Suicide has become a top cause of death for middle schoolers

Youth is supposed to be bright, radiant, full of opportunity and self-discovery. In middle school, this journey is often just beginning, and it can be an incredibly challenging one to undertake at such a young age. Children are introduced to a new social dynamic in middle school, one that has made itself notorious for bullying, cliques, and social pressure all while students undergo the changes that come with puberty. Not all of those changes are welcome.

The CDC reported that in 2014, more middle school students died by suicide than in car accidents. Car accident fatalities have been on a steady decline, with a few hiccups here and there, but the suicide rate among youth ages 10-14 has set itself to a painful beat, increasing steadily year by year. In the 7-year span before the CDC report, 425 children within that age bracket were victims of suicide. What went wrong, and what is currently wrong, with treatment and acknowledgement of mental health?

What causes suicide?

Teen and youth suicide is a growing health concern. As recently as January, two girls aged 12 and 14 leapt to their deaths from the top of a parking garage, with the reasoning surrounding the incident left unclear. According to the Jason Foundation, an organization devoted to addressing and preventing youth suicide, there are over 5,000 suicide attempts daily among young people from grades 7-12.

Many youth who feel like social outliers are often targets for bullying, a theme so ingrained into our society that it’s hard to find any form of entertainment with a middle or high school setting that doesn’t include the token “outcast”, often a “geeky”, “alternative”, or otherwise non-conformant youth. However, they aren’t the only targets. LGBTQIA youth are often preyed upon by cruel peers, and even teachers. Religious and ethnic minorities, along with troubled or disabled students often fall into their sights as well.

High Speed Connection to Harassment

Whether it be by personal computer, tablet or phone, access to social media and the internet as a whole is widespread and often unsupervised. Cyberbullying is a particularly potent form of harassment: the anonymity provided by the Internet gives bullies more freedom to inflict pain on their victims, and students often feel like there is no escape because the harassment follows them home after school hours. One victim died from suicide after enduring years of online harassment, her weight being the target for torment.

In Alamo Heights, a 13 year old girl died from suicide, harassed by classmates on an anonymous Instagram account. It wasn’t the community’s first encounter with youth suicide, with a previous loss leading to the implementation of “David’s Law.” Anti-bullying seminars are being held and bills passed, counselors are available, but the continuing epidemic has yet to be solved. Even emergency room providers sometimes fail to stop what is an exceptionally preventable cause of death.

Addressing Mental Health

Due to neglect from schools to fully address the problem, mental health issues in youth are often on the back burner, if addressed at all. Identifying at-risk students is critical to preventing youth suicide. Middle school students aren’t too young to develop serious mental conditions that often have high suicide rates, such as:

• Bipolar Disorder
• Eating Disorders
• Anxiety Disorders
• Depression

In addition, ADHD and autism spectrum disorders may go unchecked, and have the potential to impact grades and a student’s social life during a critical development period. The services students have access to at school, including academic and counseling resources, are often too few and under-utilized due to stigmas surrounding mental illness.

Look for the Signs

Parents, educators, friends-everyone involved in a student’s school life should be willing and able to spot warning signs of potentially life-threatening behavior in youth. “Picky eating” or “moodiness” due to oncoming or onset puberty are common dismissals of problematic behavior in youth, especially in girls. Talk of death, a disrupted sleep pattern, loss of appetite, sudden fears and social withdrawal are all common identifiers and red flags that may be easier to spot if adults combined seminars and programs with listening.

Survivors Aren’t Alone

Where the mental health system falls short, families of victims are left with few answers. The public is left with mounting concerns for the care of the suicidal, and those who may be inching closer to being at risk.  The last group anyone wanted to consider a risk pool is undoubtedly our youth. The Law Offices of Skip Simpson take every case seriously. Children should not only have access to adequate mental health care, but to understanding support networks and opportunities to flourish academically and socially. Suicide prevention attorney Skip Simpson is dedicated to this cause, and to finding justice for survivors who have been let down by flaws in the system. If this tragedy resonates with you or someone you know, contact us today.

More than 60% of the United States’ 30,000 annual gun-related deaths are due to suicide, outnumbering homicides. This is a startling statistic, one that leaves countless families with empty places at the dinner table and loved ones with questions that can never be answered. What caused this? What could have been done to stop it? And why is it often too late?

