Every minute two people make a suicide attempt in the U.S. Every 13 minutes one of those people will die. Suicide is the second leading cause of death in persons 25-34 years of age, the third leading cause of death in the 15-24 year old age group, and the tenth leading cause of death across all age groups in the U.S. Up to 76% of people who die by suicide had contact with their primary care provider in the month prior to the suicide.
So why do we rarely talk about suicide except briefly in the aftermath of the death of a beloved celebrity like Robin Williams? National Suicide Prevention Week and the World Suicide Prevention Day take place every September in an effort to increase awareness of this tragic yet preventable problem. However, we need to increase our awareness year-round.
But talking about suicide makes people uncomfortable. Even well-trained and well-meaning health care professionals often feel ill-equipped to adequately assess suicidal risk and to intervene accordingly and thus do not give it adequate attention. Some are afraid of liability, although neglecting to assess and treat a potentially lethal condition is not a very good defense. Some think that asking about suicide will offend their patients or, even worse, give their patients ideas and prompt them to act. The opposite is true – open and caring discussions around suicidal ideation is one of the most helpful things you can do.
Other providers feel helpless and believe that if a person is determined to commit suicide, nothing can stop them. The reality is that most suicidal people do not really want to die; they just want the pain to stop and do not see any other way out. Even individuals who make attempts will waiver between wanting to live and die up until the last minute.
So what can you do? Start by educating yourself about suicide prevention.
Familiarize with the warning signs for suicide. The strongest warning signs are threatening to hurt or kill self or talking about death or wanting to die. Seeking access to lethal means is another strong warning sign along with other potentially preparatory behaviors such as updating life insurance, giving away personal items, and writing goodbye notes. Other warning signs that someone may be suicidal include severe anxiety and agitation, depression, insomnia, sleep disturbance, increased drug/alcohol use, hopelessness, purposelessness, dramatic mood changes, marked withdrawal, feeling trapped, rage, uncontrolled anger, seeking revenge, and reckless/risky behavior. When any of these are present, a suicide risk assessment is warranted.
Learn how to do a suicide risk assessment and safety plan. This includes direct inquiry in a nonjudgmental way about suicidal ideation, including details about any plans, intent and access to means. While most patients typically do not spontaneously report suicidal ideation, most will talk about it honestly when asked. A good risk assessment also includes a thorough assessment of risk factors and protective factors. The strongest predictor of suicide is a previous attempt. Other key risk factors include a family history of suicide, major depression, substance abuse, chronic pain, insomnia, a history of trauma, a traumatic brain injury, recent events leading to humiliation, shame or despair and other psychiatric conditions. Certain populations such as aging white males, adolescents, veterans and lesbian, gay, bisexual and transgendered individuals are at heightened risk. Protective factors include sense of responsibility, religious faith, social support, good problem solving and coping skills, and hope for the future.
Research shows that “no suicide contracts” are usually not helpful in preventing suicide. They focus too much on what the patient should not do and not enough on what they should do. Instead a good safety plan should include limiting access to lethal means, helping patients identify early warning signs of a pending crisis, identifying calming and coping strategies, identifying social supports, and providing access to professional support including crisis lines, calling 911 or going to the emergency room. The National Suicide Prevention Lifeline is 1-800-273-TALK (8255). Ensure mental health conditions are adequately treated and always arrange for follow-up monitoring.
A very useful suicide prevention toolkit developed for primary care providers (but applicable to all health care providers) by the Suicide Prevention Resource Center can be found at www.sprc.org/for-providers/primary-care-tool-kit. Other useful resources can be found at www.stopasuicide.org/ and at www.afsp.org (American Foundation for Suicide Prevention).