed as an initial screen- ing to guide a clinician in suicide risk assessment and to help stratify patients into categories of low, moderate, or high risk.
Evidence Appraisal
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 previ- ously 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 con- structs (severity of ideation, intensity of ideation, behavior, and lethality), based on factors identi ed 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% speci city for identifying suicidal behaviors (Mundt 2013).
Similar ndings have been reproduced by oth- ers. 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 classi cation for suicide-related behavior within 6 months (sensitivity 69%; speci city 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 con- comitant 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).

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 de ne 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.

Next Steps

Protocols vary by institution, but most recommend a complete assessment by a psychiatrist and inpatient admission for patients identi ed 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.

CALCULATOR REVIEW AUTHOR

Joshua Salvi, MD, PhD

Department of Psychiatry, Massachusetts General Hospital / McLean Hospital, Boston, MA

CD3

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Use the Calculator Now

Click here to access the C-SSRS on MDCalc.

Calculator Creator

Kelly Posner, PhD
Click here to read more about Dr. Posner.

References

Original/Primary Reference

• Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency ndings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266-1277.

DOI: https://doi.org/10.1176/appi.ajp.2011.10111704

Validation References

• Mundt JC, Greist JH, Jefferson JW, et al. Prediction
of suicidal behavior in clinical research by lifetime sui- cidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. J Clin Psychiatry. 2013;74(9):887-893. https://www.ncbi.nlm.nih.gov/pubmed/24107762

• Glennon J, Purper-Ouakil D, Bakker M, et al. Paediatric European Risperidone Studies (PERS): context, rationale, objectives, strategy, and challenges. Eur Child Adolesc Psychiatry. 2014;23(12):1149-1160.
DOI: https://dx.doi.org/10.1007%2Fs00787-013-0498-3

• Legarreta M, Graham J, North L, et al. DSM-5 posttraumatic stress disorder symptoms associated with suicide behaviors in veterans. Psychol Trauma. 2015;7(3):277-285.
DOI: https://doi.org/10.1037/tra0000026

• Viguera AC, Milano N, Laurel R, et al. Comparison of electronic screening for suicidal risk with the Patient Health Questionnaire item 9 and the Columbia Suicide Severity Rating Scale in an outpatient psychiatric clinic. Psychoso- matics. 2015;56(5):460-469.
DOI: https://doi.org/10.1016/j.psym.2015.04.005

• Madan A, Frueh BC, Allen J, et al. Psychometric reevalua- tion of the Columbia-Suicide Severity Rating Scale: ndings from a prospective, inpatient cohort of severely mentally ill adults. J Clin Psychiatry. 2016;77(7):e867-e873.
DOI: https://doi.org/10.4088/JCP.15m10069
Other References
• Brent DA, Greenhill L, Compton S, et al. The Treatment of Adolescent Suicide Attempters study (TASA): predictors of suicidal events in an open treatment trial. J Am Acad Child Adolesc Psychiatry. 2009;48(10):987-996.
DOI: https://doi.org/10.1097/CHI.0b013e3181b5dbe4
• Crosby AE, Han B, Ortega LA, et al. Suicidal thoughts and behaviors among adults aged ≥ 18 years–United States, 2008-2009. MMWR Surveill Summ. 2011;60(13):1-22. https://www.ncbi.nlm.nih.gov/pubmed/22012169
• United States Food and Drug Administration. Guidance for Industry: Suicidal Ideation and Behavior: Prospective Assess- ment of Occurrence in Clinical Trials. Rockville, MD: United States Department of Health and Human Services; 2012. https://www.fda.gov/downloads/Drugs/Guidances/ ucm225130.pdf
• Gratalup G, Fernander N, Fuller DS, et al. Translation of the Columbia Suicide Severity Rating Scale for Use in 33 Countries. Paper presented at: 9th Annual Meeting of the International Society for CNS Clinical Trials and Methodol- ogy; February 19-21, 2013; Washington, DC.
Copyright © MDCalc • Reprinted with permission.

Emergency Medicine Practice • May 2019

ED-SAFE Patient Safety Screener (PSS-3)

The ED-SAFE Patient Safety Screener (PSS-3) is a screening tool used for identifying suicidality in emergency department patients.

