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Suicide, Risk Evaluation, Emergency Medicine

Basics

Description

- The intentional taking of ones own life - Suicidal ideation: - Passive: A conscious desire not to live - Active: Intention to die with or without a plan

- Occult presentation: - Many individuals at risk for suicidal behavior seek care in the ED for nonbehavioral complaints - Improved suicide screening practices may be needed to capture this population.

- Modified SAD PERSONS Score: - Sex: Male 1 point - Age <19 or >45 yr 1 point - Depression or hopelessness 2 points - Previous attempts or psychiatric care 1 point - Excessive alcohol or drug use 1 point - Rational thinking loss 2 points - Separated/divorced/widowed 1 point - Organized or serious attempt 2 points - No social supports 1 point - Stated future intent 2 points - Data suggests that patients with a score of <5 can safely be managed as an outpatient

- Collateral information from outpatient care givers, family, friends - Safety plan: - Would the patient immediately seek help if suicidal ideation recurred? - Elimination of means of suicide - Access to other means of suicide - Support and supervision in the outpatient setting - Prompt outpatient follow-up with psychiatric therapy - Patient investment in not attempting suicide - Identifying reasons for living - Safety contracts are no guarantee that individuals will not attempt suicide.

- Suicide is a leading cause of death among young people 15 " “24 yr of age. - More than 4,000 adolescents commit suicide every year (CDC 2009) - Rapidly increasing in young black males ages 10 " “14 yr - Less evidence available to link suicide in youth to overt psychiatric illness - Stresses: - Prior attempts - Family disruption - History of psychiatric disorder - Depression - Disciplinary crisis - Broken romance - School difficulties - Bereavement - Rejection - History of physical or sexual abuse

  • The intentional taking of ones own life
  • Suicidal ideation:Passive: A conscious desire not to liveActive: Intention to die with or without a plan
  • Parasuicidal behavior: Self-injury not intended to cause death (e.g., superficial cutting, cigarette burns, head banging)
  • Reckless behavior: Not taking prescribed medications, taking too much of prescribed medications, running into traffic
  • Risk-to-rescue ratio " ”lethality of plan compared with likelihood of rescue:High risk-to-rescue ratio indicates increased severity of attempt.
  • Occult presentation:Many individuals at risk for suicidal behavior seek care in the ED for nonbehavioral complaintsImproved suicide screening practices may be needed to capture this population.

Etiology

  • 36,891 suicides in US (CDC 2009)
  • 12 " “25 attempts per every completed suicide
  • 25.4 per 100,000 males (CDC 2009)
  • 7.4 per 100,000 females
  • 11.1 per 100,000 general population
  • 2 peaks in age group most at risk for suicide:Age 15 " “24 yr (3rd leading cause of death in this age group)Age >60 yr (highest rates of any age group, increasing incidence with age)

Risk Factors for Suicidal Behavior

  • Depression (bipolar or unipolar)
  • Alcohol or drug abuse
  • History of physical or sexual abuse
  • Unemployment
  • Incarceration
  • History of head injury or neurologic disorder
  • Firearms in the home
  • Cigarette smoking
  • Positive family history of suicide attempt
  • Psychiatric or medical comorbidities
  • Gender:Women 3 times more likely to attempt suicide.Men 3 times more likely to complete suicide.
  • Psychological:Impulsivity/aggressionDepressionAnxietyHopelessnessSelf-consciousness/social disengagementPoor problem-solving abilitiesLack of social supportsWidowedDivorcedSeparatedLack of social supportsRecent loss of relationshipAnniversary of loss
  • Environmental
  • Rural areas:Access to firearmsPovertyUnemployment

Risk Factors for Completed Suicide

  • Male
  • Age >60 yr
  • White or Native American
  • Widowed/divorced
  • Living alone
  • Unemployment/poverty
  • Past suicide attempt

Methods of Suicide (CDC 2009)

  • Firearms (most common among men and 2nd most common in women)
  • Overdose (Most common among women); most common means of suicide attempt (70% of failed attempts are by overdose)
  • Hanging
  • Suffocation

Populations at Highest Risk for Completing Suicide

  • >90% of patients who commit suicide have a psychiatric diagnosis.
  • Depression " ”especially psychotic depression
  • Anxiety and panic disorder
  • Alcohol or drug intoxication
  • Schizophrenia
  • Adolescents

