Life Saving

Addressing patient suicide risk: Communication is key

Suicide is now the 10th leading cause of death in the U.S., the CDC reports. Here are the steps physicians can take to help their patients.

Editor’s note: This essay was originally published by Health Care Service Corporation and has been edited for The DO. It has been reposted here with permission.

As soon as the woman answered the phone, Jane Ziegler could tell something was wrong.

Ziegler, a licensed clinical social worker for a health insurer, had been following up with the patient after a sleep study to discuss some financial issues. But it was clear she was struggling with mental health issues as well. The patient tearfully told Ziegler she was very depressed and had been having thoughts of harming herself, setting in motion immediate communication between Ziegler and the woman’s counselor.

“When she started telling me all of this, it turned from a medical call to a behavioral health issue,” says Ziegler, who works for Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas. “I reached out to her counselor and said the patient needs a re-evaluation of her depression and possibly a revised treatment plan, which resulted in her being seen more frequently. I might have caught her at just the right time.”

For people with mental health issues, a well-timed call like Ziegler’s, a few extra questions during a routine check-up, or even paying close attention to the answer to “How are you?” may be the difference between life and death.

The high-profile suicides of designer Kate Spade and TV chef Anthony Bourdain — both within the same week — have brought renewed focus on the issue of suicide. Coupled with that are new national numbers showing an increase in the number of people taking their own lives.

The Centers for Disease Control and Prevention reports suicide is the 10th leading cause of death in the United States and joins Alzheimer’s disease and drug overdoses as the only three causes of death that are increasing. From 2000 through 2016, the U.S. suicide rate increased 30 percent, and it went up more than that in half of the states. In 2016, almost 45,000 people died by suicide in the United States, according to the CDC.

The American Psychological Association declared suicide to be a public health priority after the CDC released its report. Frank Webster, MD, who spent almost a decade as an emergency department psychiatrist, agrees.

“Everybody is going to die, but nobody should die out of despair,” says Dr. Webster, who is now senior medical director for behavioral health for the five Blues Plans. “Suicide typically comes out of feeling like you are out of options and there is nobody to talk to about it.”

Identifying the signs of suicide risk

As a clinical social worker, Ziegler was prepared to help. Dr. Webster also is trained in what to look for in patients who may be at risk for suicide.

Many physicians and other health care professionals, however, don’t regularly work with mental health patients. It can be much more difficult for them to identify patients who need help, says Mignon Mulvey, behavioral health case management coordinator for the five Blues Plans. In addition, more than half the people who died by suicide in 2016 (54 percent) did not have a diagnosed mental health condition, according to the CDC.

Mulvey would like to see physicians and other health care providers ask patients to rate their mental health the same way they frequently ask patients to rate their pain on a scale of 1 to 10. She also suggests they use and listen for words other than “depressed” and “anxious.” A patient may say they aren’t sleeping, for example, or missing a lot of work. Both may be signs of depression.

“Get specific with your questions,” she says. “Are you getting out of bed every day? Are you going to work? Are you doing what you normally do? Sometimes people don’t even realize that they aren’t doing what they used to do until you ask those types of questions.”

The most important thing, she says, is to start the discussion.

“A big piece in helping these patients is for doctors to not be afraid to ask about risk factors and not being afraid to change how they are asking,” Mulvey says.

The following are 12 common warning signs of suicide, according to the CDC:

-Feeling like a burden

-Being isolated

-Increased anxiety

-Feeling trapped or in unbearable pain

-Increased substance use

-Looking for a way to access lethal means

-Increased anger or rage

-Extreme mood swings

-Expressing hopelessness

-Sleeping too little or too much

-Talking or posting about wanting to die

-Making plans for suicide

What to do next

A physician who determines a patient might be at risk for suicide should ask more detailed questions: Do you have a plan to carry out a suicide? Are there weapons in your home? Do you feel safe enough to go home? Do you have the phone number to call or text a suicide prevention hotline?

If the patient appears intent on attempting suicide, the doctor can call 911 and get the patient to the ER, Mulvey says. In the case of children younger than 18, the parents are part of that decision as well. From there, decisions can be made about the best type and setting of care.

If the patient isn’t at immediate risk, doctors can prescribe medications to ease anxiety and provide therapy resources to be used in tandem with medication. If the patient is unable to do so, the physician’s office can help determine which therapists the patient’s insurance will cover, then make sure an urgent appointment gets scheduled.

Even if all these resources and systems are in place, Mulvey says, there is no ironclad way to prevent someone from taking their own life if they want to — or to gauge with 100 percent accuracy how serious they are about doing it. Spade, for example, told her father the day before she died that she was planning a trip to California with her teenage daughter. Her father said he knew of her troubles with mental illness, but he didn’t think she was on the brink of suicide.

“That’s the cloudiness all around suicide,” Mulvey says. “If someone is determined to take their own life, unfortunately there is a good chance they’re going to do it. But that risk shouldn’t stop anyone from taking the time to intervene and offer support and resources to someone who is struggling. In many cases, it can make the difference between life and death.”

If You Need Help

If you are struggling with depression or considering harming yourself, please get help. The National Suicide Prevention Lifeline provides free, confidential support for people in distress 24 hours a day, seven days a week. It also will provide advice to professionals and resources to aid in prevention and crisis situations. Please call 1-800-273-8255 to speak to a counselor or go to suicidepreventionlifeline.org/chat for online help.

Further reading

5 key takeaways from Medscape’s 2018 physician burnout report

Advice for physicians struggling with burnout or mental illness

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