Routine use of the Beck Scale for Suicide Ideation in a psychiatric emergency department

Reducing short term suicide risk after hospitalization: A randomized controlled trial of the Collaborative Assessment and Management of Suicidality

BACKGROUND

This study compared the "next day appointment" (NDA) use of the Collaborative Assessment and Management of Suicidality (CAMS) to treatment as usual (TAU) for individuals discharged from the hospital following a suicide-related crisis. We hypothesized that CAMS would significantly reduce suicidal thoughts and behaviors as well as improve psychological distress, quality of life/overall functioning, treatment retention and patient satisfaction.

METHODS

Participants were 150 individuals who had at least one lifetime actual, aborted, or interrupted attempt and were admitted following a suicide-related crisis. There were 75 participants in the experimental condition who received adherent CAMS and 75 participants who received TAU. Suicidal thoughts and behaviors, psychological distress, and quality of life/overall functioning were assessed at baseline and at 1, 3, 6, and 12 months post-baseline. Treatment retention and patient satisfaction were assessed at post-treatment.

RESULTS

Participants in both conditions improved from baseline to 12 months but CAMS was not superior to TAU for the primary outcomes. A small but significant improvement was found in probability of suicidal ideation at 3 months favoring TAU and amount of suicidal ideation at 12 months favoring CAMS. CAMS participants experienced less psychological distress at 12 months compared to baseline.

LIMITATIONS

The study was limited by only one research clinic, lower than expected recruitment, and imbalance of suicidal ideation at baseline.

CONCLUSIONS

All participants improved but CAMS was not more effective than TAU. The NDA clinic was feasible and acceptable to clients and staff in both conditions and future research should investigate its potential benefit.

Low Level of Agreement Between Self-Report and Clinical Assessment of Passive Suicidal Ideation

OBJECTIVE

Discrepancies between patient reports during clinical evaluations and self-reported suicide ideation are of vital importance. We study the agreement in passive suicidal ideation between reports made by clinicians and patients' self-reports.

METHOD

Wish of death in 648 outpatients was assessed by attending clinicians. Within 24 h after clinical evaluation, patients completed a self-report questionnaire in which they were asked whether they had no desire to live. We used cluster analysis to determine the clinical profile of a population of patients according to the concordance between reports made by clinicians and self-reported information.

RESULTS

A low level of agreement (kappa = 0.072) was found between clinicians and patients, as 56.4% (n = 366) of clinician reports classified as containing no death-related ideas although on self-report the patient did state that they had no desire to live. In this group containing discrepancies between the two reports, two clusters were found to have shared characteristics: female sex, middle age, cohabitation, active employment, no history of suicidal behavior, and diagnosis of neurotic, stress-related, and somatoform disorders. In a third, more severe cluster, patients self-reported sleep disturbances, less appetite, poor treatment adherence, and aggressiveness.

CONCLUSIONS

We found low agreement between self-reports and clinician assessments regarding the death wish. Self-reporting may be useful in assessing suicide risk. HIGHLIGHTSLow agreement was found between self-reports and clinician assessments regarding passive suicidal ideation.Most patients in whom the clinician underestimated the risk of suicide were women.Our results suggest that clinicians require adequate documentation of suicidal risk assessment to identify the high-risk population.

Development and validation study of the suicide screening questionnaire-observer rating (SSQ-OR)

BACKGROUND

Observer rating scales are necessary to evaluate the risk of suicide because individuals at risk for suicide are often unwilling to seek help on their own. Reliability and validity were evaluated for the newly developed Suicide Screening Questionnaire-Observer Rating (SSQ-OR).

METHODS

Preliminary items were assessed by 251 experts online and 25 questions were selected. 328 individuals at high-risk and 661 controls from 12 Crisis Response Centers and 5 university counseling centers were recruited to complete SSQ-OR, Beck Scale for Suicide Ideation (BSSI) and Patient Health Questionnaire-9 (PHQ-9). In a 6 months follow-up, we reached out to 176 participants to ask whether they had experienced a suicidal thought, plan, or attempt since the baseline assessment. Cronbach's α, Mann-Whitney U test, Spearman's correlation, factor analyses, Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to verify the SSQ-OR.

