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Chapter 185. Emergency Assessment and Stabilization of Behavioral Disorders

Lance H. Hoffman

In the last 2 decades, mental health-related visits to emergency departments (ED) in the United States increased 38% to 23.6 per 1000 population.

Suicidal patients are often forthcoming about their intentions for self-harm. The patient's intentions may be more difficult to infer after a nontraumatic suicide attempt and if the patient has an altered level of consciousness than after a self-inflicted traumatic injury. Patients with multiple seemingly unrelated somatic complaints may be depressed. High- and low-risk profiles for suicide risk are summarized in Table 185-1. Medication overdose is the most common type of suicide attempt.

Table 185-1 Evaluation of Suicide Risk in Adults and Adolescents
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Table 185-1 Evaluation of Suicide Risk in Adults and Adolescents

Demographic, Health, and Social Profile

High Risk

Lower Risk

Gender

Male

Female

Marital status

Separated, divorced, or widowed

Married

Family history

Chaotic, conflictual

Family history of suicide

Stable

No family history of suicide

Job

Recently unemployed

Employed

Relationships

Recent conflict or loss of a relationship

Stable relationships

School

In disciplinary trouble

No disciplinary problems

Religion

Weak or no suicide taboo

Strong taboo against suicide

Health

Physical

Acute or chronic, progressive illness

Excessive drug or alcohol use

Good health

Little or no drug or alcohol use

Mental

Depression (SIG E CAPS + MOOD)*

History of schizophrenia or bipolar disorder

Panic disorder

Antisocial or disruptive behavior

Feelings of helplessness or hopelessness

Few, weak reasons for living

Unstable, inappropriate affect

No depression

No psychosis

Minimal anxiety

Directable, oriented

Has hope, optimism

Good, strong reasons for living

Appropriate affect

Suicidal ideation

Frequent, intense, prolonged, pervasive

Infrequent, low intensity, transient

Suicide attempts

Repeated attempts

Realistic plan, including access to means

Previous attempt(s) planned

Rescue unlikely

Lethal method

Guilt

Unambiguous or continuing wish to die

No prior attempts

No plan, lacks access to means

Previous attempt(s) impulsive

High likelihood of rescue

Method of low lethality

Embarrassment about suicide ideation

No previous or continuing wish to die; large appeal component

Relationship with health professional

Lacks insight

Poor rapport

Insight

Good rapport

Social support

Unsupportive family, friends

Socially isolated

Concerned family, friends

Socially integrated

*SIG E CAPS + MOOD is a mnemonic for the eight symptoms of depression plus depressed mood: S = sleep disturbance; I = loss of interest in usual pleasurable activities; G = guilt; E = loss of energy; C = inability to concentrate; A = loss of appetite; P = psychomotor slowing; S = suicidal thoughts, MOOD = depressed mood (ie, “Have you felt blue, down, or depressed most of the day for most days in the last 2 weeks?”). Fulfillment of 5 or more of the 8 items from the list of 8 symptoms indicates the presence of major depression. Symptoms must be present nearly every day for 2 weeks and must include depressed mood or loss of interest or pleasure in activities. Symptoms must represent a change from previous functioning resulting in social, occupational, or other ...

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