What do you do with a suicidal client? Jessica L. Estes DNP, APRN-NP Estes Behavioral Health, LLC KCNPNM Annual Conference 2014

Objectives To determine appropriate assessment tools for primary care; To determine the local and national recources available; and When to refer a client for suicidal ideation.

Scope of the Problem Approximately 35,000 people die by suicide each year in the U.S. Estimated 45% of those dying by suicide saw their primary care physician within one month of death (McDowell, Lineberry, & Bostwick, 2011) One VA study found 63% suicide decedents had at least one primary care visit in year prior to death (Denneson et al., 2010)

Scope of the Problem More than 32,000 deaths by suicide occur each year in the U.S. Suicide rates across demographic groups are higher in rural counties than in urban counties. Suicide is the second leading cause of death in persons years old in the U.S. Suicide is the third leading cause of death in persons years old in the U.S. Suicide is the eleventh leading cause of death (all ages) in the U.S.

Adults – Aging white males have the highest suicide rate of all demographic groups. Adolescents8 – Suicide rates rise rapidly during adolescence; rates are very low before age 14 and approach adult levels by age 19. American Indians and Alaska Natives – For ages 10-39, Native American and Alaska Natives have the highest suicide rates of all races and ethnicities. Lesbian, Gay, Bisexual, and Transgendered Individuals – These groups have disproportionately high rates of suicide attempts. Veterans – Veterans in the general population are twice as likely to die by suicide as non-veterans.

Why Don’t Primary Care Providers Ask About Suicide?

Too Many Barriers Time Expertise Fear Overwhelmed Not a big problem Other reasons?

Screening vs. Assessment

What’s the Goal? Screening Snapshot Quick Focused Next steps Assessment Comprehensive Specialty care Case conceptualization Treatment planning

Cost/Benefit of Screening

Who Should be Screened? At a minimum, anyone being seen for depression or with a history of depression Those with alcohol abuse problems Receiving catastrophic medical news Exhibiting significant changes in mood McDowell et al., 2011

Other Conditions to Monitor Comorbid anxiety or agitation – Particularly PTSD, panic disorder, social anxiety disorder, and generalized anxiety disorder Significant sleep problems (Ribeiro et al., in press)

Mention of Suicide/Desire for Death Doesn’t always mean there is a crisis

Know the Warning Signs Significant anxiety Psychomotor agitation (e.g., “feeling like want to crawl out of my skin”) Poor sleep Concentration problems Hopelessness Social isolation Significant increase in substance use McDowell et al., 2011

What Information do You Need? Step-wise approach – Move from general to specific Feeling hopeless or thinking about death? Specific thoughts about suicide? Family history and own history of self-directed violence McDowell et al., 2011

What Tools Should I Use? No standardized measure can predict who will/won’t engage in self-directed violence Identification of similarity between an individual patient and known groups Single item indicators very limited utility Valid and reliable, in particular with good criterion validity

Potential Measures Heisel and colleagues (2010) reported 15-item Geriatric Depression Scale cut-off of 5 for men and 3 for women accurately identifying ideation – Designed for primary care patients 65 and older Patient Health Questionnaire % agreement with SCID-I – 10.2% false positives, 10.8% false negatives (Uebalacker et al., 2011)

Suicidal Behaviors Questionnaire- Revised Cut-off score of 8 discriminates between adult psychiatric inpatients with/without history of suicide attempt/serious consideration 7 cut-off for non-clinical Valid, reliable, easy to administer and score Self-report can be completed prior to appointment Specifically designed as a suicide screening tool

How Accurate is the SBQ-R? Adult psychiatric inpatients 95% of those with a history of serious ideation/attempts (positive predictive value) 87% of those without a history of suicidality (negative predictive value). 5% false positives 13% false negatives Non-clinical undergrads PPV & NPV = 1.00

Key components of a suicide risk assessment Assess risk factors Suicide Inquiry: thoughts/plan /intent/access to means Assess protective factors Clinical judgment Document

My Patient is High Risk Now What do I do?

