You Have A New Patient!
A 19-year-old male was brought to the emergency room (ER) by his family with the assistance of an ambulance. The patient was discovered unconscious in his car, surrounded by leftover pills of an unknown medication. Upon arrival at the ER, he was assessed by the medical team and found to have regained consciousness, with a Glasgow Coma Scale (GCS) score of 12 and stable vital signs.
Introduction
Suicide is one of the top ten causes of death worldwide, with increasing rates of occurrence and mortality observed across various countries and patient populations in recent years [1]. It is the second most common cause of death among individuals aged 10-14 and 20-34 years [1]. Suicide is defined as “an act with a fatal outcome, that is deliberately initiated and performed by the person in knowledge or expectation of its fatal outcome.”
Durkheim classifies suicide into four types: egoistic suicide, altruistic suicide, anomic suicide, and fatalistic suicide [2]. The act of suicide can be completed using various methods, with risks influenced by factors such as gender, age, family history of suicide, comorbid mental and physical disorders, and social and psychological stressors (e.g., poor financial stability, unemployment, divorce, isolation).
It is well established that females have higher rates of suicide attempts, while males have higher rates of completed suicide. The most common method of suicide among men is hanging, whereas women most often use drug overdose as a method of suicide [3,4].
Notable psychiatric risk factors predisposing individuals to suicide include depressive disorders, alcohol dependence or abuse, schizophrenic disorders, and personality disorders. Medical risk factors include chronic physical illnesses and epilepsy. Despite advancements in suicide prevention, the most significant risk factor remains a past history of suicide attempts or deliberate self-harm [5].
General Approach
When approaching a patient with suicidal thoughts or behaviors, it is essential to provide empathetic and patient-centered care to ensure their safety and well-being. Key steps include implementing safety precautions, such as placing the patient in a private, secure environment without access to dangerous objects and ensuring continuous observation or restraints when necessary [6]. A focused medical assessment should be conducted, emphasizing the evaluation of cognitive and emotional status, drug ingestion, or other medical conditions that may influence the patient’s mental state. This targeted approach is preferable to routine “medical clearance,” as it avoids the misconception that standard diagnostic testing is always required [6,7].
In cases of an active suicidal attempt, immediate stabilization is paramount, with a focus on addressing any abnormalities in airway, breathing, or circulation. Initial interventions include checking vital signs, obtaining a rapid blood glucose level, initiating cardiac monitoring and pulse oximetry, and establishing IV access. Oxygen administration and IV fluids may also be warranted depending on the patient’s condition [7]. Physical signs such as pupillary changes (indicating drug intoxication), altered consciousness (assessed by the Glasgow Coma Scale), respiratory distress or depression, and self-harm injuries should be carefully evaluated [2]. Comprehensive vital assessments, laboratory investigations (e.g., electrolytes, liver and renal function tests), and ECGs may provide further insight into the patient’s medical condition and guide interventions.
The cornerstone of management is a comprehensive suicide risk assessment, which involves evaluating the patient’s personal and psychiatric history, current mental state, and specific suicidal thoughts or behaviors. This assessment should explore the presence of a suicide plan, prior attempts, mental illness, substance abuse, and agitation. For low-risk patients, management by the emergency department provider and discharge home may be appropriate. However, most patients require a thorough risk evaluation, which can be aided by tools like the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) if mental health specialists are unavailable [6]. Establishing rapport with the patient through a sympathetic yet direct approach is crucial for obtaining reliable information, including details about suicidal ideation, and collateral sources such as family or friends can provide additional context [6].
Once medically stabilized, a mental status examination is necessary to evaluate the patient’s affect, attention, orientation, memory, and behavior, with particular attention to changes in cognition and alertness [7]. If the patient is deemed to pose a high risk of harm to themselves or others, inpatient admission is often warranted to provide intensive monitoring and care. Conversely, if the patient demonstrates insight, judgment, and stability, outpatient follow-up with close monitoring may suffice. Obtaining collateral history from family or other reliable sources is a critical component of the psychiatric evaluation, providing context for the patient’s condition and ensuring a comprehensive risk assessment. It is essential to remember that asking about suicidal thoughts does not incite suicidal behavior, and most suicidal crises are transient, underscoring the importance of timely and appropriate intervention [6].
