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Some ED Patients Are Suicidal but Present with Unrelated Complaints
June 1, 2024 5 minutes read
Many youths who die by suicide interacted with the healthcare system in the year before death.1 This raises the question: Should ED providers be screening all youth for suicide risk, regardless of their chief complaint?
“Obviously, the utility of screening efforts only go as far as clinics and providers are able to appropriately respond to positive screens,” says Jeffrey D. Shahidullah, PhD, ABPP, an assistant professor in the Department of Psychiatry and Behavioral Sciences at The University of Texas at Austin’s Dell Medical School.
At Dell Children’s Medical Center of Central Texas, the ED is well-equipped to appropriately respond to suicide screening risk identification. On-site social workers are available to provide mental health and social needs resources. Additionally, the ED has an on-site mental health unit within the same medical center. Shahidullah and colleagues set out to evaluate the ED’s universal suicide screening program to identify adolescents experiencing suicide risk, including patients presenting for non-mental health reasons who would not have been identified with targeted suicide risk screening. The researchers also sought to identify demographic factors that were linked to a higher risk of suicidality.
The researchers analyzed patient data for all patients ages 12 to 18 years who were screened for suicide risk in a six-month timeframe in 2019.1 Some key findings:
• Of 1,155 patients identified as positive for suicide risk, most (69.1%) were female.
• Overall, 9.1% of patients were experiencing some level of suicide risk.
• Of patients with positive scores, 10% were not presenting for a mental health reason and had no mental health history.
“The results confirmed our rationale for implementing universal suicidality screening, given there were likely many youths we were not identifying as having suicidality concerns, including several who screened in the high-risk range,” says Shahidullah. Because these patients were flagged in the screening process, they were able to be supported at the time of the ED visit. If patients were deemed to have imminent risk (such as a suicide plan with intent) and would not be safe going home, they could be admitted to the mental health unit. Otherwise, they could be sent home with a carefully developed safety plan. Typically, this includes constant monitoring/supervision by an adult and removal of pills and sharps, and a plan for a soonest-available outpatient appointment with a mental health provider through the hospital’s outpatient mental health center or through a provider in the community that the on-site social work team would help facilitate.
“These youth would likely not have been flagged and supported if they presented in the ED prior to roll-out of our universal screening approach,” observes Shahidullah. However, universal suicidality screening is not feasible for all EDs. Shahidullah says these are common obstacles:
• ED providers often encounter workflow-related barriers.
One common example is difficulty getting a consult from a child psychiatrist if the patient is being sent home with a safety plan or admitted as an inpatient. “Many ED attendings or residents would rely on getting that psychiatry or psychology consult in to determine safety risk and management decision-making,” explains Shahidullah. These consults may not aways be available on weekend, evening, or holiday hours. This can lead to long ED stays for families while the team is planning disposition.
• Patients or families do not always appreciate being screened for suicide if they present for a completely unrelated reason.
• Some providers are uncomfortable inquiring about suicidality; even if providers do ask, there often is a lack of hospital resources to deploy if they do get a positive response.
“Thus, ED suicidality screening processes in pediatric emergency departments must be guided by hospital-specific needs, resources, and capacities,” says Shahidullah.
Suicidal ideation in ED patients, and patients generally, is common. “Many times, patients with severe anxiety and depression somaticize their mental health issues,” says Michael M. Wilson, MD, JD, a Washington, DC-based healthcare attorney.
A patient may report a history of severe left-sided chest pain instead of telling the ED triage nurse that they were rejected by their girlfriend or boyfriend and now want to kill themselves, for example. “ED physicians should be alert to this frequent and well-known incidence of psychiatric issues presenting as somatic complaints,” underscores Wilson. Unfortunately, in an ED setting, it is not feasible to delve into the psychosocial history of each patient who presents with a somatic complaint.
“However, the history must be conducted in a sufficiently open-ended manner to give the patient an opportunity to tell the physician of [their] severe mental distress and suicidal ideation if those exist, so that an appropriate psychiatric referral can be made,” says Wilson.
Unfortunately, there are no effective ways to quickly, accurately, and consistently screen for suicide risk other than to listen to what the patient is saying. It is not realistic for ED physicians to universally screen patients for suicidal ideation, asserts Wilson. Even if EDs did so, there are no effective ways to predict which of those patients who provide positive responses will go on to attempt or commit suicide.
Wilson says that if an element of significant history presents that raises a major risk of suicide, then it is important to inquire about suicidal ideation and plans and document the responses in the record. A simple note of “Patient denies suicidal ideation” can help in defending a subsequent case. “In an ED setting, it is not always possible to have a detailed psychiatric interview even for the patients at apparent risk of suicide,” acknowledges Wilson.
However, if there is something concerning noted, good documentation could be helpful in defending a lawsuit for a subsequent suicide. For example, the ED provider might document: “The patient recently became blind from surgery for a brain tumor. The patient appeared depressed with a flat affect. Had discussion, and the patient denied any suicidal ideation and said was accepting the condition and making plans for computer programs to read to the patient and other adaptive devices. Referral was made to psychiatrist Dr. Jones, and the patient agreed to make an appointment to discuss their feelings about the changes he was going through. Patient was satisfied with this referral.”
“If, however, the [emergency physician] believes that there is an immediate risk of harm, then a psychiatric consultation or transfer to an appropriate institution may be warranted,” says Wilson.
REFERENCES
- Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med 2014;29:870-877.
- Do L, Piper K, Barczyk AN, et al. Universal suicidality screening in a pediatric emergency department to improve mental health safety risk. J Emerg Nurs 2024; Mar 25. doi: 10.1016/j.jen.2024.01.008. [Online ahead of print].
Many youths who die by suicide interacted with the healthcare system in the year before death. This raises the question: Should ED providers be screening all youth for suicide risk, regardless of their chief complaint?
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