The Biggest Elephant in the Room: Addressing Suicide Risk

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Conversations assessing and responding to suicide risk with your patients destigmatizes suicide and mental illness while strengthening your skills as a provider.

The most common question I get from medical provider colleagues is about assessing and responding to suicide risk. The thought of missing some obvious suicide risk scares doctors almost as much as actually recognizing it does.

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Suicide is not common. In fact, suicide accounted for only 1.3% of worldwide deaths in 2019, with an estimated global suicide rate of 10.5 per every 100,000 people.1 Suicidality or even thinking about suicide, though, is much more common and always precedes death by suicide. A survey of nearly 1000 patients with rheumatic and musculoskeletal diseases reported that 1 in 10 patients had suicidal thoughts and more than half of patients reported that their pain made life seem unmanageable.2 I have written previously about the overlap between rheumatic disease and mental illness. Those same mental illnesses (eg, depression) increase the risk for suicide. In some studies, depression is related to a 4-fold increase in the risk for suicidal ideation.3,4 Suicide risk factors that are common among patients with rheumatic diseases include greater pain severity, poor sleep, poor disability perception, and a history of childhood trauma.

Patients who are actively suicidal do contact their providers. In fact, a retrospective study of patients who died by suicide suggested that they were more likely to have visited their physician than a mental health provider in the months leading up to their death.5 In total, 83% of patients who die by suicide have spoken with a healthcare provider in the year prior to their death.6 The stakes are high for rheumatologists and you play an important role in managing suicide risk.

When I teach professionals about recognizing and responding to suicide risk, I make a point to tell them that the only wrong way to address suicide risk is not to do so. Making eye contact with someone’s distress and starting even the clumsiest conversation is a step in the right direction. Remember that asking about suicide does not increase suicidal ideation or the frequency or lethality of attempts in any way. In fact, asking about suicide risk is directly associated with more effective treatment and management.7 You will be evaluating your patient’s risk for suicide based partly on their responses to your direct questions (eg, “are you thinking about killing yourself right now?”) but also on their history (behavior) and the presence of other warning signs. Those warning signs include reports of hopelessness and helplessness, social withdrawal, increased or decreased anxiety and agitation, changes in personality or appearance or hygiene, and/or the disclosure of feelings of guilt or shame or burdensomeness. Some of the more alarming behavioral markers of suicide risk include increased substance use, new or increased self-destructive/self-harming, or risky behaviors. Importantly though, no single or some combination of these factors is more predictive of suicide risk and these feelings and behavior changes aren’t always pathological. Feeling hopeless doesn’t mean you are at risk for dying by suicide. It just means you need some support.

Start by asking direct questions to open the line of communication. If a patient confirms they are having suicidal thoughts, ask about the intensity and duration of those feelings and if (and how) they have attempted suicide in the past. To gauge their risk for suicide, you will also want to know about their plan (eg, the specificity and lethality of that plan) and their access to the means to carry out that plan. The more detailed and feasible their plan is, the greater the suicide risk. Practice active listening and resist the urge to try to talk them out of it; problem-solve, or offer advice at this point. Empathizing and validating their feelings are the most powerful intervention here. For a more standardized approach, consider using a screening instrument with everyone (such as NIMH toolkit’s “Ask Suicide-Screening Questions”). If more information would be helpful, you can also use the “Brief Suicide Safety Assessment” from the same toolkit.

Recognizing that there is no objectively “right” answer. If your clinical impression suggests that your patient is an imminent threat to themselves, you must work to have them transferred to your local emergency room for evaluation and treatment/referral. Preemptively take some time to learn about your state’s requirements for civil commitment or your local emergency room’s preferences for intake. In most states, physicians can make the initial referral for an evaluation of commitment of a patient. The process varies by state but typically starts by calling the police or emergency department unless your patient voluntarily commits themselves. Again, this section applies only when you determine that your patient is not safe or if they are expressing active suicidal ideation with intent to harm themselves; this comports with the standards of care. In these cases, privacy laws (eg, HIPAA) allow providers to notify a patient’s family members or caregivers. The important meta-messages to your patient are that you take them seriously, that you care about their well-being, and that you will step in to act if you determine they pose a risk to themselves. You will not rupture your relationship and it will always be worth the risk.

Besides these rare circumstances where your patient is actively suicidal and warrants hospital evaluation, you will find yourself developing a safety plan or contract for safety with your patient. Safety planning is a collaborative, brief brainstorming session outlining how your patient will recognize that they are in trouble and what they are going to do if that happens. I like to first elicit a very behavioral definition of distress: ask them to describe the experience of their most anxious or hopeless state and write that down (“When I feel…”) and then ask them to help you generate ideas for what they will do when they feel like that. In a training with the countries’ leading suicide expert, Tom Joiner, PhD, I was struck by his visual of pulling his chair around alongside his patient for this safety planning.

Some great entries for the bottom half of this piece of paper (“I will…”) include “call my friend Bob at 555-1234,” “take my dog for a walk around the block,” or “use the breathing exercise that Kim and Maddy recommended.” You will help them create a list; not every option will work in every crisis. Make sure to suggest the addition of a local mental health resource and make a point to add crisis lines there too, such as Crisis Text Line and Suicide Prevention Lifeline.

More information and some great tips our Colorado colleagues can be found here with a great template , too. Additionally, the Denver VA’s library has everything you might need.

This is hard and thankless work and like any primary prevention effort, if you are successful, you’ll never see even the problem. Remember to debrief with your colleagues and share your experience. These conversations destigmatize suicide and mental illness and will make you an even more skillful provider. Reach out for support where you need it (watch for a column coming soon). You’ve got this.

Maddy Pontius is a Master’s Student in Forensic Psychology at the University of Denver with interests in rehabilitation psychology, health psychology, and neuropsychology. She is hoping to work within the overlap of offender rehabilitation and healthcare in the future.

References:

1. World Health Organization. (2019). Suicide worldwide in 2019. Retrieved from https://www.who.int/teams/mental-health-and-substance-use/suicide-data

2. Mandrup Thomsen, L. (2019, June 12-15). The influence of pain on sleep problems, mental health and use of strong painkillers among patients with arthritis [Presentation]. Annual European Congress of Rheumatology, Madrid, Spain. https://www.eular.org/sysModules/obxContent/files/www.eular.2015/1_42291DEB-50E5-49AE-5726D0FAAA83A7D4/09_abstract_3683_and_4723_lack_of_psychological_care_in_arthritis_final.pdf

3. Hassett, A., Aquino, J., & Ilgen, M. (2014). The Risk of Suicide Mortality in Chronic Pain Patients. Current Pain and Headache Reports. https://link.springer.com/content/pdf/10.1007/s11916-014-0436-1.pdf

4. Treharne, G., Lyons, A., & Kitas, G. (2000). Suicidal ideation in patients with rheumatoid arthritis. The BMJ, 1290. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119025/

5. McDowell, A., Lineberry, T., & Bostwick, J. (2011). Practical Suicide-Risk Management for the Busy Primary Care Physician. Mayo Clinic Proceedings, 86(8), 792-800. doi: 10.4065/mcp.2011.0076

6. Ahmedani, B., Simon, G., Stewart, C., Beck, A., Waitzfelder, B., Rossom, R., Lynch, F., Owen-Smith, A., Hunkeler, E., Whiteside, U., Operskalski, B., Coffey, M., & Solberg, L. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870-877. doi: 10.1007/s11606-014-2767-3

7. Norris, D. & Clark, M. (2012). Evaluation and Treatment of the Suicidal Patient. American Family Physician, 15(6), 602-605. https://www.aafp.org/afp/2012/0315/p602.html