A Holistic Approach to Suicide Prevention: Screening Limitations and Implications for Primary Care Providers

By: Amy Bennett-Staub

Predicting which patient will complete suicide has proven to be extremely difficult, as no statistical method to identify these patients has been found that would improve treatment.[1] While a variety of screening tools exist, screeners lack adequate specificity and sensitivity, and reliance upon them may result in false reassurance for false negatives, and unnecessary interventions for false positives. About half of all patients who die by suicide denied any suicidal ideation or behaviors at their last visit and about half of all completed suicides are by patients identified as “low risk.”[2] Given this reality, what can providers reasonably do to mitigate suicide risk among their patients?

Understanding the limitations of screening tools and opting for a more comprehensive, holistic approach is a first step. SAFE-T is a five-step evaluation and triage paradigm that provides a structured way to engage with patients and their problems.

1. Identify Risk Factors

Note that some risk factors can be modified to reduce risk.  Alan Berman conducted a study on risk factors proximate to suicide and suicide risk assessment in the context of denied suicide ideation and noted the following risk factors were charted for the majority of decedents, with or without suicidal ideation:

• History of prior suicide ideation or attempt

• Acute anxiety/agitation/impulsivity and sleep problems

• Acute interpersonal problems or job/financial strain

• Comorbid mental illness

• Increasing use of alcohol and drugs

• Social isolation and withdrawal

• Family history of mental illness and/or suicide

Decedents who denied having SI were similar in charted diagnoses, symptoms, behaviors, and environmental circumstances to decedents who responded affirmatively to having SI. Reliance on verbalized or reported SI as a gateway to a suicide risk assessment therefore must be questioned.

Additional risk factors:

Acute factors are known to contribute appreciably to the assessment of short-term risk and arise from significant changes of existing chronic factors or completely new sources. Chronic factors may impact suicide risk over one’s lifetime, and may be permanent and non-modifiable.

2. Identify Protective Factors

Note that these can be enhanced to reduce risk. Protective factors include[3]:

• Accessible and responsive social support

  • Connected to medical and psychiatric care

  • Family/friends cohesion and involvement

• Meaningful activities

  • Involvement in work, school, and community

• Coping mechanisms

  • Presence of good problem-solving skills

  • Ability to consider options

• Dependents

  • Children under 18 in the home

  • Pregnancy

• Other

  • Cultural and religious beliefs that provide meaning and discourage suicide

  • Multiple reasons for living

  • Expression of hope for the future

  • Fear of death or dying due to pain and suffering

It is important to remember that most suicidal patients do not wish to die, but rather are carrying unbearable pain and see no other way out of their suffering.[4] Increasing modifiable protective factors, such as teaching coping mechanisms through psychotherapy sessions or helping patients connect to social supports can decrease their suicide risk.[5]

3. Conduct Suicide Inquiry

Assess suicidal thoughts, behaviors, plans, and intent. As noted above, history of prior suicidal ideation is highly correlated with completed suicide, even if cases of denied suicidal ideation at last visit. It is therefore crucial to ask the patient about passive and active SI, when they last had these thoughts, and if they have any prior suicide attempts. Ask the patient if they have a plan, and what the plan is. Assess the patient’s idea of what would happen if they followed through with their plan.

Just as important is whether or not the patient has a history of or thoughts of hurting themselves without a desire or intention of death (non-suicidal self-injurious behavior [NSSIB]). In addition to the possibility that NSSIB may accidentally result in death and may coexist with suicidal behavior, NSSIB gives individuals the capacity to tolerate increasing pain, and should be seen as a step on the continuum of suicidal behavior.[6] It should never be minimized as attention-seeking behavior, and instead treated seriously as a suicidal behavior.

Lastly, it is crucial to inquire into access and availability of any means, particularly those means that an individual may identify as part of a plan.[7] Lethal means may include firearms, pills or ingestible poisons, sharps, high places such as rooftops or bridges, or materials/opportunity for hanging or asphyxiation.

4. Determine Risk Level

Risk stratification, while imperfect, can help you choose evidence-based interventions.

5. Document

Be objective in your documentation of assessment of risk, interventions, and follow up plans.

This five step approach takes a far more holistic and in-depth approach than screening alone, which is insufficient in specificity and sensitivity when it comes to assessing suicide risk and interventions.