Integrated Primary Care Approach to Suicidal Youth and Adults

Transcription

1 Integrated Primary Care Approach to Suicidal Youth and Adults Bill Elder, PhD Professor of Family and Community Medicine University of Kentucky College of Medicine

2 Source: Dr. Thomas Insel, PowerPoint Presentation, NIMH Alliance for Research Progress, February 7, 2014.

3 In 2014 there were 42,773 suicides in the U.S. (1 suicide every 12 minutes). Center for Disease Control WISQARS website, (January, 2016)

4 Expected outcome and objectives For the Primary Care setting An advanced set of knowledge and skills about how to understand and intervene with patients in suicidal crisis Recognize the problem Speak with the patient helpfully Assess correctly Understand more about how warm handoffs work.

5 Case Example A 15-year-old girl is brought to the emergency room by the lunchroom teacher, who observed her sitting alone and crying. On questioning, the teacher learned that the girl had taken five unidentified tablets after having had an argument with her mother about a boyfriend of whom the mother disapproved. Toxicology studies are negative, and physical examination is normal.

6 Which of the following is the most appropriate course of action? a. Hospitalize the teenager on the adolescent ward b. Get an IBH consult c. Get a social service consultation d. Arrange a family conference that includes the boyfriend e. Prescribe an antidepressant and arrange for a prompt clinic appointment

7 The adolescent who has attempted suicide should be hospitalized so that a complete medical, psychological, and social evaluation can be performed and an appropriate treatment plan developed. Hospitalization also emphasizes the seriousness of the adolescent s action to her and to her family and the importance of cooperation in carrying out recommendations for ongoing future therapy. The treatment plan may include continued outpatient psychotherapy or family therapy.

8 So they were in the hospital What do we know about that? Many suicides are in the hospitals Post hospitalization Suicide rates spike after hospitalization. Stay elevated for a year. Highest number of deaths first day. First two weeks are critical.

9 Leading Causes of Death by Age

10 Primary Care Suicide Facts Suicide has surpassed car accidents as the No. 1 cause of injury-related death in the United States. There has been a 28% increase in the number of suicides in the United States since Males complete suicide at a rate four times that of females. Females attempt suicide three times more often than males. Firearms most commonly used suicide method. nearly 50% of all completed suicides. Center for Disease Control WISQARS website, (January, 2016)

11 Planners 4-12% of those who attempt die 29% of those w/ thoughts of suicide Attempters 40% of those w/ plans SAMHSA, 2012

12 Primary Care Suicide Facts 3.3 percent of patients in an urban primary care outpatient clinic reported suicidal ideation (Zimmerman, 1995) Many pts who commit suicide have seen their PCP within several months before their death Most of the physicians unaware of the patients suicidal ideation or their prior attempts (Murphy, 1995)

13 Does USPSTF recommend routine screening by physicians for suicide? In a word No (LeFevre, 2014) the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. Unlike many diagnostic procedures assessing relatively stable phenomena, there is not, at present, a single test, or panel of tests that accurately identifies the emergence of a suicide crisis (Fowler, 2012)

14 Recommendation for physicians Screen all patients presenting with any type of psychological distress for suicide ideation

15 What about you in practice Should you routinely screen all clients for suicide?

16 Case Example A 28 year old married father of two comes to the office visit at the insistence of his wife. She accompanies him and is supportive. He was laid off 4 days ago, the only one on his team. PHQ-9 score = 13 (moderate depression) with suicidal ideation and worthlessness GAD-7 score = 15 (moderate to severe anxiety). Answers your questions openly. H & P: Red-eyes from crying. Tired from lack of sleep. No history of depression or substance abuse. No weapons at home.

