Christine Bucago, RN, MN, CPMHN(C) 1,2
Hermia Cheung, RPh, BScPhm, MSc1
Maria Zhang, RPh, BScPhm, PharmD, MSc1,3
1Centre for Addiction and Mental Health
2Lawrence S. Bloomberg Faculty of Nursing
3Leslie Dan Faculty of Pharmacy, University of Toronto
Suicide is a major public health concern worldwide. In Canada, approximately 4,000 people die by suicide every year and approximately 90% of these individuals lived with a mental health problem or illness 1. Every suicide is a tragedy that has lasting impacts on the families, friends, classmates, coworkers, and communities left behind.
Suicide is a complex issue involving biological, psychological, social, cultural, spiritual, economic and environmental factors. Depending on how these factors interact, a person experiencing suicidal thoughts may be encouraged or discouraged from seeking help. The stigma related to suicide also plays a role in this decision.
Hope exists despite these complexities, and all members in a person’s health care team, including pharmacists, can play a key role in the identification and management of suicide risk. Pharmacists are uniquely positioned to assess risk and implement interventions to support a person’s safety across the care continuum. This article will focus on two main roles for pharmacists: assessing suicide risk, and connecting individuals experiencing thoughts of suicide to resources.
WHAT IS A SUICIDE RISK ASSESSMENT?
According to the American Psychiatric Association, “the goal of a suicide risk assessment is to identify factors that may increase or decrease a patient’s level of suicide risk, to estimate an overall level of risk, and to develop a care plan that addresses their safety and modifiable contributors to suicide risk” 2.
Research has demonstrated that asking about suicide does not generally increase chances that an individual will attempt suicide 3–5. In fact, acknowledging and talking about suicide may reduce suicidal ideation and lead to improvements in mental health in treatment seeking populations 3.
When assessing suicide risk, a pharmacist can observe for possible warning signs, and then ask specific questions to better understand a person’s risk factors and protective factors (Table 1 and Figure 1). While it may not be feasible to complete a full suicide risk assessment, especially in a community pharmacy setting, pharmacists are well-placed to critically assess, and undertake a more specific suicide inquiry if needed. For example, during the course of a usual interaction with patients, you may already be aware of some warning signs and risk factors that put them at higher risk of suicide.
Table 1: Examples of warning signs, risk factors and protective factors
|Warning signs||Risk factors||Protective factors|
|Indicators that someone may be at immediate risk of suicide.
||Modifiable or non-modifiable characteristics of a person or their environment that increase the likelihood they will die by suicide
||Factors that may mitigate the risk of suicide
Figure 1: 3 Steps to helping someone thinking about suicide 6,7
Ask: “Are you thinking about suicide?”
Listen: If the person says “yes”, give them time and space to discuss their thoughts and feelings.
Get Help: Stay with them and/or contact others that can be relied on to stay with them. Crisis lines are available 24/7 across Ontario and Canada. They are a good place to start and can provide direct support to the individual expressing thoughts of self-harm, and/or to the pharmacy team to discuss options. Patients may need to be accompanied to emergency departments by emergency medical services, if their life may be in immediate danger (i.e., they have a plan and intend to end their life soon).
As with all clinical interventions, your assessment of suicide risk and related actions should be documented. This is also valuable in communicating to other health care providers (e.g., paramedics, emergency department team, patient’s primary care provider). See Figure 2.
Figure 2: Sample scenario and corresponding documentation:
“Patient presented to pharmacy around 10:30pm on Saturday, November 24, wishing to purchase a large quantity of acetaminophen tablets. She appeared tearful and upon questioning, voiced an intent to consume the entire bottle in order to die by suicide. I reviewed her medication profile which indicated that she was non-adherent to her antidepressant medications. Risk factors were assessed (history of depression, medication non-adherence) as well as protective factors (sister, nieces and nephews). Notably, she has not attempted suicide previously. Patient was open to calling her sister who met her at the pharmacy. Sister will spend the night with her and escort her to her physician’s office in the morning. Sister agreed to call me tomorrow with an update.
This note has also been shared with the patient’s family physician.”
Signed: Pharmacist’s Name, RPh
November 24, 2019
- Have conversations about sensitive topics in a private space.
- Don’t be afraid to ask questions if you notice warning signs. Remember, talking about suicide will not increase the chances that the individual will attempt suicide.
- For patients on medications with links to suicidal ideation (e.g. antidepressants, isotretinoin, varenicline etc.), consider enlisting the help of family members to keep an eye on any behavioural changes.
- Pay special attention to patients buying unusually large quantities of medications or who demonstrate poor adherence to medications used to treat psychiatric conditions.
- Keep a list of who or where to call for help in the pharmacy (see Resources).
- Be transparent and involve the patient as much as possible with the intervention. For example, let them know that you’d like to call the crisis line for additional support, and then call them together so that the patient is aware of what you’re saying. Even in situations where patients may refuse help, you can still inform others of what’s happening6.
- Document your interactions and keep other members of the health care team informed in a timely manner.
- Consider getting trained in Mental Health First Aid and/or obtain a free Psychological First Aid Guide from the Canadian Red Cross.
- Provincial services:
- Specialty services:
- Kids Help Phone: 1-800-668-6868 or www.kidshelpphone.ca
- Trans Lifeline (Operators within Canada and United States): 1-877-330-6366; more information available at https://www.translifeline.org/hotline
- Hope for Wellness Help Line (counselling and crisis intervention for all Indigenous Canadians): 1-855-242-3310 and www.hopeforwellness.ca
- Indian Residential Schools Crisis Line: 1-866-925-4419
- Federal services:
- Canada Suicide Prevention Service: 1-833-456-4566 [24/7]
- Canadian Association for Suicide Prevention to find a crisis support centre near you: https://www.suicideprevention.ca/need-help
- Stories of how individuals experiencing suicidal thoughts find resilience: https://www.cbc.ca/listen/live-radio/1-45-ontario-today/clip/15550961-suicide-making-your-way-back-from-a-dark-place
1. Government of Canada. Suicide in Canada: Key Statistics. https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html. Published 2019. Accessed October 29, 2019.
2. American Psychiatric Association. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors.; 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed October 29, 2019.
3. Dazzi T, Gribble R, Wessely S, Fear NT. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychol Med. 2014;44(16):3361-3363. doi:10.1017/S0033291714001299
4. Eynan R, Bergmans Y, Antony J, et al. The Effects of Suicide Ideation Assessments on Urges to Self-Harm and Suicide. Crisis. 2014;35(2):123-131. doi:10.1027/0227-5910/a000233
5. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating Iatrogenic Risk of Youth Suicide Screening Programs. JAMA. 2005;293(13):1635. doi:10.1001/jama.293.13.1635
6. Crisis Services Canada. Helping Someone Thinking About Suicide. Crisis Services Canada. https://www.crisisservicescanada.ca/en/helping-someone-thinking-about-suicide/. Published 2018. Accessed October 31, 2019.
7. Canadian Mental Health Association (National). Preventing Suicide. https://cmha.ca/documents/preventing-suicide. Published 2016. Accessed October 31, 2019.