'You will not find what you are not looking for': How PCPs can fight record suicide levels

Key takeaways:

• Data from the CDC indicate that suicide levels are rising in the U.S., hitting a new record in 2022.
• PCPs can provide mental health care, like depression screenings and medication management.

In the wake of record suicide numbers, primary care physicians are in a unique position to offer front-line mental health care, according to experts.

In late November, the CDC’s National Center for Health Statistics released the latest provisional mortality data for 2022, updating numbers from August and revealing a record number of suicides in the United States. The number of suicides was 3% higher than the previous year, rising from 48,183 in 2021 to 49,449 in 2022.

“The mental health crisis in the U.S. is alarming,” Teresa L. Lovins, MD, FAAFP, a member of the board of directors of the American Academy of Family Physicians, told Healio. “One of the reasons why ... is because it is preventable.”

Although the news is troubling, this is not a new problem, Caleb Hentges, DO, an osteopathic physician specializing in pediatrics, said.

“The mental health of the citizens of our nation has often been either ignored or scapegoated for gain by others,” he said. “If we want to see real change and lasting benefit for the mental health of people in our country, we need to start listening to the actual experts and stop trusting the most popular or loudest voices.”

Of the 6 states he has trained and practiced in, Hentges said there is not a place he has worked “that is not severely lacking mental and behavioral health specialists available to help people who are struggling.”

“I’ve had to adjust my expectations and practice style to make sure people don’t fall through the cracks and are at least receiving some sort of mental health care,” he said.

‘The first line of contact’

As professionals in what is widely regarded as the keystone of medicine, PCPs specifically have a major opportunity to help patients struggling with depression or suicidal ideation, according to Lovins. She emphasized that PCPs have a holistic view of a patient’s health, and they are “uniquely positioned to provide proactive, preventive care that prioritizes long-term patient wellness — including mental health.”

“PCPs, especially family physicians, are often the first line of contact for patients who enter the health care system and for those seeking mental health care,” she said. “Research shows nearly 40% of all visits for depression and anxiety are with PCPs. ... Family physicians are well equipped to help patients with a wide range of mental health needs.”

So, PCPs should be screening, following and treating depression and anxiety, Hentges said.

The Patient Health Questionnaire (PHQ) is one example of a common screening tool, and recent research has demonstrated that simple screenings can be more effective for suicide prevention than PCPs expect. In one study, the PHQ-9 was the most effective strategy for correctly identifying patients who would attempt suicide in the near term — more effective, even, than screening tools specifically asking about suicidal ideation.

Ashley Poole, PsyD, LPC, an assistant professor at the Philadelphia College of Osteopathic Medicine department of clinical psychology, added that “the appropriateness of mental health screeners vary depending on age,” and physicians who work with kids “may need to rely on screeners that parents can also complete to gain a full picture.”

“It is vitally important for PCPs to address the mental health of their patients,” Hentges said. “They are often times the first to identify suicidal ideation and play a crucial role in preventing suicide and getting people the help that they need.”

In her nearly 30 years of experience, Lovins said she has treated many patients who have had mental illness and helped several in an acute mental health crisis.

“During those times, it was very important to me to help the patient know that they are not alone in their feelings and that there are many ways to help them overcome their symptoms,” she said. “I have also learned that patients want to have someone who they trust to help them through this very personal experience. As a family physician, I often tell patients that I am here to help them understand what is going on and to help them get better. As a family physician who has personally had depression, I will often share with patients my experience so that they know I understand what they are feeling at that moment.”

Poole also emphasized the “critical role” PCPs play in managing depression and other mental health symptoms, noting that they are “integral to improving access to mental health care and reducing stigma associated with mental health conditions.”

“Many people are likely to visit their PCP before seeking a mental health professional for mental health concerns. It’s very important for PCPs to incorporate mental health screeners in their practice to assess for mental health issues, especially suicidal ideation,” Poole said. “PCPs serve as an essential link between patients and the broader mental health care system, contributing to the early identification and management of mental health issues.”

Behavioral health integration

To allow for more coordination between a primary care team and mental health care, “there is a movement to integrate behavioral health professionals into the primary care setting,” Lovins said.

“The U.S. faces a shortage of behavioral health professionals,” she said. “By integrating mental health professionals into primary care, the mental health professional can counsel patients while the primary care physician helps manage the medication treatment plan.”

Poole, who mentioned that she was previously an intern at a primary care practice, said she is an advocate for integrating behavioral health into primary care, which would improve access to mental health care for many. She said, along with assessing the severity of a patient’s symptoms via screenings, PCPs can provide therapy referrals, offer medications, help patients identify possible risk factors and “support the implementation of appropriate interventions.”

“Having mental health professionals in the same location as PCPs minimizes the barriers patients often encounter when seeking mental health treatment,” Poole said. “Having [mental health professionals] can also help destigmatize mental health as patients may feel more comfortable saying they’re going to their primary care vs. specifically saying they’re seeking mental health treatment.”

Integrating behavioral health care can also help with medication management because PCPs can prescribe psychotropic medication when psychiatric services are unavailable, she said.

“There is a shortage of psychiatrists in the field, and having [mental health professionals] work collaboratively with PCPs supports a solution-focused approach,” Poole said.

Hentges also mentioned that PCPs addressing mental health are particularly important considering “the depravity of available mental health professionals throughout the country.” Because of the delays in care from these specialists, he said, “patients are suffering, and some even lose faith that they can be helped.”

“The mental and behavioral health system in our country is strained if not broken,” Hentges said. “I believe every primary care practice should have mental/behavioral health (psychologists, psychiatrists, therapists and counselors) professionals integrated in their offices. There should be warm handoffs to them whenever possible. There should also be close follow-ups with those who have expressed thoughts and/or intentions of self-harm and/or suicide.”

As a pediatrician, Hentges said he does all he can to help the patients under his care, but he has learned two important things: patients who want help “are the ones we can help the most” and because he is not a trained therapist or psychiatrist, his abilities are limited.

“We need more behavioral and mental health specialists in all parts of the country,” he said.

Although behavioral health integration can prove difficult to fully implement and many PCPs must work within the system they are already in, Hentges said PCPs can make a major difference “by simply asking the right questions.”

“If there is evidence of depression and/or suicidal thoughts, even if they’re seeing you for a cough, ask the questions,” he said. “You will not find what you are not looking for.”

Reference:

• Life expectancy increases, however suicides up in 2022. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2023/20231129.htm. Published Nov. 29, 2023. Accessed Dec. 21, 2023.