Suicide Prevention and Risk Assessment: Are Providers and the Healthcare System Ready to Respond?
By Gretchen Vaughn, Ph.D.
The alarming 30% rise in the suicide rate in the United States over the past 20 years (CDC, 2018a), and the media coverage of recent high-profile celebrity suicides, has led to an increase in public conversations about suicide. However, is the public informed enough to access suicide prevention care or to overcome the long-standing stigma regarding suicide? Is enough information available for healthcare professionals to adequately address suicide risk in their communities?
Numbers
The numbers cannot be ignored and are critical to educating the public and healthcare professionals about the importance of this issue.
Suicide is the 10th leading cause of death in the United States. In 2016, suicide was responsible for 45,000 deaths, or one death every 12 minutes. The number of adults who think about suicide, 9.8 million people, or attempt suicide, 1.3 million people, is sobering (CDC, 2018b). Though suicide rates vary by race, ethnicity, age, and occupational group, suicide affects all ages. American Indian/Alaskan Native and white populations are disproportionately impacted by suicide; these groups have the highest rates across all ages (CDC, 2018b). It is important to recognize the diversity of the tribes, traditions, and cultures that are a part of the American Indian/Alaskan Native population; suicide rates vary widely among tribes (SPRC, 2013). Youth suicide is a significant concern; suicide is the second leading cause of death for young people ages 15-24, which translates to 14 youth suicides daily (CDC, 2018b). In addition, sexual minority youth experience more suicidal ideation and behavior than nonsexual minority youth (CDC, 2018b).
Researchers note, however, that these numbers must be interpreted with caution, because suicides are notoriously underreported and capture only a portion of the data. Until recently the National Violent Death Reporting System did not collect data from all 50 states. In addition, there is a “minority suicide paradox.” Despite the existence of risk factors for some groups (e.g., blacks, Hispanics, Asian-Pacific Islanders), the data show a lower suicide rate for these groups than for non-Hispanic whites. While this paradox has often been attributed to protective factors, Rockett et al. found that suicide underreporting and misclassification for these groups exist on several levels (e.g., forensic evidence of a suicide note is found for 31% of white persons who commit suicide compared to 18% of black and 21% of Hispanic) (Rockett et al., 2010). Further interdisciplinary research into suicide data disparities, particularly for these groups, is highly recommended (Rockett et al., 2010).
A critical question is: Do mental health and other healthcare practitioners receive adequate training? Although providing care to individuals at risk for suicide is common, healthcare professionals often do not receive formal training in suicide-specific, evidence-based prevention and treatment. Using evidence-based training and formal assessments have been shown to increase practitioner confidence in treating individuals who are suicidal (Schmidt, 2016). Studies have found gaps in the formal suicide risk and management training that mental health masters and doctoral level training programs offer (Schmidt, 2016). State licensing boards lack uniform suicide risk assessment and management training requirements (Schwab-Reese et al., 2018). However, 10 states have passed legislation mandating suicide prevention training, and seven states have policies encouraging training for healthcare professionals (Graves et al., 2018).
Empirically derived core competencies from multiple disciplines have been identified for healthcare providers, as have methods to integrate suicide training frameworks. Methods include exposing practitioners to validated suicide assessment instruments, supervised assessment interpretation, role-playing vignettes, etc. The Suicide Competency Assessment Form is used to rate 10 core competency areas (Cramer et al. 2013):
- Know and manage your attitude and reactions toward suicide
- Maintain a collaborative, empathetic stance toward the individual
- Know and elicit evidence-based risk and protective factors
- Focus on current plan and intent of suicidal ideation
- Determine level of risk
- Develop and enact collaborative evidence-based treatment plan
- Notify and involve other persons
- Document risk, plan, and reasoning for clinical decisions
- Know the law concerning suicide
- Engage in debriefing and self-care
Dr. Carl Bell writes that “Preventing risk factors from becoming predictive factors by using protective factors is one pathway to pursue” (Bell, 2018). The social ecological model used in the CDC’s Preventing Suicide Technical Package of Policy, Programs, and Practices enables an understanding of both the risk factors (hopelessness, substance use, victimization, detachment, availability of lethal means) and protective factors (culture, resilience, religiosity, family support, optimism) that have been identified for suicide on multiple levels (individual, relationship, community, and societal) (Stone et al., 2017). This requires an awareness and expertise in facilitating prevention strategies that go beyond the individual to have a broader impact on communities.
