Preventing suicide in primary care

There is debate over whether screening patients for suicide risk factors actually reduces suicide deaths, yet many primary care clinics are training clinicians and staff to recognize suicide risk factors in their patients.

Suicide is on the rise in the U.S., and the crisis has hit close to home for some primary care practices. Recently, a patient at a primary care clinic at the University of California, San Francisco (UCSF), died by suicide. The patient had a psychiatric admission and had been seen by his primary care physician not long beforehand, said Maki Aoki, MD, a general internist at the clinic.

“In cases like that, it feels heavier [than other patient deaths],” she said. “Even though it's a disease process as any other that patients die from, I think it feels much more like we failed at prevention.”

The Joint Commission advises screening all patients for suicide risk factors using a brief standardized evidence-based screening tool and reviewing screening questionnaires before patients leave the
The Joint Commission advises screening all patients for suicide risk factors using a brief, standardized, evidence-based screening tool and reviewing screening questionnaires before patients leave the appointment or are discharged. Image by iStock

In June 2018, the CDC reported that suicide rates increased by 25.4% from 1999 through 2016, when nearly 45,000 Americans took their own lives. And like the UCSF patient, many may have had recent contact with a primary care clinician. In a study of about 5,000 people who died by suicide, nearly all patients (83%) had a health care visit in the year prior to death, and about half did not have a documented mental health diagnosis, according to results published in June 2014 by the Journal of General Internal Medicine. About 50% of patients made a health care visit within one month of death, most often to a specialty setting (25%) or primary care setting without a mental health diagnosis (21%).

However, the effectiveness of suicide prevention efforts can be controversial. Many factors, such as relationship problems and financial issues, contribute to suicide irrespective of mental health conditions, according to the CDC, and given that life circumstances can rapidly fluctuate, prevention efforts are not foolproof. Yet many primary care clinics are bolstering mental health resources when they can, as well as training clinicians and staff to recognize suicide risk factors in their patients and to know where help is available.

To screen, or not to screen?

There is debate over whether screening patients for suicide risk factors actually reduces suicide deaths, and existing recommendations and guidelines disagree.

As of January 2016, the U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in the general adult population (B-grade recommendation). However, in May 2014, it concluded that routine screening for suicide risk has not been proven to be of benefit, and current evidence is insufficient to recommend for or against screening in primary care. That said, monitoring and reassessing risk for suicide may be justified in patients with a history of suicidal intent or behavior, especially those with mental health diagnoses, the USPSTF said.

The June 2013 Veterans Affairs/Department of Defense clinical practice guideline for assessment and management of patients at risk for suicide also noted that evidence was insufficient to definitively determine whether using existing screening tools to prevent suicide is beneficial.

More recently, The Joint Commission in February 2016 released Sentinel Event Alert 56, which recommended that primary, emergency, and behavioral health clinicians look for suicidal ideation in all patients in both nonacute and acute care settings. The Joint Commission advised 1) reviewing each patient's personal and family history for suicide risk factors, 2) screening all patients for suicide risk factors using a brief, standardized, evidence-based screening tool, and 3) reviewing screening questionnaires before the patient leaves the appointment or is discharged.

Research suggests that a brief screening tool is more reliable at identifying patients at risk for suicide than a clinician's personal judgment or questions about suicidal thoughts that use vague or softened language, The Joint Commission noted. In one study, published in December 2013 by Psychiatric Services, response to item 9 regarding suicidal ideation on the Patient Health Questionnaire-9 (PHQ-9) was a strong predictor of suicide attempt and suicide death in the following year. Individuals who responded “nearly every day” to item 9 had a 4% probability of any suicide attempt at one year, a tenfold increase over those who responded “not at all” (0.4%).

However, not everyone agrees with The Joint Commission. Although suicidal ideation is reasonably predictive of future ideation and nonfatal suicide attempts, it has little association with suicide mortality, according to an editorial published online in June 2018 by General Hospital Psychiatry. The editorialists pointed to a study of 157 patients who died by suicide and were seen by clinicians within the last 30 days of life. Two-thirds said they had no suicidal ideation, and half of those were dead within two days, according to results published in April 2017 by Suicide and Life-Threatening Behavior.

“Though the letter of the law may be adhered to, clinicians, patients, administrators and Joint Commission reviewers will have a false sense of security about these efforts as if they will prevent suicide. … We suggest that [primary care physicians] focus on patients who are clearly in acute psychiatric crisis, utilizing approaches based on individual needs and employing thorough and sympathetic active listening, with benefits beyond even the lowering of suicide risk,” the editorialists wrote.

But not all patients who plan suicide are “clearly in acute psychiatric crisis.” In a study of 1,590 patients seeking emergency treatment for nonpsychiatric reasons who completed mental health screening, 31 (2%) reported that they were planning to kill themselves, but only six had past or present suicidality noted in their medical records, according to results published in April 2005 by the British Journal of Psychiatry. Within 45 days of discharge, four patients who had planned to kill themselves returned to the ED after surviving an attempt.

