ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature



      Caring for suicidal patients can be challenging, especially in emergency departments without easy access to mental health specialists. The American College of Emergency Physicians and the American Foundation for Suicide Prevention appointed a working group to create an easy-to-use suicide prevention tool for ED providers.


      The writing group created an easy-to-use mnemonic for the care of adult patients as a way of organizing sequential steps, accompanied by a systematic review of available ED-based suicide prevention literature. The systematic review was performed both to ensure that all relevant evidence was taken into account as well as to evaluate the strength of evidence for each recommendation. Levels of evidence were assigned utilizing the ACEP level of evidence classification.


      The writing group created the mnemonic ICAR2E, which stands for Identify suicide risk; Communicate; Assess for life threats and ensure safety; Risk assessment (of suicide); Reduce the risk (of suicide); and Extend care beyond the ED. 31 articles were identified in the search, and were included in the systematic review.


      The ICAR2E mnemonic may be a feasible way for practicing ED clinicians to provide evidence-based care to suicidal patients. However, further research is needed.


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        • United States Centers for Disease Control
        Web-based injury statistics query and reporting system (WISQARS): leading causes of death reports.
        Date: 1981-2016
        Date accessed: August 19, 2018
        • Hedegaard H.
        • Curtin S.C.
        • Warner M.
        Suicide mortality in the United States, 1999–2017.
        National Center for Health Statistics, Hyattsville, MD2018
        • Betz M.E.
        • Boudreaux E.D.
        Managing suicidal patients in the emergency department.
        Ann Emerg Med. 2016; 67: 276-282
        • David-Ferdon C.
        • Crosby A.E.
        • Caine E.D.
        • Hindman J.
        • Reed J.
        • Iskander J.
        CDC grand rounds: preventing suicide through a comprehensive public health approach.
        Morb Mortal Wkly Rep. 2016; 65: 894-897
      1. Ting SA, Sullivan AF, Boudreaux ED, Miller I, Camargo CA, Jr. Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008. Gen Hosp Psychiatry. 2012;34(5):557–565.

        • Larkin G.L.
        • Claassen C.A.
        • Emond J.A.
        • Pelletier A.J.
        • Camargo C.A.
        Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001.
        Psychiatr Serv. 2005; 56: 671-677
        • Chakravarthy B.
        • Hoonpongsimanont W.
        • Anderson C.L.
        • Habicht M.
        • Bruckner T.
        • Lotfipour S.
        Depression, suicidal ideation, and suicidal attempt presenting to the emergency department: differences between these cohorts.
        West J Emerg Med. 2014; 15: 211-216
        • Baraff L.J.
        • Janowicz N.
        • Asarnow J.R.
        Survey of California emergency departments about practices for management of suicidal patients and resources available for their care.
        Ann Emerg Med. 2006; 48 ([458 e451-452]): 452-458
        • Horowitz L.M.
        • Bridge J.A.
        • Teach S.J.
        • et al.
        Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department.
        Arch Pediatr Adolesc Med. 2012; 166: 1170-1176
        • Wilson M.P.
        • Seupaul R.A.
        Are there tools to screen children and adolescents in the emergency department with mental health and substance abuse issues?.
        Ann Emerg Med. 2018; 71: 233-235
        • American College of Emergency Physicians
        • American Foundation for Suicide Prevention
        Date accessed: June 17, 2019
        • Office of the Surgeon General (US), National Action Alliance for Suicide Prevention (US)
        2012 national strategy for suicide prevention: goals and objectives for action: a report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention.
        in: Publications and reports of the surgeon general. 2012
        • D'Onofrio G.
        • Jauch E.
        • Jagoda A.
        • et al.
        NIH roundtable on opportunities to advance research on neurologic and psychiatric emergencies.
        Ann Emerg Med. 2010; 56: 551-564
        • Larkin G.L.
        • Beautrais A.L.
        • Spirito A.
        • Kirrane B.M.
        • Lippmann M.J.
        • Milzman D.P.
        Mental health and emergency medicine: a research agenda.
