Asking about Suicidal Thoughts in the outpatient?

[ara96]

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Hi,
I'm finishing up 3rd year in a few months and heading into C&A fellowship. I have noticed that whenever I ask about Suicidal Ideations in my outpatient rotation, I get somewhat of a sarcastic response from some patients like, "why in the world would you ver ask me that, I'm not crazy and I don't need to be in a mental institution, just refill my xanax and get away from me."

A majority of my patients are stable and have never had any suicide attempts in their life. In my opinion, they can be managed by their PCP. However, as I will deal more with children, should I just ask this question more subtly? I want to be able to make sure my notes are very thorough from a legal aspect, but I don't want to offend my patients either.

Thanks for any tips.

 

[SpartanWolverine]

I find it easiest to ask about SI in the context of other relevant mood questions (for example, "it sounds like your anxiety is really affecting your life -- has there ever been a time where it's been so difficult to handle that you thought you might be better off dead?" or "Sometimes when people are as down as you are they might feel like life isn't worth living anymore. Do you ever have those thoughts?"). You're well beyond my training but framing SI questions in the context of current mood issues has helped me assess my patients without quite as much of a defensive response.

 

[WingedOx]

You'll get better at it with time and practice so it doesn't stand out as an awkward question.

...now that xanax though...

 

[bashir]

Hi,
I'm finishing up 3rd year in a few months and heading into C&A fellowship. I have noticed that whenever I ask about Suicidal Ideations in my outpatient rotation, I get somewhat of a sarcastic response from some patients like, "why in the world would you ver ask me that, I'm not crazy and I don't need to be in a mental institution, just refill my xanax and get away from me."

A majority of my patients are stable and have never had any suicide attempts in their life. In my opinion, they can be managed by their PCP. However, as I will deal more with children, should I just ask this question more subtly? I want to be able to make sure my notes are very thorough from a legal aspect, but I don't want to offend my patients either.

Thanks for any tips.

I am also finishing third year. I have enjoyed my patient interactions more once I gave myself permission not to ask questions that aren't pertinent. For a patient whose presentation warrants screening for suicidality I usually preface the question with some kind of normalizing statement, like "a lot of people who suffer from depression at some point have thoughts about harming or killing themselves." But if screening for suicidality feels absurd for a given patient whom you know well, don't do it. I document something like "no indication of suicidality."

 

[splik]

It is not considered the standard of care to ask about suicidal ideation for every outpatient visit (this is espeically the case if you're doing psycgotherapy or have regular follow up with patients). You should always ask about suicidal ideation at every new patient visit, or where there is a change of clinical status (for example worsening depression/anxiety/panic, new psychiatric disorder, stressful life events, new or change in substance abuse/withdrawal) or when there is any other reason to ask about it. I rarely ask patients about psychiatric symptoms at all. I also have pts fill out a PHQ-9 any any other screening tools. That is another easy way to ask about SI without actually asking.

 

[Armadillos]

I also have pts fill out a PHQ-9 any any other screening tools. That is another easy way to ask about SI without actually asking.

I’ve been thinking about doing this so I don’t have to spend 5 minutes doing a “sigecaps ROS” every visit and can spend more time talking about whatever seems important to the patient. How do you structure reviewing it into your visit? Do they do it in the waiting room?

 

[ara96]

It is not considered the standard of care to ask about suicidal ideation for every outpatient visit (this is espeically the case if you're doing psycgotherapy or have regular follow up with patients). You should always ask about suicidal ideation at every new patient visit, or where there is a change of clinical status (for example worsening depression/anxiety/panic, new psychiatric disorder, stressful life events, new or change in substance abuse/withdrawal) or when there is any other reason to ask about it. I rarely ask patients about psychiatric symptoms at all. I also have pts fill out a PHQ-9 any any other screening tools. That is another easy way to ask about SI without actually asking.

What? How do you rarely ask patients about psychiatric symptoms?

 

[singasongofjoy]

PHQ9 in the waiting room; review as you walk back. In our system, required to screen (which can include PHQ9 in some cases; in person in others) and enter (including PHQ scores) into EPIC at least yearly for all patients; ask more frequently as need indicates. For in-person, a normalizing lead-in tends to work (as someone mentioend w/ mood above), or sometimes I might add before asking "and we ask these questions of every single person we see in this clinic; it's not just you. That's because these feelings/behaviors are actually not all that uncommon from time to time, so we ask everyone." Leading in with self-harm and then asking about SI seems easier for me too.

I work with dev. disabilities (mostly ASD) so tend to not use the questionnaire but still ask in most cases, again usually asking about self-harm first (ever tried to/wanted to hurt yourself ON PURPOSE; the "on purpose" part is important for the ASD folks. Otherwise I've wasted a good bit of time trying to figure out a kid who was perseverating on his having fallen down on accident and hurt himself and how afraid he was of that happening again, but it took 10 minutes to figure out that it was an accident)