While most of us are concerned about the grim daily news reports and the safety of our communities from firearms (and rightfully so), there is also a population at risk of suicide, and access to a gun increases the risk of death. Suicide rates have increased over the years, becoming the 10^th leading cause of death in the United States in 2013.

Are we equipped to deal with this? We’re told to watch for warning signs of active suicidal ideation that might become reality such as a loss of interest in activities, talking about death, and withdrawal from socializing. Mental illnesses, especially bipolar disorder, schizophrenia, anorexia nervosa, and major depression can make everything more complex as they are at a much higher risk for suicide attempts. In addition, a sudden negative life event like a breakup, loss of a job, or financial crisis, can trigger thoughts of self-harm.

One key to understanding suicide risk is to realize that decisions to end one’s life are often, even if they’ve been planned, impulsive. Given time, the acute desire for suicide will pass. This means that anyone with access to a fast way to end their life is in far more danger.

Guns provide the means for many deaths by suicide

A gun in the home provides a lethal, and accessible, means of carrying out suicidal thoughts. Currently, there are an estimated 55 million Americans who own guns, and there are about 21,000 suicides by firearms yearly.  In April 2009, the eased process of becoming one of those millions of gunowners proved itself to be deadly with the purchase of a gun in New Hampshire. A young man visited a gun shop near Manchester, and within hours of leaving, had died by suicide. He was one of three people that week who had done the same thing after buying guns from the same store.

This prompted a nationwide movement, Means Matter, to partner suicide prevention with gun shop owners. There was, and still is, no telling what reason someone has to buy a gun. However, there is now a national call to attempt to educate shop owners on how to potentially spot a suicide risk in their business.

• Providing pamphlets and posters advertising suicide hotlines and help centers for shop owners to keep in the open. Hopefully, these materials will catch the attention of at-risk buyers.
• Dialogue: if a customer says they only need a small amount of ammunition, or that they’re not particular about a certain gun or learning about its use, this should send a red flag to the clerk to try and dissuade a purchase. Engaging in targeted dialogue can also cause a person to think twice; again, suicidal ideation usually passes with time.
• Distribution or encouragement to purchase gun locks. Access to firearms is all too easy. The more protection a gun has, the longer it’ll take to access, and the more time there is to prevent suicide.

Minors are especially at risk for suicide. Texas has seen too many youth gun-related suicides where the gun was already in the home, easy to access. Many were the result of bullying, one even prompting the passing of “David’s Law” that made cyber bullying a misdemeanor. In one such case, a Texas girl died by suicide in front of her family after relentless cyber harassment. Why was that gun so easy to access?

Texas has no state registry for firearms, and there is no waiting period to purchase one. While guns must be locked and kept away, that initial access needs to take less than a walk-in visit to a gun store, and homeowners need to keep an eye on their loved ones, another on the gun safe. This is a long process, involving the action of the public—gun owners and not, medical staff and psychiatrists, and the de-stigmatization of mental illness so people can find help.

There are too many questions, but there can be answers.

Contact the Law Offices of Skip Simpson for a free case evaluation if suicide has affected you or your loved ones, and if it could’ve been prevented by better action of practitioners. Accessing the means to self-harm is one step, ensuring the safe care of suicidal patients and at risk people is another. Give us a call today.

For years, facilities operated by the Department of Veteran’s Affairs have seen an epidemic of inpatient suicides. Over the last decade, an initiative taken to address suicide risks in patients’ physical environments has done a great deal to curtail that danger.

The VA is leading the way for civilian facilities in many different ways and I commend them for doing so. I hope the new commander-in-chief will keep up the good work—I am optimistic.  Patient safety starts with excellent leadership—that means from the very top.

Introduced in 2007, an “environmental checklist” was meant to help secure safer surroundings for those veterans placed in inpatient care to help curb the persistent suicide epidemic. The “checklist” has 114 items for VA hospitals and inpatient centers to tick off when identifying environmental risks that would pose opportunities for an attempt to complete a suicide. Items such as hooks, clothing rods in closets, door knobs and electrical sockets can be more than part of standard furnishing in a patients’ room; they can pose a deadly opportunity for veterans already at risk to act on ideations.  If the patient is psychotic, the patient must be observed line of sight or one to one. If not the patient can stuff food, clothing, toilet paper, or anything down his or her throat.

