1. The First Step: Evidence- Based Suicide Screening Across Medical and Mental Health Facilities Dr. Jeffrey Garbelman Milwaukee VA, Wisconsin Department of Corrections Jeffrey.garbelman@att.net or at linkedin 1

2. Community Suicide Prevention Good Suicide Prevention Requires a Public Health Perspective 2

3. Medical/Mental Health Appointments and Suicide: To Screen or not to Screen…That is the question…. “do we have to assess for suicide every time we have patient contact?” 3

4. When answering this question, consider what we know… (and what advocacy groups, accreditation agencies, and lawyers know or should know…) 4

5. Good screening/assessment and documentation can and does save lives 5

6. What are we talking about? Manipulative Suicidal ideation SEROIOUS Deliberate self-harm SUICIDE ATTEMPT Self destructive behavior Suicide Suicide attempt Completed suicide Suicide gesture Suicide acts Parasuicide Self- inflicted injury Intrapersonal violence Self mutilation (Brown, 2002) 6

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11. Expect to See It Across All Medical Disorders and beyond… Suicidality prevalent across all medical disorders 25.5% have ideation 8.9% make an attempt Druss and Pincus, 2000 Cancer patients population based ideation 17.7% independent of depression Schneider & Shenassa, 2008 11

12. Dilemmas: What Can’t We Rely On? Presumptions of Clinical Contact The trouble with ‘contact’ is not the lack of it (Friedlander, 2012; Liu, 2012). Approximately 2/3 of completed suicides occur on the first attempt (Goldblatt, 2011) Quantity vs.Utility (Fowler, 2012; Fawcett, 1990;Bush, 2003; Goldstein, 1991; Porkorny, 1983) 12

13. The Joint Commission (healthcare facility accreditation and certification) Sentinel Alert, issue 56, February 24, 2016 Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives. Emphasized the importance of suicide risk screening/assessment and across all facilities Calls upon medical, emergency, and primary care to have effective and evidence-based means of detecting suicide and suicide prevention policy/process Reference but do not mandate the CSSRS For mental health professionals to be trained to meaningfully assess (versus screen) for suicide risk, triage/treatment recommendations etc. 13

14. Quick aside…. Screening versus Assessment Screening: Large scale Possibly administered by non-mental health professionals Target critical portions but not all of the construct of suicide Group probabilities versus customized to the individual Higher acceptable risk of false positives Goal to ‘catch’ as many people as possible and have them more meaningfully assessed 14

15. Quick aside… Suicide Risk Assessment: Use of group probabilities combined with individual factors Used of evidence-based instruments as the ‘base of the soup’ not the entire soup- as a part of the clinical decision-making process In-depth assessment of suicidal ideation, behaviors, non- suicidal self-injurious behaviors, protective factors, chronic, acute and imminent risk factors… 15

16. Suicide Documentation Strategies Strategic clinical use of: Documentation Consultation/Collaboration Thought Process Transitional Data Acute Risk/Imminent Risk Mental Status Exam Suicidal Behavior vs. Suicide Attempt Theories of Suicide: Evidence-based decisions Evidence-based assessment/screening 16

17. Columbia Suicide Severity Rating Scale (C-SSRS) Training Agenda C-SSRS Screen Version and the CSSRS Screen Version Severity of Ideation Subscale- (questions 1-5) Suicidal Behavior (question #6) C-SSRS Lifetime/Recent Version Severity of Ideation Subscale- (questions 1-5) Intensity of Suicide Subscale Suicidal Behavior Subscale Lethality subscale 17

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26. C-SSRS Screen Version Timeframes: Suicidal ideation is assessed in past month Suicidal behaviors assessed last month and ‘ever’ i.e, ‘have you ever…?’ The C-SSRS Screen Since Last Visit assesses the time period since last contact 26

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28. Transition Data Cumulative Probabilities of transition: Ideation to Plan 34 % Plan to Attempt 72 % Fowler, 2012; 28

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34. Recent Suicidal Ideation (1 month) Past Suicidal Ideation(lifetime) Recent Suicidal Behavior (3 months) Past Suicidal Behavior (lifetime) Very Low RiskNNNN Low RiskY Questions 1-2Y Questions 1-3NN Moderate RiskY Questions 3Y Questions 4-5NY (at least 1) High RiskY Questions 4-5 NY Very High RiskY Questions 4-5 YY Catholic Health Partners.. 34

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36. 6) Suicide Behavior Question "Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. If YES, ask: How long ago did you do any of these? ・ Over a year ago? ・ Between three months and a year ago? ・ Within the last three months? 36

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39. Dallas Morning NewsDallas Morning News: Large-scale hospital implementation of this scale which found 1.8 percent of its patients to be at high risk for suicide an additional 4 percent to 4.5 percent are at moderate risk In total this would represent about 6% of the hospital patients which may have otherwise gone undetected 39

40. US News and World ReportUS News and World Report: Centerstone- One of the nations largest providers of mental health treatment noted improved suicide rates following a large-scale role of out of the CSSRS. Becky Stoll, Centerstone’s Vice President of Crisis and Disaster Management called the C-SSRS the “hinge pin” of their suicide prevention initiative.“[The C-SSRS] has inspired system wide transformation in TN… [and] catapulted a transformation of practices in TN by ensuring professionals and family members who come in contact with an individual who may be having thoughts of taking their own life receive the help they need before it is too late.”the “hinge pin” of their suicide prevention initiative 40

41. Columbia Suicide Severity Rating Scale (C-SSRS) Training Agenda C-SSRS Screen Version and the CSSRS Screen Version Severity of Ideation Subscale- (questions 1-5) Suicidal Behavior (question #6) C-SSRS Lifetime/Recent Version Severity of Ideation Subscale- (questions 1-5) Intensity of Suicide Subscale Suicidal Behavior Subscale Lethality subscale 41

42. Good screening/assessment is part science…. And all about attitude 42

43. Thank you for your time…. Dr. Jeffrey Garbelman Milwaukee VA, Wisconsin Department of Corrections Jeffrey.garbelman@att.net or at linkedin Columbia Suicide Severity Rating Scales Available at: http://cssrs.columbia.eduhttp://cssrs.columbia.edu 43