Currently, however, Washington and Kentucky are the only states with suicide-specific requirements for licensure. Recent efforts to mandate training in California failed when Gov. Jerry Brown (D) vetoed the measure after heavy lobbying efforts by various mental health professional organizations, including the California chapter of the National Association of Social Workers, which argued that it should be entrusted to train its members on a volunteer, as-needed basis.
Even when clinicians have received proper training and met all standards of practice, some patients still may be lost, said Dr. Myers, who also is immediate past vice chair for education and residency training director at SUNY Downstate Medical Center. “You can’t save everyone,” he said. “Some patients are just hell-bent on killing themselves and will very cleverly pull the wool over our eyes.”
He also pointed to the gaps in care that training alone cannot prevent, specifically citing the instances in which people complete a suicide because of a lack of follow-up – the kind of intensive discharge planning that might include several daily phone calls and plans for whom to talk to when thoughts of suicide arise. Those kinds of protocols are not widely used, Dr. Myers said, partly because of the cost.
But Dr. Myers also points to a failing that, while not documented, he said is well-known among his mental health peers: calculated avoidance of at-risk patients.
“There are those, therapists especially, who are cherry picking their patients. They try to make sure they don’t have to look after suicidal people. They do their best to avoid them, and will even screen referrals to avoid them,” said Dr. Myers, who has written extensively about suicide. “It’s equivalent to an oncologist saying to a referring physician: ‘Sure, I will see your patient with breast cancer, but she doesn’t have metastasis, does she?’ It’s unconscionable.”
It would help if there were guidelines for care similar to oncology or cardiology, he said, to help clinicians better balance science with instinct.
Dr. Quinnett thinks the crisis is likely to worsen before it gets better. At least one study has shown strong associations between rates of joblessness in the United States and suicide rates (Soc Sci Med. 2014 Sep;116:22-31). “I’m particularly worried about those people whose lives have been economically hollowed out by the Great Recession,” said Dr. Quinnett, also of the department of psychiatry and behavioral sciences at the University of Washington. “There are men who are aging out [of the workforce] without retirement plans or any other fallback [and who], face losing their dignity and self-esteem, and will need handouts. It’s going to be very ugly.”
Dr. Myers has written several books, including “Touched by Suicide: Hope and Healing After Loss” (New York: Gotham/Penguin, 2006). Dr. Quinnett’s suicide prevention nonprofit, the QPR Institute, is listed on SAMHSA’s National Registry of Evidence-based Programs and Practices.
Coming soon: A national suicide registry?
At the National Institutes of Health, a movement is afoot to create a national suicide registry.
“Registries can help us in all kinds of conditions. That’s how we got ahead in cancer,” Jane Pearson, Ph.D., the National Institute of Mental Health’s program chief for Suicide Treatment and Preventive Interventions Research, said in an interview.
It’s early days yet, but Dr. Pearson and her colleagues are looking into how to leverage data already collected, how to determine the quality of those data, and whom to task with its oversight and interpretation. Then there is the need to know what questions matter most, either to create new registries or to cull patterns from currently available data.
Dr. Pearson said a dedicated suicide data collection effort in a large health care system or a single state would, theoretically, allow patterns to emerge that would help create infrastructures to support specific populations at risk for suicide and guidelines for referral to support.
“Mental health issues have always been a challenge for primary care. As long as they have a partner they can refer to, it’s a much easier [task],” she said. “We wouldn’t ask them to be cardiovascular specialists. When a patient has a stroke, they figure it out and move people along. The registry ideas encompasses that. It’s about creating a whole system for how we are going to do better.”
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