1. Suicide Inquiries in Primary Care Medical Encounters University of Washington Department of Psychiatry and Behavioral Sciences VA Puget Sound Health Care System 2009 Steven Vannoy, PhD, MPH Assistant Professor

2. Disclosure No conflicts of interest Funding sources –NIH/NCRR (National Center for Research Resources) 1 UL1 RR 025014-01 –NIMH NRSA Training Grant (T32MH73553) –National Council for Community Behavioral Healthcare

3. Medical Settings Most people receive mental health treatment in primary care 45% of people who die by suicide have seen their PCP within 1 month of death vs 19% having seen MH specialist Specialty clinics employing chronic disease model are better setup for addressing mental health concerns

4. Suicide Risk Management Identify Patients at Risk Assess Level of Risk Make Clinical Risk Management Decision Perform Risk Management Tasks

5. Assessing Risk Relies on subjective reporting Requires discussing stigmatized topic

6. What We DON’T Know The nature or quality of the discourse The quality of the risk assessment The types of interventions initiated Whether follow-up occurs Rate of referrals that are completed How to improve practice as usual Does any of this save lives

7. Suicide Discourse Related to mood disorders (depression/anxiety/panic) Related to psycho-social functioning/stress Related to “suicidal” thoughts/behaviors –Passive Thoughts that life isn’t worth living or “I’d be better of dead” Thinking of death –Active Thoughts of self-harm Thoughts of killing oneself “committing suicide” –Behavior Preparatory Attempt

8. A Model of Suicide Discourse in Primary Care How is the “question” asked? Are patients “prepared” for it? How is the initial question followed-up?

9. 1. Kravitz et. al, JAMA 2005; 2. Feldman et al. Annals of Family Medicine 2007 Background Patients’ Requests for Direct-to-Consumer Advertised Antidepressant 1 –Standardized Patients (SPs) Carpal tunnel syndrome/depression Low back pain/adjustment disorder Requesting antidepressant Family and Internal Medicine PCPs Suicide discussion in 36% of encounters 2

10. Analyses of the SP Data Method Text based search of keywords –suicid* hurt*, harm*, kill*, death, dying, etc. Coding into suicidal behavior categories Evaluating for “pre-contextualizing” Evaluating “post-contextualizing”

11. 298 transcripts 91 suicide dialog 6 truncated Coding scheme 11 mislabeled Frequency Range 108 SPs reported suicide inquiry Inductive review

12. Model of Suicide Inquiry Inquiry ContextFollow-up 3 PCP utterances preceding inquiry 3 PCP utterances following inquiry Key word search (suicid*, hurt*, harm*, kill*, death, dying), transcript review

13. Inquiry Self harm (56%) “…had thoughts of hurting yourself?” Suicide or killing (48%) “…feeling suicidal at all?” Indirect (13%) “…any feeling that life is not worth living?” Death (3%) “…ever thought about death a lot?”

14. N% 16975% 21922% 333% 400% In how many ways was the inquiry phrased?

15. How is the Inquiry Framed? Indication of typical outcome –“Has this stress gotten to the point where you’ve had thoughts about killing yourself?” Normalizing –“We ask everyone this question…” Acknowledging awkwardness –“This may sound strange, but…” Asking permission –“Let me ask you an important question…”

16. Are Some Questions Better Than Others? “Negative Phrasing” n = 9 (10%) –No thoughts of harming yourself, right? – But yeah I assume you are not suicidal –And what I'd like you to do is I'm going to make a contract. If things get bleaker than this so that you actually feel suicidal-- you haven't done any of that? –I'm going to see you in a couple weeks and I don't get the impression-- are you telling me you're not feeling suicidal?

17. Preparing the Patient for Sensitive Questions Frequency of Multiple Contextualizing Statements ContextPreceding2 removed3 removed in/mixed80 (88%)79 (87%)73 (80%) Preceding Statements ( N = 91) 0123 9 (10%)4 (4%)6 (7%)72 (79%)

18. Do physicians respond with a context relevant statement Follow-up Statements - in context? (n = 91) ContextProximal2 removed3 removed in/mixed89 (98%)78 (86%)74 (81%) 0123 2 (2%)23 (26%)8 (9%)79 (70%) Frequency of Contextualized Follow-ups

19. What is “follow-up context”? CategoryN% Direct Suicide follow-up3235% Supportive2527% Depression3945% Mental Health/Psychosocial1011%

20. Are Some Follow-ups Better than Others? What does “Okay”, “Good”, “All Right” communicate? –N = 17 (20%) With in-context of follow-up –N = 8 (9%) With off-topic follow-up What does an apology communicate? –“sorry, just something I have to ask” –N = 6

21. Closing off dialogue? DR: Okay. No thoughts of harming yourself, right? SP:No. DR:Okay. Okay. Alright. Let me take a look at your back and we'll talk a little bit about the insomnia.

22. What about this? DR: Have you felt like the bridge? SP: The bridge? DR: Have you felt like doing away with yourself? SP: No. DR: Good then. Well let’s check you over.

23. Analysis of the SP Data Discussion “When asked, the majority ask in an apparently effective manner –22% phrase in more than 1 way –10% coded as negative Unlike many other topics in primary care, the question is contextualized –80% of the time at least 3 preceding statements are relevant to mental health, depression, psychosocial functioning More than 80% of the time the question is followed with a context relevant statement –33% follow up with direct suicide related statements

24. Analysis of the SP Data What are the effects of –Contextualizing –Negative Phrasing –Follow-up Statements Limitations –All SP’s denied any ideation –Cross sectional, 1st time encounters

25. Suicide Risk Management in Oncology? How would patients perceive this? What would their preference be? Can we get providers to engage? Does it have a clinical impact?

26. Thank You