
According to the Centers for Disease Control and Prevention
(CDC), death by suicide is the 10th leading
cause of death in the United States when viewed across the lifespan. Additionally,
while the impact of the COVID-19 pandemic on suicidality rates has not been
fully ascertained, an early
report in EClinicalMedicine, published by The Lancet, suggests that the
prevalence of suicidality may be increasing in racial and ethnic minority
populations disproportionately driving rates.
The growing issue of suicidality is further compounded by
the maldistributed
access to psychiatric care in many communities. This is largely due to the
increase in demand for specialty psychiatric services combined with a shrinking
psychiatric workforce. Inadequate numbers of practitioners are being
trained to replace those leaving/retiring from community practices. This
workforce shortage is being partially mitigated by the increased number of Psychiatric Mental Health Nurse Practitioners
(PMHNP) in the field, less restrictive advanced nursing practice regulations
nationally, and the use of innovative patient access modalities to psychiatric
care, such as telehealth. Despite these best efforts, there remains a shortage
of available providers to meet the growing need of people for psychiatric
services.
Advanced Practice Registered Nurses (APRNs) in primary care
and other community-based practice settings have the potential to be effective
stop-gaps to meet this disparity in psychiatric access. While it would not be
wholly advisable to shift all psychiatric care to non-psychiatric providers, it
is feasible to provide non-psychiatric providers the skills to identify and
treat low or moderate acuity mental health conditions.
While mild depression and anxiety symptoms are already
widely treated outside of the traditional psychiatric specialty care, is
suicidality a condition that can be managed without immediate access to acute
psychiatry? A
recent analysis from Vanderbilt University Medical Center (VUMC) written by
Ketel, et al. (April, 2021) may suggest that it can. In 2018, a nurse
practitioner-led, interprofessional primary care practice implemented universal
suicidality screening at every patient visit. After analyzing 2 years of
quality improvement data, they found that, out of 1,733 unique patients, 149 patients
(8.6%) had some level of suicidality. Remarkably, a majority (62%) of patients
that screened positive for suicidal ideation came into the practice for only
medical complaints.
VUMC practice was able to effectively manage 112 patients
(75%) without elevating the patient to specialty psychiatry. They accomplished
this through the use of standardized, evidence-based screening and triage tools
accompanied by regular follow-up and counseling by an embedded licensed master social
worker (LMSW). In fact, out of the 149 patients screened, only 8 patients (5%)
required referral/elevation to acute specialty psychiatry settings. On the
downside, 29 patients (20%) who initially screened positive for suicidality were
“lost to follow-up” or refused to accept care. In general, however, of the 112
patients that engaged with care, there were no suicide attempts or deaths.
Additionally, the practice achieved complete resolution in suicidality in 84
patients (75%).
How was this possible? Suicidality, like most other physical
and mental health conditions, has a range of acuities and is associated with both
protective factors
(factors that decrease acuity or prevalence) and risk factors (factors
that increase acuity or prevalence). Both protective and risk factors can generally
be quantifiably accessed and stratified. Protective factors that work preventatively
against suicide or self-harm include a strong social support network, responsibility
for the well-being of another person/animal (i.e. child/pet), and religious
beliefs that prohibit suicide. On the other hand, risk factors are traits or
situations that increase a person’s likelihood to complete suicide or self-harm.
They may include being unemployed, experiencing a recent loss, experiencing psychological
or physical trauma, and having immediate access to deadly means (i.e. firearms
or medications).
While considering these protective and risk factors in
individual patients can appear intimidating at first glance, it aligns with the
course of care for most other clinical conditions encountered within the scope
of primary care or community-based care.
As with other conditions, suicidal ideations present on a
wide continuum of acuity. Suicidal thoughts can range from infrequent, passive
thoughts of suicide, to constant,
active attempts to do self-harm or kill oneself. The most widely accepted tool
to measure suicidal ideation severity is Beck’s
Suicidal Ideation Scale. In general, most patients presenting to
non-psychiatric settings are not in this latter state of suicidality. When they
do, it is obviously a time to engage the most immediate and intense emergency
systems available. This would be akin to a patient presenting to a practice with
acute chest pain or a person found unresponsive. Another example may be a patient
with diabetes with an acute and severe episode of hyperglycemia. The
appropriate response in this case would also be to immediately elevate the
patient to a higher level of specialty care or emergency setting.
