11
Suicidal Patients in Primary Care
Responding to the Challenge
Primary health care has undergone a rather radical transformation in recent times. We have witnessed a transition from an acute care model primarily oriented toward serving the ill to a comprehensive, continuous model of population-based health care that emphasizes all components of treatment: prevention, acute care, and chronic condition management. The composition of the primary care team is also changing in response to the adoption of the patient-centered medical home model. This approach views the primary care clinic as a “one-stop shopping” venue in which a patient can expect to have access to a basket of integrated services, including integrated behavioral health care. Not surprisingly, the roles of the primary care provider (PCP) and affiliated health care team members have been redesigned. In general, medical visits are getting briefer and briefer, might involve a “warm hand-off” to an embedded behavioral health provider, and are equally focused on providing acute care, chronic disease management, and preventive health care services. With all these system changes in process, there is still one overarching truth about suicidal patients that has not changed: Most of them will have seen their PCP in the days before a completed suicide. Roughly 20% of patients who have completed suicides have seen their medical provider within 24–48 hours of their death. Another 20% will have been seen the PCP within the preceding month (see Luoma et al. 2002; Pirkis and Burgess 1998). Why is this so?
For many patients, primary care is the first point of contact in the process of accessing services, whether contact is for a general health, mental health, or substance use problem or for one of many social determinants of health (e.g., poverty, violence, lack of available social resources). Like it or not, there is a long-standing tendency in Western civilization to visit the doctor to discuss many kinds of personal difficulties, including thoughts of suicide. Numerous studies have shown that psychosocial issues drive up to 70% of ambulatory health care services. Results of a large national study showed that half of the patients seeking help for mental health or substance abuse issues received care solely from a PCP. About 50% of all people afflicted with mental health or substance use problems seek no professional care at all for that condition (see Kessler and Wang 2008; Kessler et al. 2005). However, those same individuals have a disproportionately high rate of ambulatory medical care service seeking, often with physical complaints (e.g., headache, insomnia, diffuse musculoskeletal pain, gastrointestinal distress, nausea, indigestion) that tend to mask their underlying, stress-related problems.
Often, medical providers not only lack the specialized training given to mental health providers but also tend to omit asking about suicidal thoughts even when there are clear indications for doing so. Most PCPs point to the lack of onsite mental health resources and the unreliability or inaccessibility of community-based mental health services as the biggest barriers to actively trying to detect and manage suicidal risk. However, we must remember that our patients do not make these kinds of discriminations. They do not decide to give us a break and not be suicidal because of the barriers the PCP must overcome. System-level change may help address some of these barriers over time, but at the end of the day, quality health care must involve paying attention not only to the patient’s physical health but also to the psychosocial factors that drive adverse health outcomes. In this chapter, we argue for a biopsychosocial approach, in which equal time and attention are paid to biological, psychological, and social factors. When these three categories of information are collected and integrated into a single treatment plan, the outcomes and cost of medical care are optimized.
The impact of psychosocial factors on medical practice is made even clearer by various studies showing that medical providers spend as much as one-half of their practice time directly managing mental disorders and chemical addictions. The likely prevalence of current suicidal ideation in the primary care population is as high as 10% (see Bryan et al. 2008). Although suicidality is certainly not limited to people with mental disorders, PCPs need to have knowledge of suicidal behavior to deal effectively with this large segment of the primary care population.
Studies of the prevalence of mental disorders among medical outpatients have consistently shown that anywhere from 6% to 10% have a condition that meets diagnostic criteria for major depressive disorder, panic disorder, generalized anxiety disorder, or somatization disorder (see Kessler and Wang 2008). One classic study screened patients in a primary care waiting area for clinical symptoms of depression and anxiety and found a greater than 50% prevalence (Von Korff et al. 1987).
Mental disorders are generally underrecognized in primary care settings. For this reason, a great deal of clinical research has been focused on screening for depression in primary care, in part because of its heightened association with suicidal ideation or behavior. Despite the heavy emphasis on screening for depression, it is important to remember that the prevalence of suicidality is just as high in patients with anxiety disorders, substance abuse conditions, serious persistent mental illness, and certain kinds of personality disorders (e.g., borderline personality) as it is in patients with depression.
