A Noble Step, but in the Right Direction?
In 2016, 1,141 people in the state of Washington died by suicide, putting Washington State above the national average. Acknowledging the work of suicide-prevention advocates in recent years, the Washington legislature recognized suicide as one of the public health crises that warranted action.
Effective January 1, 2016—with an extension of the Matt Adler Suicide Assessment, Treatment, and Management Act of 2012—all Washington physicians are required to receive training on suicide risk assessment, treatment, and management. There are now more than 60 state-approved courses from which clinicians are required to choose (see page 17). Only five other states mandate similar training (Nevada, Kentucky, New Hampshire, Pennsylvania, and Utah)—limited, however, to social workers, drug-addiction counselors, and those in the field of mental health.1
Often due to stigma or problems accessing mental health care, patients are likely to have contact with a primary-care physician before a mental-health provider. According to one study, almost half of people who died by suicide saw a primary-care physician in the month before death.2 Studies show that 59% of all psychotropic drugs are prescribed by non–mental health specialists.3 These physicians in particular are critical gatekeepers for their patients’ mental health care.
“In the scope of suicide care, most physicians,” according to Dr. Jeffrey Sung, past president of the Washington State Psychiatric Association (WSPA), “will be in the role of being a ‘gatekeeper’ of mental health care for a patient. I’ve trained hundreds of physicians on what they can do if they find themselves in the gatekeeper role, where you initially recognize signs of suicidality.” Gatekeeper training provides skills in recognizing the warning signs of suicide, conducting brief screenings, and providing an emotional connection that can make a difference to a patient in crisis.
Yet Dr. Sung is one of the first to acknowledge that this is but a small step—and to question the current use of health-care resources in addressing the problem.
TRAINING INDIVIDUALS VS. CHANGING SYSTEMS
“We need to ask ourselves,” continues Sung, “does the healthcare delivery system support the training in suicide? And what effects will it have to ask our colleagues to add up to 40 minutes of draining work to a seven-minute primary-care appointment, without changing their productivity requirements or payment, and the care coordination to follow? Every primary-care provider wishes they had more time. It’s hard to feel good about this without addressing systemic issues.”
Additionally, Sung cites delays in access, low availability of psychiatric hospital beds for those in crisis, and other systemic issues involved in delivering proactive mental health care that still need to be addressed. In other words, do we have the capacity to respond as we should? Is there greater efficacy with other approaches? Suicide-risk assessment training might help to resolve the immediate risk of suicide, keeping patients alive in those critical moments when inaction is unconscionable. But there is only limited evidence that supports physician training as a means to move the needle on such a critical health issue.
While evidence in support of effective ways to prevent suicide is frustratingly limited, there are bright spots to pursue that go beyond crisis intervention and get more at transforming how care is delivered.
One solution could be to integrate mental health care with primary care. That way, if a primary-care or other kind of doctor found themselves in an appointment with a patient who was noticeably distressed, they’d have the right resources down the hall, and could walk the patient directly to a mental-health specialist—just as a patient might go down the hall for a blood test or an X-ray. Better yet, a health-care consultant could be brought to the patient on the spot, so the patient wouldn’t need to change rooms.
Making a comparison to the team-based approach to cancer care, Sung points to the routine screenings that are conducted with an eye towards prevention, in addition to the diverse, wrap-around services—oncology, radiology, nutrition counseling, plastic surgery, palliative care, pain management, financial planning, spiritual support, case management, and much more—that cancer patients receive as a matter of course during treatment. Embedding psychiatric care within primary care might well provide the integration that combines physical health with mental health.
ZERO SUICIDE: IT CAN HAPPEN. IT ALREADY HAS.
Sung also cites the national movement taking shape around “Zero Suicide,” noting a recent case study from the Behavioral Health Services division of the Henry Ford Health System. To achieve a radical transformation over a course of 11 years, that organization focused on three key components:
- Improving access to care.
- Restricting access to lethal means of suicide.
- Instituting “Just Culture”.
Their efforts resulted in an 80% (or more) reduction in suicides that was maintained over a 10-year period, including one year of zero suicides (2009).4 The case study concludes that a goal of perfection is viable, given the right components and social transformations. The case study goes on to cite Just Culture as a lynchpin to the pursuit of perfection, and notes that effective suicide prevention requires systemic changes that go beyond a series of interventions.
THE LONG, HOPEFUL ROAD
Few could argue with the intent behind physician training to create awareness for the signs of suicide and to save lives; in a sense, training might seem like the right thing to do simply because inaction during a crisis is not acceptable. But while the efficacy of broad-based suicide training is debated among some, and systemic improvements continue to be made across the spectrum of care delivery, the true successes in preventing suicide will be achieved by keeping a broad view.
“I appreciate the motivation around training, and hope it will be accompanied by the infrastructure to support the training,” Sung says.
For those in the field of creating hope, continued infrastructural improvements are the challenge that remains.
* * *
RESOURCES - SUICIDE PREVENTION TRAINING
ALASKA / Alaska Department of Health and Social Services
Suicide Prevention Training with QPR Approach for Gatekeepers
IDAHO / Idaho Department of Health and Welfare
Suicide Prevention and Risk Assessment Training: May 21, 2018
OREGON / Oregon Health Authority
Workforce Training for Behavioral and Physical Health-care Providers
WASHINGTON / Washington State Department of Health
Suicide Prevention Training for Health Professionals
WYOMING / Wyoming Department of Health
Wyoming Suicide Prevention Trainings
RESOURCES - (800) 273-TALK
One Number | Easy Access to Support
The National Suicide Prevention Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress, 24 hours a day, 7 days a week. Calls to this number access local resources, if available.
Learn more at www.suicidepreventionlifeline.org.
* * *
3 Mark, T.L., Levit, K.R., and Buck, J.A. “Datapoints: Psychotropic drug prescriptions by medical specialty.” Psychiatric Services, 60: 1167. 2009.