How to Improve Suicide Screenings in Primary and Integrated Care

September is National Suicide Prevention Month, when mental health advocates, prevention organizations, survivors, allies and community members unite to promote suicide prevention awareness. Relias is one such ally. We admire the strength of our clients who work daily to help prevent suicide and are committed to supporting other organizations doing the same. Relias is participating in National Suicide Prevention Month through September and beyond, by sharing helpful information, tools and resources across a variety of settings so that we can help to meet the needs of individuals where they live, work and learn.

The Role of Primary Care

Primary care services are often the first lines of defense in suicide prevention. Physicians, nurse practitioners and physician assistants are often seen first or even instead of behavioral health providers due to barriers such as access, financial resources, and even stigma associated with seeking mental health care. Because of this, it is important for primary care professionals to be deeply aware of suicide risk factors and warning signs, understand how to effectively screen for depression and suicide, know when a more formal suicide assessment is needed, and how to follow up with an informed treatment and care transition plan.

The Role of Integrated Care

Integrated care is “the systemic coordination of general and behavioral healthcare. Integrating mental health, substance abuse and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs.”

Combining physical health care with mental health care is becoming more common, and for good reason. There are several risk factors healthcare professionals need to be aware of that can be involved in suicide. One of those factors includes mental health conditions. In fact, people living with serious mental illness die, on average, 25 years younger. Integrated care has shown us that any treatment provided for a single condition is less effective when the other conditions are not considered and incorporated into a comprehensive treatment plan.

The Harsh Realities of Suicide

In 2017, more than 47,000 people in the U.S. died by suicide and it was the second leading cause of death in people between the ages of 10 and 34. To add perspective, the number of suicides were more than twice the number of homicides (19,150) in 2017. These numbers grow considerably in adults with suicidal thoughts and behaviors, as shown below.

Additionally, it has been said for more than three decades that for every death by suicide, there are six people exposed to it who knew the individual. However, a recent study finds that number to be far greater at 135. This translates to 6.9 million people losing someone they know to suicide each year. This is astounding, especially since Americans have seen a 30% increase in suicide rates over the past 20 years, while the rest of the world has seen a 29% decrease over the same amount of time.

Challenges for Rural Communities

There are three main issues that pose a challenge to suicide prevention nationwide: access to behavioral health services, staffing and availability of behavioral health professionals, and stigma. These issues are exacerbated in smaller, more rural communities.

Insufficient providers in smaller communities limit an individual’s access to behavioral health care due to factors including long drives and appointment wait times. Some providers are working toward same-day access to care, whereas rural communities are working on improving access in general.

The healthcare industry is also entering a staffing crisis that is creating far more open positions than available professionals. Unfortunately, college and graduate school numbers aren’t keeping up with demand, so this trend will continue.

Issues of stigma around mental health are magnified in smaller communities, where everyone knows everyone. This often affects dual relationship issues and privacy concerns, especially if substance use treatment is involved.

Missed Opportunities

The American Journal of Psychiatry published a study to determine the frequency at which individuals who died by suicide contacted either their primary care doctor or a mental health care professional beforehand. The findings indicated that within one year before their suicide, 75% of people had contact with a health care professional and 33% had contact with a mental health professional. Within one month before their suicide, around 45% had contact with primary care services and 20% of people had contact with mental health services.

Within one month before their suicide, around 45% had contact with primary care services.

While this study was from 2002, a 2014 study revealed that most individuals who died by suicide received health services within the year prior to their deaths and half made a medical visit within the month prior.

What You Can Do

Evidence has shown that suicide risk screenings in primary care are effective, yet there is still a serious need to improve the frequency with which they’re conducted.

Conducting effective and routine suicide screenings requires organization-wide change that moves beyond just training or adjusting intake forms. It requires addressing your staff’s fears and concerns about suicide so they feel confident in their ability to assess, identify and address suicide. It also requires educating your staff on the risk factors of suicide as well.

There are several tools available to screen for suicide, both for behavioral health and substance abuse. Here are just a few:

• Columbia-Suicide Severity Rating Scale (C-SSRS) for suicide
• Patient Health Questionnaire (PHQ-9) for depression/bipolar
• Generalized Anxiety Disorder (GAD-7) for trauma/anxiety
• Screening, Brief Intervention and Referral to Treatment (SBIRT) for substance use

Additional Resources

• Suicide Prevention Resource Center: Toolkit for primary care providers
• SAMHSA-HRSA Center for Integrated Health Solutions
• Zero Suicide: Information, toolkits and resources specifically developed for medical providers
• National Council for Behavioral Health: Resources and technical and training assistance for primary care facilities and hospitals that incorporate behavioral health services

Learn how Relias helps primary care and behavioral health staff get better at identifying and responding to suicide risk.