Physical Examination
A thorough physical examination is an essential component of evaluating patients with psychiatric complaints and should be conducted with the same diligence as in patients presenting with medical conditions. Along with the patient’s history and mental status examination (MSE), the physical exam helps to distinguish between functional (psychiatric) and organic (medical) causes of the symptoms. A complete and systematic approach ensures that critical diagnoses are not missed, as studies have highlighted that incomplete evaluations often result in missed medical conditions and potentially dangerous outcomes [7].
Key Aspects of the Physical Examination
The general appearance of the patient should be carefully observed for signs of anxiety, distress, or other physical manifestations of their condition. For example, in one case study, the patient appeared anxious, which provided an important clue to their mental and physical state [7].
Vital signs are a critical starting point. These include heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature. Abnormalities in vital signs should be promptly evaluated and managed. However, studies indicate that vital signs are not consistently documented, with complete sets recorded in only 52% of cases. This underscores the importance of thorough documentation during assessments [7].
The cardiovascular examination involves assessing the pulse for rate and regularity. For instance, in a referenced case, the patient presented with an irregular pulse, which necessitated further evaluation with an electrocardiogram (EKG) to assess for potential arrhythmias [7].
In the respiratory system, clinicians should observe the patient for signs of tachypnea or respiratory distress and auscultate the lungs for abnormal sounds like crackles. In the same case study, the patient exhibited tachypnea and crackles at the lung bases, prompting the need for a chest x-ray to investigate potential causes such as pneumonia or heart failure [7].
The extremities should be examined for signs of edema or dryness, as these can provide clues about systemic or localized medical conditions. Similarly, the abdomen should be assessed for tenderness and abnormalities, ensuring it is soft and non-tender [7].
The neurological examination plays a pivotal role in identifying focal deficits, meningeal signs, or changes in alertness, cognition, and behavior. Basic neurological assessments can provide insight into potential underlying causes of psychiatric complaints, such as an organic brain disorder [7].
Skin and hair changes should also be noted, as they may indicate systemic illnesses. Additionally, other physical complaints such as cough, fever, heat intolerance, headache, neck pain, or stiffness should be carefully documented and investigated [7].
Integrating Findings with Further Testing
The findings from the physical exam, combined with the history and MSE, should guide laboratory investigations and imaging studies. For example, abnormal vital signs may warrant blood tests or imaging such as chest x-rays or EKGs. Missed diagnoses often stem from inadequate physical evaluations, reinforcing the need for comprehensive assessments to ensure patient safety and optimal outcomes.
Risk Assessment
Through History
During the history-taking component of the assessment, the most critical indicator of high suicide risk is a direct statement indicating intent for suicide. Research shows that many patients verbalize their suicidal intent to close contacts prior to an attempt and may have also visited their general practitioner or psychiatrist before the suicide attempt. History-taking should incorporate questions addressing potential risk factors for suicide, such as:
- Previous history of suicide attempts
- Marked hopelessness
- Social isolation
- Depressive disorder
- Alcohol dependence
- Current death wishes
- Current suicidal intent
- Auditory hallucinations of a commanding or derogatory nature
The SAD PERSONS mnemonic is a helpful tool in assessing suicidality in patients by highlighting common risk factors that can be identified during history-taking [8].
| Risk Factor | Description |
|---|---|
| Sex | Male gender has an increased risk of suicide |
| Age | Age <19 or >45 years |
| Depression | Including bipolar depression |
| Previous Attempt | Previous suicide attempt |
| Excess Alcohol | Alcohol or substance use |
| Rational Thinking Loss | Poor judgment in different situations |
| Social Support | Lacks social support |
| Organized Plan | Use of death notes or wills |
| No Partner | Unmarried, divorced |
| Sickness or Stress | Chronic illnesses or stressful life events |
The SAD PERSONS scale, widely used for assessing suicide risk, categorizes individuals into three risk levels based on cumulative scores: low risk (0–4 points), moderate risk (5–6 points), and high risk (7–10 points). Despite its popularity, the scale has faced significant criticism regarding its clinical utility. A key concern is its low sensitivity. Another major critique is its oversimplification of complex individual risk factors. The scale’s binary scoring system may overlook the nuanced aspects of a patient’s mental health, potentially leading to inadequate risk assessment.
