Many ED patients who present with suicidal ideation also had been diagnosed with substance abuse and psychiatric disorders, according to the authors of a recent study.1

“In my practice experience, we see a lot of patients who have both substance abuse and suicidal ideation, which led to my interest in the relationship between the two,” says Allison Tadros, MD, FACEP, the study’s author and a professor of emergency medicine at West Virginia University.

Tadros and colleagues reviewed charts of 427 ED patient visits for suicidality that occurred from October 2016 to March 2017. Ninety-two percent had received a psychiatric diagnosis. Fifty-one percent had received more than one such diagnosis. Fifty-eight percent of patients had substance abuse disorders. About half patients had visited the ED three or more times in the prior year.

Suicide decedents are disproportionately likely to have visited an ED in the prior months.2 “Less was known about whether patients with suicidal ideation, but not self-harm, are also at increased risk of suicide,” says Mark Olfson, MD, MPH, professor of psychiatry, medicine, and law at Columbia University Irving Medical Center.

To learn more, researchers reviewed ED records of 648,646 patients who visited a California ED from 2009 to 2011. ED patients with deliberate self-harm or suicidal ideation were at a substantially higher risk of suicide (and other mortality) in the year after their visit.3

Rates of death from suicide were higher among men, people age 65 years or older, and non-Hispanic white patients. The results confirm that in addition to self-harm, suicidal ideation without self-harm is a marker for higher risk of suicide. “Predicting suicide and suicidal behavior at the individual patient level is extremely difficult, given the uncommonness of these events, even in high-risk patients,” says Olfson, one of the study’s authors.

Access to and quality of locally available mental health services are outside the control of ED clinicians. “However, appropriate discharge planning is a key aspect of the emergency management of this patient population,” Olfson adds.

Researchers were motivated by a desire to approach suicide risk with the same tools and approaches found to be helpful in other areas of medicine. “Cancer patients are entered into a data tracking system from the day they are diagnosed, literally.4 We, in various ways, follow cancer patients from that day forward. And we do this for all cancer patients, in all settings,” says Michael Schoenbaum, PhD, senior advisor for mental health services, epidemiology, and economics at National Institute of Mental Health.

Tracking patients’ experience over time allows researchers to improve outcomes. In heart surgery, there are similar systems for tracking patients’ outcomes even after they have left the hospital. “It struck us that we could, but generally don’t, do the same kinds of tracking for people with suicide risk,” Schoenbaum says.

Outcomes of all the people who come to EDs with suicide risk, overdose, intentional self-harm, or nonfatal intentional overdose are not really tracked in any consistent way. “We thought we should try to do that for suicide risk or overdose risk, and look at the patterns of survival after such ED visits, in essentially the same way that the cancer community and heart surgeons routinely track survival,” Schoenbaum says.5

Investigators found people who came to California EDs with deliberate self-harm or suicidal ideation recorded disproportionately high suicide rates. “In addition, they have a really high risk of dying from unintentional injury — accidents, including but not limited to accidental overdoses,” Schoenbaum reports.

This group also is more likely to die by homicide. Researchers found the same was true for those who visited an ED for unintentional overdose. “When we looked at what happened to those people, they had tremendously higher risk of dying in the next year by overdose, but also much higher risk of dying by accident not involving overdose,” Schoenbaum says.5 “It is clinically important to recognize these overlapping patterns.”

The goal in the ED is to stabilize the emergency. “It’s important that [patients] leave the hospital alive, but we want more for them than that. One marker of what more we want for them is: Are they still alive a year later?” Schoenbaum says.

There are evidence-based interventions, both within the ED and after discharge. “Encouragingly, some of those are things that don’t require an inpatient setting, and don’t even require a psychiatrist,” Schoenbaum says.

These include safety planning, which involves offering coping tactics, and is provided by clinical staff in the ED (e.g., a nurse or social worker).6 If patients with opioid use disorder visit EDs with a nonfatal overdose and receive medication during that initial encounter, they are much more likely to end up continuing the treatment.7

“That’s an evidence-based intervention that can be done. But somebody has to provide the infrastructure for that to happen in the ED,” Schoenbaum says.

For patients who visited an ED related to suicide risk, but are now back in the community, check-in texts or phone calls are another evidence-based intervention that can be handled by EDs. “We have a crisis. But we don’t have the tools to drive QI,” Schoenbaum says. “We need to figure out how to improve patient outcomes, and one way to do that is to start measuring outcomes.”

REFERENCES

  1. Tadros A, Sharon M, Crum M, et al. Coexistence of substance abuse among emergency department patients presenting with suicidal ideation. Biomed Res Int 2020;7460701.
  2. Ahmedani BK, Westphal J, Autio K, et al. Variation in patterns of health care before suicide: A population case-control study. Prev Med 2019;127:105796.
  3. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of suicide and other mortality with emergency department presentation. JAMA Netw Open 2019;2:e1917571.
  4. Enewold L, Parsons H, Zhao L, et al. Updated overview of the SEER-Medicare data: Enhanced content and applications. J Natl Cancer Inst Monogr 2020; 55:3-13.
  5. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Mortality following nonfatal opioid and sedative/hypnotic drug overdose. Am J Prev Med 2020;59:59-67.
  6. Stanley B, Brown GK, Currier GW, et al. Brief intervention and follow-up for suicidal patients with repeat emergency department visits enhances treatment engagement. Am J Public Health 2015;105:1570-1572.
  7. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA 2015;313:1636-1644.