17 Which of the following is the most appropriate course of action? a. Call a peace officer to take him to ER. b. Wife to take him to ER, calling the attending to suggest they admit him. c. Get a behavioral health consult d. Start him on any antidepressant that has the right side effect profile. e. Prescribe a brief course of an anxiolytic. f. Create a no suicide contract

18 Risk: Predisposing Factors US Geography Age Gender LGBT identity Race/Ethnicity Marital status Personality traits Occupation Economic factors

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20 Suicide Among Young Children? Very rare (CDC, 2009) Maybe not. 3 rd leading cause of death 33 suicides among children ages 5-1, (U.S ) Poor or non-existent concept of death Ideation rates are similar to adults once past 12. Highly circumstantial

21 Acute Risk Factors Mental health Addiction Physical health Interpersonal Life Stressor

22 Percentage of Suicides, by Age Group, Sex and Mechanism, United States, (CDC, 2009)

23 Medications and Suicide Specific medications that are currently being investigated for their role in possibly causing suicidal ideations: Anticonvulsants such as Depakote, Lyrica, and Neurontin Smoking cessation medications: Allergy medication: Singulair Acne medication: isotretitnoin (Accutane) Antidepressants: SSRIs when used with young people.

24 Psychiatric Illness and Suicide Review of psychological autopsy studies found that Mental Disorder was the strongest associated variable (Cavanaugh, 2003) > 44% of persons who commit suicide have a diagnosed psychiatric illnesses at the time of death (CDC,2014) 31% are in treatment at the time of their death Most often: depression (40%), Alcohol abuse (17.3%), or both 13.6% have an Other substance abuse problem Bipolar disorder (i.e., manic-depressive illness) and schizophrenia are also associated with suicide However, no disorder, including classification of diagnostic subtype, has been reliably shown to predict suicide by itself

25 Suicide Risk: Depression Patients with depression have a suicide risk that is 20x normal. Up to 15% of patients suffering from severe major depression commit suicide. Short-term risk of suicide is not necessarily decreased and may even be increased by antidepressants in adult patients. Increased suicide risk with SSRIs (2005 Cochrane review) No increased suicide risk with SSRIs (2005 meta-analysis)

26 Not Just Depression Suicidal ideation and behaviors occur in multiple mental disorders not just depressive disorders Odds highest in eating disorders with purging New tool to screen all distressed patients Level One Cross-cutting Symptom Measure 13 different psychological domains* Domain VI (item 11) is suicide thoughts of actually hurting yourself?

27 Suicide rate is not just a level of depression During the recession, the suicide rate for men grew at four times the rate for women. Divorced men kill themselves nearly 2.5 times as often as married men. There s no difference in the rates between divorced and married women. Men over eighty-five kill themselves thirteen times as often as women.

28 Suicide rate is not just a level of depression Age range Rate increase for males Age 9 Same rate Males twice as likely Males four times females Males five time females

29 Joiner s Interpersonal Theory of Suicide--Why People Die by Suicide 3 common factors (Joiner, 2005) among those at highest risk of death: 1. Feeling of being a burden on loved ones 2. Sense of isolation 3. The learned ability to hurt oneself 1. Practice results in overcoming fear of death 2. 40% of those who die by suicide have made a previous attempt (Cavanagh, 2003)

30 How the Three Factors are Related Thwarted Belongingness I Am Alone Desire For Suicide Preconceived Burdensomeness I am a burden Suicide or near-lethal suicide attempt Capability For Suicide My Family would be better off without me

31 Weighing Protective Factors Vs Risk Factors Known protective factors Children at home (except in custody disputes) Pregnancy A sense of responsibility to family Religiosity Generally protective Hope something to look forward to Resilience--positive coping skills Problem-solving skills Positive social support Positive doctor-patient relationship

32 Acute high risk for suicide 56% of suicides occur on first attempt In addition to factors described before, look for comorbid affective, substance abuse or anxiety disorders. Prospective study of 954 patients w/ mood disorders: Severity of ideation, past attempts, and hopelessness associated with suicide after 2-10 yrs. Severe psychic anxiety, panic attacks, severe insomnia, severe anhedonia, recent onset of alcohol abuse associated with suicide within one year. Study of 100 suicide attempts, 90% anxiety, 70% panic, 40% severe insomnia. Study of 76 inpatient suicides, 77% had 2 or more days of anxiety or agitation.

