Feature

Q&A: AFSP discusses the clinician's role in suicide prevention

Jill Harkavy-Friedman

Oct. 10 is World Mental Health Day, and WHO has declared suicide prevention as the focus for 2019. According to WHO, someone dies by suicide every 40 seconds, and it chose this year’s theme “to raise awareness of the scale of suicide around the world and the role that each of us can play to help prevent it.”

The overall suicide rate in the United States has increased significantly over the past two decades, and clinicians can play a vital role in suicide prevention and reversing this trend, according to Jill Harkavy-Friedman, PhD, vice president of research for the American Foundation for Suicide Prevention.

Harkavy-Friedman spoke with Healio Psychiatry about how to identify patients who are at risk, how clinicians can have open conversations with these patients and research priorities to aid prevention efforts. – by Joe Gramigna

Question: Why might the overall increasing suicide trend be occurring?

Answer: One thing to keep in mind is that it has been a gradual trend after a decline in suicide for several years. We do not know of one specific reason for this increase. In fact, suicide is a complex, multi-faceted problem, so it is unlikely that any one factor is leading to the rise.

We do, however, have a couple of ideas. One contributing factor is that people are reporting suicide more often because of the reduction in stigma around suicide. Thus, people are more likely to have their deaths reported as suicide. Another factor might be the decline in access to mental health care over these years. If an individual who is at risk for suicide is feeling particularly stressed and they don't have access to mental health care, that could contribute to the increase. At this point, it is all speculation because we do not actually know for certain what is causing the increase.

Q: What are the major warning signs clinicians should look for to identify patients who might be at risk for suicide?

A: When we talk about warning signs for suicide, we are not talking about something that just appears right before somebody engages in suicidal behavior. These warning signs often start to show up before the person is considered at risk for suicide. We want to encourage clinicians to learn what the warning signs are. Do not wait for crisis to happen. If you notice worrisome changes in your patient, do an assessment then and there and continue to assess for suicide risk and also offer intervention.

We tend to categorize warning signs by talk, behavior and mood. A patient may be talking about wanting to die, taking their life or being a burden. Other examples include talking about feeling desperate or as if there is no way out, even if these thoughts come and go. We want clinicians to check in with patients as soon as they hear that.

In terms of behavior, look out for increases in alcohol or substance use, as well as changes in sleep and appetite. Also look for reckless behavior, as this can signal that a patient may not care whether they live or die.

Sometimes people will start giving possessions away. They might not explicitly say ‘I am giving this away because I will not need it anymore,’ but they might say ‘I am giving you this because it is something that I have always wanted you to have.’

In terms of mood, depression is not the only one associated with suicide. Irritability, agitation, rage and humiliation are other associated moods. It is vital for clinicians to have a pipeline to patients’ support systems, because sometimes a family member sees things that do not show up in the office. For instance, rage and irritability may not surface during a 30- or 45-minute session, but the patient may be quite irritable at home. It helps to have a release of information for somebody close to the person from the very onset of when a clinician begins seeing the patient.

Q: Do you have tips for clinicians to help them have open and honest conversations about suicide and prevention strategies with patients?

A: Asking about suicide directly, non-judgmentally and with an open mind is the most important. If someone is thinking about suicide, it does not necessarily mean that they are at imminent risk. It may mean they are feeling terrible and they do not feel that they have any place to talk about that.

We have much more to offer now in terms of prevention and support than we did, say, 15 years ago. It is really important that clinicians get training on the different treatments and interventions that are available to help them work with patients who might be at risk for suicide. It is important to remember that ideation in and of itself does not mean that somebody is at risk for suicide, so have that conversation, listen to what they are saying and try to understand exactly what they are thinking.

Clinicians should also establish a sense of patient risk factors, which include a mental health condition, a physical health condition, chronic pain, head injury and early trauma. Any one of these things on their own does not mean that somebody is going to be at an increased risk for suicide, but it can be more likely when variables come together. Overall, understand what a patient is thinking and feeling and be aware of the interventions that are available to help them.

Q : What should clinicians prioritize in treatment to help decrease suicide trends ?

A: It's important to treat the mental health condition a patient has because 90% of people who die by suicide have a potentially diagnosable and treatable mental health condition. However, most people with mental health conditions do not die by suicide, so it's not enough just to treat the mental health condition. Clinicians have to also help people manage suicidal ideation so that they don't act on it, and hopefully with ongoing therapy and medication, those thoughts will eventually subside. Devising a safety plan or following up with a patient and/or alerting support when you're worried about them is very important. It's really about learning what interventions are out there.

Q : What areas of research concerning suicide prevention should be undertaken, in your opinion?

A: Future research should involve understanding the underlying mechanisms of suicide, particularly those that are malleable. We also need more work on how to identify patients who are at risk. We're not so bad at lifetime risk, but we still need to work on when someone is sitting in front of us, how we can know in the moment whether they're at an increased risk. Intervention development is also important, as is understanding the brain and the decision making of people during that crisis moment. There's a lot to learn going forward.

Question: Is there anything else you would like to add?

Answer: We have a great opportunity. We now have tools and interventions to help people who are suicidal. We’ve also come to understand that we’re not going to make somebody suicidal by talking with them about it, but instead, doing so could save their life. Have those open, frank conversations and be clear with patients that they can talk about suicide without fearing that they’ll have to go to the hospital or that the police will be called. Together, the clinician and patients can figure out the best course of action to help get through that crisis moment.

Reference: WHO. World Mental Health Day 2019: focus on suicide prevention. https://www.who.int/news-room/events/detail/2019/10/10/default-calendar/world-mental-health-day-2019-focus-on-suicide-prevention. Accessed Oct. 9, 2019.

