In 2022, the Centers for Disease Control and Prevention (CDC) listed suicide as the 11th leading cause of death. Suicide claimed the lives of over 49,000 people which corresponds to one person every 11 minutes dying from suicide. A death from suicide can have a tremendous effect on the emotional and economic aspects of a family and can result in an increased risk of suicide for other family members making suicide prevention a top health priority. Primary care providers can play a huge role in reducing suicide rates due to their frequent interactions with patients. According to Schreiber and Culpepper, 80% of suicide victims had a visit with their primary care providers in the year preceding their deaths. Only 25–30% had seen a mental health provider. This study highlights the impact primary care physicians can have on suicide prevention by assessing a patient’s risk of suicide.
Related: Assessment and Prevention of Suicide
Improved terminology for discussing suicide
In recent years, the CDC and American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluation of Adults have published improved terminology. This will improve communication between physicians and patients and reduce the stigma impeding patients from reaching out for help. All healthcare providers should use the following terms.
- Aborted or self-interrupted attempt: When steps are taken towards making a suicide attempt but are stopped by the person.
- Affected by suicide: Anyone who feels the impact of a suicide.
- Bereaved by suicide or survivors of a suicide loss: Family members, friends, co-workers, and others affected by the suicide of a loved one.
- Interrupted attempt: When another person or an outside circumstance prevents a person from carrying out a self-destructive act.
- Means/methods: The instrument, material, or method used to self-inflict injurious behavior.
- Non-Suicidal Self Injury (NSSI): Intentional injury without suicidal intent and can include actions such as carving, cutting, or burning oneself, banging or punching objects or oneself, or embedding objects under the skin.
- Safety plan: A written list of warning signs, coping responses, supports, and emergency contacts that an individual may use to avert thoughts, feelings, impulses, or behaviors related to suicide.
- Suicidal behaviors or preparatory actions: Preparation steps toward making a suicide attempt.
- Suicidal plan: Plan of the method, means, time, place, or other details for engaging in self-inflicted injurious behavior with any intent to die from the behavior.
- Suicide attempt: A non-fatal, self-directed, potentially injurious behavior with any intent to die.
Factors for patient’s risk of suicide
Research has been able to identify multiple factors that are associated with the risk of suicide; however, there is no evidence available that can predict the occurrence of suicide. Factors that are related to suicide belong to many different aspects of one’s life and can include the following.
Demographic factors
Children exposed to adverse childhood experiences such as abuse, trauma, violence, or loss have a higher risk for mental health disorders and suicidal ideations/attempts.
Men over the age of 85 have the highest rate of suicide and is often a group of individuals over-looked for screening and prevention. In the elderly, the loss of loved ones, isolation, and untreated depression contribute to the higher risk of suicide.
Cultural and socioeconomic factors
During times of economic adversity (high unemployment, poor job market), the risk of suicide is increased. When controlling for depression, a change in financial status is better correlated with suicidal ideation than poverty. Additionally, certain social groups such as American Indians, Alaskan Natives, and immigrants are associated with higher rates of suicide.
Family and home factors
Loss of loved ones by suicide increases the risk of suicide within family members bereaved by suicide. Family aspects such as violence, abuse, lack of support, and mental health issues of parents will negatively affect the coping skills of children. This can lead to higher rates of mental illness and suicide.
Mental health factors
Depression and substance abuse disorders are the most common diagnoses seen in suicide victims. Mental health comorbidities associated with depression can significantly increase the risk of suicide attempts such as obsessive-compulsive disorder, anxiety, and schizophrenia. One group in particular at high risk is those recently discharged from psychiatric inpatient units. The first week after discharge poses an elevated risk for completed suicides.
Patient’s risk of suicide assessment strategies
An assessment involves an in-depth process for evaluating and screening an individual to obtain a better conceptualization of the patient. The assessment often utilizes additional information gained from interviewing the patient to better develop the next steps in the treatment of the patient.
An effective strategy must include a model that identifies at-risk patients. It should also effectively present them to the next provider in the care of the patient. This can include a medical assistant performing appropriate screening tests to ensure the results are appropriately documented for the next provider.
Each primary care provider must then follow up with the patient. They should conduct a structured interview using a non-judgmental, non-condescending, matter-of-fact approach. This requires reducing the stigma on suicide and following up on vague statements made by the patient. The process should identify the risk level of each patient. It should also evaluate the patient’s access to deadly means of committing suicide.
Depending on the findings of the assessment, a provider may need to refer to a mental health provider and develop a safety plan. In some cases, immediate referral and evaluation by a mental health provider may be indicated.
Treatment and management of at-risk patients
The complexity involved in the treatment and management of suicide requires clinicians to develop a biopsychosocial treatment plan. Identifying social support resources, family members, and other supportive resources is an important part. It should be included in the patient’s treatment plan.
Determining what level of care the patient needs helps to give each patient support during crucial times. When assessing a patient’s risk of suicide, clinicians should be knowledgeable about the available options such as:
- Immediate or involuntary hospitalization
- Partial hospital program
- Intensive outpatient program
- Outpatient treatment when deciding next steps in care
Developing a safety plan for each patient is key. It can provide them with the tools to manage their thoughts and seek the appropriate treatment. The importance of primary care providers in helping assess, treat, and manage patients at risk of suicide cannot be overstated. With 80% of patients who have sought primary care within the year before suicide attempts, applying appropriate assessment and management strategies can have a significant impact on this healthcare emergency.