RESULTS

Structural validity was supported by a two-factor solution using exploratory and confirmatory factor analyses. Excellent model fit indices for the two-factor structure using exploratory factor analysis were confirmed (RMSEA = 0.033, TLI = 0.980, CFI = 0.983). The SSQ-OR demonstrated strong internal consistency. The concurrent validity based on the correlations with other self-reported indicators of suicidal potential-BSSI and PHQ-9- revealed substantial relationships. The high-risk group was effectively characterized by a cut-off point of 4, with a sensitivity of 0.73 and a specificity of 0.79. The SSQ-OR scores were significant predictors of suicidal thoughts and behaviors within 6 months.

CONCLUSIONS

The SSQ-OR exhibits sound psychometric properties, and could be used as a complement to a self-report or clinical-administered scale to screen suicide risk comprehensively.

Protocol of a Multi-centric Randomized Controlled Trial to Evaluate Efficacy of Telephone-Based Psychosocial Interventions on Future Suicide Risk in Suicide Attempters

BACKGROUND

Persons with previous history of a suicide attempt are at increased future risk of death by suicide. These vulnerable individuals, however, do not seek receive or seek help from mental health services. Telephone-based psychosocial interventions are potential strategies in augmenting mental health care in such persons.

METHODS

We aim to compare the efficacy of telephone-based psychosocial interventions (TBPI) with routine telephone reminders in persons with recent suicide attempts using a multi-site, parallel group, rater-blind, two-arm randomized controlled trial design in 362 participants. In the first group, participants will receive three sessions of TBPI comprising of brief supportive interventions, problem-solving strategies, and reminders for adherence to prescribed mental health treatment at weekly intervals. In the second group, participants will receive three telephone reminders for adherence to prescribed mental health treatment at weekly intervals. We will follow up participants for 6 months. Primary outcomes are suicidal ideation scores on Beck's Scale for Suicide Ideation and number of repeat suicide attempts. Secondary outcomes are scores on Beck's Hopelessness Scale, Beck's Depression Inventory, Connor-Davidson Resilience Scale and Visual Analogue Rating Scales for acceptability of interventions. Outcomes will be assessed at 1, 3, and 6 months after receiving telephone interventions or reminders.

RESULTS

The trial is currently underway after prospective registration under Clinical Trials Registry of India and has recruited 260 participants till August 15, 2020.

CONCLUSION

This study has potential to generate evidence on additional strategies for use along with standard mental health treatments in management of high-risk suicide behaviors.

MCP-2/CCL8 Level Associated With Suicidal Ideation in Elderly Men With Major Depression

OBJECTIVES

We compared serum levels of chemokines between male elders with major depressive disorder (MDD) and healthy controls, verifying whether any difference exists in the levels of these mediators between those with and without current suicidal ideation (SI).

METHODS

We enrolled 145 male elders aged 65 or older and analyzed 40 chemokines in patients with MDD with SI (n = 24) and without SI (n = 23), as well as healthy controls (n = 98).

RESULTS

The patients with MDD with SI presented higher levels of MCP-2/CCL8 (p < 0.001) compared with the patients with MDD without SI and the healthy controls.

CONCLUSIONS

Current findings suggest a potential role of MCP-2/CCL8 in suicidality among elderly males with depression.

Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial

BACKGROUND

Depressed patients presenting to emergency departments with acute suicidal ideation are a major public health concern. Ketamine, a rapidly acting antidepressant with antisuicidal properties, might offer relief.

METHODS

In a randomized, double-blind, placebo-controlled, proof-of-concept trial, 18 depressed subjects with acute suicidal ideation, who required hospitalization, were randomized to either an intravenous ketamine 0.2 mg/kg group or a saline placebo group. Safety and efficacy evaluations were scheduled for 15, 30, 60, 90, 120, 180, and 240 min, and on Days 1, 2, 3, 7, and 14 after infusion. The main outcome measure was suicidal ideation with secondary measures of depression.

