First-Ever Suicide Prevention Recommendations Released

Pauline Anderson

April 18, 2018

The first-ever recommendations to improve standard care for individuals at risk for suicide have been released by the National Action Alliance for Suicide Prevention.

Dr Mike Hogan

The feasible, practical, evidence-based recommendations include screening for patients at heightened risk for suicide, developing an intervention and "safety plan," and timely follow-up, Mike Hogan, PhD, a principal of Hogan Health Solutions, a member of the National Action Alliance for Suicide Prevention Executive Committee and former New York state commissioner for mental health, told Medscape Medical News.

They recommendations are aimed at professionals who work in mental and behavioral health, primary care, and emergency department (ED) settings.

"For a very small fraction of patients — and in general medical settings, that percentage may be something like 2% — death by suicide is the greatest immediate health risk," said Hogan.

"So we should not be blind to it, and we should be using feasible, brief interventions with those patients across all settings." Identifying suicidality and using these brief interventions "would save thousands of lives," he added.

Suicide prevention should be managed in the same way as prevention of medical conditions such as cardiovascular disease. Standard heart disease care includes not only interventional cardiology but also prevention advice, such as diet modification, and possibly taking a medication.

Statistics from the Centers for Disease Control and Prevention show that suicide is the tenth leading cause of death in the United States. More than 44,000 such deaths occurred in 2015. Among those aged 15 to 34 years, suicide is the second leading cause of death.

The rate of suicide deaths rose significantly between 2000 and 2015 — from 10.44 per 100,000 to 13.26 per 100,000.

Suicide is an important issue for the medical profession. At least two thirds of suicide deaths occur within about 30 days of a medical contact, be that an emergency department (ED), a primary care practice, or a mental health professional, said Hogan.

No Ownership

That statistic is even higher — up to 70% — among the older male psychiatric population, he said.

"I don't think there's any way to explain that, short of these individuals were having distress, pain of some kind, and they went to a trusted professional, and it didn't get addressed. So we have many missed opportunities to do something."

Until recently, suicide care was not seen as a core responsibility of most healthcare organizations. Managing patients at risk for suicide was left to mental health crisis care and inpatient psychiatry units.

The United States did not have a national strategy for suicide prevention until 2000, and it was not until that strategy was updated in 2012 that the goal of promoting suicide prevention as a core component of healthcare services was added.

A contributing factor is that "the medical profession, including the vast majority of mental health professionals, get little or no training in suicide," said Hogan. He described the lack of education "shocking." Also, he said, "In the US, there are no measures of suicide outcomes for health plans; it's not established as a priority within Medicaid or Medicare."

The idea that suicide prevention should be part of healthcare is "a very new idea," noted Hogan, adding that this field is evolving "pretty quickly."

To improve identification of patients at elevated suicide risk, Hogan and his team believe that screening should be introduced in all healthcare settings.

"We don't recommend universal screening; we recommend screening in patients who have a mental health or substance use diagnosis or are getting treatment for a mental health or substance use issue," he said.

Brief Interventions Endorsed

There are numerous tools to screen for heightened suicide risk. One of these is the Patient Health Questionnaire (PHQ).

Hogan referred to research involving thousands of patients who had completed the PHQ. That research showed that the vast majority of suicides occurred among those who had indicated they were having thoughts about suicide.

Another evidence-based screening tool is the Columbia Suicide Severity Rating Scale.

"These are both feasible screeners and are quite sensitive," Hogan said. As well as screening tools, he said clinicians should use "their own judgment."

One of the new recommendations is to introduce brief interventions. Evidence has emerged within the past 10 years or so that such interventions can be very effective, said Hogan.

"It's almost like an intervention for problem drinking, but a little bit more robust, that helps the patient identify when these thoughts or feelings about suicide come on and gives them tools to change that trajectory."

In addition, if the patient has thoughts about a specific means of suicide, the intervention would help that patient reduce the specific risk through, for example, safe storage of a weapon or use of medications, said Hogan.

"It's important to just create some distance between the person and those impulses," he said.

Such intervention involves creating a safety plan and should take only a half hour or 40 minutes. It can be carried out by a physician assistant or nurse, said Hogan.

"I don't think this is unreasonable to ask for a very small percentage of patients who are going to have suicide risk," he said.

Part of the intervention is to try to refer the patient to an appropriate expert, for example, one who can provide psychotherapy.

Long Wait Times for Care

Hogan recognized that many referrals for mental health care will not be successful, owing to "problematic" waiting lists or because the patient is reluctant to engage in such care.

He also acknowledged that EDs face a "real challenge" in identifying suicidal patients.

"We don't have the alternative crisis care we ought to have that can take care of the patients with behavioral health problems in this setting," he said. "We know that EDs are overloaded as it is, yet, as advocates, we feel like just waiting until that problem gets solved may not be good enough."

He would like to see ED staff screen for suicide risk "if there's an injury that might have been self-inflicted or the patient has a known diagnosis or treatment."

Another recommendation is next-day follow-up, by telephone or text message, to ask patients how they're doing.

"The evidence for these brief, caring contacts is very strong," said Hogan.

This might be especially applicable for patients after release from a psychiatric institution.

"The population at greatest risk of suicide across any demographic, any setting, is patients who got out of the hospital the day before," said Hogan.

"So one example of change in practice would be a follow-up call within at least 48 hours. This is not commonly done but is common sense when you think of the risk and look at the literature," he said.

Thumbs Up From the APA

The new recommendations are aimed at psychiatrists as well as other mental health experts.

"In good practices and hospitals, this is getting done, and it's increasingly getting done, but it's still not the norm, and so, yes, the recommendations apply to psychiatrists as well," said Hogan.

He and his colleagues aim to seek endorsement of the recommendations from patient advocacy organizations and to approach professional groups, such as the American Psychiatric Association (APA)

The APA appears keen to embrace the recommendations.

"The recommendations have the potential to help transform how healthcare systems assess, treat, and prevent suicidal behaviors," Dwight L. Evans, MD, chair of the APA Council on Research, told Medscape Medical News.

"They are based on thoughtful, evidenced-based approaches that can significantly impact the increasing mortality rate of suicide," Evans said.

He noted that the recommendations are part of a national effort among the Action Alliance and the American Foundation for Suicide Prevention to reduce the annual suicide rate by 20% by 2025.

National Action Alliance for Suicide Prevention. Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe.  Full text

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