Recent celebrity deaths and new data on rising suicide rates from the Centers for Disease Control and Prevention have drawn attention to the problem of undetected and untreated mental illness. Half of deaths by suicide are by people with undiagnosed mental illness.
How can the practicing physician — primary care or specialist—– help address this growing problem? Here are three things each of us can do:
- ASK: Perhaps you, like many physicians, are uncomfortable asking patients about suicidal thoughts. It may seem out of place when a patient has come to you seeking help for a respiratory infection or a painful joint. However, the two-question PHQ2 screen (along with screens for anxiety, trauma, and substance abuse) ought to be administered by staff just as frequently as any other vital sign. Or consider routinely asking patients about suicide as part of the annual exam, for example like this: “Given the recent celebrity suicides and publicity about increasing suicide rates, I’ve decided to start asking all of my patients: Have you had any thoughts that you would be better off dead or of hurting yourself in some way?”
- TREAT: For most of your patients who screen positive for depression, a licensed psychotherapist and you can provide high-quality, evidence-based care. For medication treatment, use a good algorithm as your guide, and use serial PHQ9s in the same way you would follow blood pressure or cholesterol levels. However, high-quality care usually requires medication and psychotherapy and, besides, it is much more comfortable to ask about suicidal thoughts when you have a trusted mental health specialist working at your side. In primary care and multi-specialty practices, consider hiring your own licensed mental health clinician — a mental health social worker, for example. In fact, new Medicare CPT codes encourage physicians to hire mental health specialists into their practices and even pay for informal consultation from a psychiatrist. Indeed, our collective advocacy for expansion of the use of these “collaborative care” codes to Medicaid and to commercial insurance would greatly improve access to mental health care for our patients.
- EDUCATE: Consider becoming an advocate for universal training in your community in Mental Health First Aid, a program that teaches people how to spot and address the signs of an emerging mental health challenge or crisis. Your local community mental health center has experts in Mental Health First Aid and would welcome you as a partner in spreading the word about the availability of its training sessions. Mental Health First Aid training allows people to feel more comfortable asking about suicide and other mental health challenges. By the way, most severe mental illness emerges in adolescence and early adulthood, so it is especially important to train high school and college educators how to spot a problem.
Suicide does not discriminate, and neither does major depression or substance use disorder, both risk factors for suicide.
That means that all of your patients are at risk and, in fact, the patient you are most reluctant to ask about it — perhaps your local celebrity — may be the one who most desperately needs someone in whom to confide. Indeed, many people who die of suicide saw a doctor in the months prior to dying.
Working together with others in our communities, we can ensure that the next opportunity to save a life is not overlooked.
James Baker, MD, is associate chair in the Department of Psychiatry at The University of Texas at Austin Dell Medical School and a member of TMA’s Council on Science and Public Health.