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J Can Chiropr Assoc 2021; 65(2) 137
ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2021/137–155/$2.00/©JCCA 2021
The chiropractor’s role in primary, secondary, and
tertiary prevention of suicide: a clinical guide
Zachary A. Cupler, DC, MS1
Clinton J. Daniels, DC, MS2
Derek R. Anderson, PhD2
Michael T. Anderson, DC, MS1
Jason G. Napuli, DC, MBA3
Megan E. Tritt, MSW, LCSW1
1 Butler VA Health Care System, Butler, PA, USA
2 VA Puget Sound Health Care System, Tacoma, WA, USA
3 St. Louis VA Health Care System, St. Louis, MO, USA
Corresponding author: Zachary A. Cupler, Butler VA Health Care System
e-mail: zachary.cupler@va.gov
© JCCA 2021
The views expressed in this article are those of the authors and do not reect the ofcial policy or position of the Department of Veterans Affairs,
or the United States Government.
The authors have no disclaimers, competing interests, or sources of support or funding to report in the preparation of this manuscript. ZAC, CJD,
DRA, MTA, JGN, MET received indirect support from their institutions in the form of computers, workspace, and time to prepare this article.
Abbreviations
Acceptance Commitment Therapy – ACT Motivational Interviewing – MI
Centers for Disease Control and Prevention – CDC Post-traumatic stress disorder – PTSD
Cognitive Behavioral Therapy – CBT Social determinants of health – SDOH
Columbia-Suicide Severity Rating Scale – C-SSRS Veterans Health Administration – VHA
Dialectical Behavioral Therapy – DBT World Health Organization – WHO
Mindfulness-Based Stress Reduction – MBSR
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
Rôle du chiropraticien dans la prévention primaire,
secondaire et tertiaire du suicide : guide clinique
Objectif : Donner aux chiropraticiens en exercice les
connaissances de base nécessaires pour leur permettre
de mieux saisir les mesures de santé publique primaires,
secondaires et tertiaires servant à prévenir le suicide.
Méthodologie : On a fait une revue descriptive de la
littérature à l’aide des mots-clés suivants : lombalgie,
cervicalgie, psychosocial, douleur, santé publique,
suicide, facteurs de risque de suicide et prévention du
suicide. On a évalué la pertinence des articles en anglais
portant sur la prévention du suicide et la profession
de chiropraticien. On a examiné d’autres documents
138 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
for Disease Control, Veterans Health Administration,
and the World Health Organization were reviewed. Key
literature from the clinical social work and clinical
psychology elds were provided by authorship team
subject matter experts.
Conclusion: No articles reported a position statement
regarding suicide prevention specic to the chiropractic
profession. Risk, modiable, 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.
(JCCA. 2021;65(2):137-155)
KEY WORDS
: suicide prevention, chiropractic, public
health, biopsychosocial, primary prevention, secondary
prevention, tertiary prevention
provenant de Centers for Disease Control, de la Veterans
Health Administration et de l’Organisation mondiale de
la santé. Des experts en la matière, membres du comité
de rédaction, ont fourni des articles importants sur le
travail social clinique et la psychologie clinique.
Conclusion : Aucun article ne renferme d’énoncé
de principe sur la prévention du suicide issu de
professionnels de la chiropratique. Les facteurs de
risque, les facteurs modiables et les facteurs de
protection associés à l’automutilation sont des aspects
importants à examiner. La prise en charge des patients
vulnérables d’une manière proactive consiste entre
autres à établir et à entretenir des liens de collaboration
avec les professionnels de la santé mentale.
(JCCA. 2021;65(2):137-155)
MOTS CLÉS
: prévention du suicide, chiropratique,
santé publique, biopsychosocial, prévention primaire,
prévention secondaire, prévention tertiaire
Introduction
“Knowing is not enough; we must apply. Willing is not
enough; we must do.” – Goethe
Chiropractors primarily manage spine-related disor-
ders and other various musculoskeletal complaints.1,2
Chronic pain is a frequent chief complaint which has
associations to suicidal self-directed violence.3–5 Con-
cerningly, suicide is a major global health predicament
and an important cause of mortality and morbidity with
nearly 800,000 deaths annually.6,7 Self-directed violence
accounts for 1.4% of all deaths worldwide and was the
eighteenth leading cause of death in 20168, while in Can-
ada, the suicide rate declined by 24% from 1981 to 2007
and has remained stable through 20179. Worldwide, males
have been found to complete suicide three times more
often than females, while females far exceed males in the
number of attempts of suicidal self-directed violence.10
Apart from a small survey11 assessing chiropractic interns
and doctors of chiropractic near Toronto on their know-
ledge of a suicide lethality scale and patient management
questionnaire and a recent call to action12, there is no liter-
ature describing suicide prevention efforts specic to the
chiropractic profession.
Suicide preparatory behavior and suicidal self-directed
violence has been conceptualized as a continuum13 and is
a stigmatized issue for many people including health care
professionals14. Similar to pharmacists15, occupational
therapists16, and audiologists14, chiropractors should con-
sider their broader role in the health care delivery system
with relation to suicide prevention. The chiropractor’s di-
dactic education and clinical training includes considera-
tions of the biopsychosocial components of health.17 This
suggests chiropractors may play a role in identifying be-
havioral health risk factors and coordinating appropriate
referrals to other members of the health care team.18
Foundational suicide prevention knowledge for the
chiropractor includes understanding myths and appropri-
ate terminology (Table 1). Historically, there have been
inconsistencies in the terminology used to communicate
about suicide, suicide attempts, and self-directed violence
in the peer-reviewed literature and in public messaging.19
Terms such as ‘parasuicide’ and ‘suicide survivor’ were
used regularly in the literature but have since been deemed
unacceptable terms.19,20 The National Center for Injury
Prevention and Control, Division of Violence Prevention,
part of the Centers for Disease Control (CDC), has estab-
J Can Chiropr Assoc 2021; 65(2) 139
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
lished uniform nomenclature to improve communication
between clinicians and researchers (Table 2).20 There are
also several myths and stereotypes that may hinder suc-
cessful suicide prevention efforts (Table 3).21–25 By rec-
ognizing the existence of personal bias and stigmatizing
attitudes, chiropractors have the opportunity to improve
communication with communities and patients at risk of
suicide-related behaviors.
