ArticlePDF Available

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

  • Butler VA Health Care System


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.
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
© JCCA 2021
The views expressed in this article are those of the authors and do not reect the ofcial 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.
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 specic to the chiropractic
profession. Risk, modiable, 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)
: 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 modiables 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)
: prévention du suicide, chiropratique,
santé publique, biopsychosocial, prévention primaire,
prévention secondaire, prévention tertiaire
“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 specic 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 denitions 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
(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
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-specic. 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
selsh, 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 difcult 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 signicant 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
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 specic 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 unied resource for the following:
1) factors associated with suicide self-directed violence
relevant to common conditions seen in the chiropractic
ofce, 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.
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 identication, protective factor
identication, 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.
No articles reported a position statement regarding sui-
cide prevention and management specic to the chiro-
practic profession. We identied 93 articles relevant to
the implementation of public health approaches, suicide
prevention, risk factor screening, or crisis management
strategies for musculoskeletal providers.
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, modiable, 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 denitions to con-
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 modiable 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-
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 modiable 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 identied 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 ofce 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 dened
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 magnied 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 ofce,
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 identied in the
chiropractor’s ofce 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 (Modiable) 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
Post-traumatic stress disorder
Marital status
Sexual minority
Occupational status
Military service
Chronic medical illness (i.e. diabetes, cancer, HIV/
AIDS, chronic pain)
Childhood adversity
Rural residence
Active psychological symptoms
Suicidal ideation
Suicidal communication
Suicidal intent
Treatment adherence
Substance use
Psychiatric admission
Psychosocial stress
Problem-solving decits
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
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
identication 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 signicant 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-efcacy and that changes
in these factors can inuence 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 ofce that evaluate risk factors associat-
ed with self-directed violence and also assessment tools
specic 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 specic clinical characteristic co-occurrences sig-
nicantly 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
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
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, magnication,
feeling helpless).
13-item tool with a 4-item rumination subscale, 3-item magnication subscale, and 6-item helplessness
Pain Self-Efcacy Questionnaire
(PSEQ)77 Unidimensional assessment of self-efcacy 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
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
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 signicant 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
# Caution is advised in interpreting a single assessment tool as an indication of risk of suicide, unless the tool specically 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 identied 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 specic 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 benet 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 efciency 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 ofce)
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 qualied
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 stratied,
the patient is triaged to a clinically appropriate level of
care and is given the necessary treatment referrals, while
incorrect stratication 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 identica-
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 deciencies and symptoms of
psychological distress in patients who have attempted
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. Specic 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
signicant 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-
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-efcacy. 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 signicant 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 benecial 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 ofce
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
ofce, the implementation of suicide prevention efforts
in the ofce 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 ofce 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
ofce well to include established contact lists with avail-
able resources, something else that requires frequent up-
dating and verication of information accuracy. This may
be difcult in a solo provider ofce and in ofces 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 reect on clinic ow to de-
termine the feasibility of addressing suicide prevention
screening in the chiropractic ofce.
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 specic 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 ofce 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 condence 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
Biological, psychological, social, and cultural factors
all have a signicant 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.
1. Brown R. Chiropractic as part of the solution to the world
crisis in spine-related disability. J Chiropr Humanit.
2018; 25: 6-9. doi:10.1016/j.echu.2018.10.001
2. Himelfarb I, Hyland J, Ouzts N, Russell M, Sterling T,
Johnson C, et al. Practice Analysis of Chiropractic
2020 – A project report, survey analysis, and summary
of the practice of chiropractic within the United States.
National Board of Chiropractic Examiners. Accessed
June 25, 2020.
3. Tang NKY, Crane C. Suicidality in chronic pain: a
review of the prevalence, risk factors and psychological
links. Psychol Med. 2006; 36(05): 575. doi:10.1017/
4. Hassett AL, Aquino JK, Ilgen MA. The risk of suicide
mortality in chronic pain patients. Curr Pain Headache
Rep. 2014; 18(8): 436. doi:10.1007/s11916-014-0436-1
5. Santos J, Martins S, Azevedo LF, Fernandes L. Pain
as a risk factor for suicidal behavior in older adults:
a systematic review. Arch Gerontol Geriatr. 2020;87:
104000. doi:10.1016/j.archger.2019.104000
6. Alicandro G, Malvezzi M, Gallus S, La Vecchia C,
Negri E, Bertuccio P. Worldwide trends in suicide
mortality from 1990 to 2015 with a focus on the global
recession time frame. Int J Public Health. 2019; 64(5):
785-795. doi:10.1007/s00038-019-01219-y
7. Sentinel Event Alert 56: Detecting and treating suicide
ideation in all settings. Accessed March 31, 2020. https://
8. Mental Health: Suicide Data. World Health Organization.
Accessed May 28, 2020.
9. Varin M, Orpana HM, Palladino E, Pollock NJ,
Baker MM. Trends in suicide mortality in Canada by sex
and age group, 1981 to 2017: a population-based time
series analysis. Can J Psychiatry. 2021; 66(2): 170–178.
10. Bachmann S. Epidemiology of suicide and the
psychiatric perspective. Int J Environ Res Public Health.
2018 Jul 6; 15(7): 1425.
11. Josefowtiz N, Gurvey M, Dobson R, Weichel C.
Recognizing and helping the suicidal patient in
chiropractic practice. J Manipulative Physiol Ther. 1983;
6(2): 71–75.