Thankfully, more than 150 VA hospitals have sought to implement the checklist; installing shelving and cubbies that lack sharp edges, removing hooks from walls and backs of doors, and moving towards making electrical outlets tamper proof. Eliminating these physical hazards takes stress off of hospital staff and allows them to focus on direct patient care; checking on the patients more frequently and receiving more elaborate training on how to identify, care for, and report patients at a risk for suicide. With the high turnover of staff and without the physical change of the patients’ environment, some precautions might be overlooked. Dr. Vince Watts, leader of a study on the checklist, commented that “hardwiring” changes into the facilities means that new or rotating staff couldn’t be forgetful regarding modifications.

Thankfully, the program seems to have had some success. During the duration of Dr. Watt’s study, the average length of stay in VA mental health facilities dropped from 11 days to around 7 days.

Has this method made a significant impact on veteran suicides?

While completed suicides among veterans remain far too prevalent in our society, the evidence shows that this is beginning to change. Prior to the checklist being implemented, the National Center for Patient Safety’s database reported a rate of 4.2 suicides per 100,000 admissions. Without such precautionary measures such as the checklist system in place, every patient could be one step away from taking their life. After the checklist was put into place, the suicide rate plummeted to 0.74 suicides per 100,000 admissions, showing that there is hope for the mental health care that our veterans deserve after their dedicated service.  However environment of care is just one part of the triad to protect patients: the other two parts are proper observation levels and medication.

The risk of suicide for veterans is currently 21% higher than the civilian population, but preventative measures are steadily helping to decrease that number. Crisis lines are actively hiring new responders and putting them through extensive training to properly handle the calls and issues they will face, measures to identify high risk veterans are being taken so a crisis can be stopped before it even takes place.

The VA’s example shows that something as seemingly trivial as a checklist for inpatient facilities to follow can save lives, and civilian hospitals ought to follow suit. By removing physical dangers from a patients’ presence and replacing them with more continuous, educated and accessible care, we can hope to see more lives continue and zero end too soon.

Inpatient psychiatric care is supposed to keep patients at acute risk of suicide safe and provide them with the assessment and standard of care they need to recover. But often, the nurses responsible for caring for these patients lack the training and proper experience needed to prevent suicide.  Hospital leaders, including all physicians, must ensure all staff—including psychiatric nurses– are trained and properly supervised to protect patients from injury or death. Sadly some hospitals put profits before safety and training takes from the bottom line.  Nurses, who believe they are not competent to protect patients must obtain proper training to become competent and not attend to patients until they are properly trained.

According to a report published in the Journal of the American Psychiatric Nurses Association, there are no standard competencies for assessing and managing the suicide risk for psychiatric mental health (PMH) nurse generalists – even though the majority work with acutely suicidal patients in inpatient psychiatric settings.

The language used in this report is chilling for anyone with an interest in the well-being of patients at risk of suicide. The APNA’s report indicated there are “serious gaps in nursing education” in suicide risk assessment, prevention and intervention, and there are “no developed structures and processes” for these generalist nurses who provide care and treatment to patients at risk of suicide.  Hospitals, to their detriment, are often relying on nursing schools to properly train nursing students on patient safety as it relates to suicide prevention.  The nursing schools don’t know what they don’t know about patient safety for suicidal patients. Consequently nursing students are being graduated not equipped for their duties in psychiatric hospitals.  Furthermore licensing boards are not properly testing nurses for suicide prevention in hospitals.

Other care providers in these same inpatient settings, such as most psychiatrists and some—but few– mental health clinicians, have specific training in suicide prevention. But because generalist nurses have, according to the APNA report, “the greatest contact with suicidal patients,” their lack of training exposes these patients to significant risk. The warning signs of suicide are often subtle and intermittent, and they can easily be overlooked by a psychiatrist or clinician who spends limited time with the patient. Meanwhile, the nurses who provide at-risk patients with direct care rarely understand how to recognize those warning signs – or how to appropriately intervene.  Most inpatient nurses do not know that death by hanging is the number one way patients die in psychiatric hospitals; nor do they know that patients will have irreversible brain damage in just a few minutes when brains are deprived of oxygen by hanging.  If nurses knew these facts they would resist any physician order requiring a suicidal patient to be watched only every 15 minutes.

