An integrative framework for prevention and treatment of suicidality

By Julie Luzarraga

Your patient presents for his annual wellness exam. He is a relatively healthy Caucasian male in his late 40s. He is married with three children. In the past he has identified his professional life as an executive as a stressor. Physically, he is moderately overweight and has presented with back problems in the past. Religion is important to him and he exercises on a regular basis. Today, he presents with flat affect and shares that his wife has asked for a divorce. He reports difficulty sleeping, racing thoughts, and nausea that is making it difficult for him to eat regularly. He has already made an appointment with a mental health provider in your clinic. 

Would you ask him if he has had thoughts of suicide? 

According to the Centers for Disease Control and Prevention, there were 44,965 reported suicides in the United States in 2016; a 30 percent increase since 1999. The Substance Abuse and Mental Health Services Administration reports one person will die from suicide every 12 minutes in the United States. This concerning increase has created a call to develop more effective approaches to prevention and treatment of suicidality. The defining principles of integrative healthcare provide a framework for the treatment and assessment of suicidality for integrative practitioners.

The University of Arizona Center for Integrative Medicine (AZCIM) states “alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount”. Additionally, it provides a framework for assessing and treating suicidality in the integrative setting. These principles include:

• A focus on the therapeutic relationship between provider and patient
• Attention to all aspects of a person’s health
• The use of evidence-based approaches provide a framework for assessing and treating suicidality in our patients

Prevention and treatment start with an integrative approach to assessment which includes “all factors that influence health, wellness, and disease . . . including mind, spirit, and community, as well as the body,” according to the AZCIM.

Many integrative practitioners believe better assessment and treatment happen when we inquire about all aspects of a patient’s life. With the increase in suicides and the number of people who experience suicidal ideation, questions and conversation about suicidality should always be a part of our integrative assessment.

It is easy to assume that a patient has not or will not have thoughts of ending their life.  However, in 2013, an estimated 9.3 million adults aged 18 or older had serious thoughts of suicide in the past year. Whether we are aware of it or not, health providers encounter patients with suicidality on a regular basis.  This is true for both mental health providers and primary care providers.

A 2002 review by Jason Luoma, MA, and colleagues showed that45 percent of patients who commit suicide had seen primary care within one month of suicide and 20 percent had contact with a mental health provider.  In an integrative setting where patients are being seen for chronic health conditions, there is an even greater need for ongoing assessment of suicidality. There is evidence that depression occurs more frequently in patients with physical disorders, according to Hee-Ju Kang, MD. Many patients seen in an integrative care setting experience both physical and emotional distress, which makes them more at-risk.

Understanding the prevalence of suicidality and the importance of assessment is the first step in prevention and treatment. The next step is ensuring integrative practitioners develop a comfort level with fostering the patient-provider relationship in assessments through asking the tough questions. 

In a 2011 analysis of primary care physicians, Steven Vannoy, MD and Lynne Robins, MD, found that suicide-related discussion occurred in only 11 percent of encounters despite finding 59 percent of the patients endorsed suicidal ideation. Providers, including integrative practitioners, need to develop a comfort level in asking patients about suicide.

One way to assist with these conversations is to utilize assessment tools. The U.S. Preventive Services Task Force and National Action Alliance for Suicide Prevention recommend primary care providers screen adolescents and adults for depression. The National Action Alliance for Suicide Prevention provides examples of screening tools that can be used in the clinic setting.

In addition to validated assessment tools, simply asking patients the question, “within the last two weeks, have you had thoughts of killing yourself, or that you would be better off dead?” can identify at-risk patients.

Becoming comfortable with asking these questions is important. A patient is less likely to honestly respond when the questions are clunky or rote.  They are also less likely to respond if a provider is obviously uncomfortable with the subject. Vannoy and Robins found providers were likely to use language indicating a preference for the patient to deny suicidality and that they were more likely to show engaging communication style when a patient denied suicidality. Integrative mental health practitioners can also be utilized for both assessing patients and coaching other integrative practitioners in assessment and how to ask patients about suicidality.  For more information, the Suicide Prevention Resource Center has developed tools and guides specific to primary care providers which can be adapted for any integrative practitioner.

Properly assessing suicidality includes being familiar with the risk and protective factors related to suicide.  Eric Caine, MD, and his colleagues found one of the barriers to effective suicide prevention is the inability to discriminate between those who are truly at risk and those who may seem at risk due to a pre-existing psychological disorder.  Many of these patients will be diagnosed with depression or another mental illness.  The U.S. Preventive Services Task Force reports about 87 percent of patients who die by suicide meet the criteria for one or more major mental illness. We cannot assume suicidality is present in only depressed patients.  Not all patients will have been diagnosed or meet the full criteria for a major mental disorder. Knowing the risk factors can help guide integrative practitioners in conducting a thorough assessment with questions important to understanding a patient’s risk for suicidality.

The Suicide Prevention and Risk Center provides a list of risk and protective factors providers can utilize when assessing patients.  Some of the risks are:

• Prior suicide attempt(s)
• Access to lethal means
• Knowing someone who has died by suicide
• Chronic disease
• Social isolation
• Experience of discrimination

It is also important to know population risk.  For example, men between the ages of 50 and 54 years old have shown the greatest increase in suicide rate, according to the. They are also unlikely to be asked or disclose suicidal ideation, said Vannoy and Robins.

