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Addressing Suicide Risk in Primary Care: A Next Step for Behavioral Health Integration.

As primary health care settings across the United States move forward with major efforts to enhance the delivery of mental health care the issue of suicide and suicide prevention must be clearly addressed. Patients with the common mental disorder major depression represent the largest group of patients in primary care that die by suicide (Ferrari et al., 2014). For providers and staff in primary care settings suicide is a dreaded outcome of mental health disorders. In 2015 suicide resulted in the deaths of more than 800,000 people globally and 44,000 in the United states making it overall the 10th most common cause of mortality in the United States (Kann et al., 2014; World Health Statistics, 2017). For specific populations the rates are higher including women in pregnancy for which it is a leading cause of mortality and for those age 15 to 29 where it is the second leading cause of death (Oates, 2003; Palladino, Singh, Campbell, Flynn, & Gold, 2011). As with mental health more broadly, primary care represents a key piece of the health system for identifying risk and intervening. It has been estimated that half of those who die by suicide in the United States had contact with a primary care provider in the month before their deaths (Ahmedani et al., 2014).

Despite the magnitude of this health burden and the recognized role that primary care settings could have in the identification of risk and intervention to reduce suicide there is a great lack of capacity to implement these service needs. Few primary care sites have well defined systems for assessing risk of suicide and systematically addressing this risk or with providers trained to implement a suicide prevention plan among their patients. While individual providers received training at some point in the assessment of risk, the lack of systematic screening and protocols for addressing risk make practical benefit of these skills unlikely. Practices that are familiar to many providers but that are no longer recommended such as contracting for safety further undermine the capacity of primary care to effectively address suicide risk (Bryan et al., 2017).

In this issue of Families, Systems, & Health two articles written by Dueweke and colleagues from the University of Arkansas address key elements of systems needed to improve detection of suicide risk. The first article (Dueweke & Bridges, 2018) reviews evidence for interventions in primary care and the second assesses the ubiquitous two-question "prescreen" of the Patient Health Questionaire-9 (PHQ-9) for detecting patients with thoughts of self-harm. Through a systematic methodology these investigators identified four elements of interventions addressing suicide prevention: training, screening, managing depression symptoms, and assessing and managing suicide risk. As would be expected training in itself is necessary but insufficient for reducing the risk of suicide. Also consistent with the large amount of evidence for benefits of multidisciplinary team care for common mental disorders is that the use of teams improves outcomes for suicide risk in primary care. In other words, training should include all members of the team rather than only primary care providers. The use of a single session intervention, something that could fit in the workflow of busy primary care, also has evidence of benefit (Dueweke & Bridges, 2018).

A critical issue for both common mental disorders and suicide risk is how to implement a screening system that is effective and can be sustained. Even relatively brief measures such as the widely used PHQ-9 are too burdensome for the high volume of primary care--particularly when the rates of detection are generally less than one out of 10. The widely recommended and adopted strategy of using only the first two questions of this measure (the so-called PHQ-2), as a prescreen reduces this burden and improves the capacity of primary care to sustain screening effectively. These items have been shown to have adequate sensitivity to identify patients who will go on to have risk of major depression and so achieve the goal of ruling out patients with this disorder quickly and efficiently. In the second article (Dueweke, Marin, Sparkman, & Bridges, 2018) these authors assess the ability of this measure to identify thoughts of self harm, the ninth question on the full PHQ-9, and show that a substantial number of patients would be missed. This is an important point and one that needs to be considered as we move forward with enhancing our ability to identify patients at risk of suicide. While not assessing alternative approaches they make the reasonable suggestion that a "PHQ-3" approach (the first two questions plus the ninth), might be a reasonable solution to this issue though additional research is needed to evaluate the utility of this strategy.

These two articles provide excellent starting points for thinking through how to ensure that risk of suicide is identified and addressed in a systematic and useful way. Any clinician working in primary care can use these two articles and the resources they contain to inform efforts at systemic change to reduce suicide risk.


Ahmedani, B. K., Simon, G. E., Stewart, C, Beck, A., Waitzfelder, B. E., Rossom, R.,... Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29, 870-877.

Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., ... Rudd, M. D. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64-72.

Dueweke, A. R., & Bridges, A. J. (2018). Suicide interventions in primary care: A selective review of the evidence. Families, Systems, & Health, 36, 289-302.

Dueweke, A. R., Marin, M. S., Sparkman, D. J., & Bridges, A. J. (2018). Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients. Families, Systems, & Health, 36, 281-288.

Ferrari, A. J., Norman, R. E., Freedman, G., Baxter, A. J., Pirkis, J. E., Harris, M. G.,... Whiteford, H. A. (2014). The burden attributable to mental and substance use disorders as risk factors for suicide: Findings from the Global Burden of Disease Study 2010. PLoS ONE, 9, e91936.

Kann, L., Kinchen, S., Shanklin, S. L., Flint, K. H., Kawkins, J., Harris, W. A.....the Centers for Disease Control and Prevention (CDC). (2014). Youth risk behavior surveillance--United States, 2013. MMWR, 63, 1-168. Retrieved from

Oates, M. (2003). Perinatal psychiatric disorders: A leading cause of maternal morbidity and mortality. British Medical Bulletin, 67, 219-229.

Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. J. (2011). Homicide and suicide during the perinatal period: Findings from the National Violent Death Reporting System. Obstetrics and Gynecology, 118, 1056-1063.

World Health Statistics. (2017). Monitoring health for the SDGs, Sustainable Development Goals. Geneva: World Health Organization.

Ian M. Bennett, MD, PhD University of Washington

Correspondence concerning this article should be addressed to Ian M. Bennett, MD, PhD, Departments of Family Medicine and Psychiatry & Behavioral Sciences, University of Washington, Box 453696, Seattle, WA 98105-6099. E-mail:

Received April 26, 2018

Accepted April 27, 2018
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Title Annotation:COMMENTARY
Author:Bennett, Ian M.
Publication:Families, Systems & Health
Date:Sep 1, 2018
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