The purpose of this descriptive review is to provide
the practicing chiropractor foundational knowledge to
enhance the understanding of primary, secondary, and
tertiary suicide prevention. Organized by public health
Table 1.
Uniform denitions for self-directed violence and suicide20
Self-directed violence Behavior that is self-directed and deliberately results in injury or the potential for injury to
oneself.
(This does not include risk-taking activities such as parachuting, gambling, excessive speeding in
a motor vehicle, or substance abuse.)
Suicidal self-directed violence Behavior that is self-directed and deliberately results in injury or the potential injury to oneself.
There is evidence, whether implicit or explicit, of suicidal intent.
Suicide attempt A non-fatal self-directed potentially injurious behavior with any intent to die as a result of the
behavior and may or may not result in injury.
Interrupted self-directed violence – by self A person takes steps to injure self but is stopped by self prior to fatal injury
Interrupted self-directed violence – by other A person takes steps to injure self but is stopped by another person prior to fatal injury. The
interruption can occur at any point during the act such as after the initial though or after the onset
of behavior
Preparatory acts Acts of preparation towards making a suicide attempt, but before the potential for harm has
begun.
This can include anything beyond a verbalization or thought, such as assembling a method or
preparing for one’s death by suicide.
Suicide Death caused by self-directed injurious behavior with any intent to die as a result of the behavior
Table 2.
Unacceptable self-directed violence terms and recommended acceptable terms20
Completed suicide Implies achieving the desired outcome whereas those involved in the mission of “reducing disease, premature death, and
discomfort and disability” would view this event as undesirable.
Recommended Term: suicide
Failed attempt Negative impression of the person’s action, implying an unsuccessful effort aimed at achieving death
Recommended Term: suicide attempt or suicidal self-directed violence
Nonfatal suicide “Suicide” includes a death while “nonfatal” indicates no death occurred
Recommended Term: suicide attempt
Parasuicide Formally, used to refer to a person’s self-directed violence whether or not the individual had an intent to die
Recommended Term: non-suicidal or suicidal self-directed violence
Successful suicide Implies achieving a desired outcome whereas those involved in the mission of “reducing disease, premature death, and
discomfort and disability” would view this event as undesirable
Recommended Term: suicide
Suicidality Often used to refer simultaneously to suicidal thoughts and suicidal behavior. These phenomena are vastly different in
occurrence, associated factors, consequences, and interventions so they should be addressed separately.
Recommended Term: suicidal thoughts and suicidal behavior
Suicide gesture,
manipulative act,
suicide threat
Each of these terms gives value judgment with a pejorative or negative impression of the person’s intent. They are
usually used to describe an episode of nonfatal, self-directed violence.
Recommended Term: non-suicidal or suicidal self-directed violence
140 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
Table 3.
Common* myths associated with suicide22
Myth Fact
Suicide only affects individuals with
a mental health condition Many individuals with mental illness are not affected by suicidal thoughts and not all people who
attempt or die by suicide have mental illness. Relationship problems and other life stressors such
as criminal/legal matters, persecution, eviction/loss of home, death of a loved one, a devastating or
debilitating illness, trauma, sexual abuse, rejection, and recent or impending crises are also associated
with suicidal thoughts and attempts.
Once an individual is suicidal, he or
she will always remain suicidal Active suicidal ideation is often short-term and situation-specic. Those with mental illness, the proper
treatment can help to reduce symptoms. The act of suicide is often an attempt to control deep, painful
emotions and thoughts an individual is experiencing. While suicidal thoughts may return, they are not
permanent and an individual with previously suicidal thoughts and attempts can go on to live a long life.
Most suicides happen suddenly
without warning Warning signs, verbal and/or behavioral, precede most suicides.
People who die by suicide are
selsh, cowardly, or just looking for
attention, and take the easy way out.
Typically, people do not die by suicide because they do not want to live—people die by suicide because
they want to end their suffering. Individuals who experience suicidal ideations do not do so by choice.
They are not simply, “thinking of themselves,” but rather they are going through a very serious mental
health symptom, often associated with at least one mental health condition, or a difcult life situation.
Talking about suicide will lead to and
encourage suicide. There is a widespread stigma associated with suicide and as a result, many people are afraid to speak
about it. Talking about suicide not only reduces the stigma, but also allows individuals to seek help,
rethink their opinions, and share their story with others.
Someone who is suicidal is
determined to die Suicidal people are often ambivalent about living or dying. People are often looking for a way to stop
their emotional and physical pain.
People who talk about suicide do not
mean to do it. People who talk about suicide may be reaching out for help or support. A signicant number of people
contemplating suicide are experiencing anxiety, depression, and hopelessness and may feel that there is
no other option.
Someone making suicidal threats
won’t really do it Those who talk about committing suicide or express thoughts about wanting to die are at risk and need
attention
Asking a person if he/she is thinking
about suicide will put the thought in
his/her head and prompt to try it
If you know a person is depressed or in crisis, asking if they are thinking about suicide is actually
helpful, giving them a chance to talk, which can be the rst step toward nding help and solutions.
Medications and therapy are of little
help Treatment can work, whether it comes in the form of therapy, medication, or in combination
*Although, the nuances of specic societal and cultural variations surrounding suicide perception preclude us from addressing all myths for the
purposes of this paper.
prevention level, this paper aims to provide the chiroprac-
tic profession with a unied resource for the following:
1) factors associated with suicide self-directed violence
relevant to common conditions seen in the chiropractic
ofce, 2) how to communicate with the patient about
self-directed violence and suicide intentions, 3) how to
identify a patient at risk for suicidal self-directed violence
through an evidence-based assessment, and 4) considera-
tions for interprofessional collaboration and referral.
