Webinar 4: What are the most effective services to treat and prevent suicidal behavior?

Transcription

1 Webinar 4: What are the most effective services to treat and prevent suicidal behavior? April 29, 2015 National Council for Behavioral Health in Collaboration with the National Action Alliance for Suicide Prevention and the National Institute of Mental Health Webinar Series

2 Moderator Linda Ligenza, LCSW, is a licensed clinical social worker and Clinical Services Director for the National Council for Behavioral Health. She provides consultation and technical assistance to both the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) as well as National Council trauma initiatives. Ms. Ligenza brings a background and expertise in clinical, administrative and public policy work based on her 30 year career. She worked first with the New York State Office of Mental Health and subsequently with HHS Substance Abuse Mental Health Services Administration (SAMHSA) in their Traumatic Stress Services branch of the Center for Mental Health Services. Her area of expertise is in disaster trauma.

3 View Past Webinars in the series Why do people become suicidal? How can we better detect and predict suicide risk? What interventions prevent suicidal behavior?

4 Next Up Upcoming webinars in the series Wed., May 27: What suicide interventions outside of health care settings reduce risk? Wed., June 24: What research infrastructure doe we need to reduce suicidal behavior? View all upcoming webinars from the National Council at

5 Presenters Colleen Carr, MPH Manager of Policy and Stakeholder Engagement. Colleen is responsible for advancing policy efforts, delivering technical assistance focused on policy analysis and system change; developing high-level public and private-sector leadership communications and briefings; engaging Action Alliance Executive Committee members, and advancing Action Alliance priority initiatives and sustainability efforts. She has over ten years of experience working in public health and suicide prevention. She received her undergraduate degree from the University of North Carolina at Chapel Hill in Public Policy Analysis and her master s degree from Boston University in Public Health.

6 Presenters Jane Pearson, Ph.D. chairs the National Institute of Mental Health's (NIMH) Suicide Research Consortium. She is the Associate Director for Preventive Interventions in the Division of Services and Intervention Research, and she is currently leading the staffing for the National Action Alliance for Suicide Prevention Research Prioritization Task Force. Dr. Pearson serves as the National Institutes of Health representative to the DHHS Federal Steering Group on Suicide Prevention. She assisted in the development of the Surgeon General's Call to Action to Prevent Suicide and the first National Strategy for Suicide Prevention. She served as a member of the Veterans Administration Blue Ribbon Workgroup on Suicide Prevention. Dr. Pearson is an adjunct associate professor at Johns Hopkins University, a Fellow of the American Psychological Association, a recipient of a U.S. Health and Human Services Secretary's Award, the American Association of Suicidology Marsha Linehan Award for Treatment Research, and a Public Service award from the American Foundation for Suicide Prevention. She has had a private practice in clinical psychology, and has authored papers on the ethical and methodological challenges of suicide research.

7 Presenters Brian K. Ahmedani, PhD, LMSW, is a research scientist at Henry Ford Health System with appointments in the Center for Health Policy and Health Services Research and the Department of Psychiatry. He received both of his graduate degrees from Michigan State University, where he maintains an adjunct faculty appointment in the School of Social Work. Dr. Ahmedani is also a licensed clinical therapist in the State of Michigan. As a researcher, his main interests have centered around mental health/substance use services, with a special focus on suicide prevention. He is the PI or Site-PI of several research projects in these areas, including his role as Site-PI for the Mental Health Research Network, where he leads the Suicide Prevention Scientific Interest Group.

8 A PRIORITIZED RESEARCH AGENDA FOR SUICIDE PREVENTION: KEY QUESTIONS FOR BEHAVIORAL HEALTH PROVIDERS APRIL 29, 2015 National Council for Behavioral Health Webinar Series Released February

9 National Action Alliance for Suicide Prevention The Action Alliance is the Public/Private Partnership Advancing the National Strategy for Suicide Prevention (NSSP) in the U.S organizations are involved in Action Alliance activities (via the Executive Committee, 14 Task Forces, Priority Initiatives, and Advisory Groups). Mission: To advance the NSSP by: Championing suicide prevention as a national priority. Catalyzing efforts to implement high-priority objectives from the NSSP. Cultivating the resources needed to sustain progress.

10 Revised National Strategy for Suicide Prevention Zero Suicide Initiative: Major Action Alliance Accomplishments The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience Clinical Workforce: Guidelines for Training Action Alliance/Poynter Reporting Institute Prioritized Research Agenda for Suicide Prevention

11 What will be included in this webinar Brief Overview of the Prioritized Research Agenda for Suicide Prevention; this is the 4th of 6 webinars Consider the research needed to address Key Question 4 in the Agenda. What services are most effective for treating the suicidal person and preventing suicidal behavior?

