Unrecognized suicidal ideation in ED patients: are we missing an opportunity?

OBJECTIVE: To determine whether patients who disclosed suicidal ideation during a health-risk survey had their mental health symptoms documented by physicians and were given mental health referrals and to evaluate how many of these patients subsequently attempted suicide.
METHODS: As part of a larger survey, patients responded to questions on a computer kiosk about general health risk behaviors and mental health symptoms. Fifteen months after initiating the survey, we reviewed medical records on those patients who had disclosed suicidal ideation. A standardized abstraction sheet was used to collect data regarding the ED diagnosis at the time of enrollment, physician documentation of suicidal ideation, and referral to psychiatric services, as well as subsequent ED and clinic visits and suicide attempts.
RESULTS: Of the 165 patients who disclosed suicidal ideation on the computer survey, 118 charts (72%) were available. During the index ED visit, only 25% of patients had suicidal ideation or other mental health issues noted on the chart. The majority (76%) of patients were discharged home, 10% were transferred to psychiatric services, and 3% were admitted for medical reasons. Although 72 patients had no future visits to the ED or other hospital-affiliated clinics, 39% of patients had at least one subsequent visit to the ED, and 17% had at least one visit to the psychiatric services. Four patients attempted suicide after their initial index visit to the ED.
CONCLUSION: Suicidal ideation was self-disclosed frequently by waiting room patients in our urban ED, and patients who disclosed suicidal ideation did not always receive referrals for mental health services.