RESULTS

Nine subjects were randomized to each group. There were no differences between groups at baseline in any demographic or assessment scales. A reduction in suicidal ideation was noted at 90-180 min (p < .05). Ninety minutes after infusion, 88% of the ketamine group had achieved remission of suicidal ideation compared with 33% in the placebo group (p < .05). No serious adverse events were noted.

CONCLUSIONS

Ketamine was safe and effective for rapid reduction in suicidal ideation in depressed, highly suicidal subjects presenting to the emergency department. Our results support further study of ketamine for acute suicidal ideation.

The Effect of Eye Movement Desensitization and Reprocessing (EMDR) on the severity of suicidal thoughts in patients with major depressive disorder: a randomized controlled trial

OBJECTIVE

Depression is a major risk factor for suicide and more than 90% of people who attempt suicide suffer from depression. The present study aimed to investigate the effect of eye movement desensitization and reprocessing (EMDR) therapy on the severity of suicidal thoughts in patients with major depressive disorder.

STUDY DESIGN

Randomized Clinical Trial.

METHODS

This clinical trial was performed on 70 people with major depressive disorder who exhibited suicidal thoughts. The patients were selected via convenience sampling and were randomly divided into control (n=35) and experimental (n=35) groups. EMDR was performed individually in the experimental group for 45-90 min, 3 days per week, on alternate days, for 3 weeks (9 sessions in total), whereas the controls group received routine treatment without intervention. Both groups completed the Beck Scale for Suicide Ideation (BSSI) at pre- and post-test. The obtained data were analyzed with descriptive and inferential statistics using SPSS 22 (α=0.05).

RESULTS

Mean BSSI score for the experimental group was reduced significantly at post-test (11.11±4.15) compared to pre-test (26.48±5.74) (p<0.001). Although the control group's mean BSSI score was also reduced at post-test (24.93±4.42) compared to pre-test (26.68±5.05), this difference was not statistically significant (p>0.05).

CONCLUSION

EMDR therapy has been shown in this study to reduce the severity of suicidal feelings. Therefore, it can be recommended as an alternative treatment method for reducing the severity of suicidal thoughts in patients with major depressive disorder.

Agreement between self and psychiatrist reporting of suicidal ideation at a Veterans Administration psychiatric emergency clinic

BACKGROUND

With suicide rising in the United States, identifying and preventing suicides is increasingly important. To provide a valuable step toward achieving effective suicide risk assessment, this study examines the agreement between self-report measures and psychiatrist documentation of suicidal ideation and behaviors (SI) at a Veterans Administration (VA) psychiatric emergency clinic.

METHODS

A total of 377 veterans presenting at a VA psychiatric emergency clinic completed a self-report survey on SI and other acute risk factors for suicidal behavior. We examined agreement between veterans' self-reported SI and psychiatrists' clinical notes regarding SI.

RESULTS

A total of 199 veterans (53%) self-reported SI; 80 psychiatrist notes (21%) indicated SI. Psychiatrists and veterans differed in 44% (164/377) of cases. Among the discordant cases, the veterans' self-report was more severe than the psychiatrists' in 97% of cases. Of the 120 veterans with SI and documented as having no SI by psychiatrists, 31 (26%) reported having a suicide plan and 18 (15%) plan preparations. Findings were similar when controlling for presenting problem, current depression, presence of a standardized suicide risk assessment, psychiatrist training level, past suicide attempt, homelessness, diagnosis of personality, or substance use disorder.

CONCLUSIONS

Agreement between veterans' self-reports and psychiatrists' documentation of SI was generally low, with veterans self-reporting SI significantly more often than psychiatrists documented SI in their clinical notes. This suggests that inclusion of a self-report questionnaire provides an additional source of data to complement information gleaned from the clinical interview for a more comprehensive risk assessment, but only if actually examined by the clinician.

Validation of the Beck Hopelessness Scale in patients with suicide risk

INTRODUCTION

Only a few scales have been validated in Spanish for the assessment of suicide risk, and none of them have achieved predictive validity.

OBJECTIVE

To determine the validity and reliability of the Beck Hopelessness Scale in patients with suicide risk attending the specialist clinic.

METHODS

The Beck Hopelessness Scale, reasons for living inventory, and the suicide behaviour questionnaire were applied in patients with suicide risk attending the psychiatric clinic and the emergency department. A new assessment was made 30 days later to determine the predictive validity of suicide or suicide attempt.

