By Lori Zitelli, David Jedlicka, Tricia Scaglione, and Ivette Cejas

Suicide Risk Assessment and the Audiologist’s Role

Suicide was the tenth leading cause of death in the United States overall in 2018 and the second leading cause of death for individuals 10 to 34 years of age, according to the U.S. Centers for Disease Control (CDC, 2020). Rates of suicide have been increasing since 1999, highlighting suicide as a global health concern. 

Many health-care providers do not have specific training in this area and, consequently, lack the skills required to recognize warning signs and risk factors for suicide (Schmitz et al, 2012). In an effort to address this deficit, the American Association of Suicidology developed a curriculum titled “Assessing and Managing Suicide Risk” that details the core competencies required to assess and manage individuals at risk for suicide (Suicide Prevention Resource Center, 2021). 

Although suicide risk assessment (SRA) is a process most commonly employed by mental health professionals, health-care providers in other roles may be presented with crucial opportunities to identify and mitigate suicide risk (Silverman and Berman, 2014). Audiologists are no exception. 

Our patient population includes individuals suffering from complex medical needs that have been linked with higher rates of depression and anxiety (Riccio et al, 1994; Iliadou and Iakovides, 2003; Jüris et al, 2013; Aazh and Moore, 2017; Ziai et al, 2017; Cusack et al, 2018; Shoham et al, 2019; Lawrence et al, 2020; Siepsiak et al, 2020; Zhu et al, 2020), putting them at higher risk for suicidal thoughts and behaviors (Too et al, 2019). Depression is the most common diagnosis associated with suicide (Brådvik, 2018).

The prevalence of depression is often elevated in individuals with chronic medical conditions (Katon, 2011). Hearing loss, tinnitus, dizziness, and other hearing- and balance-related disorders are likely to require frequent medical appointments and have been linked with higher rates of depression or other mental health conditions (Savastano et al, 2007). Specifically, one study reported elevated rates of depression and anxiety in an otology practice using a mental-health screener (Cejas et al, 2021). 

Despite this identified need to screen patients of audiology practices, little has been done to train audiologists in the foundational skills needed to implement such screenings. Audiology students and recent audiology graduates are unlikely to demonstrate competence in the area of suicide prevention, as 91 percent of audiology doctoral programs in the United States do not address issues related to the identification and prevention of suicide or self-harm (Whicker et al, 2017). There is no data available to indicate audiologists’ level of familiarity or comfort with identifying risk factors and warning signs of suicidal behavior. 

While one may argue that suicide assessment and treatment is outside of audiology’s scope, audiology screenings are not. Screenings provide an avenue to help identify areas of concern before they develop into more serious or long-term problems. 

To identify patients who may be at an increased risk for suicide, audiologists have been encouraged to use validated screening measures such as the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983) or the Patient Health Questionnaire-9 Item (PHQ-9) (Kroenke et al, 2001) to assess symptoms of anxiety and depression (Schwartzer and Parker, 2019). The goal of using these tools is to identify those who may need further evaluation by a qualified mental-health specialist. 

Audiologists who choose to use these questionnaires should know that these measures are used to help identify individuals at risk who may need a comprehensive mental-health evaluation. Elevated scores do not mean that the individual meets diagnostic criteria for a mental-health disorder. Audiologists interested in using these screening measures should familiarize themselves with the scoring procedures and referral criteria (see TABLE 1).

ITEMSCORING PROCEDUREREFERRAL CRITERIAREFERENCE
HADSThere are seven items each for depression and anxiety subscale. Each item is scored on a scale from 0–3, providing a 0–21 severity score.Total subscale score ≥ 8(Zigmond and Snaith, 1983)
PHQ-9There are nine items. Each item is scored on a scale from 0–3, providing a 0–27 severity scoreScore of ≥ 10(Kroenke, Spitzer, and Williams, 2001)
TABLE 1. Scoring Procedures and Referral Criteria for the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 Item (PHQ-9) Questionnaires

Although screening tools may help identify those individuals ready to fully disclose their symptoms, they may not identify those individuals who are fearful of sharing their thoughts. Thus, audiologists should also familiarize themselves with the warning signs for suicide, as these may be more passive or subtle (Rudd et al, 2006; Al-Mosaiwi and Johnstone, 2018; Crisis Services, 2021). 

Patients may not always explicitly state their suicidal thoughts or intentions and may use vague language to allude to the aforementioned (Isometsa et al, 1995). Therefore, audiologists should be alert to any early signs that their patients may be at risk. Evidence suggests that becoming familiar with the warning signs of suicide may increase the ability to recognize suicidal crises (Van Orden et al, 2006). TABLE 2 provides a non-exhaustive list of warning signs and examples of statements or actions that would fall into each category (Rudd et al, 2006; Al-Mosaiwi and Johnstone, 2018; Crisis Services, 2021). 

