Suicidal Patient Assessment

Quick Answer

One-liner: Comprehensive suicide risk assessment requires structured evaluation of ideation severity, risk/protective factors, and safety planning, not risk categorization prediction.

Emergency Department (ED) suicide assessment has shifted from "predicting" suicide (statistically impossible with acceptable sensitivity/specificity) to stratifying risk and implementing evidence-based interventions. Use validated screening tools (C-SSRS, ASQ), assess modifiable risk factors, strengthen protective factors, and create collaborative safety plans. Universal screening detects twice as many at-risk patients compared to clinical intuition alone. Never rely on "no-suicide contracts"—they lack evidence and legal standing.

---

ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Neuroanatomical basis of depression/suicidality (prefrontal cortex, limbic system)
• Physiology: Neurotransmitter dysregulation (serotonin, noradrenaline, dopamine)
• Pharmacology: Psychotropic medications, antidote knowledge for overdoses

Fellowship Exam Relevance

• Written: Universal screening protocols, involuntary detention criteria, safety planning, lethal means counseling
• OSCE: Risk assessment communication, breaking bad news (high risk), capacity assessment, involuntary detention documentation
• Key domains tested: Medical Expert, Communicator, Professional (ethics), Health Advocate (Indigenous health equity)

---

Key Points

---

Epidemiology

Australian/NZ Specific

• Indigenous Australians: Suicide rates 2-4 times higher than non-Indigenous Australians, especially in remote communities [5]
• Māori (NZ): Suicide rates 1.6 times higher than non-Māori, with youth disproportionately affected [6]
• Rural/remote: Higher rates due to social isolation, limited mental health access, firearm access [7]
• Psychiatric boarding: Mental health patients wait 2.5-3 times longer in ED (8-24+ hours vs 4-hour target) [8]

---

Pathophysiology

Biological Mechanisms

Suicidal behavior is multifactorial, involving:

• Neurotransmitter dysregulation: Serotonin hypofunction (impulsivity, aggression), noradrenaline/dopamine deficits (anhedonia, hopelessness)
• HPA axis dysfunction: Chronic stress → cortisol dysregulation → prefrontal cortex impairment
• Genetic factors: 43-55% heritability for suicide attempts; family history increases risk 3-4 fold [9]

Psychological Progression

Chronic stressors + Psychiatric illness → Hopelessness + Cognitive rigidity → Suicidal ideation → Planning → Attempt → (Survival or Completion)

Why It Matters Clinically

Understanding that suicide is not impulsive in most cases (70% have ideation for weeks/months before attempt) allows for intervention windows. The transition from ideation to attempt is influenced by access to means and protective factors.

---

Clinical Approach

Recognition

Triggers for suicide screening in ED:

• All psychiatric presentations
• Deliberate self-harm/overdose
• High-risk groups: Chronic pain, terminal illness, recent psychiatric discharge, substance abuse
• Universal screening: Joint Commission mandates screening for all behavioral health evaluations

Initial Assessment

Primary Survey (if post-attempt)

• A: Airway protection (GCS <8 post-overdose/hanging)
• B: Respiratory depression (opioid/benzodiazepine overdose), hypoxia (hanging)
• C: Haemodynamic stability (exsanguination, dysrhythmia from TCA/beta-blocker)
• D: GCS, pupils, blood glucose, antidote administration
• E: Ligature marks, wrist lacerations, pill bottles, toxicology screen

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Appearance: Self-neglect, disheveled, flat affect, psychomotor retardation
• Behavior: Agitation, pacing, poor eye contact, tearfulness
• Injuries: Ligature marks (neck), wrist lacerations (vertical vs horizontal), signs of physical trauma

Specific Findings

---

Investigations

Immediate (Resus Bay - post-attempt)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

Not routinely indicated for suicide assessment, but useful for complications:

• FAST scan: Post-jump/fall with abdominal trauma
• Cardiac ultrasound: Cardiotoxic overdose (TCA, beta-blocker)

---

Management

Immediate Management (First 10 minutes)

1. Ensure safety: Remove sharps, ligatures, belts; 1:1 nursing observation
2. Medical stabilization: ABCDE resuscitation if post-attempt (airway, antidotes, decontamination)
3. Initiate universal screening: ASQ (pediatric) or C-SSRS (adult) within first 30 minutes
4. Contact psychiatry early: Minimize boarding time; initiate telepsychiatry if needed
5. Engage family/whānau: Cultural safety for Indigenous patients; family involvement in safety planning

Structured Risk Assessment

Columbia Suicide Severity Rating Scale (C-SSRS)

Gold standard validated tool [14]

Ideation Severity (past month):

1. Wish to be dead: "I wish I were dead" (passive)
2. Non-specific active ideation: "I've thought about killing myself"
3. Ideation with method: "I've thought about overdosing"
4. Ideation with intent (no plan): "I've seriously considered it"
5. Ideation with intent AND plan: "I plan to hang myself on Friday" (HIGHEST RISK)

Behavior (lifetime and past 3 months):

• Actual attempt
• Interrupted attempt
• Aborted attempt
• Preparatory acts (writing note, gathering pills)

Predictive validity: C-SSRS severity ≥4 predicts attempt with OR 6.5 [14]

Alternative: Ask Suicide-Screening Questions (ASQ) - Pediatric

Sensitivity 96.9%, Specificity 87.6% [15]

1. "Do you wish you were dead?"
2. "Do you have thoughts about killing yourself?"
3. "Have you ever tried to kill yourself?"
4. "In the past week, have you been thinking about killing yourself?"

Positive screen = YES to any question → Full C-SSRS assessment

Risk and Protective Factors

Static Risk Factors (cannot be modified)

• Previous suicide attempt: Strongest predictor (OR 10-20) [11]
• Psychiatric illness: Depression (OR 20), bipolar (OR 15), schizophrenia (OR 8.5) [16]
• Substance use disorder: Alcohol (OR 6), drugs (OR 5) [17]
• Male gender: 3x higher completion rate (but females attempt 2x more often)
• Age extremes: Adolescents (15-24), middle-aged (45-54)
• Family history: First-degree relative suicide (OR 3-4) [9]

Dynamic Risk Factors (modifiable - TARGET THESE)

• Access to lethal means: Firearms (OR 3-5), pesticides (OR 2-3) [12]
• Acute psychiatric crisis: Recent discharge from inpatient unit (30-day high-risk period)
• Psychosocial stressors: Job loss, relationship breakdown, financial crisis
• Hopelessness: Beck Hopelessness Scale greater than 9 predicts attempt [13]
• Social isolation: Living alone, estranged from family
• Acute intoxication: Alcohol/drugs reduce inhibition, increase impulsivity

Protective Factors (strengthen these)

• Reasons for living: Children, pets, religious beliefs, future goals
• Strong social support: Family, friends, whānau, community
• Therapeutic alliance: Engaged with mental health services
• Problem-solving skills: Ability to manage distress, seek help
• Restricted access to means: No firearms in home, medications locked away

Safety Planning Intervention (Stanley-Brown Model)

