Written by: Kaitlin Ray, MD (NUEM PGY-4) Edited by: Matt Klein, MD (NUEM ‘18) Expert commentary by: Julie Cooper, MD (NUEM ‘11)
Approach to Assessing Suicidal Ideation in the Emergency Department
As the 10th leading cause of death in the United States, suicide has become a pervasive public health issue taking over 44,000 lives annually . Each year, over 12 million emergency department (ED) visits are related to mental health and substance abuse issues, and over 650,000 patients are evaluated for suicide attempts . An estimated 9.3 million American adults reported having suicidal thoughts in 2015, among which 2.7 million thought through a suicide plan. Of those adults who have thought through a plan, half 1.3 million actually attempted suicide . Unfortunately, suicidal ideation is one of the most common psychiatric chief complaints encountered by emergency medicine physicians, and the ED is playing an increasingly critical role in providing acute psychiatric care .
The unfortunate reality is that many mental health programs and community initiatives have limited resources and are at maximum capacity . As such, the ED is often the only available option for management of acute and subacute psychiatric illness . In fact, the Joint Commission’s National Patient Safety Goal (NPSG) orders that general hospitals “conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide”. Further, the National Action Alliance Clinical Care and Intervention Task Force specifies that suicide assessment “should be completed by a professional with appropriate and specific training in assessing for and evaluating suicide risk…and [the professional] must have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment” .
In an attempt to meet these goals and provide psychiatric care to those in need, EM physicians are faced with the unique expectation to execute an organized, efficient, and effective approach to suicide assessment that ensures patient and public safety. The process of eliciting the aforementioned ‘candid disclosure’ can be a daunting task during an emergent visit without a previously established relationship . This problem is further complicated by the increasing reliance on the ED for acute psychiatric care which can exacerbate overcrowding, leading to decreased quality of care and increased likelihood of medical error. Further, mental health associated visits are 2.5x more likely to result in an admission requiring resource intensive care, which can negatively impact quality of care for other patients .
The continued emphasis on screening for suicidal ideation in the ED necessitates EM physicians to understand and perform a suicide risk assessment . Of note, it is critical to differentiate suicide screening and suicide assessment. Screening refers to a standardized instrument or protocol that identifies individuals at risk for suicide; a process often performed in triage independent of chief complaint or presenting symptoms. Assessment refers to a comprehensive evaluation performed by a clinician to not only confirm suspected suicide risk, but also to estimate immediate danger to the patient and implement a treatment plan . The focus of this piece is targeted toward the assessment and evaluation of a patient once already determined to be at risk for suicide per various screening methods (Mental Health Triage Scale, Behavioral Health Screening, Manchester Self-Harm Rule, ReACT Self-Harm Rule, P4 Screener, Beck Depression Scale, Geriatric Depression Scale) .
Suicide assessment and evaluation in the ED is an imperfect science with a limited evidence base to guide management . Further, neither the American Psychiatric Association nor the American College of Emergency Physicians (ACEP) have issued guidelines addressing acute ED management of suicidal patients, leading to markedly varied practice patterns in hospitals across the United States . While there are efforts to develop a quantitative method through which to identify those at highest risk of suicide, there is no universally accepted scoring system, and currently clinical judgment remains the most essential factor .
In the majority of emergency departments across the country, the EM physician is responsible for the assessment and disposition of patients with suicidal ideation. Multiple factors are taken into account when defining the role of an EM physician during this process including the following:
Providing a safe environment: Take care to ensure the safety of both the patient and other health care providers. This process often requires taking patient’s clothing in exchange for a hospital gown, searching and withholding personal belongings, 1:1 observation, and physical or chemical restraints if deemed appropriate. Conduct the evaluation in a non-judgmental fashion, preferably in a private or semi-private setting utilizing open-ended questions .
Ruling out “reversible” causes of depression/suicidal ideation: Consider toxic ingestions, infectious processes, toxic-metabolic etiology, and trauma as possible causative factors when clinically indicated. ACEP issued a Level B recommendation regarding obtaining routine laboratory testing in alert, cooperative patients with normal vital signs and a non-focal history and physical. Routine urine drug screens (UDS) are a Level C recommendation and should not delay patient evaluation or transfer to more advanced psychiatric care . Of note, one should insist on a clinically sober assessment, not based on BAC, given the disinhibiting effect of alcohol.
Assessing the degree of imminent risk to the patient: Arguably the most challenging yet critical component of the process. The Suicide Prevention Resource Center (SPRC) has developed a 5-step process to guide the clinical assessment of patients with suicidal ideation and is one that can be implemented in the ED setting . SAFE-T, the Suicide Assessment Five-Step Evaluation and Triage, is a simple methodical approach that focuses on identifying risk factors for suicide, identifying protective factors, conducting the suicide inquiry, determining the risk level of the patient, and finally documenting the clinical assessment . Each component will be elaborated on separately.
