Suicide is a leading cause of death in the U.S., according to the National Institute of Mental Health, but many providers, regardless of their point of care, don’t consider screening patients for suicide risk their responsibility.
What’s more, recent research published in JAMA Network Open indicates that suicide is on the rise and shows no signs of stopping. Between 1999 and 2016, rates among Americans between 25 to 64 years rose by 41 percent. In rural counties, rates are 25 percent higher than in major metropolitan areas.
Because mental health is such an urgent matter in the U.S. — but nursing and physician assistant programs often neglect it — providers should educate themselves about the risk factors and signs of suicidal ideations, says Pam Greene, PhD, RN, assistant professor in College of Nursing and Health Sciences at Texas A&M University, Corpus Christie. Dr. Greene helped the American Psychiatric Nurses Association (APNA) develop a curriculum for teaching new psych nurses to assess and manage acutely suicidal patients.
One of the best places to start, according to Dr. Greene, is learning about the “reliable and valid” screening tools. “Don’t invent your own,” she tells Florence Health.
What are the Best Screening Tools for Suicide Risk?
Of the screeners that are easy to administer and score, Dr. Greene is partial to the PHQ9. It applies the Likert scale (0 means “not at all”; 3 means “nearly every day”) to questions addressing depression, such as, “Over the last two weeks, how often have you been nervous, anxious or on-edge?” The ninth and last question explicitly addresses suicide. There’s also a child-friendly version of the PHQ9.
“I’m not wed to the PHQ9, but it’s gained a lot of popularity because it’s easy to use and can lead into a more in-depth assessment,” Dr. Greene explains.
An abbreviated take on the PHQ9 is the PHQ4, ideal for providers working in primary care or another specialty where your list of questions to ask the patient seems endless. Just make sure that before using the PHQ4 you determine what severity of responses will prompt you to ask follow-up questions. For example, if a patient indicates he or she’s been worrying a lot, you might ask the patient to “say more about that,” Dr. Greene says. “When you do that, more often than not, it won’t lead to a crisis trail, and you’ll be glad you pursued it more fully.”
For providers interested in a more rigorous tool, Dr. Greene recommends the 20-question Columbia-Suicide Severity Rating Scale.
If you’re uncomfortable asking questions about suicide and self-harm…
Know that this feeling is totally normal. Dr. Greene offers these tips to make yourself and the patient feel more at ease:
- Be as relaxed as you can, and allow the patient plenty of time to respond.
- Be direct. For example, saying “hurting yourself” instead of “killing yourself” might lead the patient to say “no,” even though he or she is at risk.
- If the patient says “no,” but your clinical judgement indicates otherwise, find time to ask the question again in a different way.
- Know the populations that are at high risk of suicide, in particular active military and veterans, college students and senior citizens.
- Try role-playing with a colleague. This can help you build up your comfort with saying the words.
- Treat questions about suicide risk the same way as other challenging screenings you’ve performed, such as those relating to violence or drug use.
- Remember that it gets easier with time and practice (but it never gets completely easy).
How Often Should Practitioners Ask Patients About Suicide Risk?
It probably won’t surprise you to hear that Dr. Greene advocates for screening for suicide risk every time you encounter a patient — but she makes an especially compelling argument why.
“It takes many patients time to work up the courage to say something,” she explains. “It’s hard for people to endorse that they’re having suicidal thoughts. You never know how a clinician is going to take that, and often people struggle with feelings of shame or guilt. It’s harder than we appreciate to tell somebody, ‘I’m thinking about killing myself.'”
At the very least, do a brief screening each time just to see if anything has changed for the patient. “If somebody has an abnormally high blood-pressure reading, you’ll make a plan to recheck that,” Dr. Green adds. “A long time ago, clinicians divided the patient into two parts, and it’s time to put them back together again.”
What Should Practitioners Do if They Suspect a Patient is Suicidal?
Even if it seems daunting, “be upfront and share your concern,” Dr. Greene says. “Ask if they have the means and about their emergency contacts.”
Ultimately, as a clinician, you’ll have to make your own decision regarding next steps, but you should have on-hand the crisis hotline and local ED numbers. And of course, assess whether a behavioral health specialist should see the patient immediately.
Dr. Greene also stresses the importance of knowing how to help patients develop a safety plan, regardless of your care setting. She recommends Stanley and Brown’s, used by APNA and the American Association of Suicidology, among others. And whenever possible, PCPs should collaborate on patients’ treatments with their behavioral health specialists.
Last, make an effort to follow up with the patient. “It sounds so simple, but a follow-up call or text can be hugely powerful for that individual,” Dr. Greene adds.
What Else Can Practitioners Do to Address the U.S.’s Suicide Epidemic?
Dr. Greene encourages providers of all specialities to start thinking of suicide as a public health issue — and to take action in their communities the same way they would promote CPR education. For example, advocate for posting information on suicide risk and awareness in your facility’s waiting room.
“A lot of people want to do something when their friend or colleague looks in distress, but they don’t know what to do so they back off,” Dr. Greene says. “We want people to know that saying something to the individual, even if it comes out wonky, and sharing that crisis number is better than doing nothing at all.”
Patient Health Questionnaire (PHQ9), United States Preventive Services Task Force.
Columbia-Suicide Severity Rating Scale, Columbia University.
Safety planning guide: A quick guide for clinicians, Suicide Prevention Resource Center.
Last updated 9/10/2019