The Case

An 18-year-old man with a reported history of untreated depression and suicide attempts at age 13 (with cutting behaviors and over-ingestion of medication), but no history of psychiatric hospitalizations, was seen in the Emergency Department (ED) with a chief complaint of suicidal ideation. He reported feeling more depressed lately. He had been open with his older brother about suicidal thoughts for some time, but 2 days prior to presentation, he became intoxicated and reported having purchased a gun, but did not disclose details. After the brother disclosed this information to their mother, emergency medical services (EMS) brought the patient to a local ED. He initially reported taking 10 ibuprofen tablets, although he later denied this quantity.

The patient was not on any psychiatric medications and did not have an outpatient therapist or psychiatrist. He denied auditory and visual hallucinations, had no somatic complaints, denied illicit substance use but did endorse alcohol use and occasional cannabis use. He had stable vital signs, was calm and cooperative, and displayed a stable affect. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. Laboratory studies were only remarkable for a positive cannabis result on urine toxicology screen. The Psychiatry team’s recommendation was for discharge with outpatient therapy. The patient’s mother agreed with this plan. He was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions.

One month later, the patient had his first visit with his new primary care physician (PCP). He was again sent to an ED after he described a suicidal gesture consisting of superficial cutting of his wrist with a kitchen knife several days earlier, which he stated was in reaction to a recent romantic disappointment. In the ED, he was placed on emergency hold civil commitment for “persons posing risk of serious harm by reason of mental illness.” However, he stated that the thoughts of hurting himself had passed quickly, and he had no plan to hurt or kill himself or anyone else. He denied any safety concerns at home--he reported living alone but was looking forward to moving in with his brother in 1 week and noted strong family support in the area. He cited future-orientation including enjoying working in a hotel. The Psychiatry team recommended that the patient was safe for discharge with outpatient follow-up, which was arranged. They also recommended that patient start an antidepressant medication, but the patient declined, stating he does not like to take medications.

Ten days later, the patient had a follow-up phone visit with his PCP. He mentioned that two days prior, he had been up all-night sending texts to a girl and felt “manic,” or restless with racing thoughts. He reported recurrent thoughts of harming himself but no plan and no self-injurious behavior. He thought that he would be able to manage these feelings himself as he did not want to kill himself and did not want to go to the ED again. The only medication he expressed interest in taking was “a stimulant for his ADHD,” which he self-diagnosed due to his impulsivity. The patient’s PCP felt he would likely benefit from inpatient psychiatric care but documented that he denied suicidal ideation or an active plan. Nonetheless, the PCP was quite concerned and scheduled a therapy appointment for the next day, with a plan for the therapist to call the patient later in the day.

Later that day, the patient was found with a loaded gun in a hotel room. He said he was about to shoot himself in the head. He called his mother, who called the police, who quickly came and took him to the ED for the third time. There he was evaluated and involuntarily admitted to an inpatient psychiatric hospital for five weeks. He was ultimately discharged with a diagnosis of “Bipolar 1 – moderate-severe with mixed features.” Suicide risk at discharge was assessed as being “chronic risk which was mildly elevated,” although he did well with no known instances of suicidality or suicide attempts in the next six months of follow-up.

The Commentary

By Jane L. Erb, MD, Sejal B. Shah, MD and Gordon D. Schiff, MD

Few considerations are more critical than identifying a person at risk for taking their own life. The frequency of suicide is distressingly high—every year 800,000 people globally, of whom nearly 50,000 reside in the U.S, die by suicide. In 2019 in the U.S., 12.0 million adults had serious thoughts of suicide of whom 3.5 million made suicide plans and 1.4 million attempted suicide with suicide rates rising every year over the past two decades.¹ While this past year has been an exception, in that suicide rates slightly decreased in 2020 for reasons that are not well understood, we know that COVID-19 has also increased many stresses and risk factors such as social isolation, unemployment, substance use, and depression, and there is worry that any downward trends in suicide rates may not continue.²