RESULTS

The evaluation included a total of 244 patients, with a mean age of 30.7±13.2 years, and the majority were women. The internal consistency was .9 (Kuder-Richardson formula 20). Four dimensions were found which accounted for 50% of the variance. It was positively correlated with the suicidal behaviour questionnaire (Spearman .48, P<.001), number of suicide attempts (Spearman .25, P<.001), severity of suicide risk (Spearman .23, P<.001). The correlation with the reasons for living inventory was negative (Spearman -.52, P<.001). With a cut-off ≥12, the negative predictive value was 98.4% (95% CI: 94.2-99.8), and the positive predictive value was 14.8% (95% CI: 6.6-27.1).

CONCLUSION

The Beck Hopelessness Scale in Colombian patients with suicidality shows results similar to the original version, with adequate reliability and moderate concurrent and predictive validity.

Quality of life of depressed and suicidal patients seeking services from traditional and faith healers in rural Kenya

Background

In rural Kenya, traditional and faith healers provide an alternative pathway to health care, including mental health care. However, not much is known about the characteristics of the populations they serve. The purpose of this study was to determine the relationship between depression, suicidal ideation, and socio-demographic variables with Quality of Life (QoL) indicators in a sample seeking mental health services from traditional and faith healers in rural Kenya. Understanding QoL in this sample can help develop mental health policy and training to improve the well-being of this population.

Method

This was a cross-sectional epidemiological survey (n = 443) conducted over a period of 3 months among adult patients seeking care from traditional and faith healers in rural Kenya. Data were collected using the Beck Depression Inventory II (BDI-II), Beck Scale for Suicide Ideation (BSS) and WHO Quality of Life Survey- BREF (WHOQOL-BREF), and analyzed using correlation analyses, parametric tests, and regression analyses.

Results

Increasing levels of depression were associated with lower QoL among patients seeking care from traditional and faith healers. BSS scores were significantly negatively correlated with overall, physical, psychological, and environmental QoL, p < .05. There was a statistically significant difference between mean scores for overall QoL between depressed (M = 2.35, SD = 0.76) and non-depressed participants (M = 3.03, SD = 0.67), t(441) = 8.899, p < .001. Overall life satisfaction for depressed participants (M = 2.23, SD = 0.69) was significantly lower than non-depressed participants. Regression analyses indicated that depression, suicidal ideation, and being married predicted lower overall QoL controlling for other variables. Post hoc tests and subgroup analysis by gender revealed significant differences for females only. Depression, and older age predicted lower life satisfaction whereas being self-employed predicted higher life satisfaction, when controlling for other variables.

Conclusion

This study sheds light on correlates of QoL in depressed and non-depressed patients in rural Kenya. Evidence suggests that traditional and faith healers treat patients with a variety of QoL issues. Further research should focus on understanding how these issues tie into QoL, and how these healers can target these to improve care.

Intimate Partner Sexual Coercion Mediates the Childhood Sexual Abuse–Suicidal Ideation Link Among African American Women

Suicide is a leading cause of morbidity and mortality among women. Childhood sexual abuse (CSA) and intimate partner violence are significant risk factors for suicidal ideation among women. The purpose of this study was to examine the interrelationships among these three constructs and test if intimate partner sexual coercion may explain the CSA–suicidal ideation link. African American women ( N = 141) completed an assessment of childhood trauma, intimate partner sexual coercion, and suicide ideation. A significant positive correlation was found between CSA and sexual coercion, between CSA and suicidal ideation, and between sexual coercion and suicidal ideation. Also, intimate partner sexual coercion was found to mediate the relationship between CSA and suicidal ideation when controlling for covariates such as spiritual well-being, self-esteem, and barriers to services. The association between CSA and suicidal ideation may be explained by sexual revictimization in the context of an intimate relationship among African American women. Clinically, practitioners should engage in regular screening for suicide ideation among African American women who have experienced CSA and intimate partner sexual coercion.