Identifying risk factors for suicide:
Prior history of suicide attempts: The single strongest predictor of suicide with these patients being 6x more likely to make another attempt .
Current lethal plan: Highly predictive of future suicide attempt .
Older age: While younger patients typically have more attempts at suicide, older patients are more likely to succeed2. The highest rates of suicide are found among middle-aged populations between 45-64 years old .
Coexisting psychiatric disorder: Major Depressive Disorder, schizophrenia, personality disorder, borderline personality disorder, bipolar disorder, PTSD 
Recent psychosocial stressor: Ask about marital status, employment, social support, homelessness, financial stressors
Caucasian Race: Highest suicide rates among whites, specifically white males who account for 7/10 suicides in the US . The 2nd highest suicide rate is among American Indians/Alaska Natives, where suicide is now the leading cause of death in those aged between 10-34 years of age .
EtOH/Drug Abuse: Chronic use elevates suicide risk long term, while acute intoxication disinhibits and impairs thought process, increasing suicide risk in a more immediate context .
Other factors to consider :
Gender: Women attempt suicide 4x more frequently than men; however men are 3x as successful as women in completing suicide .
Access to firearms: Utilization of firearms accounts for 50% of all suicides in the US, with higher rates among men1. Poisoning is the most common method among females .
Impulsivity: Look for behaviors and statements from the patient that establish a pattern of impulsive behavior .
Family history of suicide/mental illness
History of childhood trauma
Chronic physical illness
Identifying protective factors for suicide
No past suicidal ideation: Denies feelings of hopelessness and depression 
Supportive family and social network 
Willingness to seek and accept help 
Strong personal relationships 
Female gender 
Ethical, moral, or religious suicide taboos 
Employment and financial stability 
Having dependents 
Positive self-esteem 
Conducting suicide inquiry 
Ideation: Frequency? Intensity? Duration? How often in past 48 hours? Past month?
Plan: Inquire about timing, location, lethality, availability, and any preparatory acts that may be involved
Behaviors: Past attempts? Aborted attempts? Any rehearsals—tying a noose? Loading a gun?
Intent: Evaluate the extent to which the patient intends to carry out the plan and believes the act to be lethal versus self-injurious. If possible discuss with patient their reasons to die vs. reasons to live.
Determining risk level and need for interventions
A patient’s risk level and subsequent treatment disposition is based on clinical judgment!
Charted below is a general rule of thumb in guiding a patient’s disposition from the ED :
Documenting the clinical assessment
Documentation is the fifth and final component of a suicide assessment in the ED. Be clear to document the patient’s estimated risk level as well as the rationale for doing so. Specify the treatment plan that will address the patient’s current risk .
Perhaps the most challenging portion of assessing a suicidal psychiatric complaint is determining the patient’s disposition. In many facilities, a formal psychiatric assessment would require an inpatient hospitalization. Additionally, it is state (not federal) laws that govern conditions in which you may involuntarily hold a patient for an emergency psychiatric evaluation, with a hold >72 hours typically requiring a court order. Unfortunately there is no clear evidence to support the use of suicide contracts in the ED—i.e. written or verbal agreements between the physician and the patient in which the patient agrees to abstain from self-harm behaviors while in the ED and for a set amount of time thereafter. While psychotropic medications are rarely initiated in the emergency department, it may be reasonable to prescribe a short course of anxiolytics as a bridge to psychiatric follow up in a patient determined safe for discharge home. Patients determined safe for outpatient follow-up should be given strict return precautions in addition to resources that include emergency and crisis phone numbers. Finally, as with all other life threatening conditions that come through the ED, documentation regarding the risk assessment and disposition of the patient is critical .
Ultimately, until our mental health and community resources have the means to meet the growing psychiatric demands of our country, the emergency department will continue to be a resource to provide acute psychiatric care. Limited evidence-based recommendations and no official standardized guidelines exist to assist emergency physicians in assessing risk of suicidality; however, adhering to the basic process of identifying high risk features in addition to protective factors, while simultaneously asking direct questions regarding suicidal ideation, plan, behavior, and intent, can guide EM physicians towards making an appropriately and timely disposition for the suicidal patient.
Thanks so much for this excellent review of the approach to the patient with suicidal ideation. What a complex task to perform in our already complex practice, but also what a pleasure to care for someone when the major tool in our toolbox is taking the history! This review correctly notes that the emergency physician “must have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment”. So, what exactly are those skills?