Disclosures: Harkavy-Friedman reports no relevant financial disclosures.

Jill Harkavy-Friedman

Oct. 10 is World Mental Health Day, and WHO has declared suicide prevention as the focus for 2019. According to WHO, someone dies by suicide every 40 seconds, and it chose this year’s theme “to raise awareness of the scale of suicide around the world and the role that each of us can play to help prevent it.”

The overall suicide rate in the United States has increased significantly over the past two decades, and clinicians can play a vital role in suicide prevention and reversing this trend, according to Jill Harkavy-Friedman, PhD, vice president of research for the American Foundation for Suicide Prevention.

Harkavy-Friedman spoke with Healio Psychiatry about how to identify patients who are at risk, how clinicians can have open conversations with these patients and research priorities to aid prevention efforts. – by Joe Gramigna

Question: Why might the overall increasing suicide trend be occurring?

Answer: One thing to keep in mind is that it has been a gradual trend after a decline in suicide for several years. We do not know of one specific reason for this increase. In fact, suicide is a complex, multi-faceted problem, so it is unlikely that any one factor is leading to the rise.

We do, however, have a couple of ideas. One contributing factor is that people are reporting suicide more often because of the reduction in stigma around suicide. Thus, people are more likely to have their deaths reported as suicide. Another factor might be the decline in access to mental health care over these years. If an individual who is at risk for suicide is feeling particularly stressed and they don't have access to mental health care, that could contribute to the increase. At this point, it is all speculation because we do not actually know for certain what is causing the increase.

Q: What are the major warning signs clinicians should look for to identify patients who might be at risk for suicide?

A: When we talk about warning signs for suicide, we are not talking about something that just appears right before somebody engages in suicidal behavior. These warning signs often start to show up before the person is considered at risk for suicide. We want to encourage clinicians to learn what the warning signs are. Do not wait for crisis to happen. If you notice worrisome changes in your patient, do an assessment then and there and continue to assess for suicide risk and also offer intervention.

We tend to categorize warning signs by talk, behavior and mood. A patient may be talking about wanting to die, taking their life or being a burden. Other examples include talking about feeling desperate or as if there is no way out, even if these thoughts come and go. We want clinicians to check in with patients as soon as they hear that.

In terms of behavior, look out for increases in alcohol or substance use, as well as changes in sleep and appetite. Also look for reckless behavior, as this can signal that a patient may not care whether they live or die.

Sometimes people will start giving possessions away. They might not explicitly say ‘I am giving this away because I will not need it anymore,’ but they might say ‘I am giving you this because it is something that I have always wanted you to have.’

In terms of mood, depression is not the only one associated with suicide. Irritability, agitation, rage and humiliation are other associated moods. It is vital for clinicians to have a pipeline to patients’ support systems, because sometimes a family member sees things that do not show up in the office. For instance, rage and irritability may not surface during a 30- or 45-minute session, but the patient may be quite irritable at home. It helps to have a release of information for somebody close to the person from the very onset of when a clinician begins seeing the patient.

Q: Do you have tips for clinicians to help them have open and honest conversations about suicide and prevention strategies with patients?

A: Asking about suicide directly, non-judgmentally and with an open mind is the most important. If someone is thinking about suicide, it does not necessarily mean that they are at imminent risk. It may mean they are feeling terrible and they do not feel that they have any place to talk about that.

We have much more to offer now in terms of prevention and support than we did, say, 15 years ago. It is really important that clinicians get training on the different treatments and interventions that are available to help them work with patients who might be at risk for suicide. It is important to remember that ideation in and of itself does not mean that somebody is at risk for suicide, so have that conversation, listen to what they are saying and try to understand exactly what they are thinking.

Clinicians should also establish a sense of patient risk factors, which include a mental health condition, a physical health condition, chronic pain, head injury and early trauma. Any one of these things on their own does not mean that somebody is going to be at an increased risk for suicide, but it can be more likely when variables come together. Overall, understand what a patient is thinking and feeling and be aware of the interventions that are available to help them.

Q : What should clinicians prioritize in treatment to help decrease suicide trends ?

A: It's important to treat the mental health condition a patient has because 90% of people who die by suicide have a potentially diagnosable and treatable mental health condition. However, most people with mental health conditions do not die by suicide, so it's not enough just to treat the mental health condition. Clinicians have to also help people manage suicidal ideation so that they don't act on it, and hopefully with ongoing therapy and medication, those thoughts will eventually subside. Devising a safety plan or following up with a patient and/or alerting support when you're worried about them is very important. It's really about learning what interventions are out there.

Q : What areas of research concerning suicide prevention should be undertaken, in your opinion?

A: Future research should involve understanding the underlying mechanisms of suicide, particularly those that are malleable. We also need more work on how to identify patients who are at risk. We're not so bad at lifetime risk, but we still need to work on when someone is sitting in front of us, how we can know in the moment whether they're at an increased risk. Intervention development is also important, as is understanding the brain and the decision making of people during that crisis moment. There's a lot to learn going forward.

Question: Is there anything else you would like to add?

Answer: We have a great opportunity. We now have tools and interventions to help people who are suicidal. We’ve also come to understand that we’re not going to make somebody suicidal by talking with them about it, but instead, doing so could save their life. Have those open, frank conversations and be clear with patients that they can talk about suicide without fearing that they’ll have to go to the hospital or that the police will be called. Together, the clinician and patients can figure out the best course of action to help get through that crisis moment.

Reference: WHO. World Mental Health Day 2019: focus on suicide prevention. https://www.who.int/news-room/events/detail/2019/10/10/default-calendar/world-mental-health-day-2019-focus-on-suicide-prevention. Accessed Oct. 9, 2019.

Disclosures: Harkavy-Friedman reports no relevant financial disclosures.