From the biopsychosocial perspective, because of financial or other resource limitations, many suicidal medical patients do not have access to mental health care. Both rural and urban parts of the United States have poor to nonexistent mental health care resources. There may be few, if any, mental health providers in these areas. Even when referral for mental health care is available and acceptable to a suicidal patient, considerable travel time may be required to attend sessions, and access to the mental health provider may be severely limited. In these situations, if a crisis develops, it is the initial responsibility of the PCP to manage it. In sum, in a large number of cases, the suicidal patient will receive all needed treatment in the PCP’s office—the major de facto mental health system in the United States. In this chapter we provide guidance to the PCP whose patient is suicidal or at risk of suicide.
The Best Option: Integrate Behavioral Health Services on Site
Consider for a moment the general value of bringing a behavioral health clinician onto your medical team to help you address the full range of behavioral issues with which patients present in your medical practice. A widely used and relatively inexpensive approach is called the Primary Care Behavioral Health Model (see Robinson and Reiter 2016). This approach involves embedding a behavioral health consultant in the medical examination area to see patients in real time as behavioral health issues emerge during medical visits. The consultant sees referred patients briefly for a problem-focused interview and brief intervention that is then shared with the referring PCP and integrated into the patient’s treatment plan. Obviously, having a behavioral health consultant on site offers the PCP an immediate outlet when a medical patient is screened for or spontaneously discloses suicidal thinking or behavior. Rather than tying up an examination room for hours or having to take a medical assistant offline to monitor the patient while waiting for an evaluation to be arranged, the PCP can simply let the behavioral health consultant figure out the best course of action. Evidence is accumulating that screening and intervention for suicidal medical patients by behavioral health consultants result in robust, positive treatment outcomes. Suicidality is positively impacted by even brief behavioral interventions, and in most cases, there is no need for referral out to a specialized level of care (see Bryan et al. 2008). This effect has also been demonstrated with depressed elderly primary care patients, a sometimes overlooked high-risk group (see Bruce et al. 2004).
Prepare to Deal With This on Your Own
If resources are not available to hire an embedded behavioral health consultant, or if you cannot locate a consultant nearby, you need to be prepared to handle suicidal crises yourself as they arise in your medical practice. The solution is for you, the PCP, to help defuse the suicidal crisis by following the intervention principles outlined here.
One of us (K. D. S.) has worked side by side with PCPs for three decades, and we understand that the primary care clinic can be a most difficult arena in which to properly address suicidality. Much is going on, decisions must be made quickly, and the database is often incomplete. When a patient is suicidal, the situation is usually emotionally charged, and the push to do something quickly can often seem overwhelming. Suicidal patients do not always fit easily into a setting that relies on evaluation, focused treatment, and long intervals between follow-up visits. To deal with suicidality, you must have a thorough understanding of both your personal reactions to the suicidal patient and basic intervention principles. The unfortunate reality is that your personal reactions to a suicidal patient can get in the way of your being clinically effective. We strongly recommend that you review Chapter 2 (“The Clinician’s Emotions, Values, Legal Exposure, and Ethics”) to evaluate how your moral, emotional, and legal concerns may influence how you respond to such patients. Just as occurs with mental health providers, your “hot buttons” can get in the way of doing good work with suicidal patients.
Many PCPs believe that it is very difficult, if not impossible, to conduct anything resembling an effective intervention with a suicidal patient within the confines of a 15-minute medical examination. They rightly wonder how a 15-minute (or even 5-minute) intervention can be done when trained mental health providers have 50-minute sessions. The key difference, your ace in the hole, is the context—the primary care setting is one in which things happen rapidly, and most patients have a certain readiness for this.
In contrast, the mental health context is oriented toward the process of deliberate and detailed discussions focused on producing change in many aspects of the patient’s life. At times, you, the PCP, have a distinct advantage over the mental health therapist, notwithstanding the fast pace of PCP visits. Both you and your patient are acclimated to a setting in which action is expected, the instructions are crisp, and adherence is high. This acclimation evolves from the long-term, sometimes lifelong, relationship you have with the patient and the fact that the patient sees you as a trusted, friendly physician, not an imposing, inquiry-driven stranger.