Managing At-risk Patients Don’t try to convince your patient that “life isn’t that bad” Chatting about psychosocial issues isn’t enough Need a plan ahead of time so know what to do with screening data Longitudinal monitoring, structured follow-up, appropriate referral to mental health Vannoy et al., 2011

PCP Information Primary care providers, especially in rural areas, are invaluable in the treatment of potentially suicidal patients. Important interventions that can be carried out in a primary care office include treatment of psychiatric symptoms, including depression and severe anxiety, strengthening the support network, developing a safety plan, and helping the patient practice coping strategies in the plan. Depression treatment – Benefits of medication outweighs the risk of inducing suicidal thoughts. Studies have found no evidence that antidepressants increase the risk of suicidal thinking in adults over age 24. Encourage a support network Safety Planning NOTE: No-suicide contracts have been found to be ineffective in preventing suicidal behavior. It is more important to make a plan with your suicidal patients concerning what they will do in the event that they feel suicidal and are worried about their safety, rather than what they won’t do.

Safety Planning Fairly quick and easy to complete in CPRS Print, discuss, and send home with patient Consider involving significant others Keeping safe until can be seen by mental health Hospitalization does not have to be first option

Documentation and Follow-up Care Thoroughly document suicide risk assessment (and rationale), management plan, actions that occurred (e.g., met with family) and any consultation (e.g., with psychiatrist). In the case of hospitalization, it will be necessary to provide this information to the admitting facility. Thorough documentation will help ensure that the patient receives appropriate referrals and follow up. Close follow up with a potentially suicidal patient is critical. Studies show that even very simple follow-up contacts with suicidal patients reduce their risk of repeat attempts and death. Every follow up contact is an opportunity to assess for recurrent or increased suicidality. Flagging the records of patients at risk for suicide with color coded labels, as is frequently done for allergies or certain chronic diseases, may help insure suicide risk is reassessed on follow up visits.

Treatment of Likely Drivers of Suicide Collaborative care models may be particularly effective for treating depression (McDowell et al., 2011) – Education and support for physicians – Depression care managers – Monitoring patient outcomes and adherence – Facilitating communication between patients, primary care, and mental health providers Treatment of substance use disorders Consider antidepressants

To Refer or Not to Refer Do they have a plan? Have they taken steps to prepare/practice? Access to lethal means? Intent to die?

Disposition Tied to imminence of risk More frequent primary care contact Case management Outpatient mental health Intensive outpatient treatment Inpatient hospitalization

But I Don’t Want to Talk to Mental Health May not be necessary Empathy and concern enough? Other supports?

When Can I Stop Worrying? Once identified as elevated risk need to keep monitoring Successful treatment of contributing factors Periodic assessment for increased problems Watchful waiting stance

Methods to Reduce Malpractice Failure to take appropriate and sufficient action to prevent death. Failure to follow the rules and procedures of a setting Failure to provide an acceptable standard of care Errors in judgment about whether to confine a client, in conjunction with negligent assessment and diagnosis. Failure to document activities performed on behalf of the client. – Assessment: The Cornerstone

References Centers for Disease Control and Prevention. Web-Based Inquiry Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Accessed August 15, Singh GK, Siahpush M. The increasing rural urban gradient in US suicide mortality, Am J Public Health. 2003;93(5): Centers for Disease Control and Prevention. Web-Based Inquiry Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Accessed August 15, Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:

Stovall J, Domino FJ. Approaching the suicidal patient. Am Fam Physician. 2003;68(9): National Institute of Mental Health. High risk populations. National Institute of Mental Health website. prevention.shtml. Accessed August 1, Centers for Disease Control and Prevention. (2008) Suicide: Facts at a glance. Accessed July 28, Centers for Disease Control and Prevention. Web-Based Inquiry Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Accessed August 15, King M, Semlyen J, Tai S, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70. Ryan, C, Huebner, D, Diaz, RM, Sanchez, J. Family rejection as a predictor of negative health outcomes in white and latino lesbian, gay, and bisexual young adults. Pediatrics, 2009;123: Congressional Research Service. Suicide Prevention Among Veterans. May 5, CRS Report for Congress. Washington DC: CRS. Accessed November 3, Kaplan MS, Huguet NH, McFarland BH, Newsom JT. Suicide among male veterans: A prospective population-based study. J Epidemiol Community Health. 2007;61: Department of Veterans Affairs National Survey of Veterans final