CME

Primary care assessment of patients

at risk for suicide
Valerie Bono, MS, PA-C; Christine Lazaros Amendola, MS, PA-C

ABSTRACT
Primary care providers (PCPs) play a crucial role caring for
patients with depression, managing antidepressant therapy,
and assessing patients for suicide risk. Ten percent of the
more than 20 million primary care visits for depression each
year involve mental health issues, and account for 62%
of the antidepressants prescribed in the United States.1,2
Psychiatric disorders appear to be underrecognized and
undertreated in primary care. Suicidal ideation is present in
a significant percentage of depressed primary care patients
but rarely discussed.3 This article describes the warning signs
and risk factors associated with suicide and recommends
screening tools that can help PCPs identify patients at risk.
Keywords: suicide, depression, primary care, suicidal ide-
ation, mental health, guns

Learning objectives
Explain the warning signs and risk factors associated with
suicide.
Discuss suicide screening tools useful to primary care
providers.

S
uicide
i id iis a major
j publicbli h l h concern.11,2,4-6
health 246
E
Every
year, suicide is among the top 20 causes of death
globally for all ages.3,7,8 Global estimates suggest that is the tenth leading cause of death.9-12 Reducing the rates
each year 10 to 20 million people attempt suicide, and 1 of suicide in the United States is a national imperative.4
million people commit suicide.8 In the United States, suicide Suicide is a stigmatizing behavior accounting for more
than 30,000 deaths and more than 300,000 self-harm-
related ED visits per year in the United States.1,3 These
Valerie Bono has been practicing inpatient medicine (internal
rates have remained stable despite widespread prevention
medicine, general surgery with subspecialties, psychiatry and
emergency medicine) for the past 15 years in New York City. She now efforts, including significant increased use of antidepres-
practices outpatient medicine in Brooklyn and prepares physician sant therapy.1
assistant students for the national certification examination and Primary care providers (PCPs) must be prepared, trained,
physician assistants for the recertification examination. Before and competent in the suicide assessment and prevention
becoming a PA, she worked as a mental health counselor for 10 years.
process and knowledgeable of patient and provider factors
Christine Lazaros Amendola is associate director of the Bronx Sexual
Assault Response Team at North Central Bronx Hospital, Jacobi that influence this process.4 The CDC recommends that
Medical Center, and Lincoln Medical and Mental Health Center, and PCPs screen all patients for depression and suicide risk, in
an assistant clinical professor in the PA program at Pace University/ particular at-risk patients (such as older adults and patients
Lenox Hill Hospital, all in New York City. She also practices emergency with comorbid medical conditions) who are less likely to
medicine at Jacobi Hospital. The authors have disclosed no potential
report suicidal ideation.3,4 The Joint Commission mandates
conflicts of interest, financial or otherwise.
Acknowledgment: The authors would like to thank Billy Moylan for his
suicide risk screening in all patients diagnosed with a
assistance with this article. behavioral or emotional disorder.13
DOI: 10.1097/01.JAA.0000473360.07845.66 Before suicidal behavior can be prevented, PCPs need to
Copyright © 2015 American Academy of Physician Assistants identify patients at risk. Patients who may attempt suicide

JAAPA Journal of the American Academy of Physician Assistants www.JAAPA.com 35

Copyright © 2015 American Academy of Physician Assistants

CME
Key points
PCPs play a crucial role in caring for patients with
depression, prescribing antidepressants, and assessing
patients for suicide risk.
A significant percentage of depressed patients have suicidal
ideation, but this is rarely discussed in primary care.
By knowing the risk factors and screening all patients for
suicide risk, PCPs can identify patients at risk.
Older adults have the highest rate of suicide; the aging
population means that PCPs who care for older adults
must address suicide risk in these patients.
Collaboration with a mental healthcare professional is key
for treating and following up with patients who have a
history of depression or suicide attempts.
may not be in close contact with a mental healthcare
professional, so PCPs should be equipped with the tools
to properly identify and refer at-risk patients.7 Patients
who commit suicide are 2.5 more times likely to have seen
a PCP than a mental health specialist before their death.
