Self-Assessment, Family Engagement and Treatment for Suicidal Youth: The SAFETY Program

Transcription

1 Self-Assessment, Family Engagement and Treatment for Suicidal Youth: The SAFETY Program Daphne Korczak MD MSc FRCPC(peds) FRCPC (psych) Director, Children s Integrated Mood and Body (CLIMB) Depression Program The Hospital for Sick Children. Assistant Professor, University of Toronto Katie Stadelman MSW RSW Psychiatric Social Worker, Inpatient and Day Treatment Programs, The Hospital For Sick Children. Adjunct Professor, University of Toronto

2 Objectives 1. To learn about a novel model for the treatment of acute suicidality among adolescents. 2. To appreciate the strength of family/caregiver engagement in the treatment of suicidal adolescents. 3. To discuss lessons learned and future directions.

3 Noah Noah is a 14 year old boy who lives at home with his parents. He enjoys socializing with his friends and plays competitive hockey. Since he started grade 9, there has been increasing conflict between him and his parents as Noah has been skipping school. Yesterday, his family received another call from the school, informing them that Noah had not attended school again. This led to a heated argument between Noah and his father. After the argument Noah decided he was going to end his life by hanging himself. He texted his mother to say goodbye. Noah s parents were able to reach him quickly and brought him to the Emergency Room, where he was assessed. He was admitted to the psychiatry unit for stabilization and further management.

4 Number of deaths Suicide in Canadian Children Year Olds: Cause of Death

5 Suicidal Ideation: Grade 9-12 Student survey: 17% seriously considered attempting suicide in the previous 12 months (22.4% of females and 11.6% of males) 14% made a plan about how they would attempt suicide in the previous 12 months (16.9% of females and 10.3% of males) Centre for Disease Control, 2015

6 Acute and Recurrent It is estimated that for every completed suicide, there are as many as 20 suicide attempts. Discharge Data: 10% of those hospitalized for depression in Canada were readmitted within 30 days, 30% were readmitted within 1 year. What are the best practices in the treatment of acutely suicidal youth? What are evidence-based treatments for the outpatient treatment of suicidal youth?

7 Suicide After Intentional Overdose in Ontario Adolescents (n=20,471) At 1 year: HR 32 1; 95% CI At 10 years: HR 9 8; 95% CI Finkelstein et al. (2015) Lancet Psychiatry

8 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls: Asarnow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB

9 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls Asarnow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB Facilitate engagement (aftercare) Ougrin (2011) n=70 Ther Assess t (x1) (+) adherence to aftercare (-) SRB

10 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls Asarnow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB Facilitate engagement (aftercare) Ougrin (2011) n=70 Therapeutic Assess (x1) (+) adherence to aftercare (-) SRB Increase safety skills, problem-solving behaviours Hazell (2009) n=72 Group (x10) (-) SI/SRB Green (2011) n=366 Group (x10) (-) SI/SRB Donaldson (2005) n=39 Individual (x10) (-) SI/SRB

11 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls Asarnow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB Facilitate engagement (aftercare) Ougrin (2011) n=70 Therapeutic Assess (x1) (+) adherence to aftercare (-) SRB Increase safety skills, problem-solving behaviours Hazell (2009) n=72 Group (x10) (-) SI/SRB Green (2011) n=366 Group (x10) (-) SI/SRB Donaldson (2005) n=39 Individual (x10) (-) SI/SRB Ask youth to nominate supports King (2009) n=448 YST (x1) (+) more contact w supports (-) SI/SRB

12 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls Asarnow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB Facilitate engagement (aftercare) Ougrin (2011) n=70 Therapeutic Assess (x1) (+) adherence to aftercare (-) SRB Increase safety skills, problem-solving behaviours Hazell (2009) n=72 Group (x10) (-) SI/SRB Green (2011) n=366 Group (x10) (-) SI/SRB Donaldson (2005) n=39 Individual (x10) (-) SI/SRB Ask youth to nominate supports King (2009) n=448 YST (x1) (+) more contact w supports (-) SI/SRB Involve parents/families Diamond (2010) n=66 ABFT (x10-20) (+)SI?SRB Roussow (2011) n=80 MBFT (x20) (+) SRB Harrington (1998) n=162 Brief FT (x4) (-) overall (+) if no MDD

13 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls Asarnow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB Facilitate engagement (aftercare) Ougrin (2011) n=70 Therapeutic Assess (x1) (+) adherence to aftercare (-) SRB Increase safety skills, problem-solving behaviours Hazell (2009) n=72 Group (x10) (-) SI/SRB Green (2011) n=366 Group (x10) (-) SI/SRB Donaldson (2005) n=39 Individual (x10) (-) SI/SRB Ask youth to nominate supports King (2009) n=448 YST (x1) (+) more contact w supports (-) SI/SRB Involve parents/families Diamond (2010) n=66 ABFT (x10-20) (+)SI?SRB Roussow (2011) n=80 MBFT (x20) (+) SRB Harrington (1998) n=162 Brief FT (x4) (-) overall (+) if no MDD Focus on parents/families Pineda & Dadds (2013) n=48 Parents only (x4) (+) SI/SRB

