Addressing patient suicide risks in your practice

Physicians Practice®: One of the effects of social isolation resulting from pandemic response protocols that has caused great concern is the potential for exacerbation of mental health issues, particularly the risk of self-harm and suicide in at-risk populations.

Thankfully, two recent papers published in JAMA Open in the last few weeks of January indicate that these fears may have not come to fruition.

In "Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic in the US", John W. Ayers et. al. replicated the methods of a previous cross-sectional study to examine Google search rates per 10 million searches for the term 'suicide'. The authors found that these searches deceased during the early stages of the pandemic, between March and July of 2020.

Though counter to their expectations, the authors report that their findings are supported by extant literature. They also suggest that the search rates may change and even increase, warranting continued monitoring.

In a second paper published in January, "Suicide Deaths During COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020" Jeremy Samuel Faust, MD, MS, et. al., assembled suicide death data for persons aged 10 years and older form the Massachusetts Department of Health Registry of Vital Records and Statistics from January 2015 to May 2020. Here, suicide deaths remained at levels previous recorded in recent years, indicating that the early pandemic did not necessarily have a resultant increase on suicide.

However, the authors note that as the pandemic continues, these rates may change, especially as more cases are completed by a medical examiner.

In today's episode of Perspectives, though we won't be discussing the pandemic's effects on suicide rates, you will hear from Dr. Anisha Abraham, author of the book "Raising Global Teens: A Practical Handbook for Parenting in the 21st Century," about addressing suicide risks in your patients.

Though her book focuses on parenting in general, her insights into addressing suicide risks in pediatric and adult patients remain crucial for all caregivers treating these populations.

In stark contrast to the studies mentioned earlier, the CDC still holds that death by suicide is the second leading cause of death among adolescents between 10 and 24 years of age. The prevalence of suicidal tendencies among teens presents an interesting conundrum for physicians who want to help prevent the worst possible outcome: how and when can you intervene, and what does care look like when one of your patients presents suicidal warning signs?

Dr. Anisha Abraham: Well, there are a number of warning signs that providers need to be thinking about when they're working with young people that can include: someone talking about death, or writing about death, feeling increasingly depressed or anxious. Other signs might be feeling increasingly irritable, having a change in sleeping or eating patterns, and giving away their belongings. These are all things that providers should be aware of when they're working with young people.

Physicians Practice®: Beyond these behavioral warning signs, Dr. Abraham says that there are also common physical signs and risk factors for physicians to watch out for.

Dr. Abraham: Other physical facts that I think are really important to look out for are, if there are signs when or certainly in the interview, that they're not giving you good eye contact, if they clearly seem that they're withdrawn, if there are any recent changes in terms of what's happening in their own home environment or in terms of their own physical health.

There are certainly a number of risk factors that we need to consider as well. Young people that have had a history of suicide in the past are at an increased risk for having a suicidal ideation in the future. And many times, people that have actually attempted suicide have come in to see a health provider in the last six months to a year. So being aware of that I think is really important.

Certainly, other risk factors include having a history of depression or anxiety; having a family History of suicide also increases their likelihood. Use of alcohol or drugs or an increasing use of alcohol or drugs puts younger people at higher risk as well. What we do know is if there's been any history of bullying, or particularly cyber bullying, there's been a higher risk of suicide. If young people identify as being LGBTQ—they could also be at increased risk. There's a host of different issues that we as providers need to be aware of.

Physicians Practice®: If you suspect that one of your patients might be at risk of suicidal tendencies, Dr. Abraham suggestions asking very direct questions when your patient comes in for an appointment.

Dr. Abraham: I would certainly say that if you are concerned about a patient that might be suicidal, asking very specifically about how they're feeling, have there been any issues in terms of depression, and have there been times that they felt sad or down or life was not worth living, asking about other self-harm related issues as well. So certainly, has there been any history of them trying to cut before—we certainly know that that might increase your likelihood of suicidal ideations as well.

I just want to reiterate that by specifically asking, you're more likely to get information, not to put them at higher risk for suicide, but getting direct information and providing the opportunity to get them support. The questionnaire that I would recommend using and certainly in our academy of pediatrics also encourages the use of questionnaires, would be one called the patient health questionnaire nine, which is a validated survey, but there are many validated surveys that, again, providers can use in their clinical setting.

But in addition to that, asking very specific questions about depression and suicide are also very helpful. Those questions will include things like have you been feeling down or sad or depressed? Have you felt that life was not worth living? Do you have a specific plan? And is there a way that you would act on this? These are all questions I think are very important to consider. If you are concerned about a patient being depressed or suicidal.

Physicians Practice®: Once you have identified that r patient may be suicidal, the next step, Dr. Abraham says, is to get psychiatrists or psychologists involved.

Dr. Abraham: I believe it's very important for physicians to ensure that they get a psychiatrist or a psychologist involved as soon as possible.

If a patient is actively suicidal, then certainly making sure they go into the nearest emergency room or they are screened by a psychiatrist would be very important. If they are not actively suicidal, that certainly have some ideations there are some risks in terms of them being suicidal in the future. Certainly, assessing whether or not there may be any way for them to act on it. Also, ensuring that there are not any firearms or other methods in which they could actually attempt suicide, giving an information about suicide hotlines, and ensuring that they will be able to see a provider counselor as soon as possible are all very important.

It's challenging in a clinical setting, but I think it's again, very important to make sure you have a good connection with mental health providers and providing those referrals as quickly as possible.

_References

_{Jeremy Samuel Faust, M. (2021, January 21). Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts. Retrieved January 21, 2021, from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775359?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=012121}

_{John W. Ayers, P. (2021, January 21). Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic. Retrieved January 21, 2021, from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775358?resultClick=3}