Nelly Burdette, Psy.D. Friday, April 17, 2015 Suicidality in Primary Care: Assessment and Treatment Care Transformation Collaborative of R.I. Nelly Burdette, Psy.D. Friday, April 17, 2015

Objectives Learn how to assess the risk factors for suicide in adolescents and adults within a busy primary care setting. Understand rates at which certain populations will express suicidal thoughts vs risk of acting on those thoughts. Develop proficiency in conducting a brief suicide assessment in primary care.

Suicide is on the rise Suicide is the 3rd leading cause of death in RI. (a) More suicide deaths in RI than car crash deaths. [2010] (a) Highest % of suicide among adults ages 45–64 years. (a) More than 78% of adults who died by suicide were men, 22% were women. (a)

Life stressor circumstances of adult suicide by gender in RI, 2004-2010 (a)

Medical Conditions Increasing Suicidal Risk (c) Illness Increased Risk HIV or AIDS 6.6x Huntington’s Disease 2.9 Malignant Neoplasms-All Sites 1.8 Malignant Neoplasms-Head/Neck 11.4 Multiple Sclerosis 2.4 Peptic Ulcer 2.1 Chronic Renal Failure-Dialysis 14.5 Chronic Renal Failure-Transplant 3.8 Spinal Cord Injuries Systemic lupus 4.3

Adolescent Data Suicide is the 3rd leading cause of death for ages 15- 24 both nationally and RI (e) For every completed suicide in this age group, there are approximately 100-200 suicide attempts (e) Every year in RI, about 500 youth are seen in the ED for a suicide attempt. (e) Identifying as LGBT doubles your risk (e)

Primary Care - perfect melting pot How often do patients who complete suicide visit with their PCP? More than twice as often as mental health clinicians. (b) Estimated 45% of those dying by suicide saw their PCP in the month before their death. (b) 50% of suicides have never had psychiatric contact. (c)

Psychological Autopsy of Suicide More than 90% have a psychiatric disorder (b) Anxiety, depressive disorders, and alcohol use disorders are the most common in primary care More than one psychiatric illness = higher risk (b) Especially both depressive disorders and substance use disorders Predicting Suicide?

Warning Signs Risk Factors Relationship to suicide Proximal Distal Evidence basis Clinically derived Empirical research Applicable group Individuals Populations Clinical implications Intervene to resolve Limited ability to address Time basis Transient Often static Examples Threats to harm self Planning for suicide Talking or writing about suicide Hopelessness Rage, anger, seeking revenge Impulsive or reckless actions Feeling trapped Increasing alcohol or drug use Withdrawing from others Anxiety or agitation Increased or decreased sleep Dramatic mood changes No purpose or reason for living White Male History of a suicide attempt Family history of suicide Psychiatric diagnosis Smoker Firearms access Physicians Prisoners History of sexual abuse History of psychiatric admission Increasing age Divorced

Where to start? Every patient being evaluated for depression or with history of depression should be asked about suicidal thoughts and behaviors. (b) PHQ-9 (d) Useful to identify individuals at risk for suicide who would not otherwise have been identified. Denial of suicidality should be probed further if there are other risk factors for suicide present.

Hierarchy of Suicide Assessment (b) Thoughts of death Suicidal ideation Plan for suicide Means for available Intent

Brief Suicide Assessment “Do you have a plan to take your life or anyone else’s?” If yes, go to question 2. If no, identify this as low-risk in your documentation of suicide assessment and continue to question 4 and 5.

Brief Suicide Assessment “What is your plan?” and “Do you have access to {weapons, pills, etc}?” based on what the caller states the plan involves. If yes to plan and yes to access, identify this risk as moderate in your documentation of suicide assessment, and continue to question 3. If no access to means in which to complete the plan, identify this risk as moderate in your documentation of suicide assessment and continue to question 4 and 5.

Brief Suicide Assessment “What is stopping you from acting on this plan?” If there is no immediate answer provided that strongly encourages the nurse that the patient is safe, identify this risk as high in your documentation of suicide assessment. Continue to questions 4 and 5.

Brief Suicide Assessment “Have you ever attempted to take your life or anyone else’s?” If the answer to this is yes, the risk is heightened regardless of the previous level of assessed risk. “Are you currently under the use of any alcohol or drugs outside of the prescriptions made by your PCP?” If the answer to this is yes, the risk is heightened regardless of previous level of assessed risk.

Evaluating the suicide plan RISK High Moderate Low

Decision Tree For Patients or Callers with Suicidal or Homicidal Ideation Depression Screening Positive >10 PHQA or PHQ9 + SI/HI Have a plan to take your life or anyone else's? If YES then What is your plan? Do you have access to {weapons, pills, etc}? If no then STOP If yes then call 911 What is stopping you from acting on this plan? Vague response should consider calling 911 If NO then STOP Previous attempts to take yours or anyone else’s life? If YES, then risk increases Are you currently under the use of any alcohol or drugs? - SI/HI Schedule PCP/BH appt as needed Suicide/Homicide Assessment Low Risk Moderate Risk High Risk

Vague response should consider calling 911 National Suicide Prevention http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf

Policies and Procedures Do have a policy for how each member of the team would respond in the event of SI? Front desk staff Nursing PCPs Do you have a workflow for how to manage patients who verbalize SI/HI? Via Telephone Via In-Person

Resources National Suicide Prevention Lifeline: 1-800-273-TALK (8255) Spanish: 1-888-628-9454 Tele-Interpreters support over 150 languages 24/7, free and confidential Suicide Prevention Resource Center offers free online classes to learn more, http://training.sprc.org/ RI Youth Services Suicide Prevention Project http://www.riyouthsuicidepreventionproject.org/ Best Practices Registry http://www.sprc.org/bpr

Bottom Line

Save the Dates Motivational Interviewing in Primary Care From Substance Use to Healthy Lifestyle Behaviors in Chronic Disease 6/19/15 Chronic Pain In Primary Care Skills not Pills 9/18/15

References Adult Suicide and Circumstances in Rhode Island, 2004–2010, YONGWEN JIANG, PhD; JEFFREY HILL, MS; BEATRIZ PEREZ, MPH; SAMARA VINER- BROWN, MS Practical Suicide-Risk Management for the Busy Primary Care Physician; Anna K. McDowell, MD; Timothy W. Lineberry, MD; and J. Michael Bostwick, MD Guide to Suicide Assessment and Intervention, Harvard Medical School Uebelacker, L. A., German, N. M., Gaudiano, B. A., & Miller, I. W. (2011). Patient Health Questionnaire Depression Scale as a Suicide Screening Instrument in Depressed Primary Care Patients: A Cross-Sectional Study. The Primary Care Companion to CNS Disorders, 13(1), PCC.10m01027. doi:10.4088/PCC.10m01027 RI Child Death Review Team Youth Suicide Issue Brief (2005-2010). RI Dept of Health, (2011), Available at: http://www.health.ri.gov/publications/issuebriefs/2005- 2010YouthSuicide.pdf

Questions Nelly Burdette, Psy.D. naburdette@providencechc.org Director, Integrated Behavioral Health, PCHC Integrated Behavioral Health Practice Facilitator, CTC MHI Faculty Advisor, HMS Center for Primary Care Faculty, Alpert Brown Medical School & University Of MA Medical School Center For Integrated Primary Care