ACTively Integrating Suicide Risk Assessment Into Primary Care Settings (original) (raw)
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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.
General Hospital Psychiatry, 2015
Objective: To understand emergency department (ED) providers' perspectives regarding the barriers and facilitators of suicide risk assessment and to use these perspectives to inform recommendations for best practices in ED suicide risk assessment. Methods: Ninety-two ED providers from two hospital systems in a Midwestern state responded to open-ended questions via an online survey that assessed their perspectives on the barriers and facilitators to assess suicide risk as well as their preferred assessment methods. Responses were analyzed using an inductive thematic analysis approach. Results: Qualitative analysis yielded six themes that impact suicide risk assessment. Time, privacy, collaboration and consultation with other professionals and integration of a standard screening protocol in routine care exemplified environmental and systemic themes. Patient engagement/participation in assessment and providers' approach to communicating with patients and other providers also impacted the effectiveness of suicide risk assessment efforts. Conclusion: The findings inform feasible suicide risk assessment practices in EDs. Appropriately utilizing a collaborative, multidisciplinary approach to assess suicide-related concerns appears to be a promising approach to ameliorate the burden placed on ED providers and facilitate optimal patient care. Recommendations for clinical care, education, quality improvement and research are offered.
Managing suicide risk in primary care: Practice recommendations for behavioral health consultants
Professional Psychology: Research and Practice, 2009
Psychologists working in primary care clinics can have a significant positive impact on preventing suicide. For psychologists working within the behavioral health consultant (BHC) model in primary care, however, the issue of how to appropriately manage suicide risk within this model has yet to be adequately addressed. Given the time-limited and focused nature of the BHC model, it is important to establish a framework for psychologists to provide adequate care that is practical within this model of health care. This article offers 26 empirically supported recommendations for suicide screening, accurate and time-efficient risk assessment, and effective risk management strategies, as well as suggestions for consultation with primary care physicians, all of which are consistent with the BHC model.
Suicide risk management: development and analysis of a telephone-based approach to patient safety
Translational Behavioral Medicine, 2011
Research-based queries about patients' experiences often uncover suicidal thoughts. Human subjects review requires suicide risk management (SRM) protocols to protect patients, yet minimal information exists to guide researchers' protocol development and implementation efforts. The purpose of this study was to examine the development and implementation of an SRM protocol employed during telephone-based screening and data collection interviews of depressed primary care patients. We describe an SRM protocol development process and employ qualitative analysis of de-identified documentation to characterize protocol-driven interactions between research clinicians and patients. Protocol development required advance planning, training, and team building. Three percent of screened patients evidenced suicidal ideation; 12% of these met protocol standards for study clinician assessment/intervention. Risk reduction activities required teamwork and extensive collaboration. Research-based SRM protocols can facilitate patient safety by (1) identifying and verifying local clinical site approaches and resources and (2) integrating these features into prevention protocols and training for research teams.
2005
A suicidal patient requires a prompt, coordinated intervention. In this paper, we describe a process for developing a suicidality policy, which may help clinics develop effective, locally adapted policies. We present the process in the framework of the Quality Improvement Plan-Do-Study-Act cycle. The process we describe occurred as part of a quality improvement project. Translating Initiatives for Depression into Effective Solutions (TIDES) is an evidence-based, quality improvement intervention for depression, implemented in seven Veterans Administration primary care clinics in five states. A multidisciplinary workgroup, the Collaboration Workgroup (CWG), created for this project supports the collaborative care process through evaluation and improvement of policies, including those for institutional response to suicidality. During the "plan" phase, the workgroup reviewed existing policies from each of the seven participating intervention clinics. This review revealed significant gaps and implementation difficulties. During the "do" phase, workgroup members developed or adapted site-specific policies as needed based on the initial CWG review, and assisted sites in implementing them. During the "study" phase, workgroup members reviewed what had worked and what had not worked in implementing policies for threatened suicide at each site, and identified a set of key features of successful policies. Features included a clearly defined chain of responsibility, well-defined followup procedures, and documentation of actions in the medical record. The workgroup developed templates that emphasized these key features but allowed for necessary local adaptation. Workgroup clinicians assisted clinics to implement site-specific policies. During the "act" phase, which is ongoing, site policies are in effect and are being evaluated.
Psychiatric services (Washington, D.C.), 2015
Objective: The study examined changes in self-reported attitudes and practices related to suicide risk assessment among providers at emergency departments (EDs) during a three-phase quasi-experimental trial involving implementation of ED protocols for suicidal patients. Methods: A total of 1,289 of 1,828 (71% response rate) eligible providers at eight EDs completed a voluntary, anonymous survey at baseline, after introduction of universal suicide screening, and after introduction of suicide prevention resources (nurses) and a secondary risk assessment tool (physicians). Results: Among participants, the median age was 40 years old, 64% were female, and there were no demographic differences across study phases; 68% were nurses, and 32% were attending physicians. Between phase 1 and phase 3, increasing proportions of nurses reported screening for suicide (36% and 95%, respectively, p<.001) and increasing proportions of physicians reported further assessment of suicide risk (63% and ...