“NOW WHAT DO I DO?”

Last week, a few days after I testified to the Washington state House of Representatives Committee on Health and Wellness that doctors and nurses ought to face required suicide-prevention training, I received a call from a newspaper reporter. He wanted to know why I was so adamant.

I told him what I tell the professionals I train: “You can’t make a diagnosis you don’t know, and you can’t treat a problem you can’t diagnose.”

Or, as I sometimes put it, “If you don’t want to know if your patient has a temperature, then don’t take his temperature.”

As regards suicide, if you don’t want to know if your patient is suicidal, then for Pete’s sake don’t ask! Because if you ask and the patient is suicidal, you’ve just created a big problem for yourself. And it is usually a good idea to have a solution to a problem you just asked for.

Most doctors don’t.  Including my own. With exceptions, routine avoidance of this diagnostic probe is the rule. The danger is this: Risk you don’t know about cannot be managed, mitigated, or controlled. When the Buddha said, “Recognize all danger and avoid it” apparently there were no doctors in the audience.

Each of us recognizes danger and tries to avoid it every day. We don’t drive unbuckled through freeway traffic. We don’t drink and drive. We walk carefully on ice and make sure our children brush their teeth.

Ask yourself, “Would I fly on a plane whose pilot had very little training and doesn’t know what a pre-flight checklist is?”

Ask yourself, “Would I send my suicidal brother to a doctor who has very little training in suicide prevention and doesn’t know what a suicide checklist is?”

The problem with the S Question is that if the patient is positive for suicidal ideation, a past suicide attempt, or a current plan, now you have to do something. And that something matters.

I explained to the reporter that in the absence of specific training on how to detect and diagnose suicidal behavior it is essential that clinicians be able to A) ask the suicide question in a way that the patient is not encouraged to say no, and B) conduct a structured interview to learn if the patient desires death, is planning to die, and how, where, when, and why.

If you don’t want to know all this, here’s how to get patients to lie to you: “Given all you’ve told me, you’re not suicidal are you?”

Patients are polite; they would rather lie to you than upset you.

The majority of mental health care is provided by non-psychiatric physicians. Since the majority of people who end their own lives suffer from an untreated or undertreated mental illness, and given that they are cared for by these same professionals, it only makes sense that improving their ability to diagnose would improve their ability to treat.

But rather than lecture to you about all of this, how about I tell a personal story about my own doctor.

Now retired, Dr. Fred Viren is an internal medicine physician still conducting research and training in his subspecialty.  

As my personal physician he has followed my suicide prevention work for better than 30 years. When he retired, we moved from a professional relationship a more personal one. He’s an avid fly fisherman and we see each other on the stream from time to time, where it is much easier to talk about fly selection than blood pressure and my eating habits. 

During my doctor visits I taught Fred how he could routinely ask his patients about suicide. He then instituted the practice, not with everyone, but with people that worried him or about who he felt some concern.

Some weeks later I got a call at my office:

“Paul, I just asked one of my older depressed patients whose wife died last year and who has a low-grade prostate cancer, if he was having thoughts of suicide. He is! Now what do I do!?”

Fortunately at the time I was, among other jobs, the Director of Elder Services at Spokane Mental Health.

I asked, “Can you keep the patient there for a little while?”

He said, “Sure I know the patient well.”

I was then able to send a psychiatric nurse and social worker to his office to see and assess the patient, and to coordinate a treatment plan. Turns out this older gentleman – I’ll call him George – had also lost a brother to illness within a year, and was terribly isolated. George was seriously depressed and required a brief hospitalization at our local inpatient psychiatry unit. After a week of getting his sleep reordered and his brain functioning close to normal limits, he made a wonderful recovery, got back on his feet, and eventually became a volunteer driver for our Care Cars program at Elder Services program in Spokane County, a division of Frontier Behavioral Health. George died a few years later of natural causes, but his remaining time on the planet was spent with purpose, meaning, and in the service of others.

Let me end this post with a couple of observations and links.

There are at least 10 reasons why doctors and nurses don’t want to be required to complete some kind of suicide prevention education or training. A colleague and I published an academic paper on this question in the Journal Suicide and Life-Threatening Behavior, wherein we attempted to counter these arguments with ones of our own.

