Text adapted from "Assessment and management of suicide risk" in Psychiatry in primary care by Marilyn A. Craven and Paul S. Links, (CAMH, 2019).
Primary care practitioners are in a unique position to help prevent suicide and detect and manage suicidality. Of people who complete suicide, 45 percent saw a primary care practitioner in the month before their death. This figure is even higher among older adults (Luoma et al., 2002).
Consider these Canadian statistics:
- In 2015, there were 4,405 deaths by suicide, a rate of 12.3 suicides per 100,000 people (Statistics Canada, 2018).
- Men die by suicide three to four times more often than women, but women are three to four times more likely to attempt suicide.
- Suicide rates are highest among people aged 40 to 59 years. In 2009, 45 percent of all suicides were in this age group, compared with 35 per cent among people aged 15 to 39, and 19 per cent among those over age 60 (Statistics Canada, 2012a).
There are gender differences in suicide method.
Table 1 Suicide method in Canada, 2000–2009 (10-year average)
|
Method |
Males |
Females |
|---|---|---|
|
Hanging |
6% |
37% |
|
Self-poisoning |
20% |
42% |
|
Firearms |
20% |
3% |
|
Other |
14% |
18% |
Source: Statistics Canada (2012b).
Suicide prevention in primary care
There are many things primary care practitioners can do to help prevent suicide. Consider these strategies:
- Ask about suicide in patients at risk.
- Identify and treat depression aggressively.
- Monitor treatment response with validated measurement tools (e.g., the self-report Patient Health Questionnaire [PHQ-9] for depression. See other tools in the 2016 Clinical Guideline for the Management of Adults with Major Depressive Disorder, developed by the Canadian Network for Mood and Anxiety Treatments (see Resources).
- Monitor for suicidality as treatment progresses.
- Use antidepressants cautiously in adolescents.
- See patients who are newly started on antidepressants once a week for four weeks, then every two weeks for four weeks, then at 12 weeks, and as clinically indicated after 12 weeks (Jacobs et al., 2010).
- Flag the charts of patients at higher risk of suicide.
- Closely monitor patients at higher risk of suicide. Risk factors include:
- previous suicide attempts
- previous episodes of self-harm
- recent discharge from psychiatric inpatient care
- a family history of suicide or suicide attempts
- a history of serious alcohol or other substance use problems
- Use the powers of mental health legislation to intervene for protection.
Pay special attention to transitions in care: you should see patients discharged from hospital or the emergency department within 24 to 48 hours. Review discharge notes before the visit, and call and rebook no-shows. If you refer patients to outpatient mental health services, you should see them at regular intervals until the mental health visit takes place (Zero Suicide Initiative, n.d.).