Suicidal Patients: Defining and Addressing Emergencies

November 22, 2016
Patrick T. Triplett, MD

Volume 33, Issue 11

Here: a review of issues related to assessment of patients for suicide risk in the ED -- and an overview of emerging approaches and research that one day will lead to more reliable assessment and interventions based more on science than on art or luck.

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Once a patient has arrived, the duty of ED clinicians is to understand the potential for suicide and to formulate a plan to help mitigate risk. A busy ED triage is not the place for exhaustive psychiatric histories and assessments; however, triage nurses or other clinicians can quickly determine whether a patient needs a more thorough assessment. Screening assessments tend to be shorter and simpler than more exhaustive clinical assessments and generally have high sensitivity.

A major concern with ED suicide screening tools is the challenge of achieving acceptable sensitivity and specificity. Basic screening assessments for suicidality may alert non-psychiatric clinicians to a patient’s need for further psychiatric assessment and/or treatment. This article reviews some of the issues related to assessment of patients for suicide risk in the ED, and discusses emerging approaches and research that one day will lead to more reliable assessment and interventions that are based more on science than on art or luck.

CASE VIGNETTE 1

Mr. R is a 64-year-old former pipefitter who is receiving disability benefits for stage IV COPD. He is brought to the ED by a staff member at his internist’s office. Mr. R is oxygen-dependent but continues to smoke and has been noncompliant with using his oxygen tank. He saw his internist today for a refill of narcotic medication for low back pain.

His internist had suggested an antidepressant in the past, but Mr. R repeatedly refused. During today’s visit, he was given a version of the Patient Health Questionnaire–9 and scored positively on the last question, which focuses on wishes for death and suicidal thoughts. Further questioning by his internist revealed that Mr. R had concerns about being able to walk only short distances without having to stop to catch his breath; he also fears that he will no longer be able to walk his beloved dog.

He has a passive death wish and some suicidal thoughts, including that he “might” shoot himself in the head if his physical condition worsens, but says he “probably” wouldn’t do it. He has 2 firearms at home, lives alone, and has few friends. His doctor fears that Mr. R minimizes the amount and frequency of his drinking.

Mr. R has been divorced for over 10 years and is estranged from his children and grandchildren. He had grudgingly agreed to be escorted to the ED by clinic staff for further assessment, but on arrival he is already demanding to leave.

 

Assessment of suicide risk

The ED can be an exciting and stimulating environment and a great place for education and training. It can also be challenging and sometimes humbling, with too-frequent reminders of how limited our predictive powers can be. The first case vignette includes a number of factors that must be juggled at once: a seemingly high risk of suicide, possible untreated depression and suspicion of alcohol misuse, few family or other social supports, medical comorbidity, and a patient who is unwilling to be treated or even assessed.

Suicide risk assessment can involve life-or-death decisions, often based on information that is likely to be incomplete. Clinicians make decisions based on information from patients whom they have often just met. These critical decisions are based on available history and data; knowledge of epidemiologic, clinical risk, and protective factors for suicide completion; a clinical assessment; and whatever information the patient and collateral informants are able and willing to divulge as part of the clinical examination.

Working in a busy ED without the benefit of more extensive training, clinicians may reflexively categorize patients being assessed for suicide, using their own experience and hunches as guides.

Suicide screening and risk assessment tools may be useful adjuncts to a clinical examination, but they are not an adequate replacement for patients at elevated risk. There are a number of tools for suicide screening or assessment with varying degrees of complexity, ranging from 1 or 2 straightforward questions to more complicated instruments with cascading questions and decision points based on patient responses or other findings.1 Some may tabulate a score or a range (eg, high, medium, low) of risk and may even have recommendations for treatment options for each score or range. Systematic assessment of suicide risk is important, and clinicians may want to “develop their own systematic risk assessment methods based on their training, clinical experience, and familiarity with the evidence-based psychiatric literature.”2 The Substance Abuse and Mental Health Services Administration’s SAFE-T3 guide provides an example of a format for working up suicide risk, though it must be tailored to the patient and situation.

Once a suicide attempt or ideation has been revealed, clinicians must delve further with questions about the patient’s suicide plans, including lethality, intent, means, stage of planning, and any details of previous attempts. Guides such as the Beck Suicidal Intent Scale4 help gauge the seriousness of an attempt and may help elicit details of plans and intention but should still be nested within a more extensive work-up.

