MDs Fail to Screen for Suicide Risk Factors in ED Setting

Caroline Cassels

May 20, 2015

TORONTO — Physicians, including psychiatrists, often fail to screen for known suicide risk factors in the emergency department (ED) setting, new research shows.

Investigators at Queen's University in Kingston, Ontario, Canada, found established suicide predictors including bullying, childhood trauma and suicidal plan and intent were not commonly assessed. Even though many of these predictors were deemed important by physicians they were missed in ED assessments.

"We looked at risk factors that are commonly missed in the ED department by psychiatrists and ED physicians. We all know that suicide is one of the most frequent mental health–related reason for ED visits. It is still very difficult or impossible for us to predict deaths by suicide," study coinvestigator Taras Reshetukah, MD, told reporters attending a press briefing here at the American Psychiatric Association (APA) 2015 Annual Meeting.

"The only tools we have are the actual tools in the clinical assessment. We wanted to know what physicians are using to establish that risk; what risk factors do they consider most important and what risk factors are most often missed," he added.

Difficult to Predict

It is estimated that more than 40,000 individuals in the United States die by suicide every year and that suicidal behavior is one of the most common reasons for ED visits. However, despite extensive research into the identification of suicide risk factors, the investigators note that completed suicide remains largely unpredictable with current tools and assessments.

Moreover, they note, "some suicide risk factors may not be included consistently in suicidal risk assessments in the ER [emergency department] by either emergency physicians or psychiatrists."

To better understand suicide risk predictors that are considered most important in clinical decision-making in the ED setting, Nazanin Alavi, MD, and colleagues conducted an online survey of all psychiatry and emergency physicians at a single center and compared results between the two physician groups.

They also conducted a chart review of all patients (n = 2080) with a mental health complaint between 2011 and 2013 to examine suicide predictors that were assessed and those that were missed. Among these patients, 672 had suicidal ideation/behavior and 307 received a psychiatry consult.

The suicide risk factors assessed in the ED were then compared with the results from the screening questionnaire.

Among 85 psychiatrists and psychiatry residents, 55 responded to the survey; among 62 ED attending/residents, 35 responded to the survey.

The two physician groups did not significantly differ with respect to suicide risk factor ranking.

On a 3-point scale (low to high risk), survey respondents ranked the importance of risk factors as follows:

  • Psychiatric disorders (including mood disorders, psychosis, and drug and alcohol use): 2.5/3

  • Stressors and lack of support: 2.7/3

  • Suicide plan, intent, suicide notes, previous attempt, severity of attempt, and not being future oriented: 2.9/3

However, the investigators found that despite recognizing the importance of these known suicide risk factors, physicians frequently did not screen for them.

In addition, said Dr Alavi, physicians did not routinely screen for a history of being bullied or abuse, both of which are important suicide risk factors.

On the basis of these findings, the researchers suggest a checklist that includes three categories — past and current psychiatric history, patient environment, and characteristics of suicidal behavior — each of which would include various suicide risk factors.

"We are hoping to implement our checklist in the emergency rooms. This way, physicians will gradually remember the risk factors they often miss by looking at the checklist whenever they are in the emergency room," Dr Alavi told Medscape Medical News.

However, Dr Alavi emphasized that such a checklist should be used only as a reminder and not be viewed as a replacement for a full clinical assessment.

Leading Cause of Death

Commenting on the findings Jeffrey Borenstein, MD, chair of the APA Council on Communications and president and CEO of the Brain and Behavior Research Institute, noted that suicide is the 10th leading cause of death in the United States and the second leading cause of death among young people, after accidents.

"More people die from suicide in our country than from homicide which is an extraordinary statistic…so it is an extremely important topic. The more we can do to identify those at risk and get them appropriate treatment the more lives we can save," said Dr Borenstein.

Dr Reshetukah, Dr Alavi, and Dr Borenstein disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2015 Annual Meeting. Abstract P5-086. Presented May 18, 2015.

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