Baseline data for the US indicates that nearly 45,000 people die by suicide each year and there is both uncertainty and concern about how these numbers will be impacted by the Covid-19 pandemic. Today’s weekly explores potential interventions to address this problem in primary care settings.
People who have been suicidal before could have a spike in suicidal risk under the current circumstances. New patients expressing thoughts of suicide may also emerge during this time. Factors such as fear, self-isolation, physical distancing, extended confinement with others, pre-existing mental health diagnoses, loss of employment, financial and educational stressors are all significant stressors and risk factors.
Primary care clinicians see a large portion of the patients who subsequently die by suicide (~80% in the year preceeding a suicide)– this suggests that an approach to case-finding based upon risk factors may be warranted.
Clearly patients experiencing major compound life stressors and those with histories of depression and other mood disorders and especially those with past histories of suicidal thinking or action would be populations that would benefit from interventions that address the issue. Simple inquiry as to how these folks see themselves faring in the face of the current crisis would be helpful. Asking folks to rate their degree of distress and inquiring about suicidal feelings and thoughts can be helpful.
Treating individuals at risk for suicide can be anxiety-producing under the best of circumstances and the pressures of current conditions make patient care interactions more challenging, even in traditional clinic settings. Using telehealth contacts with potentially suicidal individuals presents another layer of unique challenges.
Guidelines for Telehealth Intervention with potentially suicidal patients.
Initiating contact
♣ Prior to contact, develop a plan for how to stay on the phone/video with the client while arranging emergency rescue, if needed, using ancillary personnel as needed.
♣ Develop a contact plan should the call/video session be interrupted, requesting updated emergency contact information when needed.
♣ Seek to identify the person’s location (address, apartment number) at the start of the session in case you need to contact and deploy emergency services.
♣ Secure the client’s privacy during the telehealth session as much as possible.
♣ Assess client discomfort in discussing suicidal feelings, normalizing these communications as routine clinical inquiry.
Covid-19 specific Adaptations for Suicide Risk Assessment
In addition to standard risk assessment, assess for the emotional impact of the pandemic on suicide risk.
♣ Identify and explore potential COVID-related risk factors for the patient: social isolation; social conflict in sheltering together; financial concerns; worry about health or vulnerability of self and others; decreased social support; increased anxiety and fear; problems sleeping; disruption of routines and support.
♣ When higher risk is identified, inquire about access to lethal means (particularly stockpiles of medications, especially acetaminophen (Tylenol) and psychotropic medications).
Adaptations for Clinical Management
♣ Make provisions for continuity of contacts and for increased clinical contact (even brief check-ins) if concerns are evident but risks are not imminent, until risk deescalates; remember risk fluctuates.
♣ Identify the limits or your clinic’s crisis availability and provide crisis hotline (1-800-273-8255) and crisis text (Text “Got5 to 741741) information. San Diego’s Crisis Line is 800 479-3339– accessible 7x24x365.
♣ Assist patient in identifying individuals in their environment who could help monitor their suicidal feelings, thoughts and behaviors in-person or remotely; and seek permission and have direct contact with those individuals.
♣ Develop a safety plan with the patient so they have concrete steps to take to help manage suicide risk on their own if their status deteriorates.
♣ Discuss substance use issues and encourage risk avoidance behaviors.
♣ Review treatment compliance and access to needed health resources, including medication refills, med compliance,
Bottom Line: The use of evidence-based suicide care practices can significantly reduce suicide thoughts and behaviors, even when delivered via telehealth.
Reference:
http://www.sprc.org/system/files/private/event-training/COVID-19TelehealthWebinar.pdf
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30171-1/fulltext