Despite the strengths of this special kind of leverage, many PCPs respond with a not-in-my-office approach and try to refer the suicidal patient to some form of psychiatric treatment. This action is often based on the premise that the patient needs to be discharged from the clinic and admitted to the mental health care system. It is a promise not always fulfilled. Many times, a gap of days and even weeks occurs between the patient’s leaving one system and entering another, if the transfer happens at all. In some clinical settings, as many as three-fourths of the patients referred from primary care never arrive for their first mental health appointment.
A common referral practice, and one that sometimes seems set up to fail, is to give the patient a phone number for a mental health provider or mental health agency, with instructions to call for an appointment. The patient may not call; it is one more impersonal task to perform. If the patient does call, he or she may get one (or more) busy signals and become discouraged or may become frustrated while navigating through automated phone menus only to end up leaving a voicemail. Even worse, no one may call back. Almost as discouraging is the fact that if a busy clinic clerk answers or ultimately returns the call, the patient might be told that no appointments are available for a month or so. In these eventualities, your patient remains in limbo, and you remain in a position of potential liability for a negligence suit in the event of an adverse outcome.
Our recommendation is to solidify any community-based referral relationships with a bidirectional agreement to provide the referring party with a documented confirmation that a transfer of care has been accomplished. In addition, develop procedures for managing the period that is so often overlooked and so important—the “in the meantime.” In the remainder of this chapter, we discuss those procedures, and we hope the discussion will give you the tools you need for treating these patients within your clinic structure.
Implementing a Quick, Effective Screening and Assessment Protocol for Suicidality
Screening for suicidality during a medical examination is not just a matter of asking the “suicide question” once and moving on if the answer is no. In a study looking at the use of a behavioral health consultant to screen PCP-referred patients for suicidality, the behavioral health consultant screening resulted in a 12.4% prevalence rate of suicidal ideation; in contrast, only 2.2% of those referred patients ever mentioned suicidality to their PCP (Bryan et al. 2008). Because of the stigma associated with endorsing suicidality, even to as trusted a source as the family doctor, it is important to ask about suicidality in more than one way, at more than one time, without coming across as argumentative or accusatory.
One essential rule pertains to any assessment procedure: It is part of treatment. A reasonable and caring assessment, even a 5-minute one, leaves the patient with the understanding that the problem has been taken seriously and that help is on the way. Because many suicidal patients visit a PCP in the hours to weeks before an attempt, assessment in primary care should be proactive regarding suicidal behaviors. All patients should be screened for suicidal thoughts and behavior as part of their initial health care assessment questionnaire on intake into your practice. Questions about suicidality should be a universal part of the screening process during medical examinations and not linked only to particular psychiatric states such as depression and anxiety. This is particularly important if you rely on a structured medical interview format with its decision tree method. These tools are now widely available in a variety of electronic health record templates designed to standardize and speed up the general medical examination.
A common error when using this type of screening algorithm is to ask about depression and, if the answer is no, to skip questions about suicidal ideation or behavior. As we have pointed out in this book, suicidality occurs in many patients who have many different types of mental health or substance use conditions and even in patients who have no diagnosable psychiatric disorder. As the screening study discussed earlier highlights, some patients will initially deny being suicidal but when asked again later will say they are experiencing suicidal ideations (Bryan et al. 2008). The best analogy we can think of is to use the same strategy that is employed when a patient with high blood pressure is thought to have “white coat” syndrome: let the patient get comfortable in the examination room and with the examination process and then recheck the patient.
The Suicidal Thinking and Behaviors Questionnaire (Appendix E) is a screening tool that can be used to assess suicidal history, intensity, causality, and efficacy. This questionnaire provides you with a good basic data set regarding the patient’s past and present suicidality. We have developed a primary care version of this tool, the Suicidal Behaviors and Thinking Questionnaire—Primary Care Version (SBTQ-PC), which is presented in Table 11–1. This short screening tool can be included in an annual patient health survey, something that is now required by many accountable care organizations and state Medicaid programs. In addition, if the patient appears distraught or is presenting for care of a personal or emotional problem, it is relatively easy to have a medical assistant go through the screening protocol while the patient is waiting for a medical examination.
