Back to Table of Contents | January 2011

Clinical and Health Affairs

The Physician’s Role in Suicide Prevention: Lessons Learned from a Public Awareness Campaign

By Melissa Boeke, M.S., Tom Griffin, Ph.D., M.S.W., and Daniel J. Reidenberg, Psy.D., FAPA

Abstract
The suicide rate in Minnesota has increased every year since 2000, making suicide a serious public health problem. In the spring and summer of 2009, the nonprofit organization Suicide Awareness Voices of Education (SAVE) launched a public awareness campaign targeting four populations at high risk of suicidal behavior and suicide: adult men, seniors, teens, and American Indians. The goals of the campaign were to increase awareness about suicide in general and to let people know how they could help someone who may be at risk. In their evaluation of the campaign, researchers found a need to provide physicians and other health care professionals with appropriate information about suicide and resources that are available for those who may need help. They also learned the importance of engaging physicians in planning future campaigns.

Suicide is a serious public health problem in the United States that results in approximately 33,000 deaths and 395,000 emergency room visits annually.¹ Minnesota’s suicide rate rose from 8.9 per 100,000 population in 2000 to 11.0 per 100,000 in 2007. From 1998 to 2007, the state’s overall age-adjusted suicide rate was 16.5 per 100,000 for males and 3.6 per 100,000 for females. In 2007, Minnesotans 50 to 64 years of age had the highest suicide rate of all age groups: 16.1 per 100,000.²

Depression, bipolar disorder, and other illnesses that underlie 90% of all suicides are medical disorders just like cancer, heart disease, and diabetes. People who suffer from these disorders not only have behavioral symptoms but also frequently complain of stomachaches, headaches, and back pain—physical manifestations of the shame they feel. We know from listening to survivors of suicide attempts that if their doctors had just asked about a mental health problem when they saw them for other reasons, many would not have made their attempt.

More than 80% of patients who are depressed prefer to be treated by their primary care physician rather than referred to a mental health specialist.³ Although many patients are reluctant to seek mental health treatment, up to 75% of those who commit suicide have seen a primary care clinician for some reason within the month prior to their death.⁴ One out of every 10 persons who commits suicide has been seen in an emergency department within two months of his or her death.⁵ Physicians and other primary care providers need to be aware of the signs of suicide and feel comfortable addressing the issue with their patients.

The Campaign

In the spring and summer of 2009, Suicide Awareness Voices of Education (SAVE), a nonprofit organization working to prevent suicide in Minnesota, launched a public awareness campaign that targeted four populations at high risk of suicidal behavior and suicide: adult men, seniors, teens, and American Indians. The messages were directed at gatekeepers, that is, family, friends, colleagues, and peers who might intervene with and provide assistance to members of these high-risk populations. The goals of the campaign were to increase awareness about the problem of suicide and to let people know what they can do if someone is at risk. Messages were placed on signs in bus and transit shelters and skyways, in newspaper ads, in church bulletins, on billboards, and in radio public service announcements.

The Minnesota Institute of Public Health, a nonprofit organization that applies research findings and provides programming services to communities, evaluated the campaign to determine the extent to which it helped gatekeepers of adult men better understand that suicide is a serious problem and that there are things they can do to help prevent it from happening. The institute used a multi-method approach to do the evaluation, including records reviews, intercept interviews (a convenience sample of people approached for a brief interview in this case at farmers’ markets and in skyways and shopping malls), focus groups, and web-based questionnaires.

A total of 626 Minnesota residents were either surveyed or interviewed about whether they were aware of the campaign and whether they were aware of how they could help the targeted group—adult men.

When asked what they would do if they knew someone who might be depressed or contemplating suicide, a majority of respondents noted that they would 1) talk to the person, spend time with him, and be supportive; 2) seek help or try to talk the person into seeking help; or 3) do both—talk to the person and then seek help. The respondents who indicated that they would seek outside help most often mentioned that they would turn to a physician for guidance (Table).

What Physicians Need to Know about Suicide

Physicians were frequently identified as the individual to whom gatekeepers would refer people at risk for suicide. But physicians do not necessarily understand the clinical rationale for suicide risk assessment and the role they play in preventing suicide attempts. The U.S. Preventive Services Task Force found that primary care providers need to improve their ability to screen for depression and manage and assess suicide risk in patients with psychiatric disorders.^6,7 Yet, medical students receive little training regarding suicide and continuing education offerings for practicing physicians are few and far between.^8-11 There is also no requirement by licensing boards nationally or in Minnesota for training in suicide prevention.

