What I Wish I Knew - Suicide Prevention

Rachel Bauer, PharmD, BCPS, BCPP
Clinical Pharmacist
Salt Lake City, UT

Dr. Bauer graduated from the University of Tennessee Health Science Center (UTHSC) College of Pharmacy and completed the PGY1 managed care residency with UTHSC College of Pharmacy and Tennessee Department of Mental Health and Substance Abuse Services. She then completed her PGY2 in psychiatry at University of North Carolina Medical Center. She currently works as an inpatient psychiatric pharmacist and in mental health transitions of care pharmacy at the George E. Wahlen VAMC in Salt Lake City. She has served on the hospital’s suicide prevention oversight committee (SPOC) since 2019 and was appointed chair by the Department of Mental Health for 2020. She loves Mexican food, mountains, weightlifting, her backyard garden, and her Frenchie Memphis.

I initially planned on writing a professional review of my tips for new practitioners who may be interested in suicide prevention as a subspecialty. In thinking a little more about what I wish I knew about suicide prevention, though, I realized that the subject is a lot deeper than I had initially given it space to be. I think those depths are important to discuss for new practitioners. So consider this your trigger warning, we’re gonna get personal.

Assessment of Suicidal Ideation

Suicide is the 2nd leading cause of death for people aged 10-34 in the United States. It is the 4^th leading cause of death for people aged 35-44, 5^th for ages 45-54, and the 10^th leading cause overall1. As mental healthcare providers, it is our responsibility to know how to triage, assess and respond to suicidal ideation. I won’t provide complete instructions for that in this article because there are almost certainly protocols or policies specific to where you work. It’s important to find and review those, so you know what your baseline expectations are. However, most professionally accepted suicide assessment techniques involve directly asking patients about thoughts of suicide. Effectively discussing acute suicidal thoughts with patients is a specific skill in which many pharmacists have not received formal training. If you’re not accustomed to these conversations, it’s likely going to require a decent amount of learning and practice to become comfortable with it, and that’s okay. Start with the first step.

There are unlimited resources for those who wish to gain deeper knowledge of assessment, statistics, clinical research, training, patient supports, etc, pertaining to suicide prevention. It can quickly become overwhelming just to decide where to begin. Here are some great starting points for the basics:

• American Foundation for Suicide Prevention https://afsp.org/
• Suicide Prevention Resource Center https://www.sprc.org/
• Suicide Awareness Voices of Education https://save.org/
• The Joint Commission National Patient Safety Goal on Suicide Prevention https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/
• Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/mental-health/suicidal-behavior/resources

Limiting Access to High-Risk Medications

In professional pharmacy training, treating suicidal ideation is often only discussed in the context of other mental health diagnoses: treat the underlying disease, and you’ll treat the suicidal ideation. While that is generally true, there are universal approaches to reducing risk for suicide that can be easily adopted well within the pharmacy scope of practice.

One of the most evidence-based components to effective suicide prevention is limiting access to lethal means.^3,4,5 Poisonings represent 13% of suicide deaths overall and 30% of the suicide deaths among women.² Most medical professionals are likely acutely familiar with the dangers of opioid medications, but it may be surprising how many top 200 medications are commonly associated with overdose deaths in the US due to a low LD₅₀. Frequency of use of these medications has the potential to create a false sense of safety for both patients and prescribers. Pharmacists are specially trained in toxicities of medications and can easily suggest lower-risk, evidence-based alternatives. Though not specific to suicide, the Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS) is a good resource for analysis of relative contribution to fatality for overdoses.⁶ This can be a helpful guide as to what medications to watch out for. By critically reviewing medication lists with suicide risk reduction in mind, pharmacists can effectively reduce access to lethal means by guiding prescribing.

As suicide attempts are often impulsive with very little planning,⁷ many people utilize methods that are easily accessible to them in the moment.³ Safe medication use, storage, and disposal of stockpiles can improve overall safety for all who live the home. While it is preferable to avoid high-risk medication all together, dispensing short supplies can be a helpful tool for or limiting access to large amounts of medication. Safes or lock boxes can be protective if another person holds the keys (or re-sets the combination, etc) and dispenses medication doses when due. Bubble/blister packs are often touted as an effective method. Certainly they’ve been shown to be helpful in places like the UK, where a reduction in suicide deaths was observed after legislation was passed requiring blister packaging for all acetaminophen products.⁸ It should be noted that in addition to blister packaging, the total number of pills allowed per package was also reduced by roughly half in that study/legislation, Blister packaging alone, without a concomitant reduction in the number of pills dispensed, may not have the same protective effect. A survey of suicide survivors observed that almost half contemplated for less than 10 minutes before taking action.⁷ It may be reasonable to consider a delay in access to to be a benefit if other safety options are not available.

