Suicide Prevention: From a Pharmacist s Perspective. Daina L. Wells, Pharm.D., BCPS, BCPP VA PBM Academic Detailing Service

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1 Suicide Prevention: From a Pharmacist s Perspective Daina L. Wells, Pharm.D., BCPS, BCPP VA PBM Academic Detailing Service

2 CPE Information and Disclosures Daina L. Wells declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

3 CPE Information Target Audience: Pharmacists and Pharmacist Technicians ACPE#: L04-P/T Activity Type: Knowledge-based

4 Learning Objectives Explain the role of the CPS in transitions of care. Identify best practices related to transitions of care and suicide prevention. Explain the role of the pharmacist in suicide prevention.

5 Self-Assessment Questions Suicide is the leading cause of death in the U.S. a) 3 rd b) 5th c) 10th d) 15th

6 Suicide Prevention National Issue 10th leading cause of death in the nation 45,000 deaths per year nationally Veteran Issue Military Issue

7 Important Figures

8 Rates are Highest Among Younger Male Veterans Rate per 100,000 population Comparison of Suicide Rates by Age Group For Veteran Males, 2015

9 Magnitude of Suicide is Highest Among Men Age Number of Suicides Comparison of Suicide Counts by Age Group For Veteran Males, 2015

10 Suicide is preventable but it s happening more and more We can change the trend

11 The Joint Commission Sentinel Event Alert A complimentary publication of The Joint Commission (Issue 56, February 24, 2016) At the point of care, providers often do not detect the suicidal thoughts (also known as suicide ideation) of individuals (including children and adolescents) who eventually die by suicide, even though most of them receive health care services in the year prior to death, usually for reasons unrelated to suicide or mental health.

12 The Challenges We Face Preventing Patient Suicide Stigma Fear of doing the wrong thing or missing something Complex patients Overwhelmed healthcare practitioners Lack of training and education amongst healthcare professionals regarding suicide prevention

13 Asking about suicide will plant the idea in my patients head Asking how your patient feels doesn t create suicidal thoughts any more than asking about chest pain will cause angina

14 Role of Healthcare Providers in Suicide Prevention Ensure appropriate management of mental health and medical conditions Recognize and identify patients at risk for suicide Evaluate suicide risk Recommend care, make referrals, and follow-up

15 Components of Suicide Risk Assessments VA/DoD Guidelines 1. Suicidal ideation 2. Suicidal intent 3. Preparatory behavior/plan 4. Previous suicide attempt 5. Risk factors, protective factors 6. Level of risk assessment 7. Suicide risk reduction plan May also conceptualize by using Substance Abuse and Mental Health Services Administration screening tool, SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) Suicide Risk Assessment Guide Look for warning signs, assess risk, protective factors, ask the questions, respond in an appropriate way

16 Key Roles for Pharmacists Ensure appropriate Key Roles management for Pharmacists of mental health and medical conditions Medication Management Monitor medication use and mental health status Review and optimize medication treatment plans E.g., deprescribing, appropriate treatment for medical and mental health conditions Collaborate with other practitioners to ensure conditions are being adequately managed (e.g., referrals for psychotherapy)

17 Recognition and treatment of patients with psychiatric disorders is essential Mood or affective Mental disorders Health (major depression, Opportunities bipolar, post-partum) Schizophrenia Anxiety Posttraumatic Stress Disorder (PTSD) Substance Use Disorder (e.g., alcohol, opioids, nicotine) Insomnia Mental Health Opportunities Education regarding the association between mental health disorders and suicide is needed Psychiatric disorders are diagnosed in more than 90% of completed suicides 50-75% of those in need receive inadequate treatment

18 Medical Condition Medication Management Opportunities The issue extends beyond Mental Health Chronic pain Terminal disease HIV/AIDS Chronic illness (e.g., diabetes) All clinicians can play a role in identifying risk

19 Key Roles for Pharmacists Recognize and identify patients at risk for suicide

20 Risk Factors for Suicide

21

22

23 How are We Asking About Suicidality?

24 Compassion

25 Self-Assessment Questions Asking about suicide will plant the idea in my patients head a) True b) False c) Unsure

26 Who Does the Patient Trust on the Healthcare Team? Do not pass judgement Suicide can be understood by the individual as an attempt to solve a problem they find overwhelming Remain calm and listen more than you speak Recognize that the situation is serious but remain calm, empathetic, and objective Be aware of your non-verbal communication as well as your tone and pace. Asking about suicide quickly is more likely to lead to an omission of information

