Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Basics in Mental Health Screening for Suicide Risk Assessment in Dermatology

By Catherine R. Judd, MS, PA-C, CAQ Psych, DFAAPA

Catherine R. Judd, MS, PA-C, CAQ Psych, DFAAPA, is Clinical Adjunct Faculty at University of Texas Southwestern School of Health Professions, Department of Physician Assistant Studies in Dallas, Texas.
Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.

ABSTRACT
Suicide is a major public health concern. It is the tenth leading cause of death in the United States, the second leading cause of death for individuals ages 10 to 34, and the fourth leading cause of death for individuals ages 35 to 44.1 In 2019, approximately 12.2 million adults in the United States considered death by suicide and 1.2 million people attempted suicide.2 According to the Center for Disease Control and Prevention, in 2020, a total of 45,979 people died by suicide; that is one person dying by suicide every 11 minutes.2 Approximately 54 percent of Americans have been affected by a suicide death leading to emotional, physical, and economic sequelae.1 It is estimated that 1 out of 7 young adults reported suicidal thoughts at some point in their lives and at least five percent had made an attempt.3 More than 90 percent of adults who survive a suicide attempt do not go on to die by suicide.2,4 Identifying patients who have a history of a previous suicide attempt or who are at risk for a suicide attempt may be effective in preventing a subsequent potentially lethal event. All healthcare providers in primary care and medical subspecialties, including dermatology, have a responsibility for suicide prevention. Routine screening of patients for suicide risk and appropriate referrals to mental health services will decrease the number of patients who end their lives by suicide each year.1

INTRODUCTION
Suicide is Preventable
Many chronic medical conditions, including skin diseases, are associated with psychiatric comorbidities. Fifty-four percent (54%) of patients who end their lives by suicide had visited a healthcare provider some point in the year preceding their death by suicide;5,6 however, mental illness was not identified as a risk factor for suicide in their medical record.7–10 Screening, assessment, and documentation of suicide risk is the first step in the prevention of suicide. Early identification and documentation of a patient’s risk factors for suicide, as well as protective factors and safety planning in the medical record is critical. Within healthcare settings, healthcare providers in primary care and medical subspecialties, including PAs practicing in dermatology, can play an important role in suicide prevention.7–10

Impact of Dermatologic Diseases on Mental Health
There is an increased risk of suicide among patients with skin diseases, several of which are commonly seen by healthcare providers.11,12 The medical literature reports a high prevalence of patients with chronic skin diseases who report suicidal thoughts. This increased suicide risk should be of concern, especially in dermatology, yet the psychological burden of these chronic disorders often goes unrecognized.11–13
The medical literature documents the role of psychological and emotional stress in the exacerbation of psoriasis, urticaria, eczematous dermatitis, herpes virus infections, and other skin diseases.11,12 Skin diseases may cause extreme psychological and emotional distress for patients.

Skin diseases can be potentially lethal, not because of their primary pathology but because of the psychological and emotional issues that may develop as a result. The dermatology literature has documented patients with psoriasis, atopic dermatitis, and acne have an increased risk of death by suicide.11,12,14 There is an even higher risk of suicide in patients who suffer from skin conditions associated with or causing clinically significant high levels of emotional distress, such as hidradenitis suppurativa (HS), or for those where there is an increased level of distress related to changes in their appearance or body image. For those whose skin diseases cause problems in the level of functioning, or who experience problems in interpersonal relationships, the risk is even higher.11,13,15,16

Psoriasis is a chronic inflammatory skin disease with a complex immune-mediated pathophysiology characterized by frequent episodes of redness, itching, and dry silvery scales on the skin. The impact of psoriasis on a patient’s quality of life can be significant even when it involves only a limited body surface area (BSA). For example, itching on just the palms, soles, or genital regions can affect activities of daily living (e.g., personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating). Psoriasis has a higher association with psychiatric illness, including depression, and an increased suicide risk compared with other dermatological conditions.13,14 Life stressors have been identified as both a causative as well as an aggravating factor in psoriasis.13 Patients diagnosed with psoriasis have been found to have experienced a major stressful life event in the 12 months preceding the diagnosis of the disease. These patients are more likely to have a previous psychiatric diagnosis, and more likely to have experienced thoughts of suicide in the past than patients with other skin diseases.16

Understanding the underlying neuro-mediated mechanisms of stress-induced skin diseases is increasing.13 In the presence of perceived stress, the skin responds by releasing inflammatory cytokines.17 Research describes how the elevation of inflammatory cytokines is regulated by the tyrosine kinase 2 (TYK2) pathway, which in turn regulates the inflammatory process involved in immune-mediated diseases such as psoriasis.17,18 The TYK2 process has been identified as the key to the inflammatory axis involving interleukin (IL)-23/IL-17 in psoriasis and a number of other immune-mediated skin diseases.17,18

Unique Role of Dermatology Providers
Dermatology physician assistants (PAs) play an important role in providing emotional support for patients struggling with feelings of hopelessness and helplessness due in part to their skin conditions. These feelings may go unrecognized if patients are not asked and assessed regarding mental health issues. For patients who may be dealing with debilitating psychological and emotional issues, the recognition and validation of their mental health concerns by their providers is important.

