Advertisement
Mayo Clinic Proceedings Home

Suicide Prevention in Primary Care Medicine

Published:October 05, 2015DOI:https://doi.org/10.1016/j.mayocp.2015.09.011
      Suicide is the 10th leading cause of death in the United States. In adults younger than 55 years, suicide is among the 5 most common causes of death.

      Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Fatal injury reports, national and regional, 1999-2013. http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Accessed August 5, 2015.

      During the past 50 years, US suicide rates have not declined.
      National Center for Health Statistics
      Health, United States, 2014: With Special Feature on Adults Aged 55-64.
      In fact, between 1999 and 2010, suicide rates increased significantly, especially in men 50 to 59 years of age.

      Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Fatal injury reports, national and regional, 1999-2013. http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Accessed August 5, 2015.

      Evidence, albeit limited, suggests that many suicide decedents had contact with a health care provider shortly before death.
      • Luoma J.B.
      • Martin C.E.
      • Pearson J.L.
      Contact with mental health and primary care providers before suicide: a review of the evidence.
      The report by Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      in the current issue of Mayo Clinic Proceedings highlights an important opportunity to expand suicide prevention in primary medical care settings and the potential for primary health care providers to take a larger role in suicide prevention.
      Office of the Surgeon General, National Action Alliance for Suicide Prevention
      2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention.
      Unlike most other studies examining the link between health care visits and suicide, Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      used a control group to ascertain whether the pattern of health care use in suicide decedents was, or was not, different from that in nonsuicide patients. In addition, Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      used electronic health record (EHR) data to assess health care visits, a rather innovative information-gathering approach in suicide research. Previous research found that 70% or more of elderly patients who died by suicide saw their primary care physician within a month before death.
      • Conwell Y.
      • Duberstein P.R.
      Suicide in elders.
      Most patients with psychological problems receive care solely in primary care settings, and in 2008, Kessler and Stafford
      • Kessler R.
      • Stafford D.
      Primary care is the de facto mental health system.
      noted that “primary care is the de facto mental health system.” Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      found that patients who died by suicide had recent health care visits, but this was the case in the control group as well.
      Although primary care is the sole source of medical care for many patients with mental health conditions, few patients exhibit suicidal risk factors during primary care visits.
      • Kessler R.
      • Stafford D.
      Primary care is the de facto mental health system.
      Most patients who visit their primary care provider for psychosomatic reasons report physical health concerns that require evaluation, which can result in mental health issues going unrecognized.
      • Kessler R.
      • Stafford D.
      Primary care is the de facto mental health system.
      The evidence regarding health care use before suicide is mainly based on medical record review of the decedents or retrospective psychological autopsy.
      • Luoma J.B.
      • Martin C.E.
      • Pearson J.L.
      Contact with mental health and primary care providers before suicide: a review of the evidence.
      Little is known about whether primary care use is higher in patients who die by suicide compared with patients who do not. The novel way in which Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      used EHR data expands our knowledge in this area.
      The use of EHRs in health care settings has risen dramatically since passage of the Health Information Technology for Economic and Clinical Health Act in 2009, which authorized incentive payments through the Centers for Medicare and Medicaid Services to promote meaningful use of EHRs.
      Department of Health and Human Services, Centers for Medicare and Medicaid Services
      Medicare and Medicaid programs; Electronic Health Record Incentive Program final rule.
      As EHR use increases, EHR data will become more relevant to track and enhance health care services, and these efforts will continue to improve the quality and completeness of EHR data used for research.
      • Weiner J.P.
      • Fowles J.B.
      • Chan K.S.
