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).
