Taking Suicide Prevention into Primary Care Settings

A healthcare provider talks with a young adult patient

The opioid epidemic continues to ravage the nation. In 2020, the number of drug overdose deaths rose to about 93,000, including about 69,500 deaths involving opioid drugs. But there is a second epidemic that also claims tens of thousands of lives each year—suicide. According to the Centers for Disease Control and Prevention, about 45,000 people died from suicide in 2020. The number of suicide attempts is even higher; in 2019, there were about 30 suicide attempts for every death by suicide.

The opioid and suicide epidemics overlap. Research shows that about 20 to 30 percent of opioid-overdose deaths are due to suicide. The Helping to End Addiction Long-term^® Initiative, or NIH HEAL Initiative^®, is investigating ways to mitigate suicide risk for people who misuse opioids or have opioid use disorder and in people with chronic pain.

Suicide prevention and treatment occur mainly in mental healthcare settings as well as in emergency departments. However, there are often not enough mental health providers to adequately care for all people at risk of suicide. HEAL-funded researchers are seeking to expand suicide prevention efforts by developing new tools to help primary care providers identify patients at suicide risk and provide necessary care.

Suicide Risk Is Increased in People With Opioid Use Disorder or Chronic Pain

People with depression and other mental health disorders are more likely to have opioid use disorder and to die by suicide; similarly, people with opioid use disorder have higher rates of depression and other mental health disorders. Overall, people with opioid use disorder are significantly more likely to die by suicide than the general population, and the risk is greatest in those who also have a mental health disorder.

Chronic pain is another common factor contributing to suicide risk. People experiencing chronic pain often may feel hopeless and depressed, especially if their pain cannot be relieved effectively. It has been estimated that people with chronic pain are at least twice as likely to show suicidal behavior or die from suicide than the general population.

Identifying People at Risk for Suicide in Primary Care

Many people with opioid use disorder, chronic pain, and/or mental health disorders that put them at risk of suicide are not seen by mental health providers. Research has shown that 50 percent of people who die by suicide visited a healthcare provider in the previous month, most often a primary care provider. However, many primary care providers are not well equipped to identify and treat people with an elevated suicide risk.

Says HEAL researcher Edwin Boudreaux, Ph.D., of the University of Massachusetts Medical School in Worcester, “We know that many primary care providers are afraid of what happens when they identify a patient at risk for suicide. They don’t feel competent to do a screening, and when they do recognize that a patient is suicidal, they try to call in a behavioral health provider or, more often, simply send the patient to the emergency department.”

But, as Boudreaux explains, primary care clinics often have no mental health provider onsite, and emergency care in many cases is not appropriate to address a patient’s needs. Therefore, he and his team want to empower primary care providers to identify patients at risk for suicide as part of their routine clinical processes and provide care, such as putting into place a safety plan. Such plans list concrete and personalized instructions on what a person should do when they feel depressed or have suicidal thoughts (such as soothing activities or contact information for trusted people) until they are safe.

The Zero Suicide Model

The Zero Suicide model is a framework for healthcare systems to prioritize and improve care of people at risk of dying by suicide. Because people experiencing suicidal thoughts and urges often fall through the cracks of healthcare systems, Zero Suicide aims to transform systems to prevent this from happening. The model is based on seven elements that target both a healthcare system and care for an individual patient:

Lead: Leadership must commit to a system-wide culture change dedicated to reducing suicides.
Train: It is essential to train competent, confident, and caring staff who can engage people at risk.
Improve: Leadership and staff need to improve policies and procedures through continuous quality improvement.
Identify: Healthcare providers must conduct comprehensive screening and standardized assessment at every visit and need to be comfortable to talk about suicide directly and without judgement.
Engage: Healthcare providers must engage all individuals at risk of suicide by developing suicide care management plans or safety plans together with the patient.
Treat: Healthcare providers should offer evidence-based treatments to address suicidal thoughts and behaviors directly.
Transition: Healthcare providers must transition patients through various stages of the treatment process (e.g., from inpatient to outpatient care) with direct linkage to the next care provider (warm hand-offs) and regular supportive contacts.