12. Cupler, ZA, Daniels, CJ, Anderson, DR, Anderson MT,
Napuli JG, Tritt ME. Suicide prevention, public health,
and the chiropractic profession: a call to action. Chiropr
Man Therap. 2021; 29(1): 14.
13. Ganz D, Braquehais MD, Sher L. Secondary prevention
of suicide. PLoS Med. 2010; 7(6): e1000271.
14. Zitelli L, Palmer C. Recognizing and reacting to risk
signs for patient suicide. Semin Hear. 2018; 39(1): 83-90.
15. Carpenter DM, Lavigne JE, Roberts CA, Zacher J,
Colmenares EW. A review of suicide prevention programs
and training policies for pharmacists. J Am Pharm Assoc.
2018; 58(5): 522-529. doi:10.1016/j.japh.2018.05.004
16. Kashiwa A, Sweetman MM, Helgeson L. Occupational
therapy and veteran suicide: a call to action. Am J
Occup Ther. 2017; 71(5): 7105100010p1. doi:10.5014/
17. Green BN, Johnson CD, Haldeman S, Grifth
E, Clay MB, Kane EJ, et al. A scoping review of
biopsychosocial risk factors and co-morbidities for
common spinal disorders. PLoS One. 2018; 13(6):
e0197987. doi:10.1371/journal.pone.0197987
18. Gliedt JA, Schneider MJ, Evans MW, King J,
Eubanks JE. The biopsychosocial model and
chiropractic: a commentary with recommendations for
the chiropractic profession. Chiropr Man Ther. 2017;
25(1): 16. doi:10.1186/s12998-017-0147-x
19. Mishara BL, Dargis L. Systematic comparison of
recommendations for safe messaging about suicide in
public communications. J Affect Disord. 2019; 244: 124-
154. doi:10.1016/j.jad.2018.09.031
20. Crosby AE, Ortega L, Melanson C. Self Directed
Violence Surveillance: Uniform Denitions and
Recommended Data Elements, Version 1.0. Centers for
Disease Control and Prevention, National Center for
Injury Prevention and Control; 2011.
J Can Chiropr Assoc 2021; 65(2) 149
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
21. Schurtz DR, Cerel J, Rodgers P. Myths and facts about
suicide from individuals involved in suicide prevention.
Suicide Life Threat Behav. 2010; 40(4): 346-352.
22. Saxena S, Krug EG, Chestnov O. Preventing Suicide: A
Global Imperative. World Health Organization; 2014.
23. Fuller K. 5 Common Myths About Suicide Debunked.
National Alliance on Mental Illness (NAMI) Blog.
Published September 6, 2018. Accessed May 25, 2020.
24. Dazzi T, Gribble R, Wessely S, Fear NT. Does asking
about suicide and related behaviours induce suicidal
ideation? What is the evidence? Psychol Med. 2014;
44(16): 3361-3363. doi:10.1017/S0033291714001299
25. Arendt F, Scherr S, Niederkrotenthaler T, Krallmann S,
Till B. Effects of awareness material on suicide-related
knowledge and the intention to provide adequate help
to suicidal individuals. Crisis. 2018; 39(1): 47-54.
26. Fikar PE, Edlund KA, Newell D. Current preventative
and health promotional care offered to patients by
chiropractors in the United Kingdom: a survey. Chiropr
Man Ther. 2015; 23(1): 10. doi:10.1186/s12998-015-
27. Buettner-Schmidt K, Maack B, Larson M, Orr M,
Miller DR, Mills K. Systems change to improve tobacco
use identication and referral in the chiropractic setting:
a pilot study. Chiropr Man Ther. 2018; 26(1): 45.
28. Côté P, Bussières A, Cassidy, JD, Hartvigsen J,
Kawchuk GN, Leboeuf-Yde C, et al. A united statement
of the global chiropractic research community against
the pseudoscientic claim that chiropractic care
boosts immunity. Chiropr Man Ther. 2020; 28(1): 21.
29. Ilgen MA, Bohnert ASB, Ignacio RV, McCarthy JF,
Valenstein MM, Kim M, et al. Psychiatric diagnoses and
risk of suicide in veterans. Arch Gen Psychiatry. 2010;
67(11): 1152. doi:10.1001/archgenpsychiatry.2010.129
30. Conwell Y, Duberstein PR, Caine ED. Risk factors for
suicide in later life. Biol Psychiatry. 2002; 52(3): 193-
204. doi:10.1016/S0006-3223(02)01347-1
31. Hooten WM. Chronic Pain and Mental Health Disorders.
Mayo Clinic Proceedings. 2016 Jul; 91(7): 955–970.
32. Ranger TA, Cicuttini FM, Jensen TS, Manniche C,
Heritier S, Urquhart DM. Catastrophization, fear of
movement, anxiety, and depression are associated with
persistent, severe low back pain, and disability. Spine J.
2020; 20(6): 857-865. doi: 10.1016/j.spinee.2020.02.002.