Methods
We performed a descriptive review using PubMed. We
searched from index inception through April 2021. Search
terms included low back pain, neck pain, chiropractic,
psychosocial, pain, public health, suicide, suicide risk
factors, and suicide prevention. Additional relevant texts
and documents from the CDC, Veterans Health Adminis-
tration (VA), and the World Health Organization (WHO)
were also reviewed. Pertinent articles from the author’s
libraries were included. Key literature from the clinical
social work and clinical psychology elds were provided
by authorship team subject matter experts (D.A., M.T.).
Inclusion criteria
Articles describing suicide prevention in terms of pri-
mary, secondary, or tertiary measures were included when
they were applicable and relevant to ambulatory health
care environments. Clinical studies describing clinic-
al screening, risk factor identication, protective factor
identication, or referral for management of suicide risk
J Can Chiropr Assoc 2021; 65(2) 141
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
were considered relevant. The search was limited to Eng-
lish language articles only.
Exclusion criteria
Articles were excluded if they pertained to inpatient, acute
care settings, and were not directly related to ambulatory
health care environments. Due to the practice scope of
a majority of chiropractors2, studies focused on pharma-
cologic intervention for the management of risk factors
(e.g., depression) were beyond the focus of this project
and were excluded.
Results
No articles reported a position statement regarding sui-
cide prevention and management specic to the chiro-
practic profession. We identied 93 articles relevant to
the implementation of public health approaches, suicide
prevention, risk factor screening, or crisis management
strategies for musculoskeletal providers.
Discussion
Suicide is more than a mental health problem. It is a
public health crisis that can, and must, be prevented by
all health care providers. Chiropractors have previously
demonstrated interest in public health efforts in the areas
of physical activity promotion26, smoking cessation27, and
most recently the COVID19 pandemic28. Making suicide
prevention a priority in one’s community and professional
practice means considering the chiropractor’s role at the
primary, secondary, and tertiary prevention levels.
Risk, modiable, and protective factors associated
with self-directed violence and spinal pain
Similar to low back pain, suicide and self-directed vio-
lence are associated with numerous psychiatric comor-
bidities, social, and occupational circumstances; thus
the need to consider the entire person through the con-
text of biopsychosocial framework.17,29,30 Spinal disor-
ders, chronic pain31, and self-directed violence appear to
overlap for several comorbid conditions such as depres-
sion29,32, pain catastrophizing33, and post-traumatic stress
disorder (PTSD)34. The chiropractor should be cognizant
that risk factor associations do not equate to absolute risk
and correlation for suicidal self-directed violence. For
suicide factors, there are several key denitions to con-
sider:
1) Risk factors are characteristics or conditions
of the patient that have been found to have a
statistical relationship to the presence of self-
directed violence22,35;
2) Dynamic or modiable factors are character-
istics or conditions of the patient that have
been found to have a statistical relationship
to the presence of self-directed violence and
can be targeted for treatment or intervention
(e.g., medication for depression, new employ-
ment)36;
3) Protective factors are characteristics or con-
ditions of the patient that have been found to
have a statistical relationship to the absence of
self-directed violence22,35.
The literature suggests chiropractors have the poten-
tial to impact modiable factors for self-directed violence
related to opioid use.37–40 Non-pharmacological care for
chronic pain, including chiropractic services, has been
found to reduce the likelihood of suicide risk factors and
potentially play a protective role for self-directed violence
in active military members who transitioned care to VA.41
Chiropractors should also be concerned with risk factors
that may present alongside of a spinal pain complaint.
Depression has been identied during consensus state-
ments for the chiropractic profession and interprofession-
al panels as a key clinical condition to routinely screen
for, in particular with older adults.42,43 Meanwhile, PTSD
has also been evaluated as a co-occurring condition in the
chiropractic ofce and appears to have a negative correla-
tion with outcomes from care for neck or back pain.34, 44–46
Finally, poor coping strategies may play an important role
in both low back pain chronicity and suicidal ideation.47, 48
Primary suicide prevention: social determinants of
health and health promotion
Public health primary prevention intends to address risk
factors in susceptible populations and can emphasize so-
cial determinants of health (SDOH).13 SDOH are dened
as the conditions in which people are born, grow, live,
work, and age, and are further shaped by the distribu-
tion of money, power, and resources at global, national,
and community levels.49 Upstream disease prevention in
healthy individuals and populations, through the identi-
cation of SDOH barriers, has historically been considered
142 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
a key component of chiropractic wellness care.18,50 At the
primary prevention level, chiropractors should be know-
ledgeable of SDOH and regularly incorporate them into
evaluations and care planning.51 Health disparities born
out of the inequalities in SDOH contribute to self-directed
violence risk.52 While suicide may have a basis in depres-
sion or substance abuse, the simultaneous contribution
of risk comes from social factors like community break-
down, loss of key social relations, economic depression,
or political strife.53 Self-directed violence risk factors are
further magnied by emotional states like hopelessness
and impulsiveness.54,55
Lifestyle behaviors have been shown to have posi-
tive and negative relationships with suicide prevention.55
In understanding the various risk factors and protective
factors for self-directed violence, chiropractors can tar-
get SDOH (Table 4). For example, smoking cessation
counseling is supported as a means to target primary
prevention of suicide as multiple cohorts have found a
dose-response association between smoking and risk of
suicidal self-directed violence.56 Physical activity, another
promotable health behavior in the chiropractor’s ofce,
has been associated with lower rates of suicidal ideation
in both adolescents and adults.57–61 Moreover, depression
is a predictor of risk for suicide29,62 and it is very like-
ly depressive symptoms may initially be identied in the
chiropractor’s ofce as it relates to spinal pain through
yellow ag screening17, 32.
