Suicide Prevention in Primary Care PracticePrint This Post
I live and practice in Fairfax County, VA, suburb to Washington, DC. Many residents here are “defense contractors” and they must maintain a security clearance. They were a model nuclear family: Matthew, 16, and Christopher, 12, both doing well in academics, sports, and socialization in local high school and middle school; Albert, the father, a 57-year-old white male executive; Kathleen, 52, worked for a consulting firm. They had lived in the same brick home in a good neighborhood for nearly 30 years and grilled on the outside barbecue while the sons played soccer in the front yard.
I am using the past tense here because all four were found dead in their home Tuesday after co-workers of Kathleen contacted police because she had not come to work Monday or Tuesday. Needless to say, this event was the major local news story of the day and it was soon determined that the father had shot the other family members and then turned the gun on himself. There was no sign of social, economic, or personal problems.
Media interviews with friends and neighbors say that the father, who was by all outward appearances prospering in every sense, was worried about the Federal budget “sequestration” that may result in most defense contractors losing their jobs, but that is as much a topic of normal conversation here now as the Redskins or the Nationals. Those of us who live in the Washington area are used to this Congressional threat every year. What could I have done if I were this family’s physician?
On Saturday, a story in the local newspaper stated that “a close friend…who did not want her name published” said that she knew that both Albert’s father and uncle had committed suicide at a young age and that some of what she heard him say sounded “paranoid.” Despite the recent change in the Department of Defense policy that allows personnel to decline to answer questions about mental health treatment on security clearance documents, there is still a fear and stigma to seeking behavioral health care in our community despite excellent insurance coverage and ample private sector availability.
Later in the week, I attended a religious service at Georgetown University for the beginning of Yom Kippur. The rabbi’s message was also a shock; she revealed that her sister committed suicide this past summer. The most important thing she could communicate for this holiest day was that we should do everything we can in the coming year to convince ourselves or someone else that, no matter how hopeless they feel, that there is some other solution to their problems.
Thursday morning, the lead story in the national news was a “stand down” day for the Army worldwide to teach suicide prevention. This year there has been an average of at least one suicide per day among US active-duty personnel. In conjunction with that, the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury CME webinar for September was on identifying and managing suicidal behavior.
Over one third of those who commit suicide have seen a primary care practitioner in the previous month, and many of those in the previous week, before death. We need to assess risk in every patient we see, screen those at increased risk, and refer those with active suicidal behavior. Knowing about a family history of suicide might have prompted some further questions and perhaps saved the lives of four productive members of our community.
Almost any behavior disorder increases the risk of suicide, but depression and alcohol misuse are foremost and common in primary care. Routine screening for depression and alcohol misuse is recommended by the US Preventive Health Task Force for adults, but a recent study suggests that these screenings are done in only 3% of visits to community based primary care physicians.
The PHQ-2 screen for depression and the NIAAA 1Q for alcohol abuse which are validated in primary care populations take about a minute each. Asking “Have you felt depressed or lost interest in everything?” and “When is the last time you had more than X alcoholic drinks in one day?” (where X=4 for men and 3 for women) takes less than 15 seconds. I also remind everyone that more people are injured or killed by firearms they own than by the guns of strangers.
PTSD is also a known risk factor for suicide. Although PTSD screening is currently only recommended for military and veterans, the lifetime prevalence of significant traumatic events in primary care is 70% to 90%. The PC-PTSD is validated in primary care and takes about 2 minutes. It consists of the following:
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
- Have had nightmares about it or thought about it when you did not want to? YES / NO
- Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO
- Were constantly on guard, watchful, or easily startled? YES / NO
- Felt numb or detached from others, activities, or your surroundings? YES / NO
If any 3 of the 4 are positive, a suicide screening is prudent as would be a further evaluation for PTSD.
Problems with job, school, health, or relationships, disrupted sleep, pain, loneliness, or veteran status are risk factors less likely to be on a problem list. If a patient’s dress, posture, facial expression, or tone of voice expresses distress, despair, detachment, or unexpected elation, suicide screening is warranted. Visits for multiple somatic complaints may indicate emotional stress. A history of a previous suicide attempt may warrant repeat screening every visit. There is no screening tool validated for primary care, but experts agree that asking does not make the behavior more likely and that most people appreciate your concern whether they are considering suicide or not. I routinely ask my patients about suicide. “Are you considering that now?” If the answer is yes, “How would you do it?”
If there is evidence of a plan, do what you can to distance the individual from lethal means and tell them you can get them to someone who will review their situation with them and assist them to find other options. Make sure that you and your office as well as the patient are safe from imminent danger. Calling 911 activates local resources and begins the transition from your responsibility. Make certain that someone connects the patient or their support system to whatever resources you have available, e.g., a staff member who will dial 1-800-SUICIDE for them (or 1-800-273-TALK); these hotlines can find local resources. If there is an emergency referral, make sure that someone transports them from your office. In short, treat this as you would any life threatening emergency. You may not be able to prevent every suicide, but at least you have not missed an opportunity which happens to some PCPs somewhere in the US every hour of every day.
Charles Sneiderman, MD PhD
Falls Church, VA
Published on October 30, 2012
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center.
Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975. He completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. He was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences. He maintains certification by the American Board of Family Medicine and has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.
- Harrison DL, et al. Variations in the probability of depression screening at community-based physician practice visits. Prim Care Companion J Clin Psychiatry. 2010;12(5e1-8).
- Freedy J, et al. Traumatic Events and Mental Health In Civilian Primary Care: Implications for Training and Practice. Fam Med. 2010;42(3):185-92.