Psychiatric nurses themselves identify a significant risk to patients

Perhaps most concerning of all, these PMH generalist nurses have self-identified the issue as being dangerously unprepared to work with suicidal patients. In one study cited in the APNA report, not one of the PMH nurses interviewed believed they were adequately educated to work with suicidal individuals. Most stated that they felt a “sense of inadequacy” when caring for patients at substantive risk of suicide – and those feelings of inadequacy could well cause those nurses to fail to intervene at critical moments.

Yet despite these significant warning signs, too many inpatient care facilities throw these generalist nurses, who will work with their most vulnerable patients, into a so-called “baptism by fire.” They are expected to learn on the job with little continuing education or support – and that dangerously inadequate level of care puts their patients at extreme risk of dying by suicide.

Fortunately, the APNA has stated that it will take steps to train psychiatric nurses in suicide assessment, prevention and intervention to provide a higher standard of care to future patients. However, inpatient care facilities are responsible for the safety of their patients. When patients at acute risk of suicide come to inpatient care, their care cannot be left in the hands of medical professionals not adequately trained in suicide prevention. And when patients die by suicide after not receiving adequate care, those negligent inpatient facilities must be held accountable.

Deaths by suicide can be prevented when services are in place

According to The Department of Health and Human services, a staggering 55% of counties across the US do not have a single psychiatrist, psychologist or social worker. Incredibly, every one of those counties is rural. That means that for a person who is living in one of these areas who is at a high risk of suicide, a visit to the closest psychiatrist’s office to get the help they need requires hours of travel and missing up to a day of work, something that may not be possible.

According to a recent New York Times article, the isolation and loneliness that can come from living in a rural town, combined with lower income, health problems and family issues can have a negative impact on any resident. For those who are at risk of suicide, that impact could be much greater, especially when the help they need is hours away. Some posit that this isolation could be one reason for the increase of suicides in rural areas over the last few years.

Stigma associated with mental health puts patients at risk

There is still a great deal of stigma associated with seeking help from a mental health professional, so much so that some people who need help actively won’t seek it for fear of  being seen coming or going from a psychiatrist’s office. This stigma is especially strong in rural areas, where the perception is that there is little expectation of privacy.

When there aren’t any dedicated mental health professionals in their area, a person may try to find help through other means. Some rely on friends or family members. Others may turn to drugs and alcohol. But many who need help seek it from their primary care doctors, whom they know and are comfortable with. According to a 2002 analysis published in the American Journal of Psychiatry, nearly half of the people who died by suicide had visited their primary care physicians within a month of their death. Most reported minor symptoms such as trouble sleeping or headaches.

Bridging the gap with integrated care

Unfortunately, this tendency to see the primary care doctor for mental health issues is quite dangerous. Most primary care physicians are not properly trained in identifying risk factors for suicide, which means they cannot protect those patients in the ways that are most needed. If those patients who went to their doctor for headaches or sleepless nights could then see a medical heath professional on the same day, they would have access to the standard of care they need to reduce the risk of dying by suicide. Because those services are rarely available in rural areas, thousands of people are put at elevated risk.

Experts cited in the Times article have suggested adding a mental health component to primary care practices, either by having an affiliated psychiatrist practicing in the same building or by using video conferencing to get patients immediately evaluated by an off-site psychiatrist. That way, patients can seek mental health services without having to go to a building specifically dedicated to mental health – and thus avoid the weight of the social stigma.

However, with limited space and resources available, adding these services in rural areas is a challenge. Additional resources are needed to provide those essential mental health services to those who are most in need of help. Just as importantly, the public needs to be educated about the high cost of letting mental health services suffer – and the social stigma needs to be replaced with an understanding that seeking treatment for mental health is no different from seeking treatment for any other medical issue.

If you or a loved one has been effected by a death by suicide, contact Skip Simpson today. He knows that a person who is at high risk of suicide cannot seek help that isn’t there. Contact him today for a free and confidential case evaluation.

If you are a mental health provider, you absolutely must read “Constant Observation of Suicidal Patients: The Intervention We Love to Hate,” by Mark J. Russ, MD (Journal of Psychiatric Practice, 2016;22;382–388). This study is a must-read for psychiatric and general hospital risk managers, staff, and attending psychiatrists – because it provides valuable information that can help you protect your patients from serious harm or death.

Constant observation (CO) is defined by Dr. Russ as maintaining uninterrupted, physically close visual surveillance of a patient. He says it has been a mainstay of the inpatient care of the acutely suicidal patient. But sadly, in many hospitals, rehabilitation centers and other residential facilities, patients at acute risk for suicide are not put under CO. This is a dangerous decision.

