Suicidal ideation should always be taken seriously

Clinical pearls for frontline PCPs

The office nurse stops the physician in the hallway between patients.

“Doc, John — the 30-year-old patient who OD’d 3 months ago — just called and said that he’s at the end of his rope and just can’t take it anymore. His girlfriend just left him and, if you remember, prior to the OD, he had lost his job. I’m pretty worried about this patient. You had a cancellation at 2:30, so I put him in there. He has no specific plans to harm himself now, and there are no firearms in the home. I asked him to stay with his brother, who was on his way over to John’s place, and to have his brother drive him to the appointment. After talking with him, I am confident that he’ll keep that appointment.”

The patient arrives with his brother, and the medical assistant checks him in. She remarks, “Doc, this patient looks so depressed. He told me that he has nothing to live for anymore. He lost his job as a store manager 3 months ago and took a lot of pills. His brother brought him to the ER and they were able to revive him. They set him up with Psychiatry, but he never followed through on that. He’s been drinking more since he lost his job — at least a six pack per day and usually more. According to his brother, his girlfriend of 3 years got fed up with his drinking and broke up with him last night. That set him into another tailspin. His brother just doesn’t know what else to do.”

Philip A. Bain

The physician enters the exam room and sits down.

“Tell me what’s going on right now, John.”

“Well, doc, I OD’ed 3 months ago after I got let go from my job. They saved my life in the ER. Things have gone downhill from there. I’ve been drinking more, and I ticked off my longtime girlfriend last night, and she broke up with me. I am feeling so down, I just don’t have much to live for anymore.”

The physician reviewed the patient’s chart before seeing him. The patient has a history of alcohol use disorder, with the level of drinking usually mirroring his mood. He has had ADHD since childhood. He joined the military after dropping out of college and served a tour in Afghanistan.

He has had PTSD-related flashbacks from his time there. He has a history of depression and hopelessness. This is the lowest that the physician has seen him over the five visits that the patient has had with him. He has seen Psychiatry sporadically at the VA but has not followed through regularly with them. He has a history of impulsivity and generalized anxiety disorder. He denies any history of hallucinations and has never been hospitalized for a psychiatric disorder.

His mother died by suicide when he was 18. There has never been any evidence of sexual abuse, but his stepfather physically and emotionally abused him when he was in high school. The patient moved out of the house shortly after graduating from high school.

“Who helps you with the stress, John?” asks the physician.

“Well, my girlfriend helped me a lot, but she got fed up with me. My brother helps, but he has his own life to live. About a year ago, I adopted a black lab from the Humane Society and he’s the best friend that I‘ve got. I really don’t have any other friends.”

The physician continues, “John, I’m really worried about you. Have you had specific thoughts about whether you would end your life? Do you have access to firearms?”

“Well doc, this is hard to talk to you about. I have definitely thought that I would be better off dead. No, I don’t have any guns around — frankly, they scare me. I don’t have any more pills around at home except those that I found at my stepdad’s place. They were my mom’s depression meds. I guess there’s valium for nerves and some sleeping meds. I don’t know how many I have. I suppose I could get more on the street if I needed to."

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“You sound like you’re in a pretty dark place,” the physician says. “I would like you to give all of your meds to your brother, Dave, for safe keeping. I am going to get you set up with a therapist that I think you will really relate well with. I will call her after our visit and ask her to get you in within the next day or two. Here’s a card with emergency numbers and crisis numbers to call if you’re feeling like you’re going to harm yourself. Here’s our office number, and we have someone on call 24/7.”

The physician hands the patient a piece of paper.

“Let’s come up with a crisis plan if things should spiral downward,” he says.

Together, they worked through completing the document:

1. My warning signs that a suicidal crisis may be developing
2. What I can do on my own to distract me from the suicidal thoughts
3. People in my life I could call to distract me from having those suicidal thoughts
4. People I can call when I am in crisis and who would support me in coping with these thoughts
5. Emergency contacts: 988 Crisis & Suicide Lifeline, or text 741741 and type HOME in the message
6. My plan to remove potentially lethal ways that I could use to hurt myself
7. My hope for the future and reasons for living

Using the Columbia-Suicide Severity Rating Scale, the physician determines that the patient is not at a high risk that would require immediate evaluation and/or hospitalization.

“I would like to see you back in a week,” the physician says.

John returns in 1 week. He gave his meds to his brother, who checked in on him three to four times in the past week. He has seen the therapist twice since the last visit. He still has nonspecific thoughts about suicide. The therapist recommended that he be started on an antidepressant, and the physician began him on sertraline 50 mg one-half tab daily for 2 days, then 1 full tab daily. The therapist asked him to identify ways that he could calm his mind down and distract himself when he is panicky. He was able to do that — take his dog to the dog park, take slow deep breaths and listen to the app that she recommended. She reviewed his crisis plan with him. She referred him to a social worker who gave him some information on where he can get food and rent assistance temporarily, as well as some information about jobs through the division of vocational rehabilitation (DVR). He brings his dog with him to his appointment with his physician today.

