Prevalence and outcomes of occult suicidality in a multiethnic emergency department population

Abstract

Study objectives: Because suicide completers frequently visit the emergency department (ED) for reasons other than suicide before their death, we sought to establish the prevalence of occult suicidality in patients seeking treatment for routine, nonpsychiatric problems in the ED. Methods: A prospective cohort of waiting room patients recruited during random time blocks in a large, urban ED were screened with an anonymous, computerized mental health assessment for a tripartite construct of suicidality: passive ideation, frequent thoughts of death and being "better off dead"; active ideation, specific thoughts about self-harm; and serious intent, defined as an endorsement of the statement "I am planning to kill myself." Patients younger than 18 years, with mental status impairment, or with a psychologic chief complaint were excluded. Results: Passive ideation was endorsed by 184 of 1,590 patients (11.6%), whereas 143 (8.4%) patients acknowledged active thoughts about killing themselves and 31 (1.6%) patients acknowledged imminent plans to kill themselves. Black patients were most likely and Hispanic patients least likely to endorse passive and active suicidal ideation, respectively (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1 to 2.1; OR 0.50; 95% CI 0.34 to 0.73, respectively). Patients reporting both ideation and serious intent were demographically similar to all other ED patients with similar reasons for visit. Fully 97% of 184 ideators screened positive for 1 or more mood, anxiety, or substance-related disorders, and 30% of serious intent patients endorsed problems in all 3 axis I domains. Of 31 actively suicidal patients, 24 remained undetected, receiving neither psychiatric diagnoses nor referral; only 6 patients had any mention of suicidality on the index ED record. None of the 31 patients expressing suicidal intent died within 3 months of enrollment, but 4 returned within 60 days, having made serious attempts; all survived. Conclusion: Occult suicidality is common in ambulatory ED patients presenting for nonpsychiatric problems but may be unmasked with a simple screen during routine ED evaluation.