An estimated 45% of suicidal patients saw a PCP within
1 month to 1 year preceding their death, compared with
20% who saw a mental healthcare professional in that
same time frame.1,3,7,9-11,14 This is especially true for women
and older patients.10 The literature tells us that PCPs who
see older adults will inevitably be confronted with address-
ing suicide risk in a greater proportion of their patients.1,15
GROUPS AT RISK FOR SUICIDE
Risk factors for suicide vary with age, sex, and ethnicity
(Table 1). Females have a higher rate of suicide ideation
and suicide attempts than males; males have a higher rate
of suicide completion. Among adolescents, Hispanic females
are especially at high risk for attempting suicide because of
difficulties with acculturation and autonomy.11,12,16,17 Amer-
TABLE 1. Risk factors for suicide4-7,9-13,16,18,20
• Presence of a firearm in the home
• Impulsive behavior
• Nonsuicidal self-injury such as cutting or burning
• Disciplinary problems
• Taking unnecessary risks
• Interpersonal losses including death, divorce, separation,
broken relationship, suicide of friend or family member
• Family violence
• Family stress (dysfunction)
• Family history of mental health disorder
• Family history of suicide
• Childhood trauma
• Physical and sexual abuse
• Victim of bullying
• LGBTQ
• Medical illness
36 www.JAAPA.com
Copyright © 2015 American Academy of Physician Assistants
ican Indian and Alaskan Native youth have the highest
rates for attempt and completion followed by Hispanic and
non-Hispanic males.11,12,15,18 Youth who are lesbian, gay,
bisexual, or transgender and questioning their own sexual
orientation or gender identity (LGBTQ) are two to three
times more likely to complete suicide than other youth.12,16
Although youth suicide is on the rise, the highest rates
are among adults over age 50 years.15,19 Adults age 65 years
and older have the highest rates of gun ownership in
America as well as a high prevalence of depression and
suicide. Dementia and functional limitations can add to
suicide risk.15
Members of the military and veterans, especially those
returning from Afghanistan and Iraq, may suffer from
mental illness, such as post-traumatic stress disorder
(PTSD), or substance abuse, increasing their risk for
suicide.5
Ninety percent of suicide victims have a mental illness
at the time of their death.4,7,12 The presence of a mental
illness (Table 2) is associated with an increased risk for
suicide; a lifetime history of depression more than doubles
the risk.3,4,7,8,10-12,20,21 The single most predictive factor
associated with major depressive disorder is a family his-
tory of depression.11,12 The mental health disorders most
likely associated with suicide attempts and completion are
depression and substance abuse.4,11,12,21
Although clinicians regularly assess patients with major
depressive disorder for suicide risk, findings point to the
additional need for suicide screening and intervention for
patients with anxiety disorders, particularly those with
low occupational and social functioning.8 Acute anxiety
and agitation are critical suicide warning signs.10 Severe
anxiety is prominently associated with suicide within the
hospitalized patients or patients who were recently dis-
charged.10 A previous suicide attempt is a specific predictor
for future attempts.7,11-13,16 However, suicidal ideation is a
more sensitive risk factor preceding suicide attempts, and
is common in patients with one or more anxiety disor-
ders.8,13 Anxiety and impulse control disorders such as
bipolar disorder and borderline personality disorder seem
to be an integral part of progression to suicidal behavior
associated with depression.7,10,12
Gun safety is another increasing public health concern.20
Access to a firearm is considered one of the most lethal risk
factors associated with suicide and the most common method
of suicide for all age groups. Use of firearms accounts for
more than half of suicides, followed by hanging-suffocation,
and poisoning-overdose.11,18,22 PCPs need to keep in mind
that suicidal patients can be homicidal and vice versa.
