Suicidality in Ohio: Reversing the Trend in 2020
By Justin Trevino, MD - Medical Director, Ohio Department of Mental Health and Addiction Services
Most of us have seen the reports indicating the escalating trends of suicide in the nation and in Ohio. The numbers are troubling and attention-grabbing: from 2007-2018 suicide deaths in Ohio increased over 40 percent with the number of deaths reaching approximately 1850 (about 5 people dying each day) in 2018. Suicide is now the leading cause of death for Ohio youth ages 10-14 years as well as the second leading cause of death for Ohioans ages 15-34 years. Rates of increase in suicide provide more unsettling news: during the period from 2007-2018 in Ohio, there has been an approximately 65 percent increase in youth (ages 10-14 years) suicide rate, an almost 50 percent increase in older adult (over age 65 years) suicide rate, and about a 35 percent increase in suicide for those ages 25-44 years and 45-64 years. Males have a rate of suicide four times that of females across the lifespan. Since 2014 rates of suicide for black, non- Hispanic males have increased over 50 percent and for white non- Hispanic males by nearly 25 percent. For males, firearms and suffocation (hanging) are the most reported mechanisms of suicide accounting for 85 percent of deaths, while for females, these two mechanisms plus drug overdose account for almost 90 percent of deaths. I would encourage reading of the Ohio Department of Health report Suicide Demographics and Trends, Ohio, 2018 (November 2019 release) for additional important information on suicide in Ohio, keeping in mind that the report details deaths related to suicide and not the much more prevalent manifestations of suicidality - namely suicidal thinking and suicide attempts.
Having provided this background, my hope is that the readership is very aware of the issue of suicidality in terms of its numerous and often devastating implications. It is estimated that one suicide impacts well over 100 people in the community who were close to, involved with, or gained knowledge of the deceased person. Information about the identification of those at high risk of suicidality and engaging and working with them in an ongoing manner to manage the condition has become increasingly available in recent years. While all clinicians will not be able to fully utilize all these practices, it is vitally important that all clinicians are able to identify those at high risk for suicide, provide them evidence- based interventions, and assist them in directly accessing the care they desperately need. It will take a concerted effort of those in healthcare as well as those in social service and law enforcement agencies to reverse the upward trend in suicide deaths in Ohio.
Providers of health care services are well-positioned to identify and intervene with those at high risk for suicide. In both national and Ohio-specific studies, about 80 percent of those dying by suicide were seen in a healthcare setting within 12 months of death with close to 50 percent receiving a service in a health care setting one month prior to death. Most of these individuals are seen in primary care clinics and emergency departments rather than behavioral health care practices and most are not in behavioral health treatment at the time of death. The 2012 National Strategy for Suicide Prevention (US Department of Health and Human Services Office of the Surgeon General and National Action Alliance for Suicide Prevention) included the goal of promoting suicide prevention as a core component of health care services. The Zero Suicide (ZS) Model, an overall framework for implementing evidence-based practices for suicide prevention followed from the 2012 Report. The clinical practices reviewed are all important elements of the model. See www.zerosuicide.sprc.org for information about the ZS Model.
While predicting those who will ultimately die from suicide is not currently possible, there are several evidence-based screening instruments that provide prompts to guide suicide risk assessment. Screening those with known behavioral health and substance use conditions for suicidality is prudent, given the increased rates associated with these illnesses. Universal screening meets the goal of providing a person with comprehensive care and is necessary to identify those with varying degrees of suicidality with no previously identified/current behavioral health or substance use conditions. Such screening instruments include the Columbia Suicide Severity Rating Scale (C-SSRS), which is available in multiple versions, the briefest of which is a version consisting of 6 questions. The C-SSRS can be completed by the patient and then reviewed by the clinician or completed in the course of an interview. It poses specific prompts relating to thoughts of not wanting to live anymore, of wanting to end one’s life, of planning to end life as well as developing a specific life -ending plan and engaging in behavior(s) to end life. Another validated instrument, the Patient Health Questionnaire-9 (PHQ-9), asks about the presence of feelings of depression and hopelessness, symptoms of depression, and thoughts of being better off as a result of engaging in self-harm or potentially lethal actions.
These two instruments assist in screening for suicide risk; they provide important data but do not replace sound clinical judgment. Patients not comfortable admitting to having suicidal thoughts/plans/taking action to harm themselves and those who have determined that they would be better off dead may not screen positive for suicide risk on these instruments. The presenting circumstances, expressed distress about current life situation or physical status, statements about being unable to cope with life/feeling hopeless, and clinician observation of the person’s display of sadness, anxiety, anger, or apathy provide additional valuable information in assessing suicide risk. Taking the opportunity to ask one (or more) of the important screening questions again, possibly in a slightly different manner, when a patient is evidencing significant distress but screening negative for suicide risk, can potentially prompt more revealing responses. Inquiring directly about suicidal thoughts, plans, and behaviors in a compassionate manner communicates both the importance of the issue and the clinician’s interest in this most important matter. These direct inquiries do not “place” thoughts of suicide in patient’s minds or increase suicide risk.