Therefore, reducing the suicide rate may require more proactive methods in order to identify and treat those at risk, according to a January 2018 editorial published in The Joint Commission Journal on Quality and Patient Safety. “Current practice generally misses those with occult risk—that is, who may only disclose suicidal thoughts/behaviors if they are asked directly,” they wrote.

Screening in practice

Despite the lack of uniform guidance, health systems are implementing suicide screening protocols. With the USPSTF depression screening recommendation in place, tools like the PHQ-9 are already widely in use in primary care settings. Some practices use a shorter version, the PHQ-2, which asks two questions about depression symptoms and reflexes to the PHQ-9 if a patient answers in the affirmative.

At Dr. Aoki's clinic, universal depression screening began in September 2017 with the PHQ-2 reflexing to PHQ-9. Then, in November 2017, UCSF primary care clinics decided to add screening for suicide risk and intimate partner violence. “The suicide screening question is not asked to everybody,” only those patients who screened positive on the PHQ-2, she noted.

Even though the screener didn't need to change, implementation was still challenging because of the multiple staff members involved, said Dr. Aoki, who is also an assistant professor of medicine at UCSF. The front desk hands out the screener (on paper), the medical assistant inputs the results in the electronic health record (EHR), and a best practice alert pops up when the clinician sees a patient who screened positive for suicidality, she said.

There was also concern about what to do if the patient is being seen for an acute problem, like a sprained ankle, and the visit is derailed. But Dr. Aoki said positive suicide screens are not that common, “and we've been actually able to identify [patients at risk] and have those conversations that we otherwise wouldn't have.”

At the same time, the clinic also strengthened its mental health resources by starting a depression collaborative care support team, which includes a licensed clinical social worker and a behavioral health navigator. The social worker can handle high-risk situations by creating safety plans with patients, said Dr. Aoki. “It actually doesn't get used all that often, but I think just knowing that that's available is reassuring.”

In 2015, Parkland Health & Hospital System in Dallas started an even more wide-ranging universal suicide screening protocol. The health system, which has more than 1 million outpatient encounters each year, screens all patients ages 10 and older at its community-oriented primary care health centers, ED, and hospital.

In the outpatient primary care clinics, a medical assistant or nurse asks suicide screening questions alongside other screening questions at check-in, said Kimberly Roaten, PhD, director of quality for safety, education, and implementation in the department of psychiatry at Parkland.

For adult patients, the health system uses the Columbia Suicide Severity Rating Scale (C-SSRS), a validated screening tool that is a standard set of three or six questions. It also built into its EHR the Parkland Algorithm for Suicide Screening (PASS), a clinical decision support tool for frontline staff.

The algorithm classifies patients into three risk categories: no risk identified, moderate risk identified, and high risk identified. Patients at moderate risk are seen by a social worker and connected with outpatient mental health care, whereas patients at high risk are also seen by a behavioral health clinician and, until then, placed under what's called line-of-sight supervision, said Dr. Roaten. “We don't have a separate one-to-one person who's sitting with the patient, but the nurse is aware that they need to keep the patient in their view at all times,” she said.

While identifying more patients through screening requires the appropriate resources, it may also allow health systems to use resources more wisely. For instance, before screening was implemented at Parkland, patients who were identified as being at moderate risk for suicide may have ended up handcuffed in the back of a police car, involuntarily transported to the hospital for evaluation, Dr. Roaten said.

“Those patients don't need that,” she said. “We were inappropriately using resources in that way prior to the implementation of a more standardized process.”

The process for patients at risk for suicide was similar at UCSF before implementing suicide screening. If a clinician felt like a patient needed an inpatient evaluation (and, therefore, an escort), he or she didn't know any other way to get help besides calling 911 or an ambulance, said Dr. Aoki.

To solve this issue, the clinic partnered with a nonprofit that has a mobile crisis phone number. “They'll come and do the assessment, and they can do the 5150 [involuntary psychiatric hold] if needed, but they'll take them in in a van, not in a police car. … If not, then they'll do the safety planning and connect them to resources that can help them as an outpatient,” she said.

For smaller or rural clinics, Dr. Roaten recommended being creative when selecting community partners. Since most patients will not need constant observation, “It may be perfectly appropriate to have a patient talk to somebody on a crisis hotline while they're sitting in their primary care appointment if there's nobody on site to do the evaluation,” she said. (See sidebar for the National Suicide Prevention Lifeline and other resources.)

Dr. Roaten emphasized that suicide prevention efforts do not end when patients screen positive but continue in the form of evidence-based interventions. For example, compared to usual care, a safety planning intervention with telephone follow-up was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge, according to a study published in July 2018 by JAMA Psychiatry.

