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The Role of Primary Care in Addressing Suicide Risk

It has been estimated that up to 18 Veterans die each day by suicide. The subgroup of Veterans who receive care within the VA health care system are at greater risk for suicide compared to non-Veterans; the rate of suicide within this subgroup has decreased only slightly in recent years.¹ Well documented risk factors for suicide include previous suicide behaviors, psychiatric and general medical conditions, male sex, poor psychosocial support, access to means for suicide (especially firearms), losses, and recent psychiatric hospitalization.

VA Suicide Prevention Activities

The VA has developed a comprehensive strategy in an effort to reduce the incidence of suicide. Specifically, the VA has implemented screening for conditions commonly associated with suicide behaviors; developed national performance measures and tools to facilitate assessment of suicide risk; and created a "Veterans Suicide Prevention Hotline" that provides ready access for Veterans and their families to seek and receive help. The VA has also implemented training programs for VA staff and created the Suicide Prevention Coordination Program, which funds suicide prevention coordinators at VA facilities and facilitates monitoring and safety plan development for high risk patients. In addition, through the Primary Care-Mental Health Integration and Translating Initiatives for Depression into Effective Solutions (TIDES) initiatives, the VA has implemented colocated and collaborative mental health care approaches designed to support primary-care based Patient Aligned Care Teams (PACTs), and to enhance primary care patient access to high quality mental health care.

Primary Care Interactions with Veterans at Risk

Primary care clinicians have a critical role to play in addressing suicide risk of Veterans by detecting and treating important mental and general medical conditions, and being prepared to identify and respond to opportunities to intervene when Veterans are at high risk. Prior research indicates that a considerable proportion of individuals who die by suicide make contact with health care clinicians prior to death. According to multiple studies, half of individuals make contact with primary care providers in the month prior to death, while a much smaller proportion make contact with mental health care clinicians during that month. During these contacts, it is not clear whether patients are specifically seeking help for emotional distress versus seeking care for general medical conditions, although several recent studies suggest that emotional issues are frequently not addressed at these last visits.^2,3 In a study using a small sample of Veterans from Oregon who subsequently died by suicide, we found that less than one-third of the patients acknowledged suicidal ideation even when they were asked about it during last visits with primary care clinicians.2

Mental disorders are common among Veterans treated by primary care clinicians, and these disorders, as well as general medical conditions, increase risk for suicide behaviors. Key conditions for primary care clinicians to detect and treat include depression, anxiety, and substance use disorders. These conditions have been well-documented to increase risk for suicide behaviors, and many Veterans who receive treatment for these disorders receive it only in primary care settings. Less clear is the relationship between PTSD and suicide--while some studies have shown PTSD increases risk for suicide, others have found weaker associations between PTSD and suicide. Traumatic brain injury, which is often comorbid with PTSD, may also be an important risk factor for suicide. However, to date there are few data available to support this relationship; studies examining this question are in progress. Finally, other studies have shown that chronic pain frequency and intensity may be associated with a two-fold increase in rates of suicide behaviors. Importantly, insomnia and anxiety may further increase risk for suicide among individuals who have pain or other comorbid conditions.

Further innovation and research is needed to optimize the role of PACTs in suicide prevention. We need to further develop and implement training programs that enhance PACT members' ability to: a) address and treat depression, anxiety, substance use disorders, chronic pain, and insomnia; b) recognize and respond to suicidal ideation as well as other warning signs of patient distress; and c) use motivational interviewing techniques to help high-needs patients transition to specialists when specialty care is indicated. At a systems level, it is important that the VA continue to support development and testing of sustainable collaborative approaches, including decision support and care management for conditions that increase the risk for suicide behaviors. Development of additional processes that facilitate communication and coordination among PACTs, mental health clinicians, and Veterans as Veterans make transitions between care settings is also needed.

References

1. Blow, F.C. et al. "Suicide Mortality Among Patients Treated by the Veterans Health Administration from 2000 to 2007," American Journal of Public Health 2012; 102(S1):S98-S104.
2. Denneson, L.M. et al. "Suicide Risk Assessment and Content of VA Health Care Contacts Before Suicide Completion by Veterans in Oregon," Psychiatric Services Journal 2011; 61(12):1192-7.
3. Smith, E.G. et al. "Treatment of Veterans with Depression who Died by Suicide: Timing and Quality of Care at last Veterans Health Administration Visit," Journal of Clinical Psychiatry 2011; 72(5):622-9.