Suicide Risk Assessment for Medical Providers
Dear Doctor or Allied Healthcare Provider:
In July of 1999 the Surgeon General, Dr. David Satcher, released a “Call to Action to Prevent Suicide,” stating that suicide is currently the 8th leading cause of death in the United States and the 3rd leading cause of death in teenagers. One of the key recommendations made in this report is to help primary care providers to learn how to recognize and refer potentially suicidal patients and/or treat depression, substance abuse, and other mental disorders of mood and thought associated with suicide. It is anticipated that competent medical and psychological treatments can save lives.
A number of researchers have noted the frequent failure of primary care physicians to recognize and aggressively treat depression and other problems related to suicide (1-6). In an unpublished survey of practicing physicians conducted by our Institute, we found that 65% of reporting physicians had had no formal training in suicide risk assessment or management of suicidal patients. Of these, 84% percent reported they did not routinely screen for suicide on health history forms, yet 50% reported they had seen a suicidal person in the past six months. In our limited survey, 33% acknowledged a need for training.
We have also conducted a number of informal surveys of other healthcare providers (dentists, physician’s assistants, chiropractors, pharmacists, and others) and found that they, too, lack specific training in the recognition and assessment of potentially suicidal persons. In its recent 2002 report, Reducing Suicide: A National Imperative, the Institute of Medicine confirms these findings.
As you know, suicide risk increases with medical co-morbidity, and with advancing age. Between 50-70% of depressed persons first seek help from a PC provider and 30% or more of suicide victims and attempters visit a personal physician within a month of the event(4,8). It is unknown how many suicidal persons have “last professional contact” with their pharmacist, chiropractor or dentist.
Early recognition of depression and suicidal thinking, coupled with appropriate treatment, significantly reduces morbidity and mortality. In his 1999 presidential address to the 20th Congress of the International Association for Suicide Prevention, Dr. Robert D. Goldney reported on a number of large studies linking treatment to successful suicide prevention.
Despite these findings, there is relatively little reported disclosure of suicidal symptoms to non-psychiatric physicians and some feel that patients may perceive PC physicians as being more superficial and less interested in this issue than mental health providers (2,4,5).
In our own review and experience in training physicians, ARNPs, PAs, and nurses and other healthcare providers we find, as others have, that they do not consistently utilize screening instruments for depression and rarely inquire about suicidal thoughts or behaviors. Finally, many PC providers reportedly lack confidence in their ability to manage suicidal patients and in the training they have received (11).
Increasing demands on medical care systems to treat large numbers of patients in a short period of time force brief, infrequent visits. Yet, the need for enhanced, focused communication with at-risk patients is clear. To assist the busy clinician with this important interaction, the faculty of the QPR Institute has developed a brief seven-question interview and suicide risk assessment protocol for medical providers. This tutorial will train you in the use of this protocol and takes no more than one hour, with options to spend additional time in areas of particular interest.
Thank you,
The QPR Institute Faculty
REFERENCES
1. Andersen, S.M., and Harthorn, B.H. (1989). The recognition, diagnosis and
treatment of mental disorders by primary care physicians. Medical Care, 27:
869-886.
2. Coombs, D.W, et al. (1992). Pre-suicide attempt communications between parasuicides
and consulted caregivers. Suicide and Life Threatening Behavior, 22: 289-302.
3. Hirschfeld, R., et al. (1997). The national depressive and manic depressive
association consensus statement on the under treatment of depression. Journal
of the American Medical Association, 277(4): 333-340.
4. Miller, M.C., Paulsen, R.H. (1999). Suicide assessment in primary care settings.
In Jacobs, D.G. (ed.). The Harvard Medical School Guide to Suicide Assessment
and Intervention. San Francisco: Jossey-Bass.
5. Orleans, C.T. (1985). How primary care physicians treat psychiatric disorders:
a national survey of family practitioners. American Journal of Psychiatry, 142(1):
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contradictions. Utility of feedback from the GHQ. General Hospital Psychiatry,
10: 189-196.
7. Moscicki, E.K. (1999). Epidemiology of suicide. In Jacobs, D.G. (ed.). The
Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco:
Jossey-Bass.
8. Gliatto, M. F. and Rai, A. K. (1999). Evaluation and treatment of patients
with suicidal ideation. American Family Physician 59: 1500-1506.
9. Katon, W., and Schulberg, H.C., (1992). Epidemiology of depression in primary
care. General Hospital Psychiatry. 14: 237-247.
10. Kaplan, M.S., Adamek, M.E., and A. Calderon. (1999). Managing Depressed
and Suicidal Geriatric Patients: Differences Among Primary Care Physicians.
The Gerontologist: 39(4):417-425.
11. Uncapher, H., Arean, P.A. (2000). Physicians are less willing to treat suicidal
ideation in older patients. Journal of the American Geriatric Society 48: 188-192.
Posted by Brian Quinnett