12 Source: CDC vital statistics causes death.html Leading causes of death for selected age groups United States, 2013 Rank years years years years years years All Ages 1 Unintentional Injuries Unintentional Injuries Unintentional Injuries Unintentional Injuries Malignant Neoplasms Malignant Neoplasms Heart Disease 2 Malignant Neoplasms Suicide (4,878) Suicide (6,348) Malignant Neoplasms Heart Disease Heart Disease Malignant Neoplasm 3 Suicide (386) Homicide Homicide Heart Disease Unintentional Injuries Unintentional Injuries Chronic Low Resp Ds 4 Congenital Anomalies Malignant Neoplasms Malignant Neoplasms Suicide (6,551) Liver disease Chronic Low Resp Ds Unintentional injury 5 Homicide Heart Disease Heart Disease Homicide Suicide (8,621) Diabetes Mellitus Cerebrovascular 6 Heart Disease Congenital Anomalies Diabetes Liver Disease Diabetes Mellitus Liver Disease Alzheimer s disease 7 Chronic Low Resp Ds Influenza & pneumonia Liver Disease Diabetes Cerebro- Vascular Cerebrovascular Diabetes 8 Influenza & Pneumonia Diabetes HIV Cerebrovascu lar Chronic low resp ds Suicide (7,135) Influenza & Pneumonia 9 Cerebrovascular ds Complicated pregnancy Cerebrovascular HIV Septicemia Septicemia Nephritis 10 Benign neoplasms Chronic Low Resp Ds Influenza & Pneumonia Influenza & Pneumonia HIV Nephritis Suicide (40,600)

13 Research Prioritization Task Force Overarching Goal Overall U.S. rates of suicide deaths have not decreased appreciably in 50 years. Each year, over 678,000 individuals report that they received medical attention for a suicide attempt; each year, more than 30,000 individuals die by suicide. RPFT Goal: To develop an agenda for research that has the potential to reduce morbidity (attempts) and mortality (deaths) each, by at least 20% in 5 years, and 40% or greater in 10 years, if implemented successfully.

14 Research Prioritization Task Force Agenda Development Process Process Designed Burden of Suicide Deaths and Attempts Identified Literature Review and Portfolio Analysis NIH Request for Information (methodological roadblocks and proposed new paradigms) Stakeholder Survey and Delphi Process Selection of Aspirational Goals Research Agenda Development (short- and long-term objectives) Models of Potential Attempts Averted and Lives Saved Expert Consultants Claassen et al, 2013, Crisis Dissemination of Agenda Maintenance, Updating 14

15 Stakeholders Suicide research funders Scientists/Researchers Leaders of organizations and sectors that can reach individuals at risk Clinicians and care providers Survivors of suicide loss Overlapping Groups! Suicide attempt survivors Those at risk for suicide Concerned family members 15

16 Example Aspirational Research Ideas Proposed by Providers for the Prioritized Agenda Provide better training for clinicians; invest in evidence-based practice Use new technology to help those at suicide risk (and family members) link to affordable, affective care (e.g., phone apps; telehealth) Use collaborative care models to help clients navigate the fractured care systems Find safe and effective alternatives to emergency room care (long boarding times), like crises care 16

17 6 Key Questions & 12 Aspirational Goals (AGs) Question 1: Why Do People Become Suicidal? Aspirational Goal 1: Know what leads to, or protects against, suicidal behavior, and learn how to change those things to prevent suicide. Question 2: How Can We More Optimally Detect/Predict Risk? Aspirational Goal 2: Determine the degree of suicide risk (e.g., imminent, near-term, longterm) among individuals in diverse populations and in diverse settings through feasible and effective screening and assessment approaches. Aspirational Goal 3: Assess who is at risk for attempting suicide in the immediate future. Question 3: What Interventions Prevent Individuals From Engaging in Suicidal Behavior? Aspirational Goal 4: Ensure that people who are thinking about suicide but have not yet attempted, receive interventions to prevent suicidal behavior. Aspirational Goal 5: Find new biology treatments and better ways to use existing treatments to prevent suicidal behavior. Aspirational Goal 6: Ensure that people who have attempted suicide can get effective interventions to prevent further attempts. 17

