Show Notes
Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry
Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department.
Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression?
Nachi: That would certainly be all of our listeners!
Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval?
Nachi: Again, just about all of our listeners I’m sure!
Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes?
Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in.
Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University.
Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside.
Jeff: Quite the team, from a variety of backgrounds.
Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt.
Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23%
Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode.
Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable.
Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions.
Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history.
Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest.
Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks.
Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning.
Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes.
Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD.
Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder.
Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself.
Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.”
Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt.
Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan.
Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%.
Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers...
Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients.
Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men.
Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older.
Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression.
Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide.
Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US.
Nachi: That’s an incredible amount and much more than I would have guessed.
Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals.
Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often.
Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods.
Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts
Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another.
Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study.
Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation.
Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality.
Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization.
Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations.
Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions.
Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations.
Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in...