However, in both of these examples, possible cardiac event or
severe diabetic hyperglycemia, the better alternative would have been for the
APRN to detect and intervene well before the acute event occurred. This is done
through detection and management of the patient’s unique set of risk factors
and clinical indicators in early stages of disease progression. In the cases of
cardiac disease and diabetes, regular and consistent use of evidence-based
clinical detection and treatment modalities in the early stages of the disease
progression can prevent or postpone the need for higher levels of acute or
emergent care.
Early detection and treatment of suicidal ideation can be
seen in this same light. If detected early, initial management of suicidal
ideation is absolutely possible and appropriate in non-psychiatric settings.
This does not imply that patients with persistent suicidal ideations do not
require eventual elevation to specialty psychiatric care, but it does allow primary
care and other ambulatory clinical settings to intervene at lower acuity
levels. This will help shift at least some of the demand for acute psychiatry
services and allow greater access to patients in truly acute psychiatric
distress.
At minimum, most primary care practices can act as community
“gatekeepers” for suicidal detection. A community suicide gatekeeper is a
person or organization that is capable of identifying, approaching, discussing,
and referring individuals in psychiatric distress to the appropriate level of
care. Generally, gatekeepers have ongoing access to a community or have regular
interactions with the public as a part of their normal routine. It is not a new concept. Originally it was
developed in the early 1990’s as a way to engage school age children,
adolescents, and young adults in school-based settings. A
more updated article in RAND Health Quarterly by Burnette, et al. (2015)
provides an excellent description of the scientific underpinnings for community
gatekeeping.
Over the past 30 years, gatekeeping has expanded from just
schools to include many social service and community organizations. In 2021 and
in partnership with the National Action Alliance for Suicide Prevention and the
United States Federal Government, the US Surgeon General released a “Call
to Action” for the prevention of suicidality in the United States. This
call to action is a “broadening of the vision” initiated in the 90’s. This is
an expansive call that outlines six actions to decrease the impact of suicidality.
It is an excellent plan and worth reading in its entirety, and this brief
article could not do it complete justice. With that said, the first action in
the statement seeks to encourage and empower every individual and organization
to play a role in suicide prevention. That includes primary care practices and
the APRN community of providers.
How do you get started addressing suicidality in primary
care or as an APRN provider in the community? The first step is to identify partners
and resources within your community that can help support your practice once
patients are identified with suicidal ideation. This obviously includes
traditional mental health service organizations in the community, but it also
includes other community organizations who interact frequently with your
population. Having a robust community network allows for close collaboration
and sense of community togetherness around suicide prevention. An excellent
evidence-based model for building community connectedness around suicidality is
the CDC’s “Preventing
Suicide: A Technical Package of Policy, Programs, and Practices.” The next
step is to officially engage with your individual state’s suicide prevention
program. A list of contacts by state can be found at the Suicide Prevention Resource Center. At
this site, you will also find access to free
online and in-person training to get your entire practice prepared to
assist patients with suicidality. Other excellent resources to consider would be
the American Foundation
for Suicide Prevention and SAMHSA. Both of these organizations have copious amounts of
resources for overall mental health, as well as the screening tools needed to
fully implement suicidality screening effectively. Once your practice has
accessed all of its available resources, it is time to take the next step and
start confidently asking your patients about suicidal ideations.
Christian Ketel, DNP, RN-BC (He/Him/His)
Assistant Professor of Nursing
Director Vanderbilt Primary Care-West End
Co-Director of the Meharry-Vanderbilt Alliance
Inter-Institutional Interprofessional Student Program
LEAN for Health Care Trainer and Facilitator
Tennessee ACEs Building Stronger Brains Initiative Trainer
Vanderbilt University School of Nursing