While a large published series of all types of diagnostic errors in medicine found that “failure to consider” a particular diagnosis was the leading contributor to misdiagnosis, failure to consider suicide risk was not the problem in the current case.³ The patient had recently been seen twice in the ED, and he had several contacts with his primary care clinician, all of whom worried about and weighed this risk. We can debate whether the ultimate diagnosis of bipolar disorder might have been made earlier, the diagnosis that he was at risk for suicide was strongly considered, although in hindsight one could argue this risk was not considered seriously enough.This “near miss” illustrates many of the issues and challenges that primary care and mental health provider face in assessing and helping such patients.

In clinical medicine, patients are generally forthcoming with their medical history, symptoms, concerns, and plans. However, some patients who are seriously contemplating suicide hide their thoughts or intentions out of shame or because they do not want to be detected and stopped. A recent meta-analysis examining the sensitivity of inquiring about suicidal thoughts showed that the overall pooled sensitivity was 41%, and in non-psychiatric settings (e.g., general medical practices), the sensitivity was only 22%.⁴ Another meta-analysis of more sophisticated prediction models concluded that while they did identify some patients at risk and helped classify overall population-level risks, they had low positive predictive values with high false positive and false negative rates if implemented in isolation (“their accuracy in predicting a future event is near zero”).^5,6 These sobering findings have important implications for our ability to use simple screening questions (such as question #9 in the PHQ-9, which asks patients whether they had “thoughts that you would be better off dead, or thoughts of hurting yourself in some way”). Numerous studies have shown that the PHQ-9 is neither sensitive nor specific enough to predict imminent suicide. An analysis of > 200,000 PHQ-9s showed that a positive screen on question #9 was associated with an increased risk over days to months but was not good at predicting acute risk for an individual patient.^6,7

Approaches to Improving Safety

Nonetheless, a variety of understandings and tools can help us better assess patients. First is having knowledge of which populations are at higher risk of suicide and factors that increase or reduce risk. High risk groups include male sex, being young, veterans, Indigenous tribes, lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ).⁸ Factors such as serious mental illness, prior suicide attempts and self-harming behavior, alcohol or substance use, serious recent illness or diagnosis, physical pain, a history of trauma or recent loss, and severe anxiety or insomnia, to name a few, are associated with increased risk of suicide. Risk factors can be divided into non-modifiable risk factors (sex, family history) and modifiable risk factors, which include protective factors such as having a stable and meaningful job and family/friend support. The Joint Commission now recommends that all patients with behavioral health risk factors receive screening further assessment and screening with one of the validated tools they have identified.⁹

The second is having a continuing care connection and carefully following the patient. In one study, about 45% of patients who died by suicide visited a primary care physician in the preceding 30 days.¹⁰ In many cases, there are identifiable opportunities to help the patient overcome issues such as social isolation, refer for additional help, provide resources (particularly telehealth access), and prevent or minimize access to lethal means such as firearms and pills. And, as in many other chronic diseases, a long term, trusting, personal relationship with a primary care provider can help in improving access, assessments, and accuracy of decision making.

Finally, standardized screening tools should be routinely available, utilized, and their results documented and acted upon in the patient’s medical record. Although there insufficient evidence to recommend any one tool,¹¹ several mentioned by the Joint Commission and the national Zero Suicide initiative,⁹ one widely used tool they recommend and which we favor is the Columbia Suicide Severity Rating Scale (C-SSRS) Screener.^12-14 It is among the best evidence-based tools to help screen for and triage risk for suicidal behavior.¹⁵ It has a demonstrated ability to identify those at higher imminent risk for suicide and thus direct resources to those at highest risk. It consists of 2 versions-one for initial screening and a second for follow-up. It has both better specificity (99%) than the final question of the PHQ-9 (fewer false positive responses) as well as higher (93%) sensitivity.¹⁴ After two questions about wishing one were dead and/or having actual thoughts of killing oneself, any positive findings open a branch of three additional questions to delve further into whether one is thinking about methods of suicide and having any intent or preparatory behavior. Everyone, regardless of their answers about suicidal thoughts, is then asked about any history of attempting suicide, including just starting to attempt or preparing for an attempt, and how long ago that was. Using the C-SSRS does not require mental health training, as it was designed for use by clinicians as well as non-clinicians such as police, clergy, school counselors, crisis hotlines, and paramedics. It is publicly available in over 100 languages.¹³