33. Brown LA, Lynch KG, Cheatle M. Pain catastrophizing
as a predictor of suicidal ideation in chronic pain patients
with an opiate prescription. Psychiatry Res. 2020; 286:
112893. doi:10.1016/j.psychres.2020.112893
34. Coleman BC, Corcoran KL, DeRycke EC, Bastian LA,
Brandt CA, Haskell SG, et al. Factors associated with
posttraumatic stress disorder among veterans of recent
wars receiving veterans affairs chiropractic care. J
Manipulative Physiol Ther. 2020; 43(8): 753-759. doi:
35. Stone DM, Holland KM, Bartholow, B, Crosby AE,
Davis S, Wilkins, N. Preventing Suicide: A Technical
Package of Policy, Programs, and Practices. Atlanta,
GA; National Center for Injury Prevention and Control,
Centers for Disease Control and Prevention; 2017.
36. Bouch J, Marshall JJ. Suicide risk: structured
professional judgement. Adv Psychiatr Treat. 2005;
11(2): 84-91. doi:10.1192/apt.11.2.84
37. Corcoran KL, Bastian LA, Gunderson CG, Steffens C,
Brackett A, Lisi AJ. Association between chiropractic
use and opioid receipt among patients with spinal pain:
a systematic review and meta-analysis. Pain Med. 2020;
21(2): e139-e145. doi: 10.1093/pm/pnz219.
38. Whedon JM, Toler AWJ, Kazal LA, Bezdjian S,
Goehl JM, Greenstein J. Impact of chiropractic care on
use of prescription opioids in patients with spinal pain.
Pain Med. 2020; 21(12): 3567-3573. doi: 10.1093/pm/
39. Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA,
Becker WC, Edmond SN, et al. Opioid use among
veterans of recent wars receiving Veterans Affairs
chiropractic care. Pain Med. 2018; 19(suppl_1): S54-S60.
40. Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
Association between utilization of chiropractic services
for treatment of low-back pain and use of prescription
opioids. J Altern Complement Med. 2018; 24(6): 552-
556. doi: 10.1089/acm.2017.0131.
41. Meerwijk EL, Larson MJ, Schmidt EM, Adams RS,
Baurer MR, Ritter GA, et al. Nonpharmacological
treatment of army service members with chronic pain is
associated with fewer adverse outcomes after transition
to the Veterans Health Administration. J Gen Intern Med.
2020; 35(3): 775-783. doi:10.1007/s11606-019-05450-4
42. Hawk C, Schneider MJ, Haas M, Katz, P, Dougherty P,
Gleberzon B, et al. Best practices for chiropractic care
for older adults: a systematic review and consensus
update. J Manipulative Physiol Ther. 2017; 40(4): 217-
229. doi:10.1016/j.jmpt.2017.02.001
43. DiNapoli EA, Craine M, Dougherty P, Gentili A,
Kochersberger G, Morone NE, et al. Deconstructing
chronic low back pain in the older adult – step by
step evidence and expert-based recommendations for
evaluation and treatment. part V: maladaptive coping.
Pain Med. 2016; 17(1): 64-73. doi:10.1093/pm/pnv055
44. Dunn AS, Passmore SR, Burke J, Chicoine D. A Cross-
sectional analysis of clinical outcomes following
chiropractic care in veterans with and without post-
150 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
traumatic stress disorder. Mil Med. 2009; 174(6): 578-
583. doi:10.7205/MILMED-D-02-3508
45. Dunn AS, Julian T, Formolo LR, Green BN,
Chicoine DR. Preliminary analysis of posttraumatic
stress disorder screening within specialty clinic setting
for OIF/OEF veterans seeking care for neck or back
pain. J Rehabil Res Dev. 2011; 48(5): 493. doi:10.1682/
46. Dunn AS, Passmore SR. Consultation request patterns,
patient characteristics, and utilization of services
within a Veterans Affairs medical center chiropractic
clinic. Mil Med. 2008; 173(6): 599-603. doi:10.7205/
47. Ciaramella A, Poli P. Chronic low back pain: perception
and coping with pain in the presence of psychiatric
comorbidity. J Nerv Ment Dis. 2015; 203(8): 632-640.
48. Bazrafshan M-R, Jahangir F, Mansouri A, Kash SH.
Coping strategies in people attempting suicide. Int J High
Risk Behav Addict. 2014; 3(1). doi:10.5812/ijhrba.16265
49. World Health Organization and Calouste Gulbenkian
Foundation. Social determinants of mental health.
Geneva, World Health Organization. Published online
50. Ndetan HT, Bae S, Evans MW, Rupert RL, Singh KP.
Characterization of health status and modiable
risk behavior among United States adults using
chiropractic care as compared with general medical
care. J Manipulative Physiol Ther. 2009; 32(6): 414-422.
51. Johnson C, Green BN. Public health, wellness,
prevention, and health promotion: considering the role of
chiropractic and determinants of health. J Manipulative
Physiol Ther. 2009; 32(6): 405–12.
52. Samaan Z, Bawor M, Dennis BB, El-Sheikh W,
DeJesus J, Rangarajan S, et al. Exploring the
determinants of suicidal behavior: conventional and
emergent risk (DISCOVER): a feasibility study. Pilot
Feasibility Stud. 2015; 1(1): 17. doi:10.1186/s40814-
53. Institute of Medicine. Reducing Suicide: A National
Imperative. Washington, DC; National Academies Press;
2002. doi:10.17226/10398
54. Neufeld E, O’Rourke N. Impulsivity and hopelessness
as predictors of suicide-related ideation among older
adults. Can J Psychiatry. 2009; 54(10): 684-692.