27 Key Roles for Pharmacists Evaluating level of suicide risk Determining level of risk can help confidence in providing an appropriate recommendation and help the patient get the care they need

28 VA Identified Pharmacist Role to Screen Based on Area of Practice Primary screen (PHQ-9 Item 9) Secondary Screen (C-SSRS Screen) VA Comprehensive Suicide Risk Assessment Mental Health CPS* Primary Care CPS** *Training and Practice Authority **Clinical Reminder Driven Columbia-Suicide Severity Rating Scale (C-SSRS), Available at

29 Primary Screen Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way? Secondary Screen CSRE VA Uses a Standardized Screening Question 29

30 Primary Screen Secondary Screen (C-SSRS) CSRE Q1: Wish to be dead Q2: Suicidal Thoughts Q3: Suicidal Thoughts with Method (no specific plan or intent to act) Q4: Suicidal Thoughts with Some Intent (no specific plan) Q5: Suicidal Thoughts with Specific Plan and Intent to carry out plan Q6: Suicidal Behavior, Lifetime and Past 3 months Response Options for all questions: YES or NO

31 VA Comprehensive Suicide Risk Evaluation (CSRE) CSRE Includes: Suicidal Ideation History of Attempts Warning Signs Risk Factors Primary Screen Protective Factors and Reasons for Living Secondary Screen Clinical Impressions of Acute Risk (low, intermediate, high) Clinical Impressions of Chronic Risk (low, intermediate, high) Disposition: Strategies for Mitigating Risk, including appropriate level of care CSRE

32 VA CPS Document Key Interventions PhARMD Project Tool is used across practice settings by VA CPS to document intervention capture Used by over 5,200 pharmacists across the VA Includes over 50 disease conditions and 170 individual interventions Suicide Risk Assessment, Screening and/or Education Intervention is captured as a component of CMM services Pharmacists Achieve Results with Pharmacists Achieve Results with Medications Demonstration (PhARMD)

33 PBM CPPO PhARMD Tool September 2018 Suicide Risk Assessment/Screening/Education Performed by Pharmacists per Quarter: July 2014 through July 2018

34

35 Key Roles for Pharmacists Recommend care, make referrals, and follow-up Lethal means safety counseling Safety planning crisis standard operating procedure or treatment plan for crisis Referrals for care, using the team Connecting the patient to higher-levels of care if needed

36 Self-Assessment Questions What is the most common lethal means used in suicides? a) Medication b) Illicit drugs (e.g. heroin) c) Suffocation d) Firearm

37 Lethal Means 25.90% 11.30% 51% Drug Poisoning Firearm Suffocation U.S. Data 2016; NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates.

38 Lethal Means Safety Counseling Gun locks Opioid overdose education and naloxone distribution (OEND) Medication lock boxes or safe storage options Limit medication quantities dispensed Medication disposal options

39 Academic Detailing Pharmacists

40 Strong Practice Factors Every CPS should be aware of the facility and/or clinic resources and emergency plan Care Coordination Agreement Guidance on documentation of activities Clear team collaboration, including process for referrals to higher levels of care Defined responsibility of the CPS in the monitoring plan High Risk Committee membership pharmacists can take a more active role in suicide prevention team efforts

41 Suicide Prevention Resources SAMHSA website National Suicide Prevention Lifeline Call, chat, text ( or text )

42 42

43 Key Points Suicide is a public health crisis Pharmacists have an important role in suicide prevention

44 Answers To Self-Assessment Questions Suicide is the leading cause of death in the U.S. a) 3 rd b) 5th c) 10th d) 15th Asking about suicide will plant the idea in my patients head a) True b) False c) Unsure

45 Answers To Self-Assessment Questions What is the most common lethal means used in suicides? a) Medication b) Illicit drugs (e.g. heroin) c) Suffocation d) Firearm

46 Closing Remarks Daina L. Wells, Pharm.D., BCPS, BCPP VA PBM Academic Detailing

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