Warning signs are more specific than risk factors, and
consist of symptoms or behaviors that are acute or subacute
in nature (Table 3).10 These signs can be identified, explored
further, and addressed with clinical and psychosocial
interventions. Warning signs are an indicator for a more
acute risk for suicide.10
Volume 28 • Number 12 • December 2015

BARRIERS TO SUICIDE ASSESSMENT
Evidence indicates that PCPs rarely assess patients for
suicide risk even if the patient is known to be depressed
and even though antidepressants were prescribed.1,3,4
Research indicates several factors that deter PCPs from
suicide risk assessment, including uneasiness at starting a
conversation with a patient about suicide, time constraints,
lack of knowledge about suicide risk assessment, and lack
of confidence in treating those at risk.13
TRAINING AND ASSESSMENT
Many training methods and assessment tools have been
used to identify depression and other suicide risk factors
(Tables 4 and 5). Research has shown that PCPs educated
on assessing patients for suicide risk are more likely to
screen, detect, and refer at-risk patients.13 A screening
instrument should be used in patients with depression,
especially older adults and those with comorbid medical
conditions.4 Screen persons with multiple PCP or ED
visits for vague physical symptoms or complaints.4,12 Focus
on patients during periods of high risk, such as immediately
after discharge from the hospital or ED if the patient was
seen for deliberate nonsuicidal self-harm such as cutting.10,23
The Joint Commission National Patient Safety Goals
mandate suicide risk assessments for patients in psychiat-
ric and general hospitals who are identified as being at-risk.10
Identifying suicide risk is the first critical step.7,10 Start
with a stepwise approach, asking a general question and
then becoming more specific with each success.10 Ask open-
ended questions such as “How are things at home and
school?” “Have you ever felt that life is not worth living?”
“Do you have thoughts of death or wishing you were dead?”
“Have you ever felt like hurting yourself or wanting to kill
yourself?” “Do you feel suicidal?” “What suicide plans
have you made in the last few days?” “What suicide plans
have you made and acted on in the last several months?”
“Are you considering killing someone else?” and “Is there
a gun in your home?”15 These questions can be incorporated
into an already existing medical template. Read nonverbal
cues (such as poor eye contact, flat affect, and poor hygiene)
and give substantial attention to psychosocial factors such
as divorce, unemployment, and loss of a loved one.1,4
The patient’s family member, guardian, or durable power
of attorney should remove any firearms or lethal means
from the home; ask which medications are in the home and
how they are stored.11 If the family member is uncoopera-
tive, PCPs can inform the police or local adult protective
services about safety concerns. Carefully document all
interventions.15
No universally adopted national guidelines or standard-
ized screening tests exist for suicide assessment specifically
in primary care.4 To be practically useful, tools should be
brief enough to be conducted in a primary care setting.5
The Beck Depression Inventory II (BDI-II) and the Patient
Health Questionnaire 9 (PHQ-9) are self-report measures
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
Primary care assessment of patients at risk for suicide
TABLE 2. Mental illnesses associated with
suicide risk3-5,7,8,10-12
• Major depressive disorder
• Substance abuse
• Bipolar disorder
• Schizophrenia and other psychoses
• Persistent depressive disorder
• Postpartum depression
• Generalized anxiety disorder
• Panic disorder
• Social phobia
• Post-traumatic stress disorder
• Attention-deficit hyperactivity disorder
• Oppositional defiant disorder
• Borderline personality disorder
• Antisocial personality disorder
• Conduct disorder
• Body dysmorphic disorder
TABLE 3. Warning signs5,9,11-13,16,20,21
• Suicidal threats in the form of direct and indirect state-
ments: “Everyone would be better off without me.”
• Talking or any mention about dying, disappearing, jump-
ing, shooting oneself, or other types of harm
• Suicide notes and plans
• Prior suicidal behavior
• Making final arrangements, such as planning one’s
funeral, writing a will, giving away prized possessions
• Preoccupation with death
• Change in personality: Sad, withdrawn, irritable, anxious,
tired, indecisive, apathetic
• Change in behavior: Cannot concentrate on school, work,
or routine tasks
• Loss of interest in friends, hobbies, and activities the per-
son previously enjoyed
• Feeling no hope for the future: Believing that things will
never get better and that nothing will change
• Low self-esteem: Lack of self-confidence; feelings of
worthlessness, shame, overwhelming guilt, self-hatred
with good sensitivity and specificity in primary care.3,10,12,24,25
Both evaluate and rank depression symptom severity in a
time efficient manner. The BDI-II is the most widely used
instrument for detecting depression. PHQ-9 is a nine-
question self-report based on the Diagnostic and Statistical
Manual of Mental Disorders-IV, which asks specifically
about suicide and is used for baseline screening and mon-
itoring.10 The Home Education Activity Drugs Sexuality
Safety Suicide and Patient Symptom Checklist interviews
can help identify areas in need for further assessment.12
TREATMENT AND FOLLOW-UP
A large body of evidence found psychotherapy effective
as a first-line treatment in reducing suicide attempts in
high-risk persons.7,9,11 However, psychotherapy did not
www.JAAPA.com 37
CME
TABLE 4. Suicide risk assessment training programs9,10,21,22
• Safetalk is a 2.5- to 3-hour training that prepares anyone
over age 15 years to identify persons with thoughts of sui-
cide and connect them to suicide first-aid resources.
