DR. RODGERS: After all we’ve talked about, I’ve decided to implement depression and substance use screenings for all my patients. They fill them out in the waiting room, and then I can assess the results before speaking with them. DR. EBER: That’s great. So, who’s your next patient?
DR. RODGERS: Her name is Judith. She’s been my patient for a few years. She has osteoarthritis, so I had prescribed her Ibuprofen and physical therapy, but she's been back to see me a few times this year because of the pain.
DR. EBER: Before you speak with Judith, let’s look at her screening results.
DR. EBER: Judith’s responses to the substance-use screener suggested that she’s most likely not engaging in risky substance use, but her score of four on the PHQ-2 indicated that she needed to be screened further for depression, so we had her take the PHQ-9. Let’s take a look at the results.
Judith says she’s had trouble sleeping, little energy, and abnormal eating habits nearly every day over the last two weeks and has experienced decreased interest in doing things and hopeless feelings on more than half the days. She also reports that she’s had thoughts that she would be better off dead or of hurting herself on several days. Judith scored a 19, which correlates to moderately severe depression. We need to talk to her about this, and we definitely need to follow up about question nine, where she indicates the possibility of suicidal thoughts.
DR. RODGERS: What’s the best way to talk with a patient about suicide?
DR. EBER: Some providers have the misconception that asking a patient about suicide will plant the idea in the patient’s head. This is not the case. Asking about suicide does not increase suicidal tendencies, and patients who are at-risk for suicide often welcome an opportunity to talk to someone about what they’re going through.
The key is to be direct. You can say something like, “Sometimes people may feel like they don’t want to live anymore or think about killing themselves. Have you had any thoughts like these?” If the patient answers “yes,” ask if she has a plan and the means to carry out that plan. If the patient answers “no,” ask what has prevented her from harming herself so far. This will help you determine how immediate the patient’s risk might be.
Here are some risk factors and warning signs for suicide:
Suicide Risk Factors
Social stressors, like unemployment or financial loss that lead to a sense of worthlessness
Risky use of substances
Lack of social support
Death of a loved one Previous suicide attempt
Family history of suicide or psychiatric illness
Suicide Warning Signs
Agitated, irritable, or depressed affect
Dramatic changes in mood
Purposelessness or hopelessness
Rage or uncontrolled anger
Insomnia or hypersomnia
Withdrawal from friends, family, and society
Loss of interest in normal activities
Feeling that the world would be better off without them
DR. EBER: If you recognize risk factors and warning signs, again, you can ask the patient if she’s having thoughts of suicide. You can also follow up with a screening tool—like the PHQ-9 or C-SSRS—to help determine the level of risk specifically related to symptoms of depression.
DR. RODGERS: Once I have some idea of the patient’s risk level, what do I do next?
DR. EBER: Well, patients may need a referral for mental health services or medication, or both. If the patient is actively suicidal and you believe they are an imminent threat to themselves, you’ll need to take immediate action. You may be able to arrange for them to be admitted to the hospital voluntarily, or if they’re unwilling to pursue voluntary hospital admittance, take steps for involuntary admittance as a last resort, which could require you to call 911. If the patient’s risk level is lower, you should work with them to develop a plan for what to do to stay safe when suicidal thoughts surface in the future.
Safety Planning
Triggers: Help patients identify triggers for suicidal crisis. For example, they might say they think about suicide more when they are drinking. Being aware of this can help them plan for these feelings in advance.
Coping Strategies: Ask what coping strategies have worked for them in the past, like relaxation techniques or exercise.
Sources of Support: Help them identify friends and family who can help them during a crisis. Refer them to health professionals or agencies to contact in the event of a crisis, such as the National Suicide Prevention Lifeline (1-800-273-TALK).
Access to Lethal Means: If they have access to lethal means they may use in a suicidal crisis, talk about how to keep safe. For example, they may choose to lock up or throw away drugs, like painkillers. They may ask a friend to keep their gun or they might put it in a lock box in a difficult to reach place. Increasing the time for them to access lethal means decreases the chances of acting on impulse.
DR. EBER: Now it’s time for you to speak with Judith. In this conversation, your goal is to gather information about her presenting complaint, as well as her depression symptoms. Then, together, you’ll decide on a treatment plan. DR.
RODGERS: Okay… (seems a bit uneasy)
DR. EBER: I know you probably don’t have conversations like this very often, and it’s normal if you feel a little uncomfortable. Even so, make sure you keep a calm and direct tone, so the patient doesn’t get alarmed or feel alienated.
DR. RODGERS: Right. Okay, let’s do it. Here is Judith’s medical history.
Patient History & Physical:
Name: Judith Meyers Age: 66
Chief Complaint: Worsening wrist pain and headaches History of Present Illness: Wrist pain from arthritis has intensified recently. Notes new and worsening headaches (top of head) that come and go. No photophobia or phonophobia, visual disturbances or loss of balance. No vomiting or other GI symptoms.
Medical History: Umbilical hernia due to pregnancy, osteoarthritis, primarily in wrists
Surgical History: laparoscopic hernia repair
Family History: Family- Mother deceased- hypertension and coronary artery disease; Father deceased- hypertension, hyperlipidemia, stroke. Husband and daughter. No siblings. No tobacco, alcohol, recreational drugs.
Allergies: Penicillin- mild rash Medication: Ibuprofen 400 mg Q6 hours PRN You will hear an example of the talk with Judith. At times, you’ll hear advice and feedback from your coach, Dr. Eber, commenting on what Dr. Rodgers said and guiding him to more effective techniques.
Medication: Ibuprofen 400 mg Q6 hours PRN
You will hear an example of the talk with Judith. At times, you’ll hear advice and feedback from your coach, Dr. Eber, commenting on what Dr. Rodgers said and guiding him to more effective techniques.