COMMENTARY

Yes, Clinicians Can Reduce Suicide Risk in Their Patients

Jeffrey A. Lieberman, MD

Disclosures

August 26, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Jeffrey A. Lieberman, MD: I'm Dr Jeffrey Lieberman of Columbia Psychiatry, here today for Medscape at the American Psychiatric Association meeting in San Francisco, which is celebrating its 175th anniversary. With me is Dr Christine Moutier, who is the medical director of the American Foundation for Suicide Prevention (AFSP). Christine, great to have you here.

Christine Moutier, MD: Thank you for having me.

Discussion About Suicide Risk and Prevention: A Top Priority

Lieberman: Any effort to try to inform practitioners and the public about mental illness and mental health care has to have, right up at the top of priorities, a discussion about suicide, about which you are in a position to know the latest developments. I would like you to talk to that. Given the gravity of suicide and the manifest awareness of the fact that this occurs in our population, it seems to me that the Mark Twain adage applies: "Everybody talks about the weather, but nobody does anything about it." The suicide rate has not gone down over many years, despite medical progress.

Moutier: That is true. I do think new science, though, is shedding light even more so in terms of what drives suicide risk and what really constitutes effective suicide prevention efforts. That is true also for the clinical world and clinical interventions that are still, to this day, being developed and studied that specifically target suicide risk reduction. Once we know that there are effective treatments and system change that works, it is so important that we translate that science into clinical practice and scale it around the nation.

Lieberman: There is a clear knowledge base of how to identify individuals at risk and how to implement treatment or preventive measures, but it's not being applied adequately.

Moutier: Right, and I think that is because there have been some misunderstandings and because the science is truly still evolving, with new data showing us what is effective. In the past, there has actually been a lot of confusion between prevention and prediction. For example, cardiologists don't bother with the problem that you can't predict who's going to die and when, but they know specifically which risk factors to go after in order to reduce overall mortality and improve people's lives. We need to be doing that also in suicide prevention. There are changes in practice that are not just about screening and assessment, but are about the care steps to take, whether you're a mental health provider, in primary care, or in an emergency department, for that matter.

Suicide Risk Assessment

Lieberman: Can you explain to clinicians exactly what steps one would want to take in evaluating [patients] and then putting in place a prevention plan or surveillance plan? And also, why aren't we doing it?

A suicide risk assessment needs to go far beyond just the assessment of the suicidal ideation…

Moutier: Sure. Once you have identified that a patient may be at risk for suicide, it's really important, of course, to do a more full suicide risk assessment if you have time to do that. But if you are in an acute care setting or some situation where it's not possible to do the full suicide risk assessment, then there are still steps that you should take. Safety planning as a brief intervention is a very important and fairly recent development that includes lethal means counseling and other steps that the patient can take to learn about their own triggers.

Lieberman: Let's break that down. You are a clinician and treating someone for the first time or someone you have seen before, but you are concerned, for some reason, about their potential for self-harm. The first thing you want to do is assess, and then after that, there is a plan. What does the assessment consist of?

Moutier: A suicide risk assessment needs to go far beyond just the assessment of the suicidal ideation, plan, method, and intent. It includes all of the past history that constitutes risk factors, prior history of trauma, family history of suicide, and early childhood adverse events and then current life circumstances, including changes in the person's life, changes in their cognition around hopelessness, and how they are able to think through their current circumstances. If it seems like they are someone who normally thinks very flexibly and creatively in their coping and now they are not and it's narrowing down, that is a very concerning moment of cognitive constriction that happens with higher acute risks.

Lieberman: It's not simply saying, "Have you thought of hurting yourself and do you feel suicidal?" There are these other risk factors that may not be directly associated with self-harm but, because of studies and statistical analyses, are known to increase risk for this possibility. Are most clinicians aware of that?

Moutier: This is more of the norm if you are training in this day and age. But I believe that if you trained more than 10 years ago, you didn't learn to practice this way.

Lieberman: Where can clinicians find that information?

Moutier: Several training programs are [available]; my organization is launching one. We are starting with primary care, but it will soon be available to mental health clinicians.

Lieberman: Is this something you can get online or do you have to attend a conference?

Moutier: It will be online. You can learn more on afsp.org. Because of our AFSP chapter network in all 50 states, they are interested in giving this training to their local clinics, so you can also contact your local AFSP chapter for [information].

Lieberman: The message is: If you don't know, you can either go online, or you can go to a local chapter to get the description of the assessment protocol. What about the prevention plans?