        Acad Emerg Med. 2009; 16: 1110-1119
        • American College of Emergency Physicians
        Date accessed: June 17, 2019
        • American Association for Emergency Psychiatry
        Date accessed: June 17, 2019
        • Emergency Nurses Assocation
        Date accessed: June 17, 2019
        • Graham R.
        • Mancher M.
        • Miller Wolman D.
        • Greenfield S.
        • Steinberg E.
        Committee on standards for developing trustworthy clinical practice guidelines.
        in: Clinical practice guidelines we can trust. National Academies Press, Washington, DC2011
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Riaz I.B.
        • Khan M.S.
        • Riaz H.
        • Goldberg R.J.
        Disorganized systematic reviews and meta-analyses: time to systematize the conduct and publication of these study overviews?.
        Am J Med. 2016; 129 ([e311-338]): 339
        • Rowe B.H.
        Can I combine the results of this study with others? An introduction to systematic reviews.
        in: Wilson M.P. Guluma K.Z. Hayden S.R. Doing research in emergency and acute care: making order out of chaos. Wiley-Blackwell, Oxford, England2016: 223-230
        • Hogan M.F.
        • Grumet J.G.
        Suicide prevention: an emerging priority for health care.
        Health Aff (Millwood). 2016; 35: 1084-1090
        • Suicide Prevention Resource Center
        Caring for adult patients with suicide risk: a consensus guide for emergency departments.
      2. Sentinel Event Alert. 2016; 56: 1-7
        • Agency for Healthcare Research and Quality
        National guideline clearinghouse extent adherence to trustworthy standards (NEATS) instrument.
        (Previously available at)
        • Allen M.H.
        • Abar B.W.
        • McCormick M.
        • et al.
        Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration.
        Suicide Life Threat Behav. 2013; 43: 313-323
        • Arias S.A.
        • Sullivan A.F.
        • Miller I.
        • Camargo Jr., C.A.
        • Boudreaux E.D.
        Implementation and use of a crisis hotline during the treatment as usual and universal screening phases of a suicide intervention study.
        Contemp Clin Trials. 2015; 45: 147-150
        • Arias S.A.
        • Miller I.
        • Camargo Jr., C.A.
        • et al.
        Factors associated with suicide outcomes 12 months after screening positive for suicide risk in the emergency department.
        Psychiatr Serv. 2016; 67: 206-213
        • Bennewith O.
        • Peters T.J.
        • Hawton K.
        • House A.
        • Gunnell D.
        Factors associated with the non-assessment of self-harm patients attending an accident and emergency department: results of a national study.
        J Affect Disord. 2005; 89: 91-97
        • Bertolote J.M.
        • Fleischmann A.
        • De Leo D.
        • et al.
        Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS study.
        Crisis. 2010; 31: 194-201
        • Betz M.E.
        • Miller M.
        • Barber C.
        • et al.
        Lethal means access and assessment among suicidal emergency department patients.
        Depress Anxiety. 2016; 33: 502-511
        • Bolton J.M.
        • Spiwak R.
        • Sareen J.
        Predicting suicide attempts with the SAD PERSONS scale: a longitudinal analysis.
        J Clin Psychiatry. 2012; 73: e735-e741
        • Boudreaux E.D.
        • Camargo Jr., C.A.
        • Arias S.A.
        • et al.
        Improving suicide risk screening and detection in the emergency department.
        Am J Prev Med. 2016; 50: 445-453
        • Brown G.K.
        • Currier G.W.
        • Jager-Hyman S.
        • Stanley B.
        Detection and classification of suicidal behavior and nonsuicidal self-injury behavior in emergency departments.
        J Clin Psychiatry. 2015; 76: 1397-1403
        • Carroll R.
        • Knipe D.
        • Moran P.
        • Gunnell D.
        Socioeconomic deprivation and the clinical management of self-harm: a small area analysis.
        Soc Psychiatry Psychiatr Epidemiol. 2017; 52: 1475-1481
        • Carter G.L.
        • Clover K.
        • Whyte I.M.
        • Dawson A.H.
        • D'Este C.
        Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning.
        BMJ. 2005; 331: 805
        • Carter G.L.
        • Clover K.
        • Whyte I.M.
        • Dawson A.H.
        • D'Este C.
        Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning.
        Br J Psychiatry. 2007; 191: 548-553
        • Carter G.
