(This is the third part of a 4-part series that ran in the Psychiatric Times. The previous pieces provided an intro to the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference, plus an update on attention-deficit/hyperactivity disorder. The last piece will discuss substance use disorders. )
Primary care is a key setting for suicide prevention. Suicide rates in the United States have increased 30% since 2000,1 with an estimated 48,344 suicide deaths in 2018—more than twice the number of deaths due to homicide.2 Analysis of the US National Violent Death Reporting System (NVDRS) indicates that only 27% of adults who die by suicide are in current mental health or substance abuse treatment (ie, behavioral health care), and only 36% had ever received such treatment.3 Thus, adults who are not receiving behavioral health treatment account for the majority of suicide deaths in the United States each year. Although those who die by suicide are unlikely to be engaged in behavioral health treatment, they are often seen in primary care, emergency departments, and other medical settings in the weeks and months before their deaths,4 representing a critical need for suicide prevention in primary care.
Suicide Risk Assessment and Management in Primary Care
The goal of a suicide risk assessment is not to predict whether or not patients will die by suicide—the goal is to determine the most appropriate actions to take to keep patients safe.5 It is also important to remember to take action for any and all endorsements of suicide ideation, but not the same action for every level of risk. Finally, it is also important to remember that most patients will not spontaneously report suicidal thoughts and behaviors—it is up to clinicians to ask.
Suicide risk assessments are safe and do not cause or create suicide ideation. Suicidal thoughts are a symptom of depression, but they can occur in adults without depression. These thoughts should always be taken seriously as both a sign of risk and a sign of distress, even if there is not an indication that the patient is at imminent risk of suicide. Suicide ideation is categorized as “passive” (ie, thoughts that one would be better off dead or wishing for death) and “active” (ie, thoughts of killing oneself).
A review of assessment tools and strategies for suicide risk in adults in primary care (focused on older adults) is available,6 and the Columbia Suicide Severity Rating Scale is considered a “gold standard” for standardized clinical interviews for suicide risk assessment. Another tool for assessing both passive and active ideation is a self-report depression screening tool, the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 assesses the 9 symptoms of depression in the DSM diagnosis of a major depressive episode; the final item asks how often the respondent has had “thoughts that you would be better off dead or of hurting yourself in some way.” If a patient reports having passive or active suicide ideation (PHQ-9 item lumps them together), you must follow-up to determine if the ideation is “passive” or “active,” and whether the patient has current intent to act on their thoughts. You can follow-up by asking, “in the past 2 weeks have you had thoughts of killing yourself?”
In addition, there are routinized screeners for following up the PHQ-9, including the P4 Screener for Assessing Suicide Risk.7 If a patient reports active suicide ideation, the P4 can be administered. The 4 Ps in the P4 are past suicide attempt, suicide plan, probability (perceived risk), and (lack of) protective factors.
To address risk, good clinical judgment must be exercised, and any clinic procedures must be followed. Actions that could be considered to address risk include 1) expressing concern and care about suicide ideation; 2) means safety discussions; 3) creating a safety plan that addresses risk factors; 4) involving the family if possible; 5) engaging a depression care manager if available; 6) initiating treatment for any psychiatric disorders and addressing social determinants that may contribute to risk (ie, engaging social work); 7) considering emergency services if necessary (ED, mobile crisis).
Treatment and Prevention
There are few evidence-based interventions for suicide—only a handful of randomized trials have ever demonstrated effects on suicide deaths. Psychotherapies and collaborative care models for depression have been shown to reduce the severity (or frequency) of suicidal thoughts and prevent nonlethal suicide attempts,8 but these interventions have not been shown to prevent suicide deaths (in randomized trials), in part because the sample size and length of follow-up needed to examine an effect on suicide deaths is prohibitive (due to the low base rate of suicide deaths even in clinical populations). There are no evidence-based assessment methods for suicide risk (regarding efficacy for preventing suicidal behavior). Yet,primary care clinicians must make decisions every day about how to best prevent suicide and provide high-quality, compassionate care that promotes quality of life in their patients.
My presentation at the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference will directly address the tension of needing to act in the absence of definitive data to guide practice. We will discuss common features of compassionate and useful suicide risk assessment and management approaches in primary care. We will strive to consider diverse perspectives, including patients from underrepresented backgrounds and those with lived experience of suicide(those who have experienced suicidal thoughts and behaviors). We will also address key competencies in suicide prevention training, as recommended by the National Action Alliance for Suicide Prevention.9
We hope you will join Dr Van Orden to learn more about suicide risk assessment and prevention at the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference on Saturday, March 12. Find conference details, including the schedule, description of presenters, and registration at Psychiatry.arizona.edu/Psych4PCPs.
Dr Van Orden is a clinical psychologist and associate professor in the Department of Psychiatry at the University of Rochester Medical Center. She directs the Helping Older People Engage (HOPE) Lab and codirects the Rochester Roybal Center for Social Ties and Aging. Her lab studies programs to promote social connection and healthy aging, and to prevent suicide.
1. Hedegaard H, Curtin SC, Warner M. Suicide rates in the United States continue to increase. NCHS Data Brief. 2018;(309):1-8.
2. WISQARS – Web-Based Injury Statistics Query and Reporting System. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2018.
3. Stone DM, Simon TR, Fowler KA, et al. Vital signs: trends in state suicide rates – United States, 1999-2016 and circumstances contributing to suicide – 27 states, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(22):617-624.
4. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6):870-877.
5. Pisani AR, Murrie DC, Silverman MM. Reformulating suicide risk formulation: from prediction to prevention. Acad Psychiatry. 2016;40(4):623-629.
6. Raue PJ, Ghesquiere AR, Bruce ML. Suicide risk in primary care: identification and management in older adults. Curr Psychiatry Rep. 2014;16(9):466.
7. Dube P, Kurt K, Bair MJ, et al. The p4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients. Prim Care Companion J Clin Psychiatry. 2010;12(6):PCC.10m00978.
8. Hawton K, Witt KG, Taylor Salisbury TL, et al. Pharmacological interventions for self-harm in adults. Cochrane Database Syst Rev. 2015;2015(7):CD011777.
9. Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention. Suicide Prevention and the Clinical Workforce: Guidelines for Training. National Action Alliance for Suicide Prevention; 2014.