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Suicide prevention in rheumatology: Engagement is key


 

Fibromyalgia patients with no documented suicide attempt spent far more hours in face-to-face meetings with providers than did those who made a suicide attempt over a 20-year period at a single academic medical center. The results, based on a machine-learning analysis of electronic health records, shed more light on the heavy burden of suicidality among patients with rheumatologic illnesses.

Dr. Lindsey McKernan, assistant professor of psychiatry and behavioral sciences at Vanderbilt University, Nashville, Tenn.

Dr. Lindsey McKernan

“People who didn’t have suicide attempts were present at the doctor 50 hours in a year, compared to less than an hour in a year for those who did attempt suicide. It’s a staggering difference,” said study author Lindsey McKernan, PhD, of the department of psychiatry and behavioral sciences at Vanderbilt University, Nashville, Tenn. What’s more, patients who did not have suicidal thoughts averaged about 6 office hours per year, compared with less than 2 hours for those with suicidal ideation (Arthritis Care Res. 2018 Sep 7. doi: 10.1002/acr.23748).

Fibromyalgia patients are at about ten times the risk of suicide as the general population, and rates of depression and anxiety are higher in patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic disease as well.

Still, mental health issues often go unaddressed. “Many times rheumatologists focus on the patient’s joints and their rheumatologic illness, and they don’t focus on their mental health, and as a result depression in a suicidal patient is, I think, more often missed in a rheumatologic practice than it should be,” said Rakesh Jain, MD, of the department of psychiatry at Texas Tech University, Odessa.

Dr. Barton Wise of the departments of orthopedic surgery and internal medicine at the University of California, Davis Courtesy UC Davis Health

Dr. Barton Wise

But that gap isn’t for lack of awareness, says Barton Wise, MD, of the departments of orthopedic surgery and internal medicine at the University of California, Davis. “In general, people recognize that depression is a major problem in their patients,” he said. He was the lead author of a study that found that rheumatologists often lack the time, confidence, and connections to properly address a patient’s mental health needs (J Clin Rheumatol. 2016 Sep;22[6]:307-11).

Together, the two studies underscore the pressing need for better mental health care among rheumatology patients. Such issues often take a back seat to a rheumatologist’s primary concern about joint and overall health, but studies have shown that mental health issues are tied to worse rheumatologic disease outcomes. “Addressing comorbid depression will just make the rheumatological outcome be better. So why not do it?” Dr. Jain said.

Dr. Rakesh Jain, a clinical professor of psychiatry at the Texas Tech University School of Medicine at Permian Basin

Dr. Rakesh Jain

Screening is a key consideration, according to Dr. Jain, who recommends the Patient Health Questionnaire-9. But even when a problem arises, rheumatologists may lack the confidence to tackle mental health issues. This can be addressed through various resources, such as courses at professional meetings, but another challenge awaits. Rheumatologists may also be unsure of who should be responsible for handling mental health concerns. Even though the rheumatologist may see the patient more often than his or her other providers, “you often feel that you can’t manage everything,” Dr. Wise said.

One way to address that is to establish relationships with mental health providers who can receive referrals for patients who require it. In academic medical centers or other large institutions, relationships can be formalized, so that a patient could see a psychiatrist on the same day as the rheumatologist visit. He even suggests group sessions for patients with similar comorbidities, such as depression related to fibromyalgia or lupus.

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