Report helps primary care doctors identify suicidal patients

Family physician Barbara Yawn, MD, MPH, said her heart races whenever she sees patients with serious suicidal ideations. That includes patients who thought about how to kill themselves and have the means to do it, and those who attempted suicide in the past.

"Suicidal ideation is always a risk and always should be taken seriously," said Dr. Yawn, director of research at Olmsted Medical Center in Rochester, Minn.

But she said many primary care physicians have limited training on how to identify suicidal patients and assess the urgency of the risk.

A report in the August Mayo Clinic Proceedings gives primary care physicians practical recommendations for managing patients' suicide risk.

The report urges them to ask about suicidal thoughts and behaviors every time they screen a patient for depression, a risk factor for suicide. The authors recommend that physicians implement collaborative care models for treating depression, and they urge them to pay attention to patients with acute anxiety and agitation, which are critical suicide warning signs.

About 1% of all deaths in the U.S. each year are suicides, the report said. In 2007, there were 34,598 deaths by suicide, more than half of which involved a firearm, said the Centers for Disease Control and Prevention.

But those are potentially preventable deaths, said Timothy W. Lineberry, MD, one of the study authors and chair of the hospital practice division at Mayo Clinic in Rochester, Minn.

"Many times suicides are among the young, and they have conditions that can respond to treatment," he said.

Researchers reviewed studies on suicide and compiled what they view as the most important facts for primary care physicians. Among those statistics: about 45% of people who commit suicide see their primary care doctor in the month before their death. An estimated 20% of such individuals visit a mental health professional the preceding month.

Identifying suicidal patients

A key step to prevent suicide is discussing the issue with patients, Dr. Lineberry said. The report recommends that physicians ask every patient who is being evaluated for possible depression and those with a history of the disorder about suicidal thoughts and behaviors. The authors suggest starting with the question, "Do you feel hopeless or have thoughts of death?"

If the patient has such feelings, the physician should ask if the individual has a specific suicide plan and the means and intention to carry it out. Doctors also should inquire about the patient's previous suicide attempts and any family history of suicide.

Low-risk patients are those who have no specific plans or intent to commit suicide and no history of active suicidal behavior. They should receive follow-up care in an outpatient setting.

High-risk patients have serious thoughts of suicide, a plan and/or intent to commit suicide and prominent agitation, impulsivity, psychosis or a recent suicide attempt. The report said doctors should ensure constant observation of such patients while arranging to transfer them for psychiatric evaluation or hospitalization.

For all suicidal patients, physicians should recommend that family and friends secure or remove firearms, large quantities of medication and other obvious means of self-harm. Doctors also are encouraged to inform patients about who they can contact during a suicidal crisis.

The report urges doctors to be familiar with the warning signs of suicide, such as anxiety, hopelessness, sleep problems, trouble concentrating and excessive or increasing use of alcohol or drugs.

The report said more than 90% of people who commit suicide have a psychiatric illness, such as bipolar disorder or major depression.

For the most effective depression treatment, the authors recommend primary care physicians use a collaborative care model. Such a model could include education for the doctors and care managers to monitor patients' outcomes and encourage treatment adherence.