The suicidal pediatric patient: an emergency medicine focus

Overview 

Soon after he was appointed Surgeon General, David Satcher, MD, PhD, announced that he considered suicide to be a major public health problem and that suicide prevention would be one of his top priorities. Suicide has particular relevance for primary care and ED physicians. Of the more than 30,000 Americans who kill themselves each year, 90% suffer from a psychiatric disorder that is often diagnosable and treatable, and up to two-thirds have seen a physician within a month of their death.

Considering that more than 500,000 visits to EDs in 1997 were related to suicidal behavior, the relevance to emergency medicine is clear. The purpose of this article is to provide a framework for understanding suicide risk and management for children and adolescents presenting to the ED with suicidal behavior. How biologic, familial, and personality risk factors, and the role of firearms, psychiatric comorbidity, and previous suicide attempts alter the risk of suicide will be summarized. We will address how to assess, provide a safe disposition, and discuss potential interventions for children and adolescents with suicidal behavior.

Burden of disease and epidemiology 

In the US, as of 1993, over 31,000 suicide deaths were reported annually with an age-adjusted rate of 11.2 deaths per 100,000 persons.1 An estimated 210,000 people attempt suicide each year, resulting in more than $115 million in direct medical expenses alone.2

Suicide is the third leading cause of death in persons between the ages of 10 and 24 years, as well as a leading cause of years of potential life lost3 (Fig 1). The rate in teenagers has increased substantially over the past decade, with 1.6 deaths per 100,000 persons between the ages of 10 and 14 and 9.5 deaths per 100,000 persons between 15 and 191 (Fig 2). The rate among teenage males increased threefold, whereas the rate among females remained stable (Fig 3). Boys are four times more likely to commit suicide, and girls are twice as likely to attempt suicide. From 1972 to 1992, the Native American male adolescent and young adult suicide rate in Indian Health Service Areas was the highest in the nation, with a suicide rate of 62 per 100,000. African American male adolescents have also shown an increasing rate of suicide over the 1990s (Fig 4). Although risk factors are important in the assessment of suicide risk, no factors have been found that predict suicide completion on an individual level. Moreover, in up to 40% of adolescent suicide deaths, there was no reported change in previous behavior in the hours preceding the attempt.4

View Large Image Download to PowerPoint

Figure 1. Leading causes of mortality in adolescents/young adults, ages 10-24, 1997.1

View Large Image Download to PowerPoint

Figure 2. Suicide rates by age, 1997.1

View Large Image Download to PowerPoint

Figure 3. Suicide rates by age and gender, 1997.1

View Large Image Download to PowerPoint

Figure 4. Suicide rates by race/ethnicity, ages 15-19, 1997.1

The clinician should also consider the role of psychosocial, environmental, and specific life events in the risk evaluation of suicide. Recent losses, lack of social supports, and recent divorce can affect the lethality of a suicide attempt.5 In adolescents, humiliating life events such as interpersonal discord (poor relationship with parents or a recent break up of an important relationship) can also affect the lethality of an attempt. Recent exposure to others who have attempted suicide may also influence adolescents to make an attempt and is an important feature of cluster suicides.6, 7, 8 The presence of a chronic illness is another important risk factor for suicide across all age groups. A family history of suicide is also a significant risk factor. Studies of twins and adopted children show that a much higher percentage of suicide completers had a parent who had completed suicide.9 Adolescents who are gay, lesbian, or bisexual are at higher risk for depression and suicide compared to heterosexual youth.10

Assessing risk of suicide and disposition 

The suicidal patient presents to the ED in crisis. A rigid algorithmic approach in the ED is unlikely to be beneficial because of the unique characteristics and risk factors of the individual patient. In the assessment of the suicidal patient, the emergency physician must utilize information about risk factors often in consultation with a mental health professional to determine the appropriate disposition of the patient. Indications for psychiatric evaluation include acute suicidality, a combination of risk factors for suicide, recurrent ED visits over a short period of time, poor or non-existent social and mental health supports, and a specific plan with lethal means.

As in any medical examination, the physician will start with the chief complaint, and a review of present illness including what brought the patient to the ED. Patients with a high risk of suicide frequently present to the ED with nonspecific somatic complaints ranging from vague digestive problems and aches and pains, to other symptoms more directly linked to depression—changes in appetite, fatigue, and insomnia. In patients at higher risk of suicide, a staged suicide risk assessment with brief screening questions should be undertaken. Risk factors that increase the likelihood of suicide, such as recent drug use or trauma (domestic violence or rape), a previous suicide attempt, or gender identity issues should prompt the ED provider to continue with a more in depth assessment of suicidal risk. Examining prior inpatient or ED records can assist in identifying previous attempts. Unfortunately, structured instruments have shown a large false positive and negative rate in general medical populations; further research on the best way to classify patients with suicidal behavior is required. Thus, there is greater utility for risk factor initiated suicide screening in the ED compared to universal ED screening.

