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

Thank you for returning to this blog. And if this is your first visit, welcome.

While this is not a news blog per se, big fish are being fried.

Last Wednesday in Olympia, Wash., several of us testified before the Health Care and Wellness Committee of the House of Representatives in support of House Bill 2315. If passed, the bill would require a minimum of six hours of training in suicide risk assessment, treatment, and management for all primary care providers.

Here’s the target list: chiropractors, naturopaths, all nurses, osteopathic physicians and surgeons, osteopathic physician assistants, physical therapists and assistants, physicians assistants, and physicians. Six hours, over six years. Either get trained or lose your license to practice.

Why a requirement? Don’t they know this stuff already?

No, they don’t. Persistent, willful professional ignorance has never solved a serious public health problem. Look no further than the resistance to HIV-AIDS education in the early days of the epidemic.

Louis Pasteur had problems convincing doctors that something called “bacteria” were killing their patients. Untold thousands of people died from preventable infections before physicians were convinced that washing their hands between surgeries or delivering babies was a good idea.

When I was a boy, TV doctors sold cigarettes.

Global research has repeatedly shown that primary care providers have the most frequent “last contact” with those who die by suicide. These last contacts amount to missed opportunities to observe, recognize, detect, routinely screen, assess, and respond to suicidal people who may have started on that terrible, lonely journey to self-destruction.

Denial is not a river in Egypt but rather a professional belief system that says, “I don’t like to talk about suicide with my patients because I am not comfortable with the subject, and I might actually cause them to kill themselves if I do.”

Times change, research informs, and avoidance of the uncomfortable costs lives.  When I train physicians in how to screen for suicide risk, I often ask them, “Which is more difficult, conducting your first DRE (digital rectal exam) or asking if a patient is considering suicide?”  Finding: DRE probes are easy, suicide probes are hard.

Too many professionals in primary care fail to understand that if they do not have “the conversation” with their suicidal patient, the suicidal mind may perceive this indifference as permission to proceed — thus does inaction inflame the infection of hopelessness. 

If HB 2315 were to pass, and with medicine in the game and taking the point (I am certain once they see the direction the parade is headed they will rush around to get into the lead), the suicide prevention movement would soar. With Washington state leading the way, others would follow. Research funding would jump. Obama’s Decade of the Brain would suddenly find new and urgent exploratory directions. Medical and nursing school curricula would change, practice standards would rise, and suicide rates would drop. As a country we could take pride in knocking down the last vestiges of medieval ignorance, fear, and stigma about suicide.

The practice of medicine is old, suicide prevention is new, and we need their help at the helm. Resistance to change is greatest among our oldest institutions; universities, medicine, and the Roman Catholic Church. But the suicide prevention movement is swirling all around medicine; and as I like to remind people, just because you close your eyes doesn’t mean they can’t see you.

While professionals testified for and against 2315, and suicide survivors captivated the committee, I was most proud of two young suicide–attempt survivors who told their personal stories. Each had encountered primary care professionals on their journey toward a violent death. In both cases their primary care providers failed to recognize, screen for, ask about, or otherwise attempt to intervene in their desperate journey to a suicide attempt. In the young man’s case, and on his last visit, he was given sufficient medication to complete a lethal overdose.  Except for the heroic efforts of others after his OD, he would have died.

Public health research has shown that data do not change hearts and minds, stories do.  And these stories were spellbinding.

Each speaker was given 2 minutes. Here’s my testimony:

Madam Chair, and members of the committee, my name is Paul Quinnett.  I live in Cheney. I am a clinical psychologist and suicidologist.

In addition to being a clinical assistant professor at the University of Washington School of Medicine, Department of Psychiatry and Behavioral Science, I am the CEO of the QPR Institute, an educational organization dedicated to preventing suicide. More than 7,000 certified QPR instructors have trained more than 1.5 million people in 18 countries in how to prevent suicide. In full disclosure, suicide prevention education training is our only mission and training fees sustain our small, veteran-owned business.

I’m not here to tell you what you already know. I am here to create a sense of urgency.

This past spring I attended a meeting of national leaders to address the 28% rise in suicide rates among our work force, and the expected rise in veteran and older American suicide rates in the coming years. All agreed: We must institute actionable research and available best practices now.

Not later. Now!

In training, we have two choices: voluntary or mandatory.

