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In Practice

Suicide prevention in primary care

Dan PaGE for the Boston Globe

Several years ago, a college student asked me for feedback about an essay she’d written. I usually enjoy helping young writers, but this
request made me very uncomfortable. In the essay, the student detailed her long struggle with depression, including several hospitalizations and suicide attempts. She mentioned in the last paragraph that sometimes she still wished she were dead.

When we met for coffee to discuss her work, I told the student that as a doctor — not to mention the mother of a daughter her age — I could not comment on the literary merits of her essay without expressing concern about its content. Was she under a psychiatrist’s care? Did she feel safe? Did she have a support network to whom she could turn if she felt suicidal again?

The answer to all these questions was yes. She acknowledged that she still had dark thoughts now and then, but assured me that she would not harm herself. She was taking medication and seeing a therapist frequently. She had close relationships with her parents and with many friends in whom she could confide. We kept in touch for a few months afterward and, indeed, she seemed to be thriving.


Earlier this month, the World Health Organization released its first report on suicide prevention. The report noted that suicide is a global crisis, causing 800,000 deaths per year worldwide. Though poverty, social isolation, and limited access to mental health care are all risk factors, neither wealth, popularity, nor psychiatric treatment make someone immune, as the recent suicide of comedian Robin Williams sadly highlighted.

The WHO report set a goal of reducing suicide rates 10 percent by 2020 and mentioned several steps that might be taken to do so, including limiting the availability of firearms, avoiding sensationalized media coverage of suicides, and increasing efforts to identify and treat people whose mental illness and substance abuse place them at high risk of self-harm.


Identifying those who are at high risk is challenging, though. A study published earlier this year revealed that half of those who commit suicide have no prior psychiatric diagnosis. In a review of nearly 6,000 cases, researchers found that although the majority of people who killed themselves sought medical care in the year before they died, and one in five had visited a doctor in the week before, they were more likely to have seen a primary care doctor than a psychiatrist.

This study underscored the need for primary care doctors to improve our skills at recognizing patients at risk for suicide. This isn’t always easy. Unlike most other potentially lethal conditions, there is no blood test, no X-ray to determine whether someone is suicidal. We must rely, to a large extent, on what a patient says — and that may be hard to interpret.

When I’ve asked patients whether they intend to harm themselves, I’ve gotten three types of answers. At one extreme — quite rare in a primary care office — a patient announces that he or she has decided to commit suicide. This is a medical emergency and such patients are admitted to the hospital, against their will, if necessary. At the other extreme, a patient says that though they’re feeling down, they’d never consider suicide. In the middle are patients like a man I saw recently who was struggling with financial and marital troubles. He told me that while he had no intention of killing himself, he’d be lying if he said that the idea hadn’t crossed his mind occasionally.


In recent years, a variety of measures have been taken to help primary care doctors prevent suicide, including embedding mental health workers in medical practices and connecting PCPs with psychiatrists via video-conferencing. In my practice, each patient is asked to fill out a two-question screen, the PHQ-2, when they come in for their annual physical. If they state on the form that, in the previous two weeks, they’ve often felt down, depressed, or helpless, or they’ve lost interest or pleasure in doing things, they’re given a second form, the PHQ-9. This includes seven additional questions, one of which asks about “thoughts that you would be better off dead, or of hurting yourself in some way.”

Some patients are surprised or even insulted by being handed these forms, and many PCPs, myself included, have wondered if they contribute anything more than adding to the increasing pile of paperwork we slog through each day.

But, in fact, the PHQ-2 and PHQ-9 have been validated as sensitive and specific screening tools for depression and suicide risk. I’ve found that sometimes even when the screens don’t indicate that a patient is clinically depressed or suicidal, they prompt a useful conversation that might not otherwise have taken place. One woman told me that until she filled out the PHQ-9 she didn’t realize how much caring for her elderly father had been interfering with her sleep and her ability to function at work, and she resolved to get more assistance.


There’s no guarantee that patients whose responses to the screens suggest they might be depressed will accept mental health treatment. The man who told me he occasionally thought about suicide refused psychiatric counseling. I’ve scheduled more frequent appointments to see him, but I can’t force him to comply with that plan, either.

After Robin Williams’s death, the late Joan Rivers, whose husband killed himself in 1987, spoke of the anguish and guilt survivors feel about having failed to prevent someone from taking his or her life. Health professionals often share these feelings. The most vigilant doctors, like the most loving families, can’t save everyone intent on suicide, but we need to keep trying.

Not long ago, I searched the Internet for that young woman whose essay I read. She was quite talented and I wondered if she had pursued writing after college. Her name was unique and there was no question that the single item that popped up, dated over a year after we met for coffee, was hers: an obituary.

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. She can be reached at