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06-23-2021 | Mental health | Ask the expert | Article

Suicide risk in diabetes: Why doctors may hesitate to screen, but should not


Speaker: Mary de Groot

Mary de Groot explains the importance of screening for suicidal ideation in people with diabetes, and addresses common concerns that may make doctors hesitate to do so (7:22).

0:00 Introduction/Depression and suicide ideation are more common than you might think.
0:57 Screening and the guidelines.
1:25 Emotions and assumptions about screening for suicidal thoughts.
2:44 Will I open Pandora’s box?
3:55 Leaning into protocols for support.
5:30 Can asking about suicidal thoughts trigger them?

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So our topic is screening for suicide by health care providers. And thank you for the opportunity to speak to this topic today. I am a clinical psychologist and work closely with patients with diabetes in the context of an embedded health psychology service in adult endocrinology. And this is a topic that's very important for all of us, whether we are mental health or behavioral health providers or endocrinologists or primary care providers, to have sensitivity to and to have a plan of action to address, because we know that both depression and suicidal ideation are much more prominent in our patient populations than we might initially imagine.

So let's talk a little bit about the nuts and bolts of screening. So one of the things we know is that screening for depression and suicidal ideation are a part of the standards of medical care for people with diabetes. This is built into the standards of care for the American Diabetes Association, and those same standards have been adopted internationally.

So why would we possibly want to ask our patients about depression and suicide? That sounds like a really downer topic, doesn't it? And in fact, as health care providers, perhaps not you as the listener here, but perhaps many of your colleagues, we all know colleagues who have a considerable amount of feelings about doing this kind of screening. We have fears that screening for feelings of depression or suicidal ideation may be beyond the scope of our practice. I may not feel trained to be able to ask those questions and know what to doing.

We may make some assumptions that it doesn't apply to the patient that's sitting directly in front of us. And in many cases that might be true-- that assumption might hold true. But there may be other cases in which we don't actually know that the person that is sitting before us has been struggling with mood or struggling with suicidal ideation. And unless we ask, we won't know. Although, that will still be there for them, whether we ask or not. And so asking those questions are very important so that we can get that on the table and be able to work with it.

Sometimes, as health care providers, we have fears that asking open-ended questions might take up too much time in the clinical encounter. We all wrestle with our schedules. We wrestle with the amount of time-- the limited amount of time-- we have to work with our patients and particularly our patients with diabetes. And so asking questions like, how is your mood, or what would you like from your appointment today, or have you been feeling safe, those are questions that can sometimes feel like we might be opening up a Pandora's box. And how will we ever get it closed?

And, of course, my response to that is, don't worry about it. In the medical setting, we have all kinds of ways that we shut patients down when we need to. And so if we have a conversation with the patient that goes beyond the assessment that we need to conduct or the evaluation that we need to make about safety, we have ways of steering our patients in the conversation back to important parts that we need to cover. So not to worry-- we all have those skills.

We might also have fears about not knowing what to do if someone tells us they're at risk of self-harm. And this is an important fear that we need to tune into and also talk back to. So we know that risk of self-harm and harm to patients is part of our medical environment, in the sense that we have many different kinds of medical presentations that can represent threat to the health and safety of our patients, whether it is chest pain or whether it's hypoglycemia or maybe it's hyperglycemia and DKA, we have protocols for all of these different kinds of medical presentations of what to do, how to assess, how to evaluate, and steps to take, depending on the outcomes of those assessment questions.

Suicidal ideation is the same. Every health care system has protocols for how to handle these situations. And so if we don't happen to be familiar with those protocols, we know that we can turn to our practice protocols and use those steps to address these kinds of questions when they come up with our patients. And in that way, it is very much the same as what we would do for any other kind of medical presentation. We have tools, we have processes, and we have steps that we can take.

And finally, I would say that there's one other fear that sometimes we have tucked in the back of our brain that is really kind of a myth around self-harm and suicidal ideation, and that is that if we bring up the topic, if we ask people about thoughts of death or thoughts of self-harm or intent to engage in self-harm, are we inducing that idea for the very first time, and will that place our patient at greater risk simply by talking about it? The very good news is that it does not work that way. That if people are thinking about self-harm, they're thinking about it long before we raise the question. And that, in fact, the idea of asking about self-harm can be a tremendous relief for people, because they may have been thinking about this in the deep recesses of their mind for a long time before they're asked about it. And to get that out into the open and to have someone to talk with about it who will not be shaming or blaming, whose understanding, but who's also in a position to take steps to help the patient be safe, can be a tremendous relief for people who are having those kinds of thoughts.

So asking about it is very important. Because if it is there, it needs to be addressed. And if it's not there, we have the relief of knowing that our patient is feeling safe and that we can proceed with the other aspects of the agenda that they bring to the table and that we want to address as well.

About the speaker

Mary de Groot

Mary de Groot, PhD, is an Associate Professor of Medicine and acting director of the Diabetes Translational Research Center at Indiana University.

Full biography


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