We have covered numerous critical topics in the Ped EM Morsels over the past numerous years. Many are quite attention grabbing (ex, Tonsillectomy Hemorrhage, Delayed Sequence Intubation, and Submersion Injuries, and Lawn Mower Injuries), but that does not diminish the importance of other less flashy topics.  In fact, the vast majority of what we do in the Emergency Department is not heroic or flashy.  We also need to appreciate the opportunity that we have to help prevent injuries by remaining perceptive, receptive and vigilant.  One area that deserves special attention is Suicide Risk.

Suicide Risk Deserves Our Attention

• Suicide is the 3rd leading cause of death in the USA for people 10-24 years. [Heron, 2013]
• Suicide is the leading cause of death from intentional injury. [Heron, 2013]
• Suicide affects young people from ALL races and socioeconomic groups. [Shain, 2007]

Suicide Risk Factors

• Fixed Risk Factors
  • Family history of suicide or suicide attempts
  • Male gender
  • Parental mental health problems
  • Homosexual
  • History of physical or sexual abuse
  • Previous suicide attempt
• Environmental/Social Risk Factors
  • Presence of firearms in the home
  • Poor child-parent relationship
  • Homeless
  • Neither working nor attending school
  • Social isolation
  • Presence of stressful life event
• Predisposing Mental Health Issues
  • Depression, Bipolar, Panic attacks
  • Posttraumatic Stress Disorder
  • Aggression, Impulsivity, Severe Anger

Suicidal Thoughts Don’t Have to Look Sad

• We are all aware of the need to be concerned about suicidal ideation in those who present with complaints consistent with depression…
• But, patients may also present with somatic complaints: [Shain, 2007]
  • Abdominal pain
  • Dizziness
  • Syncope
  • Headache
  • Chest Pain
  • Weight Loss
• One study found ~5% of patients presenting with non-psychiatric complaints had significant suicidal ideation. [Horowitz, 2010]
• So, this requires that we are actively considering the possibility of important non-organic causes… and not just happy to say that “it isn’t appendicitis.”

Suicidal Risk Screening

• Screening patients without psychiatric complaints has been shown to be feasible in the ED. [Horowitz, 2010]
• There are several tools available:
  • HEADS-ED [Cappelli, 2012]
    • Home, Education, Activities, Drugs, Emotions, Discharge resources
  • Risk of Suicide Questionnaire (RSQ) [Horowitz, 2001, Ballard, 2013]
    • 4 questions:
      • Are you here today because you tried to hurt yourself?
      • In the past week, have you been having thoughts about killing yourself?
      • Have you ever tried to hurt yourself in the past (other than this time)?
      • Has something very stressful happened to you in the past few weeks (a situation very hard to handle?
    • Has been validated. [Ballard, 2013]
    • A positive response to one or more of the questions constitutes a positive screen and warrants further exploration.
  • Remember that while confidentiality is important, safety takes precedence over confidentiality. Be clear about this with the patient. [Shain, 2007]

Moral of the Morsel

• Suicide is a public health problem for which we must remain vigilant.
• Not ever patient who needs your help will present with obvious depressive symptoms – consider somatic complaints also.
• Routinely ask parents/guardians to leave the room while you finish your sensitive questions with your adolescent patients.
• Utilize a screening tool (ex, RSQ).

References

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