“John, I’m glad that you brought your dog in with you today,” the physician says. “It sure seems like he means a lot to you. I am going to give you a few suggestions about how you can cut back on your drinking, because alcohol can have a depressive effect. For example, I would like to have you sub out every other beer with a nonalcoholic (NA) beer — there are many options that taste like regular beer without the depressive effects of alcohol. Let’s check back in 2 weeks to see how you’re doing. Thanks for bringing in that crisis plan that we came up with at the last visit and reviewing it with me.”

During the next 2 weeks, the patient meets with his therapist three times per week. She gives him some “homework,” such as identifying things that make his stress worse and what he might do to reduce those stress makers. He continues to drink about six beers per day, but as recommended, he has started to substitute NA beer for a few of the beers each day. Overall, he has reduced his drinking by about half compared with what he was drinking before being seen. He has starting walking his dog to the dog park two times a day. He feels that this takes his mind off things even for a little bit, and he is grateful for that. He has tolerated the sertraline well and the dose was increased to 75 mg daily. With John’s permission, his brother took the medications that John allowed him to keep to the local police station drop box. Working with the social worker, he was in fact able to get short-term food and rental assistance. He has been able to make a small amount of money watching his neighbor’s dog a few afternoons per week. This gives him quite a bit of satisfaction. He has met with DVR and has filled out some job applications for part-time work.

The therapist referred him to an alcohol and drug counselor, who he has met with. He was started on a medication to cut down on cravings. It has not been completely “smooth sailing” — he has relapsed twice with his drinking — but, after meeting with the counselor more frequently, he was able to quickly get back on track.

He continues to meet with the therapist, the substance abuse counselor and the social worker regularly and the physician once monthly. He is less depressed and is somewhat hopeful that he can remain sober and possibly be able to hold down a part-time job. He has not had any recent suicidal thoughts. His girlfriend even stopped by last week and agreed that they could talk on occasion.

Lessons learned

1. Suicide is common — the 10th leading cause of death in the country, according to the CDC, and the third leading cause of death among children, adolescents and young adults. It can be prevented with an organized approach involving multiple members of the care team.
2. Many risk factors and demographic variables have been linked to suicide — male sex, certain occupations, comorbid conditions like depression and anxiety, access to firearms, and alcohol and other substance misuse are some of the more common factors.
3. Suicidal ideation should always be taken seriously. It is well recognized that a significant number of patients visit their primary care provider 3 to 4 weeks before they die by suicide, often coming in for evaluation of unrelated somatic symptoms. PCPs must be prepared to assess these patients. One of the most helpful resources is the SAFE-T laminated card (see graphic).
4. Suicidal patients often have similar characteristics — preoccupation with death, a sense of isolation and withdrawal, few friends or involved family members, emotionally distant from others, lack of pleasure (anhedonia), hopelessness and helplessness, and preoccupation with past failures and shortcomings.
5. Talking about suicidal ideations does not increase the risk for suicide. Patients are often relieved to be able to talk openly about their thoughts and feelings regarding suicide. Direct questions such as if the patient has had specific thoughts about hurting himself or herself are important. If suicidal thoughts are present, questions should include whether they have attempted suicide in the past and/or if they have specific plans for how they might hurt or kill themselves. The more specific the plan, in general, the greater the danger. For example, if they have recently purchased a gun, made out a will and their plans include using the firearm, that would be very worrisome.
6. Firearms are a leading cause of successful suicide. The patient should be explicitly asked if they have the weapon or access to one. If the person is having suicidal thoughts, it is important to ask about homicidal thoughts as well, because they often coexist.
7. Acute intervention is based on the risk assessment. The patient must not be left alone. If at home, 911 may need to be called. The patient should be cared for initially in a safe, secure, highly supervised place. The involvement of friends and family can be very helpful to ensure their safety. Anything that the patient can use to injure or kill themselves should be removed, including medications. Sometimes, asking a friend or family member to keep the potentially dangerous object (eg, firearm, medications, rope) for safe keeping will be acceptable to the patient.
8. The national Crisis & Suicide Lifeline can be accessed 24/7 by dialing or texting 988. It is free and confidential and staffed by skilled counselors who can help.
9. Once the initial situation has stabilized, the second phase of the treatment approach involves close mental health follow-up.
10. The use of IV ketamine in actively suicidal patients presenting to the ER is currently being investigated as an acute option.
11. Although suicide can represent a devastating loss of life, there are methods that the PCP can intervene with and help to prevent the suicide from occurring. Those who are interested in learning more about how to recognize the warning signs of suicidal behavior and intervene — what’s referred to as question, persuade and refer, or QPR — can visit the QPR Institute’s website.

References:

• CDC. Suicide. https://www.cdc.gov/nchs/hus/topics/suicide.htm. Last updated on June 2023. Accessed Aug. 26, 2024.
• Columbia-Suicide Severity Rating Scale (C-SSRS). https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/. Accessed Sept. 3, 2024.
• Norris DR, Clark MS. Am Fam Physician. 2021;103(7):417-421.
• Soreff SM, et al. Suicide risk. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441982. Accessed Aug. 26, 2024.
• Stanely-Brown Safety Planning Intervention. https://suicidesafetyplan.com/. Accessed Aug. 26, 2024.