Suicide Risk in Older Adults: The Role and Responsibility of Primary Care

Having a ready list of local mental health professionals with expertise in geriatrics and suicide risk to provide to the patient is also beneficial. Recall, though, that older adults are less likely to seek out and receive mental health services [19]; therefore, connecting the patient with resources or referrals during the appointment is critical. If the practitioner does not have time to do this, having a medical assistant or other staff member that the patient knows engage in this step may be appropriate. For example, the patient can call the Friendship Line or National Suicide Prevention Lifeline while in the room with the practitioner, which may reduce anxiety or stigma about doing so and connect the patient with services. Similarly, calling a local mental health professional to make a referral during the appointment may increase the likelihood that the older adult will follow up on the referral.

The most ideal method of intervention for moderate or high acute suicide risk is a warm handoff to a behavioral or mental health specialist. As primary care and behavioral health become more integrated and financially viable as reimbursement through the Centers for Medicare and Medicaid Services improves [61], it is becoming increasingly likely that such a specialist will be on-site and available. Research has found that collaborative care in primary care reduces suicide risk in older adults [46–48,62]. Mental health specialists can conduct more comprehensive assessments and spend more time intervening to reduce suicide risk among older adults with death or suicide ideation. If an on-site behavioral health specialist is not available, older adults at high suicide risk may need to be referred to an emergency department for further evaluation and follow-up. Each state has its own laws and procedures regarding this process, which should be incorporated into a practice’s procedures for addressing high suicide risk. The procedure often involves ensuring that the older adult is accompanied at all times (ie, not left alone in a room), alerting emergency services (usually via phone call to an emergency line, such as 911), and completion of paperwork by a practitioner asserting that the patient is a danger to self. Police or other emergency personnel are then responsible for transporting the patient for further evaluation and determination of whether hospitalization is required.

If more time is available, either via the treating primary care practitioner or other patient care staff in the office, other brief interventions may be beneficial. First, means safety discussions are critical, particularly for older adults with plans for suicide or access to highly lethal means. In such discussions, patients are encouraged to restrict access to the methods that they may use to die by suicide. Plans for restricting access are developed, and when possible, a support person is enlisted to ensure that the plans are carried out. For example, if an older adult has access to firearms (eg, keeps a loaded weapon in his or her nightstand), he or she is encouraged to restrict his or her access to it. Ideally, this is through removing the weapon from the home, either permanently or until suicide risk reduces (eg, giving it to a friend, turning it over to police), but more safe storage may also be an option if the older adult is not willing to remove the weapon from the home. This may mean using a gun lock or storing the weapon in a gun safe, storing ammunition separately from an unloaded weapon, removing the firing pin, or otherwise disassembling the weapon. Means safety counseling has been shown to be effective in reducing suicide rates [63] and is acceptable to patients [64]. Studies indicate that over 90% of individuals who make a suicide attempt and survive do not go on to die by suicide [65]; therefore, reducing access to highly lethal means during a suicidal crisis may be key in reducing suicide rates. Though an in-depth review of means safety counseling is outside the scope of this article, readers are directed to Bryan, Stone, and Rudd’s article for a practical overview of means safety discussions [66].