Those patients screening positive for suicide risk will require further interventions. Having a workflow or protocol in place for this situation is vital. Are there mental health clinicians in the primary care or ED setting to further assess the patient for severity of suicidality? If not, what is the plan to access such clinicians in a time-sensitive manner? Ensuring that a patient identified with a concerning level of suicidality is linked in real-time with the clinician who will provide further assessment is highly recommended as a significant percentage, in some studies as many as half, of patients provided mental health care appointments after seeking primary/urgent care do not keep the appointments.
While a specialized care referral and/or consultation is necessary for those with identified high risk, there are important clinical activities that can be conducted with the patient in the primary care/ED setting irrespective of whether care will continue in that setting or referral is made to another care provider. Two that have a significant evidence base supporting their use are the Safety Planning Intervention (SPI) and lethal means counseling. Both of these activities can be covered in the SPI process.
The SPI is a brief intervention that typically takes 20-45 minutes to complete and is intended to provide the patient with information relevant to recognizing and managing their suicidality as well as enlisting help from a variety of sources, including crisis service/emergency department care. The intervention consists of the clinician and patient engaging in the collaborative task of creating a written safety plan that the patient will have for their use following the intervention. The safety plan identifies: warning signs of increasing suicidality; internal coping strategies, social situations, and personal relationships to use to reduce the intensity of suicidal thoughts and impulses; persons who could be contacted and alerted to the patient’s increasing suicidality and could offer meaningful help through listening or their presence; clinicians/agencies/hospitals or clinics/suicide helpline or crisis lines that the patient can readily access should they experience a crisis situation with worsening suicidality.
Lethal means reduction counseling addresses the risk posed by potentially lethal items in the patient’s home/living environment that can be readily accessed and utilized in a suicidal act. As a final component to the safety plan, the patient and clinician can review such items (firearms, medications, alcohol/other substances) beginning with any that the patient has identified in thoughts or planning related to suicide. Given the frequency of their use in suicide and their lethality, firearm access should always be addressed. Specific plans for safe medication storage, removing firearms from the home or disabling them or preventing their use (with gun locks, for example), and the assistance that family members and trusted others could provide in keeping the patient safe (helping secure medications or firearms) would be reviewed and incorporated in the safety plan.
The safety plan must be developed in a collaborative manner, primarily utilizing patient input, to be effective. The clinician can provide helpful suggestions during the development of the plan, but the importance of the plan being a patient-specific product cannot be overemphasized. Once the plan is completed, its use is reviewed with the patient, any modifications made, and barriers to use problem- solved. The patient is provided the plan (and additional copies, if this would be helpful) and a copy is kept in the patient chart. Discussion with the patient would determine if there are others they would want to provide a copy of the plan and communicate the importance of the plan being transmitted to the provider of ongoing care, if this is different than the clinician involved in assisting with the creation of the plan.
A final intervention that has been demonstrated to be helpful (reducing self-harm and suicide attempts) to patients with significant suicide risk who are referred to ongoing care in an outpatient setting is the provision of timely, supportive contacts such as phone calls, text messages, or letters. These “caring contacts” should be tailored to the patient’s communication preferences and represent interest in the patient’s welfare beyond the services provided in the clinic/ED setting. The initial caring contact would be set to occur within 1-2 days of the patient encounter and utilized to determine if recommended care has taken place and if the patient feels able to manage their current situation (have they been using their safety plan, as needed?). Additionally, the contacts provide an opportunity to offer the patient encouragement for their utilizing prescribed treatments and services.
Ohio can be successful in reducing the number of suicide deaths in 2020. It will take a concerted effort of those in health care as well as those in social service, educational, and law enforcement settings to identify those at high-risk and assist them in accessing necessary care. Significant effort is currently underway to create a statewide Suicide Prevention Plan to coordinate efforts and better serve Ohioans. Promoting the consistent use of evidence- based suicide screening tools, use of the SPI, real-time linkage of patients at high-risk with specialized consultant/clinician care and performance of caring contacts are all activities consistent with the intent of the statewide plan and will greatly assist the effort to reverse the upward trend of suicide which is the current unfortunate reality in Ohio. Each of your efforts to further this goal is very much appreciated!
Patient Health Questionnaire - 9 (PHQ-9)
National Suicide Prevention Lifeline 1-800-273-TALK (8255)
Ohio’s 24/7 Crisis Text Line Text keyword “4HOPE” to 741 741