Making judgments about a person’s suicide risk fac-
tor status requires effective communication skills that
incorporates empathy, compassion, and nonjudgmental
listening.63 At the heart of this action is promoting the
knowledge that all suicides are potentially preventable,
and, with appropriate skills, chiropractors can take the
opportunity to address the whole person by considering
SDOH. Assisting the patient in overcoming their com-
plaint of spinal pain may function as an indirect protect-
ive factor for risk of suicidal self-directed violence. An
episode of acute low back pain, as a painful experience,
may be managed to resolution through education, prac-
titioner-directed interventions, therapeutic exercise, and
reassurance. In this instance, the chiropractor has the
opportunity to assist the patient in cultivating self-ef-
cacy, problem-solving, and coping strategies which are
translatable skill sets.
Suicide prevention education and training for chiro-
practors and chiropractic students are additional targets
for primary prevention strategies. To date, suicide preven-
Table 4.
Risk, dynamic, and protective factors associated with self-directed violence.22,35,36
Risk Factors Dynamic (Modiable) Factors Protective Factors
• Family history of suicide
• History of previous suicide attempt(s)
• Psychiatric disorders (i.e. depression, anxiety disorder,
bipolar disorder, schizophrenia, personality disorder)
• Substance use disorder (i.e. alcoholism, substance
abuse)
• Post-traumatic stress disorder
• Delirium
• Hopelessness
• Marital status
• Sexual minority
• Occupational status
• Military service
• Chronic medical illness (i.e. diabetes, cancer, HIV/
AIDS, chronic pain)
• Childhood adversity
• Rural residence
• Firearms
• Active psychological symptoms
• Hopelessness
• Suicidal ideation
• Suicidal communication
• Suicidal intent
• Treatment adherence
• Substance use
• Psychiatric admission
• Psychosocial stress
• Problem-solving decits
• Emotional turmoil
• Social support and relationships
• Family connectedness
• Positive coping strategies
• Subjective well being
• Pregnancy and parenthood
• Religious or spiritual beliefs
J Can Chiropr Assoc 2021; 65(2) 143
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
tion education has been under-described and limited in
medical training.63 Continued development of integrated
clinical training opportunities64, continuing medical edu-
cation65, and interprofessional collaboration with other
health care disciplines are critical to expanding exposure
to suicide prevention education.
Secondary suicide prevention: risk screening and
identication
Secondary prevention is oriented towards high-risk popu-
lations for self-directed violence thoughts and behav-
iors.13 It requires systematic processes designed to iden-
tify individuals who may be at high risk of suicide and to
work with the patient and/or support persons to reduce
risk factors and promote protective factors. Behavioral
health providers receive extensive training regarding the
identication and treatment of patients at-risk and patients
actively suicidal, but most patients who will experience
suicidal ideation are receiving care outside of the behav-
ioral health setting.66–68 Primary care has become a setting
of interest surrounding suicide prevention, but ambula-
tory care and specialty clinics can offer the same support
and intervention. As portal-of-entry providers, chiroprac-
tors are in a similar position to be in clinical contact with
patients months prior to preparatory behavior, a suicide
attempt, or suicide.
There is a signicant opportunity and moral obliga-
tion during this time to identify and connect patients to
needed public health resources or behavioral health treat-
ment. The provision of education and connection when
it matters could lead to early prevention, detection, and
management as necessary. Gatekeeper training is one for-
mal approach used in suicide prevention training for pri-
mary care providers and emergency room physicians.69,70
Suicide prevention training for health care providers is
believed to impact important factors related to suicide
prevention – knowledge, perceptions about suicide pre-
vention, reluctance, and self-efcacy – and that changes
in these factors can inuence intervention behavior.69
While the primary reason to present to the chiropractor
is typically due to spine-related disorders2, co-morbidities
relevant to the patient’s health status may warrant further
investigation or immediate referral. A rm understanding
of acceptable language (Tables 1 and 2) and communi-
cation related to self-directed violence is critical to pre-
paring for future clinical encounters. Building screening
processes into intake and evaluation is a simple way that
chiropractors may strive to identify a patient at-risk for
suicide-related behavior. For example, a review of sys-
tems within intake paperwork that queries the patient’s
experiences with depression, anxiety, PTSD, substance
use disorder, and other mental health concerns can open
the door to further investigation and conversation. A pa-
tient that has selected a mental health symptom or con-
dition requires further inquiry to the status of their cur-
rent mental health care, or lack thereof. This may play
a crucial role in encouraging them to seek the support
they need all the while cultivating patient-centered care.
There are numerous unidimensional and multidimension-
al psychosocial screening tools available for the busy
chiropractor’s ofce that evaluate risk factors associat-
ed with self-directed violence and also assessment tools
specic to suicidal self-directed violence (Table 5).71–79
For example, in a multiyear cohort study of US veterans,
Finley et al. observed veterans with various combinations
of clinical characteristics including PTSD, chronic pain,
and traumatic brain injury.80 They observed interactions
among specic clinical characteristic co-occurrences sig-
nicantly increased the risk of suicide ideation, suicide
attempt, and suicide ideation and attempts.
In 2016, The Joint Commission recommended health
systems consider evaluating suicide risk in all patients
and in all settings.7 There are many ways to ask about sui-
cidal thoughts or feelings during a medical appointment
and this will likely vary by the individual chiropractor.
Contrary to popular belief, questions related to suicidal
thoughts does not promote suicide or self-harm action.24,81
Some suggest a comprehensive question designed to as-
sess for current or historical suicidal thoughts/feelings.
For example, Bongar and Sullivan recommend the fol-
lowing: “Have you, at any time in your life, ever done
anything that anyone could have possibly interpreted as
self-destructive or even suicidal?”82 Other providers may
feel more comfortable with a succinct and direct form of
inquiry such as “Have you had any thoughts about suicide
or harming yourself in any way?” For those that prefer
standardized methods of screening and are comfortable
doing so, the Columbia-Suicide Severity Rating Scale
(C-SSRS) is a widely available questionnaire designed to
assess suicide risk level across a wide variety of medical
settings using a standardized tool.75
The frequent nature of an active care plan with a chiro-
144 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
practor for the management of spine-related disorder may
lend itself to the development of strong provider-patient
rapport, trust, and a therapeutic relationship that allows
the patient to feel more comfortable communicating men-
tal health concerns than with their other health care pro-
viders. It is imperative that the practicing chiropractor is
ready to recognize the patient in crisis (or trending to-
wards crisis) and that their clinic should have standard
operating procedures (e.g., national resources, referral
pathways, and community resources) in place to assist
these at-risk patients expeditiously (Appendices 1, 2, 3).