Suicide Prevention

Moutier: The prevention part involves several steps that are fairly basic but are things that I think we were not all trained in due to clinician anxiety and other barriers. For example, safety planning as an actual brief intervention is something you can do in the moment with a patient. Safety planning is a process that takes about 40 minutes to complete. It teams up with the patient to help them identify their own warning signs and triggers for crisis and suicide risk, and it outlines a series of steps they can take. It's a plan that they keep with them. There's an app for it. This was developed by Greg Brown and Barbara Stanley. And it's a very useful and increasingly evidence-based risk-reducing tool.

I know that sounds so simplified, but one of our strongest evidence bases for suicide preventive care…includes follow-up care and contact.

Lieberman: When patients have feelings or thoughts, they can utilize this as a way of mitigating [those thoughts] or preventing [suicide]. What about their family members?

Moutier: Family members should be involved—of course, if the patient gives permission. I think many clinicians have become confused about HIPAA and have forgotten that they should ask the patient. They may assume that this is information that the patient does not want shared. But when it comes to safety planning, lethal means counseling, and making the home environment safe, the family and significant others, and even sometimes a close friend, are very important partners in supporting the patient's plan.

After Safety Planning, What Next?

Lieberman: What happens after safety planning?

Moutier: After safety planning, you continue to care for the patient. If you are in primary care and your patient is at risk for suicide, rather than feeling like you don't have a solid referral that can see them this week or in the next 2 weeks, it is critical to know that a phone call or a visit shortly after the current one can be lifesaving. I know that sounds so simplified, but one of our strongest evidence bases for suicide preventive care that is really being recommended now, even by the Joint Commission, includes follow-up care and contact. In a review by Luxton,[1] nine out of 11 studies of things like postcards, text messaging, and phone calls, let alone in-person visits, showed risk reduction for subsequent suicide attempts.

Lieberman: After your assessment and safety plan, you maintain contact. But in the background, you are treating the underlying condition.

Moutier: Of course. Right. You are always targeting the primary psychiatric condition or conditions. I think the new way to think about suicide prevention is that you are also thinking about suicide risk in its own category. Specific steps to take in addition to what we're talking about (ie, screening, risk assessment, safety planning, lethal means counseling, follow-up care) also include evidence-based treatments that specifically target suicide risk, like cognitive-behavioral therapy (CBT) for suicidal individuals and dialectical behavior therapy (DBT), especially when there's borderline pathology but even when it goes beyond that. DBT is found to be very effective for adolescents, for example, who have had a suicide attempt. There are also things to keep in mind in terms of medication with some new advances happening, and also with the underutilization of an old one like lithium, which has a very strong evidence base for suicide risk reduction.

Lieberman: Do you need to adjust your approaches based on whether someone is suffering from psychosis versus, say, severe depression?

Moutier: Certainly, if you as the clinician have identified a pathway that leads them to become suicidal over and over in their life, it would be important to go after that. We're so accustomed to thinking from our clinical lens and our training with the DSM, and that is, of course, very solid. But suicide risk is very multifactorial. New science is showing that there are genetic risks for suicide that fall outside the genetic risks for mental illness. There are other factors at play, including cognitive traits like inflexibility, rigidity, impulsivity. As a clinician, I would try to take a big step back and look at the big picture beyond just the clinical diagnoses that we are used to operating in, and think about suicide risk as truly multifactorial.

Lieberman: If they don't have an antecedent disorder, they are most likely not seeing a psychiatrist and are seeing primary care, if anybody.

Moutier: That is very true. And that is why it is so important that primary care gets more involved in suicide preventive care.

Can We Achieve a Suicide Rate of Zero?

Lieberman: Is a suicide rate of zero achievable?

Moutier: When I say "zero suicide" and that "suicide is preventable," I don't ever mean that every single case can be prevented, just like with heart disease mortality. Science tells us that these are evidence-based measures and steps to take; we have not even scaled that yet. And so, like every other leading cause of death that has a health basis, there is a prevention pathway from a public health standpoint. That is the way I look at it in terms of the zero-suicide framework.

Lieberman: You are being cautious or not overpromising. A pulmonologist might say, "If we eliminated smoking, we could have X fewer deaths from respiratory disease." We can't necessarily say that yet with suicide prevention methods.

Moutier: If you go to our website and look at Project 2025, you will see an analysis of what would happen in terms of the number of lives saved if four pathways introduced the evidence-based interventions and were scaled up state by state with a rollout rate built in. We determined that we could get to a 20% national rate reduction by 2025.

Suicide prevention turns out to be a hard task. And there are other forces at work, of course, like the economy, the opioid epidemic, and many other societal factors.

Lieberman: That's right; it's multifactorial. Twenty percent is a lot of people. Why hasn't it been done?