Suicide prevention strategies are increasingly being implemented in every level of the healthcare delivery system. Safer suicide care through systems change advocates for increased access to health and behavioral healthcare services, more efficient and effective care, and a healthcare system that supports suicide prevention and patient safety (Stone et al., 2017). This includes:
- Reducing provider shortages in underserved areas and populations using Telemental Health services and establishing designated Health Professional Shortage Areas.
- Training primary care providers who are often the first and only medical contact for suicidal patients and providing tools for recognition and patient screening. The National Institute of Mental Health (NIMH) has developed Ask Suicide Screening Questions (ASQ) a free resource for use in medical settings. ASQ provides toolkits in multiple languages that are specifically tailored to inpatient hospital units and outpatient and emergency departments.
- Increasing healthcare insurers’ outreach to individuals through employee assistance and workplace wellness programs, providing technology for online mental health screenings and web-based tools, reducing the stigma of help-seeking and mental illness, and increasing the awareness of the National Suicide Prevention Lifeline.
This is a critical time for behavioral health practitioners to take a leadership role in promoting evidence-based training and facilitating public mental health education and community-based approaches to prevent suicide.
The data highlighted in the 2018 suicide prevention fact sheet prepared by the National Center for Injury Prevention and Control, Division of Violence Prevention at the Centers for Disease Control and Prevention is a good place to start when sharing information about this issue.
The American Association of Suicidology also provides access to national suicide statistics as soon as they become available.
The Suicide Prevention Resource Center (Funded by SAMHSA).
First Step: Share the Lifeline number 1-800-TALK (8255)
Encourage community members and colleagues to attend gatekeeper suicide prevention training. However, everyone can keep the free, 24-hour Suicide Prevention Lifeline phone number in their mobile phone.
Bell, C. C. (2018). “Blog: Are suicides up in African American Youth? Not really.” The Steve Fund. August 6, 2018. Retrieved December 2018.
CDC (2018a). Vital Signs, National Center for Injury Prevention and Control, Division of Violence Prevention at the Centers for Disease Control and Prevention. June 2018. (SOURCE: CDC’s National Violent Death Reporting System, data from 27 states participating in 2015).
CDC (2018b). Preventing Suicide Fact Sheet. National Center for Injury Prevention and Control, Division of Violence Prevention at the Centers for Disease Control and Prevention. Retrieved December 2018.
Cramer, R., Johnson, S., McLaughlin, J., Rausch, E., & Conroy, M. (2013). Suicide Risk Assessment Training for Psychology Doctoral Programs: Core Competencies and a Framework for Training. Training and Education in Professional Psychology, 7(1), 1-11.
Graves, J. M., Mackelprang, J. L., Van Natta, S. E., Holliday, C. (2017). Suicide Prevention Training: Policies for Health Care Professionals Across the United States as of October, American Journal of Public Health, 108(6),760-768.
NIMH. (2008). Ask Suicide Screening Questions (ASQ). The National Institute of Mental Health. Retrieved December 2018.
Rockett, I., Wang, S., Stack, S. DeLeo, D., Frost, J., Ducatman, A., Walker, R., & Kapusta, N. (2010). Race/Ethnicity and Potential Suicide Misclassification: window on a minority suicide paradox? BMC Psychiatry, 10(1):35.
Schmidt, R .C. (2016). Mental Health Practitioners’ Perceived Levels of Preparedness, Levels of Confidence and Methods Used in the Assessment of Youth Suicide Risk. The Professional Counselor, 6(1), 76-88.
Schwab-Reese, L. M., Kovar, V., Brummett, S., & Runyan, C. (2018). Should Suicide Prevention Training be Required for Mental Health Practitioners? A Colorado, United States case study. Journal of Public Health Policy, 39(4),424-445.
Smith, A. R., Silva, C. Covington, D. W., & Joiner, T. E. (2014). An Assessment of Suicide-Related Knowledge and Skills among Health Professionals. Health Psychology, 33(2), 110-9.
Stone, D. M., Holland, K .M., Bartholow, B., Crosby, A. E., Davis, S., & Wilkins, N. (2017). Preventing Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: American Indians/Alaska Natives. Waltham, MA: Education Development Center, Inc.