Given these limitations, clinicians are encouraged to consider alternative or supplementary assessment instruments:
- Columbia-Suicide Severity Rating Scale (C-SSRS): This tool evaluates the severity of suicidal ideation and behavior, offering a more nuanced risk assessment.
- Beck Scale for Suicide Ideation (BSI): A widely used instrument that assesses the intensity of an individual’s suicidal intentions.
- Suicide Behaviors Questionnaire-Revised (SBQ-R): A self-report measure that evaluates various dimensions of suicidality, including ideation, attempts, and future risk.
Continuous assessment during initial presentations, inpatient or outpatient encounters, and post-discharge follow-ups is essential to ensure the long-term safety of patients at risk for suicide. It is noteworthy that the first two weeks of inpatient stay and the first week post-discharge are high-risk periods for suicidal attempts among individuals with mental illness [9]. The presence of a strong social support system can significantly enhance care and reduce risk after discharge.
It is also important to assess abnormal personality traits that may increase suicide risk. Borderline personality disorder and traits such as anxiety, impulsivity, aggression, or obsessive tendencies are associated with elevated suicide risk [10].
In cases of active or past suicide attempts, history-taking should focus on the method and intent of the attempt, preparations made beforehand, the presence of a death note, and any overt communication regarding the act. These factors strongly suggest increased suicidal intent. The intent of suicide may also help differentiate between “deliberate self-harm” (also known as parasuicide) and an unsuccessful suicide attempt.
Deliberate self-harm is described as an “episode of intentional self-harm that did not lead to death and may or may not have been motivated by a desire to die.” Reasons for deliberate self-harm include the need to escape unbearable stressors, seek relief, or, in some cases, as a call for help. It is important to note that deliberate self-harm significantly increases the risk of suicide in the future [11].
In this case, the use of drug overdose as a suicide attempt is a relatively common presentation. The type and quantity of medication or drug used during the attempt are critical in determining appropriate antidotes for overdose reversal, as well as in understanding potential physical complications to organ systems caused by drug toxicity.
Helpful Interview Questions [12] for Assessing Suicide Risk:
- Suicidal Ideation: With increased stress, have you had any thoughts of hurting or killing yourself?
- Suicidal Intent: How likely are you to try to kill yourself today or in the near future?
- Suicidal Plan: Do you have a plan for how you would like to kill yourself or end your life?
Protective Factors:
Assessing protective factors is crucial to determining suicide risk. For example:
- Is there anything or anyone that stops you from attempting suicide?
Mental Status Examination
A Mental Status Examination (MSE) is a critical component of evaluating patients with psychiatric complaints. It systematically assesses seven key areas: affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization [7]. The MSE provides insights into changes in alertness, cognition, and behavior, helping clinicians differentiate between conditions such as delirium, dementia, and psychiatric illnesses, which have distinct management strategies and prognoses. Delirium, for example, is associated with decreased survival when encountered in emergency settings [7]. Alternatives to the traditional MSE, like the Quick Confusion Scale, offer a structured and easily interpretable tool for assessing mental status [7].
The MSE should be conducted in an organized and focused manner, aiming to identify whether a patient’s complaints stem from functional or organic etiologies. It is crucial to note sudden changes in behavior, mood, or thought in patients, as these may indicate underlying medical conditions. Additionally, a thorough evaluation should include an assessment of substance use, medication adherence, and medical comorbidities, alongside a careful review of physical findings such as trauma, fever, or abnormal vitals [7]. These components play a pivotal role in identifying patients whose altered mental status might otherwise be misattributed to psychiatric causes. In a review of psychiatric ward admissions, it was found that many patients with medical diagnoses had not received appropriate medical screenings, underscoring the importance of thorough medical evaluations [7].