1.Are you currently thinking about harming yourself or taking your life, or in the last 2 weeks, have you thought about, harming yourself or taking your life? Yes(Ask questions 2A–4) No(Skip remaining questions) |
2A.In the last several days, how often have you thought about harming yourself or taking your life? (circle one) |
OnceMore than onceOn several occasionsEvery day |
2B.When you have thoughts about harming yourself or taking your life, how long do you continue to think about it? (circle one) |
Brief, fleeting thoughts |
Somewhat longer, defined periods lasting several minutes before ending |
Longer periods of suicidal thinking up to an hour before ending |
Continuous thoughts lasting hours to days |
2C.When you have thoughts about harming yourself or taking your life, how vivid, intense, or realistic are those thoughts or urges to act? (circle one) |
Vague, poorly formed ideas or images and no real urge to act |
Somewhat vivid ideas or images with mild urge to act |
Vivid, well-formed ideas or images associated with strong urges to act |
3.On a scale of 1–10, where 1 means thinking about harming yourself or taking your life is not a problem at all and 10 means this is a very severe problem for you, where would you put yourself today? (circle one) |
Enter patient rating on 1–10 scale: ____ |
4.Have you actually harmed yourself or made an attempt to end your life |
a) In the past several days? |
Yes |
No |
b) At any time in your life? |
Yes |
No |
Assessing Current Suicidality
If a patient acknowledges engaging in any form of suicidal behavior in the last two weeks (i.e., a positive response to question 1 or question 4A on the SBTQ-PC), it is important that you further characterize three important aspects of the patient’s current suicidality. You should inquire about the behavior’s frequency (how often it occurs), intensity (how specific and detailed the thoughts or communications are), and duration (how long the periods of suicidality last).
The SBTQ-PC gives you some simple, straightforward questions that you, your nurse, or your medical assistant can ask to help gauge these factors. In general, as frequency, intensity, and duration increase, the patient’s sense of anxiety and agitation will increase as well. This will typically be reflected in the patient’s assigning a high severity score to the third screening question (“On a scale of 1–10, where 1 means thinking about harming yourself or taking your life is not a problem at all and 10 means this is a very severe problem for you, where would you put yourself today?”). This information, along with an assessment of the four potential indicators of suicidal potential mentioned earlier (see “Four Basic Indicators of Ongoing Risk”), will help you make an assessment of urgency of the situation.
Characterizing Indicators of Ongoing Risk
The screening questions described in the previous section set the scene for whether you will have a discussion about suicidality during the medical examination. You will want to get some additional insight into factors that may signal ongoing risk of suicidal behavior and an associated need for you to intervene. The following four indicators have some long-term (but not short-term) predictive power for suicidal potential and are helpful in developing a treatment plan. The first indicator is to ask about the problem-solving efficacy of suicide (see Appendix E, item 6, for a way to phrase this question). This question is used to assess whether a patient believes suicide will solve his or her problems. When a person feels that suicide would definitely be effective in dealing with troubles, his or her potential to use suicidal behavior is increased.
The second indicator is intolerance of emotional distress. As we outlined in Chapter 3 (“A Basic Model of Suicidal Behavior”), suicidal patients seem unable to tolerate the emotional distress they are experiencing. If a patient indicates that he or she cannot tolerate the emotional or physical pain that is present, there is a very good chance the patient will at least consider suicidal behavior. The following is a good way to ask this question: “Let’s assume the emotional pain you are in today doesn’t get any better than it is right now or any worse than it is right now. Could you stand being in this kind of pain for a while? On a scale of 1 to 7, where 1 means ‘I couldn’t stand it at all, no way,’ to 7, which means ‘I might not like it, but I could definitely stand the way I feel for a while,’ where would you put yourself?” You may also ask the patient how he or she has coped with the emotional pain up to now, using an open-ended approach: “So, what are some of the things you’ve tried so far to help yourself cope?” Pick up on some positive coping strategy, using the patient’s words if possible, and offer the patient praise and support for this tactic and for coming to see you despite this level of pain.
