In suicide prevention, “Put on your own oxygen mask first!”

Author’s note: This title echoes the mentoring words of William Longmire, MD, my surgical supervisor: “As a surgical emergency approaches, take your own pulse first. Don’t start what you are unprepared or untrained to finish.

Warning: help yourself before helping others

“The American Association of Suicidology (AAS) is committed to preventing insufficiently trained social workers and mental health professionals from working with potentially suicidal patients…”

The result of failed prevention

Before and since that 2012 AAS warning, suicide rates have increased in nearly every state, with increases greater than 30% in 25 states. Data from 2015 from 27 states indicates that 54% of people who died by suicide were not known to have a mental health condition.

The United States is at 50-year all-time highs. There has been a 50% increase in female suicides since 1999. The youth suicide rate has also skyrocketed by more than 50% in the past decade.

A significant proportion of completed suicides occur within hours, days, or weeks of the last hospital, emergency department (ED), or other clinical encounter.

Additionally, emergency care has continued to increase during the pandemic, with approximately 10% of patients being assessed for behavioral health issues. For example, emergency department visits for suspected suicidal thoughts and attempts increased year over year among adolescents aged 12 to 17, particularly among girls. This underscores the need for additional competent screening during this disruptive public health crisis.

These grim, intersecting statistics attest to a poor identification of “common” and unconventional suicidal presentations, and confirm the lack of available, humble, and sufficient “experts” in this field.

A shocking and lasting oblivion

Beyond currently ill-equipped psychiatric clinicians and projected shortages of practitioners, the lack of training in suicide assessment has been, and will likely remain, an appalling and enduring oversight across the broad spectrum of mental health disciplines.

Mental health professionals have an ethical and professional obligation to provide only those services that fall within their area of ​​expertise. Each of their respective disciplines has a code of ethics that specifies this.

However, clinicians who occasionally recognize missteps continue to work outside their scope of practice. This further undermines trust in mental health advocacy messages from once reliable sources trying to reach diverse groups. Sound familiar? These people demonstrate quasi-expertise in their initial statements — take, for example, the Surgeon General’s demand in March 2020 that the public “stop buying masks.”

Scope of ethical and professional practice

Caritas, Latin for charity, is for many the reason for engaging patients in crisis. Some believe that “at least charity to do something” is useful for the suicidal patient, a noble task in his struggle between life and death.

The serious data supports the conclusion that these self-validating clinicians, with little or no specific training or direct experience, dispense recommendations with often tragic consequences.

Indeed, many authors have specifically questioned the ethics of mental health professionals who, without adequate training, intervene with suicidal patients. Few, including general medicine, social work, and even psychiatry residents and psychiatrists themselves, have acquired specific competence in the assessment, management, and treatment of suicidal people.

Very few accredited ED psychiatry fellowships are available in New York, Buffalo, and Denver. However, the widespread impact of small numbers, even with their promise and potential, has been negligible. Likewise, the American Association of Emergency Psychiatry (AAEP), a multidisciplinary “champion” for advancing care for behavioral emergencies, and an affiliate of the American Psychiatric Association, has yet to confidently expand its impact. on training and care.


How can existing practices ensure better harmony, communication and equality of assessment results for those who need help? It is high time for changes to improve the competence of mental health professionals. Below are 10 suggestions based on the literature review and my administrative, teaching, clinical, and forensic experience.


Suicide assessment training with reasonable reductions in the number of lives lost will only improve through the disciplined use of an organized and open system for sharing and learning about innovative work.

  1. Detailed assessment guidelines and curriculum, including those offered by the AAS and AAEP, should be used to facilitate the proper training of multidisciplinary mental health trainees.
  2. These standards should also offer information specifically tailored to supervisors and instructors to ensure that trainees master the content and acquire the necessary skills in the core competencies.
  3. Improving the orientation of psychiatry and mental health instructors of emerging professionals will require above-standard mentoring expertise.
  4. Supervisors should devote time and energy to mentees from various disciplines beyond normal faculty responsibilities.
  5. Emergency medicine should be one of the biggest advocates of emergency psychiatry.


The US Task Force on Preventive Services continues to conclude that current evidence on the effectiveness of suicide risk assessment and documentation is insufficient, of poor quality, or contradictory.

  1. Rather than mindlessly following the limitations of suicide meta-analysis with often reckless and unnecessary biases, use true expedited and probabilistic (likelihood ratio) patient-centered protocols.
  2. A valid and reliable standardized assessment, in addition to clinical judgment, provides a tiered and rational “time out” checklist in busy clinical environments.
  3. The suicide assessment cascade should further assess the impact of ideation and non-ideation states on attempt rates with research-based confirmatory neurological testing.
  4. Dig beyond traditional ideation into carefully selected patient samples, the usual standard of care. Clinical impression alone and ideation-focused suicide screens continue to show poor predictive value for short-term events.
  5. The balance between the advantages and disadvantages of screening must be studied and determined in an innovative way.


Without complementary and cross-cutting advice and training, current suicide risk assessment will continue to reflect the regrettable observation (attributed to many authors) that “even a stopped clock is right twice a day”, very occasionally successful, but more generally unreliable.

Russell Copelan, MD (retired), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed his residency and fellowship in psychiatry in the emergency department. He is an examiner for Academic Psychiatry and founder of eMed International, creator and distributor of violence assessments.

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