Though CO is the standard of care for these patients, some argue against its effectiveness. One argument against it is a lack of evidence to support its use. This is a tired excuse. Another is that CO is too expensive and time-consuming, as it requires a staff member to be with one patient at all times. This excuse, at its core, puts profits over patient safety.

Even with a clinician, nurse or other health-care professional allegedly near the patient, there have been a few reported deaths by suicide that have occurred while the patient was under CO. None however, explain how the attempt was made.

Attorney Skip Simpson has a case in which a patient was able to tie a sheet to a vent and hang herself while she was allegedly being constantly watched. The reason for this death was an unsafe environment of care, poor staff training and supervision, and lack of leadership in the hospital. These are all common root causes of suicide listed by the Joint Commission.

It costs money to have a safe place to keep suicidal patients, train and supervise staff and have solid leadership. It always comes back to money—money that bean counters don’t want to spend to protect patients. Skip Simpson will not give hospitals and incompetent leaders a pass, nor will juries.

Most, if not all of the cases of suicide by patients supposedly under CO involved clinicians and staff who did not uphold the strictest level of constant observation. Any time there is a shift change or other circumstance in which a patient is left unobserved, even briefly, there is the risk of a suicide attempt.

Patients deserve the highest level of care

Given the state of our knowledge for the past 20 years, at least, an argument against the effectiveness of CO cannot be made, according to Dr. Russ. Skip Simpson agrees. The axiom asserting that “the absence of evidence is not evidence of absence” applies in this circumstance. There may be weak reasons not to recommend CO as a strategy to mitigate suicide risk in the hospital, but lack of effectiveness cannot be one. The very fact that it would be unethical to test the question with a randomized controlled trial—where some patients are properly protected and others are not—speaks to the validity of its effectiveness.

Many experts agree that CO, like most other procedures, is most effective when all medical professionals are adhering to all safety protocols. The risk of suicide can be prevented by ensuring that all staff are properly trained and follow the proper care procedures. This process also relies heavily on communication between health professionals.

Another method of care for patients who are at risk of suicide is routine 15-minute checks, or Q15. However, this has proven to be ineffective and is dangerous. With this method of observation, patients at high risk of suicide are left alone for 15 minutes at a time. This puts highly vulnerable patients at even greater risk of a successful suicide attempt. Hundreds of patients die by suicide every year while being watched every 15 minutes.

In this respect, the healthcare field is lagging behind virtually every other field. For instance, the reason most new bridges are now safe – ironically – is that so many collapsed in the early days. Whenever a bridge collapsed anywhere, bridge engineers flocked to the site to learn why. Once they found out, they made sure no one ever allowed that problem to arise again. They followed the “stop-it-next-time” rule. In contrast, hospitals do a root cause analysis of their suicides and bury the results. The public, other hospitals, researchers, the CDC, and even the hospital’s own staff don’t know why the suicide on a Q15 occurred.

Predicting a person’s exact moment of suicide is difficult; this is a reason at-risk patients are hospitalized. Every 15-minute watch for acutely suicidal patients must be eliminated. Medical professionals must be properly trained in using appropriate safety protocols, including CO. Overall, there needs to be improvement in the quality of care to help reduce the risk of suicide. This is easy—it means that the priority in healthcare must be the patient, not the pocketbooks of healthcare executives.

If you have lost a loved one to suicide while they were in an inpatient program, hospital or residential facility, contact Skip Simpson today. He has the unique expertise to help you get through this difficult time.

The suicide rate in the United States has reached its highest level since 1986 for nearly every age group in the country, according to statistics compiled recently by the National Center for Health Statistics.

The study examined the suicide rate for all age groups between 1999 and 2014, according to The New York Times. Nationwide, the suicide rate increased by 24 percent during this 15-year period. The study also compared the overall suicide rate nationwide dating even further back. In 2014, a total of 42,774 died from suicide or 13 per 10,000 people, the highest overall rate since 1986.

Some of the biggest increases in the suicide rate occurred among men and women 45 to 64 years old. The rate among women this age increased 63 percent between 1999 and 2014. Among men this age, the suicide rate rose 43 percent during the same time period.

Why did the suicide rate increase nationwide?

