Self-harm in the Emergency Department: A Cry for Help, a Call to Arms
How’s this for a practice gap? It’s estimated that 1 in 10 suicide victims are people seen in the emergency department within 2 months of dying. Suicide is an issue of public health, which, in today’s medical system, is often the domain of the emergency physician (EP).
Practically speaking, the questions useful for the emergency physician are: Which patients are at risk of suicide? Who stays, and who goes home? And in a broader sense, what can an emergency physician do to prevent successful suicide?
—J. Stephan Stapczynski, MD, Editor
You are working a typical shift: Three patients have not been seen, the waiting room has four patients to be brought back, and you are just talking with a new patient when the triage nurse comes to you about a middle-aged patient whom she is seeing. The patient came by bus because she was feeling depressed and had thoughts of not living anymore. She has a history of depression and was under treatment, but has been out of work, out of medical insurance, and out of medications for over six months. Now that she is in the ED, she feels embarrassed and knows the wait will be a few hours, so she wants to leave. The triage nurse is asking what she should do. And you say?
The definition of self-harm is multi-faceted. In the emergency department (ED), an important distinction is between self-harm with and without intent to die.
The American Psychiatric Association (APA) offers a basic classification of terms.1 Suicidal ideation involves thoughts of serving as the agent of one’s own death, and it may vary in gravity depending on the specificity of suicide plans and the degree of suicidal intent. The lethality of suicidal behavior is the objective danger to life associated with a suicide method or action as determined by the physician and is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous. For example, a patient may believe that swallowing a handful of Tylenol is no more lethal than ingesting a tube of toothpaste. Suicidal intent is subjective expectation and desire for a self-destructive act to end in death. Suicide, itself, is defined as self-inflicted death with evidence (either explicit or implicit) that the person intended to die, while a suicide attempt is self-injurious behavior with a nonfatal outcome, accompanied by evidence (either explicit or implicit) that the person intended to die. An aborted suicide attempt implies that the person intended to die but stopped the attempt before physical damage occurred. In contrast, deliberate self-harm is willful self-inflicting of painful, destructive, or injurious acts without intent to die.
Circumstances vary among patients who present to the ED with evidence of self-harm. Some are seemingly trivial acts that mask serious, underlying suicidal intent. Others are dramatic gestures intended to garner secondary gain. In general, these self-destructive behaviors exist along a continuum, and emergency providers should take all patients seriously.
At first glance, it may seem callous to consider a topic such as suicide in a mathematical and scientific manner. But the numbers help to show the significance of the problems. More than 33,000 Americans age 10 years or older die by suicide each year, making it the eleventh leading cause of death and fifth leading cause of years of potential life lost before age 65.2 Data from 2008 show that an estimated 8.3 million Americans had serious thoughts of suicide, and 900,000 made suicide plans and attempts.3 (See Table 1.) Anywhere from 395,000 to 535,000 people with self-inflicted injuries are treated in emergency departments every year,2,4 and the emergency department is the most common service used by people who harm themselves.2,4 Clearly, the scope of this problem is immense.
Data from the CDC indicates that suicide rates were gradually decreasing in the 1990s, but have since leveled off and are actually increasing among females. And while the rate of suicide is almost four times higher in males,2 some data suggest that females are more likely to think about, plan, and attempt suicide.3
Classically, older age has been associated with increased suicide risk, but recent trends show that, in both men and women older than 65, suicide rates have dropped dramatically. At the same time, rates have risen in people 25-64 years old, which now is the age group with the highest suicide rate.2 Women between the ages of 25 and 64 appear to have the sharpest increase in rate of suicide.2 And while people younger than age 25 have the lowest rates, suicide ranks as the third leading cause of death in people 10-24 years old.2
Males are more likely to use a firearm, while females resort to poisoning as their primary means. However, this trend varies by age, with people 10-24 more likely to die by suffocation and older people (especially men older than 65) more likely to use a firearm.2The relative fatality of these methods has also been compared. Firearms and suffocation tend to be more fatal than poisoning or cutting. Falling is not a common method, but it tends to be relatively fatal. Case fatality is higher among males. It is important to consider the potential lethality of these processes when patients in the ED propose suicide plans.