        • Milner A.
        • McGill K.
        • Pirkis J.
        • Kapur N.
        • Spittal M.J.
        Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.
        Br J Psychiatry. 2017; 210: 387-395
        • Cedereke M.
        • Monti K.
        • Ojehagen A.
        Telephone contact with patients in the year after a suicide attempt: does it affect treatment attendance and outcome? A randomised controlled study.
        Eur Psychiatry. 2002; 17: 82-91
        • Claasen C.A.
        • L. G.L.
        Occult suicidality in an emergency department population.
        Br J Psychiatry. 2005; 186: 352-353
        • Cooper J.
        • Kapur N.
        • Dunning J.
        • Guthrie E.
        • Appleby L.
        • Mackway-Jones K.
        A clinical tool for assessing risk after self-harm.
        Ann Emerg Med. 2006; 48: 459-466
        • Desjardins I.
        • Cats-Baril W.
        • Maruti S.
        • Freeman K.
        • Althoff R.
        Suicide risk assessment in hospitals: an expert system-based triage tool.
        J Clin Psychiatry. 2016; 77: e874-e882
        • Fleischmann A.
        • Bertolote J.M.
        • Wasserman D.
        • et al.
        Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries.
        Bull World Health Organ. 2008; 86: 703-709
        • Gunnarsdottir O.S.
        • Rafnsson V.
        Non-causative discharge diagnosis from the emergency department and risk of suicide.
        J Emerg Med. 2010; 38: 286-292
        • Hassanian-Moghaddam H.
        • Sarjami S.
        • Kolahi A.A.
        • Carter G.L.
        Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning.
        Br J Psychiatry. 2011; 198: 309-316
        • Katz C.
        • Randall J.R.
        • Sareen J.
        • et al.
        Predicting suicide with the SAD PERSONS scale.
        Depress Anxiety. 2017; 34: 809-816
        • Lopez-Castroman J.
        • Perez-Rodriguez Mde L.
        • Jaussent I.
        • et al.
        Distinguishing the relevant features of frequent suicide attempters.
        J Psychiatr Res. 2011; 45: 619-625
        • Miller I.W.
        • Camargo Jr., C.A.
        • Arias S.A.
        • et al.
        Suicide prevention in an emergency department population: the ED-SAFE study.
        JAMA Psychiat. 2017; 74: 563-570
        • Motto J.A.
        Suicide prevention for high-risk persons who refuse treatment.
        Suicide Life Threat Behav. 1976; 6: 223-230
        • Mullinax S.
        • Chalmers C.E.
        • Brennan J.
        • Vilke G.M.
        • Nordstrom K.
        • Wilson M.P.
        Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department.
        Am J Emerg Med. 2018; 36: 1779-1783
        • Ntountoulaki E.
        • Guthrie E.
        • Kotsis K.
        • et al.
        Double RASS cutpoint accurately diagnosed suicidal risk in females with long-term conditions attending the emergency department compared to their male counterparts.
        Compr Psychiatry. 2016; 69: 193-201
        • Stanley B.
        • Brown G.K.
        • Brenner L.A.
        • et al.
        Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department.
        JAMA Psychiat. 2018; 75: 894-900
        • van Veen M.
        • van Weeghel I.
        • Koekkoek B.
        • Braam A.W.
        Structured assessment of suicide risk in a psychiatric emergency service: psychometric evaluation of the Nurses' Global Assessment of Suicide Risk scale (NGASR).
        Int J Soc Psychiatry. 2015; 61: 287-296
        • Waern M.
        • Sjostrom N.
        • Marlow T.
        • Hetta J.
        Does the Suicide Assessment Scale predict risk of repetition? A prospective study of suicide attempters at a hospital emergency department.
        Eur Psychiatry. 2010; 25: 421-426
        • Wang Y.
        • Bhaskaran J.
        • Sareen J.
        • Wang J.
        • Spiwak R.
        • Bolton J.M.
        Predictors of future suicide attempts among individuals referred to psychiatric services in the emergency department: a longitudinal study.
        J Nerv Ment Dis. 2015; 203: 507-513
        • Ilgen M.A.
        • Walton M.A.
        • Cunningham R.M.
        • et al.