“If we're following our screening with an evidence-based intervention to reduce risk, I don't think there's any question that what we're doing is effective,” said Dr. Roaten, who is also an associate professor of psychiatry at the University of Texas Southwestern Medical Center. She added that another concern about screening is the risk for false positives, which she believes are still of clinical importance. “Whether or not they are imminently at risk for suicide, patients who endorse items on a suicide risk screener are trying to tell us something.”

The controversy over suicide screening will continue until conclusive evidence arises. In the meantime, Dr. Roaten feels that doing something is better than doing nothing. “It's not the perfect argument, but maybe one of the most important is that we know not asking doesn't work,” she said. “Because that's what we've been doing.”


For the most part, the Parkland staffers who screen patients are not behavioral health clinicians, Dr. Roaten noted, but they do receive training for suicide screening. Parkland created a standardized education for all personnel who screen patients, which includes a didactic presentation on suicide risk factors and a 30-minute video about suicide screening produced by the Columbia Lighthouse Project, developed by Columbia University in New York City.

Since many clinical settings don't have access to a psychologist or psychiatrist, “Our social workers really took the lead on that and have educated themselves and their colleagues and peers about good suicide risk assessment and documentation,” she said. “I think that's a strategy that other facilities could use too.”

Other facilities may need to think about suicide prevention training out of necessity, as some states now mandate training for general clinicians. In 2012, Washington became the first state to mandate suicide-related training in clinical practice for mental health counselors, social workers, psychologists, and other behavioral health professionals, according to a June 2018 analysis published in the American Journal of Public Health. The law was amended in 2014 to apply to physicians, nurses, dentists, and other clinicians. Three to six hours of training are required, depending on clinician type.

In November 2017, the University of Washington in Seattle launched All Patients Safe, which provides suicide prevention training to medical professionals. The training includes the basics of suicide prevention in addition to patient videos that show how prevention strategies can unfold during a typical primary care visit, said program co-creator Anna Ratzliff, MD, PhD, director of the university's Advancing Integrated Mental Health Solutions Center.

“We wanted to emphasize that you don't need a lot of specialty training to be able to do this. Any provider can take this on and do a good job, especially with some key support,” she said.

Sometimes, clinicians are afraid to ask about suicide because they don't want to put the idea in patients' heads, said Dr. Ratzliff, also an associate professor in the department of psychiatry and behavioral sciences at the University of Washington. “That's not going to put a patient at further risk if you ask about suicide, and asking directly about suicide—not just asking about harming yourself—is really important,” she said.

Even if clinicians do not have a lot of behavioral health support in their practice, resources like the National Suicide Prevention Lifeline are available to provide support in triaging patients to appropriate resources, Dr. Ratzliff emphasized.

“I encourage all providers to have that number in their phone so that you can utilize that resource if you're not quite sure what to do,” she said. Of note, a bill signed into law in August 2018 aims to make the resource more accessible. The National Suicide Hotline Improvement Act may change the 1-800 number to a simple three-digit dialing code akin to 911.

Although suicide is a relatively rare event, “There are enough people at risk that we need to be doing something at a systems level to recognize and manage people who are at risk,” said Dr. Ratzliff. She outlined practical ways that individual clinicians can immediately improve suicide prevention efforts in their practices.

First, she recommended becoming familiar with common suicide warning signs (see sidebar). Primary care clinicians with longstanding relationships with patients are especially attuned to behavior changes that may signify suicide risk, Dr. Ratzliff noted.

For at-risk patients, she also suggested practicing means reduction, or decreasing a suicidal person's access to highly lethal means. Physician education in depression recognition and treatment, as well as restricting access to lethal methods, reduces suicide rates, according to a systematic review of suicide prevention strategies that was published in October 2005 by JAMA.

Many studies have linked access to firearms to increased risk for suicide. In the CDC report from earlier this year, firearms were the most common method of suicide overall, leading to 48.5% of deaths. In a June 2014 position paper, ACP recommended that physicians counsel patients on the risk of having firearms in the home, especially when they are at increased risk of harming themselves or others. This conversation should include options for safe storage, regardless of your opinion on firearms, Dr. Ratzliff said, adding that a range of locking mechanisms allow for relative ease of access if patients are concerned about self-defense.

Many suicide attempts are made with medications as well, which is another concern for prescribers. “Talking about safe storage of medications can be a good conversation, especially if you're prescribing medications that are higher risk like opiates or other medications that are lethal in low doses,” she said.

Above all, Dr. Ratzliff recommended leveraging the patient-physician relationship to recognize when something's wrong and take action. “Asking and caring empathically can be an intervention in and of itself,” she said. “Be persistent. Don't let passing comments go. You don't have to be perfect to make a difference.”