Importantly, the C-SSRS does not solely rely on patients’ volunteering of suicide ideation but collects information about actual behaviors. This means that the questioner can seek out and include information from multiple sources (e.g., in our case, the patient’s brother, or in other cases a patient’s spouse or even the presence of a suicide note). At-risk behaviors are assessed in relation to their connection with intention to use them to attempt suicide rather in than a disconnected way (e.g., superficially cutting his wrist but no intention of killing himself). This markedly improves the accuracy, especially the specificity, of the screening.

One of the reasons it is important to improve not only the sensitivity of a screening tool, but also its specificity, is to prevent false positive conclusions and suboptimal resulting actions. Family members, PCPs, or mental health staff might feel it safer to send individuals to an ED anytime there is the slightest concern of suicide. Viewed through the lens of hindsight bias, any time a patient attempts to take one’s life, everyone involved may wish they had taken such an action. The problem is that repeatedly sending a patient to the ED has its own side effects and often is not the optimal way to help a patient in serious mental distress. Here, we are not simply referring to prioritizing limited ED and psychiatry resources (although we always should be mindful of these considerations), but rather what is best for the patient. If patients who do not have a high acute risk for suicide are reflexively sent to the ED, they risk spending many hours waiting to be “cleared” and receiving little more than a one-time psychiatric safety risk assessment. Unfortunately, up to 70percent of patients who leave the ED after an evaluation for suicidal ideation or behavior never attend their first follow-up appointment.¹⁶ Most importantly, when patients learn that expressing any thoughts of suicide results in being sent to the ED, they may be less likely to honestly share their thoughts or to seek mental health help in the future.

The best answer to this dilemma lies in more far-reaching upstream prevention efforts. First, it is crucial to recognize that just over half of individuals who attempt suicide do not have an established mental health history listed in their health record. About 54% of individuals who died by suicide in 27 states in 2015 had not received a clinical diagnosis of a mental illness at time of death (and attributed to relationship, substance use, health, financial, job crises).^17,18 In fact, Parkland Health and Hospital System in Dallas elected to begin screening all inpatients, outpatients, and emergency room patients using the Columbia screening tool.¹⁹ At the very least, one should consider screening any patient presenting in any setting in distress or who otherwise has significant risk factors, such as recent perceived loss, new diagnosis of serious health issue, financial or job crises, or being treated for a major psychiatric disorder. If the screening shows someone is at an elevated risk, then a more detailed analysis of other factors that contribute to risk as well as protective factors should be routine. In addition to potentially identifying individuals at risk, consider the destigmatizing benefits of inquiring about mental health as a routine matter and making it clear that it is an important component of one’s general health. Not over or under-reacting to suicidal thoughts or behaviors will also promote patients being more open with their clinicians.

Once the assessment is done, then safety planning is another key component, which consists of a brief intervention, jointly developed by a clinician and patient, that plan for coping and support.²⁰ It includes an agreed upon plan for ways to manage thoughts of suicide between provider visits, steps to reduce access to lethal means, and supports that the patient can access.²¹ Additionally, any interventions that can reduce modifiable risk factors should be implemented. This approach should replace the use of “no-harm contracts,” a practice that many consider to be ineffective, disrespectful, and at times even harmful in that these “contracts” can drive a wedge between caregivers and patients.^21-23 Much better is to jointly develop a plan that respectfully builds upon patients’ innate resiliency and problem-solving capabilities, including a series of “what-if” scenarios of what to do if suicidal feelings start to intensify.