Geographic location and ethnicity factor into suicide risk, as well. High-risk areas include the western and northwestern states, as well as the central part of the Midwest and certain parts of Florida and Michigan. Native Americans/Alaskans and Caucasians are almost three times as likely to commit suicide as people of other races.2
While age, sex, race, means of self-harm, and geographic location are all important in determining a patient’s suicide risk, perhaps most relevant is the CDC’s data regarding circumstances surrounding those who have committed suicide. Almost half (43.6%) of suicide victims had depressed mood at the time of their death, while 41.9 % had concurrent mental illness (twice as common in females). Female victims also were twice as likely to have had previous attempts. About one-third of victims had intimate partner problems, either left a suicide note or otherwise let their intent be known, or experienced crisis within the preceding 2 weeks. When patients present with self-injurious behavior or intent, determine whether these circumstances exist. These data can be used both to identify risk factors and protective factors and to differentiate patients who warrant intervention from those who can be sent home.
Suicide victims may or may not leave a note explaining why they committed the act. In fact, people have many reasons for thinking about and committing acts of self-harm. Usually, they are depressed individuals who are overwhelmed by feelings of hopelessness, guilt, or self-loathing. Some are seeking refuge from chronic pain or terminal illness, while others may have a mental illness that causes them to commit such acts. Often, suicide is attempted due to intense feelings of anger and can lead to murder-suicide, coinciding sex crimes, and other violent behavior. Chronic loneliness during childhood and history of sexual molestation are thought to lead to suicidal behavior later in life. Medications, like reserpine, benzodiazepines, barbiturates, and even some antidepressants, have been implicated, as well. During the past several years, the FDA has issued a series of warnings concerning the potential of various medications to lead to thoughts of suicide. (See Table 2.) The magnitude of this effect and its consequences have been debated by the various experts. The risk appears higher in children, adolescents, and adults younger than 24 years. The practical implications of the FDA warnings are that patients should be informed of this potential when started on these medications. Whatever the reason, it’s thought that most people who think about suicide also maintain some sort of desire to live, which may be what brings them to the ED.5
For the EP, it is important to view the causes of suicidal behavior in terms of risk factors. (See Table 3.) The CDC has summarized the risk factors as follows:
• family history of suicide
• family history of child maltreatment
• previous suicide attempt(s)
• history of mental disorders, particularly depression
• history of alcohol and substance abuse
• feelings of hopelessness
• impulsive or aggressive tendencies
• cultural and religious beliefs (e.g., belief that suicide is a noble resolution of a personal dilemma)
• local epidemics of suicide
• isolation, a feeling of being cut off from other people
• barriers to accessing mental health treatment
• loss (relational, social, work, or financial)
• physical illness
• easy access to lethal methods
• unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts.
These lists of risk factors do little to help the clinician with risk assessment, especially in a fast-paced environment like the ED, so attempts have been made to weigh the relative importance of these risk factors. The Suicide Resource Prevention Center (SRPC) has compiled “A Guide for ED Evaluation and Triage.” This guide points out “signs of acute suicide risk,” which include talking about suicide/thoughts of suicide, seeking lethal means to kill oneself, seeing no reason to live, anxiety/agitation, insomnia, substance abuse, hopelessness, social withdrawal, anger, recklessness, mood changes, previous attempt, triggering event (loss of relationship or job), and access to firearms. Among psychiatrists, the factors listed below have been touted as fundamental to risk assessment.6
Evidence suggests that more than 90% of suicide victims have a DSM-IV diagnosis, such as major depression, bipolar depression, schizophrenia, alcohol or drug abuse, post-traumatic stress disorder, anxiety disorder, bulimia or anorexia nervosa, or personality disorder (especially borderline or antisocial).7-9 Of these, mood disorders are most common. Patients with major depression are 20 times more likely to commit suicide than those without depression, and 15-20% do commit suicide, with hopelessness being the most ominous symptom.10-16 People with schizophrenia are almost 10 times more likely to commit suicide than those without the condition, and while providers should be wary of command hallucinations, suicide in these patients is more likely due to negative symptoms, such as hopelessness.17-21Personality disorders are present in 40% of suicide victims.12 And while many psychiatric disorders increase the odds of having thoughts of suicide, recent evidence suggests that, after controlling for mental illness, only disorders characterized by anxiety and poor impulse-control predict which people act on their thoughts.22,23 Physicians should consider suicidal behavior in any patient with a psychiatric diagnosis to be a red flag.
Alcohol has been shown to increase the risk of suicide at least six-fold, especially when consumed in large amounts, while use of other drugs increases suicide risk to a lesser extent.24-28 While it may be difficult to screen every alcohol and drug abuser who walks through the door, think about suicide in these patients, particularly if mechanism of injury suggests self-harm.
