Screening for Suicide Risk in Primary Care (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.
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.
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.
The Joint Commission Journal on Quality and Patient Safety, 2020
Introduction: Hospitals have become an important venue for identifying medical patients with occult suicidality. This article describes the implementation of a quality improvement project at the National Institutes of Health Clinical Center (NIHCC) to systematically screen medical/surgical inpatients for suicide risk. Methods: Using the Plan-Do-Study-Act method, questions from the Ask Suicide-Screening Questions (ASQ) tool were deployed with medical inpatients aged 10 years and older between April 2018 and April 2019. Goals included the development of a training program, policy and procedure review, electronic medical record integration and data collection, and ongoing management and troubleshooting. Results: A total of 4,284 patients were screened for suicide risk with a nurse screening compliance rate of 94.3%. Prevalence data on patients aged 10 years and older revealed an overall screen positive rate of 2.3% (97/4,284), with 3.1% of youth aged 10 to 24 years and 2.2% of adults screening positive. Of the 97 patients who screened positive, 96 were non-acute positive screens. Of the full sample, only 1 patient (0.02%) was deemed acute positive, requiring a 1:1 observer and full safety precautions. Conclusion: Universal suicide risk screening was successfully implemented in the NIHCC without incurring a need for additional resources. The intermediate step of a brief suicide safety assessment is a critical part of the workflow, providing guidance for determining appropriate follow-up in a safe and efficient manner that spares limited mental health and hospital resources. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral.
Suicide screening in general hospitals [letter]
This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues.
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.
Clinicians Should Not Adopt a Single Self-Reported Item as a Screener for Suicide
The Journal of clinical psychiatry, 2016
Letters to the Editor Clinicians Should Not Adopt a Single Self-Reported Item as a Screener for Suicide To the Editor: In their recent article, Green and associates state that item 9 of the Beck Depression Inventory, an item that pertains to suicide ideas and plans, should be used as "a brief, efficient screen for suicide risk in routine clinical care" 1(p1683) and that "clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen." 1(p1683) They imply that psychiatric outpatients and patients seen in the emergency department after a suicide attempt who do not self-report suicide ideas (with a score of 0 on item 9) do not need a "suicide risk assessment and corresponding risk management plan." While we acknowledge that item 9 might distinguish between high-and low-risk groups for suicide in a statistical sense, we believe the authors have overstated the case for its use as a routine screening tool in these populations. The World Health Organization (WHO) has very well-established guidelines outlining when screening is worthwhile. 2,3 WHO suggests that a specific diagnostic test should be available to follow a sensitive but nonspecific screening procedure like item 9. 2,3 However, there are no tests for future suicide that are specific enough to usefully divide patients into those at high or low likelihood of future suicide. 4,5 Further, according to WHO, a useful intervention should be available to justify screening. 2,3 However, there are no highly effective treatments that specifically prevent suicide or suicide attempts, and certainly none that have effectiveness over the very long period of follow-up described in the recent study. Finally, WHO recommends that screening should be shown to reduce overall morbidity or mortality. 2,3 Despite over 50 years of suicide risk research, it has never been shown that allocating treatment resources on the basis of suicide risk assessment results in fewer suicides. The thoroughness of a psychiatric assessment in these populations should never be determined by the simple presence or absence of self-reported suicidality. Every psychiatric outpatient and every patient seen in an emergency department after a suicide attempt should be thoroughly, sympathetically, and personally assessed by a mental health professional who should then be in a position to offer treatment in line with the patient's needs and wishes. 6 Unfortunately, there are no shortcuts in this realm of clinical practice.
Development and evaluation of the Clinician Suicide Risk Assessment Checklist
Advances in Mental Health, 2006
This paper describes the development and evaluation of a new instrument-the Clinician Suicide Risk Assessment Checklist (CSRAC). The instrument assesses the clinician's competency in three areas: clinical interviewing, assessment of specific suicide risk factors, and formulating a management plan. A draft checklist was constructed by integrating information from 1) literature review 2) expert clinician focus group and 3) consultation with experts. It was utilised in a simulated clinical scenario with clinician trainees and a trained actor in order to test for inter-rater agreement. Agreement was calculated and the checklist was re-drafted with the aim of maximising agreement. A second phase of simulated clinical scenarios was then conducted and inter-rater agreement was calculated for the revised checklist. In the first phase of the study, 18 of 35 items had inadequate inter-rater agreement (60%>), while in the second phase, using the revised version, only 3 of 39 items failed to achieve adequate inter-rater agreement. Further evidence of reliability and validity are required. Continued development of the CSRAC will be necessary before it can be utilised to assess the effectiveness of risk assessment training programs.
Patient Opinions About Screening for Suicide Risk in the Adult Medical Inpatient Unit
The journal of behavioral health services & research, 2016
As hospital clinicians and administrators consider implementing suicide risk screening on medical inpatient units, patient reactions to screening can provide essential input. This post hoc analysis examined patient opinions about screening for suicide risk in the medical setting. This analysis includes a subsample of a larger quality improvement project designed to screen medically hospitalized patients for suicide risk. Fifty-three adult medical inpatients at a clinical research hospital provided opinions about suicide risk screening. A qualitative analysis of responses to an opinion question about screening was conducted to identify major themes. Forty-three (81%) patients supported screening medical inpatients for suicide risk. Common themes emphasized asking patients directly about suicide, connection between mental/physical health, and the role of screening in suicide prevention. Adult medical inpatients supported screening for suicide risk on medical/surgical inpatient units. ...