What Physicians Can Do to Prevent Suicide

"Half a million people are dead who should not be dead," says a researcher who has identified a steep rise in deaths among middle-aged whites. With data like this, how can physicians not seek out more mental health training to help them understand how to effectively treat patients?

Suicide is among the reasons mortality among middle-aged whites has unexpectedly increased, according to an unsettling report published by a pair of Princeton economists this week. In order for physicians to effectively respond to these patients' needs, they should demand more access to mental health training and resources.

A couple of weeks ago I wrote about the Accreditation Council for Graduate Medical Education's focus on improving mental health resources for residents. The ACGME is holding a national symposium on the subject in a couple of weeks and it could prove to be a turning point in reducing mental health stigma within the physician community.

But the report published this week showing a marked increase in death rates among middle-aged white men points to a need to include more mental health training for physicians to address patients' needs. And a study published last year showed high rates of suicide among elderly white males. "Half a million people are dead who should not be dead," the paper's co-author, Nobel laureate Angus Deaton, said.

According to a study, published in the Proceedings of the National Academy Sciences, (after it was rejected by JAMA and others) increases in drug and alcohol poisonings and suicides "were large enough to drive up all-cause midlife mortality," specifically for whites age 45 to 54. Other causes of death include chronic liver disease and cirrhosis.

The findings are significant because they are limited to middle-aged whites, according to the report. Death rates among blacks and Hispanics continued to fall in these categories. Researchers estimated that 7,000 deaths in 2013 alone could have been avoided.

With data like this, how can physicians not seek out more mental health training to help them understand how to effectively treat patients?

Maria Oquendo, MD, president-elect of the American Psychiatric Association, attributes it to the stigma that persists among physicians about patients who present with mental illness. "There is a belief that psychiatric conditions are not real, and not that big of a deal," she says.

Stigma in Practice
Such thinking is short-sighted particularly because of numerous studies that show mental and physical health are connected. Treating diabetes, for example, without addressing a patient's depression likely decreases the chance of positive outcome.

Oquendo says she believes there is a generational shift in attitude. Younger physicians are more open to talking about mental health, she says, but backward practices in some doctors' offices persist. For example, the PHQ-9, the widely used nine-question depression screener, may be used for patient intake by a PCP or internist; however, Oquendo says doctors will administer it as a PHQ-8.

"They don't want that last question," she says. "It asks a patient whether they are having suicidal thoughts. It sends a message to the clinical staff that it is OK not to talk about this and it misses a population who is at-risk."

The apprehension that physicians have about asking that last question on the PHQ-9 is rooted in fear that once suicide is brought up, the patient will kill him or herself. But Oquendo says physicians don't need to panic.

"It doesn't make people suicidal to ask them about it," she says. "For individuals who are not, they'll comfortably tell you they aren't, but for individuals who are, they may be relieved to have someone to talk to."

Knowing how to talk to a patient is crucial. Oquendo, who is also a professor of clinical psychiatry at Columbia University, director of residency training at the New York State Psychiatric Institute and vice president of the American Foundation for Suicide Prevention (AFSP), stresses that physicians in all settings need to have strategies that address what patients need.

"As the health system moves toward having PCPs do more of the work of taking care of psychiatric patients, it will become very important," she says.

Education Shortfalls
Most suicide prevention strategies are learned informally. Psychiatrist and AFSP Chief Medical Officer, Christine Moutier, MD, says when she was a resident she had "maybe one or two hours" of lectures about psychiatric emergencies. Most residents do not even get that much. Instead, the skills are learned on-the-fly, usually in the emergency department.

"That's half of what you see in the ER," Moutier says. "What I think happens is people see it so often in clinical practice, that they assume their responses are based in education but the reality is there is a whole science behind evidence-based practice for working with suicidal people or even people who are at-risk. That is what is missing in the curriculum."

The Suicide Risk Assessment form is time-tested and used in some settings, but other suicide prevention protocols are newer, such as the  Collaborative Assessment and Management of Suicidality (CAMS). This treatment approach, says Moutier, is showing positive results among veterans.

In addition to improving curriculum for residents, Oquendo also wants education and training improved for licensed clinical social workers (LCSWs), who are being plugged into physician practices to improve patients' access to mental health services. Oquendo believes LCSWs are an important part of improving access, but wants them to be trained in risk assessment and diagnosis.

There are suicide prevention strategies and training available to physicians now. Both Moutier and Oquendo say that letting a patient talk is important. What you say back to them is equally important.

"We say, 'Don't get into debates about life or minimizing their problem," says Moutier. "Calling their thoughts 'selfish' is so wrong and for so long we've known that. What happens is the person gets into a mindset more often than not that they feel they are such a burden to everyone else in their life that suicide becomes an even more logical optional to them."

Resources
Suicide is a public health problem that is preventable. The AFSP has embarked on a nationwide training effort for not only physicians, but anyone, to take part in Mental Health First Aid. The concept is similar to common first aid techniques. It's an eight-hour training course that teaches how to recognize and respond to signs of a behavior change that could indicate mental health deterioration and/or a mental health crisis.

"Nine out 10 Americans value mental health on an equal level of physical health," says Moutier. "I sometimes feel like my colleagues are, in a way, stuck in an older time. Out in the larger public, that's really changing. Physicians should be the leaders of this kind of communication with their patients."

Both the APA and AFSP have several resources for suicide prevention as well as practice guidelines.
If you are in crisis, call the national suicide prevention number, 1-800-273-8255.