• Assist is a 2-day intensive, interactive, and practice-domi-
nated course designed to help review risk, and intervene
to prevent the immediate risk of suicide.
• QPR is a 1-hour course giving three simple steps to train
participants how to question, persuade, and refer some-
one with warning signs for suicide.
• Connect is a 3- to 4-hour training program that provides
specific knowledge and skill development for various pro-
fessions that might be involved in suicide response.
• Columbia Suicide Severity Rating Scale is a 30-minute
training module for a suicide assessment questionnaire.
The certificate of completion is valid for 2 years.
• Safety Planning Intervention provides people with a devel-
oped and rehearsed plan of action for when they become
suicidal. The training may make them more likely to sur-
vive a suicidal crisis.
• Lifelines Trilogy is a program made up of three compo-
nents: prevention, intervention, and postvention. The pro-
gram is based on more than 20 years of suicide-in-youth
research that indicates an informed community can help
prevent vulnerable teens from ending their lives.
• Stop a Suicide Today! Harvard psychiatrist Douglas
Jacobs, MD, teaches people how to recognize signs of
suicide. The program emphasizes the relationship between
suicide and mental illness and the notion that a key step in
reducing suicide is to get those in need into mental health
treatment.
• Suicide Assessment Five is a Step Evaluation and Triage
(also called SAFE-T) provides a framework for performing
a suicide risk assessment and is publicly available. The
focus is on suicidal thoughts, plans for suicide, and intent.
Risk is rated as high, moderate, or low; appropriate man-
agement recommendations are provided.
have a positive effect for adolescents and further research
is needed on treatment for this age group.9,15 Clinical deci-
sions should be individualized to the patient based on age
group and situation.7 The use of medication generally is
warranted in patients with severe or recurrent depression.
Sometimes hospitalization might be required to provide
a safe environment to stabilize the patient while allowing
the crisis to pass and precipitating stressors to be resolved.10
Cognitive behavioral therapy, interpersonal psycho-
therapy, problem-solving therapy, dialectical behavior
therapy, and family therapy are all forms of psychotherapy.
Cognitive behavioral therapy and interpersonal psycho-
therapy are effective methods with a focus on thinking
patterns and coping strategies; these therapies can be done
in an individual or group setting.7,9,12 CBT has been found
to be an effective first-line treatment for patients with severe
depression.26 Data suggest that psychosocial intervention
is highly effective and synergistic with drug therapy.27
38 www.JAAPA.com
Copyright © 2015 American Academy of Physician Assistants
PCPs need to be aware and use published guidelines for
managing patients with depression and prescribing antide-
pressants.3,4,10,12 Selective serotonin uptake inhibitors (SSRIs)
are considered first-line therapy and the most commonly
prescribed antidepressants in primary care settings.7,12
However, SSRIs do not eliminate acute suicidal thinking
and significant clinical improvement may not be apparent
for several weeks. Fluoxetine is the only FDA-approved
SSRI for children age 10 years and older with depression.12
Lithium is a mood stabilizer reported to reduce attempted
and completed suicides in patients with unipolar and
bipolar depression.7 However, lithium has a narrow ther-
apeutic index and can be fatal in overdose. Clozapine is a
second-generation antipsychotic shown to have antisuicidal
effects in patients with schizophrenia, and is also the only
FDA-approved drug for treatment of suicidal behavior.7
Electroconvulsive therapy is reserved for patients with
major depressive disorder that has not responded to two
or more adequate trials of pharmacotherapy.7
Document the patient’s baseline status at the initial visit
and compare the patient’s status to baseline on each follow-
up visit for 6 to 8 weeks.12 Suicidal patients who receive
medication have a significant risk of suicide attempt and
require immediate follow-up. Severe cases may need daily
monitoring. Document parental consent for treatment and
follow-up of minors.12
Provide patients with the phone number for the National
Suicide Prevention Lifeline (1-800-273-TALK [8255]).
