Suicide in Patients with Multiple Sclerosis: Guidance on Red Flags and Prevention

“Living with multiple sclerosis [MS] can feel like being stuck in quicksand for some patients,” notes Cleveland Clinic neurologist Mary Alissa Willis, MD. “They fight a constant battle not to lose ground in the management of some of their symptoms. Suicide can seem like the last bit of control a patient has over his or her body.”

So observed Dr. Willis in a talk on red flags for suicide in people with MS at the 2019 annual meeting of the Consortium of Multiple Sclerosis Centers (CMSC), held recently in Seattle.

The need for vigilance

Research suggests that approximately one-third of people with MS have contemplated suicide at some point in their disease course, says Dr. Willis, a staff physician with Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research. Moreover, a review of 40 published studies revealed that over three-quarters of all people who complete suicide are found to have had contact with a primary care provider within a month of their death.

“These statistics indicate that there is opportunity to intervene with patients if we are vigilant about looking for red flags for suicide,” Dr. Willis notes.

Key prognosticators

Patients with debilitating chronic illnesses like MS can have a number of risk factors for suicide that go beyond depression, Dr. Willis says.

In addition to depression, which can be screened for using the Patient Health Questionnaire (PHQ-9), red flags may be subtle and difficult to detect, including:

• Abrupt changes in health and/or behavior, such as weight loss or a new diagnosis of cancer
• Intense bereavement (especially involving loss of support)
• Statements of hopelessness
• Social isolation
• Substance abuse
• Worrying about being a burden
• Concerned family members

Don’t be afraid to ask about suicide

“There is no evidence that asking a patient about suicide increases the risk of suicide,” Dr. Willis notes. Therefore, she says, if red flags are present, it’s important to assess for safety and environment by asking specific questions about patient access to firearms and other means of suicide.

It’s also critical to establish a therapeutic relationship by scheduling more frequent visits and including family and friends in these visits if possible, limiting refills on prescriptions such as benzodiazepines that could be harmful if taken in excess and enlisting help from other providers to treat depression, anxiety and substance abuse if they are present.

Case study of a suicide protocol

To illustrate red flags and interventions in her talk at the CMSC meeting, Dr. Willis shared a letter she received from a patient who had a number of risk factors for suicide, including progressive MS, a recent cancer diagnosis, the recent death of his mother, financial issues and a lack of local care partners. He also had attempted drug overdoses twice in the prior year.

Upon receipt of the letter, which clearly suggested suicidal thoughts, Dr. Willis worked collaboratively with the patient’s other care providers, including social workers at the Mellen Center and the cancer center, to first ensure the patient’s safety and then connect him with emergency mental health resources. The patient was found alive and admitted to the hospital. He was discharged after three days but threatened suicide six days later. He was then readmitted to the hospital for two weeks and discharged with close psychiatric follow-up.

“Early follow-up is critical, since 43% of suicides occur within a month of hospital discharge,” Dr. Willis explains. “After the emergency passes, the clinician and team should review the case for any red flags, missed clues or opportunities for handling the situation differently.”

When suicide occurs, clinician self-care is in order

In cases where patients have died by suicide, it is not helpful to assume responsibility for the patient’s actions or harbor a sense of failure, Dr. Willis notes.

“Caregivers, including healthcare providers, need support and self-compassion in the aftermath of suicide,” she says. “It can be helpful to talk to other providers who have been through similar situations and to seek out counseling for common feelings of guilt, fear, minimization, anger and avoidance.”