Psychodermatology
A significant number of patients diagnosed with a dermatological condition experience a psychiatric disorder and/or some form of significant psychosocial comorbidity.20 When the psychiatric presentation is related to a skin condition, dermatology providers are in a unique position that presents opportunities to identify underlying or comorbid psychiatric issues and refer patients for evaluation and treatment by mental health service providers.

There is a growing interest in psychodermatology, a subspecialty field that integrates treatment of skin diseases and dermatology with primary and secondary psychiatric disorders.19,20 Dermatological findings in primary psychiatric conditions include skin disorders, self-inflicted skin lesions, and excoriations resulting from an underlying emotional disturbance such as depression, anxiety, or obsessive-compulsive disorder (e.g., acne excoriée). In contrast, patients may present with emotional problems such as avoidance of social situations, decreased self-esteem, loneliness, and helplessness, all in response to their skin disorder. The best examples are seen in the emotional distress and/or depression caused by severe psoriasis, atopic dermatitis, and HS.15,16,19,21

Screening and Risk Assessment
Dermatology PAs are in a unique position to identify emotional and psychiatric issues, including suicide risk, as they relate to skin conditions. Dermatology is typically a clinical practice where patients are followed regularly for chronic diseases at varying intervals, for example every two months, four months, and six months. Dermatology PAs typically have a long-term established relationship with their patients and may have a broader understanding of their patient’s medical and psychosocial history. In the context of this long-term relationship, patients may be more likely to acknowledge problems they are experiencing such as depressed mood, worsening psychosocial stressors, hopelessness, and thoughts of suicide. In this setting, Dermatology PAs have an opportunity to engage patients in a dialogue regarding their thoughts and feelings about body image, appearance, self-esteem, and self-worth. Patients with chronic skin conditions frequently experience feelings of hopelessness, social isolation, inferiority, and a sense of burdensomeness; all these issues may increase the risk of suicidal ideation and self-injury.19

A screening tool for use in clinical practice is the Suicide Assessment Five-Step Evaluation and Triage tool (SAFE-T).21 This screening tool is based on the American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors.22 The five steps of assessment are outlined in Figure 1.

A comprehensive patient assessment begins with a thorough psychosocial and mental health history. Previous psychiatric treatment and whether there is a history of previous self-injury or suicide attempts needs to be documented in the medical record. In addition, the presence of other suicide risk factors such as physical disabilities, chronic pain, chronic and debilitating medical conditions, terminal illness, feelings of being trapped, and feelings of hopelessness need to be explored. Psychosocial stressors such as unemployment, recent job loss, grief and bereavement, and social isolation can singly or collectively contribute to a patient’s risk and must be understood in the context of providing healthcare. Finally, a suicide risk assessment must include on-point questioning about the use of prescribed medications, over-the-counter medications, alcohol, illicit substances, and inhalants. Patients must be asked about “access to lethal means” and about the availability of firearms. Over half of those who ended their lives by suicide did so with firearms. All of these factors will contribute to an increased risk of suicide and emphasizes the importance of screening, especially for symptoms of depression, anxiety and substance use.

Equally important is the presence of protective factors available to the patient and should be noted in the screening and assessment of a patient’s suicide risk. Protective factors include a social support and safety network, a willingness and ability to limit access to lethal means, presence of significant others, capacity for and level of resilience, and a willingness to engage in and access mental healthcare. Dialogue regarding reasons for living, spiritual values, productive activities which can be engaged in, identifying future events to look forward to, and identifying reasons for “hope” are important.

In assessing a patient’s emotional state, the following questions are appropriate and less likely to be perceived as confrontational or threatening than directly asking the patient, “Are you thinking of killing yourself?” The best method of speaking with an individual to assess emotional state is to use a genuine, empathic, sensitive, and nonjudgmental approach with questions such as the following:

• “I’m wondering…Do you feel like you are a burden to others?”
• “I’m wondering…Do you feel like the world would be better off without you; is it difficult for you to ask for help or accept help from others?”
• “Are there people you feel like you can call upon when you need help or feel really down?”
• “Do you feel like there is no one who really cares about you or what happens to you?”
• “Who is out there for you that you can trust and turn to?”