The MSE also holds particular significance in assessing suicide risk, as it offers a snapshot of the patient’s current mental state, which may fluctuate over time. This makes it a valuable tool for monitoring recovery and ensuring the patient’s safety. The appearance of suicidal patients can vary widely, from restlessness and agitation during heightened suicidality to expressions of guilt or disappointment after a failed suicide attempt. In some cases, outward signs of suicidal risk may be absent, emphasizing the need for a thorough evaluation of the patient’s mood, current suicidal ideations, intent, and plan. Homicidal ideations may also occasionally accompany suicidal thoughts, reflecting a patient’s belief that their actions might “relieve” loved ones from perceived burdens.
Evaluating a patient’s insight into suicidal behaviors, recognition of the need for treatment, and judgment in managing future crises provides valuable guidance for clinical decision-making during risk assessment. The MSE serves as both a diagnostic and monitoring tool, helping clinicians evaluate and address the complex interplay of medical, psychological, and social factors that influence mental health.
Differential Diagnoses
When evaluating patients with psychiatric complaints, it is essential to adopt a systematic approach that encompasses a broad range of differential diagnoses, addressing both psychiatric and medical conditions. Medical conditions such as sepsis, diabetic ketoacidosis, pneumonia, pulmonary embolism, meningitis, encephalitis, hyperthyroidism/thyroid storm, intoxication, withdrawal syndromes, overdose, and trauma can mimic or exacerbate psychiatric symptoms. These conditions may also include infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic, or CNS disorders and require prompt recognition to avoid misdiagnosis [7].
Psychiatric conditions, including schizophrenia, bipolar disorder, psychosis, mood disorders, anxiety disorders, delirium, and dementia, often present with overlapping features. Differentiating between functional (psychiatric) and organic (medical) causes is particularly important in patients with sudden changes in behavior, mood, or cognition or in those with a deteriorating chronic disorder [7]. Additional considerations, such as substance abuse, alcohol withdrawal, medication effects, or salicylate ingestion, can further complicate the clinical presentation. In particular, intoxicated patients may struggle to provide a reliable history, adding complexity to the diagnostic process [7].
Risk Factors and Diagnostic Approach
Certain groups are at an increased risk of medical causes for psychiatric symptoms, including the elderly, individuals with substance abuse histories, those without prior psychiatric diagnoses, and patients with new or pre-existing medical complaints. A comprehensive history, physical examination, and mental status examination (MSE) are critical for identifying the underlying etiology of psychiatric complaints. Gathering collateral information from family or caregivers helps ensure the accuracy of the history, as missed medical diagnoses have been shown to result from insufficient history-taking or physical examination [6,7].
Diagnostic testing should be tailored to the patient’s presentation. Common evaluations include laboratory studies (e.g., CBC, metabolic panel, thyroid function tests, alcohol level, urine drug screen, acetaminophen and salicylate levels), imaging studies (e.g., chest x-ray, CT scan of the brain), cardiac assessments (e.g., ECG, troponin, BNP), and infectious workups (e.g., urinalysis, urine culture, blood cultures, lumbar puncture). These tools help distinguish between psychiatric and medical conditions and guide appropriate management [7].
Differential Diagnoses for Suicide Attempts
When addressing a suicide attempt, specific psychiatric diagnoses must be considered, including Major Depressive Disorder, Bipolar Disorder, Psychotic Disorders, Substance-Induced Mood or Psychotic Disorders, and Cluster B Personality Disorders. Each condition requires a tailored treatment approach based on the underlying diagnosis [1].
