Suicide Screening in Rural Primary Care: The Reports of West Virginia Primary Care Providers

Background: Suicide is a significant public health problem in the U.S. and rural communities have disproportionately high rates of suicide. Primary care physicians are uniquely positioned to address suicide in these areas, as the majority of individuals who die from suicide have seen a primary care physician in the year and months prior to their death. Universal suicide risk screening can increase suicide detection rates, behavioral health referral rates, and decrease acute care utilization. However, only between 11-36% of primary care physicians routinely screen for suicide risk in their patients. The overall goal of the present study was to gather evidence to help inform future implementation of universal suicide risk screening protocols in rural primary care practices. Specifically, this study describes suicide risk screening practices in West Virginia primary care, providers’ opinions of the utility of universal suicide risk screening, barriers that impede suicide risk screening, and interventions that would facilitate the process.

Methods: In-depth, semi-structured interviews were conducted with a sample of primary care providers (n = 15) whose practices were located throughout the state of West Virginia. Respondents were recruited by the West Virginia Practice Based Research Network (WVPBRN) and the principal investigator. The sample was 100% White, 53% male, and the majority (73%) were Doctors of Medicine (MDs). Interviews were tape-recorded and transcribed verbatim and then coded thematically by a team of three coders using a consensus coding methodology.

Results: Only 3 out of the 15 providers (20%) reported that they conducted universal suicide risk screening with all their patients. 53% (n = 8) reported that they screened for suicide risk based on warning signs, such as depression, anxiety or other mood disorders. 40% of the providers (n = 6) reported that they completed universal depression screening, with follow-up questions about suicide only for those patients who screened positive for depression. Although all providers noted the importance of addressing suicide in primary care, 13 (87%) of the providers reported that universal suicide risk screening was not a feasible practice in their current settings. Multiple barriers to screening were reported including: lack of time/disruptions to clinic flow, high patient loads, lack of training in regards to suicide assessment and follow-up, lack of mental health and crisis support resources, cultural beliefs specific to Appalachia, and having multiple screening burdens in primary care. Favorable interventions suggested by providers included: standardized and streamlined protocols for suicide risk screening and follow-up, access to co-located behavioral health services, the use of technology for screening, integrating screening for medical and mental health issues, utilizing a team approach, and training.

Conclusions and Implications: Primary care providers are motivated to address suicidal thoughts and behaviors through preventative patient screening, but lack the resources to do so effectively. Having streamlined, brief tools and follow-up protocols would make this process more feasible and effective. Future research should focus on developing brief, integrated suicide risk screening and follow-up protocols, integrating technology into screening methods, and examining the efficacy of having co-located behavioral health resources available for primary care practitioners.