A physical exam should be performed to rule out medical causes for psychiatric complaints. A mental status exam should be done evaluating mood, content of thought (hallucinations or delusions), and whether speech is pressured. Explicit questions about suicidal ideation, plans, attempts, and notes (Table 1) should be asked in a direct, compassionate, and confidential manner. Most importantly, the patient should be asked whether she/he can promise to contract for safety, control his or her behavior, and not act on impulses. Confidentiality is imperative. Occasionally a patient may not assent to having his/her parents or a mental health provider knowing about suicidal thoughts. If this is the case, taking a few minutes to get the patient on board before notifying personnel is important in building trust and enabling the next phase of evaluation to proceed. Despite the clinician’s best effort, patient safety may dictate the notification of family and psychiatric personnel even against the child’s or adolescent’s wishes.

TABLE 1. Assessment of Suicidal Patients

	Assessing Circumstances of an Attempt
	Precipitating humiliating event
	Preparatory actions: acquiring a method, putting affairs in order, suicide talk, giving away prized possessions, suicide note
	Use of a more violent method
	Precautions taken against discovery
	Presenting Symptoms
	Hopelessness
	Depressed mood
	Suicidal thoughts
	Psychiatric Illness
	Previous suicide attempt
	Affective disorders
	Alcoholism or substance abuse
	Conduct disorder
	Psychosocial History
	Parents recently divorced
	Multiple life stressors
	Chronic medical history
	Personality Factors
	Impulsivity, hostility
	Negativity
	Borderline or antisocial personality disorder
	Family History
	Family history of suicidal behavior
	Family history of affective disorder

The physician must gather information, weigh risk factors, and formulate a plan for managing the suicidal behavior. The most important question is whether or not the patient can be managed as an outpatient. Though hospitalization is not clearly associated with improved outcomes in suicidal youth, it remains the most common risk management tool in the acute suicidal setting. For acutely suicidal patients who can not contract for safety, inpatient care is mandatory. When this consensus is reached, patient safety is important. Suicidal patients are at risk for hurting themselves or running. As the number of suicidal and mentally ill youth increases, many pediatric EDs are investigating the use of locked rooms or on site psychiatric observation areas. Once hospitalized, care must be taken to protect the patient from hurting him/herself while in these areas. Some patients can be discharged from the ED based on their absolute risk of suicide, available social and school supports, and the availability of outpatient care. For all patients who have a serious plan for suicide or who have made an attempt, a psychiatric consultation is important in understanding an underlying psychiatric diagnosis, developing a confidential treatment plan, and managing the psychiatric needs of the patient.

Summary 

Creating a system for addressing suicidal behavior in the ED is nested within a larger public health context and includes the following mandatory pieces.

1.Effective and appropriate identification and referral for mental, physical, and substance abuse disorders, taking advantage of the “teachable moment” of the crisis visit;

2.Easy and seamless access to a variety of clinical interventions and information resources (Table 2) and support for those seeking help;

TABLE 2. Resources for Providers and Families of Suicidal Patients

	Name	Web Address and/or Phone	Comments
	American Academy of Child and Adolescent Psychiatry (AACAP)	www.aacap.org	The AACAP developed the “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior” published in a 2001 supplement to the JAACAP. This is an excellent resource that references emergency care and has extensive references and a web site list. It also gives ED discharge and media guidelines.
	American Academy of Pediatrics	www.aap.org	Suicide and Suicide Attempts in Adolescents Policy Statement. Pediatrics, April 2000. Educational Materials for Parents: “Surviving: Coping with adolescent depression and suicide,”1995
	US Surgeon General/US Public Health Service/DHHS	http://www.surgeongeneral.gov/ cmh/default.htm
	National Suicide Prevention Strategy Goals and Objectives	www.sg.gov/library/calltoaction
	Healthy People 2010	www.health.gov/healthypeople/ data/PROGRVW/Mental
	American Foundation for Suicide Prevention (AFSP)	http://www.afsp.org (888) 333-AFSP	Media guidelines
	Substance Abuse and Mental Health Services Administration	http://www.mentalhealth.org/ suicideprevention/ nsspfullreport (301) 443-4111
	Indian Health Service	(301) 443-3593
	National Institutes of Health	(301) 443-4513
	American Association of Suicidology	(303) 692-0985	Promotes the study of suicide and the improvement of suicide prevention services. Sponsors suicide prevention week and certifies suicide prevention services. Publications list available.
	National Alliance for the Mentally Ill	(703) 524-7600	Provides information on mental illness and effects on families. This coalition of local support groups offers assistance in starting local patient/family support groups.
	National Community Mental Healthcare Council	(301) 984-6200	Disseminates information and promotes development of educational resources. Maintains a database on all mental health centers.
	National Mental Health Association	(800) 969-6642
	Suicide Prevention Advocacy Network (SPAN)	www.spanusa.org

3.Restricted access to highly lethal methods of suicide;

4.Family and community support;

5.Support from ongoing medical and mental healthcare relationships;

6.Learned skills in problem solving, conflict resolution, and nonviolent handling of disputes; and

7.Cultural and religious beliefs that discourage suicide and support self-preservation instincts.

The next step is integrating these approaches into a public health intervention to prevent suicide. Emergency physicians are uniquely placed to offer entry into such a system by identifying, referring, and conscientiously caring for suicidal children and adolescents.