Suicide Risk

Suicide Risk

We have covered numerous critical topics in the Ped EM Morsels over the past numerous years. Many are quite attention grabbing (ex, Tonsillectomy Hemorrhage, Delayed Sequence Intubation, and Submersion Injuries, and Lawn Mower Injuries), but that does not diminish the importance of other less flashy topics.  In fact, the vast majority of what we do in the Emergency Department is not heroic or flashy.  We also need to appreciate the opportunity that we have to help prevent injuries by remaining perceptive, receptive and vigilant.  One area that deserves special attention is Suicide Risk.


Suicide Risk Deserves Our Attention

  • Suicide is the 3rd leading cause of death in the USA for people 10-24 years. [Heron, 2013]
  • Suicide is the leading cause of death from intentional injury. [Heron, 2013]
  • Suicide affects young people from ALL races and socioeconomic groups. [Shain, 2007]


Suicide Risk Factors

  • Fixed Risk Factors
    • Family history of suicide or suicide attempts
    • Male gender
    • Parental mental health problems
    • Homosexual
    • History of physical or sexual abuse
    • Previous suicide attempt
  • Environmental/Social Risk Factors
    • Presence of firearms in the home
    • Poor child-parent relationship
    • Homeless
    • Neither working nor attending school
    • Social isolation
    • Presence of stressful life event
  • Predisposing Mental Health Issues
    • Depression, Bipolar, Panic attacks
    • Posttraumatic Stress Disorder
    • Aggression, Impulsivity, Severe Anger


Suicidal Thoughts Don’t Have to Look Sad

  • We are all aware of the need to be concerned about suicidal ideation in those who present with complaints consistent with depression…
  • But, patients may also present with somatic complaints: [Shain, 2007]
  • One study found ~5% of patients presenting with non-psychiatric complaints had significant suicidal ideation. [Horowitz, 2010]
  • So, this requires that we are actively considering the possibility of important non-organic causes… and not just happy to say that “it isn’t appendicitis.”


Suicidal Risk Screening

  • Screening patients without psychiatric complaints has been shown to be feasible in the ED. [Horowitz, 2010]
  • There are several tools available:
    • HEADS-ED [Cappelli, 2012]
      • Home, Education, Activities, Drugs, Emotions, Discharge resources
    • Risk of Suicide Questionnaire (RSQ) [Horowitz, 2001, Ballard, 2013]
      • 4 questions:
        • Are you here today because you tried to hurt yourself?
        • In the past week, have you been having thoughts about killing yourself?
        • Have you ever tried to hurt yourself in the past (other than this time)?
        • Has something very stressful happened to you in the past few weeks (a situation very hard to handle?
      • Has been validated. [Ballard, 2013]
      • A positive response to one or more of the questions constitutes a positive screen and warrants further exploration.
    • Remember that while confidentiality is important, safety takes precedence over confidentiality. Be clear about this with the patient. [Shain, 2007]


Moral of the Morsel

  • Suicide is a public health problem for which we must remain vigilant.
  • Not ever patient who needs your help will present with obvious depressive symptoms – consider somatic complaints also.
  • Routinely ask parents/guardians to leave the room while you finish your sensitive questions with your adolescent patients.
  • Utilize a screening tool (ex, RSQ).



Heron M. Deaths: leading causes for 2010. Natl Vital Stat Rep. 2013 Dec 20;62(6):1-96. PMID: 24364902. [PubMed] [Read by QxMD]

Ballard ED1, Horowitz LM, Jobes DA, Wagner BM, Pao M, Teach SJ. Association of positive responses to suicide screening questions with hospital admission and repeated emergency department visits in children and adolescents. Pediatr Emerg Care. 2013 Oct;29(10):1070-4. PMID: 24076609. [PubMed] [Read by QxMD]

Cappelli M1, Gray C, Zemek R, Cloutier P, Kennedy A, Glennie E, Doucet G, Lyons JS. The HEADS-ED: a rapid mental health screening tool for pediatric patients in the emergency department. Pediatrics. 2012 Aug;130(2):e321-7. PMID: 22826567. [PubMed] [Read by QxMD]

Horowitz LM1, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL, Wharff EA, Ginnis K, Cannon E, Joshi P, Pao M. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012 Dec;166(12):1170-6. PMID: 23027429. [PubMed] [Read by QxMD]

Horowitz L1, Ballard E, Teach SJ, Bosk A, Rosenstein DL, Joshi P, Dalton ME, Pao M. Feasibility of screening patients with nonpsychiatric complaints for suicide risk in a pediatric emergency department: a good time to talk? Pediatr Emerg Care. 2010 Nov;26(11):787-92. PMID: 20944511. [PubMed] [Read by QxMD]

Newton AS1, Hamm MP, Bethell J, Rhodes AE, Bryan CJ, Tjosvold L, Ali S, Logue E, Manion IG. Pediatric suicide-related presentations: a systematic review of mental health care in the emergency department. Ann Emerg Med. 2010 Dec;56(6):649-59. PMID: 20381916. [PubMed] [Read by QxMD]

King CA1, O’Mara RM, Hayward CN, Cunningham RM. Adolescent suicide risk screening in the emergency department. Acad Emerg Med. 2009 Nov;16(11):1234-41. PMID: 19845554. [PubMed] [Read by QxMD]

Shain BN1; American Academy of Pediatrics Committee on Adolescence. Suicide and suicide attempts in adolescents. Pediatrics. 2007 Sep;120(3):669-76. PMID: 17766542. [PubMed] [Read by QxMD]

Horowitz LM1, Wang PS, Koocher GP, Burr BH, Smith MF, Klavon S, Cleary PD. Detecting suicide risk in a pediatric emergency department: development of a brief screening tool. Pediatrics. 2001 May;107(5):1133-7. PMID: 11331698. [PubMed] [Read by QxMD]


Sean M. Fox
Sean M. Fox
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