The numbers are stark when it comes to suicide: It is a leading cause of death in the United States, and was the second leading cause of death in the U.S. for people ages 10 to 14 and 25 to 34 in 2020. That year, millions of American adults thought of, planned or attempted suicide, and nearly 46,000 died by suicide according to the Centers for Disease Control and Prevention.
Most people who take their own life receive services in primary care and other medical settings in the year prior to death. This raises many critical questions: Did the doctor note any overt or subtle signs of suicidal ideation? Did the doctor discuss suicide with the patient? And if not, why not? Was the doctor uncomfortable broaching the subject? Did they feel unprepared to talk about suicide? Was the patient hesitant to bring it up? If so, was there something about the doctor-patient interaction that led to the patient’s hesitancy?
We are a board-certified academic psychiatrist (Gralnik) and a psychologist experienced in training clinicians (Bonnin) who have witnessed patients, practicing physicians, residents and students struggle with this topic. In our experience, as well as that of others, doctors in many specialties have difficulty asking important questions about suicide because of the long history of stigma, stereotypes and misunderstandings about this topic. This must change.
To that end, we have implemented an innovative training program at Florida International University’s Herbert Wertheim College of Medicine that is embedded throughout all four years of the curriculum. The significance of this training is that it is a required component of several medical school courses—in contrast to wellness programs, which are usually voluntary and designed to offer emotional support for students. While wellness programs may help medical students to manage their own feelings of depression, helplessness and hopelessness, they don’t give them the skills needed to talk to their future patients about suicide. In our training program, sessions beginning in the first year of medical school instruct students about the prevalence of suicide, actively train them in how to interview suicidal patients and help them develop empathy as a fundamentally important clinical skill. Students also participate in interactive sessions where they role-play as a patient and as a clinician assessing a suicidal patient and creating a safety plan.
Based on our experience, doctors sometimes are more awkward than empathetic, beginning this conversation with a preamble or even an apology: for example, “This may seem like a strange question,” “I have to ask you a question that we ask all patients” or “I’m sorry if this question seems too personal.” These types of statements, while meant to put the patient at ease, may actually increase their anxiety, reinforcing the idea that suicide is a taboo subject. How can we expect our patients to be forthcoming in disclosing their suicidal thoughts if we, as doctors, remain apprehensive about the subject?
Significant training about suicide usually does not begin until the third year of medical school, during psychiatric rotations in clinical settings, which gives the message that this subject is of limited importance to doctors in nonpsychiatric fields. Limiting training about suicide to psychiatric rotations also perpetuates the misconception that suicide occurs only in the context of a diagnosed mental illness We think that all required clinical rotations, including surgery, pediatrics, internal medicine, neurology, family medicine, and obstetrics and gynecology should incorporate enhanced training about suicide.
By including training about suicide as a fully integrated part of the curriculum, we can reduce stigma, and the topic of suicide becomes viewed as an essential part of medical training. The training also includes information about suicide as it affects medical students, residents and practicing physicians, who have high rates of anxiety, burnout and depression. It is ironic that medical students often neglect their own mental health struggles even while receiving training about psychiatric disorders.
Our long-term objective is to prepare all doctors and other medical professionals to discuss suicide openly with their patients, paving the way to better patient care and safety. As we have implemented this curriculum, we have witnessed a significant increase in the comfort level, confidence and competency of students when interviewing real patients with suicidal thoughts.
Because many suicidal people initially visit a doctor who is not a psychiatrist, it is crucial that doctors in other specialties be prepared to detect suicidal ideation, evaluate the person and take appropriate actions. Patients may feel intimidated talking to their doctor about suicide and may be more comfortable when speaking with a physician assistant, nurse or medical assistant. It is crucial that these health care professionals also receive adequate training about suicide assessment and prevention.
To see any tangible change in suicide prevention in the foreseeable future, implementation of enhanced suicide-training programs in all medical schools should begin now. Continuing medical education on this topic also needs to be developed and implemented to train current practicing physicians, and to maintain the clinical skills related to suicide assessment and prevention for future graduates.
A new number for the service formerly called the National Suicide Prevention Lifeline was activated recently: 988 replaces the old number, 1-800-273-8255 (TALK), for what is now the 988 Suicide & Crisis Lifeline. The much simpler three-digit number is a long-overdue step in the right direction toward helping those in need. Providing easier access to crisis intervention services and raising awareness about suicide are important, but there remains a real need to improve doctors’ skills when dealing with individuals with suicidal ideation.
The goal of the American Foundation for Suicide Prevention is to reduce by 20 percent the annual suicide rate in the U.S. by 2025. Suicide is preventable, but this will require a shift in medical education. We still have a long way to go.
IF YOU NEED HELP If you or someone you know is struggling or having thoughts of suicide, help is available. Call the 988 Suicide & Crisis Lifeline at 988, use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.