Others at Risk for Completing Suicide

  • Recent discharge from psychiatric facility
  • History of suicidal ideation or suicide attempt
  • Serious physical illness present in up to 70% of all suicides, particularly in elderly patients.
  • History of incarceration
  • Physicians
  • Victims of violence/abuse

Interventions that Lower Risk

  • Patients with mood disorders (major depression and bipolar disorder) treated with lithium
  • Patient with major depression treated with electroconvulsive therapy
  • Patients with schizophrenia treated with clozapine
  • NOT shown to decrease suicide rates: Treatment with selective serotonin reuptake inhibitors (SSRIs) for major depression

Protective factors

  • Strong social supports
  • Family cohesion
  • Peer group affiliation
  • Good coping and problem-solving skills
  • Positive values and beliefs
  • Ability to seek and access help

Diagnosis

Signs and Symptoms

  • Depressed mood
  • Verbalization of suicidal ideation with or without plan
  • Hopelessness
  • Helplessness
  • Anger/aggression
  • Impulsivity
  • Psychotic symptoms (i.e., paranoia, command auditory hallucinations)

History

  • Obtain history to assess risk:Asking about suicide does not increase risk for attempt
  • Degree of suicidal ideation
  • Plan immediate risk of self-injury?Means available to complete planActivity toward initiating planPatients expectations of lethality of plan
  • Intent: Reasons, goal
  • Risk-to-rescue ratio
  • Plan or intent to harm others?
  • Presence of acute precipitants:Recent losses, lack of social supports
  • Risk factors:History of past suicide attemptsPsychiatric review of symptoms: Depression, psychosis, panic/anxietyChronic medical illnessAlcohol or drug abuse
  • Serial assessment of mental status, consistency of responses
  • Factors preventing suicide

Physical Exam

  • As needed to address acute medical issues
  • Look for evidence of injuries and signs of self-neglect.

Scoring Systems

  • Modified SAD PERSONS Score:Sex: Male 1 pointAge <19 or >45 yr 1 pointDepression or hopelessness 2 pointsPrevious attempts or psychiatric care 1 pointExcessive alcohol or drug use 1 pointRational thinking loss 2 pointsSeparated/divorced/widowed 1 pointOrganized or serious attempt 2 pointsNo social supports 1 pointStated future intent 2 pointsData suggests that patients with a score of <5 can safely be managed as an outpatient

Essential Workup

  • Collateral information from outpatient care givers, family, friends
  • Safety plan:Would the patient immediately seek help if suicidal ideation recurred?Elimination of means of suicideAccess to other means of suicideSupport and supervision in the outpatient settingPrompt outpatient follow-up with psychiatric therapyPatient investment in not attempting suicideIdentifying reasons for livingSafety contracts are no guarantee that individuals will not attempt suicide.

Diagnosis Tests & Interpretation

Lab

  • Blood " “alcohol level
  • Serum toxicology screen: Aspirin, acetaminophen, and other medications
  • Urine drug screen:Many psychiatric facilities require toxicology screen before placement.
  • Carbon monoxide (as indicated)

Imaging

Not routinely indicated ‚

Diagnostic Procedures/Surgery

ECG " “ as indicated ‚

Differential Diagnosis

  • Normal despondency
  • Bereavement
  • Adjustment disorder with depressed mood
  • Major depressive disorder
  • Bipolar disorder
  • Organic mental disorder (head injury, dementia, delirium)
  • Schizophrenia
  • Panic and anxiety disorders
  • Alcohol or drug abuse
  • Borderline personality disorder
  • Antisocial personality disorder
  • Accidental death
  • Attempted homicide
  • Suicide is a leading cause of death among young people 15 " “24 yr of age.
  • More than 4,000 adolescents commit suicide every year (CDC 2009)
  • Rapidly increasing in young black males ages 10 " “14 yr
  • Less evidence available to link suicide in youth to overt psychiatric illness
  • Stresses:Prior attemptsFamily disruptionHistory of psychiatric disorderDepressionDisciplinary crisisBroken romanceSchool difficultiesBereavementRejectionHistory of physical or sexual abuse
  • Early warning signs:Progressive declining schoolworkMultiple physical complaintsSubstance abuseDisrupted family relationsSocial withdrawalAnhedonia
  • Suicide rates highest in age >65 yr
  • Completed suicide: 83% men
  • Risk factors: Divorced, widowed, male, social isolation
  • Tend to use more lethal methods
  • Lower ratio of attempts to completions

Treatment

Pre-Hospital

  • For potentially dangerous patient who refuses transport to treatment facility; involve police and impose restraint.
  • Risk to medics on the scene in cases of firearms or other weapons
  • Know state and local laws, availability of mobile crisis units, and when to involve the police.

