Upping Our Game to Prevent Suicide

As a nation, we are not making progress in reducing the number of deaths by suicide. The Centers for Disease Control and Prevention (CDC) reported that in 2014 there were 42,826 deaths by suicide compared with 29,199 in 1999. While the U.S. population increased in that time period as well, the rates of suicide per 100,000 also increased—from 10.5 per 100,000 people in 1999 to 13.4 per 100,000 in 2014. Of course, many individuals who die by suicide never reach our offices and thus do not get treatment, but for those patients who are in treatment, are we doing our best to identify those at risk for suicide? Can we do better to identify these patients as early as possible and provide treatment that reduces the pain they are experiencing and give them hope for recovery?

As mental health professionals, we encounter issues related to suicide or risk of suicide almost every day. We may become dulled in our ability to accurately predict suicide risk because of overexposure to suicidal thinking, anhedonia, and the chronic nihilistic thinking of depressed and dysphoric patients—as well as having our attention and energy diverted by having to deal with administrative burdens. As we now know, however, there are several interventions that all behavioral health professionals can easily adopt to step up our game with regard to suicide management. If every behavioral health professional systematically applied the following five strategies, it is highly likely that we could bend the curve of our rising suicide rate in the right direction: (1) review suicide risk systematically, (2) address suicide directly, (3) make a safety plan with at-risk patients, (4) manage means by which patients can die suicide, and (5) follow up with high-risk individuals.

Reviewing suicide risk systematically directly means routinely assessing risk through the administration of a valid, standardized risk assessment tool such as the Columbia Suicide Rating Scale. Addressing suicide directly means approaching suicide itself as a focus of treatment. Several suicide therapeutic techniques have been shown to improve outcomes. These include cognitive therapy for suicide prevention (CT-SP) and the Collaborative Assessment and Management of Suicidality (CAMS).

Another component of an overall approach to preventing suicide is the routine use of a suicide safety plan or crisis management plan. This is not a “no-suicide” contract or prescription; rather it is a person-centered document that is prepared by the patient with input from a trusted professional. Templates of such plans are widely available—the National Suicide Prevention Lifeline has a Patient Safety Plan Template available on its website. Don’t overlook the value of including the phone number of a suicide hotline; a good one to include is the National Suicide Prevention Hotline at (800) 273-8255. Also, there are smartphone apps that can help patients recognize the warning signs of suicide, ask about suicidal thoughts, and direct patients to help.

One of the most successful strategies for reducing the risk of suicide is “means management”—that is, asking patients whether they have access to the means to attempt or die by suicide. Given the high rate of death by suicide that is associated with firearms, it is particularly important to ask patients about their access to firearms and talk with their loved ones about the need to temporarily or permanently eliminate access to functioning firearms and ammunition. The same should be done with regard to the possibility that patients are stockpiling pills.

Finally, don’t forget about outreach. Often people at risk for suicide have difficulty engaging, miss appointments, and fall through the cracks of our complex health systems. The implementation of a systematic way to identify patients who fit this profile and reach out to them can be lifesaving.

The journey of a thousand miles begins with a first step, and the first step we need to take today as a profession may save thousands of lives. It begins with thinking about each patient who comes into our office and that person’s relative risk for suicide. I encourage all of us to implement protocols and practices that ensure that the lives of our patients are not cut short by preventable acts. Check out the Zero Suicide website for other ideas you can incorporate into your own practice. ■