This 24-hour emergency toll-free line can tell patients about
available local emergency services in the event of a suicide
crisis.6,10 Patients also should carry a document outlining
warning signs that might indicate they are in a crisis; cop-
ing strategies; ways to keep their environment safe; people
and social settings that can provide distraction; a reminder
of something or someone important to them or a reason
to live; and the names, addresses, and phone numbers of
professionals, local agencies, or urgent care services or
persons they can ask for help.6,12
PCPs should consider including mental healthcare provid-
ers in their practices, creating a collaborative care model in
which clinicians are available to refer and consult patients
who are severely depressed and at risk for suicide.2,4,7,10,12,14
Another way in which to collaborate and refer patients to
mental health specialists is through virtual examination rooms
that let patients consult via video technology with the appro-
priate providers regardless of location and accessibility.
CONCLUSION
Suicide claims 36,000 lives a year—nearly 100 per day—
in the United States.5 About 1% of Americans will die by
suicide each year.14 Eighty percent of those thinking of
suicide want others to realize their emotional pain and
stop them from dying.16 Suicide assessment in primary care
is essential in preventing suicide. PCPs play a significant
role in caring for patients with depression and assessing
Volume 28 • Number 12 • December 2015

TABLE 5. Suicide risk assessment tools1,7,10,12,13,24,25,29,30
Classifications
• DSM-V
• Beck Depression Inventory II
• Zung Self Depression Scale
Screening
• Mental Status Examination
• Patient Health Questionnaire 9
• Home Education Activity Drugs Sexuality Safety Suicide
• Pediatric Symptom Checklist
• Columbia Suicide Screen
Risk assessment
• PATHWARM is a mnemonic for warning signs: purpose-
lessness, anxiety, trapped, hopelessness, withdrawal,
anger, recklessness, and mood changes.
• Modified 5 As: Ask permission to discuss feelings. Assess
for suicide risk. Advise by expressing empathy and provid-
ing options. Agree on a treatment plan or contract not to
hurt oneself. Assist with treatment (resources, referral, and
follow-up).
• 5 Elements of BATHE Technique: Background: “What is
going on in your life?” Affect: “How does that make you
feel?” Trouble: “What troubles you the most?” Handling:
“How could you handle that?” Empathy: “That must be
very difficult.”
them for suicide risk, so educating PCPs is an effective
strategy for suicide prevention.4,7,8,10,21 Focusing on screen-
ing high-risk patients in primary care may reduce suicide
rates.7,10,14 Evidence does not support routinely screening
for suicide risk in adolescents and adults.9,11,28 However,
screening and treatment for depressed patients is appropri-
ate, but only if staff support for depression care is in place.10
Suicide is preventable.7,21 JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.
org. Successful completion is defined as a cumulative score of at least
70% correct. This material has been reviewed and is approved for 1 hour
of clinical Category I (Preapproved) CME credit by the AAPA. The term
of approval is for 1 year from the publication date of December 2015.
REFERENCES
1. Vannoy SD, Tai-Seale M, Duberstein P, et al. Now what should I
do? Primary care physicians’ responses to older adults expressing
thoughts of suicide. J Gen Intern Med. 2011;26(9):1005-1111.
2. Leading health indicators. Healthy People 2010. www.
healthypeople.gov. Accessed August 31, 2015.
3. Vannoy SD, Robins LS. Suicide-related discussions with depressed
primary care patients in the USA: gender and quality gaps. A
mixed methods analysis. BMJ Open. 2011;1(2):e000198.
4. Hooper LM, Epstein SA, Weinfurt KP, et al. Predictors of primary
care physicians’ self-reported intention to conduct suicide risk
assessments. J Behav Health Serv Res. 2012;39(2):103-115.
5. Haney E, O’Neil M, Carson S, et al. Suicide risk factors and risk
assessment tools: a systemic review. US Department of Veterans
Affairs, Washington, DC. March 2012.
