Can you spot a suicide in the making?

Many patients who eventually make suicide attempts deny thoughts of suicide at primary care visits before the attempt—even when specifically asked about suicidal ideation on the patient questionnaire, according to authors of a recent study in Psychiatric Services.

So, if a patient won’t tell you he’s contemplating suicide, how are you to know? How could you possibly intervene if you can’t see it coming?

Indeed, there’s a generally held belief that individuals with emerging psychosis don’t seek help from medical professionals, according to researchers in a recent article in JAMA Network Open. A substantial number of these individuals wind up in the hands of law enforcement before seeing a mental health specialist, the researchers reported.

However, many individuals who enter into care through the judicial system or other secondary routes had previously seen a primary care physician. Unfortunately, primary care physicians often fail to identify insidious symptoms in clinically high-risk patients, the researchers noted.

These high-risk patients may eventually receive a diagnosis of psychosis, which often results in suicide. However, clinical high-risk symptoms of psychosis are frequently nonspecific, which makes diagnosing it difficult.

“Ideally, primary care physicians would have better information about the symptoms that could help them identify patients at [clinically high-risk] and who should undergo further assessment for psychotic symptoms,” wrote Sarah A. Sullivan, PhD, University of Bristol, Bristol, United Kingdom, and coauthors.

At-risk individuals do seek help

To that end, Dr. Sullivan and colleagues sought to determine whether specific symptoms could be used to identify patients in primary care who later developed psychotic illness. They identified 13 clinical high-risk symptoms from the literature, including attention-deficit/hyperactivity disorder-like symptoms, bizarre behavior, blunted affect, depressive symptoms, social isolation, symptoms of mania, obsessive-compulsive disorder-like symptoms, sleep disturbance, suicidal behavior (including self-harm), and others.

The researchers analyzed primary care patient data from more than 93,000 individuals in the United Kingdom. They found that 12 of those 13 high-risk symptoms were associated with an eventual diagnosis of psychosis. The strongest association with psychosis was suicidal behavior, particularly among young men (aged 24 years and younger) and to a lesser degree among women aged 25-34 years.

Importantly, individuals who were found to have psychosis had sharply increased their number of primary care visits within 3 months of diagnosis—a finding that upends the commonly held belief that people at risk don’t attempt to seek help.

“Primary care physicians are therefore an important part of the care pathway for people with psychosis,” Dr. Sullivan and coauthors wrote. “As a consequence, primary care physicians must recognize those at [clinically high risk] to expedite referral…for early treatment.”

The researchers recommended that primary care physicians should be alert for the 12 clinical high-risk symptoms to identify patients who might benefit from further assessment.

How do you ask about suicide?

If you observe such symptoms, how can you probe further? Bear in mind that many patients who eventually make a suicide attempt will initially deny suicidal thoughts, as researchers reported in the study in Psychiatric Services.

These at-risk individuals did have some commonalities, the researchers observed. Some individuals made suicide attempts under the influence of alcohol or drugs, particularly when suicide was completely unplanned. But others who attempted suicide (even after denying thoughts of self-harm) feared that the clinician would overreact without empathy (and immediately suggest hospitalization) or they wished to avoid the shame and stigma of being viewed as suicidal. Still others said they weren’t experiencing suicidal ideation at the time they were screened.

These individuals suggested that providers could help patients overcome their fear of reporting suicidal thoughts by listening in a nonjudgmental way and offering expressions of caring without overreacting. Providers could also offer support and practical help (eg, ways to cope with suicidal thoughts), the authors noted.

“Studies have shown that expressions of caring and concern can foster a sense of social connection in suicidal patients and reduce risk and, along with inquiries about contemplated methods and attempts at means restriction, constitute initial simple steps that clinicians can take to help those contemplating suicide,” wrote Peter Roy-Byrne, MD, professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, in a NEJM Journal Watch commentary on the study.