In my experience, voluntary training is desirable, but insufficient.  Given the choice and the evidence, most professionals avoid the subject of suicide.  Voluntary training has been recommended for decades, and nothing much has happened, or we wouldn’t be sitting here today.  Voluntary training is a failed strategy. Further debate or delay will only perpetuate the status quo, which now amounts to “willful ignorance.”

As a psychologist, I don’t want legislators telling me how to practice my profession. On the other hand, my ethical obligations require me to not practice out of my area of competence. Thus, if I am seeing suicidal patients, I should either a) screen and refer them to another qualified practitioner, or b) complete recommended best practice training. To do otherwise is to place my patients at unnecessary risk.

You will hear arguments that if this training is mandated, all kinds of other training mandates will follow. Maybe, but I don’t think so.

From a public health perspective, no topic is more urgent than to address what it is people are dying from. Therefore, the litmus test should be: if mandated, will this training save lives? You have your own DOH (Department of Health) report to answer that question.

As the past chair of the Washington State Examining Board in Psychology, my mission, and the board’s, was to protect the public, not the profession. It still is.

Given recent advances in suicide prevention knowledge and suicide care – and given the resistance to voluntary training thus far – I wonder how long licensing boards can continue to assure the public that those they license are adequately trained prevent suicide deaths among their customers. Given that an estimated 32% of American suicide victims die while in the active care of a  healthcare professional, I submit they cannot. And if they cannot, how is the public to be informed and protected?

I do know this: Continued professional risk blindness about the needs of suicidal patients currently in our care is not acceptable.  

Finally, recent publications by successful healthcare organizations aiming to achieve “zero suicides” among their patients all require mandatory employee training, and even competency testing. Not voluntary, not elective, but mandatory training.

If Washington is to lead the way to “zero suicide” in healthcare settings, passing 2315 is a major step forward. Thank you.

That was my testimony. Two minutes was not enough. I was talking when the yellow light came on. I was talking when the red light came on. I was talking when the committee chair told me to shut up.

If I’d had another minute I could have explained that psychologists like me belong to a special self-help group; it’s called On and On and On and On….

Pushback testimony was clear: We don’t want to be told what training we need. One committee member asked one professional group, “What percentage of your membership have had suicide prevention training?” The flummoxed leader had no answer.

Changing the status quo requires us to blow a few people up in their suits, or at least cause their food to go down in lumps. I think it was a good day for our side. But of course as a chronic optimist I live on soap bubbles.

One supportive email: “I’m so proud of the testimony this morning – the gravity in testimony had me in tears . . .  I believe the message was well received and I could not agree more at the embarrassment of the testimony of those opposed to mandatory education – they obviously don’t get it.” 

This was from a professional family who had recently lost their gifted son to suicide while in the care of health professionals.

To see what happens next, watch this space.

Key links:

Pat our leader on the back: Tina Orwall (D-33rd) @ http://www.leg.wa.gov/house/representatives/Pages/orwall.aspx

Read 2315: http://apps.leg.wa.gov/documents/billdocs/2013-14/Pdf/Bills/House%20Bills/2315.pdf

Analysis of HB 2315: http://apps.leg.wa.gov/documents/billdocs/2013-14/Pdf/Bill%20Reports/House/2315%20HBA%20HCW%2014.pdf

Related op-ed: http://www.spokesman.com/stories/2013/dec/29/guest-opinion-suicide-bills-are-a-game-changer/

I submit to you nothing is intractable. If your goal is deemed unreachable and impractical by others, you are on the right track to make a difference in this world; when they think you are utterly unreasonable you have all the confirmation you need to begin.

Dr. Paul

 

Welcome!

This first blog entry is going to be brief.   Others will vary in length, but all will be interesting. To hook your interest, here are a few things you need to know about me and my plans.

First, I’m a writer, a clinical psychologist, a suicidologist, and fly fisherman.  If you were wondering…,  a “suicidologist” is someone who studies suicide and how to prevent it.  This blog is going to be about suicide, not fishing.

I’m also part-time professor at the University of Washington School of Medicine in Department of Psychiatry and Behavioral sciences, and I’ve trained thousands of doctors, psychologists, social workers, nurses, and counselors in suicide prevention for more than 40 years.   I’m also an older gent with two main missions: prevent the next suicide, and catch a few trout along the way.

I realize that only you (the reader) can help me prevent the next suicide.  I cannot do it alone.  Preventing  suicide is up to all of us, and no one is exempt from this duty to our fellow human beings.   This is why my tag line, “Preventing suicide…, it’s what people do” is intended to bring us all to the same place; learning to help each not die before we really have to. 