For Major Depressive Disorder, first-line treatment often involves antidepressants, while Bipolar Disorder may require antipsychotics or a combination of antipsychotics with mood stabilizers. Psychotic Disorders are typically managed with antipsychotics, whereas substance-induced mood or psychotic disorders may necessitate antidepressants, mood stabilizers, or antipsychotics, depending on the clinical presentation. Cluster B Personality Disorders benefit from a detailed personality assessment and psychotherapy approaches such as Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT) [1].
Management
Emergency Treatment and Interventions
Effective emergency treatment for patients presenting with psychiatric or medical emergencies involves a combination of medical stabilization and supportive interventions. Medical stabilization is the first priority and focuses on addressing any identified medical issues. This may include administering supplemental oxygen, managing acute conditions such as hyperthyroidism or thyroid storm, and providing appropriate medications or therapies based on the patient’s needs [7].
For patients who are medically stable and being discharged, brief interventions are essential to ensure safety and continuity of care. These interventions often include patient education, personalized safety planning, and counseling to reduce access to lethal means [6]. Safety plans should identify warning signs, coping strategies, and emergency contacts, tailored to the individual’s circumstances. Lethal means counseling involves discussing strategies for the safe storage of firearms and toxic medications to mitigate risk [6].
Rapid referral for outpatient follow-up care is a critical component of post-discharge planning. Efforts should be made to arrange follow-up appointments within 24 hours and no later than 7 days. Providing patients with specific appointments and addressing potential barriers to follow-up care, such as transportation or availability, ensures better adherence to treatment plans [6].
Another important intervention includes caring contacts after discharge, such as brief communications via telephone calls, text messages, emails, or mail [6]. These contacts serve to maintain connection with the patient, encourage treatment adherence, and demonstrate ongoing support during their recovery process. By combining these strategies, emergency treatment not only addresses immediate medical needs but also promotes long-term safety and mental health stability.
When To Admit This Patient
The disposition of patients presenting with psychiatric crises, particularly those at risk for suicide, should be guided by their assessed level of risk and the availability of supportive resources [6]. Psychiatric hospitalization is appropriate for patients in acute crisis with moderate to high suicide risk. When feasible, voluntary admission is preferred to foster patient cooperation and engagement in treatment. For patients assessed to have a low risk of imminent suicide, outpatient management may be appropriate if they have a stable living environment, supportive relationships, and restricted access to lethal means [6]. Additionally, all patients should be provided with the National Suicide Prevention Hotline, if available, as an immediate resource for crisis support and suicide prevention, ensuring they have access to help when needed. This tailored approach to disposition ensures both immediate safety and continuity of care.
Additional ED Considerations
Proper management of patients presenting with psychiatric crises requires attention to several important considerations. Thorough documentation is essential to ensure a clear record of the patient’s history, physical examination, mental status evaluation, risk assessment, and any interventions or treatments administered [7]. Comprehensive documentation not only supports continuity of care but also provides a medico-legal record of the clinical reasoning and decisions made during the encounter.
Emergency departments (EDs) should have a written policy outlining the care of suicidal patients. Such policies help clarify care pathways, standardize procedures, and support provider actions, ensuring consistent and effective care delivery for this vulnerable population [6].
Collaboration with mental health professionals, including psychiatrists, psychologists, and social workers, is critical for delivering comprehensive care [6]. This interdisciplinary approach allows for a more holistic understanding of the patient’s needs and facilitates the development of individualized treatment plans that address both immediate and long-term concerns.
Further Management Considerations
Inpatient Management
If inpatient admission is required, the patient should be assessed for any underlying diagnoses that may have contributed to the suicide attempt. Medications tailored to the underlying diagnosis should be prescribed, with the patient under close observation during their stay. Inpatient staff must ensure the safety of the environment by removing sharp objects or any potential items that could be used for self-harm. Psychotherapy sessions may be initiated during this time. Upon discharge, safety netting is crucial to ensure the patient is aware of early warning signs and available support systems to help manage future crises.
Outpatient Management
For outpatient treatment, the patient must maintain regular follow-up appointments to monitor symptoms and assess ongoing suicide risk. Appropriate medications and psychotherapy sessions should be provided as needed. Depending on the treatment regimen, regular follow-up laboratory tests may be required to monitor for potential side effects. Psychotherapy sessions should also continue during this period.