Ketamine for Treatment of Suicidal Ideation and Reduction of Risk for Suicidal Behavior

Ketamine, an NMDA receptor antagonist with efficacy as a rapid anti-depressant, has early evidence for action to reduce suicidal ideation. This review will explore several important questions that arise from these studies. First, how do we measure reductions in suicidal ideation that occur over minutes to hours? Second, are the reductions in suicidal ideation after ketamine treatment solely a result of its rapid anti-depressant effect? Third, is ketamine only effective in reducing suicidal ideation in patients with mood disorders? Fourth, could ketamine's action lead us to a greater understanding of the neurobiology of suicidal processes? Last, do the reductions in depression and suicidal ideation after ketamine treatment translate into decreased risk for suicidal behavior? Our review concludes that ketamine treatment can be seen as a double-edged sword, clinically to help provide treatment for acutely suicidal patients and experimentally to explore the neurobiological nature of suicidal ideation and suicidal behavior.

Prevalence of suicidal ideation and other suicide warning signs in veterans attending an urgent care psychiatric clinic

BACKGROUND

Suicide prevention in the clinical setting is focused on evaluating risk in the coming hours to days, yet little is known about which factors increase acute risk.

PURPOSE

To determine the prevalence of factors that may serve as warnings of heightened acute risk.

METHODS

Veterans attending an urgent care psychiatric clinic (n=473) completed a survey on suicidal ideation and other acute risk warning signs.

RESULTS

More than half the sample (52%) reported suicidal ideation during the prior week. Of these, more than one-third (37%) had active ideation which included participants with a current suicide plan (27%) and those who had made preparations to carry out their plan (12%). Other warning signs were also highly prevalent, with the most common being: sleep disturbances (89%), intense anxiety (76%), intense agitation (75%), hopelessness (70%), and desperation (70%). Almost all participants (97%) endorsed at least one warning sign. Participants with depressive syndrome and/or who screened positive for post-traumatic stress disorder endorsed the largest number of warning signs. Those with both depressive syndrome and post-traumatic stress disorder were more likely to endorse intense affective states than those with either disorder alone. All p-values for group comparisons are <.008.

CONCLUSION

Our major findings are the strikingly high prevalence of past suicidal ideation, suicide attempts, current suicidal ideation and intense affective states in veterans attending an urgent care psychiatric clinic; and the strong associations between co-occurring post-traumatic stress disorder and depressive syndrome with intense affective states.

Disagreement between self-reported and clinician-ascertained suicidal ideation and its correlation with depression and anxiety severity in patients with major depressive disorder or bipolar disorder

OBJECTIVES

To study the disagreement between self-reported suicidal ideation (SR-SI) and clinician-ascertained suicidal ideation (CA-SI) and its correlation with depression and anxiety severity in patients with major depressive disorder (MDD) or bipolar disorder (BPD).

METHODS

Routine clinical outpatients were diagnosed with the MINI-STEP-BD version. SR-SI was extracted from the 16 Item Quick Inventory of Depression Symptomatology Self-Report (QIDS-SR-16) item 12. CA-SI was extracted from a modified Suicide Assessment module of the MINI. Depression and anxiety severity were measured with the QIDS-SR-16 and Zung Self-Rating Anxiety Scale. Chi-square, Fisher exact, and bivariate linear logistic regression were used for analyses.

RESULTS

Of 103 patients with MDD, 5.8% endorsed any CA-SI and 22.4% endorsed any SR-SI. Of the 147 patients with BPD, 18.4% endorsed any CA-SI and 35.9% endorsed any SR-SI. The agreement between any SR-SI and any CA-SI was 83.5% for MDD and 83.1% for BPD, with weighted Kappa of 0.30 and 0.43, respectively. QIDS-SR-16 score, female gender, and ≥4 year college education were associated with increased risk for disagreement, 15.44 ± 4.52 versus 18.39 ± 3.49 points (p = 0.0026), 67% versus 46% (p = 0.0783), and 61% versus 29% (p = 0.0096). The disagreement was positively correlated to depression severity in both MDD and BPD with a correlation coefficient R(2) = 0.40 and 0.79, respectively, but was only positively correlated to anxiety severity in BPD with a R(2) = 0.46.

