By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
Early data suggests that deaths due to suicide and overdose have increased since the beginning of the COVID-19 mitigation measures in the United States. Social isolation, financial insecurity, and unemployment increases the number of deaths from suicide, overdose, and illness. The factors leading to suicide disproportionately impacting communities of color. Individuals who have a history of Adverse Childhood Experiences (ACEs) are particularly at risk.
Primary care clinicians have the opportunity to screen, intervene and prevent these events. There is no way to know if someone is in trouble unless they are asked. When risk for suicide is identified, there are tools and resources that reduce the probability of suicide attempts.
One best practice is to routinely screen for depression using the PHQ-2 and PHQ-9 questions, adding some additional questions about depression risk for any patient screening positive for depression (PHQ-9 score of 10 or greater).
The National Institute on Mental Health (NIMH) developed the Ask Suicide-Screening Questions (ASQ), four questions in 20 seconds to identify people at risk of suicide. In a NIMH study, a “yes” response to one or more questions identified 97% of youth aged 10 to 21 at risk of suicide:
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that you or your family would be better off if you were dead?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to kill yourself?
If an individual responds “yes” to one or more of the four Ask Suicide-Screening Questions, they are at “imminent risk” or “potential risk” of suicide.
The next step to better understand risk-level, if any of the four questions above are answered “yes”, ask “are you having thoughts of killing yourself right now?” and if the individual says “yes,” then they are at imminent risk of suicide and need an urgent mental health evaluation to ensure immediate safety. If the individual answers “no,” then a potential risk is identified and they require a brief suicide safety assessment to determine next steps.
The Zero Suicide Model is an evidence-based practice outlining how to apply this model in a clinical setting. Practices include:
- Make a safety plan the patient can follow if thoughts of suicide appear, including calling help lines such as the National Suicide Prevention Lifeline (1-800-273-255).
- Discuss restricting access to things they might use to hurt themselves – especially firearms (firearms in the house are a major risk factor for completed suicide).
- Create a follow-up monitoring plan to ensure the patient receives ongoing help and support.
All three of these activities are appropriate for those who answered “yes” to any of the four ASQ questions above.
Overdose and Suicide: An overdose or self-harm event in the emergency department indicates an extreme high risk. An opioid overdose indicated an 18-fold greater risk of suicide and over 100-fold greater risk of overdose in the next year, compared to the general population. A visit for suicidal ideation led to a 30-fold increase in the risk of suicide in the next year.
ACEs and Suicide: Individuals with four or more Adverse Childhood Events (ACEs) are 37.5 times as likely to attempt suicide, when compared to individuals with no ACEs. For more information on addressing ACEs in your clinical practice, visit www.ACEsAware.org.
Screening individuals for risk of suicide saves lives! Health care professionals can help people get needed care, support and resources. We recommend a refresher training for our clinical staff on this topic, in this time of increased risk of suicide.