The chiropractor may identify evidence for risk of self-
directed violence with a review of systems, intake of his-
tory, or yellow ag screening tools on evaluation or at
follow-up care when managing spinal complaints. Ask-
ing direct questions to the patient about current or recent
Table 5.
Assessment tools for screening for self-directed violence risk and risk factors*,#
Assessment tool Tool description
Columbia Suicide Severity Rating
Scale (C-SSRS)75 Designed to assess suicide risk level across a wide variety of medical settings.
3 to 8-item tool, depending on the answers provided
Fear-Avoidance Beliefs Questionnaire
(FABQ)79 Unidimensional assessment for fear of pain caused by physical activity that leads to a catastrophizing
response.
16-item tool with a 7-item work subscale and a 4-item physical activity subscale
General Anxiety Disorder-7 (GAD-
7)76 Unidimensional assessment of generalized anxiety disorder, a distinctly separate domain than depression
7-item tool
Optimal Screening for Prediction of
Referral and Outcome Yellow Flag
(OSPRO-YF)73
Multidimensional assessment of risk and protective factors drawn from 11 psychosocial screening
questionnaires and 136-items
17-item tool with a 6-item negative mood subscale, 6-item fear avoidance subscale, 5-item passive
coping subscale
Pain Catastrophizing Scale (PCS)72 Unidimensional assessment of catastrophic thoughts as it relates to pain (i.e. rumination, magnication,
feeling helpless).
13-item tool with a 4-item rumination subscale, 3-item magnication subscale, and 6-item helplessness
subscale
Pain Self-Efcacy Questionnaire
(PSEQ)77 Unidimensional assessment of self-efcacy when in pain.
10-item tool
Patient Health Questionnaire – 9
(PHQ-9)71 Unidimensional assessment for presence and severity of depression and depressive symptoms through 9
domains.
9-item tool
Patient is asked directly if they have had thoughts that you would be better off dead or of hurting
yourself in someway.
Subgroups for Targeted Treatment
Back Screening (SBT)78 Multidimensional assessment screening for factors associated with disability in the primary care setting.
9-item tool with a 4-item physical subscale and a 5-item psychosocial subscale
Tampa Scale for Kinesiophobia Scale
(TSK)79 Unidimensional assessment for degree of fear of movement and reinjury
17-item tool with a 6-item harm factor subscale and a 7-item activity avoidance factor subscale
West-Haven Yale Multidimensional
Pain Inventory-Interference Subscale
(WHYMPI/MPI-INT)74
Multidimensional assessment of pain interference in various areas of life in the social, occupational, and
relational domains.
52-item tool with 12 subscales – 5 subscales assess dimensions of pain, 3 subscales assess perception
pain impact on signicant other, and 4 subscales assess pain impact on function and activities
* Consideration of patient burden as well as clinic preparedness to handle responses to assessments should play a role in assessment tool
selection.
# Caution is advised in interpreting a single assessment tool as an indication of risk of suicide, unless the tool specically screens for suicide
risk (i.e. C-SSRS), rather assessment tools are components of a comprehensive clinical picture that includes patient history, multiple
assessment tools, and physical examination. For example, a high score on a GAD-7 alone does not necessarily indicate suicide risk, despite
high generalized anxiety.
J Can Chiropr Assoc 2021; 65(2) 145
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
suicidal thoughts or feelings can aid to build a safe, car-
ing space, and de-stigmatize self-directed violence and
self-harm while advocating for utilization of available
resources.83–85 In the clinic, patients identied as high risk
for self-directed violence or who endorse suicidal idea-
tion require additional systematic secondary prevention
intervention, typically beyond the training and comfort
of the chiropractor. When available, a referral to a trust-
ed behavioral health provider is recommended and the
follow-up often includes individual risk assessment and
safety/treatment planning designed to provide ongoing
support for the patient to reduce risk factors and promote
protective factors.
The response to a patient demonstrating suicidal be-
havior will also vary depending upon each provider’s
level of training, as well as their specic environment
of care. For example, chiropractors practicing in a large,
interdisciplinary team may have access to direct referral
to a mental health provider for additional assessment and
safety planning. In these settings, for example VA, pro-
viders often have the option of referring a patient directly
to the Emergency Department (usually for high-risk) or to
a same-day access/walk-in mental health clinic for more
comprehensive evaluation.
For providers practicing independently in private prac-
tice or more remote settings, there may likely be fewer
options and additional barriers to facilitating a smooth
transition to mental health care for evaluation. Clinicians
faced with these challenges may benet by proactively
generating a list of local mental health providers and re-
sources rather than wait until an emergent situation arises
at the clinic. A prepared list of resources is one way to in-
crease efciency in coordinating care for a patient experi-
encing suicidal behavior. Although time limitations are
a barrier, providing a warm handoff (e.g., contacting the
mental health provider while the patient is in the ofce)
is generally recommended86, 87 and may help to improve
care coordination and a greater likelihood of follow up.
Finally, there are 24/7 resources available to all clinical
care providers and patients, such as the Crisis Services
Canada Hotline. This resource can provide immediate
consultation for patients or providers needing services or
information. Appendix 1 contains Canadian and United
States national resources for crisis hotlines, Appendix 2
contains 24/7 online forum and chat access resources, and
Appendix 3 provides adolescent and pediatric resources.