CONCLUSION

Self-reported questionnaire was more likely to reveal higher frequency and severity of SI than clinician-ascertained, suggesting that a combination of self-reported and clinical-ascertained suicidal risk assessment with measuring depression and anxiety severity may be necessary for suicide prevention.

Future disposition and suicidal ideation: mediation by depressive symptom clusters

BACKGROUND

In line with hopelessness theory, both increased negative expectancies and reduced positive expectancies for the future have been associated with suicidal ideation. This study evaluated two depression symptom clusters as mediators of the relationship between future disposition and suicide: subjective feelings of depression and self-blame.

METHODS

Data from 140 undergraduate students with moderate to severe depression symptoms are presented who completed the Beck Scale for Suicidal Ideation, Beck Depression Inventory, and the Future Disposition Inventory.

RESULTS

On mediation analysis, subjective depression mediated the relationship between positive disposition and suicidal ideation. In contrast, the relationship between negative disposition and suicidal ideation was mediated by self-blame. The reverse of these relationships was not significant.

LIMITATIONS

This is a cross-sectional study of an undergraduate sample and results warrant replication in clinical samples with clinician-administered assessments.

CONCLUSIONS

Findings suggest two potential pathways to suicidal thoughts with implications for assessment and treatment. Depressed individuals with few positive expectations of the future may benefit from interventions focusing on subjective depression symptoms, such as sadness or anhedonia. For depressed individuals with negative expectations for the future, a clinical focus on negative attributions or self-blame may be warranted.

Loneliness and suicidal ideation in drug-using college students

The college years are marked by social changes and behavioral experimentation which may increase risk of suicidal ideation. We propose a novel pathway for the development of suicidal thoughts between two established suicide risk factors, loneliness and drug use, which have not been examined in a nonclinical sample. Data were collected from 207 undergraduate drug-using students at a large southeastern university. As hypothesized, suicidal ideation was positively correlated with both loneliness (r = .40) and drug use (r = .29). After controlling for several demographic variables, social desirability, and anxiety sensitivity, drug use was tested as a potential mediator in the loneliness-suicidal ideation link using a single-mediator model. Results indicated a significant indirect (mediated) effect of loneliness on suicidal ideation via drug use (ab = 0.09, 95% CI: 0.02-0.18), suggesting that loneliness may contribute to suicidal ideation through increased drug use among college students. Identification of and intervention with students reporting loneliness and drug use may be a promising suicide prevention strategy on college campuses.

Suicide risk assessment: myth and reality

To be, or not to be, that is the question - Whether 'tis nobler in the mind to suffer The slings and arrows of outrageous fortune, Or to take arms against a sea of troubles, And by opposing end them? To die, to sleep; … Hamlet, III i Hamlet's soliloquy is surely the most famous expression of suicidal ideation in English literature. However, by the end of the play, it is not Hamlet, but Ophelia who has taken her own life, even though she gave no prior hint of self-destruction.

Mediators of the daily hassles-suicidal ideation link in African American women

Depressive symptoms and hopelessness as mediators of the daily hassles-suicidal ideation link in low-income African American women exposed to intimate partner violence (n = 100) were investigated. As hypothesized, daily hassles, depressive symptoms, and hopelessness were each significantly and positively associated with suicidal ideation. Moreover, the relation between daily hassles and suicidal ideation was, in part, accounted for by depressive symptoms and hopelessness. This study demonstrates the importance of assessing for the presence of these risk factors when determining the likelihood that an abused African American woman will consider suicide. The findings further highlight the value of designing and implementing interventions that target the reduction in depressive symptoms and hopelessness in abused African American women exposed to daily hassles to reduce their suicide risk.

Evidence for the management of adolescent depression

Adolescent depression is a prevalent and disabling condition resulting in emotional suffering and social and educational dysfunction. Care for adolescent depression is suboptimal and could be improved through the development and use of quality indicators (QIs). This article reports on the development of a care pathway and QIs for the primary and specialty care management of adolescent depression from case identification through symptom remission. It presents evidence from a review of adolescent clinical practice guidelines and research literature to support QIs at critical nodes in the pathway, and describes implications for practice based on existing evidence. Barriers to measure development are identified, including gaps in empirical evidence, and a research agenda is suggested.