55. Berardelli I, Corigliano V, Hawkins M, Comparelli A,
Erbuto D, Pompili M. Lifestyle interventions and
prevention of suicide. Front Psychiatry. 2018; 9: 567.
56. Lucas M, O’Reilly EJ, Mirzaei F, Okereke OI, Unger L,
Miller M, et al. Cigarette smoking and completed
suicide: results from 3 prospective cohorts of American
adults. J Affect Disord. 2013; 151(3): 1053-1058.
57. Vancampfort D, Hallgren M, Firth J, Rosenbaum S,
Schuch FB, Mugisha J, et al. Physical activity and
suicidal ideation: a systematic review and meta-analysis.
J Affect Disord. 2018; 225: 438-448. doi:10.1016/j.
58. Sibold J, Edwards E, Murray-Close D, Hudziak JJ.
Physical activity, sadness, and suicidality in bullied US
adolescents. J Am Acad Child Adolesc Psychiatry. 2015;
54(10): 808-815. doi:10.1016/j.jaac.2015.06.019
59. Brown DR, Blanton CJ. Physical activity, sports
participation, and suicidal behavior among college
students. Med Sci Sports Exerc. 2002; 34(7): 1087-1096.
60. Khan A, Uddin R, Kolbe-Alexander T. Promoting
physical activity and reducing sedentary behaviour
can minimise the risk of suicidal behaviours among
adolescents. Acta Paediatr. 2019; 108(6): 1163-1164.
61. Simon TR, Powell KE, Swann AC. Involvement in
physical activity and risk for nearly lethal suicide
attempts. Am J Prev Med. 2004; 27(4): 310-315.
62. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D,
Hass A, et al. Suicide prevention strategies: a systematic
review. JAMA. 2005; 294(16): 2064. doi:10.1001/
63. Desai N, Chavda P, Shah S, Shah N, Shah S, Sharma
E. A novel approach to suicide prevention – educating
when it matters. Ind Psychiatry J. 2018; 27(1): 115.
64. CCE Residency Program Accreditation Standards
– Principles, Processes & Requirements for
Accreditation. Published online July 2017.
Accessed May 15, 2020.
65. Bednarz EM, Lisi AJ. A survey of interprofessional
education in chiropractic continuing education in the
United States. J Chiropr Educ. 2014; 28(2): 152-156.
66. Stene-Larsen K, Reneot A. Contact with primary and
mental health care prior to suicide: a systematic review of
the literature from 2000 to 2017. Scand J Public Health.
2019; 47(1): 9-17. doi:10.1177/1403494817746274
67. Walby FA, Myhre MØ, Kildahl AT. Contact with mental
health services prior to suicide: a systematic review and
meta-analysis. Psychiatr Serv. 2018; 69(7): 751-759.
68. Luoma JB, Martin CE, Pearson JL. Contact with mental
health and primary care providers before suicide: a
review of the evidence. Am J Psychiatry. 2002; 159(6):
909-916. doi:10.1176/appi.ajp.159.6.909
J Can Chiropr Assoc 2021; 65(2) 151
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
69. Burnette C, Ramchand R, Ayer L. Gatekeeper training for
suicide prevention: a theoretical model and review of the
empirical literature. Rand Health Q. 2015; 5(1): 16.
70. Holmes G, Clacy A, Hermens DF, Lagopoulos J.
The long-term efcacy of suicide prevention gatekeeper
training: a systematic review. Arch Suicide Res. 2019; 6:
1-31. doi: 10.1080/13811118.2019.1690608.
71. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9:
Validity of a brief depression severity measure. J Gen
Intern Med. 2001; 16(9): 606-613. doi:10.1046/j.1525-
72. Sullivan MJL, Bishop SR, Pivik J. The pain
catastrophizing scale: development and validation.
Psychol Assess. 1995; 7(4): 524-532.
73. Van Wyngaarden JJ, Noehren B, Archer KR. Assessing
psychosocial prole in the physical therapy setting. J
Appl Biobehav Res. 2019; 24(2). doi:10.1111/jabr.12165
74. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale
Multidimensional Pain Inventory (WHYMPI). Pain. 1985;
23(4): 345-356. doi: 10.1016/0304-3959(85)90004-1.
75. Interian A, Chesin M, Kline A, Miller R, St Hill L,
Latorre M, et al. Use of the Columbia-Suicide Severity
Rating Scale (C-SSRS) to classify suicidal behaviors.
Arch Suicide Res. 2018; 22(2): 278-294. doi:10.1080/13
76. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief
measure for assessing generalized anxiety disorder:
the GAD-7. Arch Intern Med. 2006; 166(10): 1092.
77. Nicholas MK. The pain self-efcacy questionnaire:
taking pain into account. Eur J Pain. 2007; 11(2): 153-
163. doi:10.1016/j.ejpain.2005.12.008
78. Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ,
Foster NE, et al. A primary care back pain screening
tool: identifying patient subgroups for initial treatment.
Arthritis Rheum. 2008; 59(5): 632-641. doi:10.1002/
79. Wertli MM, Rasmussen-Barr E, Weiser S,
Bachmann LM, Brunner F. The role of fear avoidance
beliefs as a prognostic factor for outcome in patients
with nonspecic low back pain: a systematic review.
Spine J. 2014; 14(5): 816-836.e4. doi:10.1016/j.