18 6 Key Qs and 12 AGs (continued) Question 4: What Services Are Most Effective for Treating the Suicidal Person and Preventing Suicidal Behavior? Aspirational Goal 7: Ensure that health care providers and others in the community are well trained in how to find and treat those at risk. Aspirational Goal 8: Ensure that people at risk for suicidal behavior can access affordable care that works, no matter where they are. Aspirational Goal 9: Ensure that people getting care for suicidal thoughts and behaviors are followed throughout their treatment so they don t fall through the cracks. Aspirational Goal 10: Increase help-seeking and referrals for at-risk individuals by decreasing stigma. Question 5: What Other Types of Preventive Interventions (Outside Health Care Settings) Reduce Suicide Risk? Aspirational Goal 11: Prevent the emergence of suicidal behavior by developing and delivering the most effective prevention programs to build resilience and reduce risk in broad-based populations. Aspirational Goal 12: Reduce access to lethal means that people use to attempt suicide. Question 6: What Existing Infrastructure Can Be Better Utilized, and What New Infrastructure Needs Must Be Met In Order to Further Reduce Suicidal Behavior in the United States? 18

19 Suicide Burden (Attempts; Deaths) in the United States Attempts Deaths Note overlap in subgroups and multiple opportunities to detect individuals at risk U.S. Army (CONUS) ~200 (est.) Firearm Deaths (51% of all suicides) 19,392 1 Motor Vehicle CO Poisoning Deaths ~ American Indians/AN ~430 Criminal Justice System ~465 Jail and Prison Male Inmates Veterans ~500 3 Data Sources: 1. CDC WISQARS CDC WONDER Bureau of Justice Statistics DoDSER CY 2011 Report 5. Trofimovich et al Department of Veterans Affairs CDC WISQARS 2010 & Owens et al, 2002 Active Duty Military ~300 4 ~7,000 (est.) Military Veterans ~ Seen in Emergency Department for suicide attempt in past year ~ 7,800 7 Accessed healthcare within 30 days of death ~ 17,100 5

20 U.S. Funders of Suicide Research: Support of Services Research in Multiple Sectors U.S. Federal Government (Public) Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC) Department of Defense (DoD) Department of Veterans Affairs (VA) Department of Transportation (DOT)/Federal Railroad Administration (FRA) National Institutes of Health (NIH) National Institute of Justice (NIJ) National Science Foundation (NSF) Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Private Foundations American Foundation for Suicide Prevention (AFSP) Brain & Behavior Research Foundation (BBRF)

21 Key Question 4. What services are most effective for treating the suicidal person and preventing suicidal behavior? Jane Pearson, NIMH Brian Ahmedani, Henry Ford Health System

22 Why think about optimizing health care services? Regulatory demands Suicide events Minnesota Dept of Health Adverse Events, 2014

23 How to think about services research There are many components to health care services research. Today we ll discuss approaches to: Optimal training of providers Improving access to affordable care Continuity of care Increase help seeking and referrals for at-risk individuals by decreasing stigma

24 Optimal Training of Providers Training is a process with multiple components that can affect the outcome we are seeking reduced suicide risk in clients Need to consider individual clinician characteristics (discipline, experience, motivation); training approaches/design; and practice context & resources (Cross, 2013) Training research indicates incorporating role-playing and standardized patients is better than didactic learning alone (Hershell et al. 2010) Booster sessions needed; e.g. annual training, possibly online sessions (Dimeff et al., 2009) Consider staged training approaches, where all staff have basic knowledge and skills; advanced training provided to those more likely to see high risk patients (Osteen et al., 2014)

25 Optimal Training of Providers Practice ahead of research: 4 states require annual training on suicide prevention for school personnel: Alabama, Kentucky, Louisiana, Tennessee Washington requires 6 hours for suicide training for Behavioral Health Providers State of the science: To date, training study outcomes have included increased provider knowledge of suicide warning signs, and improved attitudes regarding need for/ benefits of/ suicide risk management. Limited focus on evidence-based assessment and interventions. So far, no agreed upon competencies nor consistent approaches to their assessment (Osteen et al., 2014).

26 Optimal Training of Providers Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention org/files/guidelines.pdf October 2014 Report Phase 1: Strong support from a broad range of professionals in the clinical workforce for guidelines for training programs in suicide prevention Phase 2: Adaptation of the guidelines by each discipline, educational institution, and licensing body, as necessary. Phase 3: Evolution to a practicing environment

27 Suicide rates: Where you live does matter Suicide rates higher where there is less access to trauma centers and where there are high rates of uninsured individuals (MacKenzie et al., 2006; Tondo, et al, 2006.) Youth in rural areas have rates double that of urban areas (Fontanella et al 2015) Rural residence is a Veteran suicide risk factor, even after controlling for mental health accessibility (McCarthy et al, 2012).

