Behavioral Health

Suicide screening: How to recognize and treat at-risk adults

J Fam Pract. 2019 November;68(9):505-510

Author(s):

Meredith L.C. Williamson, PhD

Grady Hogue, MD

Jill Cotter, DO

Susan Roberman, MD

Gabriel Neal, MD

Brandon Williamson, MD

Choose a screening tool that focuses on current and past suicidal ideation, intent, and plan, and interview the patient. Plus: Avoid this common action step.

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References

1. Nock MK, Borges G, Bromet EJ, et al. Suicide and suicidal behavior. Epidemiol Rev. 2008;30:133-154.

2. National Institute of Mental Health. Suicide. https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154968. Accessed October 18, 2019.

3. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:909-916.

4. Vannoy SD, Robins LS. Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis. BMJ Open. 2011;1:e000198.

5. Feldman MD, Franks P, Duberstein PR, et al. Let’s not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5:412-418.

6. U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. 2012 National strategy for suicide prevention: goals and objectives for action. https://mnprc.org/wp-content/uploads/2019/01/2012-National-Strategy-for-suicide-prevention-goals-and-objectives-for-action.pdf. Accessed October 18, 2019.

7. The Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;(56):1-7.

8. LeFevre ML, U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:719-726.

9. American Psychiatric Association. Practice guidelines for the assessment and treatment of patients with suicidal behaviors. 2010. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed October 18, 2019.

10. Department of Veterans Affairs & Department of Defense. VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. 2013. https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf. Accessed October 18, 2019.

11. Western Interstate Commission for Higher Education. Suicide prevention toolkit for primary care practices. 2017. https://www.sprc.org/sites/default/files/Final%20National%20Suicide%20Prevention%20Toolkit%202.15.18%20FINAL.pdf. Accessed October 18, 2019.

12. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19:256-264.

13. Screening for suicide risk in adolescents, adults, and older adults in primary care: recommendation statement. Am Fam Physician. 2015;91:190F-190I.

14. O’Connor E, Gaynes B, Burda BU, et al. Screening for suicide risk in primary care: a systematic evidence review for the U.S. Preventive Services Task Force. Evidence synthesis no. 103. https://www.ncbi.nlm.nih.gov/books/NBK137737/. Accessed October 25, 2019.

15. Suicide Prevention Resource Center. Risk and protective factors. https://www.sprc.org/about-suicide/risk-protective-factors. Accessed October 18, 2019.

16. CDC. Suicide rising across the US: more than a mental health concern. https://www.cdc.gov/vitalsigns/suicide/index.html. Accessed October 18, 2019.

17. Martin A, Rief W, Klaiberg A, et al. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry. 2006;28:71-77.

18. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-1277.

19. The Columbia Lighthouse Project. Identify risk. Prevent suicide. http://cssrs.columbia.edu. Accessed October 25, 2019.

20. Uebelacker LA, German NM, Gaudiano BA, et al. Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study. Prim Care Companion CNS Disord. 2011;13:pii: PCC.10m01027.

21. Hoffman RM. Contracting for safety: a misused tool. Pa Patient Saf Advis. 2013;10:82-84.

22. Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75:894-900.

23. Suicide Prevention Resource Center. Safety planning in emergency settings. http://www.sprc.org/news/safety-planning-emergency-settings. Accessed October 25, 2019.

THE CASE

Emily T,* a 30-year-old woman, visited her primary care physician as follow-up to reassess her grief over the loss of her father a year earlier. Emily was her father’s primary caretaker and still lived alone in his home. Emily had a history of chronic pain and major depressive disorder and had expressed feelings of worthlessness and hopelessness about her future since her father’s passing. In addition to her continuing grief response, she reported feeling worse on most days. She completed the Patient Health Questionnaire-9, and results indicated anhedonia, depressed mood, psychomotor retardation, hypersomnia, decreased appetite, decreased concentration, and thoughts that she would be better off dead.

HOW WOULD YOU PROCEED WITH THIS PATIENT?

* The patient’s name has been changed to protect her identity.

In the United States, 1 suicide occurs on average every 12 minutes; lifetime prevalence of suicide attempts ranges from 1.9% to 8.7%.¹Suicide is the 10th overall cause of death in the United States, and it is the second leading cause of death for adults 18 to 34 years of age.² In one study, nearly half of suicide victims had contact with primary care providers within 1 month of their suicide.³ Unfortunately, additional research suggests that primary care physicians appropriately screen for suicide in fewer than 40% of patient encounters.^4,5

Suicide is defined as “death caused by self-directed injurious behavior with any intent to die as a result of the behavior.”⁶ When screening for suicide, be aware of the many terms related to suicide evaluation (TABLE 1⁶). Be mindful, too, of the differences between suicidal and nonsuicidal ideation (death wish); the continuum of such thoughts ranges from those that lead to suicide to those that do not.