There is no established gold standard for assessment, although there are a number of practice guidelines, such as “Caring for Adult Patients With Suicide Risk: A Consensus Guide for Emergency Departments,”5 which is specific to the ED setting. This guide can be used by any clinician in the ED and sets a fairly low threshold for when to ask for a formal suicide risk assessment by a mental health professional. The American Psychiatric Association’s “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors”6 offers a broader scope of suicide assessment, although both resources provide useful information and guidance. For adolescents, there is a set of evidence-based management guidelines developed in the US.7 The Columbia-Suicide Severity Rating Scale is a useful screening tool in some settings and shows good predictive validity in adolescents.8-10

Suicide assessment in emergency care settings most often focuses on static and dynamic epidemiologic suicide risk factors, elements particular to the patient’s history, and an assessment of his or her mental state. For those tasked with suicide assessments, a working knowledge of suicide risk factors is important, including site-specific risk factors. For example, providers who work with Native American populations need to be attuned to the factors that increase or decrease risk.11

Deciding to admit a patient to a psychiatric unit, with rare exceptions, can mitigate risk. But for the often larger percentage of patients not admitted, any sense of certainty needs to be tempered and planning for an appropriate level of support and follow-up is essential. It is worth noting that even with an exhaustive interview and gathering of data, there are limits on how much mental health providers can “know” about the inner workings of a suicidal patient’s mind. For example, direct questions about suicidal ideation or intent were answered negatively at last check by 78% of completed inpatient suicides.12

Documentation and the importance of formulation

Medical records are the primary means of capturing and communicating clinical reasoning. For suicide assessments, the risk assessment-as part of a more general formulation-should describe the clinician’s thinking that led to the decision to discharge or admit. Documentation allows for communication of risk to the next care providers, including the need for heightened level of observation. This communication is critically important for receiving-inpatient teams and, for prolonged ED stays, the next shift of ED caregivers.

Suicide risk assessment can involve life-or-death decisions, often based on information that is likely to be incomplete.

In the psychiatric ED, the risk formulation can be one of the most important parts of the record. Ideally, the risk assessment is a formulation based on salient risk and protective factors. Safety contracts with suicidal patients offer little clinically and have no legal standing. Once a person has screened positive for elevated suicide risk, a more thorough assessment is needed to characterize risk and establish appropriate next steps. A thorough formulation can include elements of interest across the psychiatric spectrum, including psychiatric disease(s)/disorders, issues of temperament, substance use or other problematic behaviors, and any life-story issues that may be involved in (or even causing) the patient’s presentation.13

CASE VIGNETTE 2

A 35-year-old man is brought to the ED by 4 police officers just before midnight. While high on cocaine and synthetic marijuana, Mr. S drove his car into the side of an ambulance stopped at a red light. The ambulance was totaled, although it fortunately was not transporting a patient at the time and the EMS crew was not injured. Mr. S was unscathed and initially feigned cooperation with police officers on the scene, then ran from them and was caught. The officers are ambivalent about taking him into custody because of his disruptive, “crazy” behavior.

In the ED, he is profane, making a number of threatening statements about his own safety and that of others; he boasts about his sexual prowess as he is escorted to an open room. In addition to any charges he might face for this event, he has a court date in 2 days that may lead to prolonged incarceration on drug distribution charges. His psychiatric record reveals self-reported diagnoses of both bipolar disorder and schizophrenia that were thought dubious because 2 past admissions at this facility were for diagnoses of adjustment disorder, substance use disorder, and antisocial and borderline personality disorder traits.

His half-brother and an uncle died by suicide, and a paternal cousin was involved in the drug trade and died under suspicious circumstances. His other family history is notable for multiple family members with mood and substance use disorders. In between threats to kill himself and everyone else in the ED, he screams, “You have to admit me-I’m suicidal,” and insists the crash was a suicide attempt.

 

The perils of an ED “siege mentality” culture

The ED can be a high-stress environment. The ED is at times the “tip of the spear” for psychiatric acuity; it is often where the greatest psychiatric symptomatology, behavioral issues, and medico-legal risk are concentrated. Suicide assessment in emergency care settings is one of the most challenging tasks for front-line clinicians. Working in a busy ED without the benefit of more extensive training, clinicians may reflexively categorize patients being assessed for suicide, using their own experience and hunches as guides. They may reduce patient presentations to several categories:

• Those who are malingering or “faking it”

• “Straightforward” patients, those who present with depression and suicidal thoughts who seek treatment voluntarily

• The “faking well,” those scariest of patients who minimize or deny symptoms, including intent to die by suicide, even when they have crafted a meticulous plan for their own demise.