There are many reasons why experts believe more people are dying by suicide in the United States. One reason cited in The New York Times article concerns a possible link between suicide in middle-aged adults and concerns about work and personal finances. The Times cited a study conducted by Katherine Hempstead of the Robert Wood Johnson Foundation.

Other experts studying the issue believe that income inequality may be a factor. “This is part of the larger emerging pattern of evidence of the links between poverty, hopelessness and health,” said Robert D. Putnam, a professor of public policy at Harvard University, interviewed by The New York Times.

Those comments were echoed by Dr. Alex Crosby, an epidemiologist at the Centers for Disease Control and Prevention, who studied the association between the nation’s economy and its suicide rate dating back to the 1920s. “There was a consistent pattern,” Crosby said in an interview with The New York Times. “When the economy got worse, suicides went up, and when it got better, they went down.”

Other reasons why more people are dying by suicide

However, the statistics compiled by the National Center for Health Statistics did not include data about the income of the people who died by suicide. In addition, the theories linking suicide with economic downtowns cannot explain recent economic trends. Since 2010, the unemployment rate has steadily declined each year. As a result, some experts analyzing the issue have questioned whether a link exists between the economy and the nation’s suicide rate.

Instead, others have cited inadequate health care and failure to diagnose depression among adults as a possible explanation for suicides. Some mental health care professionals do not take patients’ warning signs of depression and suicide seriously, according to attorney Skip Simpson, who regularly works with families nationwide on negligence and medical malpractice cases involving suicide. As a result, people dealing with thoughts about suicide sometimes do not receive the necessary treatment they need to address such issues.

Suicide is the second leading cause of death among young people between the ages of 15 to 24 in the United States. According to the American Association of Suicidology, more than 5,000 young adults and teenagers in this age range die by suicide each year. Unfortunately, teen depression is not understood as well as it should be and treatment methods – including inpatient treatment – are not always effective at providing young people with the services and support that’s necessary.

When a teen receives inpatient or outpatient care and still takes his or her own life, it is important to determine if the mental health counselors or care providers lived up to their duties as required by law. A failure to provide appropriate care and to perform a proper suicide assessment can result in a claim against any care provider, while inpatient facilities can also be held accountable for failure to adequately  monitor patients to prevent death by suicide.

Inpatient and Outpatient Treatment Must Help Teens Fight Suicidal Ideation

Argus Leader recently took an in-depth look at the problem of teen suicide, sharing the story of a 17-year-old who took her own life after a lengthy battle with depression. The young woman was a volunteer and mentor to others who took dual credit classes and who planned to attend university in the fall. Unfortunately, her family had a history of mental illness and the young woman began to develop depression after a move and after her parent’s divorce when she was in the fifth grade. She was also a victim of bullying in school, and she began cutting which is a common coping measure for teens who struggle to deal with emotional pressure. She also attempted suicide in fifth grade, and was hospitalized in an inpatient treatment facility.

She ultimately would make several more suicide attempts and be hospitalized at the same inpatient facility several times before dying by suicide.  She received a variety of different treatments, including transcranial magnetic stimulation, which is a relatively new depression treatment aimed at stimulating nerve cells in the brain using magnets. Unfortunately, the treatment efforts were not successful and she died by suicide this year.

Her story is similar to the struggles endured by many other teens, who care providers often do not understand how to treat effectively. Efforts are underway to improve the care young people receive, and 20 states have now adopted the Jason Flatt Act to require public school personnel to complete required training on youth suicide prevention and awareness.

Awareness is important, but can only go so far if the teens who are identified as being at risk are not provided with treatments that make a difference in their depression. Unfortunately, if mental health care providers and inpatient treatment centers do not develop more effective ways of treating and preventing teen suicide, tragic deaths of young people will  continue to occur.

Identifying people at risk of suicide is an essential step to providing these patients with the care they require.  A new study shows care providers in the emergency room have an important role to play in identifying people at risk; this is yet another study stating the obvious.  Healthcare professions in an ER setting must do their part to ensure patients are identified so they can receive appropriate care. If not, an attempted suicide may occur within minutes to hours of an unthoughtful disposition.

ER Nurses Can Help Identify Patients at Risk of Death by Suicide

NewsWise reported on the recent study showing the important role emergency room caregivers can play in preventing a suicide. The research was conducted by UMass Medical School.  Researchers discovered when emergency room nurses conducted a universal suicide risk screening, almost double the number of at-risk patients were identified. At-risk patients included those who were positively identified as thinking about suicide or patients with attempted suicide.