80. Finley EP, Bollinger M, Noël PH, Amuan ME,
Copeland LA, Pugh JA, et al. A national cohort study of
the association between the polytrauma clinical triad and
suicide-related behavior among US veterans who served
in Iraq and Afghanistan. Am J Public Health. 2015;
105(2): 380–387.
81. Richards JE, Hohl SD, Whiteside U, Ludman EJ,
Grossman DC, Simon GE, et al. If you listen, I will talk:
the experience of being asked about suicidality during
routine primary care. J Gen Intern Med. 2019; 34(10):
2075-2082. doi:10.1007/s11606-019-05136-x
82. Bongar B, Sullivan G. The Suicidal Patient: Clinical and
Legal Standards of Care. 3rd ed. American Psychological
Association; 2013.
83. Carpiniello B, Pinna F. The reciprocal relationship
between suicidality and stigma. Front Psychiatry. 2017;
8(35). doi:10.3389/fpsyt.2017.00035
84. Thornicroft G, Mehta N, Clement S, Evans-Lacko S,
Doherty M, Rose D,et al. Evidence for effective
interventions to reduce mental-health-related stigma
and discrimination. Lancet. 2016; 387(10023): 1123-
1132. doi:10.1016/S0140-6736(15)00298-6
85. Lotito M, Cook E. A review of suicide risk assessment
instruments and approaches. Ment Health Clin. 2015;
5(5): 216-223. doi:10.9740/mhc.2015.09.216
86. Brodsky BS, Spruch-Feiner A, Stanley B. The zero
suicide model: applying evidence-based suicide
prevention practices to clinical care. Front Psychiatry.
2018; 9(33). doi: 10.3389/fpsyt.2018.00033.
87. National Guidelines for Behavioral Health Crisis Care
Best Practice Toolkit. Substance Abuse and Mental
Health Services Administration (SAMHSA). Published
online April 2020. Accessed April 26, 2021. https://www.les/national-guidelines-for-
88. Sall J, Brenner L, Millikan Bell AM, Colston MJ.
Assessment and management of patients at risk for
suicide: synopsis of the 2019 U.S. Department of
Veterans Affairs and U.S. Department of Defense clinical
practice guidelines. Ann Intern Med. 2019; 171(5): 343.
89. Bryan CJ, Mintz J, Clemans TA, Leeson B, Burch TS,
Williams SR, et al. Effect of crisis response planning vs.
contracts for safety on suicide risk in U.S. Army soldiers:
A randomized clinical trial. J Affect Disord. 2017; 212:
64-72. doi:10.1016/j.jad.2017.01.028
90. Wilcox HC, Wyman PA. Suicide prevention strategies
for improving population health. Child Adolesc Psychiatr
Clin N Am. 2016; 25(2): 219-233. doi:10.1016/j.
91. Gøtzsche PC, Gøtzsche PK. Cognitive behavioural
therapy halves the risk of repeated suicide
attempts: systematic review. J R Soc Med. 2017; 110(10):
404-410. doi:10.1177/0141076817731904
92. Tighe J, Nicholas J, Shand F, Christensen H. Efcacy
of acceptance and commitment therapy in reducing
suicidal ideation and deliberate self-harm: systematic
review. JMIR Ment Health. 2018; 5(2): e10732.
93. Linehan MM, Comtois KA, Murray AM, Brown MZ,
Gallop RJ, Heard HL, et al. Two-year randomized
controlled trial and follow-up of dialectical behavior
therapy vs therapy by experts for suicidal behaviors and
borderline personality disorder. Arch Gen Psychiatry.
2006; 63: 757-766.
152 J Can Chiropr Assoc 2021; 65(2)
The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide
94. VA/DOD Clinical Practice Guideline for The Assessment
and Management of Patients at Risk for Suicide.
Published online 2019. Accessed April 1, 2020.
95. Slee N, Garnefski N, van der Leeden R, Arensman E,
Spinhoven P. Cognitive-behavioural intervention for self-
harm: randomised controlled trial. Br J Psychiatry. 2008;
192(3): 202-211. doi:10.1192/bjp.bp.107.037564
96. Daigle MS, Pouliot L, Chagnon F, Greeneld B,
Mishara B. Suicide attempts: prevention of
repetition. Can J Psychiatry. 2011; 56(10): 621-629.
97. Patrick DL, Richardson M, Starks HE, Rose MA,
Kinne S. Rethinking prevention for people with
disabilities. Part II: A framework for designing
interventions. Am J Health Promot. 1997; 11(4): 261-
263. doi: 10.4278/0890-1171-11.4.261.
98. Brownson CA, Scaffa ME. Occupational therapy in the
promotion of health and the prevention of disease and
disability statement. Am J Occup Ther. 2001; 55(6): 656-
660. doi: 10.5014/ajot.55.6.656.
99. Möller HJ. Efcacy of different strategies of aftercare for
patients who have attempted suicide. J R Soc Med. 1989;
82(11): 643-647. doi:10.1177/014107688908201105
100. Andriessen K, Krysinska K, Kõlves K, Reavley N.
Suicide postvention service models and guidelines 2014–
2019: a systematic review. Front Psychol. 2019; 10:2677.
101. Salsbury SA, Goertz CM, Twist EJ, Lisi AJ. Integration
of doctors of chiropractic into private sector health
care facilities in the United States: a descriptive survey.
J Manipulative Physiol Ther. 2018; 41(2): 149-155.