The problem with this approach, of course, is that none of these groups can be defined with much reliability. The patient in the second vignette provoked a strong reaction in providers, who were subjected to his threats and taunts. Some resented that he had totaled an ambulance in a limited-resource community and believed that he was “putting on a show” as a way of escaping consequences. But even if this formulation is correct, the malingering sociopath with drug dependence still has a lifetime suicide rate far beyond the population rate and, if pushed, may do something impulsive out of spite to “prove” his or her suicidality or general instability. While resentful reactions to a patient who attempts to “con” us are understandable, it does not allow us to ignore the duty of thorough and rational assessment and planning.

Culture of safety

A number of new approaches offer promise in improving the quality and safety of care delivered in the emergency psychiatry setting. The Zero Suicide initiative14 begins with the premise that for those receiving care, suicide deaths are preventable. The initiative provides training programs and resources such as clinical and administrative tools and strategies as well as evidence-based guidelines for care. The approach is rooted in principles of patient safety and quality improvement and focuses on systems-level issues to solve problems in the health care setting.

The Science of Safety model15 helps achieve substantial improvement in quality and safety in health care. The basic principles that have helped reduce central line–associated bloodstream infections can be applied to the practice of emergency psychiatry.

The Comprehensive Unit-based Safety Program (CUSP)16 fosters a culture of safety and focuses on simple questions: How will the next patient be harmed? And how can it be prevented? As part of the CUSP process, an interdisciplinary group is assembled and includes a broad array of stakeholders: emergency medicine physicians and nurses, psychiatry providers, security officers, and a member of the legal office or clerical staff. The team is assigned a senior hospital executive. A culture assessment is completed and is reviewed with other unit-specific information that offers a snapshot of the unit. All aspects of patient care and the experiences of patients, staff, families, and others may be examined. The CUSP program focuses on creating and sustaining a culture of safety that relies on caregivers to identify areas of risk and work on solutions.

A CUSP team looking at defects related to suicide assessment might start by examining past events and “near-misses,” exploring the factors that may have been involved, such as the triage process, communication among providers and other staff, handoffs, or even issues with the physical environment (eg, obvious safety risks in patient care areas).

The team’s senior executive can be helpful in obtaining the resources needed to improve safety. When done well, CUSP can create a greater sense of teamwork and shared mission, building a culture that moves away from a reactive, “siege” mentality, where even patients and other providers are “part of the problem,” to a more proactive stance, solving shared challenges.

Future directions

In addition to efforts in the patient safety and quality improvement realms, there is an array of ongoing research that examines the biological underpinnings of suicide. Suicide, at its core, is a behavior that is multiply determined and influenced, and research is being pursued from different directions.

Although only in its nascent stages, the prospect of a “third-generation” dynamic risk model for suicide has strong appeal.17 Unlike first-generation models based on elements such as expert opinion or second-generation models using static risk elements, a third-generation model would involve the fluid, responsive modeling of static and dynamic risk factors based on chronic and acute risk. The more mutable dynamic factors would be susceptible to intervention by psychiatrists. Being an older, white male, for example, is not changeable; exacerbation of a mood disorder or relapse of a substance use disorder, however, are examples of factors that with adequate warning might be attenuated by active intervention. These new models would ideally move beyond the checklist of static and dynamic factors and provide greater specificity and targeted interventions for patients at greatest risk.

Some researchers have found genetic and other biological correlates with suicide. Building on earlier studies that found low levels of 5-hydroxyindoleacetic acid in the cerebrospinal fluid of suicide completers and disruption of the hypothalamic-pituitary-adrenal axis (HPA), researchers have made a number of discoveries that may one day lead to biomarkers that can be used in the clinical setting as a suicide prevention tool. Many of the findings to date target the serotonergic and/or adrenergic systems and the HPA axis, as well as cytokines and chemokines (of inflammatory processes), all of which are tied to mood and stress and have been implicated in increased suicide risk. It has been suggested that these biomarkers may correlate more with impulsive traits or mood disorders than a “suicide gene.”

There are intriguing findings that may someday offer the ability to measure a patient’s suicide risk at baseline and at times when there are clinical indications of increased risk. These tests are not, however, ready for clinical use and any claims of their being able to “predict” suicide should be viewed skeptically.