Evidence: Reduces suicide attempts by 20-50% at 1 year [18]

Six-step collaborative process (written document given to patient):

1. Recognize warning signs
   • "I feel hopeless"

• "I isolate myself"
• "I drink heavily"

2. Internal coping strategies (use BEFORE contacting others)
   • "Go for a walk"

• "Listen to music"
• "Practice breathing exercises"

3. Social contacts for distraction (NOT for crisis support)
   • "Call my sister to chat"

• "Visit a friend"
• "Go to the gym"

4. Contacts for crisis support

   • "Call my psychologist (Dr. Smith: 04XX XXX XXX)"
   • "Call Lifeline 13 11 14 (24/7)"
   • "Call mental health crisis team (1800 XXX XXX)"

5. Professional/agency contacts

   • "Go to [Hospital Name] ED"
   • "Call ambulance 000"

6. Lethal means restriction

   • "Give my medications to my partner to store"
   • "Remove firearms from home (store at gun club)"

Lethal Means Counseling

Most effective suicide prevention intervention [19]

Firearms:

• Remove from home (store with friend, gun club, police where legal)
• Even temporary removal (during crisis period) reduces risk 3-5 fold
• "Off-site storage" is gold standard (NOT locked safe at home)

Medications:

• Remove excess paracetamol, NSAIDs, psychotropics from home
• Blister packs only (NO bottles)
• Family/friend holds and dispenses daily doses

Pesticides/Herbicides (rural/farming):

• Lock away in separate shed (not in main house)
• Family member holds key

Counseling approach: Non-judgmental, collaborative, focus on "waiting period" between impulse and action (most suicidal crises last <10 minutes) [20]

Involuntary Detention Criteria (Australian Mental Health Acts)

All Australian states require THREE criteria:

1. Mental illness present (defined by Act)
2. Imminent risk of serious harm to self or others
3. Refusal or incapacity to consent to voluntary treatment

State-specific variations:

Documentation requirements:

• Clear evidence of mental illness (not just suicidal ideation)
• Specific risk of harm (not vague "risk to self")
• Voluntary options exhausted or refused
• Capacity assessment documented
• Least restrictive option chosen

Common pitfalls:

• Intoxication alone: NOT sufficient for Mental Health Act detention (use Emergency Detention)
• Personality disorder: May not meet "mental illness" criteria in some states
• Social crisis: Homelessness, relationship breakdown ≠ mental illness

---

Disposition

Admission Criteria (Inpatient Psychiatry)

• Active suicidal ideation with plan and intent (C-SSRS ≥4)
• Recent high-lethality attempt
• Psychotic symptoms with command hallucinations
• Lack of protective factors / unsafe home environment
• Inability to contract for safety (lack of insight/capacity)
• Ongoing acute intoxication requiring medical clearance

ICU/HDU Criteria

• Medical complications of attempt: Severe overdose, hanging with anoxic brain injury, major trauma
• Ongoing resuscitation requirements
• Cardiac monitoring for cardiotoxic ingestion

Discharge Criteria (Safe for Home)

• Suicidal ideation resolved or significantly reduced
• No active plan or intent
• Strong protective factors identified
• Safety plan completed and understood
• Lethal means removed from home
• Follow-up arranged within 24-72 hours (mental health team, GP, or crisis team)
• Capacity to keep self safe
• Supportive home environment

Follow-up

Critical 30-day period: Highest risk immediately post-discharge [21]

Mandatory components:

1. Scheduled appointment within 24-72 hours: Mental health team or GP
2. "Caring contacts": Phone call or text at 1 week, 1 month, 3 months (reduces attempts by 20%) [22]
3. GP notification: Discharge summary within 24 hours
4. Crisis contact card: Lifeline 13 11 14, local mental health crisis team, safety plan

Red flags to return:

• Worsening suicidal thoughts
• Unable to keep self safe
• Access to lethal means
• Acute intoxication
• Psychotic symptoms emerge

---

Special Populations

Paediatric Considerations

• Use ASQ for initial screening (4 questions, 96.9% sensitivity) [15]
• Involve parents/guardians in safety planning (unless family conflict is trigger)
• Remove lethal means: Firearms, medications (parents often underestimate teen access)
• School notification: Coordinate with school counselor if patient consents
• Higher impulsivity: Adolescents have less developed prefrontal cortex → increased risk

Pregnancy

• Perinatal depression: 10-15% of pregnant/postpartum women
• Medication safety: SSRIs generally safe (except paroxetine); avoid benzodiazepines
• Infanticide risk: Assess risk to infant in postpartum psychosis
• Multidisciplinary approach: Obstetrics, psychiatry, social work

Elderly

• Higher completion rates: Lower attempt-to-completion ratio (1:4 vs 1:20 in young adults)
• Less impulsive: More likely to use lethal means (firearms, hanging)
• Comorbidities: Chronic pain, terminal illness, bereavement, social isolation
• Screen for dementia: Cognitive impairment may mask depression

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

• Suicide rates 2-4 times higher than non-Indigenous Australians (especially youth, remote communities) [5,6]
• Cultural safety: Avoid clinical "interrogation"; use yarning (narrative-based communication) to build trust [23]
• Social and Emotional Wellbeing (SEWB): Assess connection to country, culture, ancestors, community (not just individual psychiatric symptoms) [24]
• Whānau involvement (Māori): Family-centered decision-making (tikanga, manaakitanga protocols)
• Aboriginal Health Workers: Co-facilitate assessment where possible; cultural liaison services
• Intergenerational trauma: Current ideation often linked to historical loss of land, culture, identity [23]
• Strengths-based approach: "What keeps you strong?" vs "What's wrong with you?"
• Spiritual distress: Disconnection from ancestors/spirit is high-risk indicator (not captured by DSM-5) [24]
• Interpreter services: Mandatory for non-English speakers (NOT family members)

---

Pitfalls & Pearls

---

Viva Practice

---

OSCE Scenarios

Station 1: Suicide Risk Assessment and Safety Planning

Format: Communication Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the ED registrar. Ms. Sarah Chen, a 34-year-old accountant, has presented with her partner stating "I can't cope anymore." She has a history of depression and took an overdose of 10 paracetamol tablets 2 years ago. Your task is to:

1. Assess her suicide risk using a structured approach
2. Create a safety plan collaboratively
3. Decide on appropriate disposition

Examiner Instructions: Ms. Chen is tearful, cooperative, and willing to engage. She reports:

• Suicidal thoughts for past 2 weeks ("I think about it every day")
• No specific plan ("I haven't thought that far")
• No intent ("I don't actually want to die, I just want the pain to stop")
• Protective factors: Supportive partner, 8-year-old daughter, employed, engaged with psychologist
• Access to means: Husband's antidepressants at home (50x sertraline 100mg), no firearms
• Previous attempt: Paracetamol overdose 2 years ago (8 hours hospital observation, no NAC)

If asked directly: "I would never leave my daughter without a mother."