        Recent suicidal ideation among patients in an inner city emergency department.
        Suicide Life Threat Behav. 2009; 39: 508-517
        • Wilson M.P.
        • Brennan J.J.
        • Modesti L.
        • et al.
        Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use.
        Am J Emerg Med. 2015; 33: 527-530
        • Boudreaux E.D.
        • Miller I.
        • Goldstein A.B.
        • et al.
        The emergency department safety assessment and follow-up evaluation (ED-SAFE): method and design considerations.
        Contemp Clin Trials. 2013; 36: 14-24
        • Boudreaux E.D.
        • Jaques M.L.
        • Brady K.M.
        • Matson A.
        • Allen M.H.
        The patient safety screener: validation of a brief suicide risk screener for emergency department settings.
        Arch Suicide Res. 2015; 19: 151-160
        • Ronquillo L.
        • Minassian A.
        • Vilke G.M.
        • Wilson M.P.
        Literature-based recommendations for suicide assessment in the emergency department: a review.
        J Emerg Med. 2012; 43: 836-842
        • Stuck A.R.
        • Wilson M.P.
        • Chalmers C.E.
        • et al.
        Health care usage and suicide risk screening within 1 year of suicide death.
        J Emerg Med. 2017; 53: 871-879
        • Wolf L.A.
        • Perhats C.
        • Delao A.M.
        • Clark P.R.
        • Moon M.D.
        • Zavotsky K.E.
        Assessing for occult suicidality at triage: experiences of emergency nurses.
        J Emerg Nurs. 2018; 44: 491-498
        • Kemball R.S.
        • Gasgarth R.
        • Johnson B.
        • Patil M.
        • Houry D.
        Unrecognized suicidal ideation in ED patients: are we missing an opportunity?.
        Am J Emerg Med. 2008; 26: 701-705
        • Stewart M.A.
        Effective physician-patient communication and health outcomes: a review.
        CMAJ. 1995; 152: 1423-1433
        • Williams S.
        • Weinman J.
        • Dale J.
        Doctor-patient communication and patient satisfaction: a review.
        Fam Pract. 1998; 15: 480-492
        • Chennapan K.
        • Mullinax S.
        • Anderson E.
        • et al.
        Medical screening of mental health patients in the emergency department: a systematic review.
        J Emerg Med. 2018; 55: 799-812
        • Anderson E.L.
        • Nordstrom K.
        • Wilson M.P.
        • et al.
        American Association for Emergency Psychiatry Task Force on medical clearance of adults part I: introduction, review and evidence-based guidelines.
        West J Emerg Med. 2017; 18: 235-242
        • Wilson M.P.
        • Nordstrom K.
        • Anderson E.L.
        • et al.
        American Association for Emergency Psychiatry Task Force on medical clearance of adult psychiatric patients. Part II: controversies over medical assessment, and consensus recommendations.
        West J Emerg Med. 2017; 18: 640-646
        • Lukens T.W.
        • Wolf S.J.
        • Edlow J.A.
        • et al.
        Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.
        Ann Emerg Med. 2006; 47: 79-99
        • American College of Emergency Physicians Clinical Policies Subcommittee on the Adult Psychiatric P
        • Nazarian D.J.
        • Broder J.S.
        • et al.
        Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.
        Ann Emerg Med. 2017; 69: 480-498
        • Wilson M.P.
        • Nordstrom K.
        • Zeller S.L.
        Practical management of the suicidal patient in the emergency department.
        Emer Med Rep. 2014; 35: 1-12
        • Wilcox H.C.
        • Conner K.R.
        • Caine E.D.
        Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies.
        Drug Alcohol Depend. 2004; 76: S11-S19
        • United States Centers for Disease Control
        Vital signs: trends in state suicide rates - United States, 1999-2016 and circumstances contributing to suicide - 27 states, 2015.
        Morb Mortal Wkly Rep. 2018; 67: 617-624
        • Pisani A.R.
        • Murrie D.C.
        • Silverman M.M.
        Reformulating suicide risk formulation: from prediction to prevention.
        Acad Psychiatry. 2016; 40: 623-629
        • Ryan C.
        • Nielssen O.
        • Paton M.
        • Large M.