Community Management
Community management involves collaboration with social services to support the patient in transitioning back to professional and personal life activities after discharge. Family support and adherence to the treatment plan are vital to maintaining the patient’s stability and preventing future crises.
Clinical Pearls
Discharge Medications:
For patients with a history of suicide attempts or an increased risk of future suicide, medications should be prescribed cautiously upon discharge. It is important to avoid providing large quantities of medications, as these may be misused in potential future suicide attempts.
Anti-Suicide Medications:
Certain medications have been shown to effectively reduce the risk of suicide:
- Lithium: Proven to be effective in the management of mood disorders.
- Clozapine: Demonstrated efficacy in reducing suicide risk in patients with schizophrenia [13].
Revisiting Your Patient
The findings in our case suggest that the patient is currently medically stable but requires close observation for any potential changes. Further psychiatric evaluation is essential to assess underlying mental health issues and suicide risk factors. A definitive diagnosis cannot be established at this stage and will depend on the outcomes of additional assessments.
Author
Faisal A. Nawaz
Dr. Faisal Nawaz is a Psychiatry Resident Doctor at Al Amal Psychiatric Hospital in Dubai. Dr. Nawaz’s research expertise extends across health, global health, digital health, and medical education with over 60 peer-reviewed publications in the field. Beyond his clinical pursuits, Dr. Nawaz serves as the Co-founder of the Global Remote Research Scholars Program.
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References
- Harrison PJ, Cowen P, Burns T, Fazel M. Shorter Oxford Textbook of Psychiatry. 7th ed. Oxford University Press; 2018.
- Durkheim E. Suicide: A Study in Sociology. Translated by JA Spaulding and G Simpson. Free Press; 1951.
- Shenava M, Hitching R, Dunn LB. Suicide in the Geriatric Population: Risk Factors, Identification, and Management. In: Bhattacharya R, Agarwal V, Chaturvedi SK, eds. Clinical Geriatric Psychopharmacology. Springer; 2019:153-167. doi:10.1007/978-3-030-10401-6_8.
- Centers for Disease Control and Prevention. Multiple Cause of Death, 2018-2020, Single Race Request. Accessed January 10, 2025. https://wonder.cdc.gov/mcd-icd10-expanded.html.
- Kirkcaldy BD, Siefen RG, Urkin J, Merrick J. Risk factors for suicidal behavior in adolescents. Minerva Pediatr. 2006;58(5):443-450.
- Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001.
- Siever K, Tucci V. Medical Clearance – Suicidal Thought/Ideation. International Emergency Medicine Education Project. Accessed January 10, 2025. https://iem-student.org/medical-clearance-suicidal-thought-ideation/.
- Patterson WM, Dohn HH, Bird J, Patterson GA. Evaluation of suicidal patients: The SAD PERSONS scale. Psychosomatics. 1983;24(4):343-349. doi:10.1016/S0033-3182(83)73213-5.
- Bickley H, Hunt IM, Windfuhr K, Shaw J, Appleby L, Kapur N. Suicide Within Two Weeks of Discharge From Psychiatric Inpatient Care: A Case-Control Study. Psychiatr Serv. 2013;64(7):653-659. doi:10.1176/appi.ps.201200026.
- Paris J. Suicidality in Borderline Personality Disorder. Medicina (Kaunas). 2019;55(6):223. doi:10.3390/medicina55060223.
- Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: Systematic review. Br J Psychiatry. 2002;181:193-199. doi:10.1192/bjp.181.3.193.
- National Institute of Mental Health. Frequently Asked Questions About Suicide. Accessed January 10, 2025. https://www.nimh.nih.gov/health/publications/suicide-faq.
- Ernst CL, Goldberg JF. Antisuicide Properties of Psychotropic Drugs: A Critical Review. Harv Rev Psychiatry. 2004;12(1):14-41. doi:10.1080/10673220490425924.
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
