Suicide prevention, public health, and the chiropractic profession: a call to action

Physiotherapists often encounter clients disclosing suicidal thoughts and behaviors: a cross-sectional survey of Australian physiotherapists

BACKGROUND

All health professionals have a role in suicide prevention, although little is known about physiotherapists' contact with clients experiencing suicidal thoughts and behaviors.

OBJECTIVE

The aims of this study were to investigate physiotherapists' self-reported frequency of contact with clients who disclose suicidal thoughts and behaviors and to identify potential factors associated with frequency of contact.

METHODS

Three-hundred and thirty-eight Australian physiotherapists were surveyed using an online questionnaire, with an estimated response rate of 6.1%. Data were analyzed using descriptive analysis and logistic regression.

RESULTS

Over half the respondents (52.1%) reported encountering clients at least once a year who disclosed suicidal thoughts, and nearly half (49.4%) reported having received at least one disclosure of a suicide plan at some point in their career. Among those working in the public sector, 67.5% of respondents reported having received a disclosure of a suicide plan, and almost all physiotherapists working in pain management reported having received such a disclosure (93.8%). The binary logistic regression model explained approximately 39.7% of the variance in whether a physiotherapist had a client disclose a plan for suicide at some point in their career or not.

CONCLUSION

The results highlight that all physiotherapists should receive training in suicide prevention.

Preventing Suicide: Time to Mobilize the Physical Therapist Workforce

Each year, approximately 700,000 people, including 46,000 Americans, die by suicide; however, many more people experience suicidal thoughts and behaviors. Historically, the prevention of suicide has largely been the domain of mental health professionals working within specialist mental health care settings. An issue with this approach is that many individuals who experience suicidal ideation never disclose these thoughts to a mental health professional. The nonprofessional and paraprofessional mental health movement aims to bring suicide prevention to the people who need it, rather than wait for them to seek help. The nonprofessional and paraprofessional mental health movement does so by upskilling people who are not recognized as mental health professionals but may have contact with people experiencing suicidal thoughts and behaviors. In this Perspective, we argue that physical therapists are well-positioned to engage in suicide prevention. For example, physical therapists working in pain management are likely to frequently encounter clients experiencing suicidal thoughts and behaviors. Physical therapy is also viewed as a physical health profession, meaning that they may have contact with a broad range of populations at high risk of suicide who may be difficult to reach through traditional channels (eg, men from rural communities). Physical therapists will require training on how to provide crisis support, including how to link clients with appropriate mental health services. However, given the size of the physical therapist workforce globally, the impact of mobilizing the physical therapist workforce could be significant.

Adverse childhood experiences and trauma informed care for chiropractors: a call to awareness and action

BACKGROUND

Trauma is an emotional response to distressing events where coping and subsequent recovery are absent. Adverse Childhood Experiences (ACEs) are traumas, occurring before the age of 18 years, such as child abuse or neglect, caregiver instability, and household dysfunction. Sixty-four percent of the U.S. population report experiencing at least one ACE, with over 1 billion children experiencing abuse and neglect annually worldwide. Chronic exposure to stressful circumstances or multiple traumatic events has negative physiologic impacts. Persons who experience 3 or more ACEs in childhood are at greater risk of poor mental health outcomes and may be more likely to engage in high-risk behaviors, predisposing them to long-term health impacts, such as metabolic diseases, anxiety, depression, substance use, and chronic pain. Trauma informed care (TIC) is a recommended approach to healthcare delivery across professions, especially when a trauma history is suspected. This commentary aims to increase awareness of the impact of ACEs on health outcomes and introduce TIC concepts as they may apply to chiropractic care for adults with a history of ACEs.

DISCUSSION

This commentary reviews an introductory model (4R's: realize, recognize, respond, resist re-traumatization) as one TIC framework used by healthcare practitioners. Prior trauma can lessen trust, alter perceptions of physical touch, and hands-on examinations and chiropractic treatments may trigger stress responses. Using TIC after appropriate training, includes referrals to multidisciplinary providers to address trauma-related concerns outside the scope of chiropractic, and screening for ACEs if deemed appropriate. Creating safe spaces, communicating clearly, avoiding victimizing language, explaining procedures, asking for consent before physical contact, and giving patients choice and control in their own care may avoid triggering prior traumas.

CONCLUSION

Given the high worldwide prevalence of persons experiencing 3 or more ACEs, TIC principles are practical adaptations to chiropractic care for use with many patient populations. As TIC and ACEs are emerging concepts within chiropractic, students and practitioners are encouraged to undertake additional training to better understand these complex and sensitive topics. Exploratory research on the incidence, presentation, and impacts of various trauma types, including ACEs, to support adoption of TIC in chiropractic settings is essential.

The prevalence of suicide prevention training and suicide-related terminology in United States chiropractic training and licensing requirements

OBJECTIVE

To summarize the prevalence of suicide-related terminology in US doctor of chiropractic educational programs, residency programs, continuing education training, diplomate training programs, and state licensure requirements. The secondary objective was to provide next-step recommendations to enhance suicide prevention education and training for the profession.

METHODS

A review of public-facing electronic documents and websites occurred from April to May 2020 for doctor of chiropractic program course catalogs, residency program curriculum overviews, state licensing requirements, candidate handbooks for the chiropractic specialties, and continuing education training. Data were extracted to tables reflecting the state of suicide prevention training and suicide-related terminology. Descriptive statistics were used to report the findings.

RESULTS

Of 19 doctor of chiropractic programs, 54 relevant courses were identified. No course catalogs specifically mentioned suicide prevention education, but specific risk factor-related terminology was highlighted. For the 10 doctor of chiropractic residency programs, all required mandatory trainee training, which included suicide prevention education. Two states required suicide prevention education training as part of the state re-licensure process and are available through 4 continuing education courses. No diplomate training program handbooks included a requirement of suicide prevention education though suicide risk-factor terminology was described in some handbooks.

CONCLUSION

The state of suicide prevention training in the chiropractic profession documented in handbooks is largely lacking and widely varied at this time. The development of profession-specific suicide prevention continuing education may be beneficial for practicing chiropractors, and suicide prevention curriculum development at the doctor of chiropractic programs may prepare future doctors of chiropractic.

The chiropractor's role in primary, secondary, and tertiary prevention of suicide: a clinical guide

OBJECTIVE

To provide the practicing chiropractor foundational knowledge to enhance the understanding of relevant primary, secondary, and tertiary public health measures for suicide prevention.

METHODS

A descriptive literature review was performed using keywords low back pain, neck pain, psychosocial, pain, public health, suicide, suicide risk factors, and suicide prevention. English language articles pertaining to suicide prevention and the chiropractic profession were retrieved and evaluated for relevance. Additional documents from the Centers for Disease Control, Veterans Health Administration, and the World Health Organization were reviewed. Key literature from the clinical social work and clinical psychology fields were provided by authorship team subject matter experts.

CONCLUSION

No articles reported a position statement regarding suicide prevention specific to the chiropractic profession. Risk, modifiable, and protective factors associated with self-directed violence are important clinical considerations. A proactive approach to managing patients at-risk includes developing interprofessional and collaborative relationships with mental health care professionals.