        Clinical decisions in psychiatry should not be based on risk assessment.
        Australas Psychiatry. 2010; 18: 398-403
        • Hockberger R.S.
        • Rothstein R.J.
        Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS score.
        J Emerg Med. 1988; 6: 99):99-107
        • Runyan C.W.
        • Brooks-Russell A.
        • Tung G.
        • et al.
        Hospital emergency department lethal means counseling for suicidal patients.
        Am J Prev Med. 2018; 54: 259-265
        • Gunnell D.
        • Fernando R.
        • Hewagama M.
        • Priyangika W.D.
        • Konradsen F.
        • Eddleston M.
        The impact of pesticide regulations on suicide in Sri Lanka.
        Int J Epidemiol. 2007; 36: 1235-1242
        • Kreitman N.
        The coal gas story: United Kingdom suicide rates 1960-1971.
        Br J Prev Soc Med. 1976; 30: 86-93
        • Lubin G.
        • Werbeloff N.
        • Halperin D.
        • Shmushkevitch M.
        • Weiser M.
        • Knobler H.Y.
        Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: a naturalistic epidemiological study.
        Suicide Life Threat Behav. 2010; 40: 421-424
        • Borges G.
        • Loera C.R.
        Alcohol and drug use in suicidal behaviour.
        Curr Opin Psychiatry. 2010; 23: 195-204
        • Rockett I.R.H.
        • Caine E.D.
        • Connery H.S.
        • et al.
        Discerning suicide in drug intoxication deaths: paucity and primacy of suicide notes and psychiatric history.
        PLoS One. 2018; 13e0190200
        • Wilson M.P.
        Patients with suicidal ideation and evidence of alcohol use are discharged at higher rates from the emergency department.
        IJPP. 2017; 3: 1-5
        • Crane E.H.
        Patients with emergency department visits involving drug-related suicide attempts who left against medical advice.
        in: The CBHSQ report: September 13, 2016. Center for Behavioral Health Statistics and Quality, Rockville, Maryland2016
        • Fedyszyn I.E.
        • Erlangsen A.
        • Hjorthoj C.
        • Madsen T.
        • Nordentoft M.
        Repeated suicide attempts and suicide among individuals with a first emergency department contact for attempted suicide: a prospective, nationwide, Danish register-based study.
        J Clin Psychiatry. 2016; 77: 832-840
        • Hunter J.
        • Maunder R.
        • Kurdyak P.
        • Wilton A.S.
        • Gruneir A.
        • Vigod S.
        Mental health follow-up after deliberate self-harm and risk for repeat self-harm and death.
        Psychiatry Res. 2018; 259: 333-339
        • Knesper D.J.
        • American Association of Suicidology, Suicide Prevention Resource Center
        Continuity of care for suicide prevention and research: suicide attempts and suicide deaths subsequent to discharge from an emergency department or psychiatry inpatient unit.
        Education Development Center, Inc., Newton, MA2010
        • Luxton D.D.
        • June J.D.
        • Comtois K.A.
        Can postdischarge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence.
        Crisis. 2013; 34: 32-41
        • Woodford R.
        • Spittal M.J.
        • Milner A.
        • McGill K.
        • Kapur N.
        • Pirkis J.
        • Mitchell A.
        • Woodford R.
        • Spittal M.J.
        • Milner A.
        • McGill K.
        • Kapur N.
        • Pirkis J.
        • Mitchell A.
        • Carter G.
        Accuracy of Clinician Predictions of Future Self-Harm: A Systematic Review and Meta-Analysis of Predictive Studies.
        (First published: 03 October 2017)

      Linked Article

      • Suicide and the creation of evidence-based guidelines: the ACEP perspective
        The American Journal of Emergency MedicineVol. 37Issue 12
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          The American College of Emergency Physicians, as well as most emergency physicians, recognize that suicide is a national epidemic [1]. Suicide is the 10th leading cause of death for all ages combined [1], and from 1999 to 2016, suicide rates rose by 28% nationally [2]. Most patients have seen a physician prior to their suicide [3,4], and many of these patients have seen this physician in the emergency department (ED) [5-7]. In fact, “mental disorders” was the 9th leading diagnosis made in emergency department patients in 2015 [8].
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