When suicidal ideation and accountability for care collide

Primary care physicians strive to prevent or treat conditions to improve a patient’s condition and mitigate the risk of death. However, having claimed the lives of 49,449 Americans in 2022 alone, suicide presents a unique challenge due to a lack of clarity in accountability that can hinder effective treatment.

The complexity of determining accountability for care is starkly evident in cases of suicide or suicidal ideation. The age-old question of responsibility in traditional care models remains unresolved. This is in part due to preconceived understandings of PCP and behavioral health clinician roles.

Andrew Sassani, M.D.: ©Magellan Health

The focus of whole-person health upends that traditional, siloed dynamic. Collaborative efforts between PCPs and behavioral health professionals place accountability front and center, mitigating the confusion that can cloud how physical and mental health professionals work together. Nothing underscores the critical need for seamless coordination among care team members as much as preventing suicide or suicidal ideation. It is crucial that PCPs ask patients about their mental well-being and document it, because the risks associated with not doing so are simply too great.

The reasons are many. PCPs play an exceptionally important role in mental health care because they often already have extensive and trusted relationships with patients. Not surprisingly, PCPs often have the most frequent contact with patients. But, tragically, they are sometimes the last to find out if a patient has (or had) suicidal ideation.

Uncertainty over who is accountable for addressing suicidal ideation is the result of numerous factors.

In addition to an unclear line of communication between PCPs and behavioral health clinicians, systemic challenges and barriers to care make the situation – and the question of who is responsible for asking about and addressing suicidal ideation – more complicated.Notable contributing factors include:

There is rapidly increasing demand for care. This was made painfully clear in recent research that found physicians would need 26.7 hours each day to provide 2,500 patients with the recommended preventive, chronic and acute care annually. In today’s fast-paced environment, the time PCPs have with patients is already limited, creating perceived and real barriers to addressing whole-person health.

Ongoing shortage of PCPs and behavioral health clinicians impact access to care. As cases of suicidal ideation rise, the direct impact of the provider shortage becomes increasingly evident, given that more training, referral resources and time is needed to effectively identify, treat and manage such conditions.

Some PCPs may be reticent to ask patients about suicidal ideation. PCPs may hesitate to bring up suicidal ideation to due to perceived risk of alienating patients or concern over triggering the creation of such ideation in the first place. PCPs may also be concerned about addressing the care that will be needed. Once a PCP asks, it is their role to document the patient's response and take the necessary steps to mitigate any potential risk if the patient has disclosed thoughts of suicide.

Many PCPs worry about how to orchestrate care with behavioral health professionals because of additional operational and logistics-related challenges. Clinical workflows are already complex, with some studies indicating that many physicians spend twice as much time on administrative tasks than they do with patients.

PCPs receive relatively limited training in mental health disorders. Many do not feel they are adequately prepared or resourced to address mental health disorders, including severe depression, anxiety or thoughts of self-harm and suicide, or the social determinants of health that often accompany them.

Regrettably, for these reasons, many patients fall through the cracks. In fact, nearly half of patients who died from suicide had seen a PCP in the previous month. It is important for PCPs to engage with patients about their mental health including feelings and suicidal ideation, which is an indicator of severe mental anguish that needs to be addressed.

PCPs can make a difference by taking several important steps.

It is essential that PCPs embrace the role they are uniquely capable of assuming to ensure that patients’ mental health needs are addressed. Initial steps should include:

• Adding mental health screenings during patient visits. Many patients who have suicidal ideation will not proactively express their thoughts or concerns unless asked. Even if not using a screening tool, a PCP can still ask a patient about their mental health and if they have thoughts of self-harm or suicide.
• Developing a network of local behavioral health professionals. By creating a roster of behavioral health professionals who accept patient referrals and work with the health plans with which they are “in-network,” PCPs can ensure that patients get the appropriate referrals.
• Proactively seek patients’ consent. The ability to share clinical information and health records with behavioral health professionals is crucial to ensure that physical and mental health concerns are addressed together.
• Create an open line of two-way communication with behavioral health practitioners. Strong, two-way communication benefits everyone involved. PCPs and behavioral health providers can help inform one another on how a mutual patient is suffering. This includes social determinants of health, which also impact chronic physical conditions like hypertension and type-II diabetes.

Above all, it is crucial for all health care providers to proactively address and take responsibility for patients' suicidal thoughts as few conditions carry greater risk and create such an irreversible threat to patients' well-being.

Andrew Sassani, M.D., vice president and regional chief medical officer at Magellan Health, oversees Magellan’s commercial behavioral health services. Following his residency at Harvard, he served in various leadership positions, including department chair and hospital vice chief of staff.