In Brazil and many other countries around the world, we got used to know September as the suicide prevention month, represented by the yellow ribbon, with September 10th being the World Suicide Prevention Day. As said by Sherlock Holmes in “A Study in Scarlet,” “There is a scarlet thread of murder running through the colorless skein of life, and our duty is to unravel it, and isolate it, and expose every inch of it.” Despite the dramatic content of Holmes’s words, it is possible to draw a parallel with the current situation related to suicide in society. There is a visible red stain in front of us, and we need to unravel it, understand it, deal with it. Moreover, everything should start somewhere…

If we think about the role of the emergency department (ED) and the emergency physician in the suicide prevention and response, we will see that it is of indispensable importance, as many patients at risk of attempting suicide are sent to the ED in order to be evaluated and to stay in a “24h safe environment.” Also, many actual suicide attempts arrive at the ED requiring immediate care – for the patient and for the family. However, World Health Organization estimate that for every death by suicide, there are 20 suicide attempts, making us to questioning our capability to give extended care for those patients. Besides, if we look to the big picture, which has suicide one of the major preventable causes of death worldwide, we can ask ourselves how many patients with suicidal thoughts are seen at the ED every week due to other health problems and go unnoticed. The ED, along with the primary care in the communities, is the main entry door to the health care system and like no other, act as a nexus between outpatient and inpatient care. Gairin et al. have found that approximately 40% of people who died by suicide have visited an ED in the year before, one third of them because of self-harm injuries. (1) If we look to the last attendance before death, those who have presented with self-harm injuries presented less than two months before ending their lives.

With all of this in mind, what strategies we can use to assess suicidal thoughts and behavior at the ED? Which reliable tools are available for emergency physicians to recognize and classify these patients? Let’s take a look at the last American College of Emergency Physicians (ACEP) recommendations.