28 The Community Preventive Services Task Force (2012) Improving Access to Affordable Care Recommends mental health benefits legislation, particularly comprehensive parity legislation, based on sufficient evidence of: effectiveness in improving financial protection increasing appropriate utilization of mental health services increased access to care increased diagnosis of mental health conditions reduced prevalence of poor mental health reduced suicide rates Parity Laws & Suicide Stronger state mental health parity laws have been associated with decreases in suicide rates in the year after the law is enacted. This effect seen beyond unemployment rates (Lang, 2013; 2014)

29 Continuity of Care A Suicide Prevention Resource Center research review concluded the lack of continuity of care within and across systems increases suicide risk (Knesper, 2010). Changes in care in the Veterans health system (e.g., changes in medications) also related to increased suicide risk (Valenstein et al., 2009) Repeated follow-up contacts after hospitalization or emergency care have been found to reduce suicidal behavior (Luxton et al., 2013). What are the mechanisms of this benefit (Social Connection? Improved treatment adherence? Both?) How can health care systems build in continuity of care, and how can this type of quality improvement be tracked/ evaluated?

30 Increase help seeking and referrals for atrisk individuals by decreasing stigma* Both self-stigma and other-stigma reduces help seeking for suicidal thoughts and crises. Two research question examples: Most suicide decedent have been seen in primary care. How can patients and providers be encouraged to discuss patients suicidal thoughts? Does stigma explain why most adolescent attempters have had prior mental health treatment, but not treatment for their suicide ideation or behavior (Nock et al., 2013; Husky et al., 2012)? What health care changes could better address adolescent needs? *Using the term stigma in public messaging is not recommended, as it can reinforce negative attitudes and be counter-productive (e.g., Langford et al, 2013).

31 Perfect Depression and Zero Suicide The Perfect Depression Care (PDC) Initiative at Henry Ford Health System: Culture change focused on eliminating suicides among all patients Multi-level suicide risk assessments informed care pathways Numerous access points to care offered Reduction of access to lethal means Evidence-based psychotherapy training (CBT) Inspired others to develop the Zero Suicide, Action Alliance Clinical Care and Intervention Task Force Suicide prevention a core responsibility in health care Systematic Suicide Care...not a single, underpowered approach (e.g. a training) Applying new knowledge: o Screening o Personal safety plans o Treatment and support for suicidal feelings o Supportive contacts help keep people alive

32 Health Services Research Needed to Further Improve Suicide Prevention Ahmedani & Vannoy 2014

33 Health Services Research Needed to Further Improve Suicide Prevention

34 Health Services Research Needed to Further Improve Suicide Prevention

35 Health Services Research Needed to Further Improve Suicide Prevention

36 Health Services Research Needed to Further Improve Suicide Prevention

37 Health Services Research Needed to Further Improve Suicide Prevention

38 Health Services Research Needed to Further Improve Suicide Prevention

39 Health Services Research Needed to Further Improve Suicide Prevention

40 Key Question 4. What Services Are Most Effective for Treating the Suicidal Person and Preventing Suicidal Behavior? Short-term Objectives A. Identify efficient ways to increase the number of providers who implement adequate suicide assessment and management skills that improve care. B. In randomized practical trials, along with possible moderators (e.g., financial stress, patient age and gender) and intermediate outcomes (e.g., disengagement from care, functional limitations), find quality improvement components associated with reduced suicide risk. C. In at-risk populations, substantially increase effective help seeking and treatment engagement (e.g., involve family members and peers, information disseminated by media).

41 Key Question 4. What Services Are Most Effective for Treating the Suicidal Person and Preventing Suicidal Behavior? Long-term Objectives A. Prevent suicidal crises and injuries through effective novel care system practice approaches matched to at-risk patient needs (e.g., alternatives to inpatient care). B. Reduce suicide attempt and death outcomes through multiple, synergistic components of quality improvement with and across responsible systems (e.g., health care, justice systems, military installations, older adult care settings). C. Sustain effective quality improvements (e.g., stakeholder feedback mechanisms, such as service ratings and report cards, quality improvement collaborative involvement) that include input from those affected by those systems, including patients, providers, family members, policy leaders, and funders..

42 Social Media Connect with the Action Alliance via social media... Download the Research Agenda and the National Strategy for Suicide Prevention...

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44 Register for the next webinar in the series Wed., May 27: What suicide interventions outside of health care settings reduce risk?

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