Patient Education

Patient education can also yield positive results. People don’t always know that medications for depression, anxiety, and PTSD often take several weeks to reach full efficacy or that these medications were studied in combination with non-pharmacologic treatments like psychotherapy. Setting realistic initial expectations for medications and their role in treatment can help prevent patients from becoming more discouraged (or even hopeless) when they don’t immediately feel better. It can also help them understand the importance of their whole treatment plan (in addition to taking medications) and help them prepare for responding to bad days. Parents are often aware of the black box warning for increased suicidality for teens and young adults with antidepressants. Less common knowledge is that risk of suicide attempt in the antidepressant group was 1/3 that of the untreated group, and the same data set showed antidepressants to be protective.⁹ These simple messages can remove knowledge barriers to effective treatment.

For patients at risk for suicide who also have access to opioids (either prescribed to them or otherwise), naloxone kits are also a meaningful suicide safety intervention in the same way they are helpful for accidental overdose. Offer (with the patient’s permission) to include patients’ family, friends, or roommates in naloxone education in the event the patient cannot assist themselves. This is also a reason to offer naloxone kits to people who don’t use or abuse opioids; they may have a friend or loved one at risk for intentional overdose.

Self-Reflection

The deeper dive I mentioned in the introduction is because, unfortunately, pharmacists ourselves are not immune. A number of studies have observed increased risk of suicide for pharmacists compared to the general population.^10-14 Job problems were cited prior to death in two of these studies.^10,11 Risk factors for suicide are all too common for pharmacists,¹⁵ particularly for new practitioners. For my personal experience, I thought about dying when I was 6 months out of residency. Following the excitement of completing residency, I had joyously spent my last penny move across the country for what I thought was going to be my dream job. It didn’t go as planned. I was far away from my family and friends. I felt the full weight of my student loans and realized their crippling impact on my financial future. The “dream job” didn’t end up being a good fit for me or my values. I felt intimidated, invalidated, unsupported, isolated, and as if my new career that I loved so much was constantly being threatened. I tried to advocate for myself, but seemed like my concerns weren’t taken seriously by my leadership. I was afraid to push too hard or ask for too much lest I be perceived as “unprofessional” or “difficult”. There weren’t any other jobs available nearby, and I had no money to move again. I didn’t have an option but to stay in this situation that only seemed to be getting worse. It was like all my accomplishments, awards, degrees, sacrifices since the day I started pharmacy school had been nothing but one big, expensive mistake. Compound that with multiple losses in my personal life, and I felt like an utter failure in every way. Please understand, I am not trying to point fingers or dramatize. I’m hopeful that sharing my story provides an example of how personal and professional challenges can bottle-neck during times of transition, even (or perhaps especially) for those of us who think we’re well-prepared.

I talk about my experience to also draw attention to some thought-traps that people can fall into when working in mental health. One is that we cognitively understand mental illness and treatment. That can lead us to think we should already have the tools and skills to heal ourselves, but it doesn’t work that way. Another challenge is that the people who provide local mental healthcare are our colleagues. These professional connections can feel like they limit options for access to mental healthcare, especially when health insurance plans are tied to the healthcare systems we work for. It doesn’t have to be a barrier, though. Almost 80% of all antidepressants are prescribed by primary care providers (PCPs),¹⁶ and that can be a simple place to start. My PCP was more than competent and caring. She created an environment that I felt comfortable and safe in. Another helpful program was the human resources department (HR) at my job regularly conducted “Month-6 Stay Interviews” to reduce employee turnover. I’d delayed mine because I was afraid of what would happen, and talking to HR is can be very intimidating. When I finally agreed to the interview, I was honest. HR advised to utilize the employee assistance program (EAP), and that gave me an opportunity to get counseling. EAP would have continued to help me, but another job in a different healthcare system opened a couple of months later. My new position has a healthy, supportive work environment and actually is my dream job.

I realize now that a lot of what I experienced was because I was a new practitioner. I’d successfully navigated difficult workplaces, setting professional boundaries, and advocating for myself before; I wouldn’t have completed pharmacy school and residency otherwise. But I wasn’t prepared for how different that would feel as a practicing pharmacist on my own. This is a real-life example of how utilizing protective systems for employees can work. It’s also hopefully some validation for new practitioners who are having a rough time. I’ve spoken to many people who’ve had very similar experiences. You’re not alone

Grieving Loss

Another reason I tell my story is because someone I know is no longer here to tell theirs. Suicide is a preventable cause of death, but not 100% of the time. When you lose a colleague and a friend to suicide, there are so many things you wish you’d known. You feel like you should have been able to use your mental health clairvoyance to recognize or prevent it somehow. So many things you wish they’d known, too. How every single one of us would have dropped absolutely everything to be there for them. How devastated we’d all be to lose them. You wish they’d known how unique, valuable, and loved they were beyond their contributions, beyond the job or titles, loan payments or board certifications. Even with all the things we didn’t and still don’t know; just for who they were. It rips your heart out. It creates a different sense of failure; a much deeper, more real one. It’s difficult to process when you’re still trying to provide mental healthcare for your patients. Many of the resources previously mentioned also offer information about obtaining assistance with grief and loss.

The reality is that nobody has all the right answers. Suicide is complex, and the response to it is everchanging. That means we have to keep learning. Keep going.

If you’re having thoughts of suicide, the national 988 Suicide and Crisis Lifeline is available 24/7, free and confidential (talk and text). Help is also available via live chat at https://988lifeline.org/.