Suicide Safer Care for Primary Care Providers. Warren Jay Pires, LCSW

Suicide Safer Care for Primary Care Providers Virna Little, PsyD, LCSW r, SAP, CCM Warren Jay Pires, LCSW

Discussion for Workshop Primary Care Providers Role in Suicide Safe Care Identifying Patients at Risk for Suicide Assessing Patients at risk for Suicide Safety Planning Office Based Interventions for Primary Care Providers

1. A Call to Action for Primary Care Providers THE OPPORTUNITY Americans visited primary care physicians 462 million times in 2008, a number that is expected to increase to 565 million by 2025. While the primary reason for this increase is due to population growth, it is also attributed to an aging population and expanded access to insurance. Both older adults and those who previously did not have access to care are historically underserved populations who have had difficulty accessing quality care, especially mental health care. (Petterson et al, 2012) Primary care patients who are at risk of suicide often do not tell their provider that they are experiencing thoughts of killing themselves, and too often, providers do not ask. One study found that 45 percent of people who have died by suicide visited their primary care physician within a month of their death, with older adults having higher rates of contact with primary care providers within one month of suicide than younger adults. In one of the highest risk groups adults suffering from a major depressive episode 60.7 percent received treatment from a primary care provider. (Ahmedani et al, 2014) Most primary care providers are starting screen for substance abuse; which is a significant risk factor for suicide, especially alcohol. Adults aged 18 or older with past year illicit drug or alcohol dependence or abuse were more likely than those without dependence or abuse to have had serious thoughts about suicide in the past year (12.2 vs. 3.0 percent). Adults with substance dependence or abuse also were more likely to make suicide plans compared with adults without dependence or abuse (3.1 vs. 0.9 percent) and were more likely to attempt suicide compared with adults without dependence or abuse (1.7 vs. 0.4 percent). (SAMHSA, 2010) These data show that primary care providers are in a unique position to leverage their patients trust to create a sense that suicide is not the only option available to ease their pain. The actions taken by primary care providers and staff can help to save a life by engaging the patient and the patient s family and other loved ones in planning for safety and ultimately reducing suicide rates "I began to hear about more people in my community dying by suicide, many of them were or had been my patients I knew it was time to do something different in how I addressed suicide in my practice" NowMattersNow.org 2018 All Rights Reserved

WHY FOCUS ON HEALTH CARE SETTINGS» 84% of those who die by suicide have a health care visit in the year before their death.» 92% of those who make a suicide attempt have seen a health care provider in the year before their attempt. Almost 40 percent of individuals who died by suicide had an ED visit, but not a mental health diagnosis. Luoma, J.B., Martin, C.E., & Pearson, J.L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916.. NowMattersNow.org 2018 All Rights Reserved

What We Sometimes Hear.. I refer all of my patients out to mental health ( patients at risk for suicide have diabetes!) I don t have the knowledge to assess or intervene With such a short amount of time I don t have time to ask or address suicide risk We have so many other initiatives

JOINT COMMISSION SENTINEL EVENT ALERT 56: DETECTING AND TREATING IDE IDEATION IN ALL SETTINGS SUIC The suggested actions in this alert cover suicide ideation detection, as well as the screening, risk assessment, safety, treatment, discharge, and follow-up care of at-risk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care. NowMattersNow.org 2018 All Rights Reserved

Discussing the Columbia (continued) The Minimum HOW (to do it) IN YOUR OFFICE Do not Panic Be Present (listen closely and reflect) Provide some hope (you ve been through a lot, I see that strength) Language Matters! NowMattersNow.org 2018 All Rights Reserved

Identification Many offices are screening for depression Ask patients directly ( ask what you want to know!) Social determinants play a role Many patients don t have depression Substance and alcohol use play a role Transitions are a time of risk Do you know how many patients in your practice are at risk?

"I just always run into the issue where as soon as things start becoming difficult, they just immediately suggest that I go to the mental hospital and I just cannot stress enough that it was not a good environment for me. And, they still suggest that I go back, when it ll just make things worse... It just seems like that s one of their first options when it should be a last resort (P168)."

Assessing Risk Can and does happen in primary care settings Helpful to know speak the same language and understand assessment process This is the primary care visit