Actor/Patient Brief: You are Sarah, exhausted from work stress and feeling overwhelmed. You are relieved to be talking to someone. You WANT help. You will engage openly if the doctor is empathetic and non-judgmental. If the doctor seems rushed or dismissive, become tearful and withdrawn.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Uses structured tool (C-SSRS) vs vague questions
  • Creates written safety plan vs verbal reassurance
  • Addresses lethal means (medications) vs ignores
  • Arranges follow-up within 24-72 hours vs "see GP when you can"

---

Station 2: Involuntary Detention Discussion

Format: Communication (difficult conversation) Time: 11 minutes Setting: ED consultation room

Candidate Instructions:

Mr. David Brown, a 52-year-old with bipolar disorder, presented after a suicide attempt (hanging, interrupted by wife). He is medically stable. Psychiatry has recommended involuntary detention for inpatient admission, but Mr. Brown is refusing. Your task is to:

1. Explain the involuntary detention decision
2. Address his concerns
3. Obtain his cooperation (or manage refusal)

Examiner Instructions: Mr. Brown is angry, feels "trapped," and states "You can't force me to stay, I know my rights!" He has capacity to understand the situation but disagrees with the decision. He will challenge the candidate on legal grounds. If handled empathetically, he will reluctantly agree. If candidate is defensive or authoritarian, he will escalate anger.

Actor/Patient Brief: You are David, feeling humiliated and angry. You attempted suicide in a moment of despair but now feel better and want to go home to your wife. You believe the doctors are "overreacting." You will argue: "I have the right to refuse treatment!" and "You're just covering yourselves legally." If the doctor listens to your concerns and explains clearly WITHOUT being condescending, you will reluctantly accept.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Empathetic vs authoritarian approach
  • Explains legal criteria clearly vs vague "for your safety"
  • Discusses patient rights (appeal) vs ignores
  • Obtains cooperation vs escalates conflict

---

Station 3: Breaking Bad News (High Suicide Risk)

Format: Communication Time: 11 minutes Setting: ED relatives' room

Candidate Instructions:

You are the ED registrar. Mrs. Linda Grant's 17-year-old son, Tom, was brought in after a serious suicide attempt (hanging, 5 minutes without oxygen). He is intubated in ICU with severe anoxic brain injury. Prognosis is poor (likely persistent vegetative state or death). Mrs. Grant is in the relatives' room waiting for an update. Your task is to:

1. Break the bad news about Tom's condition
2. Address her questions about "why this happened"
3. Provide ongoing support

Examiner Instructions: Mrs. Grant is devastated, tearful, and in shock. She had "no idea" Tom was suicidal. She will ask: "Why didn't he tell me?" "Is this my fault?" "Will he recover?" Candidate must navigate grief, guilt, and uncertainty while providing clear medical information.

Actor/Patient Brief: You are Linda, Tom's mother. You are overwhelmed with grief and guilt. Tom seemed "fine" yesterday. You blame yourself for not noticing. You will cry, ask repetitive questions, and need reassurance that this is not your fault. If the doctor is empathetic and patient, you will eventually accept the information. If rushed or cold, you will become angry.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Uses "warning shot" vs blurts bad news
  • Addresses guilt compassionately vs ignores
  • Offers ongoing support vs "hands off to ICU"
  • Allows time for questions vs rushes

---

SAQ Practice

Question 1 (8 marks)

Stem: A 28-year-old woman presents to ED stating "I took 50 paracetamol tablets 30 minutes ago because I want to die." She is tearful, alert (GCS 15), and medically stable. Observations: HR 88, BP 125/78, SpO2 99% on room air, temperature 36.8°C.

Question: Outline your immediate management in the first 30 minutes (8 marks).

Model Answer:

1. Safety: Remove sharps, ligatures, belts from room; 1:1 nursing observation; high-visibility room (1 mark)
2. Medical resuscitation: IV access, bloods (paracetamol level at 4 hours post-ingestion, FBC, UEC, LFTs, coagulation), VBG (1 mark)
3. Decontamination: Activated charcoal 50g PO if within 1-2 hours of ingestion (currently 30 minutes → YES) (1 mark)
4. Antidote: N-acetylcysteine (NAC) if paracetamol level greater than 150 mg/L at 4 hours (start empirically if delay in level) (1 mark)
5. Suicide risk assessment: Use C-SSRS or ASQ to assess ideation severity, plan, intent, access to means, protective factors (1 mark)
6. Contact psychiatry: Early referral for assessment (minimize boarding time) (1 mark)
7. Engage support: Contact family/partner with patient consent; involve in safety planning (1 mark)
8. Document: Exact words ("I want to die"), timeline, mental state examination, capacity assessment (1 mark)

Examiner Notes:

• Accept: Gastric lavage within 1 hour (though less effective than charcoal)
• Do not accept: "No-suicide contract", discharge without psychiatry review, delaying NAC
• Common mistakes: Forgetting activated charcoal (within 1-2 hours), not contacting psychiatry, inadequate documentation

---

Question 2 (6 marks)

Stem: A 45-year-old man with depression is being discharged from ED after presenting with suicidal ideation (no plan, no intent). He is medically stable, cooperative, and has supportive family.

Question: List SIX components of the Safety Planning Intervention that must be completed before discharge (6 marks).

Model Answer:

1. Warning signs: Recognize personal triggers (e.g., "I feel hopeless," "I isolate myself") (1 mark)
2. Internal coping strategies: Activities to do BEFORE contacting others (e.g., "Go for a walk," "Listen to music," "Deep breathing") (1 mark)
3. Social contacts for distraction: People to contact for non-crisis support (e.g., "Call my brother to chat," "Visit a friend") (1 mark)
4. Contacts for crisis support: People who can help in a crisis (e.g., "Call my psychologist," "Call Lifeline 13 11 14") (1 mark)
5. Professional/agency contacts: Emergency services (e.g., "Go to [Hospital Name] ED," "Call ambulance 000") (1 mark)
6. Lethal means restriction: Remove firearms, medications, pesticides from home (e.g., "Give my medications to my wife to store") (1 mark)

Examiner Notes:

• Accept: Any reasonable examples of each component
• Do not accept: "No-suicide contract" as component (NOT evidence-based)
• Common mistakes: Missing lethal means restriction, vague "call someone" without specific contacts

---

Question 3 (8 marks)

Stem: You are working in a rural ED. A 58-year-old male farmer has been brought in after an interrupted hanging attempt. He is medically stable but states "I'm a burden to my family, they'd be better off without me." He has access to firearms at home.

Question: Describe your approach to lethal means counseling for this patient (8 marks).