6. National Suicide Prevention Lifeline. www.suicidepreventionlife-
line.org. Accessed August 31, 2015.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
Primary care assessment of patients at risk for suicide
7. Schwartz-Lifshitz M, Zalsman G, Giner L, Oquendo MA. Can we
really prevent suicide? Curr Psychiatry Rep. 2012;14(6):624-633.
8. Bomyea J, Lang AJ, Craske MG, et al. Suicidal ideation and risk
factors in primary care patients with anxiety disorders. Psychiatry
Res. 2013;209(1):60-65.
9. O’Connor E, Gaynes BN, Burda BU, et al. Screening for and
treatment of suicide risk relevant to primary care: a systematic
review for the U.S. Preventive Services Task Force. Ann Intern
Med. 2013;158(10):741-754.
10. McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-
risk management for the busy primary care physician. Mayo Clin
Proc. 2011;86(8):792-800.
11. LeFevre ML. Screening for suicide risk in adolescents, adults,
and older adults in primary care: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med. 2014;160(10):719-726.
12. Neves MG, Leanza F. Mood disorders in adolescents: diagnosis,
treatment, and suicide assessment in the primary care setting.
Prim Care. 2014;41(3):587-606.
13. Wintersteen MB. Standardized screening for suicidal adolescents
in primary care. Pediatrics. 2010;125(5):938-944.
14. Raue PJ, Ghesquiere AR, Bruce ML. Suicide risk in primary
care: identification and management in older adults. Curr
Psychiatry Rep. 2014;16(9):466.
15. Pinholt EM, Mitchell JD, Butler JH, Kumar H. “Is there a gun in
the home?” Assessing the risks of gun ownership in older adults.
J Am Geriatr Soc. 2014;62(6):1142-1146.
16. Youth Suicide Prevention Program. www.yspp.org. Accessed
August 31, 2015.
17. Zayas LH, Pilat AM. Suicidal behavior in Latinas: explanatory
cultural factors and implications for intervention. Suicide Life
Threat Behav. 2008;38(3):334-342. doi:10.1521/suli.2008.38.
3.334
18. American Foundation for Suicide Prevention. Understanding and
preventing suicide through research, education, and advocacy.
https://www.afsp.org. Accessed August 31, 2015.
19. Fiske A, Bamonti PM, Nadorff MR, et al. Control strategies and
suicidal ideation in older primary care patients with functional
limitations. Int J Psychiatry Med. 2013;46(3):271-289.
20. National Association of School Psychologists. Preventing youth
suicide—tips for parents and educators. www.nasponline.org/
resources/crisis_safety/suicideprevention.aspx. Accessed August
31, 2015.
21. American Psychological Association. Teen suicide is preventable.
www.apa.org/research/action/suicide.aspx. Accessed August 31, 2015.
22. Suicide Prevention Center of New York. www.preventsuicideny.
org. Accessed August 31, 2015.
23. Luxton DD, June JD, Comtois KA. Can postdischarge follow-up
contacts prevent suicide and suicidal behavior? A review of the
evidence. Crisis. 2013;34(1):32-41.
24. Beck Depression Inventory II—Clinical Assessment. www.
pearsonclinical.com. Accessed August 31, 2015.
25. Maurer D, Darnall C. Screening for depression. Amer Fam
Physician. 2012;85(2):139-144.
26. Weitz ES, Hollon SD, Twisk J, et al. Baseline depression severity
as moderator of depression outcomes between cognitive
behavioral therapy vs pharmacotherapy: an individual patient
data meta-analysis. JAMA Psychiatry. [e-pub Sept 23, 2015]
27. American Psychiatric Association. Practice guideline for the
assessment and treatment of patients with suicidal behaviors.
2015.
28. Screening for suicide risk. The Guide to Clinical Preventative
Services 2014. www.uspreventiveservicestaskforce.org. Accessed
August 31, 2015.
29. Shiner A. Tips for trainees: the bathe technique. InnovAiT.
2012;5(5):309.
30. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical
review: modified 5 As: minimal intervention for obesity counsel-
ing in primary care. Can Fam Physician. 2013;59(1):27-31.
www.JAAPA.com 39