We are not alone.  Thousands of people are now working around the globe to prevent suicide, and yet your help is critical. Where I see good things happening I will note and praise them, and I will encourage you to do the same.

 If you return to this blog, you will learn why preventing suicide is actually a new social movement; a broad, collective, humanitarian effort to expand our circle of empathy to include people we have too often stigmatized, avoided, and punished.  If we can do this, we can save lives.

Just sharing this blog will help make a difference.  And, I will personally teach you some simple “how-to” steps you can take to make what may be a life-saving difference in the lives of those you know, love, and care about.

As a value check, consider that the purpose of our lives is not see how well we can live, but if others live at all because of us.  In my view, nothing is more noble or rewarding than preventing someone suffering from a mental illness – a disease of the brain – from ending his or her own life.  I know, I’ve done it.

My first book was entitled “When Self-Help Fails, A Guide to Counseling Services.” I wrote that book 20 years ago, and I wish I was still not writing about the same subject.

But I am.  And I have to. 

Why?  Because roughly 10,000 of the people who die by suicide in America each year are in active care with a health professional at the time they die.

As reported and recommended by the CDC, “Providers need to closely monitor and continually assess the risk for suicide among persons who are receiving mental health services, especially if they have other acute stressors and are using alcohol or other substances.” (full report @ http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6106a1.htm).

If experts agree suicide is preventable, then why do people continue to die when they are actively receiving treatment?  Over the course of this blog, I will offer my explanations  and opinions, and will – where at all possible – translate breaking research and science into information you can use today.

I will attempt to answer questions about suicide from what I’ve learned from 40  years of mental health work as a clinical director of a large service where we saw 10,000 patients a year,  as a private practitioner who specialized in helping suicidal patients, and as a trainer and mentor to thousands of students, interns, medical residents and professionals.

In the blogs that follow, I will explore a variety of subjects that I think will interest the general public, professionals, leadership, and people who care about human life everywhere. 

I intend to be blunt. I will pull no punches.  While I am a professor and an academic, I promise never to bore you. At 74 years, I can wear purple and say what I want, and that’s what I will do.

For openers, I am completely aware that someone reading this blog right now may have a loved one or friend or colleague or coworker who they know to be thinking about suicide or at risk of suicidal self-directed violence.

If fact, you could be thinking about suicide yourself.  You would not be alone.  Millions of Americans and others around the globe are thinking actively about suicide today.   Which is why you will find resources on this blog to get help right now (see side bar). 

More resources will follow, including some exciting new developments in access to care, emerging treatments available through your mobile device, and other breakthroughs in helping those considering self-destruction.   

If you are worried about someone right now, you know what to do: get this person to a professional for assessment and possible care.

Before you take this person to a professional – whether to a hospital emergency room, a clinic, a private practice, mental health center –  please consider that while many primary care physicians (PCPs) are skilled in working with suicidal people, the majority are not.   They simply do not get the training necessary to assess, treat, and manage suicidal patients. 

There are exceptions, yes, but unless you know otherwise, your first choice should be a mental health professional – a psychiatrist if you can get to one, as this is the only mental health profession with specific training in this area of practice. 

If you have concerns, ask questions.  If you are uncomfortable asking questions, have someone in the family ask them.  Ask, “Have you had specific training in how to assess, treat, and manage suicidal patients?”  If the answer is no, keep looking. Make sure you feel comfortable.  A life is at stake.

A quick story. When my oldest son was 17 he needed major surgery for Hashimoto’s syndrome, a disorder of the thyroid. When the surgeon asked him just prior to the surgery if had any questions. My son said, “Yes, doctor, since you are going to cut my throat open, what kind of grades did you get in surgery?” 

In surgery and suicide care, skill and knowledge matter.

Of the 100+ Americans who will die by suicide the day you read this, an estimated 30% will be in active treatment with a healthcare professional. That the current crop of health professionals is inadequately trained to provide knowledgeable and competent suicide care to the public is one more reason why we must bring about change together.

In future blogs, I will cover a variety of topics, emergent social policy, the roles various organizations and professions can play, and I will write a number of open letters to people and groups who should be at the suicide prevention table today, but who are not currently attending.

We are faced with a huge public health problem that is at once preventable through education and training,  yet remains in the shadows of our conversations. One thing I have learned is this: You can’t fix a problem you can’t talk about. 

This blog is intended to get us all talking.

Thank you for your attention and time, and I look forward to corresponding with you if you so choose.

Dr. Paul