Is Suicide Inevitable?

By: Lori B. Gaylor, PA-C, MPAS, DFAAPA

At The Henry Ford Health System in Detroit, Michigan, the answer is a resounding NO. In 2001, Henry Ford Behavioral Health pioneered a concept known as “zero suicides” with a goal to develop the ability to assess and modify suicide risk for patients with depression. After implementing this program, for 18 months in 2009 and 2010, there were zero suicides within their system. They have had a statistically significant decrease in suicide rates in their healthcare system since its inception. Since this program was started, it has now spread throughout the world, and the hope is that this new model to eliminate suicide as a cause of death will become a cornerstone of prevention and treatment.

What does this mean for healthcare providers? A 2015 study by Ahmedani and colleagues looked at suicide attempts in US health care systems (Ahmedani et al., 2015). At that time, nearly 65% of people who attempted suicide had seen their healthcare provider within the month. Nearly 40% saw their primary care provider the week before. How can we intervene and prevent the attempt altogether? By implementing a goal of Zero Suicide. It is a lofty goal, but if we shoot for that goal, then the systemic changes that need to take place will happen.

Some statistics: 

 -In the United States, suicide is the #2 cause of death in individuals age 10-34. It used to be a homicide. 

 -Every day, approximately 121 Americans die by suicide, that is one person every 12 minutes (CDC). 

 -One person attempts suicide every 31 seconds. 

 -Almost half of those who kill themselves had a prior attempt. A previous attempt is a proven high-risk factor. 

 -Mental health diagnoses are generally associated with a higher rate of suicide. More than 90% had one or more mental health diagnoses, most often depression. 

 -Suicide fatality rates are highest in the age group 45-54 and equally as high in the elderly (over 80). 

 -Suicide rates in the elderly are 50% higher than that of all ages in the nation. 

 -80% of college students who die by suicide never contacted mental health services.

I once attended a funeral of a good friend’s young son, who had died of suicide, and her opening words when she spoke were convicted and strong. She said, “Depression is a fatal illness.” I have carried these words in my heart ever since. I had never thought about depression in that way, but for the grace of God, there goes every one of us. We all know or love someone with depression. Depression can be a fatal illness, but it does not have to be. There is help. There is treatment. And we have come so far in what we know. But we must make treatment more accessible, and we must educate ourselves, our families, our schools, and our colleagues about the warning signs of depression and suicide. The opioid crisis in our country has spawned another entire group of at-risk patients, as has the ever-present invasion of social media, enabling the speed at which bullying can spread and cause harm.

Most of us in health care are aware of the typical signs of depression, but we may not all be aware of other signs to watch for. Ask about bullying, abuse, substance use, relationships, and stressors. In your evaluation for complaints, keep an ear open for somatic complaints and sleep problems as red flags for depression. It is pretty much common knowledge to assess for anhedonia and low mood, but not everyone thinks about the associated somatic complaints, something we see quite often in our practices and in urgent care.

Identification of an at-risk patient who is in crisis becomes progressively less difficult once we become familiar with available screening tools. We often think these patients will be profoundly and deeply sad and that we will pick up on this in our assessment for suicide risk. Not necessarily. More commonly, these high-risk patients will exhibit irritability, and there are other warning signs. Use this mnemonic of SUICIDE WARNING SIGNS (IS PATH WARM) in your assessment:

I- Ideation

 S- Substance use

 

 P- Purposelessness

 A- Anxiety

 T- Trapped

 H- Hopelessness

W- Withdrawal

 A- Anger

 R- Recklessness

 M- Mood Change

When assessing for warning signs, there are risks, and there are drivers. Focus on both, and determine if there is an immediate crisis that dictates intervention right away. If not an immediate crisis, develop a safety plan in collaboration with the patient. If the safety plan is developed with patient input, you are more likely to get actual buy-in and commitment from the patient. This increases their chance of sticking to the plan. Approach them as compassionate fellow human-being rather than as authority figures threatening, reprimanding, or judging them. You have the power to instill hope through your kindness and care. Help them connect to a competent, compassionate mental health professional and then follow through to ensure continuity of care.

There are resources readily available and easily accessible for providers, patients, and their families. Medical Providers start with this video: https://youtu.be/tyfdN-4nJZQ. I cannot urge you strongly enough to stop and watch this video now. It is a little over three minutes of your time. One out of four highly severe suicide attempts were contemplated for approximately that period of time. 

I suggest www.zerosuicide.edc.org for a wealth of resources, as well as https://www.sprc.org

Patients and families can be directed here: https://suicidepreventionlifeline.org

New statistics show that nearly 85% of patients who died by suicide visited a healthcare provider in the year before their death, and approximately 45% will have seen their primary care provider in the month before their death. Research-backed interventions are becoming the standard of care, and the new protocols for treating suicidal patients are incredibly straightforward. Don’t miss an opportunity to help, and don’t be afraid to ask for help. Suicide is not inevitable, and depression does not have to be a fatal illness. As The Henry Ford Health System says: “No one should die alone and in despair.”

 

See Lori B. Gaylor, PA-C, MPAS, DFAAPA speak at the GAPA 2021 CME Conference in Hilton Head Island, SC July 12-16, 2021.

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