It also is important to take note of certain historical points. Patients often mention a recent stressor or precipitant event, such as family turmoil or instability, health problems, loss of a relationship, or loss of money or employment.29 Higher suicide rates have been observed in those who are unemployed and underprivileged.30 These stressors may bring them to their primary care doctor,31 or, if they cannot afford insurance, to the EP. Some of the highest-risk patients live alone, are socially outcast or isolated, or otherwise lack social support.32,33 This may explain why widowed, divorced, and single people are at higher risk to commit suicide,34 so be particularly wary of the recently widowed or divorced. Identifying and treating patients with recent stressful events is critical because self-harm often is brought on by a reversible short-term crisis.5
Remember to ask about past suicide attempts. Be concerned if the patient’s current situation mimics one in which a serious attempt was made. Some literature suggests that a history of multiple attempts places patients at higher risk, with added risk if the patient also has a suicide plan.35,36 Patients with a plan are more of a risk to complete suicide,13 so talk in detail with patients about the frequency, severity, and depth of their suicidal thoughts, as well as whether they have access to a weapon or other means. Ask where they have the weapon and whether they’ve taken it out or moved it recently.
And while most of the literature focuses on risk factors, there are protective factors, as well. The APA gives a list of these factors. The CDC offers a summary of these protective factors (see Table 4):
• Effective clinical care for mental, physical, and substance abuse disorders;
• Easy access to a variety of clinical interventions and support for help seeking;
• Family and community support (connectedness);
• Support from ongoing medical and mental health care relationships;
• Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes;
• Cultural and religious beliefs that discourage suicide and support instincts for self-preservation.
The psychiatry literature has acknowledged a handful of these as being most important. There is even a “Reasons for Living Inventory,” to be filled out by the patient, which has been created to help spot protective factors.37 Just as poor social support is a risk factor, good social support is protective, no matter who provides it.38 Many patients draw on religious belief for support, which has been shown to be a protective factor, with Catholics, Jews, and Protestants having the lowest suicide rates39; however, strength of belief is more protective than one’s specific religion.40 In addition to gauging the extent of support systems, try to estimate patients’ sense of duty to their families. This is particularly important in female patients, as presence and number of children decrease risk of suicide in women.41 People may mention they were on the brink of suicide but came to the ED after thinking about their children. Above all, ask patients about their reasons for living.
Just as there are many different potential causes of suicidal behavior, there are many ways that patients can present to the emergency department. Some simply will tell their doctor that they want to die. Others will come to the ED at around 11 p.m. on a Friday night, with knee pain and a normal exam, and maybe a flat affect.
Recognition of suicide potential depends on the type of patient who presents. It often helps to place patients in categories, be it depressed, elderly, male alcoholics, or teenagers with borderline personalities and fresh cut marks down their arms. Naturally, discussion of clinical features overlaps with talk about risk factors. The manner in which the patient presents also impacts clinical judgment. Patients presenting after an attempt or with clear suicidal ideation are considered differently from those with less obvious clinical pictures.
Unfortunately, there can be fundamental flaws in the way physicians approach patients who self-harm. Often, clinicians do one of two things. Either they “are overly cautious and assume that anyone who reports suicidal thoughts is at high risk for suicide,” or they “underestimate suicidality through a dismissive attitude or inept assessment.” The former “leads to unnecessary deprivation of patients’ liberties and rights as well as to the squandering of scarce clinical resources,” while the latter jeopardizes “patient safety and increase[s] physician liability should there be a negative outcome.”6,42 Because suicide risk factors often have poor predictive value, and an ED visit is a mere snapshot of the overall clinical picture, the EP should err on the side of caution. If there is any doubt regarding patient safety, strongly consider admission and psychiatric consultation.
Assessing suicide potential can be easy in someone who has just made an attempt or who complains about depression and is clear about his or her intent. Other scenarios can mask suicide risk. Silent suicide occurs in patients who are “noncompliant” with treatment of their medical conditions. Think of the AIDS patient who does not take his or her medication, or more subtly, the patient with type 2 diabetes with poor glycemic control. Occult suicide occurs when injury, like a gunshot wound or fall from a height, occurs “by accident.” And even if suicide gesture or intent is not obvious, address the potential for self-harm in all patients with chronic alcoholism, substance abuse, psychiatric disorder, and chronic illness.5
In patients who present after an attempt or with clear suicidal intent, start with a medical evaluation and treat accordingly. Ask the patient for specific details regarding the act. Patients may give an inconsistent or inaccurate history and sometimes refuse to speak, so question family members, friends, police, paramedics, and anyone else who may have information. The “Uses and Disclosures to Avert a Serious Threat to Health or Safety” exception to the Health Insurance Portability and Accountability Act (HIPAA) lets physicians disclose protected health information to these individuals “based on reasonable belief that use or disclosure of the protected health information was necessary to prevent or lessen a serious and imminent threat to health or safety of an individual or of the public.”5
Initially, the history and physical examination should focus on the possibility of drug ingestion, trauma, and sequelae of associated illness. Take note of toxidromes. Examine the patient’s ABCs, vital signs, mental status, pupils, and perform an appropriate neurologic exam. If altered mental status exists, attempt to determine whether the cause is functional or organic. Because a medical etiology goes unnoticed in up to 50% of acute psychiatric presentations,43 a careful history and examination are important.5
Further history should focus on risk factors. Unfortunately, many Emergency Nurses and physicians have poor suicide risk assessment skills, and there is no single, standard screening instrument for this purpose.44,45 The modified SAD PERSONS scale is widely used by EPs to evaluate key historical elements.5,46,47 (See Table 5.) Its use has enabled non-psychiatric medical staff to identify patients in need of specialist evaluation.48 Some EDs use this mnemonic to risk stratify patients in triage. With this approach, the training of triage nurses in risk assessment is imperative.49 Education of nurses improves attitude, confidence, competence, and reasoning skills when interacting with self injurers, and several cost-effective education programs have been implemented.44,50-52 Whether via SAD PERSONS or some other risk-assessment tool, the process of gauging suicide risk should begin in triage, and involved emergency personnel should be trained appropriately.