A number of studies are examining various pharmacological agents for suicidality. A recent Cochrane review of 7 trials of antidepressants, fluphenazine, mood stabilizers, or natural products, and a small study of flupenthixol, did not find compelling evidence to support or refute their use as interventions for self-harm.18

Despite the promise of future discoveries and new approaches to management of the suicidal patient, for now, the focus remains on fundamentals of assessment and basic safety. As our collective knowledge about the science of patient safety evolves, useful lessons from other health care settings may be applied to the psychiatric ED and to the care, assessment, and treatment of those referred for assessment for suicide risk. Further scientific advances in our understanding of the biological underpinnings of suicide, enhanced by broader principles of patient safety, offer the hope of better outcomes.

 

Additional Tools and Resources

In addition to the resources listed in the text and references, there are a number of other publications and organizations focused on suicide prevention in the ED setting. This list is not meant to be all-inclusive, but to represent a selection of related resources.

1 APA Practice Guideline for Assessment and Treatment of Patients With Suicidal Behaviors

2 Joint Commission Standards BoosterPak for Suicide Risk (N PSG.15.01.01)

3 Substance Abuse and Mental Health Services Administration (SAMHSA): After an Attempt: A Guide for Medical Providers in the Emergency Department Taking Care of Suicide Attempt Survivors

4 SAMHSA: After an Attempt: A Guide for Taking Care of Yourself After Your Treatment in the Emergency Department

5 Suicide Prevention Resource Center (SPRC) Caring for Adult Patients With Suicide Risk: A Consensus Guide for Emergency Departments

6 Suicide Prevention Resource Center (SPRC) Resources for Health Care Linkages for Suicide Prevention

Disclosures:

Dr. Triplett is Assistant Professor and Clinical Director of the Department of Psychiatry and Behavioral Sciences, Johns Hopkins and former Director of Psychiatric Emergency Services, Hopkins Hospital, Baltimore, MD. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Horowitz LM, Snyder D, Ludi E, et al. Ask suicide-screening questions to everyone in medical settings: the asQ’em quality improvement project. Psychosom. 2013;54:239-247.

2. Simon RI, Hales RE. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Association Publishing; 2012:21.

3. SAMHSA SAFE-T Guide. https://store.samhsa.gov/shin/content/SMA09-4432/SMA09-4432.pdf. Accessed October 4, 2016.

4. Beck RW, Morris JB, Beck AT. Cross-validation of the suicidal intent scale. Psychol Reps. 1974; 34:445-446.

5. Suicide Prevention Resource Center. Caring for Adult Patients With Suicide Risk: A Consensus Guide for Emergency Departments. http://www.sprc.org/resources-programs/caring-adult-patients-suicide-risk-consensus-guide-emergency-departments. Accessed October 4, 2016.

6. Jacobs DG, Baldessarini RJ, Conwell Y, et al. Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. November 2003. psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed October 4, 2016.

7. Kennedy SP, Baraff LJ, Suddath RL, Asarnow JR. Emergency department management of suicidal adolescents. Ann Emerg Med. 2004;43:452-460.

8. Sheehan DV, Alphs LD, Mao L, et al. Comparative validation of the S-STS, the ISST-plus, and the C-SSRS for assessing the suicidal thinking and behavior FDA 2012 suicidality categories. Innov Clin Neurosci. 2014;11:32-46.

9. Gipson PY, Agarwala P, Opperman KJ, et al. Columbia-Suicide Severity Rating Scale: predictive validity with adolescent psychiatric emergency patients. Pediatr Emerg Care. 2015;31:88-94.

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

11. Tingey L, Cwik MF, Goklish N, et al. Risk pathways for suicide among Native American adolescents. Qual Health Res. 2014;24:1518-1526.

12. Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry. 2003; 64:14-19.

13. McHugh PR, Slavney PR. The Perspectives of Psychiatry. 2nd ed. Baltimore, MD: Johns Hopkins University Press; 1998.

14. Zero Suicide. zerosuicide.sprc.org. Accessed October 4, 2016.

15. Agency for Healthcare Research and Quality. Understanding the Science of Safety. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/04a_scisafety/index.html. Accessed October 4, 2016.

16. Agency for Healthcare Research and Quality. CUSP Toolkit. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/. Accessed October 4, 2016.

17. Claassen CA, Harvilchuck-Laurenson JD, Fawcett J. Prognostic models to detect and monitor the near-term risk of suicide: state of the science. Am J Prev Med. 2014;47:S181-S185.

18. Hawton K, Witt KG, Taylor Salisbury TL, et al. Pharmacological interventions for self-harm in adults. Cochrane Data Syst Rev. 2015;7:CD011777.