102. Lisi AJ, Goertz C, Lawrence DJ, Satyanarayana P.
Characteristics of Veterans Health Administration
chiropractors and chiropractic clinics. J Rehabil Res Dev.
2009; 46(8): 997. doi:10.1682/JRRD.2009.01.0002
103. Kaeser MA, Hawk C, Anderson ML, Reinhardt, R.
Community-based free clinics: opportunities for
interprofessional collaboration, health promotion, and
complex care management. J Chiropr Educ. 2016; 30(1):
25-29. doi:10.7899/JCE-15-2
104. Kopansky-Giles D, Vernon H, Steiman I, Tibbles A,
Decina P, Goldin J, et al. Collaborative community-based
teaching clinics at the Canadian Memorial Chiropractic
College: addressing the needs of local poor communities.
J Manipulative Physiol Ther. 2007; 30(8): 558-565.
105. Riva JJ, Muller GD, Hornich AA, Mior SA, Gupta A,
Burnie SJ, et al. Chiropractors and collaborative care:
an overview illustrated with a case report. J Can Chiropr
Assoc. 2010; 54(3): 147-154.
106. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ,
Anderson ML, Hawkes RJ, et al. Effect of mindfulness-
based stress reduction vs cognitive behavioral therapy
or usual care on back pain and functional limitations
in adults with chronic low back pain: a randomized
clinical trial. JAMA. 2016; 315(12): 1240. doi:10.1001/
107. Ilgen MA, Kleinberg F, Ignacio RV, Bohnert ASB,
Valenstein M, McCarthy JF, et al. Noncancer pain
conditions and risk of suicide. JAMA Psychiatry. 2013;
70(7): 692-697.
108. Löfman S, Räsänen P, Hakko H, Mainio A. Suicide
among persons with back pain: a population-based study
of 2310 suicide victims in northern Finland. Spine. 2011;
36(7): 541–548.
109. Murphy JL, McKellar JD, Raffa SD, Clark ME,
Kerns RD, Karlin, BE. Cognitive behavioral therapy
for chronic pain among veterans: therapist manual.
Washington, DC: U.S. Department of Veterans Affairs.
110. D’Anci KE, Uhl S, Giradi G, Martin C. Treatments for
the prevention and management of suicide: a systematic
review. Ann Intern Med. 2019; 171(5): 334. doi:10.7326/
111. Hawton K, Witt KG, Taylor Salisbury TL, Arensman E,
Gunnell D, Hazell P, et al. Psychosocial interventions for
self-harm in adults. Cochrane Database Syst Rev. 2016;
(5): CD012189. doi:10.1002/14651858.CD012189
112. Working together to prevent suicide in Canada: the
federal framework for suicide prevention. Public Health
Agency of Canada. Published November 24, 2016.
Accessed April, 06, 2021.
113. American Public Health Association — For science. For
action. For health. Published online 2020. Accessed May
15, 2020.
114. Butler County – Prevent Suicide PA. Published
online 2018. Accessed May 15, 2020. https://www.
J Can Chiropr Assoc 2021; 65(2) 153
ZA Cupler, CJ Daniels, DR Anderson, MT Anderson, JG Napuli, ME Tritt
Appendix 1.
National crisis hotlines*
Crisis Hotline Title Crisis Hotline Description Crisis Hotline Contact Information
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)
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)
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)
National Suicide
Prevention Lifeline
The National Suicide Prevention Lifeline is
a national network of more than 150 local
crisis centers. It offers free and condential
emotional support around the clock to those
experiencing a suicidal crisis.
Phone: 800-273-8255 (24/7)
Online chat: (24/7)
Substance Abuse and
Mental Health Services
(SAMHSA) National
The Substance Abuse and Mental Health
Services Administration’s (SAMHSA)
national helpline offers condential
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)
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
The Veterans Crisis Line The Veterans Crisis Line is a free,
condential resource staffed by qualied
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:
chat (24/7)
Support for those who are deaf or hard of hearing:
*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.
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.
BetterHelp Connects people with licensed, professional
therapists online for a low, at fee. Therapy
is available whenever you need it.
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.
Outreach and
An international outreach organization
offering a variety of resources for those who
self-injure, including guides, stories, and
methods for day-to-day coping
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.
TrevorSpace TrevorSpace is an online international peer-
to-peer community for LGBTQ young people
and their friends.
7 Cups of Tea An online resource that offers free,
anonymous, and condential 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.
*Access to these resources may vary by country.
J Can Chiropr Assoc 2021; 65(2) 155
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
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
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
Education &
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
Website: (6 pm – 12 am PT):
SMS: (778) 783-0177 (6 pm – 12 am PT)
JED Foundation A nonprot 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.
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 specic guidance on a
variety of issues, including how to help prevent suicide.
Society for the
Prevention of Teen
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.
Teen Health Helps parents decide whether their child’s behavior is
just a phase or a sign of something more serious
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
To Write Love on
Her Arms
A nonprot 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
*Access to these resources may vary by country.