14 Interventions from the ED (RCT) Provide psychoeducation, follow up with phone calls Arsanow et al (2011) n=181 FISP (x1) (+) adherence to aftercare (-) SI/SRB Facilitate engagement (aftercare) Ougrin (2011) n=70 Therapeutic Assess (x1) (+) adherence to aftercare (-) SRB Increase safety skills, problem-solving behaviours Hazell (2009) n=72 Group (x10) (-) SI/SRB Green (2011) n=366 Group (x10) (-) SI/SRB Donaldson (2005) n=39 Individual (x10) (-) SI/SRB Ask youth to nominate supports King (2009) n=448 YST (x1) (+) more contact w supports (-) SI/SRB Involve parents/families Diamond (2010) n=66 ABFT (x10-20) (+)SI?SRB Roussow (2011) n=80 MBFT (x20) (+) SRB Harrington (1998) n=162 Brief FT (x4) (-) overall (+) if no MDD Focus on parents/families Pineda & Dadds (2013) n=48 Parents only (x4) (+) SI/SRB adherence? Family focussed, sufficient duration Brent 2013

15 Creating A Standardized Approach

16 3 Components Individual Environmental Family

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18 Individual Component PHASE 1

19 Patient Interviews Generally positive feedback Repetitive More space for artistic expression More graphics More variety in activities (less language based)

20 The SAFETY Workbook Formalizing approach Focus Groups Theory Driven Individual Safety Workbook

21 Safety Workbook CONSISTS OF 6 SECTIONS -Self Reflection -Family Functioning -Anger -Anxiety -Depression -Suicide Assessment and Reflection -Discharge Preparation

22 SWB

23 SWB

24 SWB

25 PHASE 2 Family/Caregiver Component

26 Family Working Visits Daily family sessions with parents/caregivers and child facilitated by frontline staff 1 hour Solution Focused Safety Planning Patient prepares topics to address Homework given

27 Topics Covered 1. Communication 2. Family functioning 3. Systemic Issues 4. Coping strategies 5. Safety planning

28 Parent Interviews Would like something to take home Their own crisis plan Local resources Written information on what was discussed in FWVs Felt uninformed about their child s SWB Internet Usage Working with schools

29 Parent Handbook

30 Parent Handbook About the SAFETY program Rules and expectations FAQ Safety checklist and check-ins Working with your child s school Internet usage FWV summary sheets Safety plan Community resources Crisis helplines

31 Parent Handbook

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33 Parent Handbook

34 Parent Handbook

35 PHASE 3 Therapist Component

36 Staff Interviews More evidence based modalities (CBT, DBT) Continuity of care between front-line care providers Family therapy skills Common questions from parents, rules, visiting etc. Visual therapeutic activities Activities for younger patients or patients with learning disabilities.

37 Case Studies Lucy is admitted to 7A Crisis Program following an overdose. It is her first day on the unit. She is on the first section of the SWB. You notice she has her head on her desk and is not completing the answers. What do you do?

38 Case Studies Raj is admitted to the unit after disclosing to his school counsellor that he has been self harming and has a plan for suicide. He is completing the SWB. When processing the section with him you notice this answer. What do you hope to achieve by being here? I am not really sure. I just want to feel better. How would you help Raj expand this.

39 Staff Training Ensure consistent approach Skills training Theoretical Approaches - DBT Family Therapy Skills Education sessions Staff handbook

40 Staff Training Frontline staff role in administering SAFETY Workbook

41 Administrator s Guide

42 Administrators Guide Staff roles Treatment phases Family therapy skills Supplementary worksheets Skills for common barriers to treatment

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49 Changing Contexts GROUP ACTIVITY

50 Next Steps Further evaluation of the SAFETY program Reproducibility of the program in other settings (e.g. emergency department/outpatient, community hospital)

51 Youth and Family Therapeutic Intervention vs. Case Navigation for Acutely Suicidal Youth in the Emergency Department: A Randomized Controlled Trial Sick Kids Daphne Korczak (PI) Yaron Finkelstein (Co-PI) Peter Szatmari Melanie Barwick Suneeta Monga Kate Stadelman CAMH Joanna Henderson Gloria Chaim Kristin Cleverley

52 Summary Suicide is a leading cause of death among Canadian youth. The Emergency Department presents a potential opportunity for secondary prevention of suicide among high-risk youth ED-based interventions have yielded disappointing results to date. Involving families may be an important treatment component that has not been included in many of these studies. The SAFETY program is a promising new, standardized, patient and family-centred program that is currently under evaluation.