Practical Suicide-Risk Management for the Busy Primary Care Physician

Abstract

Suicide is a public health problem and a leading cause of death. The number of people thinking seriously about suicide, making plans, and attempting suicide is surprisingly high. In total, primary care clinicians write more prescriptions for antidepressants than mental health clinicians and see patients more often in the month before their death by suicide. Treatment of depression by primary care physicians is improving, but opportunities remain in addressing suicide-related treatment variables. Collaborative care models for treating depression have the potential both to improve depression outcomes and decrease suicide risk. Alcohol use disorders and anxiety symptoms are important comorbid conditions to identify and treat. Management of suicide risk includes understanding the difference between risk factors and warning signs, developing a suicide risk assessment, and practically managing suicidal crises. Mayo Clin © 2011 Mayo Foundation for Medical Education and ResearchOn completion of this article, you should be able to (1) [3][4][5] These worries are based on population-level effects of the persistent increased unemployment rate due to the severe recession. [3][4][5] Serious thoughts of suicide, plans for suicide, and suicide attempts are surprisingly common in the general population (Table 1). 6 Despite that frequency, death by suicide is still a low base-rate occurrence and impossible to predict accurately. 7,8 Although a relatively uncommon event, suicide has a lifelong and profound effect personally on the families, friends, and physicians of the person committing suicide.In this concise review, we provide a pragmatic and clinically relevant background on suicide risk management for nonpsychiatrists. We will use frequently asked questions based on our clinical experiences and review key principles of depression treatment as they relate to suicide risk management. We will update and synthesize information gained from research into concerns associated with the antidepressant black box warnings (BBWs) for suicidality and highlight their 2009 revisions. 9 We will then close by describing basic principles in identifying those at risk of suicide, assessing them, and devising practical patient management strategies. IMporTAnCE To prIMAry CArETwo practice realities have spurred interventions to improve primary care recognition and treatment of depression as a public health suicide prevention strategy. 10,11 First, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. 10 A review of studies analyzing this clinical scenario estimated 45% of those dying by suicide saw their primary care physician in the month before their death. 10 Only 20% saw a mental health professional 10 in the preceding month. Women and older patients are more likely to have sought care in the month before suicide 10 than men and younger patients. Second, generalists (internists, pediatricians, family physicians) write most antidepressant prescriptions (62%) in the United States. 11 When...

Is externalizing psychopathology a robust risk factor for suicidal thoughts and behaviors? A meta‐analysis of longitudinal studies

“…Many forms of externalizing psychopathology, including impulsivity, anger, alcohol and drug use, and smoking have been proposed as risk factors for STBs (Fowler, 2012;McDowell, Lineberry, & Bostwick, 2011;Rudd et al, 2006;Van Orden et al, 2010). As such, externalizing psychopathology is frequently included as a key component of empirically based suicide risk assessment frameworks (e.g., Chu et al, 2015;Joiner, Walker, Rudd, & Jobes, 1999;Linehan, 2012).…”

National Pathways for Suicide Prevention and Health Services Research

“…Suicide risk management can be considered skills needed to assess these levels of risk, and then to inform patients, provide treatment, coordinate care, and respond to crises for those who have been identified. 8 Risk management activities can be distributed across settings and types of providers. The authors draw from research demonstrating the benefits of the chronic care management model as it has been applied to common mental disorders.…”

Major Physical Health Conditions and Risk of Suicide

“…To date, health systems have generally targeted suicide prevention and intervention for patients with known risk focusing primarily on individuals with mental health and substance use conditions or those with expressed suicidal ideation. 7,8 Supporting this approach are studies based on psychological autopsy reports indicating that 90% of individuals who die by suicide may meet criteria for a psychiatric condition. 9 Although several interventions have reduced suicide rates in these targeted behavioral health patient populations, 10–13 these efforts have not made a measureable difference in reducing the overall population suicide rate.…”