A Study in Yellow

A Study in Yellow

In Brazil and many other countries around the world, we got used to know September as the suicide prevention month, represented by the yellow ribbon, with September 10th being the World Suicide Prevention Day. As said by Sherlock Holmes in “A Study in Scarlet,” “There is a scarlet thread of murder running through the colorless skein of life, and our duty is to unravel it, and isolate it, and expose every inch of it.” Despite the dramatic content of Holmes’s words, it is possible to draw a parallel with the current situation related to suicide in society. There is a visible red stain in front of us, and we need to unravel it, understand it, deal with it. Moreover, everything should start somewhere…

If we think about the role of the emergency department (ED) and the emergency physician in the suicide prevention and response, we will see that it is of indispensable importance, as many patients at risk of attempting suicide are sent to the ED in order to be evaluated and to stay in a “24h safe environment.” Also, many actual suicide attempts arrive at the ED requiring immediate care – for the patient and for the family. However, World Health Organization estimate that for every death by suicide, there are 20 suicide attempts, making us to questioning our capability to give extended care for those patients. Besides, if we look to the big picture, which has suicide one of the major preventable causes of death worldwide, we can ask ourselves how many patients with suicidal thoughts are seen at the ED every week due to other health problems and go unnoticed. The ED, along with the primary care in the communities, is the main entry door to the health care system and like no other, act as a nexus between outpatient and inpatient care. Gairin et al. have found that approximately 40% of people who died by suicide have visited an ED in the year before, one third of them because of self-harm injuries. (1) If we look to the last attendance before death, those who have presented with self-harm injuries presented less than two months before ending their lives.

With all of this in mind, what strategies we can use to assess suicidal thoughts and behavior at the ED? Which reliable tools are available for emergency physicians to recognize and classify these patients? Let’s take a look at the last American College of Emergency Physicians (ACEP) recommendations.



IDENTIFY suicide risk – actively ask about suicidal ideation.

  • Evidence shows that as many as 10% of suicidal patients may not disclose ideation unless asked (1) 
  • In the other hand, none of the standardized questionnaires and methods currently available have strong evidence supporting its use as a universal screening tool at the ED.
  • As there is no universally accepted standard reference for suicidal ideation, the sensitivity and specificity of these methods are unknown.
  • The authors’ conclusion is that suicidal ideation should be screened in the ED, as recommended for other authorities (2,3).


COMMUNICATE with the patient.

  • Actively ask maybe not enough when we talk about mental health problems with patients and make them feel comfortable is the first step to improve the communication 
  • The ED is not what we can call a “cozy” or “receptive” environment for most of the patients, so the authors recommend providers try to make it an emotionally-safe place, using methods to improve physical and mental comfort of the patient (i.e giving blankets if its cold, providing food, do not stigmatize)
  •  Ask open questions as “what’s that been like for you?” and be clear on what you are asking when necessary – prefer “are you thinking about ending your life?” over “are you gonna be ok?”.


ASSESS for (medical) life-threats and ensure (environmental) safety.

  • The authors did not find ED-based studies assessing this topic specifically, but a consensus emerges when we think on the best practice for this step of evaluation: A complete history, a good physical exam, mental status assessment and laboratory testing as needed.
  • Regarding the environment, besides the strategies commented before (communicate), the best practice and the common sense tell us to keep the environment as safe as possible and free any kind of weapons and other objects that could be used for self-harm (sharp objects, loose wires, medications, etc.).
  • Continuous monitoring should be done in all patients with suicidal ideation, as no ED-based studies are addressing whether all patients should be observed continuously or not.

RISK assessment

  • This step assumes that, regardless of how the patient was identified (first step), there is suspicion of potential suicide risk.
  • Even though there is no reliable and easy to use tool to predict which patients will try to commit suicide in the near future, there are lots of evidence establishing risk and protective factors for a suicide attempt. 
    • Risk factors: previous suicide attempt, access to lethal means, current impaired mental status or psychiatric illness (psychosis, depression, mood changes, anxiety crisis), substance abuse, external stressors such death of loved one, financial crisis, divorce.
    • Protective factors: family and friends support, established mental care, with patient’s good adhesion, cultural and/or spiritual beliefs
  • The authors do not recommend any specific risk assessment scale. The evidence for that comes from a meta-analysis from Carter et al.(4) that investigates the predictive validity of risk scales in determining the level of risk. According to the data from this study, the currently available tools have low accuracy, so the authors recommend not to use one scale alone to determine if the patient can be discharged home or not.
  • With this in mind, the recommendation is that all patients identified as being at potential risk of attempt suicide should go under one standardized tool for risk assessment, using this as a complementary tool, along with mental status examination, history taking and evaluation of risk and protective factors.

