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Preventing suicide: What should clinicians do differently?


 

“Suicide rates are increasing,” Dr. Igor Galynker said, “and I believe they will continue to rise. These are deaths of despair, and despair is increasing in our society.”

Dr. Igor Galynker, author of "The Suicidal Crisis" and director of the Galynker Suicide Research Laboratory at the Icahn School of Medicine at Mount Sinai in New York.

Dr. Igor Galynker

Suicide is a psychiatric issue, it’s a public health issue, and it’s a societal issue. After a celebrity dies, the message to the public is both amplified and simplified: Get help. But getting help is only part of the solution; sometimes people seek help, find it, and still die.

That said, I listened with interest to the May 16 MDedge Psychcast, “Approach assesses imminent suicide risk,” an interview with Igor Galynker, MD, PhD, author of “The Suicidal Crisis” and director of the Galynker Suicide Research Laboratory at the Icahn School of Medicine at Mount Sinai in New York. In the podcast, Dr. Galynker talked about techniques for identifying those at risk for suicide among the patients psychiatrists see for evaluation and treatment.

“Using suicidal ideation as a risk factor is flawed,” he contended. “Asking about suicidal thoughts leaves us to miss 75% of people who go on to die by suicide.” Dr. Galynker noted that suicidal thoughts are often absent or not endorsed at all and clinicians should view other factors – such as the patient’s sense of being entrapped and the clinician’s own emotional responses to the patient – as more sensitive measures of elevated suicide risk.

This informative podcast left me with more questions, so I called Dr. Galynker. Suicide remains a rare phenomenon, and most psychiatrists will have limited experience with completed suicide during the course of a career. Dr. Galynker’s interest in suicide as an area of research began after he had a patient die the year after he finished residency training. Since then, he’s had one more patient suicide, and he’s aware of eight people who have died after leaving his care. “It can be devastating,” he said.

I wanted to know what psychiatrists should be doing differently after we have identified a patient at risk. While it seems obvious that a depressed patient should be treated for major depression, it also seems obvious that our interventions are imprecisely targeted and not fully successful.

Dr. Dinah Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016)

Dr. Dinah Miller

We talked about the role of hospitalization in preventing suicide. Dr. Galynker has mixed opinions on this. He noted that suicide rates skyrocket in the time right after psychiatric hospitalization. “For women, the rate is 250 times higher at the time of hospital discharge; for men it’s 100 times higher. But hospitalization may help someone to survive a transitional period and to gather their support systems.”

Dr. Galynker noted that since the podcast in May aired, the Centers for Disease Control and Prevention published findings on suicide rates in the United States. He summarized some of the key points from the findings.

“Suicide rates were going down until 1999. From 2000 to 2006, suicide rates increased by 1% per year. From 2006 until 2016, rates have increased by 2% per year. Most people who die by suicide don’t have a diagnosis of a mental illness. And finally – and what has gone unnoticed – most people who die by suicide do not express suicidal intent. In fact, in that study, suicide intent was disclosed by less than a quarter of persons both with and without known mental health conditions.”

Dr. Galynker talked about safety plans and emphasized means restriction as ways to prevent suicide, including limiting access to firearms, placing netting under bridges, and providing medications in smaller containers.

“Suicidal ideation comes late; it may happen 15 minutes before a suicidal act or attempt. We need to alert people that there are certainly things that put them at risk, and we need to look at the drivers.

“Sometimes, people die for trivial reasons.” He noted instances where a susceptible person might attempt or complete suicide after an argument or perceived slight. Work is being done to look at outreach interventions to those at risk, including phone contacts and postcards.

Untreated mental illness is often considered as a cause of suicide. Dr. Galynker, however, notes that the story is more complicated.

“We don’t have a suicide-specific diagnosis ... and people die for other reasons besides mental illness. Final romantic rejection, terminal illness, and humiliating failures in business all place people at elevated risk. We need to work to change the suicidal narrative for people away from one where life has no future; we need to help them open doors.”

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