Secondary suicide prevention: comprehensive
evaluation and safety planning overview
While it is beyond the expectation of a chiropractor to
conduct a comprehensive evaluation, it is useful to share
knowledge of next steps for educating patients and/or
loved ones. Once a patient is connected with a qualied
mental health professional, they will likely participate in a
comprehensive risk assessment that includes detailed in-
quiry regarding psychosocial history, mental health treat-
ment history (pharmacological and non-pharmacologic-
al), past/current risk and protective factors, and treatment
planning. Ideally, if suicide risk is accurately stratied,
the patient is triaged to a clinically appropriate level of
care and is given the necessary treatment referrals, while
incorrect stratication may result in harm to the patient
due to inappropriate recommendations, exposure to an
inaccurate level or dose of care, or a lack of referral for
appropriate treatments.88
When a patient is deemed to be at an elevated risk for
self-directed violence or suicide, the standard practice
also may include comprehensive safety planning. Safe-
ty planning is a collaborative process conducted with the
patient to create a “plan” that often includes identica-
tion of triggers/warning signs, internal coping strategies,
support contacts (family, friends, professional) for quick
access, and methods of increasing environmental safety
(e.g., limiting access to lethal means). Safety plans are
considered a best practice and used as part of a variety
of psychological therapies. Typically, the safety plan is
provided to the patient and is included in their medical
record so that other providers may have access to this re-
source if needed. A recent randomized controlled trial in
active duty Army soldiers found those in either response
planning groups had a 76 percent reduction in attempts, a
decline in ideation, fewer overall inpatient hospital stays,
and a reduction in negative emotion states compared to
the control safety contract group.89
Depending on an patient’s category of risk, there are
numerous levels of care that may be appropriate for a pa-
tient with elevated suicide risk, including inpatient hos-
pitalization, intensive outpatient programs (individual/
group therapy 3 to 4 times per week), as well as engage-
ment in weekly, outpatient, evidence-based treatments
such as cognitive behavioral therapy (CBT), acceptance
commitment therapy (ACT), or dialectical behavioral
therapy (DBT).90–95 There is a growing consensus in the
146 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
suicide behavior literature that treatment interventions
should address coping deciencies and symptoms of
psychological distress in patients who have attempted
suicide.96
Tertiary suicide prevention: integrated settings and
chiropractic services
Tertiary prevention approaches aim to intervene with pa-
tients with a history of self-directed violence. The goals
of these prevention efforts are to mitigate subsequent oc-
currences of self-directed violence through reducing the
impact and progression of the established disease (e.g.,
suicide ideation or prior suicide attempt) by eliminating
or reducing disability and suffering while maximizing
potential quality of life years.97, 98 In epidemiological
terms, tertiary prevention aims to reduce the number and/
or impact of complications. Specic for suicide preven-
tion, aftercare99 describes care for the individual while
postvention100 considers communities and loved ones. In
parallel with secondary suicide prevention efforts, it is
imperative that chiropractors develop the procedures that
would enhance the connection with community-based
organizations and mental health professionals. For the
chiropractor, it is prudent to be cognizant of patients who
have previously endorsed suicidal thoughts or engaged in
self-directed violence. Both secondary and tertiary pre-
vention efforts can function to support and enhance pro-
tective factors through skill building and treating painful
complaints (Table 4).
Collaboration and team-based approaches to care have
been developed in health care systems. In some instan-
ces, chiropractors are members of physical medicine and
rehabilitation departments, chronic pain programs, pain
management teams, or surgical departments.101,102 Inter-
professional team-based care contributions by chiroprac-
tors and behavioral health clinicians may optimize the
psychosocial considerations.18 Community-based teach-
ing clinics for chiropractic students have demonstrated
interprofessional care delivery for complex case manage-
ment that includes mental and behavioral conditions in
low-income populations.103, 104 Meanwhile, the vast ma-
jority of chiropractors are in private practice and are at a
signicant disadvantage for collaborating with behavioral
health specialists. A case example of co-located clinics for
a chiropractor, family physician, and mental health pro-
fessional highlights potential communication and refer-
ral pathways for anxiety and chronic tension-type head-
ache.105
Whether co-located or more fully integrated, a grow-
ing body of research indicates that collaborative behav-
ioral-primary care results in improved patient outcomes.89
Interprofessional training for mental and behavioral
health collaboration with chiropractors is largely un-
reported at this time and is a potential opportunity to en-
hance the chiropractor’s role in evidenced-based tertiary
suicide prevention.
In either a private practice or hospital-based chiroprac-
tic clinic, there are a variety of interventions that have
demonstrated success in managing chronic musculoskel-
etal pain conditions in the setting of comorbid mental
health conditions, such as prior suicide attempts or a his-
tory of suicidal ideation. Similar in framework to Gliedt
et al.18, there are several treatments and case manage-
ment strategies for spinal-related disorders that may be
considered by chiropractors that aim to promote coping
skills and self-efcacy. These strategies include mindful-
ness-based stress reduction (MBSR), concepts of motiva-
tional interviewing (MI), and CBT (Note: The delivery of
these interventions are dependent upon scope of the indi-
vidual’s licensing jurisdiction). Each can be incorporated
into a visit as an adjunct to manual and exercise therapies
and happen to reinforce concurrent mental health inter-
ventions.99 Treatment with MBSR or CBT, compared with
usual care, resulted in greater improvement in back pain
and functional limitations with no signicant differences
in outcomes between MBSR and CBT.106 These ndings
suggest that MBSR and/or CBT may be an effective
treatment option for patients with chronic low back pain
with an associated risk of comorbid risk of suicidal self-
directed violence.107, 108
As noted in secondary prevention for high-risk patients,
behavioral health specialists employ the same tools con-
textualized for suicide prevention. CBT in particular has
been shown to be effective in treating mental health disor-
ders with chronic pain109, and CBT alone reduces suicide
attempts, suicidal ideation, and hopelessness compared
with other treatments110. Evidence also supports DBT for
treating suicidal ideation and behavior.111 The DBT ap-
proach combines elements of CBT, skills training, and
mindfulness techniques with the aim of helping patients
develop skills in emotional regulation, interpersonal ef-
fectiveness, and distress tolerance.88
J Can Chiropr Assoc 2021; 65(2) 147
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
Every state in the United States—as well as federal
agencies, including the VA, Department of Defense, and
Substance Abuse and Mental Health Administration—has
fostered a community-based approach to suicide preven-
tion.88,94 Similarly in Canada, the Federal Framework for
Suicide Prevention was published in 2016 and sought to
align federal suicide prevention efforts with provinces,
territories, Indigenous organizations, non-governmental
organizations, and communities to prevent suicide.112
We encourage chiropractors to participate in commun-
ity-based interventions that are endorsed by local or na-
tional public health organizations. Organizing a monthly
group session or supporting current community-based
interventions to prevent risk factors, promote protective
factors, and mitigate suicide behaviors (Table 4) is a po-
tential unique manner for chiropractors to address SDOH
for tertiary prevention. Presenting on a variety of topics,
as an expert in public health, can be benecial and en-
courage the overall community to live a better quality
of life. Chiropractors can consider incorporating this ap-
proach into individual practices by partnering with larger
established health care systems, county health depart-
ments, and other private organizations to build a proactive
approach to reducing future suicidal occurrences through
a community network.
