Suicide: Can Emergency Departments Assist in its Prevention?

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we examine the case of a trauma patient with undetected suicidality that presented to the emergency department (ED). Patients with trauma are at a higher risk of suicide as they tend to be more accident-prone, in which the frequency of repeated, medically severe accidents consistently exceeds chance.¹ Survivors of suicide attempts are also at an elevated risk for potentially lethal behaviors.^2-4 Furthermore, there is an increasing prevalence of mental health and substance use disorders among patients with trauma which pose as additional risk factors for completed suicide.^5,6 Considering these risks, the implementation of suicide screenings and interventions in EDs would help in greater detection of potentially suicidal patients and may protect against future suicide attempts.

Case Study

“Maya” is a 40 year old female patient presenting to the ED after a motor vehicle accident. Earlier that night, she was driving her car and was involved in a head-on collision, stating that her car brakes were not working. Upon arrival, her vitals were stable but she reported neck and back pain. She did not experience loss of consciousness and reported no signs of headache, stomach pain, or neurological deficits. Her CT scans came back normal.

Upon chart review, the attending ED physician noted that she had previously presented to the ED 2 times in the last 3 months. Her first visit was in regards to abdominal pain that she stated was “probably [her] IBS acting up again.” She reported experiencing nausea, bloating, and fatigue with no changes in bowel habits. She experienced generalized pain over her entire abdomen and had tried taking Tylenol to alleviate her symptoms without much improvement. After being prescribed 20 mg of dicyclomine, she no longer experienced abdominal pain and was discharged home.

Her second presentation to the ED involved her falling off of a ladder and twisting her ankle while redecorating her house. All physical exam findings were unremarkable besides what appeared to be a sprained right ankle. Her ankle was notably swollen and inflamed with limited range of motion. It was also nonweight bearing and tender to palpation. X-ray imaging showed no signs of fracture, and she was advised to rest her ankle and take ibuprofen as needed for her pain.

All of her physical symptoms and complaints had been considered and thoroughly addressed by ED staff. Several months later, however, Maya presented to the ED once again, but this time as a survivor of a medically severe suicide attempt (MSSA). She had jumped from a fifth floor balcony and sustained multiple fractures.

Suicidality Disguised as Trauma Presentations to the ED

Suicide is an ongoing public health concern, affecting individuals globally. In 2023, approximately 3.7 million individuals planned a suicide attempt, 1.5 million individuals attempted suicide, and 49,000 individuals died by suicide in the United States, serving as the leading cause of death in those aged 10 to 34 years old. It has also been estimated that the nation has spent over $500 billion on suicide and nonfatal self-harm costs in 2020.⁷ These statistics can be partially explained by the complexity and variety of risk factors that make suicide difficult to detect and, therefore, prevent.

Most individuals who commit suicide have not made a previous attempt and are unlikely to be receiving psychiatric care. In fact, approximately 60% of suicides are first attempts.² Trauma patients presenting to EDs are an ideal target population for suicide screening considering that patient suicidality can be disguised as a trauma presentation. In one study investigating suicide rates among trauma patients in the year following their initial ED presentation, trauma patients, not including those presenting with self-harm or suicidal ideation, were 2 times more likely to commit suicide than the demographically matched general population.⁶

Not only are trauma patients more likely to commit suicide, but survivors of suicide attempts are also more susceptible to external-cause mortality. MSSA survivors, compared with high-risk patients with suicidal ideation but no attempt, were found to be more prone to accidents and most did not have a psychiatric diagnosis.^{2-4, 8,9} MSSA survivors are at significant risk of all-cause mortality, including an accident, homicide, or other hazardous behavior in the 5 years following their initial suicide attempt. This mortality risk includes a 5402-fold increase in suicide compared to the general population and can persist for over 10 years following their initial presentation.⁸

Suicidal Risk Factors

Ultimately, suicidal risk centers on the progression from suicidal ideation to intent, to attempt, and potentially to death. However, this progression is nonlinear and influenced by multiple biological, clinical, psychosocial, and environmental risk factors. Considering the obscurity involved in detecting suicidality among individuals, it is important to understand these risk factors.

Suicidal history is critical in assessing risk. Both a previous suicide attempt and suicidal ideation increase the likelihood of death by suicide. In patients presenting to an ED for a suicide attempt and suicidal ideation, they were 57 and 31 times more likely to die by suicide within 12 months following their initial ED presentation, respectively.⁶ Additionally, suicide prevalence increases by 59% among a cohort of suicide attempters compared to previous prevalence reports.²

Significant psychiatric risk factors include psychotic disorders, mood disorders, and personality disorders.¹⁰ Among patients who have attempted suicide or were hospitalized due to severe suicidal ideation and/or creation of a suicide plan, patients with schizophrenia and bipolar disorder were found to be at greatest risk compared with patients with major depressive disorder (MDD). Substance use disorders, including smoking, are also associated with elevated risks of committing suicide.⁸ This risk is especially prevalent with alcohol use disorder (AUD) as they are the second most common mental health disorder of individuals who have died by suicide, following mood disorders, and patients with AUD are 3 times more likely to engage in suicidal behavior compared with those without.¹¹

