Experts: Physicians Need to Own Suicide Prevention.
Leaving it up to suicidal patients to ask for help simply isn’t working.
Lack of clinician training and poor risk prediction are among the obstacles to reducing suicides in the U.S., said speakers at a workshop here sponsored by the Substance Abuse and Mental Health Services Administration.
On 9/11 many of the victims of the terror attacks jumped from the Twin Towers, said Taryn Aiken Hiatt, a survivor of multiple suicide attempts.
“By definition, they took their own life. They died of suicide,” she said. “Did they jump because they wanted to die? No. They jumped because they were desperate to escape unbearable pain and anguish.”
“In every attempt I had as a teen, it’s not that I wanted to die, I just didn’t know how to live with what was happening to me and I wanted to get away from it,” Aiken Hiatt said, urging listeners at the workshop to show the same compassion to those struggling with thoughts of suicide rather than judging them.
Aiken Hiatt’s father died of suicide in 2002. Had it not been for the shame and stigma of mental illness, she believes he might have lived. She said that others, including physicians, can’t put the onus of asking for help on the individual who’s struggling.
“We say, ‘Reach out. Reach out. Reach out … Choose to stay’… That’s like telling somebody with cancer, choose to live,” Aiken Hiatt said.
Suicide is the tenth leading cause of death in the U.S. and the second leading cause of death among young people ages 10-24.
While other diseases have seen death rates decline in recent years, suicide rates have risen. Life expectancy in the U.S. dipped in 2016 to 78.6 years from 78.7 years in 2015, according to the National Center for Health Statistics, and suicide appears to be one of the main reasons.
At the workshop, panelists wondered aloud why the suicide epidemic is getting worse, not better, given the number of drug and non-drug therapies proven to reduce suicide risk. These include dialectical behavioral therapy and cognitive behavioral therapy as well as pharmacological treatments such as lithium, clozapine, and now ketamine.
There are still broad gaps in the health care system’s approach to preventing suicide, said Christine Moutier, MD, a chief medical officer for the American Foundation for Suicide Prevention.
An estimated 45% of people who died by suicide visited their primary care provider in the month prior to their death, suggesting opportunities to intervene were missed, she said.
One of the gaps, Moutier and other panelists at the workshop highlighted, is clinician training.
“We would never send our loved ones to a surgeon who says ‘I don’t really have any training but I’m going to try my best,'” but that is essentially the healthcare system’s approach to suicide, said Julie Goldstein Grumet, Ph.D., of the Zero Suicide Institute.
From safety planning to screening, psychotherapy, to follow-up care during transitions, it’s clear what works, but it isn’t being taught. Clinicians aren’t learning about suicide prevention in school and continuing medical education is only required in a few states.
Goldstein Grumet said she’s “stunned” by how few primary care doctors are reaching out to groups like hers for guidance.
Payment to physicians and other affiliated workers to provide continuous care for patients with serious mental illness during times of crisis is also lacking.
Incentives could be especially beneficial if they focused on transitions, such as from the emergency department to the community or from a psychiatric hospital to the community when patients are at greater risk of suicide, said Andrey Ostrovsky, MD, CEO of Concerted Care Group (CCG) a comprehensive opioid treatment program in Maryland.
“There’s already precedent for bundled payment … It’s a matter of focusing on this particular patient population, folks with severe mental illness at risk for suicide, and making sure that the financial incentives are aligned with evidence-based practice,” Ostrovsky, formerly the chief medical officer for the Center for Medicaid and CHIP Services (CMCS), said.
A lack of data also hinders improvements in care, especially in predictive analytics.
The Department of Veterans Affairs developed a predictive algorithm which generates scores on the 6 million individuals who receive care from the VA. One factor that made this possible is a research platform — funded through the National Institutes of Mental Health — linking data from electronic health records to death records, explained Michael Schoenbaum, Ph.D., of NIMH.
“We improve what we measure,” he said, but none of the large insurers link their population data to mortality data, he said.
Healthcare systems could be tracking and analyzing their own data to determine who is at greatest risk of suicide, said Goldstein Grumet, but there’s no requirement to do so.
Not surprisingly, healthcare systems are reluctant to reveal how many of their patients die by suicide.
“So, there’s really no benchmarks,” she said.
Some panelists, including Moutier, questioned why there wasn’t more funding for research.
But Michael Hogan, Ph.D., a former New York state mental health commissioner who now has a consulting firm, said the research on suicide prevention is “unequivocally established.” He put the blame elsewhere for not using it.
“The really big problem is getting health care providers to say, ‘It’s our responsibility to keep our patients alive,'” Hogan said.
One aspect of that problem may be subtle and unintentional signals that providers send to patients. Aiken Hiatt urged clinicians not to judge patients or their reasons for considering suicide.
When speaking to a patient in crisis, said Keith Wood, of Emory University in Atlanta, clinicians’ focus should be on making a connection: validating what patients are feeling and thinking and letting them know their suicidal thoughts are not “abnormal.”
He tells patients he understands why they might want to kill themselves, given the difficulties they are battling.
He also tries to bridge that distance between “us” and “them”: for example, by not demanding that schizophrenia patients acknowledge their illness when they lack insight into it.
“What we do may increase the likelihood of someone becoming suicidal,” he said, citing research suggesting that insight in such patients may increase their risk of suicide.
Wood also noted the role played by the persistent stigma attached to mental illness. “I do believe that shame is one of the biggest barriers and it’s one of the biggest challenges,” he said.