There are also national and local public health organiz-
ations for chiropractors to join as members. For example,
the American Public Health Association (APHA) has a
suicide prevention special interest group. Several other
APHA sections, including Chiropractic Health Care, Pub-
lic Health Education and Health Promotion, and Occu-
pational Health and Safety, provide chiropractors with
resources to further assist in the development of a com-
munity-based approach to suicide prevention.113 A chiro-
practor’s county, province, and/or state funded crisis line,
task force, or coalition is likely in need of volunteers. For
example, Butler county in Pennsylvania, United States,
maintains a local branch of ‘Prevent Suicide PA’.114
Potential barriers to suicide prevention in the
chiropractic ofce
While a patient endorsing thoughts of self-directed vio-
lence or reporting plans to perform self-directed violence
are an unexpected clinical encounter in the chiropractic
ofce, the implementation of suicide prevention efforts
in the ofce do result in several logistical concerns. Addi-
tional assessment tools, scoring, and interpretation of
screening tools is an additional burden to both the patient
and the chiropractor. The chiropractic ofce is likely to
have a certain ow or pace (e.g., appointment time) for
new and follow-up patient care. Whereas a patient who
ags for risk factors of suicide will require impromptu
focus and time for potential further assessment or inter-
vention. Standard operating procedures would serve the
ofce well to include established contact lists with avail-
able resources, something else that requires frequent up-
dating and verication of information accuracy. This may
be difcult in a solo provider ofce and in ofces where
patient care is busy with little time built in between pa-
tient visits. Careful planning is necessary to provide the
appropriate care for these instances with empathy, valid-
ation, and support and avoiding the appearance of being
rushed with a very sensitive topic. Practitioners may have
to allocate additional time to each of their treatment ses-
sions just in case something like this were to come up.
One should look inward and reect on clinic ow to de-
termine the feasibility of addressing suicide prevention
screening in the chiropractic ofce.
Limitations
The objective of this descriptive report left little room
to devote to the discussion of special populations such
as children, adolescents, or geriatrics as well as the re-
lationship of culture and ethnicity as they associate with
suicide-related behavior. As this was a descriptive over-
view, there are many scenarios that were not covered that
uniquely represent specic types of chiropractic practice
or particular patient scenarios. There are resources avail-
able nationally and locally, which could not be highlighted
due to limitation of space.
Further, the authors caution against the implementa-
tion and clinical application of suicide prevention in the
chiropractor’s ofce using only this clinical guide to navi-
gate the process. This article serves as introduction and
starting point to a nuanced and life-threatening condition.
Additional training and workshops should be sought to
gain condence to address this clinical concern. Many
of the organizations provided in the appendices are key
sources for supplementary education and training oppor-
tunities (Appendices 1, 2, 3).
148 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
Conclusion
Biological, psychological, social, and cultural factors
all have a signicant impact on the risk of suicide and
spine-related disorders. The chiropractic profession un-
knowingly has played a role in suicide prevention, par-
ticularly the primary and secondary prevention levels,
through education and counseling behavior change re-
lated to SDOH and treatment of painful conditions. It is
a chiropractor’s responsibility to recognize patients at
risk of self-directed violence and engage in primary and
secondary suicide prevention; however, it is beyond the
expectation of the chiropractor to conduct suicide risk
evaluation and to address a suicide crisis independently.
It is of moral and ethical obligation that we suggest a
minimum level of competency to screen for risk factors
related to self-directed violence. Efforts to implement
standard operating procedures, including community and
national resources, referral pathways, and establishing
relationships with the behavioral health community, en-
hance the opportunities for chiropractors to contribute to
the mitigation of this public health crisis.
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Appendix 1.
National crisis hotlines*
Crisis Hotline Title Crisis Hotline Description Crisis Hotline Contact Information
CANADA
Centre for Addiction and
Mental Health (CAMH)
Canada’s largest mental health teaching
hospital and one of the world’s leading
research centres in its eld.
Phone: 1-833-456-4566 (24/7)
Website: http://www.camh.ca/
Crisis Text Line The Crisis Text Line is a free text
messaging resource offering 24/7 support to
anyone in crisis.
Short Message Service (SMS):
Text HOME to 741741 (24/7)
Website: https://www.crisistextline.org/
The Canada Suicide
Prevention Service
Crisis Services Canada evolved out of
the Canadian Distress Line Network – a
national network of existing distress, crisis
and suicide prevention line services that has
been engaging members since 2002.
Phone: 1-833-456-4566 (24/7)
SMS: Text 45645 (4PM-Midnight)
Website:
https://www.crisisservicescanada.ca/en/
UNITED STATES
National Suicide
Prevention Lifeline
The National Suicide Prevention Lifeline is
a national network of more than 150 local
crisis centers. It offers free and condential
emotional support around the clock to those
experiencing a suicidal crisis.
