2023 Namey/Burnett Preventive Medicine Writing Award author Douglas Wirthin shares information on suicide risk factors and taking a thorough psychiatric history that can help support patients experiencing a mental health crisis and identify patients at higher risk for suicide.
Douglas Wirthin, 2023 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
It had been 10 years since Troy visited the doctor’s office. At 28, his physical health was fine, but his mental health was in shambles ever since his girlfriend of four years broke up with him a month ago. Everyone said he was taking it harder than expected and it was just a matter of time before he snapped out of it and regained his positive hard-working personality. As weeks turned into months, Troy lost 20 pounds, developed dark circles under his eyes, and constantly picked at the skin on his arms. Each conversation with Troy was a broken record of the events that lead to their eventual breakup.
The voices in the dark corners of his mind became louder and louder telling him to take his own life. And so, Troy found himself sitting in the waiting room of the doctor’s office. As he was escorted to the exam room, the MA gave him a copy of the patient health questionnaire-9 (PHQ-9). Without hesitation, Troy marked “nearly every day” on the first eight questions of the survey, as they seemed to be written by someone who had been observing his life for the past month. Arriving at the final question, “Over the last 2 weeks how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?”1 Troy paused and marked “several days”. Silent moments passed and the doctor finally entered the room. Troy recounted the worn-out story of his breakup, and it fell on unsympathetic ears. In ten minutes, Troy received a lecture on his ex-girlfriend’s free agency, prescriptions for Lexapro and a benzodiazepine, and a follow-up appointment in a month. No questions about his thoughts of suicide or family history of depression.
I got a call after Troy took his benzodiazepine medication before going out drinking. After only one drink he entered a state of crippling depression that left him bedridden for a day. He was totally unaware of the interaction between benzodiazepines and alcohol. As I told him why he shouldn’t do that again, I wondered why he hadn’t received this information at the doctor’s office. Time passed and Troy spent less and less time out of his bed. Once when he did leave his bed, his mother found him wandering the rooms of his house with a belt around his neck. He needed to be hospitalized when he was found in a remote location sitting in a car with a gun in his hand. It has now been a year since his admission, and he is slowly getting better.
Watching Troy struggle with depression and suicidal ideation was the hardest part of my second year of medical school. I spent countless hours talking to him on the phone being someone who would listen and support him. Although he had a strong support system, there was a month when I wasn’t sure if Troy was going to be alive in a year. Events could have easily turned out differently. We are all blessed that Troy is still alive. Now that Troy is recovering from his depression, I often ponder how his medical care could have been improved.
As a third-year medical student, I have gained some limited perspective that has helped me to speculate on what happened on Troy’s first visit to his primary care physician. In my family medicine rotation, I observed the wide variety and high volume of patients that primary care physicians take care of daily. Troy’s doctor probably saw anywhere from 20 to 35 patients that day.3 Up to 70% of those visits could have been about mental illness.4 Of those patients seeking help for mental illness many were most likely taking similar antidepressants. Yet, each patient had a different risk for suicide. After long days seeing patients, I have felt my own capacity to show empathy grow thin, and can only imagine that other physicians have felt something similar.
Because suicide is relatively infrequent and many factors influence a patient’s risk for suicide it is challenging to accurately assess suicide risk in the primary care setting.5 Although it may seem simple, a thorough psychiatric history is vital to evaluate a patient’s risk for suicide. The American Psychiatry Association (APA) published the “Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors” some of their guidelines for suicide risk assessment are advisable in the family practice outpatient setting.6 The following list highlights some general topics that should be discussed in a psychiatric history:
- Identify specific psychiatric signs and symptoms
- Assess past suicidal behavior, including the intent of self-injurious acts
- Review past treatment history and treatment relationships
- Identify the family history of suicide, mental illness, and dysfunction
- Identify current psychosocial situation and nature of crisis
- Appreciate psychological strengths and vulnerabilities of the individual patient
- Elicit the presence or absence of suicidal ideation
- Elicit the presence or absence of a suicide plan
- Assess the degree of suicidality, including suicidal intent and lethality of plan
After gathering all of the above information, the physician will have a better idea of the patient’s risk for suicide and can adjust the treatment plan accordingly. Another essential component of the psychiatric evaluation is the presence and absence of risk factors and protective factors following table lists some risk factors and protective factors to screen as recommended by the APA.
Table 1: A Brief List of Risk and Protective Factors for Suicide
This list is not exhaustive.
|Risk Factors6||Protective Factors6|
|Suicidal ideas, plans, or attempts||Children in the home|
|Psychiatric diagnosis||Sense of responsibility to family|
|Diseases of the nervous system||Pregnancy|
|Poor relationship with family||Life satisfaction|
|Domestic partner violence||Reality testing ability|
|Recent stress life event||Positive coping skills|
|Family history of suicide or mental illness||Positive problem-solving skills|
|Childhood abuse||Positive social support|
|Access to firearms||Positive therapeutic relationship|
Performing a thorough psychiatric history may take a significant amount of time but it is essential to providing the highest quality of care to our patients. Although suicide screeners should not replace a thorough psychiatric history, family medicine physicians should utilize available suicide screeners such as the Columbia-Suicide Severity Rating scale to add them in evaluating suicide risk. Suicide prevention is a team effort and osteopathic family medicine physicians play an essential role in preventing suicide by showing genuine and performing thorough psychiatric histories.
- Kroenke K, Spitzer RL. The PHQ-9: A New Depression Diagnostic and Severity Measure. Psychiatr Ann. 2002;32(9):509-515. doi:10.3928/0048-5713-20020901-06
- Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and Adults. Am J Psychiatry. 2011;168(12):1266-1277. doi:10.1176/appi.ajp.2011.10111704
- Mechanic D. The organization of medical practice and practice orientations among physicians in prepaid and non-prepaid primary care settings. Med Care. 1975;13(3):189-204. doi:10.1097/00005650-197503000-00001
- Patricia J. Robinson, Jeffrey T. Reiter. Behavioral Consultation and Primary Care. Accessed December 31, 2022. https://link.springer.com/book/10.1007/978-3-319-13954-8
- National Vital Statistics Reports Volume 69, Number 11 September 11, 2020 State Suicide Rates Among Adolescents and Young Adults Aged 10–24: United States, 2000–2018. :10.
- Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. In: APA Practice Guidelines for the Treatment of Psychiatric Disorders: Comprehensive Guidelines and Guideline Watches. Vol 1. 1st ed. American Psychiatric Association; 2006. doi:10.1176/appi.books.9780890423363.56008