Moutier: I think that we have not understood it well enough, and it is such a complex issue. I think a lot of the myths have been creating confusion. I think policymakers have been increasingly interested but unsure that there are steps to take. But that is going to change.

Lieberman: How is that going to happen?

Moutier: For example, in the past few years, policymakers at the federal and state level are finally listening.

Lieberman: Gordon Smith is the president of the National Association of Broadcasters. He obviously has had personal experience.

Moutier: Right. And there is the Garrett Lee Smith (GLS) Memorial Act.

Lieberman: Have you thought about approaching him to try to use media?

Moutier: It's a great idea. A recent study[2] shows that all of the states that got GLS grant funding for suicide prevention for youth actually saw a reduction in the forecasting of what the youth suicide rates would have been in a state-by-state analysis compared with the states that didn't have the GLS grant. So at the community level, when you train up an army of people who are interacting with youth first-line, including parents, teachers, law enforcement, others, you can save lives. In those trainings we always drive at-risk individuals to the health system to get care. Back to our original conversation, that is why it's so important that healthcare professionals are sensitized and trained to know what to do, and that health systems have learned to treat suicide like an actual health outcome to track, just like they do other health outcomes.

Suicide and Violence: Is There Overlap?

Lieberman: How much overlap is there between suicide and violence?

Moutier: Very little in terms of harming others in the act of suicide.

Lieberman: I gather that the counts of murder/suicide scenarios were a very small percentage of overall suicides.

Moutier: Yes. I think those are highlighted in the media, but it is a fraction. Appropriately, we don't want the media covering every average citizen's suicide; there are 130 of those happening every day. My opinion is that there aren't enough data truly to do a really deep dive in terms of the science behind murder/suicide. But with the little that we have, in terms of case reports, it looks like there are key differences and, of course, some similar driving factors in terms of mental health, disturbance, and desperation. But the vast majority of people who are suicidal are not thinking of harming anybody else.

Future Directions

Lieberman: The current state of the art is that we have a body of evidence that allows for risk assessment and then we have safety planning protocols that can be used. And all of this would go in the context of the overall treatment plan of the antecedent condition, if there is one. Has anything been studied scientifically or is anything on the horizon in terms of a diagnostic measure (eg, genetic basis, biomarker, a measure of serotonin neurotransmission, viability, etc.)?

Moutier: Some of the science is looking at all of that.

Lieberman: We never want to overpromise because then we lose our credibility. I'm familiar with a lot of what is being proposed, but you're in a position where you have a view, and now you also have to exercise a degree of objectivity and restraint.

Depression associated with suicide is probably one of the highest associations with a condition right now, but not everyone who is depressed is suicidal. What is it that makes them suicidal? Presumably, there is some added factor which is either related to depression or not. Is there anything that enables us to identify that?

Moutier: The answer is yes, but it's not going to be simple. Some of the cutting-edge science is really looking at predictive analytics with big data using artificial intelligence machine learning. It's not just historical risk factors and things in the electronic health record.

It could be how you're utilizing social media and the changes and behavior patterns around that.

Lieberman: We could see contagions occurring. These are transient events which are maybe contributory, some multifactorial. With schizophrenia, it's anticipated that there are probably 100 or 200 genes involved. With depression there are even more, so why should suicide be able to be pinned on one single biologic substrate?

Moutier: That's right. And it will always be a different set among those multiple risk factors. And for any individual who is at risk, it's likely going to be multiple risk factors that are interacting and converging and causing that sense of acute suicide risk and desperation. It is important for clinicians to know and to be reminded—although I think we know this as we live it with our patients—that acute suicide risk is very temporal. It's a very short period of time. Suicide risk is dynamic as well. That is part of the reason that your ongoing care and contact with your patients, let alone if you do anything else in terms of referral into a specific evidence-based treatment like CBT, DBT, or collaborative assessment and management of suicidality (CAMS), is very likely a large contributor to them holding on to their reasons for living. The "Reasons for Living vs Reasons for Dying" inventory is one of my favorite tools. Clinicians should check it out if they have not had a chance. It can be used in clinical practice and it comes out of some treatment models like CAMS.

Lieberman: They are not high-tech, but these methods are effective. Christine, I could go on asking you things—there is nothing more important than this. Thank you for coming and talking about this today. Keep up the great work.

Moutier: Thank you, and thanks to all the clinicians who are tuning in and eager to learn more about suicide preventive care.

Lieberman: The information is out there on what to do and it's available to you. If you can't find it anywhere else, it's available at the AFSP. Thank you for tuning in and listening; I hope it's been helpful. This is Dr Jeffrey Lieberman, Columbia Psychiatry, for Medscape.

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