Suicide is a global public health concern resulting in close to 800,000 deaths every year which is equivalent to approximately one person every 40 seconds.¹ According to the Centers for Disease Control and Prevention (CDC), nearly half of the United States experienced an over 30% increase in suicide rates from 1999 to 2016, marking suicide as the 10th leading cause of death in the country with an estimated annual cost impact of $69 billion to the healthcare system.^2-4 The 2016 National Survey on Drug Use and Health, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), noted that 9.8 million adults reported serious thoughts of suicide. Of this number, 2.8 million adults made suicide plans and 1.3 million adults made a nonfatal suicide attempt.⁵  Contrary to popular belief, mental health conditions are not the sole cause of suicide. More than half of individuals who die by suicide did not have a diagnosed mental illness at the time of their death.² Suicide can stem from multiple contributing factors with the most prevalent related to relationship problems, substance abuse, physical health, job or financial stress, or other personal crisis.2 Specific risk factors identified by the CDC include: family history of suicide and/or maltreatment; previous suicide attempt(s); history of mental disorders or alcohol and substance abuse; cultural/religious belief that suicide is a noble resolution of an issue; feelings of hopelessness; impulsive or aggressive behavior tendencies; feeling of isolation; lack of access to mental health treatment; loss in any aspect of the individual’s life; physical illness; easy access to lethal methods; and unwillingness to seek help due to the stigma attached with suicidal thoughts or mental illness.⁶

Many organizations are recognizing the pivotal role that healthcare providers can play in reducing patient suicides and are publishing guidance documents and/or resources that can be used to develop policies or procedures to help reduce suicide.  Recommendations from three organizations – The Joint Commission (TJC), The National Alliance for Suicide Prevention, and the American Society of Health-System Pharmacists (ASHP) – are summarized below. 

The TJC published a Sentinel Event Alert urging healthcare institutions to improve their ability to identify and treat patients at risk for suicide.⁷  This alert included detailed strategies for front-line healthcare professionals to help detect risk for suicide in both acute and non-acute care settings.⁷    Strategies included using proactive screening tools, having resources available for patients who are in crisis mode, educating staff on identification and management strategies, establishing systematic identification and treatment processes, and ensuring appropriate education of documentation.⁷  Institutions interested in implementing suicide detection and prevention programs at their institution may find this guidance document helpful. 

The National Alliance for Suicide Prevention issued a report outlining gaps in care that need to be remedied to make health care “suicide safe”.⁸ These identified gaps, along with potential solutions identified by the National Alliance are summarized below.

1. Suicide is not proactively identified.  Data suggest that more than half of patients who succumb to suicide had a healthcare visit within the month preceding their death.  There may be a perception among healthcare providers that only mental health specialists have the training and responsibility to manage patients at risk for suicide.  Others may be afraid to broach the subject, fearing that talking about it may “plant the idea” in the patient’s head.  Both of these thought processes are unfounded.  Healthcare professionals need to feel comfortable assessing risk for suicidality in patients.  Educational programming is needed, along with the development and use of effective screening tools that are feasible to incorporate into practice.⁸ 
2. Lack of effective action.  Currently, most patients who present with suicidal thoughts are either hospitalized for a short period or referred to a mental health specialist.  The National Alliance suggests that both of these options are not enough.  A short-term hospitalization may not be long enough to reduce suicide risk.  In addition, it may take a while for a patient to get an outpatient appointment and suicide risk is highest in the time immediately following hospitalization.  The National Alliance suggests an alternative option where healthcare providers work with the patient to develop a “safety plan” including identifying triggers and using methods to manage thoughts and impulses safely.  Additionally, providers should work with the patient to reduce immediate access to lethal means.⁸
3. Lack of supportive contact.  It is important for healthcare providers to follow-up with patients who express suicidal thoughts after discharge.  This may be in the form of telephone calls, messages, or follow-up visits.  This helps remove the feeling of isolation that may precipitate suicidality by reinforcing to the patient that there is a caring contact available to them.⁸

In addition to the gaps identified above, the National Alliance provides more specific recommendations of standard care elements for a variety of different practice settings, including primary care, emergency department, and inpatient/outpatient behavioral care settings.  Individuals interested in implementing these services at their institution are encouraged to review these recommendations at  https://theactionalliance.org.

Many commonly used medications have the potential to cause depression, suicidal ideation or provoke suicide attempts.⁹  Pharmacists need to be aware of these medications and counsel patients appropriately on the risks.  ASHP has taken a leading role on this issue by creating a policy statement, issuing continuing education topics, and creating a resource center on their website that contains guidelines and links to resources such as a list of medications associated with suicidality or depression.  The resource center is available at:   https://www.ashp.org/Pharmacy-Practice/Resource-Centers/Medications-and-Suicidality/Drugs-Associated-with-Suicidality.  

With regard to policy on this issue, ASHP delegates reviewed and approved a joint council policy recommendation regarding suicide awareness and prevention at this year’s ASHP Summer Meeting.  In this policy, ASHP asserts that all pharmacists are in an ideal position to help identify and prevent suicides.¹⁰  The proposed policy recommendation calls for ASHP to collaborate with other key stakeholders (e.g., government, healthcare organizations, colleges/universities) to increase awareness and education on this issue, including the development and use of standardized tools for assessing the role of medications and other factors in provoking suicidality.¹⁰   ASHP also recognizes that suicide can affect patients and healthcare workers alike, and that optimal prevention strategies should focus on increasing the well-being and resilience of both patients and healthcare providers.¹⁰

As front-line providers, pharmacists are in an ideal position to identify suicidal behavior.  All pharmacy personnel should be trained to identify patients at high risk for suicide and intervene as appropriate and necessary.  Pharmacy workers should proactively add education on this issue to their continuing professional development plan.  Pharmacy leaders should review what policies they have in place to detect and manage suicidality and use the aforementioned resource documents to develop or improve their programs.  Finally, pharmacists should submit an FDA MedWatch alert for any medication suspected to be involved in suicidality that does not already have a warning listed in the prescribing information.   By working proactively, pharmacists can join other healthcare providers in moving towards our goal of zero patient suicides.

References

 

1. World Health Organization. Suicide Data. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. Accessed 2018 September 23.
2. Centers for Disease Control and Prevention. Suicide Rates Rising Across the US. https://www.cdc.gov/vitalsigns/suicide/index.html. Accessed 2018 September 23.
3. American Foundation for Suicide Prevention. Suicide Statistics. https://afsp.org/about-suicide/suicide-statistics/. Accessed 2018 September 23.
4. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). https://www.cdc.gov/injury/wisqars/index.html. Accessed 2018 September 23.
5. Substance Abuse and Mental Health Services Administration. (2017). Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm.
6. Centers for Disease Control and Prevention. Suicide: Risk and Protective Factors. https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html. Accessed 2018 November 20.
7. The Joint Commission.  Detecting and treating suicide ideation in all settings.  Sentinel Event Alert.  2016 56(3).
8. National Action Alliance for Suicide Prevention:  Transforming Health Systems Initiative Work Group (2018).  Recommended standard care for people with suicide risk:  Making health care suicide safe. Washington, Dc:  Education Development Center, Inc. 
9. Lavigne.  Suicidal ideation and behavior as adverse events of prescribed medications:  An update for pharmacists.  J Am Pharm Assoc.  2016;56:203-6.
10. American Society of Health-System Pharmacists.  Joint council recommendation:  suicide awareness and prevention.  https://connect.ashp.org/communities/   (accessed 2019 May 14).