Click the thumbnail above to access the calculator.

Points & Pearls

• Administration of the ED-SAFE Patient Safety Screener (PSS-3) is dependent on the patient’s ability to answer the questions, so it cannot be used in patients who are unable to engage in conversation (eg, intubated patients or patients with altered mental status).

• The PSS-3 has strong agreement with well- established but lengthier suicide risk assess- ments such as the Beck Scale for Suicide Ide- ation (BSSI).
Advice
The PSS-3 is meant to be a universal screening tool. All patients presenting to the emergency depart- ment (ED) can be screened with this tool, even when the primary complaint is nonpsychiatric.
Critical Actions
The PSS-3 is a screening tool and not an endpoint. A positive screening result should prompt the clini- cian 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.
Evidence Appraisal
Boudreaux et al (2013) designed the Emergency De- partment Safety Assessment and Follow-up Evalua- tion (ED-SAFE) study to determine whether univer- sal screening of ED patients could improve detec- tion 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 inten- tional 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 Inter- vention,” patients with a positive screening had secondary screening administered by a physician to determine whether to consult a mental health spe- cialist. 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

Why to Use

Among patients presenting to the ED with nonpsychiatric chief complaints, 3% to 12% also have suicidal ideation (Boudreaux 2013). Identi cation of these at-risk patients is

an important rst 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, ef cient screening tool that can be integrated easily into an existing clinical work ow 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.

Next Steps

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.

CALCULATOR REVIEW AUTHOR

Hyunjoo Lee, MD

Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY

CD5

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interviews or medical record reviews at 6, 12, 24, 36, and 52 weeks.

The 3-item PSS-3 was used for universal screen- ing in the ED-SAFE Study. The original Patient Safe- ty 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 ide- ation, 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, respec- tively) with the well-validated but much lengthier BSSI. The PSS-3 assessed for depression, active suicidal ideation, and prior lifetime suicide at- tempt, 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 ac-

tive 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 demon- strated 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 rst 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 cur- rent 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 imple- menting 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 re- duce 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 assess- ment, only 3.9% of those patients were assessed using the ED-SAFE–designated secondary screen- ing 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.

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Edwin D. Boudreaux, PhD
Click here to read more about Dr. Boudreaux.

References

Original/Primary Reference

• Boudreaux ED, Miller I, Goldstein AB, et al. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): method and design considerations. Contemp Clin Trials. 2013;36(1):14-24.

DOI: https://doi.org/10.1016/j.cct.2013.05.008

Validation References

•

Boudreaux ED, Jaques ML, Brady KM, et al. The patient safety screener: validation of a brief suicide risk screener for emergency department settings. Arch Suicide Res. 2015;19(2):151-160.

DOI: https://doi.org/10.1080/13811118.2015.1034604

Emergency Medicine Practice • May 2019 CD6

• Miller IW, Camargo CA, Arias SA, et al. Suicide prevention in an emergency department population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570.
DOI: https://doi.org/10.1001/jamapsychiatry.2017.0678

• Boudreaux ED, Camargo CA, Arias SA, et al. Improving suicide risk screening and detection in the emergency de- partment. Am J Prev Med. 2016;50(4):445-453.
DOI: https://doi.org/10.1016/j.amepre.2015.09.029
Other References

• Ting SA, Sullivan AF, Miller I, et al. Multicenter study of predictors of suicide screening in emergency departments. Acad Emerg Med. 2012;19(2):239-243.
DOI: https://doi.org/10.1111/j.1553-2712.2011.01272.x

• Caterino JM, Sullivan AF, Betz ME, et al. Evaluating cur- rent patterns of assessment for self-harm in emergency departments: a multicenter study. Acad Emerg Med. 2013;20(8):807-815.
DOI: https://doi.org/10.1111/acem.12188

Additional Reading

Click here to access a Pediatric Emergency Medicine Practice issue reviewing behavioral health emergencies in children and adolescents.

Related Calculators on MDCalc

• Major Depression Index (MDI)

• Hamilton Depression Rating Scale (HAM-D)

• Quick Inventory of Depressive Symptom-
atology (QIDS)

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