Preventing Suicide Begins With Regular Assessments

Psychiatrists who don’t conduct formal assessments of suicidality at every patient visit are missing an important way to track treatment outcomes and keep patients safe.

In fact, simply having patients with a psychotic disorder complete the Patient Health Questionnaire (PHQ-9) at every visit can strongly predict who will attempt suicide in the next 90 days, according to a study published in the March issue of Psychiatric Services by Gregory E. Simon, M.D., M.P.H., senior investigator at Kaiser Permanente Washington Health Research Institute and psychiatrist at Washington Permanente Medical Group, and colleagues.

“Individuals with psychotic disorders have by far the highest suicide rate of any mental health condition,” Simon said. In fact, more than 1 in 4 individuals with psychotic disorders attempt suicide and more than 1 in 20 die by suicide. Risk is especially high after the first onset of symptoms and soon after psychiatric hospitalization.

“There are a lot of outdated notions about people with psychotic disorders: There’s this idea that maybe they are not as able or willing to communicate their thoughts of self-harm, or perhaps they are not as self-aware,” Simon said. This study refutes that idea.

For the study, Simon and colleagues identified nearly 6,000 adults with a diagnosis of schizophrenia spectrum psychosis or unspecified psychosis using electronic health records from seven large integrated health systems. They tracked nearly 33,000 outpatient visits for these patients and their responses to the PHQ-9 and tallied any subsequent completed suicide attempts over the next year.

The researchers found that patients reporting frequent thoughts of death and self-harm, as indicated in response to item 9 of the PHQ-9, were four times more likely to attempt suicide within 90 days than patients reporting no such thoughts. Considering patients’ prior-year responses to item 9—not just the current response—improved detection of risk: 60% of those who attempted suicide had reported thoughts of death and self-harm within the past year.

The results were similar to a 2016 study by Simon and colleagues of 500,000 patients who completed the PHQ-9 during primary care and outpatient mental health visits. “The PHQ-9 was developed to assess depression, but we’ve found it also works to identify suicide risk and other mental health conditions,” Simon said. In fact, Kaiser Permanente has chosen to implement use of the PHQ-9 across its entire health system and requires clinicians to use it at every mental health outpatient appointment and for primary care providers to give it to patients at least once a year.

If a patient indicates thoughts of self-harm or death, physicians are instructed to follow up with the Columbia-Suicide Severity Rating Scale. Part of these physicians’ salaries hinges upon how well they adhere to established protocols when patients report having such thoughts of death or self-harm, Simon explained.

Assessments: Key to Good Mental Health Care

While it may not be the norm in many practice settings, Simon said that conducting brief formal assessments at every visit is what good mental health care is all about. In addition, having a formal process in place requiring the use of the PHQ-9 at every visit helps to keep clinicians from forgetting to ask. “I am a believer in standard processes that scale to large populations. If you’re going to a primary care doctor and the doctor never measures your blood pressure, would you keep going? No. But somehow that’s OK in mental health care.”

Many psychiatrists don’t ask, in part because they don’t feel comfortable managing suicidal patients and the risk that entails, said Maria A. Oquendo, M.D., Ph.D., APA past president and the Ruth Meltzer Professor of Psychiatry and chair of the Department of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania. Most medication management appointments are set for 10 to 15 minutes. “The system is not set up for management of these patients without major disruptions to the workflow,” she said.

Oquendo recommends that group practices and clinics establish clear written protocols, such as a decision tree, for clinicians to follow when a patient becomes suicidal, including making available to primary care providers a list of consulting psychiatrists they can call as the need arises. “The more that there is a system in place, the more likely it is that physicians will feel more comfortable screening for suicidality.”

Assessment doesn’t end with self-report questionnaires, however. “If you ask and the patient says ‘no,’ it doesn’t mean the patient is not at risk for suicide,” said Jill Harkavy-Friedman, Ph.D., vice president of research at the American Foundation for Suicide Prevention. “Providers should also consider important social risk factors for suicidal behavior, such as their current health, other mental health conditions, life stressors they are experiencing, relationships status, history of child abuse, and their access to lethal means.”

Why Don’t Patients Disclose Suicidal Ideation?

About 4 out of 10 suicide attempts in the Psychiatric Services study by Simon and colleagues occurred among patients who responded they weren’t thinking “at all” about death or self-harm within the year prior to the attempt. A study in the November 2018 Psychiatric Services by Julie E. Richards, M.P.H., a research associate of the Kaiser Permanente Washington Health Research Institute, and colleagues shed some light on why: Mental health patients who did not disclose suicidal ideation on the PHQ-9, yet went on to attempt suicide less than two months later said they were either not experiencing suicidal ideation at the time of screening or else feared the outcome of disclosure.

Specifically, such patients said they feared stigma, overreaction, and loss of autonomy. Interviews also revealed instances of heavy episodic drinking at the time of the suicide attempt, particularly when suicide was completely unplanned.

The researchers concluded that nonjudgmental listening and expressions of caring without overreaction among providers may help patients overcome their fear of reporting suicidal ideation. Screening to identify heavy episodic drinking may also help identify individuals who make unplanned suicide attempts.

The study by Simon and colleagues was supported by funding from the National Institute of Mental Health. ■