Model Answer:

1. Non-judgmental approach: "Many people in your situation have thoughts like these. Let's talk about how to keep you safe." (1 mark)
2. Firearms removal: Collaborate with family to remove ALL firearms from property. Store at police station, gun club, or friend's home (NOT locked safe at home) (2 marks)
3. Temporary removal: Emphasize this is TEMPORARY (during crisis period), not permanent confiscation. Increases patient buy-in (1 mark)
4. Rope/ligatures: Remove from home. Family disposes of rope used in attempt. Lock shed if contains ligatures (1 mark)
5. Pesticides/herbicides: Common in farming households. Lock away in separate shed (NOT in main house). Family member holds key (1 mark)
6. Medications: Remove excess paracetamol, antidepressants. Provide only 2-3 days supply in blister packs (NOT bottles). Family dispenses daily (1 mark)
7. Document: Record specific means removed, who removed them, where stored. Include in safety plan (1 mark)

Examiner Notes:

• Accept: Any reasonable approach to removing lethal means
• Do not accept: "Patient promises not to use firearms" (NOT effective), locked safe at home (still accessible)
• Common mistakes: Not addressing firearms (rural-specific), not involving family, temporary vs permanent removal

---

Question 4 (8 marks)

Stem: A 16-year-old Aboriginal girl presents with suicidal ideation. She has a history of childhood trauma (removed from family at age 8) and is currently living with her aunt. She is withdrawn and reluctant to engage with you.

Question: Describe FOUR culturally safe practices you would use to assess this patient (8 marks).

Model Answer:

1. Involve Aboriginal Health Worker or cultural liaison: Co-facilitate assessment to build trust and ensure cultural safety (2 marks)
2. Whānau/family engagement: Involve aunt (primary caregiver) in assessment and safety planning. Recognize family-centered decision-making (2 marks)
3. Yarning approach: Use narrative storytelling (not "interrogation" style). Allow patient to share story in her own words. Builds rapport (2 marks)
4. Assess Social and Emotional Wellbeing (SEWB): Ask about connection to culture, community, Country, Elders (holistic wellbeing, not just individual psychiatric symptoms) (2 marks)

Alternative acceptable answers (choose 4 from 6): 5. Trauma-informed care: Acknowledge childhood removal ("Stolen Generations" trauma). Avoid triggering questions. Build safety first (2 marks) 6. Strengths-based approach: "What keeps you strong?" vs "What's wrong with you?" Identify cultural identity, art, music, community as protective factors (2 marks)

Examiner Notes:

• Accept: Any 4 of the 6 components (2 marks each)
• Do not accept: "Just be nice," "Treat her like any other patient" (NOT culturally safe)
• Common mistakes: Not involving Aboriginal Health Worker, not assessing SEWB, Western-only psychiatric framework

---

Australian Guidelines

ARC/ANZCOR

• Not applicable: Suicide assessment is not covered by resuscitation guidelines

Therapeutic Guidelines

• Therapeutic Guidelines: Psychotropic (Version 8, 2024):
  • Antidepressant initiation in suicidal depression (SSRI first-line)
  • Avoid tricyclic antidepressants (TCA) due to overdose lethality
  • Benzodiazepines for acute agitation (short-term only)

State-Specific (Mental Health Acts)

NSW: Mental Health Act 2007

• Section 19: Emergency detention by police (up to 6 hours)
• Section 27: Recommendation for involuntary admission (up to 3 days)
• Criteria: Mental illness + risk of serious harm + refusal of voluntary treatment
• Requires: 2 medical practitioners OR 1 psychiatrist + 1 other practitioner

VIC: Mental Health and Wellbeing Act 2022

• Assessment Order: Up to 24 hours
• Temporary Treatment Order: Up to 28 days
• Emphasizes: Human rights, recovery-oriented, consumer/carer involvement
• Requires: 1 registered medical practitioner + 1 mental health practitioner

QLD: Mental Health Act 2016

• Emergency Examination Authority (EEA): Up to 6 hours
• Recommendation for Assessment: Up to 7 days
• Criteria: "Least restrictive way" principle
• Requires: 1 doctor OR authorized mental health practitioner

WA: Mental Health Act 2014

• Referral for Psychiatric Assessment: Up to 24 hours
• Involuntary Treatment Order: Up to 28 days
• Requires: 1 medical practitioner

---

Remote/Rural Considerations

Pre-Hospital

• Ambulance paramedics: Trained in Mental Health First Aid; can initiate involuntary transport under state legislation
• Police welfare check: Can be requested if patient leaves ED AMA (Against Medical Advice) and risk remains high
• RFDS coordination: May require mental health retrieval (10-15% of RFDS retrievals are psychiatric) [28]

Resource-Limited Setting

• No on-site psychiatry: Use telepsychiatry (videolink to tertiary psychiatrist)
• Telepsychiatry equivalent outcomes: Assessment accuracy comparable to in-person [31]
• Limited secure area: Improvise with high-visibility room, 1:1 nursing/security
• Medication options: Olanzapine PO/IM (sedation), droperidol IM (rapid tranquilization)

Retrieval

Criteria for RFDS retrieval:

• Involuntary detention requiring inpatient admission (no local psychiatric beds)
• High-risk patient requiring tertiary mental health unit
• Medical complications requiring tertiary ICU (anoxic brain injury post-hanging)

Retrieval challenges:

• Delay 6-24 hours (depends on distance, weather, aircraft availability)
• Boarding in rural ED during wait (intervention essential)
• Blood products/medications may be limited (arrange in advance)

RFDS mental health team: Doctor + nurse ± psychiatrist (telepsychiatry during flight)

Telemedicine

• Telepsychiatry: Videolink assessment by psychiatrist (equivalent to in-person)
• Rural follow-up: Videolink appointments with mental health team (reduces travel burden)
• "Caring contacts": Phone/SMS follow-up at 1 week, 1 month, 3 months (reduces attempts) [22]

---

Post-Attempt Medical Complications

Hanging/Strangulation

Mechanism: Compression of carotid arteries → cerebral hypoxia; compression of trachea → asphyxiation

Clinical features:

• Ligature marks: Horizontal (hanging), angled upward (strangulation)
• Petechiae: Conjunctival, facial (venous congestion)
• Delayed complications: Cerebral edema (peaks 24-72h), laryngeal edema (airway obstruction)

Management:

1. Airway: Intubation if GCS ≤8, severe stridor, or hypoxia (SpO2 <90%)
2. Cervical spine precautions: Until clinically/radiologically cleared
3. CT brain: If GCS <15, focal neurology, or prolonged hypoxic time (greater than 5 minutes)
4. Observation: Minimum 6 hours for delayed neurological deterioration
5. ICU admission: Anoxic brain injury, ongoing ventilation, therapeutic hypothermia consideration

Prognostic indicators [64]:

• GCS on arrival: GCS 3-5 = 80% mortality or persistent vegetative state
• Duration of hypoxia: greater than 10 minutes = poor neurological outcome
• Cardiac arrest: Pre-hospital cardiac arrest = 90% mortality

Overdose/Poisoning

Common agents:

• Paracetamol: 150g nomogram, NAC within 8 hours (24-hour protocol in Australia)
• Tricyclic antidepressants (TCA): QRS greater than 100ms, sodium bicarbonate 50-100 mEq IV
• Benzodiazepines: Flumazenil generally NOT recommended (seizure risk)
• SSRIs: Serotonin syndrome (hyperthermia, rigidity, clonus) → cyproheptadine 4-8mg PO
• Opioids: Naloxone 400-800 mcg IV/IM/IN; may require infusion (fentanyl, methadone)

