Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit
This measure aims to improve rates of clinician assessment of suicide risk during an encounter where a new or recurrent episode of major depressive disorder (MDD) is identified. In an epidemiologic study of mental illness in the United States with a large, representative sample, 69% of respondents with lifetime suicide attempts had also met diagnostic criteria for MDD. When considering other mood disorders related to depression, such as dysthymia and bipolar disorders, this rate increases to 74% (Bolton & Robinson, 2010). In a study of individuals who had died by suicide and were enrolled in one of eight major health systems in the United States, individuals with a depressive disorder diagnosis had 7.20 increased odds of dying by suicide within one year, after adjusting for age and sociodemographic factors (Yeh et al., 2019). A recent meta-analysis (Moitra et al., 2021) presented similar findings in which depressive disorder conferred a predictive relative risk for suicide of 7.64 after adjusting for relevant factors.
Suicide is associated with increased use of healthcare services, which provides an opportunity for intervention through assessment and intervention. Individuals who die by suicide are more likely to have any healthcare utilization (Ahmedani et al., 2019) and a higher frequency of healthcare visits than the general population (Chock, Bommersbach, Geske, & Bostwick, 2015). A study of individuals who died by suicide and were enrolled within one of eight health systems in the Mental Health Research Network in the United States found that 50% of these individuals had been seen in a health care setting within four weeks prior to death (Ahmedani et al., 2014). Better assessment and identification of suicide risk in the health care setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide. A recent analysis of depression severity and suicidal ideation symptom trajectories (Witt et al., 2021) found that suicidal ideation among children and young adults (15-25 years) might not improve with depression symptom severity. This evidence suggests the potential utility of continued suicide risk screening after improvements in depression symptoms.
Clinical Recommendation Statement
A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder [I] (American Psychiatric Association, 2010a, reaffirmed 2015).
Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness [I] (American Psychiatric Association, 2010a, reaffirmed 2015).
As part of the assessment process, impulsivity and potential for risk to others should also be evaluated, including any history of violence or violent or homicidal ideas, plans, or intentions [I] (American Psychiatric Association, 2010a, reaffirmed 2015).
The patient's risk of harm to him- or herself and to others should also be monitored as treatment proceeds [I] (American Psychiatric Association, 2010a, reaffirmed 2015).
Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors (from American Psychiatric Association’s Practice Guideline for Assessment and Treatment of Patients With Suicidal Behaviors, 2010b):
ADMISSION GENERALLY INDICATED
After a suicide attempt or aborted suicide attempt if:
- Patient is psychotic
- Attempt was violent, near-lethal, or premeditated
- Precautions were taken to avoid rescue or discovery
- Persistent plan and/or intent is present
- Distress is increased or patient regrets surviving
- Patient is male, older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking
- Patient has limited family and/or social support, including lack of stable living situation
- Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident
- Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting
In the presence of suicidal ideation with:
- Specific plan with high lethality
- High suicidal intent
ADMISSION MAY BE NECESSARY
After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated
In the presence of suicidal ideation with:
- Major psychiatric disorder
- Past attempts, particularly if medically serious
- Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection)
- Lack of response to or inability to cooperate with partial hospital or outpatient treatment
- Need for supervised setting for medication trial or ECT
- Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
- Limited family and/or social support, including lack of stable living situation
- Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up
- Evidence of putting one's affairs in order (e.g., giving away possessions, writing a will)
In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk
RELEASE FROM EMERGENCY DEPARTMENT WITH FOLLOW-UP RECOMMENDATIONS MAY BE POSSIBLE
After a suicide attempt or in the presence of suicidal ideation/plan when:
- Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient's view of situation has changed since coming to emergency department
- Plan/method and intent have low lethality
- Patient has stable and supportive living situation
- Patient is able to cooperate with recommendations for follow-up, with treater contacted, if possible, if patient is currently in treatment
Outpatient treatment may be more beneficial than hospitalization
Patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, if a safe and supportive living situation is available and outpatient psychiatric care is ongoing