Episode 28 – Depressed and Suicidal Patients in the Emergency Department: An Evidence-Based Approach

Nachi: Again, just about all of our listeners I’m sure!

Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes?

Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in.

Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University.

Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside.

Jeff: Quite the team, from a variety of backgrounds.

Nachi: And just to put this topic into perspective – annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt.

Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23%

Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode.

Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable.

Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions.

Jeff: Certainly a good place to start, but let me preface this with an important point – arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time – instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history.

Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest.

Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks.

Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning.

Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes.

Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD.

Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder.

Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself.

Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.”

Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt.

Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan.

Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%.

Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers…

Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients.

Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men.

Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older.

Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression.

Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide.

Jeff: And while it seems crass to even mention the financial impact, the number is shocking – suicide has an estimated economic burden of $5.4 billion per year in the US.

Nachi: That’s an incredible amount and much more than I would have guessed.

Jeff: In terms specific risk factors for suicide and suicide related complaints – white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals.

Nachi: You snuck in an important word there – suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often.

Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods.

Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts

Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another.

Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study.

Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation.

Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality.

Jeff: Excellent point, which we’ll reiterate a few times throughout the episode – always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care – when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization.

Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations.

Jeff: Once in the ED – start by maximizing the patient’s privacy. Always use a nonjudgmental approach and use open-ended questions.

Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations.

Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings.

Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise.

Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality – how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide.

Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt.

Jeff: In one study, using this tool doubled the number of suicide-risk cases detected.

Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener.

Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit.

Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it?

Jeff: Great question – It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations.

Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical.

Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression.

Nachi: And as you said, we would mention it a few times — In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression.

Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here.

Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease.

Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing.

Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy – urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility.

Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility.

Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management.

Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion.

Nachi: That wraps up testing. Let’s move on to treatment.

Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable.

Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation.

Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes.

Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do.

Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling).

Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary.

Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do.

Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts.

Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means.

Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend.

Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths.

Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means.

Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time.

Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling.

Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline.

Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations.

Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there.

Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up – perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan.

Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though…

Nachi: Let’s talk first about special populations – the only one we will discuss this month is military veterans.

Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms.

Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population.

Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death.

Nachi: And this is in no way meant to be a knock-on VA ED docs – they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care.

Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed.

Nachi: Let’s talk controversies and cutting-edge topics from this issue.

Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality.

Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting.

Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression.

Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future.

Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition.

Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED.

Jeff: The next controversy is a big one – alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated.

Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide.

Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED.

Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment.

Jeff: Very important point – in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines.

Nachi: Moving on to the next topic – let’s discuss post discharge patient contact.

Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%.

Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact.

Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors.

Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance.

Jeff: The last cutting-edge topic to discuss is telepsychiatry.

Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner – offering quick psychiatric care to those that never had access.

Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated.

Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations.

Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold.

Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches.

Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making.

Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization.

Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed.

Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible.

Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls.

1. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse.
2. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt.
3. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy.
4. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation.
5. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects.
6. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department.
7. Imaging of the brain should not be ordered routinely in depressed or suicidal patients.
8. Depression places patients at a significantly increased risk for alcohol abuse and dependence.
9. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient.
10. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED.
11. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER.
12. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm.
13. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes.
14. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit.

Nachi: So that wraps up Episode 28!

Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s – make sure to use the code APP4 at checkout to save 50%.

Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask.

Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!

Most Important References

1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report)

12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book)

15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients)

16. Centers for Disease Control and Prevention. Current depression among adults—United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects)

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

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