Key principles:

1. Never discharge after self-poisoning until medically cleared (paracetamol level at 4h minimum)
2. Activated charcoal: Within 1-2 hours if greater than 30 tablets ingested
3. Enhanced elimination: Hemodialysis for salicylate, lithium, methanol, ethylene glycol
4. Psychiatric assessment: Only AFTER medical clearance (capacity intact, not intoxicated)

Wrist Lacerations

Assessment:

• Horizontal ("cry for help"): Superficial, minimal tendon/nerve injury
• Vertical ("serious intent"): Deep, often involves tendons/nerves/arteries

Management:

1. Haemostasis: Direct pressure, elevation, tourniquet if exsanguinating
2. Tendon examination: Flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), flexor pollicis longus (FPL)
3. Nerve examination: Median, ulnar, radial nerve motor and sensory function
4. Vascular examination: Radial/ulnar pulses, Allen test, cap refill
5. Surgical referral: Tendon/nerve/arterial injury requires hand surgery within 6-12 hours
6. Tetanus prophylaxis: If not up to date

Disposition:

• Simple lacerations: Primary closure, hand clinic follow-up 48 hours
• Complex injuries: Theatre for exploration and repair

---

Pharmacological Management of Acute Agitation

Indications for Sedation

• Severe agitation preventing assessment
• Risk of violence to self/staff/others
• Refusing to stay for involuntary detention
• Intoxication with disinhibition

First-Line Agents (Oral)

Olanzapine (Zyprexa):

• Dose: 5-10mg PO (wafer dissolves in mouth)
• Onset: 30-60 minutes
• Duration: 6-12 hours
• Advantages: Non-sedating at low doses, low EPS risk, oral formulation
• Cautions: Avoid in Parkinson's, elderly (stroke risk), diabetes (hyperglycemia)

Lorazepam (Ativan):

• Dose: 1-2mg PO
• Onset: 20-30 minutes
• Duration: 6-8 hours
• Advantages: Rapid onset, reversible (flumazenil)
• Cautions: Respiratory depression (especially with opioids/alcohol), paradoxical agitation in dementia

Intramuscular Agents (if refusing PO)

Olanzapine IM:

• Dose: 5-10mg IM
• Onset: 15-30 minutes
• Cautions: DO NOT combine with IM benzodiazepines (respiratory depression, hypotension)

Droperidol (Droleptan):

• Dose: 5-10mg IM
• Onset: 5-10 minutes (fastest)
• Duration: 2-4 hours
• Advantages: Rapid, effective, short duration
• Cautions: QT prolongation (monitor ECG), avoid if QTc greater than 500ms, extrapyramidal symptoms (EPS) 5-10% [65]

Midazolam IM:

• Dose: 5-10mg IM
• Onset: 5-15 minutes
• Cautions: Respiratory depression, requires monitoring, paradoxical agitation

Mechanical Restraint

Indications (last resort):

• Imminent risk of violence to self/others
• Pharmacological sedation failed or contraindicated
• Acute medical emergency requiring immediate treatment (e.g., intubation)

Principles [66]:

• Least restrictive: Only use if verbal de-escalation and medication failed
• Time-limited: Maximum 4 hours, reassess hourly
• Documentation: Justification, alternatives tried, duration, reassessment
• Observation: Continuous 1:1 nursing, vital signs q15min
• Complications: Asphyxiation (prone position), rhabdomyolysis, VTE, psychological trauma

Legal requirements: Most Australian states require Medical Officer documentation + nursing supervision

---

Specific High-Risk Populations

Chronic Pain Patients

Why at risk:

• Depression comorbidity: 30-50% [67]
• Opioid use: Disinhibition, overdose risk
• Functional impairment: Hopelessness, financial stress
• Social isolation: Withdrawal from activities

Assessment considerations:

• Pain-focused ideation: "If I can't get rid of this pain, I'll end it"
• Opioid contracts: Review if patient has diverted medications for overdose
• Functional assessment: What has pain taken away? (work, hobbies, relationships)

Management:

• Pain optimization: Multimodal analgesia, refer to pain clinic
• Opioid safety: Limit quantity (3-7 days max), naloxone prescription, family holds medications
• Depression screening: PHQ-9, refer to psychologist
• Functional restoration: Physiotherapy, occupational therapy, graded exercise

Terminal Illness

Why at risk:

• Loss of autonomy and dignity
• Uncontrolled symptoms (pain, dyspnea, nausea)
• Fear of suffering and being a burden
• Depression (not inevitable in terminal illness)

Assessment:

• Distinguish: Passive death wish ("I wish it would be over") vs active suicidal intent ("I plan to overdose")
• Palliative care consultation: Symptom optimization may reduce passive wishes
• Depression treatment: SSRIs (start low, go slow), psychotherapy
• Advanced care planning: Discuss goals of care, resuscitation preferences (NOT "no-suicide contract")

Ethical considerations:

• Voluntary Assisted Dying (VAD): Legal in VIC, WA, TAS, QLD, SA, NSW (specific eligibility criteria)
• VAD ≠ Suicide: Legally distinct; patients must have capacity, terminal illness (<6-12 months), and follow formal process
• Suicidal ideation in VAD-eligible patients: Still requires assessment and treatment of reversible factors (depression, pain)

Post-Discharge Psychiatric Patients

Why at risk:

• Critical 30-day period: 100-200x higher suicide risk than general population [21]
• Transition of care gaps: Medication changes, discharge planning, follow-up delays
• Loss of structured environment: 24/7 supervision → independent living

Risk factors for post-discharge suicide:

• Discharged against medical advice (AMA)
• No outpatient follow-up arranged
• Recent diagnosis of serious mental illness
• Multiple previous admissions
• Lack of social support

Preventive interventions:

• Immediate follow-up: Appointment within 7 days of discharge (ideally 48 hours)
• Caring contacts: Phone call at 1, 2, 4, 8, 12 weeks post-discharge [22]
• Crisis planning: Written safety plan given at discharge
• GP notification: Discharge summary sent within 24 hours (email, fax, or electronic health record)
• Medication supply: 7-14 days max (NOT 30 days); family holds excess
• Community mental health team: Handover to case manager

LGBTQI+ Individuals

Why at risk:

• Discrimination and stigma: Minority stress, family rejection, bullying
• Higher rates: 2-3x higher suicide attempts than heterosexual/cisgender peers [68]
• Trans and gender-diverse youth: 40-50% lifetime suicide attempt rate [69]

Assessment considerations:

• Use patient's pronouns and chosen name: Builds trust, reduces distress
• Ask about discrimination: "Have you experienced discrimination related to your sexuality/gender identity?"
• Family support: Assess acceptance vs rejection (family rejection = 8x higher suicide risk) [70]
• Access to LGBTQI+ services: Refer to LGBTQI+ mental health services, QLife (1800 184 527)

Management:

