Suicide Prevention: Primary Care Is a Crucial Setting for Identifying Risk

Debra Davidson, MJ, CPPS, Senior Patient Safety Risk Manager, The Doctors Company

Most Americans receive their healthcare from primary care physicians. The frequent contact with patients creates opportunities for physicians to identify and address suicide risks.

Research tells us that people who die by suicide are more likely to have seen their primary care provider shortly before their death than any other healthcare professional.1

At any given time, many of your patients are experiencing stress and anxiety, and some are having thoughts of suicide. The emotional and psychological impact of the COVID-19 pandemic has added to an already fragile situation. A recent health tracking poll indicated that, since the start of the COVID-19 outbreak, 53 percent of respondents reported that the increased levels of stress and worry have had a negative impact on their mental health.2 (For more information on this topic, see our article, “Avoid Risks When Treating Stressed Patients During COVID-19.”)

While your patients present with many different concerns, it might be the concern they withhold from you that leads to tragedy.

Suicide Statistics

The Centers for Disease Control and Prevention (CDC)3 reported that, as of April 2020, suicide is the 10th-leading cause of death in the U.S., the second-leading cause of death for individuals ages 10 to 34, and the fourth-leading cause of death for individuals ages 35 to 54.

Additionally, the American Foundation of Suicide Prevention4 reported the following statistics from 2018:

  • An estimated 1.4 million individuals attempted suicide; 48,344 died.
  • Men died by suicide 3.56 times more often than women.
  • White males accounted for 69.67 percent of suicide deaths.
  • Firearms accounted for 50.57 percent of suicide deaths.
  • On average, 132 Americans died by suicide each day.

Risk Factors and Warning Signs

The following risk factors and warning signs indicate an increased or heightened risk of suicide:

  • Mental health conditions, including depression, substance abuse, bipolar disorder, anxiety disorders, post-traumatic stress disorder, a history of a suicide attempt, or recent inpatient psychiatric care.
  • Behaviors, such as increased use of drugs or alcohol, withdrawing from activities, sleeping too much or too little, or giving away prized possessions.
  • Psychosocial stressors, such as divorce, the loss of a job, or death of a family member.
  • Verbalizations, including talking about killing themselves or expressing feelings of hopelessness, having no reason to live, being trapped, or being in unbearable pain.

What You Can Do

If you identify an at-risk patient, begin with the following steps:

  • Have an honest conversation with the patient in private.
  • Listen to the patient’s story.
  • Avoid minimizing the patient’s problems.
  • Assure the patient that you care.
  • Ask directly about any suicidal thoughts.
  • Encourage the patient to seek treatment and offer referral suggestions.

If the patient acknowledges suicidal thoughts:

  • Take the risk seriously.
  • Help the patient remove any lethal means in their possession, such as drugs or firearms.
  • Call the National Suicide Prevention Lifeline at (800) 273-8255.
  • Text “HOME” to 741741 for a trained crisis counselor from the Crisis Text Line. This free service is available 24/7.
  • Escort the patient to mental health services or an emergency room if necessary.

Suicide Prevention Strategies

According to the Suicide Prevention Resource Center (SPRC), effective suicide prevention requires a comprehensive approach. SPRC offers the following strategies:5

  • Increase help seeking. By teaching patients to recognize when they need support—and helping them to find it—you can enable them to reduce their suicide risk. Provide information in your office on the National Suicide Prevention Lifeline and options for peer-support programs or other supportive relationships that promote social connectedness.
  • Ensure access to effective mental health and suicide care and treatment. A key element of suicide prevention is ensuring that patients with suicide risk have timely access to interventions, treatment, and coordinated systems of care. Be familiar with the various mental and behavioral health resources available for patient referrals in your community.
  • Document your assessment of risk, rationale, intervention, and follow-up. As always, your documentation reflecting your exam findings and thought process for treatment is critical. Include the findings of your assessment, your treatment plan and rationale, what is being done to address/reduce current risk, and your follow-up plan.
  • Utilize the Suicide Prevention Toolkit for Primary Care Practices. The comprehensive toolkit, which was developed by SPRC and the Western Interstate Commission of Higher Education Mental Health Program, addresses clinician and staff education, patient management tools, and mental health partnerships. You will find assessment guidelines, safety plans, billing tips, sample protocols, and more. The toolkit is available in an online version, as a free PDF, and as a booklet.

For additional guidance on suicide prevention measures for your practice, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or patientsafety@thedoctors.com.


References

  1. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014 Jun;29(6):870-877.
  2. Panchal N, Kamal R, Orgera K, et al. The implications of COVID-19 for mental health and substance use. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. Kaiser Family Foundation. August 21, 2020.
  3. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States. https://www.cdc.gov/nchs/products/databriefs/db362.htm. Centers for Disease Control and Prevention NCHS Data Brief No. 362. April 2020.
  4. American Foundation for Suicide Prevention. Suicide statistics. https://afsp.org/suicide-statistics/
  5. A comprehensive approach to suicide prevention. Suicide Prevention Resource Center. https://www.sprc.org/effective-prevention/comprehensive-approach

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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