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Screening for suicide: A psychiatrist’s take

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By Dr. Charles Raison

(CNN) — Should primary care doctors routinely screen their patients for suicide risk? In a new report, a panel of federal experts stops short of recommending such screenings, given the current state of our knowledge.

But that report, from the U.S. Preventive Services Task Force, is easy to misunderstand if you don’t read the fine print.

When I first read its one-sentence takeaway, I was outraged. I thought of all the good people I had worked with over the years who killed themselves to escape the anguish of their mental illnesses.

I thought of the fact that suicide is in the top five causes of death for Americans from the teen years through the mid-50s, costing an estimated 1.3 million years of potential life lost before age 85, the task force says, citing statistics from the U.S. Centers for Disease Control. And I thought about how after holding steady for about 20 years, suicide rates have risen steadily in the United States since 2005, according to the panel.

Given all this, what could be more reasonable than doctors routinely making sure that their patients are not at risk?

The problem is that there is no evidence that screening would be of any use. Few studies have examined the issue, and those that have don’t provide definitive guidance.

But this does not mean the task force — an independent panel of non-federal experts composed of primary care providers — recommends turning a blind eye to suicide risk. Far from it.

In fact, what the task force suggests is that there is something more reasonable than asking everyone about suicide, and that is being careful to ask about people about aspects of their lives that might put them at high risk for suicide and then addressing these risk factors.

Screening for suicide risk factors may include asking about feelings and concerns, as well as the presence of a psychiatric condition, whereas screening for suicide risk usually involves asking directly about suicidal thoughts.

What kinds of information are most helpful for doctors and other clinicians who want to identify people at increased risk for suicide?

Here, the answer is clear. About 90% of people who commit suicide suffer from a serious, diagnosable mental illness, according to the National Alliance on Mental Illness. Because depression is so common, it is by far the leading driver of suicide. But per-person rates of suicide are likely even higher in other mental illnesses, such as schizophrenia and bipolar disorder, which, thankfully, are far less common.

It would be comforting if we could say that the problem of suicide could be largely eliminated if we paid closer attention to people struggling with mental illness. Unfortunately, despite numerous studies over the last generation, we remain unable to predict suicide among those with psychiatric disorders with anywhere near enough accuracy to be of much clinical help.

Having said this, however, we’ve learned more about things that increase the risk for suicide on a statistical (if not overly practical) basis.

For example, although women make suicide attempts far more frequently than men do, men are far more likely than women to die at their own hand, according to the CDC. Young people are more likely than old people to make suicide attempts, but older people — especially older men — are far more likely to kill themselves. Native Americans and Alaska Natives also have higher rates of completed suicide than other groups in the United States.

There are clinical factors that can also increase the risk for suicide. The most obvious risk factor is voicing suicidal thoughts or plans. The vast majority of people who kill themselves told someone of their feelings before committing suicide. There is a myth that people who talk about suicide aren’t likely to do it because if they were serious, they’d be quiet about their plans. In fact, most people who eventually kill themselves have profound ambivalence about it, which often manifests as a cry out to others.

There is another myth that people who make repeated suicide attempts aren’t serious about dying and so are at reduced risk of eventually killing themselves. In fact, studies suggest just the opposite. The more often people attempt suicide, the more likely they are to eventually succeed.

Finally, one of the strongest risk factors for suicide is the presence of terrible anxiety/agitation, which can occur during exacerbations of a number of psychiatric conditions or less commonly in response to an overwhelming life event. If someone voices suicidal thoughts or plans when consumed by overwhelming anxiety or agitation, they should be taken with utmost seriousness.

One of the most striking things about the task force’s review of suicide prevention is how much less we know about how to treat suicide than we do about how to treat the mental disorders from which it often arises.

What evidence is available suggests that psychotherapy may be more effective than medications for reducing suicidal thoughts and feelings, despite the fact that most studies find medications and psychotherapy to be equally effective for treating depression, which is a primary driver of suicide.

The poet T.S. Eliot once wrote that “Time is no healer,” but in the case of suicidal thoughts and feelings, it often is.

This points to the great tragedy of suicide. It is a one-way decision: Once done, it’s done. I’ve treated so many people who attempted suicide, survived and later were so grateful for their lives that I am especially sensitive to how horrible suicide is.

All this points to an important clinical truth: Suicidal thoughts and wishes often pass; completed suicide never does.

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