Academic publications are just like blog posts, but with the nerve extracted. You can find the copyrighted article at: http://onlinelibrary.wiley.com/doi/10.1111/sltb.12010/abstract, and you may have to pay to read it.  Or, you can find the pre-publication version (which does not violate copyright law) at: http://www.qprinstitute.com/pdfs/PCP%20SLTB%20Word%20F_SLTB9_24.pdf

It is not that doctors and nurses don’t know there’s a problem. They do. And they care. It’s just that they don’t have enough time or help available from mental health professionals to whom they could refer the suicidal patients they find. Given the pay and hours and cost of training, there will never be enough mental health professionals to take on this job. So in my view doctors and nurses need to step up and learn how to help these patients themselves.

Personally, I’ve been working with schools of nursing education to see if nurses could not take on the role of suicide care in the front lines of medicine.  We are testing embedded training in one college nursing course now and some nurse educator leadership believes nurses could do this job as well as anyone. Nurses are already in place and are expected to deliver most of the medicine this country needs in the years to come. As a profession they already enjoy great respect from the public.  Who doesn’t love a nurse? 

Here’s a link to one informative article on the detection of suicide risk in primary care, “Let’s Just Not Talk About It: Suicide Inquiry in Primary Care” published by Dr. Feldman and his colleagues in the Annals of Family Medicine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/.  It a good study and a good read.

Finally, my friend and colleague Jenn Stuber published this op-ed in the Seattle Times just a few days ago: http://seattletimes.com/html/opinion/2022749817_jenniferstuberopedsuicideprevention27xml.html.

Oh, and that reporter who interviewed me and provided the lead to this blog post just published his story on what’s happening in Washington state.  It’s an excellent summary at: http://www.auburn-reporter.com/news/242804151.html

Thanks for your time.

Suicide is not so much a tragedy of what was, but what might have been.

Dr. Paul

4 thoughts on ““NOW WHAT DO I DO?””

  1. Paul, How can I help you and Randi Jensen get this right in WA State, and then in TX? My license to practice medicine was in WA all my years in the Army! Might I also testify to the Washington State House of Representatives Committee on Health and Wellness that doctors and nurses must have required suicide-prevention training? I call the “S Question” (the patient is positive for suicidal ideation, a past suicide attempt, or a current plan) “Pandora’s Box” …not asking so one can claim ignorance when tragedy strikes. As you said, “if you don’t want to know if your patient is suicidal, then…don’t ask!” Thing is, we DO have a solution to this problem! It’s OK if the Provider doesn’t want to carry out screening and follow-up, but then it’s their responsibility to have a behavioral health provider integrated in the practice, at least virtually, to provide same day access BEFORE a crisis occurs. I say, “If you don’t want to cook, get out of the kitchen.” The doctors in the clinic where my son, Andrew, was released without referral to behavioral specialist help (“we only have enough for active duty”) before succumbing to suicide 10 days later eventually put a process in place where anyone with a history of depression had a blue piece of paper placed in their record when checking in, regardless of reason for the current visit, but they stopped that practice in short order, extinguished without active training. Unfortunately, this excellent reminder wasn’t put in place in any other clinic in the medical center. I plan to raise this concern with the current commander and with local media in San Antonio and with the Texas State Legislature. Problem is, leadership is so wary of risk, they ignore the problem, not only refusing to ask about current anxiety and depression, but also refusing to discuss bad outcomes with families in grief after a tragedy occurs. It’s time to raise this collective issue in the media and with Congress! I am embarrassed my colleagues have taken the Buddha statement to heart, “Recognize all danger and avoid it,” but only to avoid being sued by patients and families with good cause by keeping morbidity and mortality discussions secret from the families and the media. I totally agree, “absence of specific training on how to detect and diagnose suicidal behavior is essential for (all) clinicians,” but especially Primary Care. In fact, I submit most mental health providers already have at least some training, but Primary Care has none. (Note: per The Joint Commission, clinics here are having the ‘vital sign taker’ ask “the suicide question,” just as you said, “in a way the patient is encouraged to say “No”, but there is no question to brief structured interview to learn “if the patient desires death, is planning to die,” or had such real thoughts and plans in the past. Even when patients don’t lie, they are discounted as the Provider hears what they want to hear and only documents negative responses. It is right, and good, and true that “the majority of mental health care is provided by non-psychiatric physicians,” but they they are leaving them “untreated or undertreated (for) mental illness.” This is because behavioral health is not integrated into Primary Care Clinics! Truly integrated, not the way it is in Clinics only ‘checking the box’ for TJC. Improving their ability to diagnose (with quality training WILL) improve their ability to treat,” in conjunction with integrated behavioral health partners.