The third indicator is hopelessness or the patient’s lack of faith that the future will be any better than the present. Hopelessness has been shown to have some predictive value for long-term suicidal behavior, especially among depressed persons and especially in Western cultures. You can use the Beck Hopelessness Scale, an excellent instrument for systematic assessment of this variable, or you can ask directly about the patient’s outlook on the future (Beck et al. 1985). Here is a good quick way to ask this question in an examination: “When you think about the future, does it seem black to you, like there is nothing there for you and nothing is really going to change for the better in your life, or do you see light and hope in your future, like things are going to improve for you and you have a lot to look forward to?” We like to ask this more as an open-ended question rather than ask the patient to give us a numerical rating. Listen to the quality of the patient’s response. Does it have a positive or hopeful tone even in the midst of the patient’s struggles, or does it feel dark, unforgiving, rigid, and based in black-and-white thinking? The latter type of response is more concerning in terms of ongoing risk of suicidality. Remember, as we discussed in Chapter 4 (“Assessment and Case Conceptualization”), do not equate hopelessness with depression. Hopelessness can come from a variety of conditions, including a generally reasonable assessment of one’s life circumstance and environment.
The fourth indicator to assess is the strength of the patient’s survival and coping-related beliefs. These beliefs are the positive reasons for staying alive that your patient may use to buffer the impact of suicidal impulses. The lack of strongly held coping beliefs may remove some resistance to going ahead with suicidal behavior. The importance a patient attaches to survival and coping beliefs can be an important predictor of suicide intent. The Survival and Coping Beliefs scale of the Reasons for Living Inventory (Appendix C) can be used to measure this indicator. More likely, in the time-compromised setting of a primary care examination schedule, you can simply ask the patient to give you some reasons he or she would use to not attempt suicide were the thought to occur. For example, you might say, “When people think about ending their life, it is also pretty normal for them to think about reasons for not ending their life. This might involve curiosity about their future and believing that things will get better, beliefs about the impact of killing themselves on their loved ones (spouse, partner, children, parents, close friends), religious convictions, and so forth. When you think about all the reasons you might have for staying alive at this moment in your life, what sorts of thoughts stand out for you?” Again, asking an open-ended question enables you to assess the richness of your patient’s responses. Richness in this context means that the patient gives you a lot of different reasons for staying alive with a believable, although perhaps moderate, level of conviction. If the patient expresses a very limited number of beliefs for staying alive, it is important to note whether these beliefs are strongly expressed and whether they are clearly important to the patient.
Situations Requiring Special Vigilance: Advancing Age and Poor Health
Be aware of two conditions in which the assessment of suicidality is particularly important. The first is age. Although much has been made in the literature about suicides among the young, especially from adolescence through the mid-20s, the group with the greatest suicide risk is the elderly. Rates of suicide among persons older than 75 years are more than twice as high as rates in the teenage and young adult population.
The second condition, often linked to age, is poor health. Both chronically poor health and recent deterioration in health should immediately set in motion a suicide risk screening process. These factors, especially when combined with a current mental disorder such as depression, present a potentially lethal mixture. Many people who die by suicide saw a PCP a short time before their death, and these patients often are of advanced age and in poor health.
A particularly worrisome situation occurs when both members of a couple are aged and in very ill health. It is important to inquire about suicidal thinking in a gentle and neutral way. Although you may not be able to predict or prevent a suicide in these situations, simply asking about the patient’s life outlook may trigger a much-needed discussion about end-of-life planning, advance directives, and the patient’s general outlook on living.