      New paradigms for measuring clinical performance using electronic health records.
      • Kern L.M.
      • Barron Y.
      • Dhopeshwarkar R.V.
      • Edwards A.
      • Kaushal R.
      • Investigators H.
      Electronic health records and ambulatory quality of care.
      • Angier H.
      • Gold R.
      • Gallia C.
      • et al.
      Variation in outcomes of quality measurement by data source.
      • Gold R.
      • Angier H.
      • Mangione-Smith R.
      • et al.
      Feasibility of evaluating the CHIPRA care quality measures in electronic health record data.
      Data from EHRs provide rich information regarding a patient's health care utilization, diagnoses, and treatments; many EHRs also capture data about insurance status and other sociodemographic characteristics. When used in research, EHR data can help overcome recall bias and other limitations of self-reported information (or proxy-derived data for decedents) regarding patients' health care use, medications, and other aspects of their medical history. During real-time delivery of clinical care, many EHRs can be enhanced to include clinical decision support tools and can use patients' clinical records and provide recommendations for best health care practices. Such tools have been developed to improve clinical decision making regarding diabetes treatment, asthma care, and guideline-based medication prescribing, for example.
      To date, only a few suicide-related studies have used EHR data, and most investigated suicide attempts rather than mortality.
      • Haerian K.
      • Salmasian H.
      • Friedman C.
      Methods for identifying suicide or suicidal ideation in EHRs.
      • Anderson H.D.
      • Pace W.D.
      • Brandt E.
      • et al.
      Monitoring suicidal patients in primary care using electronic health records.
      • Ahmedani B.K.
      • Simon G.E.
      • Stewart C.
      • et al.
      Health care contacts in the year before suicide death.
      In contrast, Ahmedani et al
      • Ahmedani B.K.
      • Simon G.E.
      • Stewart C.
      • et al.
      Health care contacts in the year before suicide death.
      used EHR data to evaluate health care use in a large number of suicide decedents and discovered that most suicide decedents (83%) used health care services in the year before death. However, this study did not have a control group to identify whether the pattern of use in suicide decedents would be different from that in patients who did not attempt suicide. The study by Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      helps resolve this limitation by introducing a comparison group. Using data from more than 500,000 patients who had contact with a health care provider at Mayo Clinic or Olmsted Medical Center, they identified 86 suicides. They then randomly selected, from the same patient population, 258 controls matched on birth date and sex. Comparing the frequency and type of health services received, Chock et al found no difference between the control group and suicide decedents in the likelihood of having a health care visit in the year before death, deemphasizing the importance of health care visits before death as a potential corollary for suicide. However, Chock et al did find an increase in the use of health care services before death in the subset of patients with a known mental health diagnosis.
      This research by Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      supports observations made by Gaynes et al
      • Gaynes B.N.
      • West S.L.
      • Ford C.A.
      • et al.
      Screening for suicide risk in adults: a summary of the evidence for the U.S. Preventive Services Task Force.
      that primary care providers could potentially prevent suicide in patients with known risk factors, such as mental health problems and substance dependence. But even in patients with depression who see a primary care provider, most will not attempt suicide. Thus, there is a need for more evidence to help providers understand the complex risk profile and behavior of suicidal patients. Furthermore, detrimental life events can be a short-term trigger for suicide
      • Kaplan M.S.
      • McFarland B.H.
      • Huguet N.
      • Newsom J.T.
      Sooner versus later: factors associated with temporal sequencing of suicide.
      in patients without a known mental health diagnosis, and these trigger events are difficult, if not impossible, for primary care providers to identify. In addition, negative life events that precipitate suicide affect certain populations differently, by age, sex, socioeconomic position, or other characteristics.
      • Heikkinen M.E.
      • Isometsa E.T.
      • Aro H.M.
      • Sarna S.J.
      • Lonnqvist J.K.
      Age-related variation in recent life events preceding suicide.
      Physical illness, for example, is an important suicide risk factor,
      • Hughes D.
      • Kleespies P.
