Suicide Prevention in Podiatry

As society works to break down the social stigmas surrounding mental health conditions, suicide rates continue to rise. According to the CDC, suicide is the 10th leading cause of death for all age groups in the United States and the second leading cause of death in adults under the age of 34 [1]. A history of mental illness, such as depression, is a known risk factor for suicide, and adults with diabetes are 2- to 3-times more likely to suffer from depression compared to those without diabetes [2]. As podiatrists, we are often one of the most frequently visited providers by patients with diabetes for our efforts in preventing ulcerations, amputations, and other diabetic foot complications. When a diabetes complication is present in the foot, we often see these patients more often than their own primary-care provider.

Dyane Tower, DPM, MPH, MS shares her personal experience with this issue:

While practicing in the Comprehensive Wound Healing Center at Dartmouth-Hitchcock Medical Center in New Hampshire, I was seeing complex cases in patients with complicated medical and social circumstances. Within a matter of months, I had two patients who were facing below-knee amputations (BKA). Maggie*, a woman in her early-40s with type-I diabetes, presented with recalcitrant calcaneal osteomyelitis. Isaac*, a man in his late-30s with type-2 diabetes, presented with a Charcot-deformed foot and an infected plantar ulcer. Both patients had double digit HbA1_c and other comorbid conditions. I worked with these patients for weeks trying to heal their ulcers and counsel them on their condition and treatment options. During these weeks, I got to know each of these patients and their families as they came in for their appointments. Each patient decided to undergo BKA and both seemed to be at peace with their decisions, talking it through with their multidisciplinary medical teams, patient support groups, and families. The BKA was scheduled for both patients. Just days before Maggie’s BKA, the wound care team was informed that she was found in her home, where she had died by suicide. The morning of his BKA, Isaac didn’t show up to his surgery and he was later found in his apartment; he also died by suicide. You never really know what is going on in a patient’s life or mind and if there is a way we, as podiatrists, can prevent a patient dying by suicide, we should consider it. I think about Maggie and Isaac to this day and wonder if there was something I could or should have recognized in them to prevent these tragedies.

(*Names have been changed to protect patient privacy.)

Studies suggest that 45% of people who die by suicide were seen by a primary-care provider within 30 days before they died, making the case for employing suicide prevention in the outpatient setting. Podiatrists are essential members of the health-care team who often build continuing care relationships with patients, many of whom are at high risk for mental health conditions (eg, adults with diabetes). It’s important for podiatrists to recognize and embrace their role as frequently visited providers by recognizing prevalent public health concerns and educating themselves on how to avoid poor outcomes. Suicide prevention has not historically been a priority in healthcare, leading many physicians to feel unprepared to tackle this prevalent issue. A reasonable first step toward enabling physicians to play a vital role in preventing suicide is to assist them in identifying who is at risk. Although there is no widely used, validated predictive model, screening tools in combination with clinical judgement have been found to be more accurate in identifying at-risk patients compared to clinical judgement alone [3]. A study in this issue, “Making the Case for Suicide Risk Screening in Outpatient Podiatry Patients: An Opportunity for Injury Prevention” [4] details a quality improvement project that provides a framework for employing a quick and simple suicide screening tool in podiatric outpatient clinics. The tool was administered, and the outcome addressed in 5 minutes or less, and both physicians and staff felt comfortable administering the screening tool and providing the necessary further care for those who were deemed “non-acute positive” for suicide.