Across a wide variety of practice environments, the concept of medically screening a patient who presents with suicidal ideation is often a source of friction between the emergency department and psychiatry. In theory, a medical screening exam would help the ED team identify acute medical conditions in patients with co-existing psychiatric pathology, but in reality, local guidelines and protocols can lead to extensive and often unnecessary medical workups in patients who present with strictly psychiatric chief complaints.
Medical Screening: One size may fit close to everyone
In the ED, every patient with suicidal ideation needs some form of a medical screening exam. Yet, to date, the literature does not support extensive medical screening for the vast majority of suicidal patients.
When evaluating a patient with suicidal ideation, the key things to look for are evidence of altered mental status and/or signs of attempts to harm themselves. Although suicidal patients can present with a variety of symptoms, the literature suggests that a good history and physical exam will identify most of the patients who also have an acute medical condition. While local guidelines may vary, the American College of Emergency Physicians (ACEP) recommends against ordering routine testing in patients who present with what seems like an isolated psychiatric symptom unless there are findings in the history or on the exam that would suggest that there is a significant underlying medical condition. Similarly, ACEP guidelines recommend against routine neuroimaging in patients with psychiatric complaints unless there are clear neurologic deficits.
Factors such as age, co-existing medical conditions, immunocompromise, and substance abuse may limit the efficacy of a screening history and physical. The literature suggests that despite these factors, the vast majority of adults who present with an acute psychiatric complaint are unlikely to have any lab abnormalities that would impact their disposition. In a retrospective look at over 500 adult patients who were admitted to inpatient psychiatry from the emergency department, Janiak et al. found that approximately two-thirds of the patients had labs performed in the emergency department. Out of the subset of patients who had labs performed, approximately one-third of them had completely normal labs. The most common lab abnormalities identified were positive drug screen, anemia, and hyperglycemia. In this study population there was only one patient who had findings on her initial ED medical screening exam that would have led to a different disposition. The authors describe a 46-year-old female who presented complaining of suicidal ideation and feeling "manic." The patient had a past medical history notable for hypertension, congestive heart failure, and chronic kidney disease and was taking a significant number of medications, including furosemide, spironolactone, digoxin, carvedilol, and diltiazem. In the ED, she reported having decreased energy and decreased appetite and was noted to have a heart rate of 114 bpm. Labs were not initially performed in the ED but were subsequently performed by the psychiatry team, and she was noted to have mild hyponatremia, mild hypokalemia, and mildly elevated creatinine. After being admitted to the psychiatry service, she developed hyperglycemia and had an anion gap of 27. Based on these findings, the patient received an inpatient medical consult but otherwise had no adverse events noted. Similar other studies have found that while the incidence of finding lab abnormalities is higher in medically complicated patients, the incidence of finding clinically significant issues remains exceptionally low.
“Medical Clearance” should not be the goal
One of the most crucial concepts involved with screening patients is moving away from the notion that once a patient has been assessed, they are “medically clear.” Ideally, teams in the ED and on the inpatient psychiatry side recognize that whatever assessment was performed in the ED is simply a single data point. In reality, it can be easy to label a patient as being “medically clear” and move on. This can lead to premature closure in the small subset of patients where an occult medical condition is not detected initially. As evidenced in the study by Janiak et al., patients change over time, and rather than implementing broad medical screening policies, the key takeaway should be that when seen in the ED, the patient appears to be medically stable which hopefully can guard against premature closure that can be associated with the term “medically clear.”
