Managing suicide risk in primary care: Practice recommendations for behavioral health consultants (original) (raw)

Suicide prevention in primary care

Postgraduate Medicine, 2000

Suicide prevention has been named a national priority and much work has been done to review existing evidence and identify gaps in how our nation's mental health and health care systems address this public health challenge. A national task force that was part of the effort to update the national suicide prevention strategy reviewed research and best practices from the field and concluded that suicide prevention could be improved in health care. The task force found three common characteristics among successful suicide prevention programs in health care settings. Health care staff in these organizations: k Believed that suicide can be prevented in the population they serve through improvements in service access and quality, and through systems of continuous improvement; k Created a culture that finds suicide unacceptable and sets and monitors ambitious goals to prevent suicide; and k Employed evidence-based clinical care practice, including standardized risk stratification, evidence-based interventions, and patient engagement approaches 1. Addressing Suicide Prevention for Underserved Patients 1 Background: Suicide-The Problem and the Opportunity 2 A. Why primary care should make suicide care a priority 2 B. Primary care teams can be champions of the Zero Suicide Approach 4 C. How primary care providers and administrators can take action 5 Part One: Routine Screening and Assessment in Primary Care 6 A. Linking suicide and depression screening in primary care 6 B. Know common risk factors and warning signs 7 C. Review of screening protocol and tools 8 D. Suicide risk assessment 9 Part Two: Care Management and Referral Processes 14 A. Care Management Plan 14 B. Brief evidence-based interventions 15 C. Referrals and the Stepped Care Model 18 D. Care transitions 19 Part Three: Other Considerations 23 A. Recommendation for monitoring through the Quality Improvement program 24 B. Addressing concerns about liability 24 C. Resources and tools for workforce development 25 The Association of Clinicians for the Underserved would like to acknowledge the partnership and support of Centene Corporation on this toolkit. Their generous funding, thought leadership, and collaboration allowed ACU to create this resource and its associated trainings. Additionally, ACU would like to acknowledge the partnership with the Institute for Family Health and Dr. Virna Little in the development of this project. Their expertise was instrumental in the material included here and the associated trainings for primary care providers. BACKGROUND: Suicide-The Problem and the Opportunity A. Why primary care should make suicide care a priority The rate of suicide deaths is increasing Suicide is a leading cause of death of the United States, cited as the cause of death for nearly 45,000 Americans in 2016 2. The suicide rate among individuals age 10 and older has increased by 30 percent since 1999 3. A report released by the Centers for Disease Control and Prevention (2018) revealed that suicide rates increased in all but one state between 1999 and 2016. In 2016, 9.8 million adults aged 18 and older, or about 4 percent of the adult population, reported serious thoughts of suicide 4. Suicide is linked to social determinants of health 5 Suicide is rarely caused by any single factor. Diagnosed depression or other mental health conditions are reported for less than half (46 percent) of suicide deaths. Other factors that contribute to suicide deaths include relationship problems, substance use, physical illness and chronic conditions, job loss, and financial troubles 6. The National Strategy for Suicide Prevention calls for a comprehensive approach to suicide prevention that includes action at individual, family, community, and societal levels 7. Primary care teams are uniquely positioned to identify risk and intervene Primary care providers in particular have a unique opportunity to incorporate suicide prevention into established health risk assessment and patient safety practices 8. Approximately 45 percent of individuals who died by suicide visited a primary care provider in the month before their death 9, 10. Suicide is often discussed in the context of mental illness, and suicide prevention is considered an issue that mental health agencies and systems should address. However, given that mental health conditions are only one of many factors that contribute to suicide risk, it is incumbent upon all sectors of the U.S. healthcare system to adopt evidence-based approaches to identify and care for those at risk for suicide. Health Disparities and Suicide Facts Gender k The suicide rate for males (21.3 per 100,000) is triple the rate for females (6.0) in the U.S. in 2016 11. k Suicide was the 7th leading cause of death among all males in the U.S. and the 2nd leading cause of death for males aged 15-34 in 2015 12. k Although males are at higher risk for suicide, between 1999 and 2016 the suicide rate increased at a higher rate among females (2.6%) as compared to males (1.1%) 13. Age k Young adults, aged 18 to 25 are more likely to have serious thoughts of suicide (approximately 8.8 percent) 14. k Although White males 75 years of age and older have the highest rates of suicide (48.0 per 100,000), the highest number of deaths from suicide occur among males aged 50-54 15. Race/Ethnicity k American Indian and Alaska Native populations have the highest rates of suicide overall, followed by non-Hispanic Whites, Asian and Pacific Islands, Blacks, and Hispanic/Latino(a). Urban/Rural k Suicide rates are higher in rural communities than in urban communities overall. The gap in suicide rates between rural and urban areas grew steadily between 1999 and 2015. k Non-Hispanic blacks were the only population that differed in this trend and have higher suicide rates in urban areas than in rural areas. k The suicide rate among American Indian and Alaska Native populations in rural areas is double the national average 16. k Access to firearms may contribute to disparities in suicide rates in rural areas 17. Special Populations k Justice involved individuals are at increased risk for suicidal thoughts or behaviors. Suicide is the third leading cause of death in prisons 18. k The suicide rate among Veterans is 41% higher than among the general U.S. population 19. k Youth in foster care may also be at an increased risk for suicidal behaviors.