When it comes to risk stratifying patients, practitioners place more weight on some risk factors than others. The quality of risk assessment by EPs often is questioned and deemed inadequate.53-57 More recently, though, data suggest that most EPs do use key risk factors to direct their assessment. As would be expected, EPs perceive immediate risk factors, like lethality of method and active desire to die, as most critical. This is logical given the focus placed in the ED on immediate management of life threats. Most EPs give less consideration to background risk factors, such as psychiatric history and social situation. While this may be in line with current practice, to ensure the highest level of care, consider background risk factors when assessing patients who present with deliberate self-harm.58
Aside from asking about a suicide plan, previous attempts, access to a weapon, current thoughts of suicide, and some of the other issues already discussed, it is important to ask about the patient’s attitude about surviving the attempt. Determine if the patient is sad or surprised to have survived. If the patient has taken precautions against being discovered or is found accidentally, it implies a failed serious attempt, so view this as a harbinger of continued self-injurious behavior. In general, attempts with lower likelihood of survival confer higher suicide risk, and vice versa.
People at high risk for self-harm who do not present with obvious suicidality warrant a slightly different approach. The first step is to use a sympathetic, nonjudgmental demeanor to establish a relationship with the patient. Direct questioning is necessary, but not until after a level of comfort is reached between patient and physician. Begin by evaluating the presenting complaint and pertinent history. After building rapport and getting a feel for the patient’s medical, psychiatric, and social history, move on to more specific questions about depression and suicidal thoughts. Asking patients about suicide, contrary to rumor, does not appear to plant the thought in their heads. If they are at risk for self-harm, odds are they have had suicidal thoughts for a long time.5
Empathy may seem like an obvious priority, but attitudes toward self-harm in the ED vary among staff. Doctors, nurses, and other personnel often harbor negative attitudes about patients who self-harm, potentially compromising their care. In a fast-paced environment like the ED, with a focus on the critically ill, these patients are sometimes viewed as a drain on the system and a waste of resources. For many physicians, it is counterintuitive and frustrating to treat someone who, at least outwardly, does not want to be treated or saved. Yet, a physician trained in emergency medicine should excel at dealing with this sort of paradox. It seems that the stigma attached to suicide is fading and health care workers are realizing that an open, sympathetic approach is needed. Negative attitudes can be avoided by ensuring that all ED staff have proper training in management of patients with self-injurious behavior.44,59-70 View every patient who presents to the ED with self-harm as one who is there for help.
In cases of suicidality, there is no specific diagnostic test that can be used to risk stratify patients. Usually, in the case of self-harm, the diagnosis is clear, and diagnostic testing centers around the mechanism of injury. If the patient attempted hanging, then a CT angiogram of the neck may be necessary. Patients who have jumped from a height should receive a trauma evaluation. For toxic ingestion, the work-up should focus on the substance ingested as well as possible co-ingestants. Urine drug screen, serum alcohol, salicylate, and acetaminophen levels are usually a good idea, and most ingestions deserve an ECG (particularly if tricyclic antidepressant overdose is suspected). However, routine toxicologic screening is unnecessary for most patients with suicidal ideation. Toxic ingestions usually manifest with clinical signs. Some presentations do not warrant any testing, but psychiatric facilities accepting patients often require screening laboratory tests prior to transfer. Other than building trust between ED staff and accepting psychiatric consultants, there is little that can be done about this. In general, order the laboratory tests required for transfer.5,71,72