Suicide Prevention Plan Calls for Physicians' Help

June 6, 2001 - Washington - Each year, some 30 000 people in the United
States take their own lives and another 650 000 attempt to do so.

To reduce these losses, Surgeon General David Satcher, MD, PhD, recently
released the nation's first coordinated suicide prevention strategy, a
broad public health–oriented plan that calls for increased awareness,
reduced stigma associated with mental health care, and a host of new
community-based programs.

The plan also prominently mentions primary care and emergency medicine
physicians, as well as other health care professionals such as nursing home
staff, recommending that they keep a more watchful eye out for symptoms
that precede a suicide attempt.

"The vast majority [of those who commit suicide] have a diagnosable mental
health or substance abuse disorder," said Satcher, adding that suicide
screening and depression treatment need to be better integrated into
primary care.

MISSED OPPORTUNITIES

Studies from the last decade or so show that many persons who commit
suicide - perhaps as many as two thirds - visit a physician in the month
prior to their death, meaning that health care professionals are missing
opportunities to save lives (Med Clin North Am. 1988;72:937-971).

That trend appears to be particularly striking among the elderly, who tend
to visit physicians more frequently.

But according to a report from the United States Preventive Services Task
Force (Guide to Clinical Preventive Services, Second Edition; 1996) a
number of factors make it difficult to accurately identify patients who are
a danger to themselves.

Even in those with established risk factors, such as a history of
psychiatric illness or the recent loss of a family member, only a small
percentage will attempt suicide.

"The question becomes 'Is the risk of suicide really prevalent enough in
primary care to warrant the physician becoming aware of it?'" said Herbert
C. Schulberg, PhD, during a recent Institute of Medicine (IOM) workshop on
suicide prevention.

In reviewing the literature, Schulberg, who is professor of psychology and
psychiatry at Weill Medical College of Cornell University in New York City,
found that 1% to 7% of primary care patients reported having suicidal
thoughts.

However, most felt uncomfortable discussing their self-destructive ideation
with their primary care physician; fewer than half spoke up when they had
the chance.

Instead, these patients found mental health specialists to be a more
sympathetic audience.

"Primary care physicians do not do a good job of assessing if there's been
a psychiatric episode," said Schulberg.

Indeed, this finding crept into both the Preventive Services Task Force
recommendations and the surgeon general's report.

While the task force did not find enough evidence to recommend routine
suicide screening for asymptomatic patients, it did say that clinicians
should do a better job of diagnosing and treating affective disorders,
points echoed by Satcher.

AT-RISK ADOLESCENTS

Other groups, including the American Academy of Pediatrics (AAP) and the
American Medical Association (AMA), recommend regularly screening
adolescents, in particular, for suicidal thoughts and other risk factors.

The AAP tells its members to ask adolescents about depression and suicidal
thoughts while taking routine medical histories.

The AMA's adolescent health guidelines give similar advice, telling
physicians to ask teenagers about depression and other risk factors.

If a teen's answers indicate a risk for suicide, physicians should
immediately refer the patient to a mental health specialist or, in extreme
cases, arrange for hospitalization.

During a press conference to announce the surgeon general's plan, after 2
years of work by a host of government and nonprofit organizations,
adolescents received extra attention, including a testimonial from a
17-year-old survivor of a suicide attempt.

The statistics help legitimize this focus: while the nation's overall
suicide rate has hovered around 10 per 100 000 per year since the end of
World War II, during that time the rate for teenagers has tripled, making
it the third leading cause of death in the 15- to 24-year-old age range.

While older men are at highest risk, with rates approaching 50 per 100 000
as they enter their 80s, teenage suicide attracts more attention from
researchers and the media.

Identifying at-risk teenagers is especially difficult, said Warren A.
Jones, MD, president-elect of the American Academy of Family Physicians,
"because there are so many stressors on them."

Jones said that screening questionnaires vary in usefulness because
patients tend to answer honestly only if they have established rapport with
their physician. Jones encourages family physicians to make assessments of
teenagers' mental health a normal part of the office visit.

"Instead of reaching for your screening tool the minute they walk into your
office, develop the kind of relationship that would allow you to ask if
they are at risk for using drugs or alcohol, having unprotected sex, or
being depressed," said Jones.

Developing more effective screening tools is another goal of the surgeon
general's plan, which also pushes for more research to evaluate prevention
strategies, a better suicide surveillance system, and reduced access to
guns which account for some 60% of suicides.