• Affirming care: Validate identity, avoid pathologizing
• Safety planning: Include LGBTQI+ supports (QLife, Lifeline, local LGBTQI+ groups)
• Referral: LGBTQI+ affirmative psychologist or psychiatrist

---

Crisis Intervention Techniques in the ED

De-escalation Strategies

Verbal de-escalation (use BEFORE medication/restraint):

1. SAFER approach [71]:

   • Self-regulation: Remain calm, controlled voice, non-threatening posture
   • Assess: Identify triggers (pain, fear, frustration)
   • Facilitate: Help patient identify solutions
   • Empathize: Validate feelings ("I can see you're very distressed")
   • Respond: Offer choices, collaborate on plan

2. Environmental modification:

   • Quiet room, low lighting, door open (reduce sense of confinement)
   • Remove unnecessary staff (limit to 2-3 people max)
   • Offer food, drink, blanket (basic needs)
   • Remove stressors (loud alarms, bright lights, overcrowding)

3. Communication techniques:

   • Active listening: Reflect back ("You're saying you feel hopeless right now?")
   • Validate emotions: "It makes sense you feel this way given what you've been through"
   • Avoid: Arguing, challenging delusions, dismissing concerns ("You don't really want to die")
   • Offer choices: "Would you like to talk here or in a quieter room?"

Contraindications to de-escalation (move to medication/restraint):

• Imminent violence: Patient making threats, brandishing weapon
• Psychotic agitation: Not responding to verbal cues, paranoid, disorganized
• Intoxication: Severe agitation from stimulants (methamphetamine, cocaine)

Motivational Interviewing for Ambivalent Patients

Principle: Most suicidal patients are ambivalent (want pain to end, not life to end). Use MI to strengthen life side.

OARS technique [72]:

1. Open-ended questions: "Tell me about what's been happening"
2. Affirmations: "You've been incredibly strong to make it through this"
3. Reflective listening: "It sounds like you feel trapped and don't see a way out"
4. Summarizing: "Let me make sure I understand – you're struggling with work stress, financial problems, and feeling isolated..."

Eliciting change talk:

• "What are your reasons for living?" (not "Do you have reasons for living?")
• "What would need to change for you to feel hopeful again?"
• "How have you coped with difficult times in the past?"
• "What's important to you right now?" (children, pets, future goals)

Developing discrepancy:

• "You said you love your daughter more than anything, AND you're thinking about ending your life. How do these two things fit together?"
• (Patient realizes discrepancy → strengthens commitment to life)

Managing the "Manipulative" or "Frequent Flyer" Patient

Common scenario: Patient with borderline personality disorder (BPD) or chronic suicidality, multiple ED presentations

Pitfalls to avoid:

• Labeling as "manipulative": Invalidates distress, prevents empathy, increases staff burnout
• Dismissing risk: BPD patients have same lifetime suicide risk as major depression (8-10%) [27]
• Inconsistent management: Different approaches on each visit → reinforces "splitting" behavior

Evidence-based approach [73]:

1. Consistent multidisciplinary plan: ED, psychiatry, community mental health agree on approach
2. Brief focused assessment: C-SSRS, current stressors, safety plan review (NOT lengthy exploration of past trauma in ED)
3. Validate distress + Set boundaries: "I can see you're in a lot of pain right now. We're here to keep you safe. Let's focus on getting you through tonight safely"
4. Safety planning: Short-term coping (distraction, grounding), crisis contacts, means restriction
5. Avoid admission for "respite": Admission only if acute risk (plan + intent + means). Frequent admissions reinforce maladaptive coping
6. Dialectical Behavior Therapy (DBT) referral: Gold standard for BPD (reduces self-harm by 50%) [74]

Boundary setting example:

"Sarah, I understand you're in a lot of pain, and we want to help. However, I need to be honest with you: the Emergency Department isn't the right place for long-term support. What we CAN do is make sure you're safe tonight and connect you with your DBT therapist tomorrow. Let's make a plan for the next 24 hours."

Collaborative Problem-Solving

For patients refusing admission (when involuntary detention not justified):

Step 1: Understand concerns

• "What are your concerns about staying in hospital?"
• Common responses: "I'll lose my job"
  • "Who will feed my dog?"
  • "Hospitals make me worse"

Step 2: Validate + Problem-solve

• "I understand you're worried about your job. Let's think about how we can address that. Could you call your employer and explain you're in hospital for a medical issue? Would a medical certificate help?"
• "I hear you about your dog. Is there someone who can feed him tonight? Your neighbor? We can help you make that phone call right now."

Step 3: Negotiate compromise

• "I'm concerned about your safety. How about we keep you overnight for observation, and if you're feeling better in the morning, we'll reassess?"
• "I know you don't want to stay, but I need to know you're safe. Can we agree that you'll call the crisis team every 4 hours tonight to check in?"

Step 4: Safety net if negotiation fails

• "I appreciate you working with me on this. If at any point tonight you feel unable to keep yourself safe, I need you to promise you'll call 000 or come straight back to ED. Can you commit to that?"

---

Special Clinical Scenarios

Suicide by Police (Suicide by Cop)

Definition: Deliberately engaging in life-threatening behavior toward police to provoke lethal force

Recognition:

• Threatening police with weapon (often replica/unloaded)
• Verbal statements: "Shoot me!" "I'm not going back to prison!"
• Recent suicidal ideation/attempt
• Substance intoxication

ED role:

• Post-police shooting: Trauma resuscitation (gunshot wounds)
• Psychiatric assessment: If patient survives, assess underlying suicidal intent
• Police statement: Patient may face charges; inform patient about legal implications
• Family support: Family grief + guilt + anger toward police

Prevention (police training):

• Crisis Intervention Teams (CIT): Police trained in mental health de-escalation
• Less-lethal options: Tasers, bean bag rounds, containment strategies

Mass Casualty Suicide Events

Examples: Suicide pacts, cluster suicides (contagion), mass shootings with suicidal intent

ED response:

• Activate mass casualty protocol: Multiple suicidal/self-harm patients
• Triaging: Medical stability THEN psychiatric risk
• Resource allocation: Psychiatry, social work, crisis teams
• Media management: Prevent sensationalized reporting (contagion risk)

Postvention (after completed suicide in community):

• Suicide clusters: School, workplace, Indigenous community
• Postvention team: Psychologists, social workers, community leaders
• Screening vulnerable individuals: Friends, classmates, family
• Media guidelines: Avoid graphic details, method, glorification

Physician/Healthcare Worker Suicide

Why at risk:

• Higher rates: Doctors have 1.4-2.3x higher suicide rate than general population [75]
• Access to means: Knowledge of lethal doses, access to medications
• Stigma: Fear of professional consequences (medical board, loss of license)
• Culture of stoicism: "Doctors don't get depressed"

Barriers to care:

• Mandatory reporting requirements (some states)
• Fear of career impact
• Lack of time (work demands)
• Self-treatment (inappropriate)

ED approach:

• Treat as any other patient: No special treatment, same assessment
• Confidentiality: Standard ED confidentiality rules apply
• Avoid minimizing: "You're a doctor, you know better than to do this" → invalidates distress
• Specialized services: Refer to doctor-specific support services (Beyond Blue Doctors' Helpline 1300 BEYONDBLUE)
• Mandatory reporting: Only if serious risk to public (impaired doctor actively practicing), NOT for suicide risk alone

Preventive strategies:

• Medical board reform: Reduce punitive reporting, encourage help-seeking
• Peer support programs: Confidential doctor-to-doctor support
• Workplace culture: Normalize mental health discussions, reduce stigma

---

Documentation Essentials

Medico-Legal Considerations

High-risk presentation: Suicide assessment is high medico-legal risk. Thorough documentation is essential.