SUICIDE RISK SCREENING PATHWAY [See accompanying text document] EMERGENCY DEPARTMENT Sponso red by AACAP s Abramson Grant. Created by PaCC workgroup of Physically Ill Child Committee. Presentation to ED Medically able to answer questions? NO YES Administer ASQ (ideally separate from parents) Screen when medically able YES Patient refuses to answer? NO YES on any question 1-4? YES YES to Q5? NO YES NEGATIVE SCREEN Exit Pathway NO Non-acute Positive Screen; Conduct Brief Suicide Safety Assessment (BSSA) BSSA outcome(three possibilities) LOW RISK No further evaluation needed in the ED HIGH RISK Further evaluation of suicide risk is necessary; should not leave without a full safety assessment IMMINENT RISK Patient is at imminent risk for suicide with current suicidal thoughts 1SAFETY EDUCATION Create safety plan for potential future suicidal thoughts Discusssuicidemeansrestriction Provide Resources: 24/7 National Suicide Prevention Lifeline 1-800-273-TALK (8225) En Español:1-888-628-945 4 24/7 Crisis Text Line: Text START to 741-741 Conduct Full Suicide Safety Assessment Notify family; Alert ED provider INITIATE SAFETY PRECAUTIONS 2 should not leave without a full safety assessment 2SAFETY PRECAUTIONS Per institution protocol; keep patient under direct observa tion, remove dangerous items, etc. REFERRAL to further mental health care as appropriate; continue medical care; initiate safety education 1 ; communicate positive screen to PCP NO Needs inpatient psychiatric hospitalization? YES Initiate or maintain safety precautions; medically stabilize patient Is patient being admitted for medical treatment? NO YES Transfer to psychiatric unit Safety precautions to be followed throughout transfer process Handoff clinical risk assessment information to accepting psychiatric unit upon transfer from ED Handoff clinical risk assessment information to accepting medical unit upon transfer from ED Transfer to medical unit Safety precautions to be followed throughout transfer process V6.18.18

as What to do when a pediatric patient screens positive for suicide risk: NIMH TOOLKIT: OUTPATIENT Brief Suicide Safety Assessment Suicide-Screening.Ask uestions Use after a patient (10-24 years) screens positive for suicide risk on the asq Assessment guide for mental health clinicians, MDs, NPs, or PAs Prompts help determine disposition 1 Praise patient I m here to follow up on your responses to the suicide risk screening questions. These are hard things to talk about. Thank you for telling us. I need to ask you a few more questions. 2 Assess the patient Review patient s responses from the asq Frequency of suicidal thoughts Determine if and how often the patient is having suicidal thoughts. Ask the patient: In the past few weeks, have you been thinking about killing yourself? If yes, ask: How often? (once or twice a day, several times aday,a couple times a week, etc.) When was the last time you had these thoughts? Are you having thoughts of killing yourself right now? (If yes, patient requires an urgent/ STAT mental health evaluation and cannot be left alone. A positive response indicates imminent risk.) Suicide plan Assess if the patient has asuicideplan, regardless of how they responded to any other questions (ask about method and access to means). Ask the patient: Do you have aplan to kill yourself? If yes, ask: What is your plan? If no plan, ask: If you were going to kill yourself, how would you do it? Note: If the patient has a very detailed plan, this is more concerning than if they haven t thought it through in great detail. If the plan is feasible (e.g., if they are planning to use pills and have access to pills), this is areasonfor greater concern and removing or securing dangerous items (medications, guns, ropes, etc.). Past behavior for discussing their thoughts Evaluate past self injury and history of suicide attempts (method, estimated date, intent). Ask the patient: Have you ever tried to hurt yourself? Have you evertried tokill yourself? If yes, ask: How? When? Why? and assess intent: Did you think [method] would kill you? Did you want to die? (for youth, intent is as important as lethality of method) Ask: Did youreceive medical/psychiatric treatment? Note: Past suicidal behavior is the strongest risk factor for future attempts. (If possible, assess patient alone depending on developmental considerations and parent willingness.) Symptoms Ask the patient about: Depression: In the past few weeks, have you felt so sad or depressed that it makes it hard to do the things you would like to do? Anxiety: In the past few weeks, have you felt so worried that it makes it hard to do the things you would like to do or that you feel constantly agitated/on edge? Impulsivity/Recklessness: Do you often act without thinking? Hopelessness: In the past few weeks, have you felt hopeless, like thingswould neverget better? Anhedonia: In the past few weeks, have you felt like you couldn t enjoy the thingsthatusually make youhappy? Isolation: Have you been keeping toyourself morethanusual? Irritability: In the past few weeks, have you been feeling more irritable or grouchier than usual? Substance and alcohol use: In the past few weeks, have you used drugs or alcohol? If yes, ask: What? How much? Sleep pattern: In the past few weeks, have you had trouble falling asleep or found yourself waking up in the middle of the nightorearlierthanusualinthe morning? Appetite: In the past few weeks, have you noticed changes in your appetite? Have you been less hungry or more hungry than usual? Other concerns: Recently, have there been any concerning changes in howyou are thinkingorfeeling? Social Support & Stressors (For all questions below, if patient answers yes, ask them to describe.) Support network: Is there a trusted adult you can talk to? Who? Haveyoueverseena therapist/counselor? If yes, ask: When? Family situation: Are there any conflicts at home that are hard to handle? School functioning: Do you ever feel so much pressure at school (academicorsocial) that youcan t take itanymore? Bullying: Are you being bullied or picked on? Suicide contagion: Do you know anyone who has killed themselvesortried tokill themselves? Reasons for living: What are some of the reasons you would NOTkill yourself? asq Suicide Risk Screening Toolkit