Assessment and Management of Suicide Risk in Primary Care

Crisis: The Journal of Crisis Intervention and Suicide Prevention, 2014

Background: Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. Aims: To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. Method: Data collection from clinical proformas, case records, and semistructured face-to-face interviews with general practitioners. Results: Primary and secondary care data were available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall κ = .127, p = .10). Depression, care setting (after discharge), suicidal ideation at last contact, and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices, and 33% of staff received training in suicide risk assessments. Conclusion: Risk is diffi cult to predict, but the variation in risk assessment between professional groups may refl ect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.

Screening for Suicide Risk in Primary Care

2013

The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

Potential for suicide prevention in primary care? an analysis of factors associated with suicide

1998

Background. General practitioners (GPs) need to be aware of the risk factors for suicide. GP records may provide clues to identifying the relative importance of such risk factors. Aims. To identify, in suicide cases and matched controls, the patterns of consultation, diagnosis, and treatment of mental illness, and recording of risk factors for suicide. To examine the usefulness of data routinely collected by GPs in computerized databases to investigate treatment of patients in general practice prior to suicide. Method. Case control study using GP records from the General Practice Research Database (GPRD). Three controls selected for each case, matched for age, sex, and duration of registration with practice. Information extracted of the prevalence of major disease; diagnosis of, and treatment, or referral for, mental illness; frequency of recording of recent life events; and consultations with the GP in the 12 months prior to death. Result. Of the 339 suicide cases recorded, 80% were male, which is similar to the national percentage for this age group.

ACTively Integrating Suicide Risk Assessment Into Primary Care Settings

The Journal of ambulatory care management

Adequate evaluation and response to suicide risk require (i) awareness of need, (ii) comfort gathering key information, and (iii) ongoing training. A survey administered at 2 urban primary care settings in the process of implementing integrated care measured awareness, comfort, and training related to suicide risk assessment among 31 primary care providers (PCPs). Greater PCP comfort asking patients about psychological trauma was associated with more frequent engagement in safety planning with suicidal patients. Findings highlight the need for trauma-informed primary care while showcasing the importance of enhancing PCP training to support their expanded role within the integrated health team.

Risk Assessment of Suicide in Clinical Practice

Journal of Addiction and Dependence, 2016

Suicide is a global public health problem. Its management in clinical practice is complex and challenging .Studies show about 26% suicide in mental health system. Out of these, 14% commit suicide during hospital stay; about 50-90% have at least one psychiatric diagnosis. 60-70% of patients are hospitalized due to an attempt or potential crisis, about 15-20% attempt suicide prior to admission. Suicide is also common in post-discharge period. Every psychiatrist on an average loses atleast on client due to suicide in an average span of 20 years of practice. In about 70% of cases, suicide behavior is there as on for hospitalization in acute settings. Continuous training and skill development are two of the most important measures in clinical practice for dealing with suicide behavior. High suicide rates are reported in prodromal stage, acute illness, post-hospitalization and soon after discharge in the community. A clinician faces challenging situations while determining the level of care and referral for a patient with a high suicide potential. There is continued struggle amongst clinicians for decision-making in regards to the need for hospitalization, level of monitoring, voluntary status, and time of discharge. It is generally agreed that suicide is difficult to predict and prevent; however, in order to develop clinical excellence and offer a standard of care, continued education and knowledge translation for bringing research into practice is the least that can be done. Inspite of this need, continued education for mental health professionals and psychiatrists in-training remains limited.

Suicide Prevention in mental health patients: the role of primary care

2015

Background: Primary care may be a key setting for suicide prevention as many patients visit their General Practitioner (GP) in the weeks leading up to their death. Comparatively little is known about GPs’ perspectives on risk assessment, treatment adherence, management of and interactions with suicidal patients prior to the patient’s suicide and the services available in primary care for suicide prevention. Aim: This study aimed to explore primary care data on a clinical sample of individuals who died by suicide and were in recent contact with mental health services in order to: investigate the frequency and nature of general practice consultations; examine risk assessment, treatment adherence and management in primary and secondary care; gain GPs’ views on patient non-adherence to treatment and service availability for the management of suicidal patients. Method: A mixed-methods study design including data from the National Confidential Inquiry on 336 patients who died by suicide, ...