1. 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

2. 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.

3. 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)

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

5. 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

6. Adolescent Data
Suicide is the 3rd leading cause of death for ages both nationally and RI (e)
For every completed suicide in this age group, there are approximately 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)

8. 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)

9. 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?

10. 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

11. 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.

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

13. 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.

14. 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.

15. 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.

16. 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.

17. Evaluating the suicide plan
RISK
High
Moderate
Low

18. 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

19. Vague response should consider calling 911
National Suicide Prevention

20. 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

21. Resources National Suicide Prevention Lifeline:
TALK (8255)
Spanish:
Tele-Interpreters support over 150 languages
24/7, free and confidential
Suicide Prevention Resource Center offers free online classes to learn more,
RI Youth Services Suicide Prevention Project
Best Practices Registry

22. Bottom Line

23. 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

24. 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.10m doi: /PCC.10m01027
RI Child Death Review Team Youth Suicide Issue Brief ( ). RI Dept of Health, (2011), Available at: YouthSuicide.pdf

25. 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