Screening for abuse, suicidal ideation should be priority

Each year, nearly 1,000 women in Minnesota are hospitalized for injuries resulting from domestic violence. Many others present to the emergency department (ED) with emotional and somatic symptoms stemming from psychological, mental, sexual or economic abuse. Identifying those patients requires time, understanding and careful questioning, according to Sarah M. Burke, L.I.C.S.W., a social worker at Mayo Clinic in Rochester, Minn.

"Women tend to choose the ED over a primary provider because it offers 24-hour care and anonymity," Burke says. "But they still may not admit that a presenting symptom such as anxiety, headache or abdominal pain is the result of abuse. Sometimes they may not even realize it themselves."

Burke says many of these women slip through the cracks because they present a diagnostic challenge for busy emergency providers. She stresses that any provider with a high index of suspicion about an injury or symptom should address the issue directly.

"We need to start screening for abuse in the ED. Everyone should get in the habit of asking questions such as, 'Do you feel safe at home?' or 'Does your partner ever hit or kick you?' We like providers to have the conversation about violence in the home before calling in a social worker, because that's often more powerful," Burke says. "Unfortunately, many providers don't feel comfortable having that conversation."

Once a social worker becomes involved, the focus is connecting women with resources to help them if they want to leave the home and safety planning if they choose to stay. "Studies show that it takes seven violent episodes before a woman decides to leave an abusive situation," Burke says. "It can be extremely frustrating to see someone repeatedly reconcile with a batterer, and it's easy to start blaming the victim. But it's important to remember that the most dangerous time for a woman — the time she and her children are most likely to be seriously harmed — is after she decides to leave. For her safety, and the safety of the children, many things have to be in place first."

Burke also cautions against thinking that abuse is more common among certain social or economic groups. "Abuse crosses all socio-economic lines," she says. "Low-income women are more likely to report it because they have less to lose financially, but it can happen to anyone, including people you know."

She also stresses that family violence is reported less often in smaller communities because women are afraid their privacy won't be respected. Therefore, it's incumbent upon providers to reassure patients about medical record confidentiality and voluntary police reports.

Burke reiterates that providers shouldn't be afraid to ask the hard questions, however time-consuming or uncomfortable, knowing that a social worker can assist in continuing the conversation. "The goal is to assess a woman's level of safety and offer resources and support to help her stay safe," she says.

When patients are severely depressed or suicidal

Psychiatrist Gabrielle J. Melin, M.D., also at Mayo Clinic in Rochester, says 10 percent of people who complete suicide are seen in an ED within two months of dying. Most are never assessed for suicide risk.

"The ED is the main venue for suicidal people, and the first consultation is usually with an ED physician. Unfortunately, there are few standardized guidelines to aid emergency clinicians. But I would stress the importance of asking questions," she says. "Contrary to popular belief, talking about what the patient is feeling doesn't worsen the situation or lead to suicide. A cardiologist always listens to a patient's heart. In the same way, providers need to listen to what depressed patients are saying."

Crucial questions include:

  • Have you ever thought about ending your life?
  • Are you thinking about it now?
  • How long have you had these thoughts?
  • What do you have planned?
  • Does anyone else know?
  • Do you have access to a firearm? This may be the most important question, Dr. Melin says. Women attempt suicide more often than men, but men are more likely to complete it, and two-thirds of them use a gun.

Such questions are an effective way to talk about suicidal ideation, but they aren't a formal screening protocol. Providers should obtain collateral information from people who know the patient well because those intent on self-harm may not respond truthfully. Patients who won't allow providers to talk to a friend or family member should be told they must remain in the hospital until a physician has determined it's safe for them to leave.

Identifying that level of safety is an art, Dr. Melin says. "You have to look at all the risk factors — sex, age, access to firearms, mental health history and current mental status — and make the best judgment call as to whether a particular patient is at imminent risk of self-harm," she explains. "Placing a 72-hour hold on someone is a major step and you have to have very good evidence that it's necessary based on a thorough examination, risk factors and the provider's best judgment. And even then, some people who don't seem that depressed and have few risk factors may complete suicide. It's something none of us can fully predict."

Still, Dr. Melin says all emergency providers should know how to manage psychiatric emergencies, especially in small hospitals without mental health professionals on staff. She recommends that providers look for risk in all patients and have an effective plan in place because the ED experience itself can add to a patient's distress — hours of waiting or inadequate assessment can increase suicide risk.

In general, high-risk patients can be held for further evaluation by a crisis counselor or on-call psychiatrist, and when necessary, transferred to the nearest tertiary center or psychiatric hospital. One major obstacle, though, is the severe shortage of psychiatric beds in Minnesota — the worst per capita in the United States. "People can spend weeks in a medical bed waiting for placement, so knowing who to call when there aren't any beds is important, too," Dr. Melin says.