March 2020, Volume XXXIII, No 12

  Behavioral Health

Project 2025

Partnering with physicians to reduce suicide

p to 45% of people who die by suicide visit their primary care physician in the month prior to their death. Suicide challenges the entire medical system and the services they perform. The ability of physicians to assess, intervene, and monitor suicidal behavior presents both a responsibility, and a significant opportunity, to save lives. Yet such a burden becomes especially daunting if the professional providing care is ill-prepared for such a situation. A science-based approach, coupled with outside resources, could help physicians prevent suicide.

By the numbers

It has been well documented that medical professionals from a wide range of specialties and settings will encounter individuals at risk for suicide. But many of them do not have confidence in dealing with such challenges, and the majority have minimal to no training to competently deal with a clinical situation to prevent suicide. In 2018, the Harris Poll and the American Foundation for Suicide Prevention (AFSP) found that, while 94% of American adults believe mental health is equally important as physical health (https://tinyurl.com/mp-suicide01), most do not know how to identify changes in mental health that signal serious risk, nor what to do in response.

The Centers for Disease Control and Prevention identified suicide as the 10th leading cause of death in America, accounting for 48,344 deaths in 2018. The U.S. suicide rate has risen nearly 30% over the past two decades (https://tinyurl.com/mp-suicide02), and one American now dies by suicide every 11 minutes. Overall mortality, particularly in the middle years, is increasing as a result of the so-called “deaths of despair” due to suicide, alcohol, opioids, and liver disease (https://tinyurl.com/mp-suicide03). In an era with greater technological advances and potential connectivity, research on suicide demonstrates that many forces are still active that may increase risk: human experiences of isolation, struggle, loss, and unmet expectations, alongside low mental health literacy.

Forty-five percent of people who die by suicide visit their primary care physician in the month prior to their death.

Additionally, overreliance on a sense of self-sufficiency and fear of judgment are barriers to opening up on deeper levels in our relationships, and fully integrating suicide prevention into actionable steps available through physicians, homes, and communities. Interpersonal connectivity is a basic need. When we lose that connection, whether due to changes in culture, modern frenetic living, or shame that drives people to hide their true internal experiences, then the prevalent experience of unaddressed mental health conditions and other types of suffering can contribute to the rising suicide rate.

Physicians: The front line

Physicians can learn to discuss these human experiences without shaming patients, and can become more sophisticated at recognizing moments for effective intervention that may lead a person who is struggling down a new, healthier path in which they connect to help. Additionally, allowing our patients to share these experiences more freely with trusted individuals can lead to better health outcomes in multiple areas, including suicide risk reduction. The medical community could partner with community resources to achieve these goals.

A common understanding of medical science—including neuroplasticity and epigenetics—could lead to a more compassionate, trauma-informed patient approach, and could also benefit K–12 education and workplace wellness. For example, envision settings where:

  • Basic foundational knowledge of neuroscience could teach children and adults strategies that protect and enhance cortical brain development, steps to prevent psychiatric illness could start early, and suicide prevention could be built into every pediatric clinic and school.
  • A society in which front-line citizens (e.g., first responders, health care professionals, teachers, legal/financial advisors, probation/corrections officers, and addiction counselors) are trained in basic mental health first aid and suicide prevention, and in which we move beyond the sense of shame so often related to distress or suicide.
  • The RAISE (Recovery After an Initial Schizophrenia Episode) early prevention/intervention model (https://tinyurl.com/mp-suicide04) is applied to prodromal or burgeoning mental illness with treatment and self/family strategies as part of treatment.
  • Biomarkers for suicide (https://tinyurl.com/mp-suicide05) and predictive analytics (https://tinyurl.com/mp-suicide06) are further refined and scaled to the national level so that every patient in primary care has the benefit of mental health screening and suicide preventive interventions, just as they do for other leading causes of death.
  • Providers adapt system-wide transformations to promote safer suicide care (https://tinyurl.com/mp-suicide-07)

Partnering to address suicide

These advances are at various stages of progress. New recommended care standards were recently released for better detection and clinical care that reduces suicide risk (https://tinyurl.com/mp-suicide08). The American Foundation for Suicide Prevention (AFSP) began as a grassroots effort, when a small group of families who’d lost loved ones to suicide banded together with scientists in an effort to learn more. As we have grown and expanded to become the nation’s largest suicide prevention organization, with chapters in every state, what we do is still rooted in communities. We fund research, provide community education, and serve as a catalyst for cultural transformation and suicide rate reduction through initiatives like Project 2025 (https://tinyurl.com/mp-suicide09) and creating a culture that’s smart about mental health.

