Use of an Agitation Measure to Screen for Suicide and Self-Harm Risk Among Emergency Department Patients.

BACKGROUND: Suicidality alone is insensitive to suicide risk among emergency department (ED) patients. OBJECTIVE: We describe the performance of adding an objective assessment of agitation to a suicide screening instrument for predicting suicide and self-harm after an ED encounter. METHODS: We tested the performance of a novel screener combining the presence of suicidality or agitation for predicting suicide within 90 days or a repeat ED visit for self-harm within 30 days using retrospective data from all patients seen in an urban safety net ED over 27 months. Patients were assessed for suicidality using the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener and for agitation using either the Behavioral Activity Rating Scale or Richmond Agitation Sedation Scale. We hypothesized that a screener based on the presence of either suicidality or agitation would be more sensitive to suicide risk than the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. The screener's performance is described, and multivariable regression evaluates the correlations between screening and outcomes. RESULTS: The sample comprised 16,467 patients seen in the ED who had available suicide screening and agitation data. Thirteen patients (0.08%) died by suicide within 90 days after ED discharge. The sensitivity and specificity of the screener combining suicidality and agitation for predicting suicide was 0.69 (95% confidence interval, 0.44-0.94) and 0.74 (0.44-0.94), respectively. The sensitivity and specificity for agitation combined with positive suicide screening for self-harm within 30 days were 0.95 (0.89-1.00) and 0.73 (0.73-0.74). For both outcomes, augmenting the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener with a measure of agitation improved both sensitivity and overall performance compared to historical performance of the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. CONCLUSIONS: Combining a brief objective measure of agitation with a common suicide screening instrument improved sensitivity and predictive performance for suicide and self-harm risk after ED discharge. These findings speak to the importance of assessing agitation not only for imminent safety risk during the patient encounter but also for reducing the likelihood of future adverse events. This work can improve the detection and management of suicide risk in emergency settings.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering.

BACKGROUND: Malingering is a common and challenging clinical presentation in emergency departments (EDs). OBJECTIVE: This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service. METHODS: Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses. RESULTS: Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01). CONCLUSIONS: No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters.

BACKGROUND: Suicidal behavior is increasing among US youths. Contact with the health care system is common in the months before suicide. OBJECTIVE: To assess the characteristics of suicide risk among youths presenting for health care, universal screening results from a large hospital system were analyzed. METHODS: A retrospective analysis of the Ask Suicide-Screening Questions tool administered to patients aged 10-17 years in a hospital system including an emergency department, inpatient medical units, and primary care clinics was conducted. Demographic and clinical data from 3 years of encounters were analyzed. RESULTS: The sample consisted of 91,580 pediatric encounters, predominantly white Hispanic and women, with one third speaking Spanish. Across health care settings, 2.9% of encounters produced positive suicide risk screens, with the highest rate in the emergency department (8.5%). Acute positive screens, indicating imminent risk for suicidal behavior, accounted for 0.3% of all encounters. Approximately one-fourth (27.6%) of encounters for psychiatric presenting problems screened positive compared with 2.3% for nonpsychiatric encounters. Higher rates of positive screens were present among encounters for psychiatric presenting problems across all settings. Positive screens were less common among preteen (1.8%) than adolescent (3.1%) encounters (χ2 = 65.50, P < 0.001). CONCLUSIONS: Universal screening detected suicide risk in approximately 3% of pediatric health care encounters. Screening identified risk in encounters among preteen and adolescent patients, with a higher prevalence of positive screens in encounters for youths presenting with psychiatric problems and for emergency department visits. Acute positive screens were rare, occurring in less than half of 1 percent of encounters.