3 4 5 6 as NIMH TOOLKIT: OUTPATIENT Brief Suicide Safety Assessment Suicide-Screening.Ask uestions Interview patient & parent/guardian together If patient is 18 years, ask patient s permission for parent/guardian to join. Say to the parent: After speaking with your child, Ihave some concerns about his/her safety. We are glad your child spoke up as this Have you noticed changes in your can be a difficult topic to talk about. We would now like to get your child s: o Sleeping pattern? perspective. o Appetite? Your child said (reference positive responses on the asq). Doesyour child use drugs or alcohol? Is this something he/she shared with you? Doesyour child have ahistory of suicidal thoughts or behavior that you re aware of? If yes, say: Please explain. Does your child seem: o Sad or depressed? o Anxious? oimpulsive? o Hopeless? o Reckless? ounable to enjoy the things that usually bring him/her pleasure? owithdrawnfrom friends or to be keeping to him/herself? Make a safety plan with the patient After completing the assessment, choose the appropriate disposition plan. If possible, nurse should follow up with acheck in phone call (within48 hours) with all patients who screenedpositive. q Emergency psychiatric evaluation: Patient is at imminent risk for suicide (current suicidal thoughts). Send to emergency department for extensive mental health evaluation (unless contact with a patient s current mental health provider is possible and alternative safety plan for imminent risk is established). q Further evaluation of risk is necessary: Review the safety plan and send home with a mental health referral as soon as patient can get an appointment (preferably within 72 hours). q Patient might benefit from non-urgent mental health follow-up: Review the safety plan and send home with a mental health referral. q No further intervention is necessary at this time. For all positive screens, follow up with patient at next appointment. Provide resources to all patients Hasanyone in your family/close friend network ever tried tokill themselves? How are potentially dangerous items stored in your home? (e.g. guns, medications, poisons, etc.) Doesyour child have atrustedadult they can talk to? (Normalize that youth are often more comfortable talking to adults who are not their parents) Are you comfortable keeping your child safe at home? At the end of the interview, ask the parent/guardian: Is there anything you would like to tell me in private? Include the parent/guardian, if possible. Create a safety plan for managing potential future suicidal thoughts. A safety plan is different than making a safety contract ; asking the patient to contract for safety is NOT effective and may be dangerous or give a false sense of security. Say to patient: Our first priority is keeping you safe. Let s work together to develop asafetyplan for when you are having thoughts of suicide. Examples: I will tell my mom/coach/teacher. I will call thehotline. I will call. Discuss coping strategies to manage stress (such as journal writing, distraction, exercise, self soothing techniques). Determine disposition Discuss means restriction (securingorremovinglethal means): Research has shown that limiting access to dangerous objects saves lives. How will you secure or remove these potentially dangerous items (guns, medications, ropes, etc.)? Asksafetyquestion: Do you think you need help to keep yourself safe? (A no response does not indicate that the patient is safe; but a yes is areasontoact immediately to ensure safety.) 24/7 National Suicide Prevention Lifeline 1 800 273 TALK (8255) En Español: 1 888 628 9454 24/7 Crisis Text Line: Text HOME to 741 741 asq Suicide Risk Screening Toolkit

What is a suicide attempt? A self injurious act, committed with at least some intent to die, as a result of the act.

Columbia Suicide Severity Rating Scale (CSSRS) Screening for Suicide Risk in Primary Care

CSSRS Screener for Primary Care 1 to 5 scale of suicidal ideation Timeframe Behaviors

CSSRS Using the CSSRS increases efficiency and saves resources and lives by focusing attention on people at elevated risk can be administered in under 1 minute provides simple to use and consistent language within and across sites guides next steps.

Trainings Links and information on trainings can be found at: http://cssrs.columbia.edu/training/training options/

What is Safety planning? Safety Planning Intervention consists of a written, prioritized list of coping strategies and sources of support that patients can use to alleviate a suicidal crisis. Stanley, B., & Brown, G. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256 264.

Discussing the Columbia (continued) The Minimum WHAT (to do) BEFORE THEY LEAVE YOUR OFFICE Suicide Prevention Lifeline or Crisis Text Line in their phone 1 800 273 8255 and text the word Hello to 741741 Address guns in the home and preferred method of suicide Give them a caring message (NowMattersNow.org More ) NowMattersNow.org 2018 All Rights Reserved

NowMattersNow.org Works Website visits are associated with decreased intensity of suicidal thoughts and negative emotions. This includes people whose rated their thoughts as completely overwhelming NowMattersNow.org 2018 All Rights Reserved

Safety Planning Program Lifeline or hotline into phone and call I am going to step out to see my next patient.. Call someone from the patients team Sarah and I would like to speak with you, she has listed you on her suicide safety plan Be creative Walmart! Pictures

Lethal Means How much medication is in your home? ( neighbors, family) Medication boxes, family, bubble wrap Gun locks, boxes, family or surrender for holding

Caring Contact Henry, I don t know you well yet, I a m glad t h a t you told m e a little m ore about your life. I have lots of hope for you you ve been thro ugh a lot. I hope you ll remember that and come back to see us. With care, -Nurse Matt NowMattersNow.org 2018 All Rights Reserved