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Background Suicide is a major public health concern that has wide-reaching implications on individuals, families, and society. Efforts to respond to a public health concern as a portal-of-entry provider can reduce morbidity and mortality of patients. The objective of this commentary is a call to action to initiate dialogue regarding suicide prevention and the role the chiropractic profession may play. Discussion This public health burden requires doctors of chiropractic to realize current strengths and recognize contemporaneous deficiencies in clinical, research, and policy environments. With this better understanding, only then can the chiropractic profession strive to enhance knowledge and promote clinical acumen to target and mitigate suicide risk to better serve the public. Conclusion We implore the profession to transition from bystander to actively engaged in the culture of suicide prevention beholden to all aspects of the biopsychosocial healthcare model. The chiropractic profession’s participation in suicide prevention improves the health and wellness of one’s community while also impacting the broader public health arena.
Full-text available
Objectives Suicide is a complex global public health issue. The objective of this study was to assess time trends in suicide mortality in Canada by sex and age group. Methods We extracted data from the Canadian Vital Statistics Death Database for all suicide deaths among individuals aged 10 years and older based on International Statistical Classification of Diseases and Related Health Problems, Ninth Revision (E950-959; 1981 to 1999) and International Statistical Classification of Diseases and Related Health Problems, 10th Revision (X60-X84, Y87·0; 2000 to 2017) for a 37-year period, from 1981 to 2017. We calculated annual age-standardized, sex-specific, and age group-specific suicide mortality rates, and used Joinpoint Regression for time trend analysis. Results The age-standardized suicide mortality rate in Canada decreased by 24.0% from 1981 to 2017. From 1981 to 2007, there was a significant annual average decrease in the suicide rate by 1.1% (95% confidence interval, −1.3 to −0.9), followed by no significant change between 2007 and 2017. From 1981 to 2017 and from 1990 to 2017, females aged 10 to 24 and 45 to 64 years old, respectively, had a significant increase in suicide mortality rates. However, males had the highest suicide mortality rates in all years in the study; the average male-to-female ratio was 3.4:1. Conclusion The 3-decade decline in suicide mortality rates in Canada paralleled the global trend in rate reductions. However, since 2008, the suicide rate in Canada was relatively unchanged. Although rates were consistently higher among males, we found significant rate increases among females in specific age groups. Suicide prevention efforts tailored for adult males and young and middle-aged females could help reduce the suicide mortality rate in Canada.
Full-text available
Background: In the midst of the coronavirus pandemic, the International Chiropractors Association (ICA) posted reports claiming that chiropractic care can impact the immune system. These claims clash with recommendations from the World Health Organization and World Federation of Chiropractic. We discuss the scientific validity of the claims made in these ICA reports. Main body: We reviewed the two reports posted by the ICA on their website on March 20 and March 28, 2020. We explored the method used to develop the claim that chiropractic adjustments impact the immune system and discuss the scientific merit of that claim. We provide a response to the ICA reports and explain why this claim lacks scientific credibility and is dangerous to the public. More than 150 researchers from 11 countries reviewed and endorsed our response. Conclusion: In their reports, the ICA provided no valid clinical scientific evidence that chiropractic care can impact the immune system. We call on regulatory authorities and professional leaders to take robust political and regulatory action against those claiming that chiropractic adjustments have a clinical impact on the immune system.
Full-text available
The practice of educating individuals (known as ‘gatekeepers’ [GK]) at the informal social level with the knowledge, skills, and confidence to identify an at-risk individual and provide support has been shown as an effective suicide prevention method. Despite the efficacy of gatekeeper training (GKT) in the short-term, there are concerns over the long-term efficacy of these outcomes. The objective of this review was to identify the empirical GKT studies in the literature that included evaluations at pre, post, and follow-up. Additionally, this review aimed to evaluate the long-term effect of training on GK behavior. PubMed, Cochrane Library, and PsycNET databases were searched using the terms ‘gatekeeper’ and ‘suicid*’ present in the title and/or the abstract, with the terms ‘follow-up’, ‘pre-post’, or ‘long-term’ present in any text. Studies must have involved a suicide prevention program intervention provided to general members of the community. Knowledge and self-efficacy were shown to exhibit the strongest endurance of training effect, although some decay was present for knowledge over time (M follow-up delay 6.1 months). Gatekeeper attitude at follow-up (M follow-up delay 4.4 months) had returned to baseline levels in 57% (4/7) of the identified studies that evaluated this construct. Behavioral intention and behavior both indicate a weak training effect with poor translation of training into intervention behavior. Findings indicate the ideological and socio-cultural aspects of individual GKs should also be addressed to facilitate the improved potential for long-term attitudinal change. Future research directions are discussed.
Full-text available
Background: Suicide bereavement can have a lasting and devastating psychosocial impact on the bereaved individuals and communities. Many countries, such as Australia, have included postvention, i.e., concerted suicide bereavement support, in their suicide prevention policies. While little is known of the effectiveness of postvention, this review aimed to investigate what is known of the effects of postvention service delivery models and the components that may contribute to the effectiveness. Method: Systematic review and quality assessment of peer reviewed literature (Medline, PsycINFO, Embase, EBM Reviews) and gray literature and guidelines published since 2014. Results: Eight studies and 12 guidelines were included, with little evidence of effectiveness. Still, providing support according to the level of grief, involvement of trained volunteers/peers, and focusing the interventions on the grief, seem promising components of effective postvention. Conclusions: Adopting a public health approach to postvention can allow to tailor the service delivery to needs of the bereaved individuals and to align postvention with suicide prevention programs.
Objectives Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care. Methods A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression. Results We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis. Conclusion Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.
