Assessing Risk of Future Suicidality in Emergency Department Patients

Emergency departments (ED) are the first line of evaluation for patients at risk and in crisis, with or without overt suicidality (ideation, attempts). Currently employed triage and assessments methods miss some of the individuals who subsequently become suicidal. The Convergent Functional Information for Suicidality (CFI-S) 22-item checklist of risk factors, which does not ask directly about suicidal ideation, has demonstrated good predictive ability for suicidality in previous studies in psychiatrict patients but has not been tested in the real-world setting of EDs.

We administered CFI-S prospectively to a convenience sample of consecutive ED patients. Patients were also asked at triage about suicidal thoughts or intentions per standard ED suicide clinical screening (SCS), and the treating ED physician was asked to fill a physician gestalt visual analog scale (VAS) for likelihood of future suicidality spectrum events (SSE; ideation, preparatory acts, attempts, completed suicide). We performed structured chart review and telephone follow-up at 6 months post-index visit.

The median time to complete the CFI-S was 3 minutes (first to third quartile = 3-6 minutes). Of the 338 patients enrolled, 45 (13.3%) were positive on the initial SCS, and 32 (9.5%) experienced a SSE in the 6 months of follow-up. Overall, SCS had modest diagnostic accuracy sensitivity 14/32 = 44%, (95% CI: 26-62%) and specificity 275/306 = 90%, (86-93%). The physician VAS also had moderate overall diagnostic accuracy (AUC 0.75, confidence interval [CI] = 0.66-0.85), and the CFI-S was best (AUC = 0.81, CI = 0.76-0.87). The top CFI-S differentiating items were psychiatric illness, perceived uselessness, and social isolation.

Using CFI-S, or some of its items, in busy EDs may help improve the detection of patients at high risk for future suicidality.