Initial Stabilization/Therapy

  • Prevent ability to elope
  • Ensure patient safety:Remove sharp objects, belts, shoelaces, and other articles that could be used for self-injury
  • Provide safe environment
  • Appropriate supervision

Ed Treatment/Procedures

  • Confer with patients outpatient therapist or physician if possible
  • Voluntary admission to psychiatric facility
  • Involuntary admission if patient refuses voluntary
  • For involuntary psychiatric admission, patient must have psychiatric disorder and 1 of the following:Risk for danger to selfRisk for danger to othersInability to care for self

Medication

Treat underlying psychiatric disorder. ‚

Follow-Up

Disposition

Admission Criteria

  • If patient endorses suicidal ideation with plan and intent, admission may be needed for safety.
  • If impulsivity, anger, or aggression hinder ability to control behavior

Discharge Criteria

  • Patient has no suicidal ideation.
  • Patient agrees to return to ED immediately or seek psychiatric help if suicidal ideation recurs.
  • Patient has passive suicidal ideation without plan or intent.
  • Patient has good support network or placement in appropriate crisis housing
  • Appropriate outpatient psychiatric follow-up is ensured.
  • In some cases, patients who express suicidal ideation while intoxicated may be discharged if no longer suicidal once they are sober.
  • Some patients with borderline personality disorder and chronic suicidal ideation are discharged after careful psychiatric evaluation in consultation with long-term outpatient caregivers.

Followup Recommendations

Close psychiatric follow-up for those with acute illness who do not require admission ‚

Pearls and Pitfalls

  • A careful history will identify risk factors for suicide.
  • Access collateral sources of information about patients recent thoughts and behavior.
  • Maintain patient safety during evaluation
  • Hospital admission may be required if patient endorses suicidal ideation and plan.

Additional Reading

  • Ali ‚ A, Hassiotis ‚ A. Deliberate self harm and assessing suicidal risk. Br J Hosp Med (Lond). 2006;67(11):M212 " “M213.
  • Cooper ‚ JB, Lawlor ‚ MP, Hiroeh ‚ U, et al. Factors that influence emergency department doctors ' assessment of suicide risk in deliberate self-harm patients. Eur J Emerg Med. 2003;10(4):283 " “287.
  • Miller ‚ M, Hemenway ‚ D. The relationship between firearms and suicide: A review of the literature. Clin Neurosci Res. 2001;1:310 " “323.
  • Nock ‚ MK, Borges ‚ G, Bromet ‚ EJ, et al. Suicide and suicidal behavior. Epidemiol Rev. 2008;30:133 " “154.
  • Ronquillo ‚ L, Minassian ‚ A, Vilke ‚ GM, et al. Literature-based recommendations for suicide assessment in the emergency department: A review. J Emerg Med. 2012;43(5):836 " “842.
  • 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.

See Also (Topic, Algorithm, Electronic Media Element)

Depression ‚

Codes

ICD9

  • 311 Depressive disorder, not elsewhere classified
  • V17.0 Family history of psychiatric condition
  • V62.84 Suicidal ideation
  • 300.9 Unspecified nonpsychotic mental disorder

ICD10

  • R45.851 Suicidal ideations
  • Z81.8 Family history of other mental and behavioral disorders
  • Z91.5 Personal history of self-harm
  • F32.9 Major depressive disorder, single episode, unspecified
  • T14.91 Suicide attempt

SNOMED

  • 267073005 Suicidal (finding)
  • 247650009 Planning suicide (finding)
  • 425104003 suicidal behavior (finding)
  • 160333008 Family history: Suicide (situation)
  • 161474000 History of attempted suicide (situation)
  • 304594002 Suicidal intent (finding)
  • 35489007 Depressive disorder (disorder)