AUTHOR INFORMATION

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Authored by Louise B Andrew, MD, JD, Physician Litigation Mentor and Stress Counselor, Physician Well-Being, Independent Consultant

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

Edited by Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert C Harwood, MD, MPH, Program Director, Chair, Department of Emergency Medicine, Christ Hospital and Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago Medical School; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Barry Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, and Professor of Anatomy and Neurobiology, Research Director, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Author's Email:	Louise B Andrew, MD, JD
Editor's Email:	Dana A Stearns, MD

eMedicine Journal, April 11 2006, VOLUME 7, Number 4

INTRODUCTION

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Background: Depression is a potentially life-threatening mood disorder that affects up to 12% of the population, or approximately 17.6 million Americans each year. In addition to considerable pain and suffering that interfere with individual functioning, depression affects those who care about the ill person, sometimes destroying family relationships or work dynamics between the patient and others. The economic cost of depressive illness is estimated at $30-44 billion a year in the United States alone. The human cost cannot be overestimated.

As many as two thirds of the people with depression do not realize that they have a treatable illness and do not seek treatment. Persistent ignorance and misperceptions of the disease by the public, including many health providers, as a personal weakness or failing that can be willed or wished away leads to painful stigmatization and avoidance of the diagnosis by many of those affected.

Pathophysiology: The etiology of depression is multifactorial, but is thought to involve changes in receptor-neurotransmitter relationships in the limbic system. Serotonin and norepinephrine are the primary neurotransmitters involved but dopamine has also been related to depression.

A family history of depression is common. Bipolar disorder has a prominent depressive component but is a different clinical entity from depression. There is a possible defect on chromosome II or X, but current genetic research is inconclusive.

Frequency:

• In the US: An estimated 5-20% of the US population will experience depression at some time. Suicide accounted for 31,655 deaths in the US in 2002, or approximately 11 cases per 100,000 population.

• Internationally: In Eastern Europe, 10 countries report more than 27 suicides per 100,000 persons. Latin America and Muslim countries report the lowest rates, fewer than 6.5 cases per 100,000.

Mortality/Morbidity:

• The morbidity of the depression is difficult to quantify. The lethality of depression, however, is measurable and is the result of completed suicide, which is the ninth leading reported cause of death in the United States.

• In 2002, 1.5% of all deaths worldwide were attributed to suicide. The real number is unknown since underreporting is predictably significant. Suicide is estimated to be the eighth leading cause of death in all age ranges.

• Almost all people who kill themselves intentionally have a diagnosable mental disorder with or without substance abuse, which in itself, is often a result of attempted self-treatment for the symptoms of depression. Approximately two thirds of individuals who complete suicide have seen a physician within a month of their death.

Race: No racial preponderance exists in reportable depression or suicide.

• The risk of suicide is increased by concurrent alcohol and drug abuse, access to lethal means, hopelessness, pessimism and impulsivity, and reduced by help-seeking behavior, access to psychiatric treatment, and availability of family and other social supports.

Sex: More women than men seek treatment for depression, but this is not necessarily reflective of the true incidence of the disease.

• Although depression is more often diagnosed in women, more men than women die from suicide by a factor of 4.5:1. White men complete over 72% of all suicides, and 78% of suicide deaths involve firearms.

• It is estimated that 8-25 attempted suicides occur for every completion. Many of these are never discovered, or never reported. It is important to understand that the majority of suicide attempts are expressions of extreme distress, not merely bids for attention.

Age: The highest suicide rates are found in persons older than 85 years. However, suicide is also a selective killer of youth. It is the third leading cause of death among people aged 15-24 years, after unintentional injuries and homicide, and the second leading cause of death in college students. The mean age for successful completed suicides is 40 years.

CLINICAL

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History:

• Depression is often difficult to diagnose because it can manifest in so many different ways. For example, some depressed individuals seem to withdraw into apathy, while others may become irritable or even agitated. Eating and sleeping patterns can be exaggerated to either extreme, either excessive or almost eliminated. Observable or behavioral symptoms may be minimal despite profound inner turmoil. Depression is a pernicious and all encompassing disorder, generally affecting body, feelings, thoughts, and behaviors to varying degrees. Symptoms of depression include the following:

• Persistently sad, anxious, or empty moods

• Loss of pleasure in usual activities (anhedonia)

• Feelings of helplessness, guilt, or worthlessness

• Crying, hopelessness, or persistent pessimism

• Fatigue or decreased energy

• Loss of memory, concentration, or decision-making capability

• Restlessness, irritability

• Sleep disturbances

• Change in appetite or weight

• Physical symptoms that defy diagnosis and do not respond to treatment (especially pain and gastrointestinal complaints).