Do patients and clinicians differ in their assessment of suicidal intent after self-harm using the same suicide questionnaire scale?

There have been no studies looking at differences in clinicians and patients assessment of suicidal intent in adults after presenting to emergency departments with intentional self-harm. In a non-experimental correlational study patients were asked to complete the objective section of the Beck Suicide Intent Scale whilst clinicians, as part of their routine clinical evaluation, completed the same scale blind to the patients' ratings. Clinicians rated the suicide attempts consistently less seriously than the patients and there was poor agreement on individual questions (patients mean total score 6.86, clinicians mean total score 3.41, difference 3.45 (95% confidence interval 4.41-2.50) n=22, t=-7.52, p<0.01). The results may be explained by the requirement for clinicians to defend themselves against being overwhelmed by neediness, possibly leading to minimisation of the risk of suicide.

Mental health and emergency medicine: a research agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

No cathartic effect in suicide attempters admitted to the emergency department

The goal of the present study was to test the hypothesis that suicide attempts have a cathartic effect. We retrospectively investigated sociodemographic and clinical characteristics of suicide attempters admitted to the emergency department of a university hospital who were referred for a psychiatric assessment. The participants were 158 consecutive patients admitted to the emergency department because of a suicide attempt between January, 2006, and February, 2007; controls were 360 consecutive psychiatric referrals who did not report suicidal behavior. More than 70% of suicide attempters were coded on the triage classification system as critical/urgent. Loglinear analysis indicated that the risk of suicidal ideation was 9 times higher (p <0.001) and the risk of depressive mood was twice as high (p <0.001) among the attempters as in the control group of nonattempters, while their risk of anxiety (p <0.05) and agitation (p <0.05) was approximately half that of the nonattempters. The attempters also had a 5 times greater risk of being diagnosed with bipolar disorder (p <0.001) than the nonattempters. However, despite the fact that bipolar disorders were overrepresented in the group of attempters, suicidal ideation in the few hours after a suicide attempt was associated only with depressive mood. Based on these findings, it is recommended that psychiatric evaluation of suicide attempters in the emergency department should ideally include the use of psychometric instruments evaluating suicide ideation and suicide risk.

Recent suicidal ideation among patients in an inner city emergency department

The rates and associated features of suicidal ideation among 5,641 patients seeking routine, nonsuicide related care in an inner-city emergency department were examined. Approximately 8% of patients seeking routine care in the emergency department reported some form of suicidal ideation within the past 2 weeks. Suicidal ideation was common in individuals who were single with poorer mental health, had higher depression, and had received some drug or alcohol treatment in the past 3 months or had used cocaine or marijuana in the past 30 days. Improved screening procedures could help to identify routine care patients who are at risk for suicide.

Comparison of clinical and research assessments of diagnosis, suicide attempt history and suicidal ideation in major depression

A number of studies have compared clinical diagnostic and suicide assessments to standardized schedules to determine the level of agreement. At best there is only moderate diagnostic agreement, but most often it is fair. There are only a few reports comparing clinical assessments for suicidal behavior with standardized schedules. We present the data from 201 inpatient admissions for major depression that had both clinical diagnostic and suicide evaluations by PGYII resident physicians under supervision from an attending psychiatrist and research evaluations using standardized schedules for diagnosis and suicide by at least masters' level clinicians. There was moderate agreement for diagnosis and suicide attempt history but only fair agreement for the presence of suicidal ideation using Cohen's kappa statistic. In regards to suicide attempt history a cross-tabulation demonstrated that 18.7% of those patients identified by a research schedule as having a past suicide attempt were not identified as such by the clinicians. A cross-tabulation demonstrated that 29.7% of those patients identified by structured interview as having suicidal ideation were not identified as such by the clinician. There was a statistically significant difference in the level of agreement for suicide attempt history between clinical and research assessments for attempts within a year of admission and those beyond a year. These findings suggest the importance of adding a structured diagnostic and suicide assessment to routine clinical care to improve the reliability and validity of clinical evaluations and to inform treatment planning to benefit our patients.