WARNING SIGNEXAMPLE STATEMENT OR ACTION
Talking about wanting to die or kill themselves.“I’m going to end it all.” 
“It will be over soon.”
“It doesn’t matter anymore.”
“If I see you again…”
Looking for a way to kill themselves.Seeking access to guns, pills, knives, or other objects that could be used in a suicide attempt.
Talking about feeling hopeless, having no reason to live, feeling trapped, or being in unbearable pain.“There’s no way out.”
“Things can never change.”
“I can’t live like this anymore.”
Talking about being a burden to others.“I feel so worthless.”
“Everyone would be better off without me.”
Unsafe behaviorsIncreased alcohol or drug use, reckless driving, unsafe sex, taking unnecessary risks as if they have a “death wish.”
Sleeping too much/too little or isolating themselves.Withdrawing from friends and family, increasing social isolation, expressing a desire to be left alone.
Displaying extreme mood swings.A sudden sense of calm and happiness after being extremely depressed, displaying rage, expressing the desire to seek revenge.
Getting affairs in order.Making out a will, giving away prized possessions, making arrangements for family members or pets, unusual or unexpected visits or calls to family and friends, saying goodbye to people as if they won’t be seen again.
Absolutist thinking“I always screw things up.”
“My life is totally ruined.”
“Things will never get better.”
TABLE 2. Examples of Statements or Actions that May Be Considered Warning Signs for Suicide

What to Say, How to Say It, and What to Do Next

Audiologists who have not received training in suicide prevention may have reservations about addressing this issue with patients. This hesitancy may relate to a lack of training, knowledge, education, support, and experience (Taylor et al, 2009; McHale and Felton, 2010; Conlon and O’Tuathail, 2012; Saunders et al, 2012; Giacchero Vedana et al, 2017). 

Experts in the area of suicide prevention recommend that providers should make efforts to listen non-judgmentally and express care without overreacting (Richards et al, 2019). Both verbal and non-verbal behavior is important in helping to reduce the stigma related to discussing thoughts of suicide, as well as in allowing the patient to feel comfortable disclosing thoughts and feelings. 

Simple strategies such as nodding your head, sitting versus standing, and compassionate facial expressions are extremely important. In addition, statements such as, “It seems like you have been going through a lot” or “It sounds like you are having a hard time” can help ameliorate defensiveness and allow patients to share more openly. 

When warning signs are present and/or patients report feelings of depression or hopelessness, direct questioning regarding thoughts of self-harm is warranted. These questions could include: “Have you had thoughts of hurting yourself in some way,” “Have you felt that you or your family would be better off if you were dead,” or “In the past week, have you had thoughts about killing yourself” (National Institute of Mental Health, 2021). 

If the answer to any of these questions is “yes,” a follow-up question such as “Are you having thoughts of killing yourself right now” may provide additional information that can be passed along to a provider who is qualified to complete an SRA. 

If the answer is “no,” realize that your patient may not answer truthfully for a variety of reasons, not limited to a fear of being stigmatized or losing their autonomy. In this case, consider that the individual may still display warning signs that may warrant further attention and investigation (Flasher and Fogle, 2012; Bryan and Rudd, 2018; Richards et al, 2019). 

When a crisis or a potential crisis has been identified, an audiologist should immediately attempt to find a qualified mental-health specialist to conduct a formal suicide assessment. If there is no mental-health provider available, a number of resources can be used, including, but not limited to, the National Suicide Prevention Lifeline (800-273-8255) (SAMHSA, 2021), a local crisis network, emergency medical services, or another one of the patient’s health-care providers who is qualified to provide crisis services.

Case Example 1: ‘John’

Detailed below is a real-life case example of a patient who presented with warning signs for suicidal behavior to an audiologist. 

John (a pseudonym), a man initially presenting to the office when he was 38 years old, was suffering significantly from decreased sound tolerance (DST), specifically hyperacusis, in his left ear. He worked in a steel mill and reported that, although he was not required to wear hearing protection at work, he obtained custom earplugs due to increased sensitivity to sounds. He reported occasional tinnitus that was not bothersome. 

Providers should express care without overreaching.

He ranked the severity of his DST issue, his annoyance level at bothersome sounds, and the effect of DST on his life as 10/10 on a visual analog scale (VAS) (0 being no problem, 10 being the worst problem imaginable). Loudness discomfort levels (LDLs) were reduced in his left ear.

When asked about depression, anxiety, or other relevant health issues, he reported that he experienced both anxiety and depression because of his DST. He also indicated that he occasionally felt like he wanted to “check out.” 

Recognizing this language as a warning sign for suicidal behavior, John’s audiologist provided him with contact information for the local crisis hotline and encouraged him to use that resource if needed. He was encouraged to physically present himself to an emergency room for help if he ever felt like the need was urgent and he agreed that he would be open to this. He denied having a specific plan for suicide and assured his audiologist that such thoughts were rare. 