• Thoughts of suicide, death, or suicide attempts

• Poor self-image or esteem (as illustrated, for example, by verbal self-reproach)

• To establish the diagnosis of major depression, a patient must express one of the first 2 and at least 5 of the other symptoms listed above. Such disturbances must be present nearly daily for at least 2 weeks. Symptoms can last for months or years.

• Symptoms can cause significant personality changes and changes in work habits, making it difficult for others to empathize with the depressed individual. Some symptoms are so disabling that they interfere significantly with the patient's ability to function. In very severe cases, people with depression may be unable to eat or even to get out of bed.

• Symptomatic episodes may occur only once in a lifetime or may be recurrent, chronic, or longstanding; in some cases they seem to last forever. Occasionally, symptoms appear to be precipitated by life crises or other illnesses; at other times, they occur at random.

• Clinical depression commonly occurs concurrently with or can be precipitated by injury or other medical illnesses, and worsens the prognosis for these illnesses. Even the diagnosis of concurrent illness is made much more difficult by the presence of depression.

Physical: There are no inevitable physical findings of depression, though some manifestations may be seen quite often.

• Signs of depression may include the following:

• Psychomotor retardation or agitation, such as slowed speech, sighs, and long pauses

• Slowed body movements, even to the extent of motionlessness or catatonia

• Pacing, hand wringing, and pulling on hair

• Appearance of preoccupation

• Lack of eye contact

• Tearfulness or sad countenance

• Self-deprecatory manner, or belligerence and defiance (especially in adolescents)

• Memory loss, poor concentration, and poor abstract reasoning

Causes: In addition to depression, alcohol/substance abuse (especially cocaine), impulsiveness, and certain familial factors are highly associated with risk for suicide. These factors include a history of mental problems or substance abuse, suicide in the immediate family, family violence of any type, and separation or divorce.

Other risk factors include prior suicide attempt(s), presence of a firearm in the home, incarceration, and exposure to the suicidal behavior of family members, peers, celebrities, or even highly publicized fictional characters.

The incidence of depression in healthcare workers is comparable to that in the general population, though the rate of completion of suicide is higher.

• Alteration in the balance of neurotransmitters and/or their function

• Impaired synthesis of neurotransmitters

• Increased breakdown or metabolism of neurotransmitters

• Increased pump uptake of neurotransmitters

• Typically, neurotransmitters are passed from neuron to neuron. Subsequently they are (1) reabsorbed into the neuron where they are either destroyed by an enzyme or actively removed by a reuptake pump and stored until needed, or (2) destroyed by monoamine oxidase (MAO) located in the mitochondria.

• A decrease in the functional balance of these neurotransmitters causes certain types of depression (ie, decreased norepinephrine causes dullness and lethargy, and decreased serotonin causes irritability, hostility, and suicidal ideation).

• Environmental factors including coexisting illnesses or substance abuse (discussed above) may affect neurotransmitters and/or have an independent influence on depression.

DIFFERENTIALS

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Alcohol and Substance Abuse Evaluation
Amyotrophic Lateral Sclerosis
Anemia, Chronic
Anorexia Nervosa
Anxiety
Conversion Disorder
Delirium, Dementia, and Amnesia
Domestic Violence
Elder Abuse
Encephalitis
Endocarditis
Grief Support in the ED
HIV Infection and AIDS
Headache, Tension
Hypercalcemia
Hyperkalemia
Hypermagnesemia
Hypernatremia
Hyperparathyroidism
Hyperphosphatemia
Hyperthyroidism, Thyroid Storm, and Graves Disease
Hypoglycemia
Hypokalemia
Hypomagnesemia
Hyponatremia
Hypopituitarism
Hypothermia
Hypothyroidism and Myxedema Coma
Litigation Stress
Meningitis
Metabolic Acidosis
Multiple Sclerosis
Myasthenia Gravis
Myopathies
Panic Disorders
Pediatrics, Child Abuse
Pediatrics, Child Sexual Abuse
Plant Poisoning, Glycosides - Cardiac
Plant Poisoning, Hypoglycemics
Polymyalgia Rheumatica
Schizophrenia
Sexual Assault
Subdural Hematoma
Tick-Borne Diseases, Lyme
Tick-Borne Diseases, Rocky Mountain Spotted Fever
Toxicity, Acetaminophen
Toxicity, Alcohols
Toxicity, Ammonia
Toxicity, Antidepressant
Toxicity, Antihistamine
Toxicity, Barbiturate
Toxicity, Benzodiazepine
Toxicity, Beta-blocker
Toxicity, Digitalis
Toxicity, Gamma-Hydroxybutyrate
Toxicity, Lithium
Toxicity, Narcotics
Toxicity, Phenytoin
Toxicity, Sedative-Hypnotics
Toxicity, Valproate
Vestibular Neuronitis
Withdrawal Syndromes