Providing optimal suicide prevention requires leadership support and a competent workforce. Unfortunately, most health professionals enter the workforce unprepared to work with suicide-related ideation and behavior.^24,25 It will also likely require additional resources, something even committed leaders will be challenged to dedicate in this pandemic era where resources are even more stretched and stressed.^26,27

While in the past, treatment for suicidal patients has mostly focused on the underlying mental health disorder, evidence now supports directly targeting suicidal thoughts and behaviors with approaches such as cognitive behavioral therapy and dialectical behavior therapy, and collaborative assessment.²¹

It is worth highlighting the important fact that firearms are the leading cause of death by suicide, and thus it is important to inquire whether an individual has access to a firearm.²⁸ While not every gunshot wound results in death, this method is not only the most likely to kill, but the time involved is so short that there is little opportunity for the attempt to be aborted by the individual or interrupted by another person.^28,29 Gun and ammunition storage practices may be relevant for preventing unintentional injuries, but a gun safe is not safe if an individual with a suicide plan knows the combination. According to a recent review discussing the most promising approaches for decreasing self-harm, efforts to decrease the case-fatality rate from suicide attempts by restricting access to firearms remain a high priority, especially in the United States.^29,30 However, as the authors stated, such approaches have been slow to be implemented in the US, given the high prevalence of gun ownership and the political influence of the opponents of firearm safety policies.³¹

Death by suicide is a public health crisis. Healthcare providers often feel ill-equipped to identify and manage patients who are at high psychiatric safety risk. With the use of evidence-based tools, engagement with patients and an understanding that health care providers can be a “lifeline,” the interventions described above may begin to turn the tide in this crisis.

Take Home Points

• As do many other clinicians and families, the primary care team, ED doctors, psychiatry consultants, and family struggled with the challenges of trying to help this young man who was in various ways reporting thoughts and behaviors suggesting risk of self-harm and possibly suicide.
• Screening for suicide risk, while a critical step in potentially preventing death or injury by suicide, is fraught with additional challenges centering around the poor sensitivity and specificity of many of the screening tools. The widely used PHQ-9 question about suicide has poor sensitivity and specificity. A much better screening tool we recommend is the Columbia-Suicide Severity Rating Scale Screener which can be administered by both clinicians and non-clinician individuals who have been trained in its use.
• So called “no harm contracts” are best avoided and, instead, replaced with approaches that emphasize joint planning that more respectfully builds upon patients’ innate resiliency to self-soothe, build upon one’s protective factors and reduce those risk factors that are modifiable, and problem-solve ways to create a series of “what-if” scenarios of what to do if suicidal feelings start to intensify
• Firearms are the leading means of fatal suicides in the U.S. Effort to ensure patients at risk for suicide do not have access is critical
• There is a bidirectional and undoubtedly complicated relationship between substance use and suicide. The longer-term mental health and suicide impacts of the COVID-19 pandemic are difficult to predict, but there are many reasons for concern.

Jane L. Erb, MD
Department of Psychiatry
Brigham and Women’s Hospital
Harvard Medical School

Sejal B. Shah, MD
Department of Psychiatry
Brigham and Women’s Hospital
Harvard Medical School

Gordon D. Schiff, MD
Brigham and Women’s Hospital
Harvard Medical School

Acknowledgements

The long-standing process for submitting PSNet WebM&M case submissions is anonymous. Users may contribute by submitting a case at the following link: https://psnet.ahrq.gov/webmm/submit-case

Periodically, the Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network, a collaborative project convened by the Brigham and Women’s Hospital Center for Patient Safety Research and Practice, and the State of Massachusetts Betsy Lehman Center for Patient Safety, contributes cases and commentaries from their monthly discussions of diagnosis error cases to PSNet. PRIDE is funded by a grant from the Gordon and Betty Moore Foundation. This case was produced in cooperation with the PRIDE Learning Network. We acknowledge the assistance of the PRIDE project director Maria Mirica, PhD, in preparing this case discussion.

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