The System of Safety in Primary Care

Boudreaux, along with colleague Catarina Kiefe, M.D., Ph.D., and their team, aim to implement a program called System of Safety in primary care clinics within the University of Massachusetts healthcare system. The program is based on the Zero Suicide model, which seeks to standardize suicide-risk identification and prevention throughout healthcare systems. (For more information on the Zero Suicide model and its essential elements, see textbox.)

An important aspect of Boudreaux’s approach is to design the System of Safety so that it can easily be integrated into routine workflows for busy clinicians. The team recognized that primary care clinicians have only a limited amount of time to spend with each patient and are therefore reluctant to incorporate additional demands for screening or intervention. Boudreaux and his team thus incorporated input from all affected front-line clinicians, including medical office assistants, mid-level providers, and nurse practitioners, as well as primary care physicians and behavioral health specialists.

“We tried really hard to create something that clinicians would find feasible and valuable,” said Boudreaux. “We also tried to be sensitive to the diversity of the types of practices out there, and to the availability of resources such as behavioral health services.”

Boudreaux’s team recently implemented the System of Safety in acute-care settings (such as emergency departments) in the University of Massachusetts’ healthcare system and are now introducing it into seven primary care clinics. Once established, the team will evaluate the extent to which the system improves the frequency and effectiveness of suicide risk screening and whether the enhanced implementation of interventions, such as establishing safety plans for each patient, can reduce the number of suicides and suicide attempts.

While these analyses will apply to all patients seen by participating primary care providers, a second part of this NIH HEAL Initiative study will focus on people with opioid use disorder, who are at particularly high suicide risk. They will examine the interplay between opioid misuse and suicide risk and will also evaluate whether System of Safety programs are more or less effective in people with and without addiction. They will also look at opioid-related outcomes, including intentional overdoses.

Integrating Risk Assessment for OUD and Suicide Risk

HEAL researcher Rebecca Rossom, M.D., at the HealthPartners Institute and her colleague Gavin Bart, M.D., Ph.D., at Hennepin Healthcare Research Institute, both in Minneapolis, Minnesota, are studying how to reduce suicide risk in people with opioid use disorder in primary care settings. They are developing a clinical decision tool that prompts healthcare providers to assess patients for both opioid use disorder and suicide risk and, if necessary, provide appropriate resources. The researchers will then evaluate how often providers use these assessments and whether they help patients seek outpatient mental health care.

The team previously developed the Opioid Wizard, a clinical decision support tool that, based on data in a patient’s electronic health record, helps providers identify and treat patients at high risk of opioid use disorder or overdose. The team is now adding a component to the decision tool that will calculate suicide risk scores for these patients and, for those with elevated risk, will guide providers through a process of assessing and responding to an individual’s immediate suicide risk.

“The program uses about 149 data elements from electronic health records and 164 interaction terms to predict a patient’s risk, so it’s a pretty sophisticated algorithm,” Rossom explains, adding that while many predictors would be expected, like depression or benzodiazepines, the algorithms weigh these individually and in combination to estimate suicide risk.

For people with elevated suicide risk scores, the decision tool coaches a clinician through screening for suicide risk using the Columbia Suicide Severity Risk Scale, and then completing a suicide safety plan and reducing the odds that a person attempting suicide will use lethal means.

A key goal is helping providers become more comfortable having discussions about suicide risk with their patients, Rossom explains.

“Ultimately, giving clinicians tools to increase their comfort level in addressing suicide helps to reduce stigma, making it okay to talk about suicide risk and creating a safe environment to have these conversations.”

Research Program:

Optimizing Care for People with Opioid Use Disorder and Mental Health Conditions

Research Focus Area:

New Strategies to Prevent and Treat Opioid Addiction