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Date: April 11th, 2019

Reference: Brucker et al. Assessing Risk of Future Suicidality in Emergency Department Patients. AEM April 2019

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com

WARNING:

This SGEM episode discusses suicide. This is a warning to those listening to the podcast or reading the blog post. The SGEM is free and open access initiative trying to cut the knowledge translation down from over ten years to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. If you are feeling upset by the content, then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance.

Case: A 32-year-old woman presents to the emergency department after spraining her ankle playing basketball. Although she has no other health problems, and no other complaints, you are aware of data that indicates there is a high level of psychiatric illness and suicidal ideation among emergency department patients and wonder what is the best way to approach this problem?

Background: Suicidal ideation is common; it accounts for about 1% of emergency department visits, or about 1.4 million visits a year in the United States [1]. Although there are numerous validated screening tools, such as the PHQ9, the ED-Safe Patient Safety Screener, and the Suicide Behaviors Questionnaire–Revised (SBQ-R), none have been tested against physician gestalt, and none are widely used in clinical practice [2,3,4].

The Convergent Functional Information for Suicidality (CFI-S) is a validated screening tool for suicidal ideation, but it has not been tested in an emergency department (ED) setting [5,6]. The current trial aimed at assessing the accuracy of the CFI-S in the ED, while comparing it to a screening tool already in use and physician gestalt [7].

 Clinical Question: Can the CFI-S improve on clinician gestalt for screening of all adults to an emergency department for suicidal ideation?

Reference: Brucker et al. Assessing Risk of Future Suicidality in Emergency Department Patients. AEM April 2019

  • Population: Adult patients presenting to the emergency department, without regard to the chief complaint.
    • Exclusions: Severe trauma or illness requiring emergent intervention or acute intoxication.
  • Intervention: The Convergent Functional Information for Suicidality (CFI-S) screening tool
  • Comparison: Physician gestalt
  • Outcomes: Any suicidality spectrum event in the six months after the ED visit. This was defined as a repeat ED visit or admission for suicidal ideation, preparatory acts, suicide attempts, aborted or interrupted attempts, or completed suicide.

Dr. Krista Brucker

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Krista Brucker is an emergency physician in South Bend, IN. With the help of a dedicated team of medical students and some very patient mentors, Dr. Brucker completed this work while she was an assistant professor of emergency medicine at Indiana University school of Medicine.

Authors’ Conclusions: “Using CFI-S, or some of its items, in busy EDs may help improve the detection of patients at high risk for future suicidality.”

Quality Checklist for a Prognostic Study: 

  1. The study population included or focused on those in the emergency department? Yes
  2. The patients were representative of those with the problem? Unsure
  3. The patients were sufficiently homogenous with respect to prognostic risk? Unsure
  4. Objective and unbiased outcome criteria were used? No
  5. The follow-up was sufficiently long and complete? No
  6. The effect was large enough and precise enough to be clinically significant? No

Key Results: A total of 367 patients were approach and 338 agreed to participate in the study. The mean age was around 40 years with about 50/50 male/female split. The majority of the patients were non-white. Physician gestalt data was only available on 190 of the patients.

9.5% of screened patients had a suicidality spectrum event by 6-months.

  • Primary Outcomes:
    • Initial suicide screening was positive in 45/338 (13.3%) of the patients
    • Suicidality spectrum event 32/338 patients (9.5%) as mentioned
    • Of these 32, 18 (56%) were not suicidal at first presentation
    • Suicide attempts 10/338 (3%) but there were no completed suicides
    • Psychiatric hospitalizations 16/338 (5%)
    • Aborted/interrupted attempt 11/338 (3%)
    • Preparatory acts 13/338 (4%)
    • ED visit for suicidal thoughts 29/338 (9%)

The CFI-S took a median of three minutes to complete. It was done twice in 10 patients, with reasonable agreement (the scores were within 10% of each other in 8 out of 10 patients).

The health system’s existing two question screening tool missed 18 of the 32 SSEs (56%). Both physician gestalt and the CFI-S had moderate accuracy for SSEs.

If you look at the population of patient that had data for both tests, the area under the curve for the CFI-S was 0.77 and for physician gestalt 0.75, which are neither clinically nor statistically different. 

Listen to the podcast on iTunes or Google Play to hear Krista’s responses to our ten nerdy questions.

1) Consecutive or Convenience: In the methods you refer to the patients being enrolled as “consecutive and non-selected”. In the limitation section you say it was a convenience sample. Out of 95,000 visits over the year, only 338 patients were included in the trial. It wasn’t clear to us how these 338 patients were selected, nor how their demographics compare to the other 95,000 who weren’t included. Can you clarify this for us and is there a chance of selection bias?

2) Excluded Patients: You excluded intoxicated patients. However, intoxicated patients make up a large percentage of the patients presenting to the ED with suicidal ideation. Why did you decide not to include intoxicated patients?

