Medicine must decide it wants to prevent suicides.
This post is slightly altered from one published earlier in Psychology Today.
We are missing an easy way to prevent suicides. Half or more of all suicides are potentially preventable.
First, here’s a summary of the problem that once again came to our attention with the unfortunate and untimely deaths of Kate Spade and Anthony Bourdain as reported recently in the New York Times, the Chicago Tribune, and the Washington Post.
The Centers for Disease Control and Prevention (CDC) tell us that in 2016 there were nearly 45,000 deaths by suicide in the U.S., and that the rate has increased by as much as 30% in some states (1). The tenth leading overall cause of death, suicide is twice as common in men, who use deadlier means, than women although women make more attempts. The greatest number of deaths by suicide are in the 75+ age range for men and the 45-64 age range for women. Suicide is the second leading cause of death in the 15-34 age range. Recent increases preferentially affect young adults with less formal education and those with antisocial personality disorder, anxiety disorders, depressive disorders, and a history of violence (2). These risk factors (mental health disorders) are present in more than 90% of suicidal patients (3). While the CDC says mental disorders may be as low as 50% in suicidal patients, they acknowledge that their database is not designed to determine this (1). Fry 1989—Suicidal thoughts or thoughts about death. CC-BY-SA-4.0
Now, to the point.
About 45% of patients dying of suicide have seen a physician in the month beforehand, and as many as 75% have seen a physician in the preceding year. With access to this large number of potentially suicidal patients, a skilled physician could possibly prevent a very large number of deaths (3, 4). But this would require that the physician had experience in recognizing and managing the suicidal patient.
Here’s the problem: physicians are not trained in mental health care, which includes the management of suicidal patients.
Because of a severe shortage of psychiatrists, medical physicians now provide the sole mental healthcare for 85% of all patients in the U.S (5, 6). Puzzlingly, according to the Association of American Medical Colleges, despite thousands of hours of medical education devoted to diseases, medical students receive an average of only 6 weeks of clinical experience in psychiatry—out of the entire four years of training (7). Residencies, the last stage of training before physicians go into practice, provide even less, many none at all (8). That’s about 1-2% of total teaching time devoted to actual clinical experience caring for mental health disorders—even though they are more common than heart disease and cancer combined, the most common health condition in the U.S. (9).
Of this miniscule amount of all mental health training, the suicidal patient is only a small subset, meaning that graduates receive virtually no training in suicide detection and management. Deans and others will tell you they now provide lectures, but lectures don’t help. Learners require actual clinical experience with suicidal patients and mental health patients, taught by skilled supervisors.
Why don’t non-psychiatry physician faculty teach about suicide and mental disorders? Although a rich reservoir of potential for remedial training, they are not trained either. Thus, a severe existing shortage of psychiatry faculty conducts all mental health training, including that for suicidal patients.
What about psychologists? They are about twice as common as psychiatrists. Unfortunately, few psychologists are trained in the medical needs of patients and they are not trained to prescribe medications, which are critically important treatment options for many suicidal patients (10). Nor are they on the front lines, day to day, in primary care where most patients enter the system.
Coming as little surprise, many studies indicate that medical physicians seldom recognize the mental-health problems they encounter. For the few they do recognize, care falls far below standards (11, 12).
This is why the tremendous potential to prevent suicide by physician intervention lies fallow—while desperate patients die preventable deaths and their families and friends mourn unaware.
The medical profession in general and the medical education community in particular could fix the problem tomorrow by doing the obvious: train the people who provide the care. Trained physicians would know the risk factors alerting them to the suicidal potential of a patient, they would know how to interact in this difficult situation, they would know how to determine serious intent, they would know when they could manage the patient themselves vs. when to refer to psychiatry, and they would know how to use medications for depression.
It’s a shame that the U.S. spends over $3 trillion (that’s with a ‘t’) per year on health care and does so poorly to resolve an obvious major problem getting worse.
Only when medicine decides to become serious about mental health care and the suicidal patient will we ever see a decrease in the number of suicides. Spending $3 trillion a year, how patiently must we wait for medicine to act?
Robert C. Smith, Copyright 2018
Iridescenti—London’s commonest suicide location, known as ‘Suicide Bridge’.
1. Centers for Disease Control and Prevention 2018;Pages. Accessed at Centers for Disease Control and Prevention at https://www.cdc.gov/vitalsigns/suicide/index.html on June 9, 2018.
2. Olfson M, Blanco C, Wall M, Liu SM, Saha TD, Pickering RP, et al. National Trends in Suicide Attempts Among Adults in the United States. JAMA Psychiatry. 2017;74(11):1095-103.
3. McCarron RM, Vanderlip ER, Rado J. Depression. Ann Intern Med. 2016;165(7):ITC49-ITC64.
4. Hogan MF, Grumet JG. Suicide Prevention: An Emerging Priority For Health Care. Health Aff (Millwood). 2016;35(6):1084-90.
5. Wang P, Demler O, Olfson M, Pincus HA, Wells KB, Kessler R. Changing profiles of service sectors used for mental health care in the United States. Am.J. Psychiatry. 2006;163:1187-98.
6. Melek S, Norris D. Chronic Conditions and Comorbid Psychological Disorders. Millman Research Report. Seattle, WA: Millman 2008:19.
7. Association of American Medical Colleges. Basic Science, Foundational Knowledge, and Pre-Clerkship Content — Average Number of Hours for Instruction/Assessment of Curriculum Subjects. Association of American Medical Colleges; 2012.
8. Leigh H, Mallios R, Stewart D. Teaching psychiatry in primary care residencies: do training directors of primary care and psychiatry see eye to eye? Acad Psychiatry. 2008;32(6):504-9.
9. National Alliance on Mental Illness. Prevalences of Illnesses. Support, Advocacy, Education, Research. Gainesville, FL: National Alliance on Mental Illness; 2014.
10. McDaniel SH, Grus CL, Cubic BA, Hunter CL, Kearney LK, Schuman CC, et al. Competencies for psychology practice in primary care. The American psychologist. 2014;69(4):409-29.
11. Croghan TW, Schoenbaum M, Sherborne CD, Koegel P. A framework to improve the quality of treatment for depression in primary care. Psychiatric Services. 2006;57:623-30.
12. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. In: Services USDoHaH, ed. 2nd ed. Washington, D.C.: U.S. Government Printing Office; 2000:76.