In addition, change in life circumstances such as relationship problems, life stressors, and a recent or impending crisis can be risk factors, says Gregory Simon, MD.  Asking patients about their relationships, stress level, and other areas of life improve the assessment process.  The integrative approach of making the patient-provider relationship paramount to assess all aspects of one’s health is the foundation of assessment and prevention of suicidality.

Building on the foundation of the patient-provider relationship and integrative assessment of risk, treating suicidality requires an integrative approach to care that is both evidence-based and collaborative. Multiple psychosocial therapies including cognitive behavioral therapy and psychodynamic interpersonal therapy are evidence-based approaches for suicide prevention, which Gregory Brown, PhD and Shari Jager-Hyman, PhD found in their review published in 2014. While referrals to licensed mental health providers and psychiatric providers will be beneficial to patients, integrative practitioners can provide an even higher level of intervention by collaboratively working together in treating the patient.

In 2002, Jurgen Unutzer, MD. and colleagues randomly assigned 1,801 patients to either traditional primary care for depression or the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) model of collaborative care. Traditional primary care includes medication prescribed by the primary care provider and/or referral to a behavioral health specialist. The IMPACT model consists of a care manager, primary care provider and a psychiatrist. The IMPACT team provided education and support for 12 months. At 12 months, the team found 45 percent of patients receiving the collaborative approach had a 50 percent or greater reduction in depressive symptoms from baseline compared with 19 percent of usual care participants. The collaborative care approach is what integrative practitioners use with other health conditions and should be utilized with patients at risk for suicide.  With evidence-based therapies in place, the integrative team can also work with the patient on adding complementary therapies such as supplements, exercise and light therapy to mitigate depressive symptoms.

Integrative practitioners put the patient and the relationship with the patient in the forefront of their approach to assessment and treatment.  Assessment is ongoing and takes all aspects of a person’s health and wellness into consideration, including asking questions about stress level, relationships, and any other significant events.  A person’s experience of suicidality is a crucial component of their overall health and wellness.  Utilizing these principles, integrative practitioners are uniquely positioned to increase their skills in assessing and treating patients experiencing suicidal ideation.  The integrative approach to treatment uses the evidence-based approaches in collaboration with other professionals creating a holding space for patients exhibiting suicidal ideation. The integrative approach provides an existing framework for assessment and treatment of suicidality has the potential to make a significant impact on the prevention of suicide.

References

American Foundation for Suicide Prevention.  (2016).  Suicide Statistics.  Retrieved from: https://afsp.org/about-suicide/suicide-statistics/.

Brown, G. K., and Jager-Hyman, S. (2014). Evidence-Based Psychotherapies for Suicide Prevention: Future Direction.  American Journal of Preventive Medicine.  47(3S2): S186-S194.

Caine, E. D., Reed, J., Hindman, J., Quinlan, K.  (2017, December 20).  Comprehensive, integrated approaches to suicide prevention: practical guidance.  Injury Prevention. 24: i38-i45.

Fatal Injury Data (2018).  Centers for Disease Control and Prevention.  Retrived from: https://www.cdc.gov/injury/wisqars/fatal.html.

Kang, H-J.,Kim, SY., Bae, KY., Kim, SW., Shin, IS., Yoon, JS., and Kim, JM. (2015, April). Comorbidity of Depression with Physical Disorders: Research and Clinical Implications.  Chonnam Medical Journal.  V. 51(1): 8-18.

Luoma, J.B., Martin, C.E., Peasron, J.L.  (2002, June).  Contact with mental health primary care providers before suicide:  a review of the evidence.  American Journal of Psychiatry. 159(6): 909-16.

National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group. (2018).  Recommended standard care for people with suicide risk: Making health care suicide safe.  Washington, DC: Education Development Center, Inc.

Primary Care.  (2018).  Suicide Prevention Resource Center. Retrieved from:   https://www.sprc.org/settings/primary-care

Risk and Protective Factors (2018).  Suicide Prevention Resource Center. Retrieved from: http://www.sprc.org/about-suicide/risk-protective-factors

Simon, G., Rutter, C., Peterson, D., Oliver, M., Whiteside, U., Operskalski, B., & Ludman, E. (2013).  Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?  Psychiatric Services, 64 (12), 1195-1202.

Stone, D. M., Thomas, R. S., Fowler, K.A., Scott, R. K., Keming, Y., Holland, K.M., Ivey-Setphenson, A.Z., Crosby, A. E.  (2018, June 8).  Vital Signs: Trends in State Suicide Rates – United States, 1999-2016 and Circumstances Contributing to Suicide – 27 States.  Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.  (6) 22.

Substance Abuse and Mental Health Services Administration.  (2014).  Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings.  Retrieved from:  http://www.samhsa.gov/data/ sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf.

Suicide: Facts at a Glance .  (2015).  Centers for Disease Control and Prevention (CDC).  Retrived from: https://cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.

Unutzer, J., Katon, W., Callahan, CM, Williams, J.W. Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R.D., Noel, P.H., Lin, E.H., Arean, P.A., Hegel, M.T., Tang, L., Beling, T.R., Oishis, S., Langston, C., IMPACT Investigators.  (2002).  Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial.  Journal of the American Medical Association. 288(22):2836-45.

U.S. Preventive Services Task Force.  (2015).  Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: Recommendation Statement.  American Family Physician. 91 (3).

University of Arizona Integrative Medicine. (2016). The Defining Principles of Integrative Medicine.  https://integrativemedicine.arizona.edu/about/definition.html