The evidence for the effectiveness of specific intervention strategies is building.¹² For example, Kaplan et al. reported that physicians trained to directly question patients about suicide plans elicit more pertinent information than their peers who have not had such training.¹³ For those reasons, physicians and other health care providers clearly would benefit from training on how to ask patients about suicide, how to identify the warning signs of suicide, steps to take to reduce the risk of suicide among patients demonstrating warning signs, how and when to refer to a psychiatrist for further evaluation, and when to seek hospitalization for a patient. Training also should focus on medication prescribing and compliance issues for all anti-psychotics, including the frequency of prescriptions, the amount of medication supplied (eg, a 30-day supply versus a 90-day supply), and dosage. They also may find information about who is at greatest risk for suicide to be useful.

Asking the Right Questions

Assessing for suicide risk challenges physicians to go beyond typical patient-physician communications and probe deeply for often-unstated concerns. Vannoy et al. noted that physicians should frame their questions about depression and psychosocial functioning in a sensitive and straightforward fashion.¹⁴ Closed or polarizing questions such as “You’re not feeling suicidal are you?” may stop patients from disclosing the truth. If the patient denies feeling suicidal, brief utterances by the physician such as “OK,” “good,” or “right” may convey lack of interest or discomfort with the topic and end the discussion.¹⁴ Instead, the physician might ask for more information or express supportive statements to convey concern.

Physicians should recognize the signs of depression, which include sleep disturbances; difficulty thinking, remembering, and concentrating; loss of interest or pleasure in doing things; and physical problems such as back pain, headaches, and digestive disorders.¹⁵ They also should know the signs of acute risk for suicide: talking about suicide, seeking lethal means, purposelessness, anxiety or agitation, insomnia, substance abuse, hopelessness, social withdrawal, anger, recklessness, and mood changes.⁵

When physicians inquire about suicidal ideation, they can do it in a way that feels comfortable as long as their questions include a fatality component. That is, they must use words that let the patient (or suicidal person) know that they understand what is going on. Examples of questions that include this component include the following:

• Are you going to kill yourself?
• Have you thought about killing yourself?
• Do you feel like you want to die or be dead?
• Are you thinking that it would be better if you were no longer around anymore?

If the patient answers “yes” or in any other way indicates that he is thinking about suicide, the physician should take appropriate action such as prescribing pharmacotherapy, referring the patient for psychotherapy or outpatient treatment, or hospitalizing the patient.^16,17

Conclusion

Physicians, in collaboration with other community leaders, can play an important role in reversing the suicide trend in Minnesota. They can learn to identify patients who are at high risk for suicide and take appropriate actions to reduce those risks and potentially prevent a patient’s death. They need to be made aware of the prevalence of suicide and appropriate actions to take if they suspect a patient or even a colleague is suicidal.

As this research shows, there is a need to provide appropriate information and resources on suicide to physicians because they are the ones to whom concerned family and friends will turn if they suspect someone needs help. Efforts must be made to improve the training of physicians and require continuing education on suicide. At the same time, there must be a continued effort to destigmatize mental illness and suicide so that medical professionals and the public can discuss them without fear of humiliation or loss of their job or insurance. Patients must feel comfortable coming to their doctor and saying that they have been depressed lately. As important, primary care doctors should routinely inquire about a patient’s mood, which can be symptomatic of mental illness. Showing care and concern, and understanding that mental pain can be just as severe as that caused by the worst migraine or kidney stone, is generally enough to start a conversation. MM

Melissa Boeke is manager of epidemiology and assessment services at the Minnesota Institute of Public Health. Tom Griffin is associate executive director of the Minnesota Institute of Public Health. Daniel J. Reidenberg is the executive director of Suicide Awareness Voices of Education, managing director of the National Council for Suicide Prevention, and the U.S. representative to the International Association for Suicide Prevention.
 

References
1. Centers for Disease Control and Prevention. Understanding Suicide Fact Sheet, 2010. Available at: www.cdc.gov/violenceprevention/pdf/Suicide-FactSheet-a.pdf. Accessed December 2, 2010.
2. Minnesota Department of Health. Suicide Prevention Fact Sheet. Available at: www.health.state.mn.us/divs/cfh/connect/index.cfm?article=suicideprevention.factsheet. Accessed December 2, 2010.
3. Brody DS, Khaliq AA, Thompson TL. Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Med. 1997; 12(7):403-6.
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5. Suicide Prevention Resource Center. Is Your Patient Suicidal? Available at: www.sprc.org/library/ER_SuicideRiskPosterVert2.pdf. Accessed December 7, 2010.
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