In fact, according to a study published in the American Journal of Psychiatry, almost half (45%) of individuals who die by suicide have visited a primary care provider in the month prior to their death, and 20% have had contact with a mental health service provider. Additionally, 10% of people who die by suicide have been in the emergency care department in the 2 months prior to their death.
Providers have the access and opportunity to connect one-on-one with patients, and for a patient experiencing suicidal ideation or behavior, a meeting with a healthcare provider can be the safe setting needed to help them open up and get the needed help before it’s too late.
This unique opportunity for assessment and prevention could be life-saving, so it is clearly essential that all providers know how to effectively screen for suicide risk. As a provider, you cannot predict death by suicide, but you most certainly can learn to identify people who are at increased risk, start taking precautions, and help them get effective treatment.
EFFECTIVELY OPENING A CONVERSATION ABOUT SUICIDE WITH PATIENTS
Understandably, speaking to patients about their suicidal thoughts (like other “sensitive” topics) can be a difficult conversation for many providers. However, it’s imperative to overcome this discomfort. Asking about suicidal thoughts can literally save a life.
It’s very important to understand that there is absolutely no evidence to support that talking to a person about suicide will make them suicidal or even increase their risk of suicide if they’re already thinking about it. Quite simply, asking patients about suicidal thoughts does NOT cause them commit suicide.
Beyond that fact, however, is that is is essential to learn EFFECTIVE methods for having this conversation.
To illustrate this point, let me give you an example of what will NOT work. Something to the effect of “You aren’t thinking about killing yourself, are you?” is basically guaranteed to be a conversation-ending question.
Instead, calmly and confidently open the conversation. Use a statement like “Now I am going to ask you a few questions about suicide” or “I have a few questions to ask you about suicidal thoughts and behaviors”. By being calm, confident, and direct, the provider is showing the patient that they have been provided a safe space to talk about their thoughts and feelings.
SCREENING FOR SUICIDE RISKS
After opening the conversation, the next step is to screen for suicidal thoughts. Question like “Have you thought about killing yourself?” or “Have you thought about carrying out suicide?” are effective. Note that these opening questions are open-ended. Because of this, often patients will open up and tell you everything you need to know. Again, the ideal is to open and engage in a conversation…not to have the patient feel like they are being “grilled” with questions.
The next step is to screen for suicide attempts. Patients should be asked if they have ever tried to take their own life or if they have ever attempted suicide in the past. Prior attempts are a major risk factor for future suicide death.
It is also essential to determine if the patient has a plan and then if they have the means to carry out the act. Questions such as “Do you think you might try to hurt yourself today?” or “Have you thought of ways you might hurt yourself?” and “Do you have weapons or pills in the house?” are good examples to model.
If a patient gives any indications or warning signs of risk during the screening process, it’s important that the provider digs deeper and follows up with more open-ended questions. The goal is to understand the patient’s suicidal thoughts and what brings them on. Try to understand how strong they are and how long they last. Attempt to gather more information about their plan if they have made one.
WHAT TO NEVER SAY
Even if they are well-intentioned, it’s extremely important that a provider never say things like “That’s not so bad” or “Suicide is foolish” or “Our problems are never as bad as they might seem.”
These statements imply that suicide is something this patient shouldn’t be thinking about. Yet, these patients are seriously thinking about suicide, and these types of statements make it more likely that the patient won’t open up and reveal their true intentions.
Suicide screening and prevention is an often overlooked role by many health care providers. However, I urge you to be aware of how valuable and potentially life-saving this role can be.
Learning to effectively screen and then get the proper help for at-risk patients is a skill that can be developed and honed. One helpful resource is the “Suicide Safe” app provided by SAMHSA. It’s a free learning tool for behavioral health and primary care providers that offers educational materials, treatment locations, sample case studies, and other helpful conversation starters.
For more in-depth information please contact our office at firstname.lastname@example.org or call 917-609-4990 to discuss additional training and consultation options. This is a very important skill and I would be honored to help you develop it more fully.
Amanda Itzkoff, MD