A key strategy in suicide prevention is the implementation of a minimum amount of training for suicide risk assessment and for treatment of suicidal behaviors. Suicide-specific training enhances the level of care that people who experience mental illness and suicide risk receive while also increasing provider competence and ability to provide effective, life-saving treatment.
American Foundation for Suicide Prevention
Medical providers such as pharmacists, dental professionals, rehab therapists, and others providing care in outpatient and private clinics play an important role in suicide prevention. However, many healthcare professionals acknowledge the lack of confidence, skills, knowledge, and competence in all facets of suicide awareness and prevention in their professional training and in practice. To improve this situation, suicide prevention skills must be taught in entry-level programs, so they will filter into the practice of all providers (Larivière et al., 2021).
Healthcare providers face challenges asking about suicidal feelings, partly related to the perceived reluctance of their patients to disclose suicidal ideation and because many providers believe that suicide is difficult to predict and prevent. Lack of time is also universally acknowledged as a barrier (Elzinga et al., 2020).
A large European study looked at some of the difficulties faced by healthcare providers related to assessing suicidal ideation and behaviors. Providers reported feeling stuck with patients, feeling professionally isolated, and being “lost in a referral maze”. They expressed the need to have mental health staff based in their practices, such as is done in the Netherlands’ healthcare system (Elzinga et al., 2020).
Practitioners expressed the need to improve access to—and collaboration with—mental health services. The lack of such collaboration is a common barrier to suicide prevention. In the United Kingdom, for example, studies have found that mental health practitioners tend to minimize a healthcare provider’s assessment of a patient’s suicidal state (Elzinga et al., 2020).
7.1 Pharmacists
In the United States, there are more than 68,000 community pharmacies, many of which are open 24 hours per day. This means pharmacists are a frequent healthcare touchpoint for many community members and are well-positioned as gatekeepers for suicide prevention. Community pharmacy staff have reported encountering patients either in crisis or who died by suicide and have expressed a need for training in suicide prevention skills (Stover et al., 2023).
Community pharmacists annually interact with patients with mental health issues an average of 31 times more often than a patient’s primary care provider. Despite this, little is known about pharmacists’ attitudes towards suicide prevention. Very little is also known about an individual client’s willingness to reveal suicidal thoughts to their pharmacist. Stigma, fear, embarrassment, and a preference for self-reliance can prevent a suicidal patient from seeking help (Kamal and Jacob, 2023).
Pharmacists are in a unique position to provide information about suicide to their clients despite barriers such as workload, time constraints, staff negative attitudes, and stigma towards mental illnesses. At a minimum, being able to talk about suicide and complete a simple screen for suicidal ideation and behaviors can alert them to take further action. Connecting a person to help—whether to their physician, a family member, or the suicide hotline is critical.
Widespread training of practicing pharmacists, pharmacy techs, and students can be useful. In the U.S., Washington is one of the few states that requires pharmacists to complete continuing education related to suicide prevention. In addition to building knowledge, these training programs can decrease stigmatization against people with mental health conditions (Witry and Clayden, 2020).
Pharmacy students may be exposed to people with suicidal ideation in their roles as trainees and technicians. They may experience high levels of stress and may have personal and peer experiences related to suicide. It can be beneficial to begin training student pharmacists in assessing suicide risk and referring people with suicidal ideation to resources (Witry and Clayden, 2020).
In a 2018 review that evaluated a variety of approaches for educating students and engaging community pharmacists in suicide prevention, the authors recommended that suicide prevention training for pharmacy professionals address the following areas: identifying warning signs for suicide, communicating with individuals to assess risk of suicide, referring individuals to appropriate resources, and counseling about which medications may increase risk of suicidal ideation (Stover et al., 2023).
However, only two of the reviewed five trainings for student pharmacists included information on medication counseling and the role of medication in suicidal ideation and behavior. Notably, trainings lacked medication-specific information, such as mentioning the medications labeled for increasing patients’ risk of suicidal ideation or behavior, even though more than 143 agents carry this label. This information should be included in future trainings (Stover et al., 2023).
Case: Francoise Gets Help from Her Pharmacist
Background
Francoise is a 45-year-old woman who was previously stable on medications (lithium) for bipolar disorder. She stopped filling her prescription for lithium about 3 months ago.
One day, Francoise arrives at the Rite Aid pharmacy with prescriptions for opioids and benzodiazepines from a different provider in a nearby town. She appears nervous and agitated. She also smells of alcohol, which can increase the risk of death—intended or unintended—from a combination of disturbed thought process along with certain medications and alcohol.
Screening
The Rite Aid pharmacy uses the Patient Health Questionnaire 2 to screen clients for suicidal ideation and behavior. The screening is activated when a client has a sudden change in medications, has a prescription from another pharmacy, is filling a prescription for high-risk medications, or when a client’s behavior causes staff concern. The pharmacist askes Francoise: Over the last 2 weeks, how often have you been bothered by either of these problems?