Social isolation, a sense of burdensomeness, and hopelessness are red flags that should signal a heightened alert that a patient may be having thoughts that life is no longer worth living. See Table 1 and Table 2 for a complete list of suicide risk factors and options for intervention for those identified to be at risk. There are several suicide screenings tools available that can aid the healthcare provider in identifying symptoms that point to depressed mood, anxiety, feelings of helplessness or hopelessness, and suicide risk factors. The Patient Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9) (Figure 2) are appropriate tools that can be used as an initial screening or may be used in follow-up to document improvement or worsening of symptoms over time.24 Neither screening tool is intended to make a mental health diagnosis but rather to be used as a first step in screening for mental health issues.

The PHQ-2 (Table 3) uses two prompts to assess how often the individual has been bothered by symptoms meeting criteria for major depressive disorder. Total scores on PHQ-2 range from 0 to 6. Patients with a score of 3 or more should be further evaluated with a longer screening tool such as the PHQ-9 (Figure 2) or in a direct face-to-face interview to determine if criteria are met for a depressive disorder. A PHQ-9 score of 0-4 points is considered in the normal range. A score between 5-9 points is considered mild depression; 10-14 points is considered moderate depression; 15-19 points is considered moderately severe depression; and over 20 points is considered severe depression.

The American Psychiatric Association’s Clinical Guidelines for Evaluating Suicidality23 provides a guide and prompts for interviewing patients; however, it is estimated that only one-third of healthcare providers reported using any depression screening tools.9

Improvement in the frequency of assessment and early identification of patients at risk for mental health issues including suicide risk can be achieved with an increase in the use of screening tools by healthcare providers not only in primary care but also in other subspecialties such as dermatology. It is important to look beyond depression and anxiety and screen for suicide risk.

In a recent meta-analysis of suicide victims who accessed health services prior to death by suicide, 44 studies showed services used by suicide victims were not provided by mental health providers but by primary care providers and medical subspecialties.25 Only 31 percent of patients who died by suicide received any inpatient or outpatient mental health services in the year preceding their death by suicide. In contrast, 57 percent of those individuals who died by suicide had received mental health services at some point during their lifetime. Eighty percent of suicide decedents had increased frequency of contact with their primary care provider or other health provider in the year and months prior to their death. Forty-four percent of these suicide decedents had contact with primary care in the month preceding their death.24

Practice Management
Routine screening of all patients seen in healthcare delivery settings, regardless of specialty, can reduce the risk of suicide attempts and prevent deaths by suicide. As clinical practice settings implement procedures to routinely screen patients for depression, inevitably patients endorsing thoughts of suicide will be identified. The challenge is how to incorporate and implement processes to systematically evaluate and assess suicide risk, assess the need for immediate treatment, triage, and appropriate mental health referrals.

The American Academy of Family Physicians (AAFP) provides an excellent resource for implementation of a suicide risk management initiative in a clinical practice setting. The Family Practice Management website (www. aafp.org/fpm) provides an “Immediate Action Protocol (IAP): A Tool to Help Your Practice Assess Suicidal Patients.”26 The IAP provides a guide for steps in suicide risk assessment, including assessment of intent, means, likelihood, and impulsivity, followed by guidelines for “Next Steps,” referral to mental health services, follow-up and when inpatient psychiatric treatment is indicated. A flowchart for recording “Immediate Referral Resources” should be posted in clinic areas and readily available to staff. Clinics should identify referral resources when a patient is at risk for suicide as determined by a suicide risk assessment. Available resources should include the local mental health clinic and mental health services providers, the local hospital, local emergency department, and suicide help line. If patients are resistant to inpatient treatment or no other persons are available to assist the patient, transportation resources with telephone numbers should be identified and readily available for use, such as police, ambulance, or social services.

Healthcare providers, regardless of locale, urban or rural, or size of practice, solo or large group practice, affiliated with a major medical center or not, should establish a network of mental health service providers such as psychiatrists, psychiatric PAs, and mental health nurse practitioners available for consultation. If a patient is not suicidal but may benefit from treatment for depression or anxiety, consultation with a mental health service provider may provide guidance for initiating treatment, given the challenges accessing mental health services. The United States recently transitioned from the 10-digit National Suicide Prevention Lifeline (1-800-273-TALK [8255] to 988 – a shorter, easy-to-remember three-digit number for 24/7 crisis care. See Figure 3 “Hope” poster for one example of publications and digital products available from the Substance Abuse and Mental Health Services Administration (SAMHSA) to increase awareness of this life-saving resource. More resources are available at the SAMHSA store (https://store.samhsa.gov)

CONCLUSION
Careful mental health screening and assessment of patients in any subspecialty is imperative, especially in those subspecialties where patients are known to be at increased risk for suicide, such as dermatology. Screening should be conducted periodically and ongoing. Partnerships and collaborative relationships with mental health service providers can facilitate the treatment and referral process for patients at risk.

Acknowledgement
The author would like to thank Marguerite R. Poreda, MD, from Naples, Florida, for her review of this manuscript.

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