      Suicide in the medically ill.
      especially in elderly men.
      • Conwell Y.
      • Duberstein P.R.
      • Hirsch J.K.
      • Conner K.R.
      • Eberly S.
      • Caine E.D.
      Health status and suicide in the second half of life.
      Intimate partner problems are a risk factor in young military veterans before suicide death.
      • Kaplan M.S.
      • McFarland B.H.
      • Huguet N.
      • Valenstein M.
      Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans.
      Socioeconomic problems, such as financial difficulties and unemployment, are associated with suicide in women.
      • Heikkinen M.E.
      • Isometsa E.T.
      • Aro H.M.
      • Sarna S.J.
      • Lonnqvist J.K.
      Age-related variation in recent life events preceding suicide.
      Previous studies that identified life stressors more likely to increase suicide risk have not assessed health care utilization before death, so it is difficult to link specific life situations with a pattern of use that would provide clues to a primary care provider. Chock et al showed the benefit of using EHR data in understanding patterns of use, but their data did not include information on the circumstances preceding death.
      Linking EHR data with public health surveillance data, such as the National Violent Death Reporting System (NVDRS), could fill this void and better inform prevention strategies in primary care settings. The NVDRS is a unique state-based surveillance system developed by the US Centers for Disease Control and Prevention. It links information from death certificates, medical examiner/coroner reports, law enforcement reports, and crime laboratory data, providing a more comprehensive evaluation of the circumstances surrounding violent death, including suicide. Previous linkages between NVDRS and health care utilization data can serve as examples for how to create broader linkages with this important data source. For example, South Carolina, which is one of the states currently participating in the NVDRS, successfully linked its violent death data to other administrative health care utilization data sources, including those associated with hospital inpatients and emergency departments.
      • Weis M.A.
      • Bradberry C.
      • Carter L.P.
      • Ferguson J.
      • Kozareva D.
      An exploration of human services system contacts prior to suicide in South Carolina: an expansion of the South Carolina Violent Death Reporting System.
      In a report using the South Carolina data, Weis et al
      • Weis M.A.
      • Bradberry C.
      • Carter L.P.
      • Ferguson J.
      • Kozareva D.
      An exploration of human services system contacts prior to suicide in South Carolina: an expansion of the South Carolina Violent Death Reporting System.
      linked nearly 60% of the suicide decedents to hospital discharge data. These data showed that 16% of suicide decedents had a hospital encounter 30 days before death. Further linkages between EHR and NVDRS data from suicide decedents could provide a tremendous new source of information to help health care providers identify at-risk patients. As these novel data linkages increase predictive capabilities, there may be the potential to design EHR-based clinical decision support tools to help providers identify individuals with the highest suicide risk and prompt action. For example, although not implemented as an EHR tool, the Department of Veteran Affairs and the Department of Defense have developed a clinical practice guideline for assessing and managing patients at risk for suicide. An EHR clinical decision support tool could be modeled after these Department of Veteran Affairs/Department of Defense guidelines. This tool would assess the risk of suicide based on the patient's health records and demographic characteristics and would alert providers of patients reaching the at-risk threshold. Providers could then consult an EHR suicide module, which would guide them in further assessing the risk of suicide, determining appropriate care settings, and identifying treatment options.
      Chock et al
      • Chock M.M.
      • Bommersbach T.J.
      • Geske J.L.
      • Michael Bostwick J.
      Patterns of health care usage in the year before suicide: a population-based case-control study.
      advance the field of suicide research in 2 ways. First, they provide important insight into patient health care use before death relative to nonsuicide patients. Second, they demonstrate the usefulness of EHR data in broadening our understanding of the suicide phenomenon and inspire future research that could help primary care physicians identify patients at high risk for suicide and prompt interventions for the most vulnerable populations. Data from the EHR linked to other sources, such as the NVDRS, could build further on this progress to better inform effective suicide prevention efforts.

