to the Physicians of New York State
Regarding Their Role in Suicide Prevention
Dr. William E. Tucker
Interim Chief Medical Officer (Emeritus),
New York State Office of Mental Health
A little-known fact is that more people die by suicide than from homicide in the United States and New York each year. Though not all suicides are preventable, most who die from suicide have made previous attempts, and a substantial number have consulted physicians in the weeks leading up to the event; thus, many may be preventable, if appropriate attention is devoted to identifying and intervening with those at immediate risk. (Note: Since the under-lying biological and psychosocial causes of suicidal behavior are addressed in the OMH suicide prevention plan, this document will focus only on the role of physicians in early identification and referral).
A commonly held misconception, even among many physicians, is that it is somehow embarrassing to a patient to be asked about suicidal thoughts or plans or worse, insulting; the patient will respond, "What do you think I am, crazy?" An extension of this misconception, also mistaken, is that patients will therefore deny or conceal their suicidal thoughts. In fact, the overwhelming majority of patients experience considerable relief at being asked: there is finally an opportunity to express their terrifying concerns to the person they consider responsible and and most capable of providing for their overall health. Therefore, they are forth-coming in response to being asked.
Within this framework, three questions immediately arise: Who are the most appropriate professionals to pose the question? What is an effective way to pose it? What is the appropriate next step, if the answer is positive?
Generalist and specialist physicians of all types, in their role as public health agents, make up the "front line" on this. The routine initial or follow-up visit is the appropriate setting for a physician to inquire about suicide. There need be no more index of suspicion than for any other general health issue, such as changes in diet, activity, sleep, discomfort, or somatic concern.
Broaching the subject can be as general and unexceptional as that to any other organ system. Individual styles vary, but the question may take the form of, for example, "Since your last visit, would you say that, for the most part, you have been happy with your life?" The follow-up question is simply, "Are you saying then, that you have or have not had any thoughts of suicide?" A negative response is sufficient to end the line of inquiry. If the response is positive, it is imperative to ask: "And have you made any plans to do something to carry them out?"
Positive responses to inquiries about suicidal thoughts or plans should trigger a referral to a psychiatrist, just as positive indications should be reffered to other systemic pathology outside the realm of the physicians's usual practice. It should also be acknowledged that the front-line physician is no more responsible for effecting the patient's acceptance of such a referral than that of any other referral to a specialist.
Given that there are approximately 150,000 suicide attempts by teenagers in New York State each year (though only 70 completed suicides), the pediatricians would face a significant work load increase in accordance with such a practice of inquiry; other primary-care physicians might not be similarly affected.
There is no question but that inquiring about suicidal thoughts in the course of routine visits represents a significant departure from current practice. Therefore, some resources must be dedicated to making it possible. The most direct is the provision of at least annual lectures to residents and to departmental physicians.
In the context of the national awareness of suicide, inaugurated three years ago in the Surgeon General's Report on Mental Health and likely to be given particular emphasis by the current President in his upcoming public health initiatives, it is not unlikely that pharmaceutical companies would be willing to underwrite such an effort. The goal, after all, is to reduce the rate of suicide in this state and to set a model for the rest of the nation.