3) External Validity: You focused on an urban ED, with a higher percentage of non-Caucasian and low-income patients, and a higher than average risk of suicidality. Do you see this being applied to a community hospital or rural setting with different patient populations?

4) Screening: You decided to try screening all adult ED patient, regardless of presenting complaint. We know test results are less accurate when applied to patients with very low pretest probabilities. Why did you decide to focus on all comers, rather than attempting to select patients at higher risk for psychiatric disease?

5) Composite Outcome: You used a composite outcome for the primary outcome. It combines things that are really important, such as completed suicide, with less important outcomes, like representation to the ED. Why did you decide to set a bigger target for the primary outcome?

Some physicians like myself might consider patients coming back to the ED to seek help for their suicidal thoughts a positive outcome not a negative outcome. They weren’t missed at all. They knew where to turn for help and were comfortable enough with the care to return.

6) Length of Follow-up: You decided to look at outcomes up to six months. That is a very long time. It is highly likely that patients’ moods will change over a 6-month period, and patients who were not suicidal at the initial visit may become so at some point. Why did you choose such a long time frame?

7) Harms: Your screening tool only took three minutes to complete, which is excellent when applying it to a single patient. However, if you wanted to apply this tool to all 95,000 presentations a year at your ED, it would take almost 5,000 hours to complete. That is the equivalent of almost 600 extra 8 hour physician shifts a year. Is this tool worth that cost, or the cost of other things we could be doing with that time in an already very busy environment?

8) Misses: There were 18 patients missed by the existing two question screen used in the department. However, there is not any information provided about these misses. Were they dangerous misses, in which patients actually came to harm, so simply patients that represented to the emergency department with suicidal ideation?

9) Predefined vs. Post-hoc Cut-Offs: You present cut-offs for the CFI-S of 0.65 and for clinician gestalt of 1.2. However, as far as I can tell, these were not predetermined, but rather based on this dataset. That would mean they could be overfit the current data and should be validated in an external population. Am I correct?

10) Clinical Gestalt: Why did you only have clinical gestalt on 190 of the 338 patients who agreed to participate in the study?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: The CFI-S MAY or MAY NOT help improve the detection of patients at high risk for future suicidality, but it doesn’t seem to improve on physician gestalt.

SGEM Bottom Line: Physician gestalt is probably still the most accurate and efficient manner of screening of psychiatric disease in the emergency department.

Case Resolution: After a brief discussion, you have no concerns about psychiatric problems, and discharge the patient home without any formal testing.

Clinical Application: Unless demonstrated to be better than clinical gestalt, it isn’t clear how an extra screening tool for suicidal ideation can help all comers in the emergency department.

Dr. Justin Morgenstern

What Do I Tell My Patient? You have sprained your ankle. We use a tool called the Ottawa ankle rule to decide if you need an x-ray. Based on this tool an x-ray is not needed and I can confidently say you have not broken your ankle. We will put a tensor bandage around your ankle, and you can take acetaminophen or ibuprofen for the pain. The nurse will give you are standard information sheet for managing a sprained ankle. Obviously if you have any other concerns about your health we are always happy to see you again in the emergency department.

Keener Kontest: Last weeks’ winner was Brandon McAlary a Paramedic. He knew rivaroxaban was the first synthetic direct Xa inhibitor marketed as a drug.

Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on screening ED patients for suicide? Tweet your comments using #SGEMHOP. What questions do you have for Krista and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learning website
  • Register and create a log in
  • Search for Academic Emergency Medicine – “April”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

Suicide Resources:

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’Guide to Emergency Medicine.

References:

  1. Owens PL, Fingar KR, Heslin KC, Mutter R, Booth CL. Emergency Department Visits Related to Suicidal Ideation, 2006–2013. Statistical Brief # 200. Rockville (MD): Agency for Healthcare Research and Quality, 2017.
  2. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–13.
  3. Boudreaux ED, Jaques ML, Brady KM, Matson A, Allen MH. The patient safety screener: validation of a brief suicide risk screener for emergency department settings. Arch Suicide Res 2015;19:151–60.
  4. Osman A, Bagge CL, Gutierrez PM, Konick LC, Kopper BA, Barrios FX. The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and nonclinical samples. Assessment 2001;8:443–54.
  5. Levey DF, Niculescu EM, Le-Niculescu H, et al. Towards understanding and predicting suicidality in women: biomarkers and clinical risk assessment. Mol Psychiatry 2016;21:768–85.
  6. Niculescu AB, Le-Niculescu H, Levey DF, et al. Precision medicine for suicidality: from universality to subtypes and personalization. Mol Psychiatry 2017;22:1250–73.
  7. Brucker K, Duggan C, Niezer J, et al. Assessing Risk of Future Suicidality in Emergency Department Patients Acad Emerg Med. 2018;