      References

      1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Fatal injury reports, national and regional, 1999-2013. http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. Accessed August 5, 2015.

        • National Center for Health Statistics
        Health, United States, 2014: With Special Feature on Adults Aged 55-64.
        National Center for Health Statistics, Hyattsville, MD2014
        • Luoma J.B.
        • Martin C.E.
        • Pearson J.L.
        Contact with mental health and primary care providers before suicide: a review of the evidence.
        Am J Psychiatry. 2002; 159: 909-916
        • Chock M.M.
        • Bommersbach T.J.
        • Geske J.L.
        • Michael Bostwick J.
        Patterns of health care usage in the year before suicide: a population-based case-control study.
        Mayo Clin Proc. 2015; 90: 1475-1481
        • Office of the Surgeon General, National Action Alliance for Suicide Prevention
        2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention.
        US Department of Health and Human Services, Washington, DC2012
        • Conwell Y.
        • Duberstein P.R.
        Suicide in elders.
        Ann N Y Acad Sci. 2001; 932: 132-150
        • Kessler R.
        • Stafford D.
        Primary care is the de facto mental health system.
        in: Kessler R. Stafford D. Collaborative Medicine Case Studies. Springer, New York, NY2008: 9-21
        • Department of Health and Human Services, Centers for Medicare and Medicaid Services
        Medicare and Medicaid programs; Electronic Health Record Incentive Program final rule.
        Fed Regist. 2010; 75: 44313-44588
        • Weiner J.P.
        • Fowles J.B.
        • Chan K.S.
        New paradigms for measuring clinical performance using electronic health records.
        Int J Qual Health Care. 2012; 24: 200-205
        • Kern L.M.
        • Barron Y.
        • Dhopeshwarkar R.V.
        • Edwards A.
        • Kaushal R.
        • Investigators H.
        Electronic health records and ambulatory quality of care.
        J Gen Intern Med. 2013; 28: 496-503
        • Angier H.
        • Gold R.
        • Gallia C.
        • et al.
        Variation in outcomes of quality measurement by data source.
        Pediatrics. 2014; 133: e1676-e1682
        • Gold R.
        • Angier H.
        • Mangione-Smith R.
        • et al.
        Feasibility of evaluating the CHIPRA care quality measures in electronic health record data.
        Pediatrics. 2012; 130: 139-149
        • Haerian K.
        • Salmasian H.
        • Friedman C.
        Methods for identifying suicide or suicidal ideation in EHRs.
        AMIA Annu Symp Proc. 2012; 2012: 1244-1253
        • Anderson H.D.
        • Pace W.D.
        • Brandt E.
        • et al.
        Monitoring suicidal patients in primary care using electronic health records.
        J Am Board Fam Med. 2015; 28: 65-71
        • Ahmedani B.K.
        • Simon G.E.
        • Stewart C.
        • et al.
        Health care contacts in the year before suicide death.
        J Gen Intern Med. 2014; 29: 870-877
        • Gaynes B.N.
        • West S.L.
        • Ford C.A.
        • et al.
        Screening for suicide risk in adults: a summary of the evidence for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2004; 140: 822-835
        • Kaplan M.S.
        • McFarland B.H.
        • Huguet N.
        • Newsom J.T.
        Sooner versus later: factors associated with temporal sequencing of suicide.
        Suicide Life Threat Behav. 2006; 36: 377-385
        • Heikkinen M.E.
        • Isometsa E.T.
        • Aro H.M.
        • Sarna S.J.
        • Lonnqvist J.K.
        Age-related variation in recent life events preceding suicide.
        J Nerv Ment Dis. 1995; 183: 325-331
        • Hughes D.
        • Kleespies P.
        Suicide in the medically ill.
        Suicide Life Threat Behav. 2001; 31: 48-59
        • Conwell Y.
        • Duberstein P.R.
        • Hirsch J.K.
        • Conner K.R.
        • Eberly S.
        • Caine E.D.
        Health status and suicide in the second half of life.
        Int J Geriatr Psychiatry. 2010; 25: 371-379
        • Kaplan M.S.
        • McFarland B.H.
        • Huguet N.
        • Valenstein M.
        Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans.
        Am J Public Health. 2012; 102: S131-S137
        • Weis M.A.
        • Bradberry C.
        • Carter L.P.
        • Ferguson J.
        • Kozareva D.
        An exploration of human services system contacts prior to suicide in South Carolina: an expansion of the South Carolina Violent Death Reporting System.
        Inj Prev. 2006; 12: ii17-ii21

      Linked Article