John was amenable to exploring other treatment options for anxiety and depression with his primary-care physician (PCP) and indicated that he would initiate conversations related to this topic at his next appointment. Other treatment options specific to DST were discussed (e.g., tinnitus retraining therapy (TRT) and cognitive behavioral therapy (CBT)). John wanted to consider these options before committing to a specific treatment protocol. He lived a significant distance away from his audiologist’s office and expressed the desire to receive follow-up care by phone whenever possible. 

When he left the office on the day of his initial appointment, his audiologist called John’s PCP’s office to relay information about the discussion related to suicide, which is permissible when acting in good faith to prevent or lessen a threat to the safety of patients or others. Two days after this conversation, John called his audiologist to thank them for relaying their concerns to his PCP, indicating that he appreciated the concern for his safety.

Three weeks later, the physician’s assistant (PA) from John’s primary-care office called to share that John was in their office on that day experiencing severe distress related to DST and tinnitus. John reported to the PA that he had a deer rifle in his vehicle and was considering suicide. The clinical staff at this office encouraged John to admit himself to a psychiatric unit for emergency care, but John was resistant and indicated that he was very eager to begin TRT. 

John reported that the primary reason he was resisting in-patient psychiatric treatment was that he was the primary caregiver for his daughter, but that he was agreeable to working with an out-patient psychology provider. John left the appointment at his PCP’s office with a treatment plan (outpatient psychiatric care and TRT), including a safety plan that detailed who he could notify (i.e., spouse, close family member) if he had active suicidal thoughts and what he should do with any weapons/objects he could use to hurt himself.   

John began the TRT protocol for hyperacusis immediately following this appointment. Two months after the delivery of his audiological devices, he reported by phone that he was extremely pleased with his progress and, although he had occasional days when he felt anxious about his sensitivity, his symptoms were significantly improved when compared to his pre-treatment status. 

At his four-month follow-up appointment, John repeated the VAS rankings. His severity/annoyance/effect-on-life rankings had improved to 4/7/5 (compared to initial scores of 10/10/10). He reported that he had been wearing the devices consistently and appropriately, with significant benefit. He also indicated that he had been pushing himself to participate in more social interactions, which resulted in enjoying time with his family and friends, continuing to develop relationships, and looking forward to the future. 

He declined repeat LDL testing due to time constraints (he was anxious about getting to another appointment on time) and requested to be dismissed from TRT due to the anxiety he experienced when driving into the city for appointments. John reported that he had gained the tools he felt he needed to cope with DST (on-ear devices, the educational counseling component of TRT, and an effective anti-anxiety medication). He reported feeling that he was living a normal life and feeling very hopeful about the future. 

Case Example 2: ‘Miguel’

Miguel (a pseudonym), a 51-year-old male, initially contacted a department of otolaryngology to request a tinnitus consultation. He expressed to the scheduling representative that he was experiencing suicidal thoughts secondary to his tinnitus. The representative immediately connected the patient to the department’s in-house psychologist to address Miguel’s mental-health status and offer support resources. Miguel was determined to not be of immediate risk of harm and was scheduled for an ear-nose-and-throat (ENT) consultation. 

Two days later, Miguel was seen for an in-person consultation with an ENT specialist. He presented with an outside audiogram that demonstrated normal hearing sensitivity (250–8,000 Hz) and excellent word recognition (100 percent) for both ears. At the time of his visit, he reported the onset of bilateral tinnitus and the sensation of explosions in his head following a rapid titration of Zoloft three months prior. 

The symptoms described were reported to be debilitating, resulting in the patient quitting his job and moving across the country to live with his mother. At times, the patient sought care for his tinnitus and head sensation from multiple emergency rooms within the same day, with no obvious medical findings. 

During the ENT consultation, the patient underwent management of bilateral cerumen impactions and was subsequently referred to the in-house tinnitus clinic and department of neurology. He was scheduled for a tinnitus consultation to take place in three business days. An earlier appointment was not available, as the tinnitus provider was out of the office.

Miguel contacted the American Tinnitus Association (ATA) two days following his ENT consultation to request tinnitus support. The ATA representative reached out to the same medical facility where the patient was currently receiving care and was informed that the patient was already scheduled to be seen the next business day. 

Exactly one week following his initial contact with the facility, Miguel was seen for an extended tinnitus consultation, which included a tinnitus education session, tinnitus assessment, and counseling. He was accompanied to this appointment by his mother, Sandra (a pseudonym). 

In the education session, Miguel and Sandra were counseled on understanding and managing tinnitus, including using sounds in the environment to reduce tinnitus awareness, changing negative thoughts and emotions pertaining to the tinnitus, and the use of available therapeutic devices that could aid in tinnitus management. The patient was additionally counseled on multidisciplinary management of tinnitus, including consultations with other professionals for issues that could be influencing tinnitus or contributing to tinnitus awareness/disturbance.