The study spanned a five year period. During this time, there were 236,791 visits to emergency rooms included in the study. Suicide risks screenings performed on patients increased from 26 percent to 84 percent of patients undergoing screening over the study period. This increased the rate of detection of suicide risk from 2.9 percent to 5.7 percent.

The suicide screening performed in the emergency room was simple. Nurses in the ER departments were trained to administer a brief questionnaire to patients focused on three risk factors for suicide: depressive symptoms, lifetime attempts to die by suicide, and active suicidal ideation.

Patients were identified as having a positive screen if they had either confirmed they have active suicidal ideation or if they had attempted to die by suicide within six months of the time of the visit to the emergency department.  With this screening process, a subset of patients was identified whose risk of suicide was serious enough the patients needed inpatient psychiatric treatment. Other patients were identified who needed additional evaluation and intervention resources such as a self-help safety card and information about a suicide prevention lifeline.

The lead author of the study indicated: “Our study is the first to demonstrate that near-universal suicide risk screening can be done in a busy ED during routine care. The public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.”  The lead author is correct and we applaud the entire team performing the research.  We hope that the study is transformed into action in the emergency departments and the study is not just a group soliloquy among academics.

No further efforts to help identify risk of suicide in emergency departments are needed at this time.  This need has been answered by the Suicide Prevention Resource Center last year, 2015.  Skip Simpson highly recommends the outstanding work produced by the SPRC: “Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments.”  This important work (the ED Guide) is designed to assist emergency department (ED) providers with decisions about the care and discharge of patients with suicide risk.

When patients seek either inpatient care or outpatient treatment for mental illnesses including depression, the treatment they receive is often inadequate. Depression is one of the greatest risk factors for suicide, especially among severely depressed patients who are hospitalized due to suicidal ideation. Unfortunately, even in inpatient settings where patients are supposed to receive treatment from consummate professionals, mental healthcare providers are often left guessing, because of poor training, on what treatments will be effective with no actual scientific method of helping patients.

Scientific America calls the current approach to treating mental illnesses, including depression, the “shotgun approach,” and describes the shortcomings of this treatment method. The term refers to the fact psychiatrists often try many different types of medications in a very imprecise manner.

When patients receive inpatient treatment or outpatient treatment and the wrong medications are provided to treat depression, some of these medications can actually increase the risk of suicide- especially if patients end up having to stop taking the drugs and going through a withdrawal process. Mental health professionals may sometimes be held accountable for the harm their failed treatment efforts can cause, including when a patient attempts to die by suicide. This is especially true in an inpatient setting where care providers should quickly be able to identify when a medication is doing more harm than good.

Improving Mental Healthcare in Inpatient and Outpatient Settings To Prevent Death by Suicide

Centers for Disease Control and Prevention list a history of mental disorders, and particularly clinical depression, as among the top risk factors for suicide. Unfortunately, while there are many medications to treat mental disorders, a trial-and-error approach is usually taken to decide which of these different drugs to try.

Scientific America gives an example of one patient who had been in and out of intensive psychiatric care over close to two decades. She had been diagnosed with bipolar disorder and had experienced periods of suicidal depression.  She had been prescribed antipsychotics, antidepressants, anticonvulsants, mood stabilizers, and anticonvulsants. She had also undergone group and individual therapy, cognitive therapy, and behavioral therapy- but none of the treatments received had made any lasting impact.  The medication she’d been prescribed did lots of different things, from blocking dopamine to focusing on norepinephrine.

Her story was common, as mental illnesses are frequently treated based on guessing which medications will affect observable symptoms, rather than based on getting a correct diagnosis of an underlying cause and treating that specific condition. Genetics and brain imaging in the future could provide clearer answers regarding what is actually going wrong in the brain structure or brain function so more accurate treatments could be provided, and there has been extensive research in this area. Unfortunately, there are continued challenges in finding common markers within different diagnoses.

While treating with medication and experimenting with different drug therapies is challenging and imprecise, it is likely to be the most common method of providing care until research advances. When a patient is in an inpatient setting and different medications are being experimented with, it is imperative for care providers to ensure they are monitoring the effects of medication and are alert for any potential risk of suicidal ideation.  When nothing is working,  Electroconvulsive therapy (ECT) should quickly be considered and carefully explained to the patient and the patient’s family.