Essential documentation:

1. Verbatim quotes: Document patient's exact words about suicidal thoughts ("I want to die"

• "I have a plan")

2. Risk factors: Static (previous attempts, family history) and dynamic (access to means, acute stressors)
3. Protective factors: Reasons for living, social support, engagement with treatment
4. Capacity assessment: Understanding, retention, weighing options, communication
5. Screening tool results: C-SSRS scores, ASQ responses (attach to notes)
6. Safety plan: Written copy in medical record + given to patient
7. Lethal means counseling: What means discussed, who will remove them, documented in plan
8. Disposition decision: Admission vs discharge + rationale
9. Follow-up arranged: Specific appointment time/date/provider
10. Red flags to return: Documented in discharge instructions

If discharging suicidal patient:

• Justify decision: "Low severity ideation (C-SSRS 2), strong protective factors (supportive family, employed), safety plan completed, lethal means removed, follow-up arranged 48 hours with mental health team"
• NOT acceptable: "Patient denies suicidal ideation" (without structured tool)

If involuntary detention:

• State-specific form: Complete Mental Health Act form (varies by state)
• Three criteria documented: Mental illness + imminent risk of serious harm + refusal/incapacity
• Least restrictive alternative: Why voluntary admission not suitable
• Consultation: Psychiatry consulted and agrees with detention
• Patient informed: Documented that patient informed of detention, rights to appeal, legal representation

Discharge Documentation Template

Example discharge summary:

DISCHARGE SUMMARY: SUICIDAL IDEATION

Assessment Tool: Columbia Suicide Severity Rating Scale (C-SSRS)
- Ideation severity: Level 2 (non-specific active ideation) – "I've thought about killing myself"
- No specific plan, no intent, no preparatory acts
- Protective factors: 8-year-old daughter ("I would never leave her"), supportive partner, employed, engaged with psychologist

Risk Factors:
- Previous attempt: Paracetamol overdose 2 years ago (10 tablets, no NAC required)
- Current stressors: Work stress, financial difficulties
- Access to means: Husband's sertraline 100mg x50 tablets at home

Safety Plan Completed:
1. Warning signs: "I feel hopeless, I isolate myself, I stop eating"
2. Internal coping: "Go for a walk, call my sister, listen to music"
3. Crisis contacts: "Psychologist Dr. Smith 04XX XXX XXX, Lifeline 13 11 14"
4. Professional contacts: "[Hospital Name] ED, ambulance 000"
5. Lethal means: Husband to remove sertraline from home, lock in car (patient does not have car key)

Disposition: Discharge to home with partner (supportive, aware of safety plan)
Follow-up: Mental health team appointment 09:00 Friday 26/01/2026 (48 hours)
Red flags: Worsening suicidal thoughts, unable to keep self safe, access to medications

Documented with patient: "If you feel unsafe at any time, call Lifeline 13 11 14 or come back to ED immediately"
Discharge instructions given: Written copy, patient verbalized understanding

---

References

Guidelines

1. Australian Bureau of Statistics. Causes of Death, Australia, 2023. ABS Cat. No. 3303.0. Canberra: ABS; 2024.
2. Knott JC, et al. Mental health presentations to Victorian emergency departments: 2016-2021. Emerg Med Australas. 2022;34(5):672-679.

Key Evidence

3. Da Cruz D, et al. Suicide following discharge from psychiatric inpatient care. Lancet Psychiatry. 2016;3(7):628-637. PMID: 27086885
4. Owens D, et al. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry. 2002;181:193-199. PMID: 12204922
5. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2020. Cat. No. IHPF-2. Canberra: AIHW; 2020.
6. Ministry of Health New Zealand. Suicide Facts: 2016 data. Wellington: MOH; 2018.
7. Hirsch JK. A review of the literature on rural suicide: risk and protective factors, incidence, and prevention. Crisis. 2006;27(4):189-199. PMID: 17219751
8. Gerdtz MF, et al. Waiting times and length of stay for mental health patients in Australian emergency departments. Emerg Med Australas. 2019;31(2):219-226. PMID: 30953457
9. Brent DA, et al. Familial pathways to early-onset suicide attempt. Arch Gen Psychiatry. 2002;59(9):801-807. PMID: 12215079
10. Dazzi T, et al. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychol Med. 2014;44(16):3361-3363. PMID: 24998511
11. Ribeiro JD, et al. Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychol Med. 2016;46(2):225-236. PMID: 26370729
12. Miller M, et al. Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am J Epidemiol. 2013;178(6):946-955. PMID: 23975641
13. Beck AT, et al. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry. 1985;142(5):559-563. PMID: 3985195
14. Posner K, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies. Am J Psychiatry. 2011;168(12):1266-1277. PMID: 22193671
15. Horowitz LM, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170-1176. PMID: 23027402
16. Chesney E, et al. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13(2):153-160. PMID: 24890068
17. Wilcox HC, et al. The relationship of alcohol and drug use to suicide ideation and attempts among adolescents. Drug Alcohol Depend. 2004;76(Suppl):S11-19. PMID: 15555812
18. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256-264. PMID: 29800013
19. Mann JJ, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064-2074. PMID: 16249421
20. Williams CL, et al. Duration of suicidal crises. Crisis. 1980;1(1):42-44.
21. Chung DT, et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(7):694-702. PMID: 28564699
22. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv. 2001;52(6):828-833. PMID: 11376229
23. Dudgeon P, et al. Solutions that work: what the evidence and our people tell us. Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project Report. Perth: University of Western Australia; 2016.
24. Gee G, et al. Aboriginal and Torres Strait Islander social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, editors. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. 2nd ed. Canberra: Commonwealth of Australia; 2014. p.55-68.
25. Boudreaux ED, et al. Improving suicide risk screening and detection in the emergency department. Am J Prev Med. 2016;50(4):445-453. PMID: 26654691
26. Stanford EJ, et al. No-harm contracts and suicide risk assessment. Psychiatr Serv. 1994;45(5):495-497. PMID: 8045543
27. Paris J. Suicidality in Borderline Personality Disorder. Medicina (Kaunas). 2019;55(6):223. PMID: 31146508
28. O'Meara P, et al. Royal Flying Doctor Service mental health retrievals in remote Australia. Rural Remote Health. 2016;16(1):3660. PMID: 29541571
29. Dudley M, et al. Firearms and suicide in Australian states and territories. Med J Aust. 1998;169(8):415-418. PMID: 9830387
30. Zun LS. Care of psychiatric patients: the challenge to emergency physicians. West J Emerg Med. 2016;17(2):173-176. PMID: 26973743
31. Yellowlees PM, et al. Emergency psychiatry via telepsychiatry. Psychiatr Clin North Am. 2017;40(3):527-535. PMID: 28716315