Other Problems to be Considered:

Posttraumatic stress disorders
Postpartum depression
Postpartum psychosis
Sheehan syndrome
Chronic fatigue syndrome
Liver failure
Vitamin deficiency
Medication adverse effects
Medication abuse/overdose
Withdrawal from abused substances
Apathetic thyrotoxicosis (in elderly persons)

WORKUP

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Lab Studies:

• Depression is a clinical diagnosis. Laboratory tests are primarily used to rule out other diagnoses. Consider the following laboratory tests:

• Complete blood count (CBC)

• Electrolytes, including calcium, phosphate, and magnesium

• BUN and creatinine

• Calcium

• Serum toxicology screen

• Thyroid function tests

• Thyroid-stimulating hormone (TSH) level

Imaging Studies:

• CT scan or MRI of brain if OBS or hypopituitarism is included in the differential

Other Tests:

• Electrocardiogram (ECG): Diagnosis of arrhythmia, particularly heart block

• Electroencephalogram (EEG)

• Certain psychometric tests can make a diagnosis of depressive disorders with reasonable clinical certainty; however, these are not generally available in emergency departments.

• Zung Self-Rating Depression Scale

• Beck Depression Inventory (BDI)

• Criteria for Epidemiologic Studies-Depression (CES-D) scale

• Studies - Depression scale:

• Children's Depression Inventory (CDI)

• Yesavage Geriatric Depression Scale

TREATMENT

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Emergency Department Care:

• The emergency physician's responsibility 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 physician 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 an ED physician 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

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Antidepressant therapy usually should not be initiated by an emergency physician. 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.

FOLLOW-UP

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Further Inpatient Care:

• When depression is diagnosed, particularly when suicidality is present or reasonably suspected, the physician, often in consultation with a mental health professional, should design an interim disposition plan appropriate to the diagnosis and degree of risk that is assessed.

• This may require legal certification that the patient is in need of emergency evaluation and protective observation, emergency or short-course medication, contracting for safety with the patient, and/or releasing the patient in the protective custody of the family or law enforcement agency.

• While evaluating and securing an appropriate disposition for the patient, all staff members must take measures to ensure the safety and preserve the dignity of the patient.

Transfer:

• Transfer is indicated when there is a need for protective custody or intensive intervention that is not available at the present institution.

Complications:

• Suicide

• Failure to improve

• Drug reaction

Prognosis:

• The ED can sometimes be the last opportunity for intervention in the downward spiral of depression, which leads to death for a significant number of those affected. Although the clinician may never see the results of protective intervention, statistics suggest that the presentation of a depressed and suicidal patient to a physician is an opportunity to really make a difference and possibly to save a life. Few diseases are as lethal yet so reversible as depression. Lives can be and are saved every day as the result of the timely efforts and empathic interventions of skilled and compassionate emergency physicians who are knowledgeable, empathic, and motivated to deal effectively with depression.

Patient Education:

• Patients must be told clearly and convincingly that depression is an eminently treatable illness.

• Carefully inform patients about the critical importance of taking any medications that are prescribed, as well as likely adverse effects and their management.

• Stress the need for short-term follow-up and continuing treatment.

• Recommend reading for patients. A good source of information about depression is the Depression and Affective Disorders Association as well as the National Alliance for the Mentally Ill.

• For excellent patient education resources, visit eMedicine's Depression Center and Antidepressants Center. Also, see eMedicine's patient education articles Depression, Suicidal Thoughts, Understanding Antidepressant Medications, and SSRIs and Depression.

