CME Information : Assessing Risk of Future Suicidality in Emergency Department Patients

Background: Emergency departments (ED) are the first line of evaluation for patients at risk and in crisis, with or without overt suicidality (ideation, attempts). Currently employed triage and assessments methods miss some of the individuals who subsequently become suicidal. The Convergent Functional Information for Suicidality (CFI-S) 22-item checklist of risk factors, which does not ask directly about suicidal ideation, has demonstrated good predictive ability for suicidality in previous studies in psychiatrict patients but has not been tested in the realworld setting of EDs. Methods: We administered CFI-S prospectively to a convenience sample of consecutive ED patients. Patients were also asked at triage about suicidal thoughts or intentions per standard ED suicide clinical screening (SCS), and the treating ED physician was asked to fill a physician gestalt visual analog scale (VAS) for likelihood of future suicidality spectrum events (SSE; ideation, preparatory acts, attempts, completed suicide). We performed structured chart review and telephone follow-up at 6 months post–index visit. Results: The median time to complete the CFI-S was 3 minutes (first to third quartile = 3–6 minutes). Of the 338 patients enrolled, 45 (13.3%) were positive on the initial SCS, and 32 (9.5%) experienced a SSE in the 6 months of follow-up. Overall, SCS had modest diagnostic accuracy sensitivity 14/32 = 44%, (95% CI: 26–62%) and specificity 275/306 = 90%, (86–93%). The physician VAS also had moderate overall diagnostic accuracy (AUC 0.75, confidence interval [CI] = 0.66–0.85), and the CFI-S was best (AUC = 0.81, CI = 0.76–0.87). The top CFI-S differentiating items were psychiatric illness, perceived uselessness, and social isolation. 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. With more than 4 million visits to the ED annually in the United States for mental disorders, the ED is considered by many to be the first line of evaluation for patients at risk and in crisis, with or without overt suicidality (ideation, attempts). The weighted national estimate of patients with a diagnosis From the Department of Emergency Medicine (KB, CD, JAK) and the Department of Psychiatry (JN, KR, HL, ABN), Indiana University School of Medicine; and the Indianapolis VA Medical Center (ABN), Indianapolis, IN. Received May 8, 2018; revision received August 11, 2018; accepted August 21, 2018. This work was funded by NIMH/NHLBI K12HL133310 to JK, ABN, and KB and an Eli Lilly Foundation Physician Scientist Award to KB. KB, CD, JN, ABN, and JK report no conflict of interest related to this work. ABN is listed as an inventor on a patent application for suicide biomarkers filed by Indiana University. Author contributions: JK and ABN designed the study; KB, CD, and JN collected data; KB, KR, HLN, ABN, and JK analyzed data and wrote the manuscript; and all authors reviewed the final manuscript and agreed with it. Supervising Editor: Harrison Alter, MD. Address for correspondence and reprints: Alexander B. Niculescu, MD, PhD, or Jeffrey A. Kline, MD; e-mail: anicules@iupui.edu or jefkline@iupui.edu. ACADEMIC EMERGENCY MEDICINE 2019;26:376–383. 376 ISSN 1553-2712 © 2018 by the Society for Academic Emergency Medicine doi: 10.1111/acem.13562 of “suicide or intentional self-harm” in the National Emergency Department Sample for 2013 was 1,411,770, patients, with 98.8% of those with suicidality as a first diagnosis discharged from the ED. In 2013, visits for suicidal ideation accounted for nearly 1% of all adult ED visits (108.3 million visits). To better predict and prevent suicides, emergency care providers need improved risk stratification tools for patients with overt or covert mental health crisis. Several tools—PHQ9, the ED-Safe Patient Safety Screener and the Suicide Behaviors Questionnaire– Revised (SBQ-R)—have been created and validated for suicide screening. All of these include direct questioning about current or recent suicidal thoughts. None of these tools has been compared to physician gestalt or evaluated for their ability to predict rates of adverse suicide-related events in patients who screen negative using the tool. There are yet no widespread clinically used simple objective tools to assess and track changes in suicidal risk without asking the individuals directly, although others in the field besides us are actively working on this problem and progress is being made (for example Nock and colleagues, Boudreaux and colleagues). Such tools are desperately needed, as individuals at risk may choose not to share their ideation or intent with others, for fear of stigma or hospitalization or that in fact their plans may be thwarted. The Convergent Functional Information for Suicidality (CFI-S) is a novel suicide risk instrument that comprises 22 questions and has shown good to excellent predictive value for suicidality in settings other than the emergency department (ED). The CFI-S is a checklist of risk factors for suicidality from a variety of domains including life satisfaction, mental health, physical health, environmental stress, addictions, cultural factors, and demographic information and assigns a numeric point value for each response, 0 for absent or 1 for present. In essence, it is a “polyphenic” risk score, by analogy with polygenic risk scores. The tool was designed to be easy to score by self-administration or clinician administration or based on medical records or next-of-kin information. Of note, it does not ask directly about suicidal ideation, as that is a delicate question in many nonspecialized settings, and people who are truly suicidal might not share that information for fear of being stopped. We hypothesized that the CFI-S could be used in a heterogeneous sample of ED patients to identify highrisk patients whose elevated risk was missed by both standard screening and by physician evaluation as measured by their gestalt impression of future risk. We sought to test the accuracy of the CFI-S and physician gestalt visual analog scale (VAS) in a sample of urban ED patients, with a traditionally high proportion of non-Caucasians and low-income individuals. The reason for this is this population has a higherthan-average risk of suicidality but with the lowest access to mental health services. Thus, in this population, the need for accurate suicide risk assessment is compounded by the lack of current identification of nonovert suicidal ideation and the need for pragmatic use of limited resources.