Katharine Gammon

October 28, 2013

A new protocol tries to solve the problem of undetected suicide risk when patients present to the emergency department.

"Suicide risk can be missed because it can be disguised by things like an accidental poisoning, a fall, or a vehicle accident, which we don't normally associate with suicide risk," said study author Joanne Matthews, DNP, APRN, PMHCNS-BC, BN, MHS, who is a clinical nurse specialist at the University of Kentucky in Lexington.

"Professionals who are really caring and competent in every other way can be afraid to ask whether a patient is suicidal," she told Medscape Medical News.

In 2010, there were more than 38,000 suicide deaths in the United States. Emergency departments care for more than 300,000 patients annually with problems related to suicide attempts, according to the US Centers for Disease Control and Prevention. In addition, more than 10% of emergency department patients have undetected suicidal ideation, Matthews reported.

To improve suicide assessment, Matthews created a protocol that is brief, easy to use, reliable, and effective.

She presented her research at the American Psychiatric Nurses Association (APNA) 27th Annual Conference in San Antonio, Texas.

The protocol starts with 2 questions:

  • In the past week, including today, have you felt like life is not worth living?

  • In the past week, including today, have you wanted to kill yourself?

If the answer to either question is no, no further assessment is needed.

If the answer to either is yes, a nurse would administer the SAD PERSONS scale and the patient would be assessed for a 72-hour hold.

Two follow-up questions are then asked:

  • Have you ever tried to kill yourself?

  • In the past week, including today, have you made plans to kill yourself?

The answers to those questions can identify a patient as being at high or imminent risk, and interventions can then be implemented.

Matthews also looked at why nurses do not ask about possible suicide attempts.

"Some nurses feel they don't have enough information, so they don't feel comfortable doing suicide assessment," she explained. "Nursing attitudes are also important — younger people, those with higher levels of education, and religious people seem to be more open to identifying suicide risk."

Nurses are on the frontlines and are among the most valuable assets in screening for suicide in the medical setting, explained Lisa Horowitz, PhD, MPH, a pediatric psychologist at the National Institute of Mental Health in Bethesda, Maryland, who was not involved in the research.

However, she warned against a single approach.

"A one-size-fits-all approach for adults and youth will most likely not be feasible or effective," she told Medscape Medical News.

Recent studies have shown that the majority of individuals who kill themselves visited a healthcare provider in the months prior to their death, Dr. Horowitz noted.

"The clinical challenge is that these people do not walk into their doctor's office and say, 'I want to kill myself.' Rather, they frequently present with somatic complaints, like headaches or stomachaches, and may not talk about their suicidal thoughts unless the doctor or nurse asks them directly," she explained.

"They pass through the healthcare system undetected because their chief complaint may be medical in nature, and the clinician has limited time and perhaps limited training in mental health and might not recognize the suicide risk. Clinicians must ask directly about suicidal thoughts and behaviors," Dr. Horowitz advised.

Joanne Matthews and Dr. Horowitz have disclosed no relevant financial relationships.

American Psychiatric Nurses Association (APNA) 27th Annual Conference: Abstract 2026. Presented October 10, 2013.


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