Never have I ever: Suicide Screening in the ED (Part 1)

Suicidal ideation is common in emergency care, and many at-risk patients will not disclose unless asked directly in a non-stigmatizing way. ED suicide screening centers on structured triage questions, higher-risk presentations such as substance use or unexplained crashes, and rapid identification of patients who may need immediate safety measures.

ED Suicide Risk Screening

• Hidden suicidal ideation: Patients disclose suicidal thoughts more often when clinicians ask plainly and without stigma, which is why passive detection misses a meaningful share of acute risk.
• High-risk ED presentations: Substance use disorder, especially alcohol or opioid-related visits, and unexplained single-vehicle crashes should raise concern for self-harm even when suicidal intent is not volunteered.
• Near-term mortality signal: A prior ED visit for suicidal ideation is a major red flag; one study found a 57-fold increase in death over the next 12 months, mostly from suicide.
• ED-SAFE triage screener: The ED-SAFE approach starts with 3 brief triage questions and escalates positive screens to a secondary assessment, a workflow we walk through in the episode.
• Secondary risk stratification: The ED-SAFE secondary screener uses 6 focused questions on intent, plan, mood change, and substance use to sort patients into mild, moderate, or high risk.
• Immediate safety response: Joint Commission guidance treats moderate- or high-risk screens, and patients presenting after an attempt, as indications for constant observation with a 1:1 sitter.

Why Screening Still Matters

• Universal screening rationale: If you screen everyone at triage, you will identify more patients with suicidal ideation than if screening depends on chief complaint or spontaneous disclosure.
• Outcome evidence limits: No ED screening strategy has clearly shown a mortality benefit, partly because suicidal ideation lacks a consistent gold standard definition across studies.
• Safety planning benefit: Screening matters when it leads to intervention; safety planning and structured follow-up contact have evidence for reducing later suicide mortality.
• Lethal means counseling: Asking about access to firearms or other lethal means is not just documentation; means-restriction counseling is associated with lower mortality after discharge.

References:

1. Wilson MP, Moutier C, Wolf L, Nordstrom K, Schulz T, Betz ME. ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020;38(3):571-581.PMID: 31493978.
2. Gentil L, Huỳnh C, Grenier G, Fleury MJ. Predictors of emergency department visits for suicidal ideation and suicide attempt. Psychiatry Res. Published online January 21, 2020. PMID: 32035375
3. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of Suicide and Other Mortality With Emergency Department Presentation. JAMA Netw Open. 2019;2(12):e1917571. Published 2019 Dec 2. PMID: 31834399
4. Isaacs JY, Smith MM, Sherry SB, Seno M, Moore ML, Stewart SH. Alcohol use and death by suicide: A meta-analysis of 33 studies. Suicide Life Threat Behav. 2022;52(4):600-614. PMID: 35181905
5. Miller IW, Camargo CA Jr, Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570. PMID: 28456130