First, we know that the typical ED environment is not always conducive to sensitive conversations. I once heard a resident walk up to a patient in the hallway and say “Hi! I heard you were suicidal!”. Whether the patient is mean, intoxicated, or has some kind of perceived secondary gain, observe your cognitive biases and overcome the urge to minimize their perceived risk. Consider location bias when they are in a hallway, anchoring bias when staff tell you “they were just discharged yesterday”. Those all may be reasons a patient is destabilized and at high risk, so be on alert. Many of these patients wait for hours, have difficult lives and none of us went into medicine to be mean to vulnerable people. Get them the sandwich and a warm blanket, create some privacy and pull up a chair.
Conversations surrounding mental health and suicidality can trigger intense feelings of shame or embarrassment (in both the patient and clinician), elicit anxiety surrounding the consequences of seeking help or conjure memories of negative experiences with the mental health system. Language really does matter when it comes to building trust and conveying empathy. I always start my history open ended with “how did you end up here today?” and assume no knowledge of the events that brought them in. The details of how a person actually came to be in the ED can shine a light on their risk. Did they come seeking help themselves? Did another person encourage them who may have important collateral information? Was law enforcement involved? If they are not forthcoming I might try “I heard … is that correct?”
If a patient doesn’t bring up suicidal thoughts on their own I often start with “It sounds like you have been feeling really badly leading up to today, were you worried about your safety?”. I’ll work up to “were you worried you might harm or kill yourself?” and try to tease out “how close” they might have gotten by asking “did you actually do something to try to harm yourself or was there something you were worried about doing?” For an attempt that doesn’t seem serious to me (a small over the counter ingestion or superficial self-injurious behavior like cutting) I will ask what they thought was going to happen when they did that. Often it might be a serious attempt in their eyes. When considering protective factors I always ask “what kept you from going through with it?”. This might bring up mitigating factors that reduce their suicide risk.
The assessment of a suicidal patient can be an opportunity to switch gears during a shift and focus on the kind of communication that is fundamental to the practice of medicine. If you’re looking to build your skills, consider seeking feedback from mental health professionals like psychiatrists, nurses or social workers in your department or observe them on shift to learn language you might integrate. That is how I picked up one of my favorite tools for an emotional patient encounter: expressing gratitude. If a patient acknowledges suicidal feelings, try “thank you so much for sharing that with me, I know it was hard and we are here to help.”
Julie Cooper, MD
How To Cite This Post
[Peer-Reviewed, Web Publication] Ray K, Klein M. (2019, Sept 30). Assessment of the Suicidal Patient. [NUEM Blog. Expert Commentary by Cooper J]. Retrieved from http://www.nuemblog.com/blog/assessment-SI.
Other Posts You May Enjoy
1. American Foundation for Suicide Prevention. (2015). Suicide Statistics — AFSP. Retrieved from https://afsp.org/about-suicide/suicide-statistics/
2. Bernard, C., Gitlin, D., & Patel, R. (2011). The Depressed Patient and Suicidal Patient in the Emergency Department: Evidence based management and treatment strategies. Emergency Medicine Practice, 13(9). Retrieved from ebmedicine.net
3. Suicide Facts at a Glance 2015. Retrieved from http://www.cdc.gov/violenceprevention
4. Suicide Prevention Resource Center. (2014, September 1). Suicide Screening and Assessment. Retrieved from http://www.sprc.org/sites/default/files/migrate/library/RS_ suicide%20screening_91814%20final.pdf
5. Owens, P., Mutter, R., & Stocks, C. (2010). Mental health and substance abuse-related emergency department visits among adults, 2007 (92). Agency for Healthcare Research and Quality.
6. Ronquillo, L., Minassian, A., Vilke, G. M., & Wilson, M. P. (2012). Literature-based Recommendations for Suicide Assessment in the Emergency Department: A Review. The Journal of Emergency Medicine, 43(5), 836-842. doi:10.1016/j.jemermed.2012.08.015
7. Brim, C., Lindauer, C., Halpern, J., & Storer, A. (2012). Clinical Practice Guideline: Suicide Risk Assessment. Institute for Emergency Nursing Research. Retrieved from https://www.ena.org
8. Jacobs M.D., Douglas. National Suicide Prevention Lifeline. (2017, January 14). SAFE-T: Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals. Retrieved from http://www.stopsuicide.org
9. Simon, Robert I. "Assessing protective factors against suicide: questioning assumptions." Psychiatric Times, Aug. 2011, p. 35. Academic OneFile, go.galegroup.com.ezproxy.galter.northwestern.edu/ps/i.do?p=AONE&sw=w&u=
northwestern&v=2.1&it=r&id=GALE%7CA264271238&asid=e996d06fc529b9a60a6d5306fb8c8fd4. Accessed 1 Feb. 2017.