"Physicians Need To Own Suicide Prevention" is the headline of a Ƶ article about a high-level conference in Washington focused on the rising rate of suicide in America and what to do about it.
The "experts" to which the headline refers apparently believe that the failure of physicians to "own" suicide prevention -- i.e., to identify risk and intervene to keep their patients safe -- is a major contributor to suicide.
Is this indictment fair? Although we believe that physicians can do more to address mental health problems, they are certainly not responsible for the rise of suicide in America. And what they can do is limited and nowhere near enough to achieve the rhetorical goal of "zero suicide."
The evidence that doctors are culpable in some way is that have seen a primary care physician within the prior 30 days. (For .) The thinking seems to be that that their patients were in great despair and on the verge of taking their own lives.
But the facts of the matter are that (1) and those who do are unlikely to talk to physicians or other professionals, (2) , decided upon no more than an hour before the act, (3) known , and (4) patients who complete suicide are an infinitesimal part of a primary care physician's caseload with suicides occurring only every few years and often without the physician ever knowing.
For all these reasons, it is exceedingly difficult for physicians to identify imminent suicide risk except for patients who talk openly about suicidal impulses and plans. Even then it is not easy to distinguish those with suicidal thoughts who will take their own lives from the majority that will not.
No doubt, most physicians could benefit from training in how to engage with such patients, the critical need to ask about access to guns and other lethal means, when and how to contact emergency services, as well as when and how to set up a safety plan.
That said, let's take a step back and note that physicians can help reduce the incidence of suicide in 3 different ways -- (1) in direct care of patients, (2) in the structure of group medical practices, and (3) in public health initiatives, which focus on population health rather than on the safety of individual patients.
Direct Care
As noted above, physicians often are not skilled at dealing with patients who are overtly suicidal and could benefit from better training.
In addition, physicians can use screening instruments to identify patients who are silently at risk. There are currently in any statistically reliable way, but screening for depression and substance use disorders can identify these major, treatable risk factors. Of course, what to do if there's a positive screening result can be problematic for physicians without skill in psychiatric diagnosis or treatment. It is particularly problematic in areas of the country where referrals to behavioral health professionals are unrealistic.
There are many risk factors for suicide that primary care physicians cannot modify. But there are also risk factors that are part of the experience of living with illness or injury that doctors can and should address, particularly and .
Perhaps most importantly, since guns are the major means of suicide in the United States, patients should be asked about access to guns, and doctors need to emphasize the importance of safe storage.
Structure of Medical Practices
Physicians in solo practice or small freestanding community clinics are limited in their capacity to independently address suicide risk. Large group practices, which provide a range of interventions and aspire to , should be able to do more.
Simply having behavioral health professionals on staff makes it possible for primary care physicians to with appropriately trained clinicians.
that address mental illness, substance abuse, and/or suicide may provide useful information including how to reach the National Suicide Prevention Lifeline (1-800-273-8255) while also conveying the message to patients that the doctor's office is an appropriate place to report emotional distress.
In addition, there is strong evidence that medical practices should provide . There are several models, but the gist is simple: After a primary care physician makes a diagnosis and probably prescribes a medication, a "care manager" checks whether the patient is taking the medication, how it is being tolerated, and if it is effective. In some cases, care managers also provide short-term problem-solving therapy.
Medical practices that include social workers and the like can also address "upstream" factors such as social isolation, family estrangement, inactivity and boredom, bereavement, and/or lack of a sense of self-worth, meaning, or purpose.
Public Health Initiatives
Interventions at an individual and clinic level are important, but suicide is essentially a public health challenge. Public health initiatives should include:
- Increased availability of behavioral health professionals with an emphasis on increased outreach and telepsychiatry services.
- Community-level interventions targeting (1) populations at high risk of completing suicide, e.g., working-age white men with no more than a high school education, white men 85+, men in rural communities, and -- most importantly -- people with access to guns and (2) populations most likely to attempt but not complete suicide, e.g., depressed females
- Efforts to address social determinants of depression and substance abuse such as social isolation, inactivity, bereavement, economic hopelessness, and anomie.
Conclusion
Physicians are not to blame for the rising incidence of suicide in America, but they can do more to contribute to reducing suicide through direct care, the structure of their medical practices, and public health initiatives.
Michael B. Friedman, LMSW, is adjunct associate professor at Columbia University School of Social Work and chair of the Geriatric Mental Health Alliance of New York. Paul S. Nestadt, MD, is an assistant professor and Elizabeth Prince, DO, is an instructor in the Johns Hopkins School of Medicine Department of Psychiatry and Behavioral Science in Baltimore.
Editors' response: We believe the workshop speakers quoted in our original article were making exactly the same point -- that physicians can do more to contribute to suicide prevention. Nowhere in the article, nor during the workshop on which it was based, were physicians "blamed" for increasing suicide rates.