REDUCTION STRATEGY NEEDED

In addition, the plan asks researchers developing treatments for depression
and other mental illnesses to study the treatments' potential for reducing
suicide risk.

Few studies include openly suicidal people because of ethical concerns.

This makes it more difficult to find effective ways to prevent suicide,
said Kate Comtois, PhD, of the University of Washington School of Medicine.

"By excluding high-risk patients, we are missing the critical population we
need to understand," she said at the IOM workshop.

The head of the IOM committee studying suicide (their report is due in
March 2002), William E. Bunney, Jr, MD, chair of the Department of
Psychiatry at the University of California, Irvine, School of Medicine, put
a blunter point on it. "It's depressing," he said, referring to the lack of
data.

Bunney's comment was prompted by Comtois' review of 25 studies that aimed
to reduce suicide risk. Most failed to show any benefit.

However, three studies of behavioral therapy[Image]in which depressed
patients build problem-solving skills show promise.

In addition, two medicines, clozapine and lithium, reduce risk of suicide
in people with schizophrenia and bipolar disorder, respectively.

One review article reports that lithium reduces the suicide rates of people
with bipolar disorder to levels near those seen in the general population,
a sixfold to eightfold decrease (J Clin Psychiatry. 2000;61[suppl 9]:97-104).

"If a cancer drug reduced the death rate even by half, it'd be all over the
front page. And here we're talking about an eight- or ninefold reduction,"
said IOM committee member Kay Redfield Jamison, PhD, a psychologist at
Johns Hopkins University School of Medicine and author of An Unquiet Mind,
which chronicles her own struggle with bipolar disorder.

But, she said, the stigma attached to mental illness somehow subverts the
good news about lithium's potential to reduce suicides.

While new drugs await effectiveness testing for suicide reduction, an
innovative project from the National Institute of Mental Health takes
another tack: placing "depression specialists" in primary care offices to
act as a bridge between patient and physician.

By keeping close tabs on patients, the specialists may help reduce suicidal
thoughts in depressed elderly persons.

Jane Pearson, PhD, program manager of PROSPECT, a program that spans three
medical centers in Pennsylvania and New York, said the program was inspired
by a collaborative care model for diabetes.

"It's worth having somebody to help monitor patients," she said, reducing
the burden on the physician while increasing the amount and quality of
patient contact. Early results from the trial are expected later this year.

EMERGENCY RESPONSE

Emergency physicians can also help decrease suicide deaths, according to
the surgeon general's plan.

For every person who dies of suicide, 22 others visit emergency departments
for suicidal behavior, and these patients often do not receive appropriate
follow-up care.

One study from Rhode Island, now 12 years old, found that fewer than 50% of
adolescent suicide attempters were referred for treatment following an
emergency department visit (R I Med J. 1989;72:401-405).

Another report showed that a large proportion of those who do receive
referrals skip their appointments (J Consult Clin Psychol. 1995;63:469-473).

Dick Kuo, MD, clinical director of the emergency department at the
University of Maryland Medical Center, Baltimore, said that in his
department, every patient suspected of attempting suicide or complaining of
suicidal ideation receives a psychiatric consultation.

However, these patients wait, on average, 10 to 12 hours, often stacking up
five or six deep while queued for an on-call psychiatrist to assess them
and arrange possible follow-up care.

"Staffing and funding are major concerns, without a doubt. We don't have
enough psychiatric coverage," said Kuo.

And while psychiatric consultations, however slow, are common at large,
tertiary care hospitals, Kuo said they remain uncommon at community
hospitals, leaving emergency physicians to use their own judgment on who
may do further harm to themselves.

To improve the situation, the surgeon general's plan calls for uniform
guidelines for assessing suicidal risk and increased training for emergency
department staff, which in turn can lead to better follow-through rates for
patients who are referred.

While physicians can play a prominent role in reducing suicide, the bulk of
the Surgeon General's plan deals with larger social issues: encouraging a
general recognition that suicide is preventable and developing
community-based prevention programs.

The burden lies with everyone, said Satcher, not just physicians, a point
that offers little comfort for Comtois.

"We don't have very good research [on suicide prevention]," she said. "That
means there's no standard of care for people who are suicidal."


by Brian Vastag
JAMA Medical News & Perspectives
2001 American Medical Association. All rights reserved.
http://jama.ama-assn.org/issues/v285n21/ffull/jmn0606-1.html

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