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Suicide Prevention in Primary Care: A Family Physician on Screening, Risk, and Follow-Up
Suicide prevention falls squarely in the purview of primary care practitioners, says family physician Teresa Lovins, MD. She reviews an intervention with remarkable results.
People who die by suicide are more likely to have seen a PCP in the previous month before their death than any other health care provider.1
"A typical primary care practice might see 1 or 2 patients a week with some degree of suicide risk," Teresa Lovins, MD, said in a recent interview with Patient Care.© "We often see patients weeks before a crisis. That's our window to intervene."
Lovins' experience in family medicine in Columbia, Indiana, appears to reflect the quote above from findings of a 2014 study, Health care contacts in the year before suicide death.1 She is a physician owner of Lovin My Health DPC and spoke to Patient Care about another study, this one from 2024 and by the National Institutes of Mental Health. Effectiveness of integrating suicide care in primary care, published in the Annals of Internal Medicine,2 found that a screening and safety planning program in primary care practices in Washington state resulted in a 25% drop in the rate of suicide attempts in the 90 days after a primary care visit. Lovins highlights the study and the findings and speaks to the essential role of primary care clinicians as the most frequent point of patient contact in detecting warning signs of a mental health crisis and linking the vulnerable person to care.
The following transcript has been lightly edited for length and clarity.
If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting "988."
Patient Care: Can you start by giving some context on the prevalence of mental health issues in family medicine and other primary care settings?
Theresa Lovins, MD: Family medicine is often the first point of contact for patients dealing with mental health concerns. We develop long-term relationships with patients, so they feel comfortable opening up to us. Up to 50% of our patients will have some type of mental health issue in their lifetime—whether it's depression, anxiety, ADHD, bipolar disorder, or substance use. About a quarter of the patients we see are dealing with a mental health issue at any given time. It's our job to recognize that and make sure they receive appropriate treatment.
PC: How often do primary care clinicians encounter patients at risk for suicide?
Lovins: Honestly, probably more often than we realize. A typical primary care practice might see 1 or 2 patients a week with some degree of suicide risk. We know from research that many people who go on to die by suicide have seen their primary care provider within the preceding weeks or months. That means we have an opportunity—and a responsibility—to identify and intervene before it’s too late.
PC: Tell us about the study you were involved in. What was the goal, and how did it work?
Lovins: The study, conducted by the National Institute of Mental Health, focused on identifying suicide risk early in primary care. It used a 4-question screener that could be administered by physicians or staff. The idea was to flag patients who might need further evaluation or intervention. The findings were remarkable—we found by asking those simple questions reduced suicide risk over the following 3 months by 25%. It’s a matter of asking the questions and then directing them to the right care that will keep them healthy and safe after they leave the physicians office.
PC: What warning signs or red flags should clinicians look for in everyday practice?
Lovins: A lot of it comes down to knowing your patients. If someone comes in and is presenting differently than you’re used to, if they appear more anxious, withdrawn, or have noticeable mood swings—it’s worth digging deeper. Are they engaging in risky behaviors? Sometimes it’s even a parent or a family member who comes with them to an appointment and points out that they just aren’t acting like themselves. Maybe they’re not engaging in their home life. These aren’t always specific symptoms, but they can point us toward a larger mental health concern.
PC: You mentioned screeners. Which ones are commonly used in primary care?
Lovins: The PHQ-9 for depression and the GAD-7 for anxiety are probably the most common. There are also tools specifically for assessing for ADHD and the Mood Disorder Questionnaire is used for bipolar symptoms. These are brief and often completed by staff before the physician enters the room, so the information is right there and available to start a conversation; it can be a practical part of the workflow.
PC: Should suicide risk assessment be a routine part of primary care? Could it overwhelm patients or physicians?
Lovins: I think it should be a standard part of our visits. Initially, patients might wonder why they're being asked, but if we incorporate it routinely, it won't feel out of place. Given how often patients at risk see a provider before a crisis, we have to change our approach. If a screener takes 30 seconds and could save a life, it’s well worth it.
PC: Are primary care clinicians adequately trained to know when to refer a patient with suicidal or situational depression?
Lovins: Yes, I believe we are. We can generally distinguish between someone who’s struggling and someone who needs more intensive intervention. If a patient is suicidal but doesn’t have a plan or intent, we can often work with them to create a safety plan. But if they do have a plan and intent, then it’s crucial to connect them immediately with mental health specialists.
PC: What types of community resources should family physicians be connected to for patient mental health support or referral?
Lovins: Every community is different, but in most there is a hospital with a crisis team or mental health clinics with walk-in hours. In my area, it can be as simple as a phone call to get someone in quickly, or to arrange for hospital admission if necessary. Knowing those local options and making the process easy for the patient is key.
PC: What role does follow-up care play, and how can primary care practices help patients stay on track?
Lovins: Follow-up is essential. Virtual care has made it easier to check in quickly, even the next day. Our staff can also help—sometimes a phone call from a nurse can make a huge difference. And we try to schedule follow-ups within days or a couple of weeks to ensure continuity and safety.
PC: Anything else you'd like to share with fellow primary care clinicians?
Lovins: Don’t forget to take care of your own mental health. Physicians aren’t immune, and too many colleagues have died by suicide themselves. We need to normalize asking for help and having our own primary care providers. When we reduce stigma for ourselves, we help reduce it for our patients too.
PC: Do you think the willingness to seek help has improved since the pandemic?
Lovins: I do. There’s been a shift, both culturally and legally. Some changes in federal law are helping reduce stigma—moving away from questions like “Have you ever had…” to “Are you currently impaired by…” That allows physicians to be honest about their mental health without fear that it will interfere with their ability to practice.