SUICIDE SCREENING RECOMMENDATIONS VARY

Although most health care providers would agree that intervening with a suicidal patient first requires competence in assessing suicide risk, regulating bodies differ on the use of routine screening and on appropriate screening tools for primary care. The Joint Commission recommends assessing suicide risk with all primary care patients,⁷ while the US Preventive Services Tasks Force (USPSTF) advises against universal suicide screening in primary care⁸ due to insufficient evidence that its benefit outweighs potential harm (TABLE 2^7-12). Instead, the USPSTF recommends screening primary care patients with known mental health disorders, recent inpatient psychiatric hospitalization, prior suicide or self-harm attempts, or increased emotional distress.⁸ USPSTF does support screening for depression with routine mental health measures that include items assessing suicidality.^8,13,14 The American Academy of Family Physicians supports the recommendations by USPSTF.¹³

When screening for suicide, a comprehensive suicide risk assessment is recommended by both the Joint Commission and USPSTF.^7,8 A comprehensive suicide risk assessment has 4 components: (1) identification of current suicide risk factors, (2) identification of protective factors, (3) inquiry about suicidal ideation, intent, and plan, and (4) primary care practitioner judgment of risk level and plan for clinical intervention.^9-11

Take into account both risks and protective factors

Unfortunately, there is no “typical” description of a patient at risk for suicide and no validated models to predict suicide risk.^8,10 A multitude of factors, both individual and societal, can increase or reduce risk of suicide.^11,15 Each patient’s unique history includes risk factors for suicide including precipitating events (eg, job loss, termination of a relationship, death of a loved one) and protective factors that may be evaluated to determine overall risk for suicide (TABLE 3^8,10,11,15). According to the Centers for Disease Control and Prevention (CDC), there are several warning signs for patients who may be at greater risk for suicide: isolation, increased anxiety or anger, obtaining lethal means (eg, guns, knives, ropes), frequent mood swings, sleep changes, feeling trapped or in pain, increased substance use, discussing plans for death or wishes of death, and feeling like a burden.¹⁶

CHOOSING FROM AMONG SUICIDE SCREENING TOOLS

Brief mental health screening tools such as the Patient Health Questionnaire-9 (PHQ-9) are commonly used as primary screening tools for suicidal ideation.¹⁷ However, to attain a fuller understanding of a patient’s suicidality, select a screening tool that specifically focuses on suicidal ideation, intent, or plan, and then interview the patient (TABLE 4^10,11,15).

Continue to: Several screening tools...

References

1. Nock MK, Borges G, Bromet EJ, et al. Suicide and suicidal behavior. Epidemiol Rev. 2008;30:133-154.

2. National Institute of Mental Health. Suicide. https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154968. Accessed October 18, 2019.

3. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:909-916.

4. Vannoy SD, Robins LS. Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis. BMJ Open. 2011;1:e000198.

5. Feldman MD, Franks P, Duberstein PR, et al. Let’s not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5:412-418.

7. The Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;(56):1-7.

12. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19:256-264.

13. Screening for suicide risk in adolescents, adults, and older adults in primary care: recommendation statement. Am Fam Physician. 2015;91:190F-190I.

15. Suicide Prevention Resource Center. Risk and protective factors. https://www.sprc.org/about-suicide/risk-protective-factors. Accessed October 18, 2019.

16. CDC. Suicide rising across the US: more than a mental health concern. https://www.cdc.gov/vitalsigns/suicide/index.html. Accessed October 18, 2019.

17. Martin A, Rief W, Klaiberg A, et al. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry. 2006;28:71-77.

19. The Columbia Lighthouse Project. Identify risk. Prevent suicide. http://cssrs.columbia.edu. Accessed October 25, 2019.

21. Hoffman RM. Contracting for safety: a misused tool. Pa Patient Saf Advis. 2013;10:82-84.

23. Suicide Prevention Resource Center. Safety planning in emergency settings. http://www.sprc.org/news/safety-planning-emergency-settings. Accessed October 25, 2019.

Suicide screening: How to recognize and treat at-risk adults

References

SUICIDE SCREENING RECOMMENDATIONS VARY

Take into account both risks and protective factors

CHOOSING FROM AMONG SUICIDE SCREENING TOOLS

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