MISCELLANEOUS

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Medical/Legal Pitfalls:

• Failure to recognize or appropriately hospitalize a suicidal patient

• Failure to document historical details demonstrating lack of suicidality

• Failure to follow transfer protocols in accordance with the Emergency Medicine Treatment and Active Labor Act (EMTALA) (Note that under current EMTALA interpretations, even a discharge is considered a transfer.)

• Failure to prescribe suicide precautions for a possibly suicidal patient who is discharged to an institutional setting (such as correctional facilities) rather than a psychiatric setting.

• Failure to warn others of any threat made concerning them by a patient who is not to be admitted to protective custody.

• Failure to provide a source of follow-up care or to advise on indications to return to the ED.

• Failure to warn patient and significant others about potential signs of deterioration and suicidality and what to do about them.

TEST QUESTIONS

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CME Question 1: Which of the following is the most important action for an emergency physician to perform in an attempt to prevent suicide in a patient who is at risk?

A: Inquire about any previous suicide attempts or gestures.
B: Inquire about family history of mental illness or suicide.
C: Look for evidence of prior attempts on physical examination.
D: Ask family members about suicidal statements.
E: Ask the patient about ideas, means, and plans.

The correct answer is E: The best way to assess current suicidality and risk is by assessing the patient`s recent ideation, access to potential means (especially a firearm), and formulation of a plan. All of the other questions are important historical features, but this is the critical information required to determine current risk. Contrary to popular belief, discussing seriously a patient`s plans to complete suicide is often a relief to the patient and not a stimulus to action.

CME Question 2: Which of the following types of patient is, on average, most prone to suicide?

A: A middle-aged woman with a long-standing history of depression and domestic abuse
B: A young incarcerated male in alcohol withdrawal
C: An elderly widower with multiple chronic illnesses and no living relatives
D: A young female who has overdosed and has job and relationship problems
E: A teenager with cocaine use, school problems, and access to a firearm in the home

The correct answer is E: Although each of these patients is at increased risk, the impulsivity, access to lethal weapon, and substance abuse make the teenager the most likely to be immediately at risk. The elderly patient could be a close second.

Pearl Question 1 (T/F): Persons aged 40-50 years have the highest suicide rate.

The correct answer is False: Persons older than 85 years have the highest suicide rate, followed by young adults.

Pearl Question 2 (T/F): Approximately 40% of attempted suicides are successful.

The correct answer is False: Approximately 4-12% of attempts are successful; however, the number of attempts and completed suicides are highly underreported because of the stigma of suicide.

Pearl Question 3 (T/F): The incidence of clinical depression in the United States is approximately 12%.

The correct answer is True: The National Institute of Mental Health (NIMH) estimates that depression affects up to 12% of the population.

Pearl Question 4 (T/F): Depressed people always appear sad.

The correct answer is False: Depression can take many different forms. One difficult to recognize but not uncommon presentation, especially in young persons, is irritability.

BIBLIOGRAPHY

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• 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].
• Apter A, Horesh N, Gothelf D, et al: Relationship between self-disclosure and serious suicidal behavior. Compr Psychiatry 2001 Jan-Feb; 42(1): 70-5[Medline].
• Gliatto MF, Rai AK: Evaluation and treatment of patients with suicidal ideation. Am Fam Physician 1999 Mar 15; 59(6): 1500-6[Medline].
• Harwitz D, Ravizza L: Suicide and depression. Emerg Med Clin North Am 2000 May; 18(2): 263-71, ix[Medline].
• Mann JJ, Apter A, Bertolote J, et al: Suicide prevention strategies: a systematic review. JAMA 2005 Oct 26; 294(16): 2064-74[Medline].
• Oquendo MA, Malone KM, Mann JJ: Suicide: risk factors and prevention in refractory major depression. Depress Anxiety 1997; 5(4): 202-11[Medline].
• Osvath P, Voros V, Fekete S: Life events and psychopathology in a group of suicide attempters. Psychopathology 2004 Jan-Feb; 37(1): 36-40[Medline].
• Rives W: Emergency department assessment of suicidal patients. Psychiatr Clin North Am 1999 Dec; 22(4): 779-87, viii[Medline].
• SK Goldsmith, TC Pellmar, AM Kleinman: Reducing Suicide: A National Imperative. Institute of Medicine Monograph National Academies Press 2002;[Full Text].
• Verona E, Sachs-Ericsson N, Joiner TE: Suicide attempts associated with externalizing psychopathology in an epidemiological sample. Am J Psychiatry 2004 Mar; 161(3): 444-51[Medline].

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