Primary care physicians ‘ideally positioned’ to detect patients at risk of suicide

Researchers report findings about training, screening, and treatment pathway.

Primary care physicians are in a unique place to identify and refer patients at risk for suicide, according to a report by the National Institute for Mental Health (NIMH).

September is Suicide Prevention Awareness Month and this year researchers have explored how primary care physicians could contribute to suicide prevention efforts. Suicide is a leading cause of death in the United States, with almost 46,000 people dying by suicide in 2020, 1.2 million attempting suicide and millions more seriously thinking about it, according to figures from the U.S. Centers for Disease Control and Prevention.

This month, NIMH published “A Clinical Pathway for Suicide Risk Screening in Adult Primary Care,” stating that suicide is a leading cause of death for adults in the United States, but many people at risk for suicide do not receive needed mental health care. Most of the adults will have seen a primary care physician in the year before a suicide or attempt.

“For this reason, primary care doctors are ideally positioned to improve the identification and referral of people at risk for suicide,” the report said.

On the right path

The NIMH report outlines an evidence-based suicide detection and prevention pathway for primary care physicians to use in their practices. It refers to the Ask Suicide-Screening Questions (ASQ) Toolkit, a set of four screening questions that take as little as 20 seconds to administer.

In the second step, patients with a positive risk screen receive a safety assessment administered by a trained professional. Based on the level of risk, a course of action then could range from emergency evaluation and crisis management, to safety planning or counseling

Early evidence

The NIMH report said the pathway, while grounded in research, does not yet have evidence to support how well it works or how easy it is to implement.

But there are some indicators about the effectiveness of screening in a primary care setting. One NIMH study about the ASQ questions found a “yes” answer to one or more of the questions, identified 97% of patients aged 10 to 21 years at risk of suicide.

Meanwhile, a study published in June reported training in suicide screening and identification is possible, and health care professionals improved their understanding of suicide and how to respond to patients at risk.

The training happened in Washington, which in 2012 became the first state to require such instruction for health care professionals. That state used the “All Patients Safe” program developed by the University of Washington (UW).

From November 2018 to December 2020, more than 1,500 health care workers completed a six-hour course, with pre- and post-training surveys. Participants reported greater confidence in identifying warning signs and asking patients about exposure to medicine and firearms.

“The results suggest that it is possible to provide high-quality training to health care professionals about suicide, which is an important but not sufficient step in the prevention of suicide,” study lead author Jenn Stuber, PhD, said in a news release. Stuber is associate professor of social work at the UW and a cofounder of the university’s Forefront Suicide Prevention program. “It’s also essential to look at systems and policies to ensure there is maximum support for health care professionals to implement the clinical skills they were taught in the training.”

More research coming

NIMH researchers have been asking what they have learned about suicide risk and prevention during the COVID-19 pandemic, institute Director Joshua A. Gordon, MD, PhD, said this month in his blog post, “Suicide Prevention Research in a Rapidly Changing World.”

Along with intersections of primary care and suicide prevention, NIHM researchers will continue studying how social determinants of health can affect suicide risk for racial and ethnic minority patients. They are examining youth mental health needs and how telehealth can be a tool for improving suicide prevention services, Gordon said.

“With these and many other efforts, we are hopeful that people who are at risk for suicidal thoughts and behaviors will be able to access the evidence-based support and services they need,” Gordon said. He asked physicians and anyone to share resources to recognize suicide warning signs and how to get help.

September is National Suicide Prevention Awareness Month and National Physician Suicide Awareness Day is Sept. 17, 2022. If you are in crisis, please call the National Suicide Prevention Lifeline at 988, or contact the Crisis Text Line by texting TALK to 741741.