An extensive intake was completed and included the completion of subjective tinnitus questionnaires. A mental-health screening was not performed, given the patient’s recent phone screening with the department’s psychologist. 

The tinnitus questionnaires included the Tinnitus Functional Index (TFI), which yielded a score of 96.40 out of a possible 100 and a max score of 104 on the Tinnitus Reaction Questionnaire (TRQ). Miguel also selected a score of 4 (almost all of the time) on question #24 (My tinnitus has led me to think about suicide). 

This was addressed by the tinnitus provider at the time of the visit. Miguel relayed he had thoughts of suicide, but did not have a plan or any intention to harm himself or others. His mother confirmed that she was aware of his mental state. 

Out of an abundance of caution, the tinnitus provider contacted the department’s psychologist to discuss the TRQ score. The psychologist guided the tinnitus provider to reiterate the importance of establishing care with a mental-health provider as soon as possible and to contact 911 or the nearest emergency room if Miguel was experiencing suicidal thoughts. The patient expressed an understanding of these recommendations. 

Miguel also was advised to seek a consultation with neurology regarding the sensations he was experiencing in his head, as recommended by his ENT. For the management of debilitating tinnitus, bilateral ear-level tinnitus sound generators were recommended, as was stress management including exercise and yoga. 

An audiologist may be the first and only person with whom an individual shares thoughts of suicide.

Relaxation techniques including mindfulness, deep breathing, and guided imagery, as well as smartphone applications, were reviewed with the patient. Positive affirmations, as well as cognitive behavioral therapy for tinnitus and insomnia (CBTi), were encouraged. The patient expressed that he was feeling more positive at the end of the visit. 

Two days following the tinnitus consult, Sandra reached out to Miguel’s tinnitus provider via email to express concern for her son’s well-being. The provider immediately contacted her by telephone and instructed her to bring her son to the nearest emergency room or call 911 if she had concerns for immediate harm to Miguel or others. 

Sandra advised that she herself was at a doctor’s appointment and asked that the tinnitus provider call to check in on Miguel. The provider placed a telephone call to the patient. Upon answering the phone, the patient expressed that he was not doing well and was in the act of searching the internet for painless ways to commit suicide. He verbalized that he was frustrated that he was not finding what he felt were viable options. 

While the provider kept the patient talking on the phone, they texted the department psychologist for emergency support. The provider was guided to remain on the phone and have nursing staff contact 911. The local police department was dispatched to the patient’s residence to conduct a safety and wellness check. 

The provider continued the conversation with the patient until emergency personnel arrived. At the encouragement of the provider, the patient presented himself to the officers and spoke about his immediate state. The provider disconnected from the call once they confirmed that the patient was in the direct care of the officers. 

The patient agreed to be transported to a local hospital for further assessment and was held for 24-hour observation before voluntary release. He followed up with psychiatry within one week. A department of otolaryngology social worker contacted the patient within this time frame to follow up with the patient. The patient expressed gratitude for the resources and information provided by the tinnitus specialist. 

A few weeks later, the patient contacted the tinnitus provider to notify them that he sought a second opinion with another local tinnitus facility. As the recommendations provided were similar to those offered by the initial tinnitus provider, the patient indicated he was ready to pursue ear-level tinnitus sound-generator devices. 

The patient was seen within a week to be fit with demo units to use until his own devices were received. During this time, the COVID-19 pandemic was declared, which resulted in patient-care service disruptions. Miguel’s fitting was deferred for three months, during which he was allowed to maintain the use of the demo units. 

At the time of the device fitting, Miguel reported he was under routine care of a mental-health specialist, taking a prescription antidepressant and benzodiazepine, and had been rarely using the demo units, as he found relief though using sound enrichment though electronic devices at home (tv, radio). Despite the lack of demo-device use, he was motivated to obtain his own units. 

Subjective tinnitus questionnaires were reassessed and demonstrated a reduction of 7.6 on the TFI, 18 points on the TRQ and a response to question #24 with a score of 0 (not at all). Ultimately, the patient returned the devices within the 30-day trial period and has not returned to the clinic since that time. 

Conclusion

Audiologists bear the shared responsibility of identifying and mitigating suicide risk. In a situation where a patient is suffering significantly from a hearing or balance disorder, an audiologist may be the first and only person with whom an individual shares thoughts of suicide.

These experiences should be viewed as opportunities for audiology to help bridge the mental-health gap by reducing stigma, breaking down barriers that prevent the open discussion of difficult topics, connecting with patients who are emotionally struggling, and ultimately saving lives. 

This article is a part of the September/October 2021 Audiology Today issue.

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