Project 2025’s goal is to reduce the annual suicide rate in the United States by 20 percent by the year 2025. Through system dynamics modeling, and with guidance from leaders in suicide prevention research and practice, AFSP has identified four critical prevention areas that, with strategic investments and partnerships, can be targeted to significantly reduce the suicide rate and save more than 20,000 lives over five years. The four critical prevention areas represent the settings with which a significant number of those at risk for suicide will come into contact, and thus the settings in which we must intervene to prevent as many suicides as possible. These four critical areas are firearms, health care systems, emergency departments, and correctional systems. AFSP is scaling up evidence-based solutions that can and will reduce the rate of suicide in this country.

Suicide [is] the 10th leading cause of death in America.

We remain hopeful because we see the seeds of change glimmering around the U.S.—through the leadership of our scientific community and our delivery mechanism for education, advocacy, and loss support through a chapter network in all 50 states. We see that suicide prevention is not only possible, but that we are gaining momentum in creating a culture that is smart about mental health, including making sure that front-line citizens such as health care professionals are aware of effective, evidence-based strategies to reduce rates of suicide.

We must all work together in the field of medicine with partners of many types—health system leaders, tech and corporate leaders, media, education, and policymakers—to mount an effective suicide prevention plan critical to stemming this rising tide.

New developments and current thinking include:

  • Recommended language changes that can eradicate the stigma that often prevents patients from seeking help from their providers (e.g., the recommendation to stop using the phrase “commit suicide,” as suicide is a complex health outcome, not a moral failing).
  • Employ evidence-based treatment modalities for high-risk patient populations. These include cognitive behavioral therapy for suicidal cognitions and behaviors (CBT-SP) and dialectical behavior therapy (DBT) for adults with borderline personality disorder, as well as for adolescents with elevated suicide risk.
  • New methods in suicide prevention research aimed at better risk detection.
  • An approach to clinical suicide risk assessment that incorporates underutilized tools like Reasons for Living and other tools intended to support those struggling with suicidal thoughts.
  • Integration of suicide prevention practices into primary care.
  • A health system framework called Zero Suicide that stresses high-risk follow-up contact and        evidence-based treatment that can save lives.
  • Research about the impact of the media—and social media, in particular— related to mental health and suicide prevention.

Tools and trainings

Caring for suicidal patients can be challenging, especially in emergency departments, without easy access to mental health specialists. The American College of Emergency Physicians and the AFSP appointed a working group to create an easy-to-use suicide prevention tool for ED providers. The “ICAR 2E” mnemonic (see sidebar for highlights) may be a feasible way for practicing ED clinicians to provide evidence-based care to suicidal patients.

To achieve the goals of Project 2025, AFSP sought a partner with shared values and expertise in primary care. SafeSide Prevention, founded by Tony Pisani, PhD, Associate Professor of Psychiatry and Pediatrics at the University of Rochester Center for the Study and Prevention of Suicide, now teams with Kristina Mossgraber, a suicide attempt survivor, and with primary care providers at the University of Rochester to teach and model best practices.

Summing up

Suicide prevention is a complex challenge, but we remain resolute. The nation’s readiness for effective pro-mental health and suicide prevention strategies is growing like never before, and the scientific field regarding suicide has matured enough to provide answers. We don’t have time to waste. Let’s work together to reduce suicide in the U.S.

Christine Moutier, MD, is Chief Medical Officer at the American Foundation for Suicide Prevention.

Alex Karydi, PhD, is Project 2025 Director for the American Foundation for Suicide Prevention. 

What you can do

Physicians can play a key role in identifying suicide risks in their patients and providing support intended to save lives.

Primary care providers are at the front line, since 45% people who die by suicide visit their primary care physician in the month prior to their death. In addition to the scientific background on suicide risks and prevention presented in this article, consider participating in Project 2025 (details at https://tinyurl.com/mp-project2025).

While developed for emergency department physicians, the ICAR 2 mnemonic provides tips for all health care professionals. Visit https://tinyurl.com/mp-icar2eforrecommendations regarding each of the mnemonic’s steps intended to:

  • Identify suicide risk.
  • Communicate with patients.
  • Assess for life threats and ensure safety.
  • Risk-assess patients.
  • Reduce these risks.
  • Extend care as necessary.

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Alex Karydi, PhD, is Project 2025 Director for the American Foundation for Suicide Prevention.