Immediate Concerns

It is important to do a rapid assessment of the patient’s mental status as well as their ongoing risk of self-harm or suicide while in the ED. If there is a concern for the patient’s safety or if they are at risk of absconding from the ED, they should be placed under direct supervision by a dedicated member of staff.

Intoxication very commonly co-presents with depression or suicidal ideation and may make assessment more difficult. You should ask about alcohol or drugs in assessing patients presenting with mood disturbances.

Components of the mental status exam are listed opposite. Important to note is that severe depression may also present with features of psychosis.

Mental State Exam

Appearance – How does the patient’s grooming or hygiene appear? Poor self-care is often a feature of depression.

Behaviour – Is their behaviour congruent with their presentation? Are they agitated or withdrawn?

Cognition – Are they attentive in conversation or do they appear distracted or inattentive?

Speech – Assess the speed, volume or fluency of speech. Often depressed patients will have low volume and a paucity of speech.

Mood – Do they seem objectively sad or hopeless? Is their affect flattened?

Insight – Are they aware that they are depressed or do they understand how their mood has affected their behaviour?

Thought Process/Content – Is their thought content pervasively negative?

Hallucination/delusions – Is there any evidence of hallucinations or delusions to suggest a concomitant psychosis? Are they congruent with their mood? e.g. nihilistic delusions or accusatory auditory hallucinations.

Risk Assessment

Important considerations during the assessment of a person presenting with low mood and suicidal ideation are the lethality of any suicide attempts or self-harm as well as the carrying out any final acts. These may include;

• arranging financial affairs to be completed after their death

• giving away possessions

• leaving notes for friends or family

• cancelling contracts e.g. phone bills.

Other factors to consider are;

• presence of a passive death wish

• whether the patient self-presented

• was brought in willingly by a friend or family member

• brought in by the ambulance service or was detained by Gardai for their safety and later brought to ED for formal assessment.

ED management

• Few patients presenting with depression require admission, though the Liaison Psychiatry team should be involved, particularly for those with significant risk.

• Patients should be counselled regarding drug and alcohol use. Directing patients to community drug or alcohol rehabilitation programmes may be of benefit.

• Many counselling services are available in the community and can be accessed directly by patients without a referral.

• Multiple helplines exist for patients who experience low mood and experience crisis situations e.g. Samaritans, Pieta House, Aware as well as context-specific resources for those who may need specific care and advice such as support following a cancer diagnosis, domestic abuse, sexual assault, sexuality or gender identity.

Typically, antidepressant medication is not commenced in the ED unless it is by a member of the Liaison Psychiatry team.

Involuntary admissions

Involuntary admission is a rare occurrence following a presentation to the ED with features of depression. The same criteria exist for all patients when considering involuntary admission:

• There is a serious likelihood that the patient may cause immediate and serious harm to themselves or to others

  OR

• The severity of their illness has impaired their judgement to the extent that failure to admit them to a mental health facility would lead to a serious deterioration in their condition

  AND

• The detention and treatment of the patient would be likely to benefit their condition

Further information on criteria for involuntary admission of patients experiencing mental health disorders can be found on the Mental Health Commission website(3).