Objective: Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. Design and setting: We employed a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012-2017. Subjects: We included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. We identified two cohorts of subjects: Recipients received both primary care and chiropractic care, and nonrecipients received primary care but not chiropractic care. Methods: We performed adjusted time-to-event analyses to compare recipients and nonrecipients with regard to the risk of filling an opioid prescription. We stratified the recipient populations as: acute (first chiropractic encounter within 30 days of diagnosis) and nonacute (all other patients). Results: The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients filled an opioid prescription, as compared with recipients (in Connecticut: hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.11-2.17, P = 0.010; in New Hampshire: HR = 2.03, 95% CI = 1.92-2.14, P < 0.0001). Similar differences were observed for the acute groups. Conclusions: Patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.
Chronic pain and opioid use are associated with increased risk for suicidal ideation and behaviors (SIB) in cross-sectional studies, particularly among individuals who catastrophize about their pain. This study examined the longitudinal association between two styles of pain coping, catastrophizing and hoping/praying, as predictors of subsequent SIB, as well as possible mediators of this association among patients with chronic pain receiving long-term opioid therapy. Participants (n = 496) were adults with chronic nonmalignant pain on long-term opioid therapy who did not develop an opioid use disorder. Participants were assessed for pain coping, suicidal ideation, depression, social support and pain interference at baseline, and were reassessed for SI, depression, and pain interference at 6- and 12-month follow-ups. Catastrophizing was a significant predictor of increased subsequent SIB, whereas hoping/praying did not protect against future SIB. The relationship between catastrophizing and future SIB was mediated by depression, but not social support or pain interference. In conclusion, catastrophizing was an important predictor of subsequent SIB due to its effect on increasing depression among patients with chronic nonmalignant pain receiving long-term opioid therapy. Future research should explore the extent to which targeting catastrophizing reduces subsequent depression and suicide risk.
Background context: Psychological characteristics are important in the development and progression of low back pain (LBP), however their role in persistent, severe LBP is unclear. Purpose: To investigate the relationship between catastrophization, depression, fear of movement and anxiety and persistent, severe LBP and disability. Study design/ setting: One-year prospective cohort study PATIENT SAMPLE: Participants were selected from the SpineData registry (Denmark), which enrolls individuals with low back pain of 2- 12 months duration without radiculopathy and without satisfactory response to primary intervention. Outcome measures: Psychological characteristics, including catastrophization, depression, fear of movement, and anxiety, were examined at baseline using a validated screening questionnaire. Current, typical and worst pain in the past two weeks were assessed by 11-point numeric rating scales and an average pain score was calculated. Disability was measured using the 23-item Roland-Morris Disability Questionnaire. Methods: Participants completed baseline questionnaires on initial presentation to the Spine Center (Middelfart, Denmark), and follow-up questionnaires were sent and returned electronically. Statistical analysis involved multivariable Poisson regression to investigate the association between psychological factors and the number of episodes of severe pain or disability. This study received no direct funding. Results: Of the 952 participants at baseline, 633 (63.4%) provided data one year later. Approximately half of the participants reported severe LBP (n= 299, 47.2%, 95%CI 43.3% to 51.2%) or disability (n= 315, 57.6%, 95%CI 53.3% to 61.8%) at a minimum of one time point, and 14.9% (n= 94, 95%CI 12.2% to 17.9%) and 24.3% (n= 133, 95%CI 20.8% to 28.1%) experienced severe LBP or disability at two time points, respectively. Multivariable Poisson regression showed a relationship between catastrophization, depression, fear of movement and anxiety and a greater number of time points with severe LBP and disability, after adjusting for age, gender, body mass index and duration of symptoms. However, when all psychological factors were added to the regression model, only catastrophization and depression remained significantly associated. Conclusions: This study showed that persistent, severe LBP and disability is common in a secondary care population with LBP and is associated with a variety of psychological risk factors, in particular catastrophization and depression, highlighting the importance of considering these factors in the design and evaluation of outcomes studies for low back pain.
Objective: The objective of this systematic review was to examine whether pain is a risk factor for suicidal behavior (suicide ideation, suicide attempts or suicide) in older adults. Material and methods: An extensive search was conducted on the following databases: MEDLINE, ISI Web of Knowledge, Scopus and PsycARTICLES. Search terms used were "pain", "suicid*" and "elderly". Studies that assessed the relation between pain and suicidal behavior among people aged ≥60 years were included. Two reviewers independently screened the abstracts and applied selection criteria in the full-text of all included articles. Results: Results from 38 original research articles were included and reviewed. Moderate/severe pain increased the risk of suicide ideation from OR = 1.13 (95 %CI = 1.02-1.25) to OR = 2.7 (95 %CI = 1.1-7.0). The influence in suicide attempts ranged between OR = 1.92 (95 %CI 1.17-3.15) and 3.63-fold for extreme pain; and one article reported that the risk of a successful suicide was 4.07-fold higher in pain suffering patients. In most studies, this relation was maintained, even after controlling for other risk factors. Arthritis, back/neck problems and headaches were associated with higher risks of suicidal behavior. Pain was also a stronger predictor for suicide in men (OR = 9.9; 95 %CI = 6.0-16.4) than in women (OR = 3.3; 95 %CI = 1.4-7.7). Conclusion: Our results suggest the existence of a relationship between pain and suicidal behavior in older adults. This information may be extremely relevant to inform suicide prevention strategies.