Physical illness and financial issues are also known to increase risk of suicide. Among physical illnesses, epilepsy, concussion, chronic obstructive pulmonary disease, and cancer were found to have significant associations with suicide. Sociodemographic factors, such as financial debt and unemployment, were also suggested to pose a suicide risk.¹⁰ Additionally, further environmental factors related to increased risk of suicide mortality include contact with the criminal justice system, access to firearms, and parental death by suicide.¹⁰

Conceptualizing Suicide

Further investigations into suicide and related conditions, in addition to its risk factors, allow for greater understanding for the development of interventions and preventative measures. One model that has advanced clinical understanding and conceptualization of suicide is the Interpersonal Theory of Suicide.¹² This model posits that thwarted belongingness and perceived burdensomeness lead to nearly fatal or fatal suicidal behavior in the presence of suicidal desire and the capability for suicide (Figure).¹²

Evaluations of this model have revealed more about the potential relationships between these components and how they may lead to suicide. Evidence strongly suggests that perceived burdensomeness leads to suicidal ideation and that the interaction between perceived belongingness and burdensomeness is weaker than theorized. It has also been suggested that the proposed association between suicide capability and attempt is weaker and less consistent—an observation that aligns with the notion that environmental factors can significantly influence an individual’s potential to engage in self-harm. Current evidence indicates that the proposed pathway of the Interpersonal Theory of Suicide warrants further evaluation, and additional modeling may enhance our understanding of suicide. The theory, however, continues to serve as a useful framework for clinicians assessing suicidal ideations.¹³

The DSM-5 has suggested suicide behavioral disorder (SBD) as a “condition for further study,” indicating that SBD may be included in a later edition depending on further research.¹⁴ This proposal positions suicide as a primary diagnosis, in contrast to its traditional classification in the DSM-5 and earlier editions as a symptom of MDD and borderline personality disorder, or as a secondary consequence of another psychiatric condition. Currently, for a patient to be diagnosed with SBD, they would need to meet all 5 of the following proposed diagnostic criteria:

1. Within the last 24 months, the individual has made a suicide attempt.
2. The act does not meet criteria for nonsuicidal self-injury (NSSI).
3. The diagnosis is not applied to suicidal ideation or to preparatory acts.
4. The act was not initiated during a state of delirium or confusion.
5. The act was not undertaken solely for a religious or political objective.¹⁵

However, the SBD model has significant limitations. Some of the limitations include a requirement of having a previous suicide attempt within 2 years, although 60% of suicides are first attempts, and a failure to address long-term risks of suicide attempt survivors.^2-4 Suicide attempt survivors have an elevated risk of engaging in potentially lethal behaviors for up to 14 years which is too long of a timeline for clinical utility.^2-4 More methods of prevention and detection are needed, and EDs may be where we need to implement potential solutions.

Suicide Detection and Prevention in the ED

As previously mentioned, 60% of suicides are first-attempts, and the development of suicidal ideation to action or attempt is nonlinear and unpredictable.² Assessing suicidality among trauma patients can help reduce suicide-related morbidity and improve risk detection, but doing so requires addressing key challenges in EDs, including inadequate suicide risk assessment protocols, provider attitudes, and limited training. Potential solutions to these problems include universal screenings in EDs, provider education, and usage of available guidelines.¹⁶

One example is the ICAR²E tool–a guideline and mnemonic that outlines key steps: Identify suicide risk; Communicate; Assess for life threats and ensure safety; Risk assessment (of suicide); Reduce the risk (of suicide); and Extend care beyond the ED.¹⁷ It demonstrates the highest adherence to Institute of Medicine (IOM) criteria among existing guidelines.¹⁷ This guideline can be downloaded as an app by ED providers and recommends an initial suicide risk screening with the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) patient safety screener and a secondary screening with the ED-SAFE secondary screener.¹⁸ Increasing screening among trauma patients may also help in reducing suicidal behavior long-term. In patients presenting to the ED with recent suicide attempt or suicidal ideation, screening and intervention significantly reduced subsequent suicide attempts. The intervention included a secondary suicide risk screening, resources provided at discharge, and follow-up phone calls.¹⁹ Together, these measures resulted in a 30% reduction in suicide attempts compared to patients who received treatment as usual.¹⁹ Psychiatric follow-up may serve as a protective factor for trauma patients at risk for suicide. Implementing similar interventions in EDs could play a meaningful role in addressing the ongoing suicide crisis.

Concluding Thoughts

Suicide remains difficult to detect and prevent due to its high prevalence and challenges in predictability. While current stress-diasthesis models offer some insight, they overlook key limitations–most notably, that many suicides occur on the first-attempt, and that survivors of suicide attempts remain at elevated long-term risk for future lethal behaviors. Given the established link between trauma and suicidality, trauma patients presenting to EDs represent an ideal population for targeted intervention. Tools such as the ICAR²E framework offer promising, evidence-based solutions. EDs present a unique opportunity to intervene, with potential to improve identification and continuity of care for those at risk.

Ms Alkarra is a student at Texas A&M University Naresh K. Vashisht College of Medicine. Dr Thomas is an assistant professor in the Henry J.N. Taub Department of Emergency Medicine at Baylor College of Medicine. Dr Moukaddam is a professor of psychiatry at Baylor College of Medicine, Department of Psychiatry, and the Director of Outpatient Psychiatry at Harris Health. She also serves on the Psychiatric Times Editorial Board.

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