The Role of Diagnostic Screening
Many of the existing suicide screening algorithms designed for primary care are top heavy with diagnostic elements, particularly for the diagnoses of depression and mood disorders. Because suicidality is associated with an underlying psychiatric disorder in approximately 50% of cases, assessment for these disorders is important, and treating a specific disorder is important in its own right. The problem with treating diagnosed disorders, however, is that you should not assume that the suicidal crisis is taken care of just because the psychiatric disorder is being treated. Remember (as discussed in Chapter 5, “Outpatient Interventions With Suicidal Patients”), it is not unusual for suicidality in persons with an underlying psychiatric disorder to continue in spite of treatment. In addition, recall that a considerable percentage of suicidal patients do not meet criteria for having any psychiatric diagnosis. The assumption that suicidality automatically means the presence of a mental disorder can lead you on a diagnostic wild goose chase (most often, depression is the goose).
Make sure diagnostic criteria are met before you administer psychoactive medication. It is very difficult to justify prescribing pills that are subsequently used in an overdose when a solid basis for the prescription is not found in the clinical records. Our approach is to advocate for treatment both of the psychiatric disorder and of the suicidality and to view these goals as separate aspects of good management.
Table 11–2 contains a series of brief questions to ask when screening for psychiatric illness is indicated. An answer of “yes” to any question should lead to further evaluation of that psychiatric condition. You can use this instrument to help you determine whether further information gathering may be helpful in diagnosis or treatment. Alternatively, you can use some of the brief primary care screening tools that have been developed in the past several years, such as the Patient Health Questionnaire (PHQ)–9 (depression), Generalized Anxiety Disorders (GAD)–7 (anxiety disorders), or Alcohol Use Disorders Identification Test (AUDIT)–C (alcohol or drug abuse).
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Yes | No | Has patient ever had spells similar to a heart attack when he or she became suddenly frightened or anxious and had physical symptoms such as chest pain, tightness, or trouble breathing? |
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Yes | No | Has patient ever had a period of 6 months or more when most of the time he or she felt nervous or anxious, with bodily symptoms such as weakness, fatigue, stomach problems, or muscle aches? |
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Yes | No | Has patient ever had a period of 2 weeks or more when he or she experienced a loss of interest or loss of energy or felt sad, blue, depressed, hopeless, helpless, or worthless? |
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Yes | No | Has patient ever had periods of depressed days with symptoms for 2 weeks over a 2-year period, although not every day (sporadic symptoms)? |
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Yes | No | Does patient have a history of a traumatic event or experience that has led to reexperiencing the trauma (flashbacks) and/or chronic hypervigilance (easily startled, jumpy) and/or social alienation or loss (self-isolation, interpersonal conflicts, loss)? |
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Yes | No | Has patient ever had a period of 1 week or more when he or she was so happy, excited, irritable, or “high” that he or she got into trouble, family or friends worried about it, or a physician said that patient was manic? |
Yes | No | Has patient ever had a period of at least several days when he or she felt irritable, “high,” or excited; felt very energetic; felt very impulsive or confident; or needed less sleep? |
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Yes | No | Has patient ever heard voices or seen visions? |
Yes | No | Has patient ever believed people were controlling, spying on, following, or plotting against him or her or reading patient’s mind? |
Yes | No | Has patient ever believed that he or she could actually hear or feel other people’s thoughts or that other people could actually hear or feel patient’s thoughts or put thoughts into patient’s mind? |
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Yes | No | How many days in the past week has patient consumed alcohol or used mind-altering drugs, either prescribed or not? |
Yes | No | When patient consumes alcohol, how many drinks does patient typically have? When patient uses mind-altering drugs, how many hours of the waking day will patient be under the influence of drugs? |
Yes | No | Has patient ever consumed six or more drinks at any one time when patient was drinking? Has patient ever used drugs repeatedly so as to stay under the influence all day long? |
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Yes | No | Does patient have history of emotional instability, intense and unstable relationships, periods of emotional numbness or emptiness, impulsive self-defeating behavior, or self-mutilating behavior? |
Related posts:
Suicidality and Special Populations
Suicidal Behavior and Use of Psychotropic Medications
The Repetitiously Suicidal Patient: An Intervention Approach for High-Risk Patients
Hospitals and Suicidal Behavior: A Complex Relationship
Outpatient Interventions With Suicidal Patients: Promoting Acceptance and Value-Based Problem Solving
Managing Suicidal Emergencies: Using Crisis to Create Positive Change
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