Some scales and risk assessment tools to know

  1. Columbia Protocol – link
  2. Patient Safety Screener and Tip Sheet (PSS-3) – link
  3. Secondary screener from ED-SAFE – link

REDUCE the risk

  • Safety Planning Intervention is a collaborative process in which patient and provider develop a plan on what to do if the symptoms worsen. It usually involves contact with trusted individuals, lethal means counseling, hotlines, and local resources in the community. 
  • The adherence of ED on this practice is very low, although some evidence shows that safety planning could reduce future suicide attempts (5).
  • Hospitalization is a complicated topic in this scenario. As seen on recommendations above, it is difficult to formally classify a patient as a “high-risk” for suicide in the near future. Knowing that the authors recommend hospitalization for those patients who “felt to be likely to attempt suicide after the discharge,” and voluntary admission should be preferred over involuntary.

EXTENDED CARE beyond the ED visit

  • There is good evidence that follow-up contact after the ED can help reduce the risk of subsequent suicidal behaviors.
  • The follow-up contact can be made by letters, phone calls, postcards and even in-person visits.
  • Of course, a follow-up with a mental health professional is key to good care of these patients.

How about us?

Despite all the fame and social prestige traditionally linked to doctors, it is well documented that physicians, residents and medical students experience one of the highest rates of depression and suicidal behaviors among all professions. More than that, physicians can have a risk of suicide from twice to even six times higher than the general population depending on the country (6,7). And it starts early: almost 50% of medical students experience burnout before residency (8). High rates of depression, sleep deprivation, substance abuse, stressful work environment, burnout, easy access to and wide knowledge of lethal means, all of these contribute to killing our colleagues, professors, students, and friends. Four hundred physicians per year in the US (6,7) – more than once per day. Speaking specifically of emergency physicians and residents, the specialty had always reached the top 5 in the burnout rankings (8) and less than one third will seek for help, according to a Medscape survey. We have been trained to save lives, but sometimes we also need to be saved – from ourselves.

If you are in crisis, experiencing burnout symptoms, feeling sad or suicidal, or know a friend who is, please seek for help as soon as you can.

Further Readings


  1. Gairin, I., House, A., & Owens, D. (2003). Attendance at the accident and emergency department in the year before suicide: Retrospective study. British Journal of Psychiatry, 183(01), 28–33. doi:10.1192/bjp.183.1.28
  2. Suicide Prevention Resource Center. Caring for adult patients with suicide risk: A consensus guide for emergency departments. 2015; http://www.sprc.org/sites/default/files/EDGuide_full.pdf. Accessed May 30, 2018.
  3. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;56:1-7.
  4. Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387-395.
  5. Miller IW, Camargo CA, Jr., Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570.
  6. Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med. 2019;20(3):485–494. doi:10.5811/westjem.2019.4.40970
  7. Kishore S, Dandurand DE, Mathew A, et al. Breaking the culture of silence on physician suicide. National Academy of Medicine. 2016. Available at: https://nam.edu/breaking-the-culture-of-silence-on-physician-suicide/Accessed March 15, 2019.
  8. Burnout in medical students before residency: A systematic review and meta-analysis Frajerman, Ariel et al. European Psychiatry, Volume 55, 36 – 42
Cite this article as: Arthur Martins, Brasil, "A Study in Yellow," in International Emergency Medicine Education Project, September 30, 2019, https://iem-student.org/2019/09/30/a-study-in-yellow/, date accessed: June 6, 2023

One thought on “A Study in Yellow

  1. Arthur: this is a great summary of the ICAR2E tool! Thanks for covering such an important topic.

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