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
Although appearing quite nervous and agitated, Francoise answers in the negative to each question.
What Should You Do?
The pharmacist is concerned that Francoise is denying or minimizing her feelings. Because of the combination of medications and behaviors, she is worried that Francoise is in acute danger of self-harm.
The pharmacist decides to ask some follow up questions. She uses another screening tool, the Emergency Medicine Network’s EDSAFE Patient Safety Screener that she’s familiar with from working in a hospital-based pharmacy. She asks Francoise:
- Over the last 2 weeks, have you had thoughts of killing yourself?
- In your lifetime, have you ever attempted to kill yourself? If so, when?
Francoise says she feels fine and hasn’t had any thoughts of harming herself. She says she did try to commit suicide in the past but refused to say when or how. She asks when she can get her prescriptions.
The pharmacist asks Francoise if she can contact a family member for additional information. Francoise agrees. If Francoise had declined consent, HIPAA permits a clinician to make these contacts without the patient’s permission when the clinician believes the patient may be a danger to self or others.
Because the pharmacist has a “duty to protect” her client, she asks Francoise to wait with her in a private room and directs a cashier to call her family. Francoise’ husband arrives quickly and agrees to take his wife to the ER. The pharmacist follows up the local emergency department and learns that Francoise has arrived at the hospital and is being evaluated.
Discussion
Relapsing bipolar disorder can place a person at increased risk for suicide. Because Francoise stopped taking lithium and succeeded in getting a supply of medications from a different pharmacy, she now had the means (and perhaps the motive) to self-harm. The pharmacist and her staff were able to help Francoise through a combination of engagement, screening, concern, a nonjudgmental attitude. They kept Francois in a safe environment under one-to-one observation until someone arrived to take her to the hospital. The system set up by the pharmacy to flag high-risk mediations along with a screening protocol provided help to a person in acute crisis.
7.2 Dental Professionals
Since August of 2020, dental hygienists and dentists in Washington state have been required to take a continuing education course on suicide screening and referral. Because dental professionals spend a great deal of time with their patients, often see their them on a regular basis, and are familiar with their medical history, they are in a good position to screen and refer patients who may be at risk for self-harm.
The initial assessment and ongoing, regular appointments provide opportunities to screen for risk factors associated with suicide. The intimate nature of dental work allows oral health professionals to ask about depression, chronic pain, unexplained loss of teeth, mouth lesions, as well as injuries to the head and neck.
Clinicians working within dentistry are familiar with screening for a variety of health conditions. Dental professionals also undertake routine screening for conditions such as oral cancer, non-accidental injuries, and dental disease on a daily basis (Kelly and Kilgariff, 2023). It is important for dental clinics to have policies and procedures in place that describe screening tools, employee training, and referral resources.
Patients with mental health issues may have a greater risk of oral disease because of side effects of medication, lack of self-care, and higher treatment needs because of difficulties in accessing care. Dental team members are in an ideal position to recognize signs of oral health-related mental health concerns. Also, head and neck cancer survivors are twice as likely to die by suicide than survivors of other cancers. It is important the dental team understand the effect such conditions have on patients' mental wellbeing, and the increased risk of such patient groups (Kelly and Kilgariff, 2023).
Studies of patients’ attitudes toward screening for medical conditions in a dental setting indicate that most patients express a favorable attitude toward chairside screening. They understand the importance of the dental professionals having the necessary medical knowledge and, when appropriate, the ability to refer to the other healthcare services (Friman et al., 2015).
A simple screening tool such as the Patient Health Questionnaire 2 or another short, validated screening tool (discussed in Module 3) or a waiting room questionnaire can be quick and efficient. Dental professionals must be trained in the use of a screening tool and have pre-screened referral resources readily available, including mental health and social services.
7.3 Rehabilitation Therapists and Allied Health Professionals
Suicide prevention has traditionally been the domain of mental health professionals operating within the biomedical model. Consequently, strategies to prevent suicide have been largely implemented within the setting of mental healthcare and have largely centered around the suicide risk assessment process (McGrath et al., 2023).
Although rehab therapists can act as gatekeepers in identification and referral of patients into other parts of the healthcare system (Lundin and Bergenheim, 2020), research has repeatedly found that rehab therapists experience difficulty supporting people with poor mental health. They commonly attribute their lack of confidence to a lack of training in mental health. Because of this, the ability to identify and address mental health issues is not seen as a priority within the profession (McGrath et al., 2022).
As with pharmacists and dental professionals. rehabilitation therapists are in a unique position to screen for suicidal ideation and behaviors. They routinely interact with, and care for, care for patients with musculoskeletal, neurological, and respiratory conditions. The association between suicide and poor physical health means they may encounter clients with suicidal thoughts and behaviors. Specifically, chronic pain has been identified as a risk factor for depression and suicidal ideation.