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Comments from the scientific community regarding Medical Care.

Tuesday, June 2, 2015

Exam Room Opportunities in Suicide Prevention

by Aishwarya Rajagopalan, MHS

What do Robin Williams, Alexander McQueen, and L’Wren Scott have in common? Aside from being talented, these individuals all died tragically by suicide. These are faces many of us may recognize, but each day, many families suffer losses due to suicide. The stigma against death by suicide can contribute an added burden. In an effort to stimulate meaningful conversation about suicide prevention and coping with losses by suicide, many researchers have sought to understand risk factors and disparities associated with suicide. In a recent study published in Medical Care, “Racial/ethnic differences in healthcare visits made prior to suicide attempt across the United States,” Ahmedani and colleagues sought to identify whether there were differences in healthcare visits by racial/ethnic group in the time leading up to a suicide attempt. Regular healthcare visits, such as those to a primary care provider, can be critical intervention points for people with behavioral health concerns or those experiencing suicidal ideation. Why? If a healthcare provider can detect suicidal ideation through a screener or through a patient’s disclosure, they can connect their patient to community resources, or perhaps to an appropriate treatment setting.

In the study by Ahmedani and colleagues, 22,387 people who were enrolled in the Mental Health Research Network, a consortium of ten health systems studying topics in behavioral health, were determined to have attempted suicide between 2009 and 2011. These individuals were then asked about their self-reported visits to different healthcare providers in the year prior to their suicide attempt. This information was then stratified by racial and ethnic groups. To ascertain who had attempted suicide, ICD-9 codes were utilized for the visit following the attempt. Any visits in the 365 days preceding the attempt were recorded and stratified based on their ICD-9 code into “substance use,” “mental health,” “diagnosis,” and “other.” These were then broken into setting-specific categories, such as emergency department, primary care, etc. Racial and ethnic information was obtained from medical records, and any patient who did not have a racial or ethnic group listed was excluded. Nearly 78% of included patients had a healthcare visit of some kind in the year preceding their suicide attempt.


There was substantial variation in the populations making healthcare visits prior to the suicide attempt, particularly mental health visits. About 41% of individuals who identified as white  visited a mental health professional in the week preceding a suicide attempt, compared to <35% of other racial groups (p<0.01). This trend continued in the four weeks and 52 weeks preceding a suicide attempt. People identifying as Asian were least likely to make visits to mental health professionals in these time periods. Notably, Asians were also least likely to have a mental health or substance abuse diagnosis corresponding to an inpatient stay prior to a suicide attempt, and were also least likely to have an emergency department or primary care visit relating to mental health concerns prior to the suicide attempt.

Often, we ascribe variations in access to care to having or lacking appropriate health insurance; however, everyone enrolled in the study was insured. This suggests that there may be cultural factors relating to healthcare utilization, and that public health and clinical professionals may need to take a multipronged approach to addressing suicide prevention -- addressing the matter both in the healthcare setting and in the community, through mass media and person-to-person interventions.

The study authors note that there are many barriers to accessing care that may need to be addressed. First, minorities may be less likely to present for diagnosis of a behavioral health condition because of perceived stigma or differing definitions of a behavioral health condition. This can lead to underdiagnosis. Secondly, many individuals who attempt suicide are not identified in the healthcare system because they do not make healthcare visits related to the attempt. These individuals are often missed in research, but could provide critical insight into health-related behaviors prior to suicide attempts. Additionally, this particular dataset was unable to discern whether an inpatient stay was related to a behavioral health or physical health complaint, and was not analyzed based on age, sex, or socioeconomic status, which can be important risk factors for certain predisposing behavioral health conditions. Overall, this study contributes an interesting point in our broadening national discourse on suicide prevention, but questions remain: how can we ensure that everyone is able to access suicide prevention resources? How can we make our dialogue more inclusive? And are there better places to intervene than the healthcare setting?

Aishwarya Rajagopalan is a first-year medical student at the Philadelphia College of Osteopathic Medicine. She completed her BA and MHS training in Public Health at Johns Hopkins University.