33 Responding to Suicidal Thoughts Listen Patients are best helped through any crisis by encouraging them to tell the details of their experience Intervene and assess directly or via warm hand-off Conduct Suicide Inquiry Evaluate Risk Consider Factors that Increase Acuity

34 To Identify Status and Lethality: Conduct Suicide Inquiry Status plus lethality Ideation---Intent---Plan and Lethality Three important questions: Do you ever feel hopeless or that life is not worth living? Have you thought of taking your life? How would you end your life?

35 Start intervention with: What s going on, do you think, that this is happening to you? Identifies the trigger Objectifies the suicidal thinking Puts patient into cognitive, problem solving mode.

36 Expectations for the Medical Professional for Outpatient Intervention Express care about the patient Express intent to help Crisis intervention: Consider warm hand off What is pressing the patient? What problem are they trying to solve? Assessment Suicide hotlines do work. Recommend them Contracts do not reduce suicides May prevent patient from getting back with you. Get commitment to contact you

37 Medication-Adults Starting an antidepressant is not sufficient treatment for suicidal ideation. Not all antidepressants are alike. TCAs have high risk for overdose. SIG #10 SNRIs and some SSRIs can cause jitteriness and may worsen patient distress. Educate the patient. Inpatient care norm appears to be mirtazapine but not first line treatment in primary care. Prescribe brief course of anxiolytics to manage acute anxiety Not if substance abuse risk. Replace with atypical antipsychotic if depression and anxiety continue after starting SSRI.

38 Instead of No Suicide Contracts Create a Proactive Plan for what to do if thoughts of suicide return Collaborate on a straightforward crisis plan: written down on the back of a business card, a 3 x 5 index card, or discharge paperwork MAKE A COPY FOR THE CHART Start the plan with: When I m upset and thinking of suicide, I ll take the following steps.

39 If Not Hospitalizing-- Restrict Means Make highly lethal means less accessible Attempt suicide with less lethal means or Delay suicide attempt Always assess whether the person has access to a firearm or other lethal means Work with them and their family to limit their access until they are no longer feeling suicidal Secure the contents of the medicine cabinet

40 Hospitalization Voluntary hospitalization Involuntary hospitalization Criteria: Danger to self or others by reason of mental illness May benefit from treatment Least restrictive environment Peace officer, physician, or family

41 Verified Petition for Involuntary Hospitalization or Involuntary Admission

42 Verified Petition for Involuntary Hospitalization or Involuntary Admission

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46 Case Introduction Patient: Juliette Demographics: 22 year old non- Hispanic white female Identifies as gay and currently has a girlfriend Lives with grandparents Primary diagnoses: Type 1 Diabetes and depression Follow-up visit with Primary Care Physician

47 Risk factors: Previous suicide attempt at 13 Suicidal ideation: wish to be dead, suicidal thoughts, suicidal intent without plan Negative events in significant relationship (argument with girlfriend) Previous psychiatric diagnosis (depression) Chronic medical problem (Type 1 diabetes) Protective factors: Reasons for living Responsibility to family and living with family Belief that suicide is immoral and high spirituality Engaged in college education

48 Results of C-SSRS o o Suicidal thoughts o No concrete plan o No intent o Did not appear of imminent harm to self or others. o + Previous attempt Moderate risk for suicidality

49 Many thanks to: UK IBH Team UKCoSW MSW students Substance Abuse and Mental Health Services Administration Center for Disease Control Amy Romaine, Grace Wilson and Tina Ryan all on the STFM Behavioral Science List Serve Tim Spruill, EdD, Florida Hospital Family Medicine Residency Program