Phone: 800-273-8255 (24/7)
Online chat:
https://suicidepreventionlifeline.org/chat/ (24/7)
Website: https://suicidepreventionlifeline.org/
Substance Abuse and
Mental Health Services
Administration’s
(SAMHSA) National
Helpline
The Substance Abuse and Mental Health
Services Administration’s (SAMHSA)
national helpline offers condential
treatment referrals in both English and
Spanish to people struggling with mental
health conditions, substance use disorders,
or both.
Phone: 800-662-HELP (4357) (24/7)
Website:
www.samhsa.gov/nd-help/national-helpline
Support for those who are deaf or hard of hearing:
Text to Telephone (TTY): 800-487-4889 (24/7)
The Trevor Project The Trevor Project offers crisis intervention
and suicide prevention to lesbian,
gay, bisexual, transgender, queer, and
questioning (LGBTQ) youth through its
hotline, chat feature, text feature, and online
support center.
Phone: 866-488-7386 (24/7)
SMS: Text START to 678678
Online Chat: TrevorCHAT
Website: https://www.thetrevorproject.org/
The Veterans Crisis Line The Veterans Crisis Line is a free,
condential resource staffed by qualied
responders from the Department of Veterans
Affairs. Anyone can call, chat, or text —
even those not registered or enrolled with
the VA.
Phone: 800-273-8255 and press 1 (24/7)
SMS: Text 838255 (24/7)
Online chat: www.veteranscrisisline.net/get-help/
chat (24/7)
Website: www.veteranscrisisline.net
Support for those who are deaf or hard of hearing:
800-799-4889
*Access to these resources may vary by country.
154 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
Appendix 2.
Online forums and crisis support resources*
Resource Resource Description Resource Contact Information
ADAA Online
Support Group
With more than 18,000 subscribers
worldwide, the Anxiety and Depression
Association of America’s online support
group is a safe, supportive place to share
information and experiences.
Website:
https://adaa.org/adaa-online-support-group
Befrienders Global network of 349 emotional support
centers around the world. It offers an open
space for anyone in distress to be heard.
Support is available via telephone, text
message, in person, online, and through
outreach and local partnerships.
Website: https://www.befrienders.org/
BetterHelp Connects people with licensed, professional
therapists online for a low, at fee. Therapy
is available whenever you need it.
Website: https://www.betterhelp.com/
IMAlive IMAlive is a virtual crisis center. It
offers volunteers who are trained in crisis
intervention. These individuals are ready
to instant message with anyone who needs
immediate support. IMAlive is a virtual crisis
center. It offers volunteers who are trained
in crisis intervention. These individuals are
ready to instant message with anyone who
needs immediate support.
Website: https://www.imalive.org/
Self-Injury
Outreach and
Support
An international outreach organization
offering a variety of resources for those who
self-injure, including guides, stories, and
methods for day-to-day coping
Website: www.sioutreach.org
Suicide Stop A one-stop resource center aimed at assisting
people who are dealing with suicidal or self-
destructive tendencies. It is also tailored to
provide essential information and tips for
individuals who want to help someone else.
Website:
www.suicidestop.com/suicide_prevention_chat_online.html
TrevorSpace TrevorSpace is an online international peer-
to-peer community for LGBTQ young people
and their friends.
Website: https://www.trevorspace.org/
7 Cups of Tea An online resource that offers free,
anonymous, and condential text chat
with trained listeners and online therapists
and counselors. With over 28 million
conversations to date, it’s the world’s largest
emotional support system.
Website: https://www.7cups.com/
*Access to these resources may vary by country.
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ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
Appendix 3.
Adolescent and pediatric suicide prevention support resources*
Resource Title Description Crisis Hotline Contact Information
CANADA
Kelty Mental Health
Resource Center
Parents and caregivers can nd a variety of information
and resources relating to mental health issues affecting
children and young adults
Website: www.keltymentalhealth.ca/
Kids Help Phone Kids Help Phone is Canada’s only 24/7, national support
service. Offerings include professional counselling,
information and referrals and volunteer-led, text-based
support to young people in both English and French.
Phone: 1-800-668-6868 (24.7)
Short Message Service (SMS):
“CONNECT” to 686868
NEED2 Suicide
Prevention,
Education &
Support
Online support network for Canadian youth up to 30
years. The site offers a number of different methods of
digital communication to meet the needs of youth in
crisis.
Website:
www.youthspace.ca (6 pm – 12 am PT):
SMS: (778) 783-0177 (6 pm – 12 am PT)
UNITED STATES
JED Foundation A nonprot organization that exists to protect the
emotional health and prevent suicide of our nation’s
teens and young adults. JED equips these individuals
with the skills and knowledge to help themselves and
each other, and encourages community awareness,
understanding, and action for young adult mental health.
Website:
https://www.jedfoundation.org/events/
parents-action-fall-seminar-emotional-
well-begins-home/
National Alliance on
Mental Illness
Helping a loved one with mental illness can be
challenging but knowing where to begin is an important
rst step. The National Alliance on Mental Illness offers
family members and caregivers specic guidance on a
variety of issues, including how to help prevent suicide.
Website:
https://www.nami.org/Find-Support/
Family-Members-and-Caregivers/
Preventing-Suicide
Society for the
Prevention of Teen
Suicide
Helps parents and educators raise awareness about youth
suicide and attempted suicide through the development
and promotion of educational training programs.
The site also offers resources for teenagers who are
contemplating suicide.
Website: https://www.sptsusa.org/
Teen Health Helps parents decide whether their child’s behavior is
just a phase or a sign of something more serious
Website:
https://teenshealth.org/en/parents/emotions/
THRIVE app Designed by the Society for Adolescent Health and
Medicine. It helps guide parents in starting an important
dialogue with their teenage children on a variety of
health and wellness topics
App:
https://www.adolescenthealth.org/About-
SAHM/Healthy-Student-App-Info.aspx
To Write Love on
Her Arms
A nonprot that aims to help people struggling with
depression, addiction, self-injury, and suicide by
connecting them with the appropriate hotlines, resources,
and online communities through its blog and social
channels.
Website: https://twloha.com/
*Access to these resources may vary by country.
