eMedicine Specialties > Emergency Medicine > Psychosocial

Depression and Suicide: Treatment & Medication

Author: Louise B Andrew, MD, JD, Medical-Legal, Risk Management and Trial Consultant, Litigation Stress Counselor
Contributor Information and Disclosures

Updated: Jun 23, 2008

Treatment

Emergency Department Care

  • The responsibility of emergency department clinicians in managing a patient with depression is to maintain a high index of suspicion for the diagnosis, especially in populations at risk for suicide.
  • Although primary at-risk populations include young adults and elderly persons, depression and suicidality can occur in any age group, including children.
  • Depression should be strongly suspected as an underlying factor in drug abuse or overdose (including alcohol) with self-inflicted injury or even in an intentionally inflicted injury where the assailant is known to the victim. In any such patient, screening for diagnostic symptoms of major depression and suicidality is mandatory.
  • When a patient has contemplated or attempted suicide, the burden is on the health care provider to directly explore the situation with the patient in as much detail as possible to determine the current presence of suicidal ideation as well as accessible means and plans. Discussing these is the most important step emergency department clinicians can take in an attempt to prevent suicide in a patient at risk.
  • If suicidality is present, hospitalization with the patient's consent or via emergency commitment should be undertaken unless clearcut means to assure the patient's safety exist while outpatient treatment is begun. A child who is suicidal or has made an attempt at suicide should be admitted to a protected environment until all medical and social services can be employed.
  • Psychotherapeutic interventions act synergistically with pharmacologic therapy.
  • Patients may require additional interventions that can be instituted immediately on transfer from the ED, but never actually in the ED. Electroconvulsive therapy (ECT) is safe and can be quickly effective. It is usually reserved for refractory cases, cases of pharmacologic resistance or adverse effects, and cases in which rapid reversal is indicated. Newer treatment modalities for refractory depression, including electromagnetic transcranial stimulation and repetitive vagal stimulation, are becoming more widely available. For individuals who have previously been given a diagnosis and who have been successfully treated with these modalities, rapid reinstitution can be lifesaving.

Consultations

Consult a mental health clinician after a screening evaluation is complete and all acute medical complications are addressed. The protocol for consultation should be established by the institution and should be the same for every patient.

Medication

Antidepressant therapy generally would not be initiated in the emergency department, though regional variations exist. A psychiatrist should be consulted for definitive pharmaceutical intervention. After consultation, it may be appropriate to provide a small amount of the suggested medication to sustain the patient until follow-up. It may also be appropriate to renew a previously effective medication in small quantities and with the assurance of a follow-up mechanism that is accessible to the patient.

The variety and forms of antidepressant agents available and indications for each are beyond the scope of this article.

More on Depression and Suicide

Overview: Depression and Suicide
Differential Diagnoses & Workup: Depression and Suicide
Treatment & Medication: Depression and Suicide
Follow-up: Depression and Suicide
References
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References

  1. Angst J, Angst F, Stassen HH. Suicide risk in patients with major depressive disorder. J Clin Psychiatry. 1999;60 Suppl 2:57-62; discussion 75-6, 113-6. [Medline].

  2. Apter A, Horesh N, Gothelf D, et al. Relationship between self-disclosure and serious suicidal behavior. Compr Psychiatry. Jan-Feb 2001;42(1):70-5. [Medline].

  3. Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation. Am Fam Physician. Mar 15 1999;59(6):1500-6. [Medline].

  4. Harwitz D, Ravizza L. Suicide and depression. Emerg Med Clin North Am. May 2000;18(2):263-71, ix. [Medline].

  5. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. Oct 26 2005;294(16):2064-74. [Medline].

  6. Oquendo MA, Malone KM, Mann JJ. Suicide: risk factors and prevention in refractory major depression. Depress Anxiety. 1997;5(4):202-11. [Medline].

  7. Osvath P, Voros V, Fekete S. Life events and psychopathology in a group of suicide attempters. Psychopathology. Jan-Feb 2004;37(1):36-40. [Medline].

  8. Rives W. Emergency department assessment of suicidal patients. Psychiatr Clin North Am. Dec 1999;22(4):779-87, viii. [Medline].

  9. SK Goldsmith, TC Pellmar, AM Kleinman. Reducing Suicide: A National Imperative. Institute of Medicine Monograph. National Academies Press 2002;[Full Text].

  10. Verona E, Sachs-Ericsson N, Joiner TE. Suicide attempts associated with externalizing psychopathology in an epidemiological sample. Am J Psychiatry. Mar 2004;161(3):444-51. [Medline].

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Further Reading

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Keywords

depressive illness, mood disorder, suicidal, suicidality, suicide ideation, suicide attempt, suicide attempts, self-destructive acts, self-murder, suicide gesture, major depressive disorder, MDD, unipolar depression, unipolar affective disorder, serotonin, norepinephrine, dopamine, selective serotonin reuptake inhibitors, SSRIs, tricyclic antidepressants, TCAs, norepinephrine, NE, dopamine, DA, suicide, seasonal affective disorder, SAD, antidepressants, lithium, psychotherapy, substance abuse, alcohol abuse, drug abuse

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Contributor Information and Disclosures

Author

Louise B Andrew, MD, JD, Medical-Legal, Risk Management and Trial Consultant, Litigation Stress Counselor
Louise B Andrew, MD, JD is a member of the following medical societies: American Association of Women Emergency Physicians, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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