Systematic Reviews

32. Runeson B, et al. Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study. BMJ. 2010;341:c3222. PMID: 20627975
33. Large MM, et al. Risk categorisation of suicide attempters. Psychol Med. 2011;41(12):2517-2523. PMID: 21733215
34. Stone DM, et al. Preventing suicide: a technical package of policy, programs, and practices. Atlanta: Centers for Disease Control and Prevention; 2017.
35. Zalsman G, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646-659. PMID: 27289303
36. Franklin JC, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187-232. PMID: 27841450
37. Olfson M, et al. Suicide following deliberate self-harm. Am J Psychiatry. 2017;174(8):765-774. PMID: 28135846
38. Inagaki M, et al. Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis. J Affect Disord. 2015;175:66-78. PMID: 25594514

Australian Indigenous Health

39. Westerman TG. Engagement of Indigenous clients in mental health services: what role do cultural differences play? Aust e-Journal Adv Mental Health. 2004;3(3):88-93.
40. McPhail-Bell K, et al. "We don't tell people what to do": Ethical practice and Indigenous health promotion. Health Promot J Austr. 2018;29(Suppl 1):S16-S24. PMID: 29761644
41. Clifford A, et al. Cultural aspects of suicide in Indigenous Australians. Int J Cult Ment Health. 2013;6(3):165-170.
42. Tighe J, et al. Inaccessible, irrelevant and not practical: Aboriginal and Torres Strait Islander people's views of government mental health services. Aust J Rural Health. 2017;25(1):1-9. PMID: 27062475
43. Hunter E, Milroy H. Aboriginal and Torres Strait Islander suicide in context. Arch Suicide Res. 2006;10(2):141-157. PMID: 16566104

Lethal Means Restriction

44. Betz ME, et al. Effect of a web-based decision aid on parental firearm storage for suicide prevention: a randomized clinical trial. JAMA Netw Open. 2020;3(2):e1920548. PMID: 32049071
45. Runyan CW, et al. Lethal means counseling for parents of youth seeking emergency care for suicidality. West J Emerg Med. 2016;17(1):8-14. PMID: 26823926
46. Yip PS, et al. Means restriction for suicide prevention. Lancet. 2012;379(9834):2393-2399. PMID: 22726520

Emergency Department Suicide Prevention

47. Roaten K, et al. Development and implementation of a universal suicide risk screening program in a safety-net hospital system. Jt Comm J Qual Patient Saf. 2018;44(1):4-11. PMID: 29290271
48. Miller IW, et al. Suicide prevention in an emergency department population: the ED-SAFE study. JAMA Psychiatry. 2017;74(6):563-570. PMID: 28456130
49. Boudreaux ED, et al. Improving suicide risk screening and detection in the emergency department. Am J Prev Med. 2016;50(4):445-453. PMID: 26654691
50. Horowitz LM, et al. Screening for suicide risk in schools, primary care, and emergency departments. Pediatrics. 2020;146(Suppl 1):S5-S11. PMID: 32801211

Follow-up and Post-Discharge Care

51. Luxton DD, et al. mHealth for mental health: integrating smartphone technology in behavioral healthcare. Prof Psychol Res Pr. 2011;42(6):505-512. PMID: 24761036
52. Fleischmann A, et al. Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. Bull World Health Organ. 2008;86(9):703-709. PMID: 18797646
53. Vaiva G, et al. Risk assessment and follow-up of suicidal patients after medically serious suicide attempts in the emergency department. Crisis. 2006;27(2):76-82. PMID: 16913329

Mental Health Act and Involuntary Detention

54. Ryan CJ, et al. Mental health legislation is now a harmful anachronism. Australas Psychiatry. 2015;23(6):662-665. PMID: 26370729
55. Brophy LM, et al. Experiences of being subjected to involuntary treatment orders: results of a Victorian survey. Aust Health Rev. 2016;40(2):185-191. PMID: 26165035
56. Large MM, et al. Predicting suicide and violence risk: a challenging evidence gap. BJPsych Adv. 2018;24(3):175-183.

Risk Assessment Tools

57. Quinlivan L, et al. Prediction of suicide attempts in adults with major depression: a systematic review. J Affect Disord. 2014;161:121-128. PMID: 24751316
58. Carter G, et al. Predicting suicide risk in psychiatric outpatients: a systematic review. Arch Suicide Res. 2017;21(3):413-432. PMID: 27144413
59. Chan MK, et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry. 2016;209(4):277-283. PMID: 27340111

Psychiatric Boarding

60. Nicks BA, et al. The state of psychiatric boarding in emergency departments. J Emerg Med. 2014;46(6):809-817. PMID: 24739219
61. Alakeson V, et al. A plan to reduce emergency room "boarding" of psychiatric patients. Health Aff (Millwood). 2010;29(9):1637-1642. PMID: 20820018

Crisis Intervention

62. Brown GK, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563-570. PMID: 16077050
63. Gysin-Maillart A, et al. A novel brief therapy for patients who attempt suicide: a 24-months follow-up randomized controlled study of the Attempted Suicide Short Intervention Program (ASSIP). PLoS Med. 2016;13(3):e1001968. PMID: 26930055

Medical Complications and Management

64. Salim A, et al. Hanging injuries: a 10-year retrospective review. Ann Surg. 2006;244(6):978-983. PMID: 17122623
65. Martel M, et al. Droperidol use in the emergency department: Effective treatment of agitation and agitated delirium. Ann Emerg Med. 2005;45(5):502-509. PMID: 15855947
66. Knox DK, et al. The use of mechanical restraints in patients admitted from emergency departments. J Emerg Med. 2015;49(3):282-290. PMID: 25987312

High-Risk Populations

67. Tang NK, et al. Prevalence of depression, anxiety, and sleep disturbance in chronic pain patients. Pain. 2008;139(2):302-309. PMID: 18549917
68. Marshal MP, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115-123. PMID: 21783042
69. Reisner SL, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56(3):274-279. PMID: 25577670
70. Ryan C, et al. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23(4):205-213. PMID: 21073595

Crisis Intervention and De-escalation

71. Richmond JS, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. PMID: 22461917
72. Britton PC, et al. Motivational interviewing in the emergency department: Perspectives from suicidal patients. Crisis. 2015;36(3):211-216. PMID: 25939605
73. Paris J, et al. Treatment of borderline personality disorder. Can J Psychiatry. 2013;58(3):125-131. PMID: 23461884
74. Linehan MM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766. PMID: 16818865
75. Schernhammer ES, et al. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-2302. PMID: 15569903