    Paul, you are spot on – “It’s not that doctors and nurses don’t know there’s a problem. They do…and they do care,” but the standard of care, the status quo, keeps them from doing the right thing. And “there will never be enough mental health professionals to…” do this by themselves, we must train and act together, with “embedded training” as Accountable Care organizations.

  2. Paul, How can I help you and Randi Jensen get this right in WA State, and then in TX? My license to practice medicine was in WA all my years in the Army! Might I also testify to the Washington State House of Representatives Committee on Health and Wellness that doctors and nurses must have required suicide-prevention training? I call the “S Question” (the patient is positive for suicidal ideation, a past suicide attempt, or a current plan) “Pandora’s Box” …not asking so one can claim ignorance when tragedy strikes. As you said, “if you don’t want to know if your patient is suicidal, then…don’t ask!” Thing is, we DO have a solution to this problem! It’s OK if the Provider doesn’t want to carry out screening and follow-up, but then it’s their responsibility to have a behavioral health provider integrated in the practice, at least virtually, to provide same day access BEFORE a crisis occurs. I say, “If you don’t want to cook, get out of the kitchen.” The doctors in the clinic where my son, Andrew, was released without behavioral specialist help (“we only have enough for active duty”) before succumbing to suicide 10 days later eventually put a process in place where anyone with a history of depression had a blue piece of paper placed in their record when checking in, regardless of reason for the current visit, but they stopped that practice in short order, extinguished without active training. Unfortunately, this excellent reminder wasn’t put in place in any other clinic in the medical center. I plan to raise this concern with the current commander and with local media in San Antonio and with the Texas State Legislature. Problem is, leadership is so wary of risk, they ignore the problem, not only refusing to ask about current anxiety and depression, but also refusing to discuss bad outcomes with families in grief after a tragedy occurs. It’s time to raise this collective issue in the media and with Congress! I am embarrassed my colleagues have taken the Buddha statement to heart, “Recognize all danger and avoid it,” but only to avoid being sued by patients and families with good cause by keeping morbidity and mortality discussions secret from the families and the media. I totally agree, “absence of specific training on how to detect and diagnose suicidal behavior is essential for (all) clinicians,” but especially Primary Care. In fact, I submit most mental health providers already have at least some training, but Primary Care has none. (Note: per The Joint Commission, clinics here are having the ‘vital sign taker’ ask “the suicide question,” just as you said, “in a way the patient is encouraged to say “No”, but there is no brief structured interview to learn “if the patient desires death, is planning to die,” or had such real thoughts and plans in the past. Even when patients don’t lie, they are discounted as the Provider hears what they want to hear and only documents negative responses. It is right, and good, and true that “the majority of mental health care is provided by non-psychiatric physicians,” but they they are leaving them “untreated or undertreated (for) mental illness.” This is because behavioral health is not integrated into Primary Care Clinics! Truly integrated, not the way it is in Clinics only ‘checking the box’ for TJC. Improving their ability to diagnose (with quality training WILL) improve their ability to treat,” in conjunction with integrated behavioral health partners.

    Paul, you are spot on – “It’s not that doctors and nurses don’t know there’s a problem. They do…and they do care,” but the standard of care, the status quo, keeps them from doing the right thing. And “there will never be enough mental health professionals to…” do this by themselves, we must train and act together, with “embedded training” as Accountable Care organizations.”

  3. I think the training would be beneficial not only for their patients sake, but for their own sake. Certain professionals, due to their line of work are more exposed not only to stress factors, but also to the means to suicide. See for example this article about suicide among veterinarians: http://news.vin.com/VINNews.aspx?articleId=18511

    Like in analysis, knowing how to interact with a suicidal patient might tell the caretaker as much about the patient as about oneself

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