How Clinicians Can Help Save Lives
Effective suicide prevention depends on early detection so that individuals experiencing suicidal thoughts or struggles can be connected to help as soon as possible. Healthcare settings serve as a perfect opportunity to spot individuals in distress since up to 45% of people who die by suicide visit their primary care physician in the month prior to their death and 39% make an emergency department visit in the year prior to their death. Fortunately, evidence-based tools exist to identify patients who may be at risk and steps can be taken to reduce suicide mortality. All healthcare providers can play a role in preventing this leading cause of death.
Suicide is a potentially preventable cause of death across all age groups in the U.S. Preventing suicide requires a public health approach, as with any other leading cause of death. The public health model for suicide prevention includes community and clinical actions. A few examples of this public health approach to prevent suicide include the American Academy of Pediatrics (AAP), the American Foundation for Suicide Prevention (AFSP), and experts from the National Institute of Mental Health 2021 release of a “Blueprint for Youth Suicide Prevention”. The Blueprint, along with AAP’s preventive periodicity schedule, recommends pediatricians begin universal screening for suicide risk in youth 12 years or older. Further, the Joint Commission recommends that health systems screen all individuals with mental health concerns across the lifespan for suicidal ideation using a validated screening tool. Clinicians and health systems have a critical role to play in their work with patients and families to make suicide prevention a true priority.
Until recently, evidence-based suicide-specific interventions designed for clinical settings did not exist. Thankfully, we now have a core set of evidence-based brief interventions to apply when suicide screening is positive and further risk assessment identifies any level of suicide risk. These include the Safety Planning Intervention, lethal means counseling, caring contacts (a series of communications from the clinician or health system delivered to the patient post visit manually or automated), and appropriate follow-up treatment. This approach showed a 45% reduction in suicidal behavior over the ensuing six months following suicide-related emergency department visits in a recent VA study. Incorporating feasible ways for these brief interventions to be carried out in any health setting is the key to advancing suicide prevention efforts in health systems. Beyond these brief steps, treatments with robust evidence for reducing suicide risk include Cognitive Behavioral Therapy for Suicide Prevention, Dialectical Behavioral Therapy, and Safe Alternatives for Teens & Youth (SAFETY). Additionally, a patient-centered clinical framework called the Collaborative Assessment and Management of Suicidality (CAMS) provides a practical set of steps that any mental health clinician regardless of previous training can use. CAMS has been shown to reduce suicidal suffering and suicidal ideation.
Every clinician can do a few things to reduce suicide risk in their patients, including:
1) Incorporate routine suicide and mental health screening/rating scales into your practice. Consider learning how to use the ASQ, a suicide screening and assessment tool developed and validated by experts at NIMH.
2) Implement routine suicide risk screening, followed by risk assessment, and a series of “brief interventions” considered best practice. In addition to the brief interventions outlined above, providing 988 or local crisis resources and referrals should also be incorporated into health care setting responses. This suite of actions has been shown to reduce suicide risk and can be utilized for most instances when patients are having suicidal thoughts. Hospitalization is necessary when there is imminent threat to safety, and most patients can be managed on an outpatient basis using brief interventions.
The Safety Planning Intervention should be used with all patients who have any level of suicidal ideation or suicide risk factors. Learn more here.
3) Become familiar with Counseling on Lethal Means and practice this with patients during periods of increased suicide risk.
4) Increase the frequency of outpatient visits or communication during periods of increased risk.
5) Involve the patient’s family in supportive actions when possible and with patient's permission. For example, by helping to make the home environment free of lethal means.
6) Have a referral list ready to go of specific suicide risk reducing forms of therapy such as CBT, DBT, or CAMS. Learn more about suicide specific treatments.
7) Learn the data related to medications and suicide prevention. (See my clinical handbook with Drs. Anthony Pisani and Stephen Stahl, Cambridge University Press, for information on this, including guidance related to medications.)
9) Advocate with the leadership of your healthcare organization to make suicide prevention a priority of the health system.
10) Learn about postvention procedures for supporting communities, families, and clinicians in the aftermath of suicide.
The latest statistics on suicide released by the CDC show a 4.79% increase in the suicide rate from 2020 to 2021. This should serve as a clarion call, imploring us to come together to lower the rate of suicide and help save lives. The good news is that we know strategies that have been proven to work. Healthcare professionals are in a powerful and privileged position to make a sizable difference. By educating yourselves, scaling up smart practices within your healthcare environments, and sharing information, you can help save lives. Please join me in making a difference.
We welcome guest columnist Dr. Christine Yu Moutier, Chief Medical Officer, American Foundation for Suicide Prevention.
About Dr. Moutier:
Christine Yu Moutier, MD, serves as chief medical officer for the American Foundation for Suicide Prevention and has testified before the U.S. Congress, presented to the White House, and at the National Academy of Sciences. She co-anchored CNN’s Emmy Award-winning Finding Hope suicide prevention town hall with Anderson Cooper, and has appeared as an expert in The New York Times, The Washington Post, Time magazine, The Economist, The Atlantic, the BBC, CNN, NBC and other print and television outlets.
Since earning her medical degree and training in psychiatry at the University of California, San Diego, Moutier has been a practicing psychiatrist, professor of psychiatry, a dean in the UCSD School of Medicine, and medical director of the Inpatient Psychiatric Unit at the VA Medical Center in La Jolla, treating diverse patient populations from Asian refugees to veterans to corporate and academic leaders. She also served as co-investigator for the Sequenced Treatment Alternatives to Relieve Depression study (STAR*D), a large National Institute of Mental Health trial on the treatment of refractory depression.
Dr. Moutier began her work in suicide prevention many years ago after losing physician colleagues to suicide. In addition to advocating for institutional shifts in policies and procedures that normalize help seeking for mental health concerns at individual and institutional levels, Dr. Moutier has been instrumental in highlighting the role of licensing boards in framing questions to focus on competence rather than illness. She is similarly working with other fields such as nursing, veterinary medicine, law enforcement, construction, and the entertainment industry to allow all individuals to proactively manage their mental health optimally.
Moutier has authored articles and book chapters for publications such as the Journal of the American Medical Association, Academic Medicine, the American Journal of Psychiatry, the Journal of Clinical Psychiatry, and Academic Psychiatry. She has also authored Suicide Prevention, a Cambridge University Press clinical handbook.
You can follow Dr. Moutier on Twitter at @cmoutierMD