Suicide Prevention in Pediatric OfficesSeptember 2020

Sheila Woods MD, FAAPswoods@greenvilleadhd.com

Disclosures

I have had no financial relationship or other affiliation with a commercial interest within the last 12 months.

Objectives

To review the roles of:

•Primary Care Providers AND

•Primary Care Office Staff

in Suicide Prevention and Intervention

PreventingSuicide isimportant because…

Objectives for Primary Care OfficeSuggested plan

1. Use Screening Tools2. ASK Questions during visit3. Identify Risk/Protective Factors4. Conduct Suicide Inquiry5. Determine Risk Level6. Determine Intervention Needed7. Treat Depression, if appropriate8. Follow-Up

Develop and use an office plan that works.

Prior Contact with Primary Care

Ahmedani BK,Westphal J, Autio K, et al. Variation in patterns of health care before suicide:a population case-control study. Prev Med. 2019; 127:105796. doi:10.1016/j.ypmed.2019.105796

Most adults who died by suicide had contact with primary care and/or an ER department within:

•a year 91.7%•30 days 54%

•the WEEK 29.6%

PRIOR to their suicide.

Pediatricians and Suicide in 2019

•80% reported having a patient who attempted or died by suicide

•48% said this had occurred in the past year

•80% reported patients who disclosed or screened positive for suicidal ideation in the past year

https://www.aappublications.org/news/aapnewsmag/2019/10/23/research102319.full.pdf

always61%

sometimes37%

never2%

PEDIATRICIAN SELF-REPORT ON SCREENING FOR SUICIDE

https://www.aappublications.org/news/aapnewsmag/2019/10/23/research102319.full.pdf

Summary Suicide Facts:•Males more likely to attempt suicide and use lethal methods leading to death •Females more likely to attempt suicide•Black youth suicides have increased •Alaskan & Native Americans have highestsuicide rates•LGBTQ are at extremely high risk

https://www.cdc.gov/violenceprevention/suicide/fastfact.html

https://www.cdc.gov/violenceprevention/suicide/fastfact.html

What to know• 48% of attempts occur with little

planning …within 10 minutes of crisis• Ages 5-14 - attempt an impulsive act in response to

CRISIS related to psychosocial adversity

• 90% do NOT go on to die by suicide later

• Intent and Means determine life or death

• Question patient Directly about current or past suicidal thoughts and behavior

• Let the patient know that other people have similar thoughts and feeling

https://training.sprc.org/ *Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293(6):707-14 https://www.hsph.harvard.edu/means-matter/means-matter/youth-access/#refsImage: https://23i69d6p0gw1zwz4y3smspc1-wpengine.netdna-ssl.com/wp-content/uploads/sites/25/2016/11/ThinkstockPhotos-505699273.jpg

https://training.sprc.org/https://www.hsph.harvard.edu/means-matter/means-matter/youth-access/#refs

Firearms

#1 Leading Cause of Suicide Deaths

in SC and US

Medication

#1 Leading Cause of Suicide Attempts

in SC and US

Suffocation

#2 Leading Cause of Suicide Deaths

in SC and US

Lethal Means

1. Screening Tools

• PHQ-9-Depression and Suicide

• PHQ-2-Suicide

• SAFE-T-Suicide

• ASQ and ASQ Toolkit-Suicide• https://www.nimh.nih.gov/research/research-conducted-at-

nimh/asq-toolkit-materials/asq-tool/screening-tool_155867.pdf

http://zerosuicide.edc.org/toolkit/identify#quicktabs-identify=1

https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening-tool_155867.pdfhttp://zerosuicide.edc.org/toolkit/identify#quicktabs-identify=1

1. Screening Tools

• C-SSRS Columbia Suicide Severity Rating Scale• https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-

SLC_11.14.16.pdf

• PSS-3 Patient Safety Screener• http://www.sprc.org/micro-learning/patientsafetyscreener

• TASR-A Tools for Assessment of Suicide Risk• https://teenmentalhealth.org/wp-content/uploads/2014/09/TASR-Am.pdf

• SBQ-Suicide Behavior Questionnaire• https://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/comm

unications/SDQ-Color.pdf

https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdfhttp://www.sprc.org/micro-learning/patientsafetyscreenerhttps://teenmentalhealth.org/wp-content/uploads/2014/09/TASR-Am.pdfhttps://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/communications/SDQ-Color.pdf

1. PHQ-9 Scoring

Not at all = 0 Several days = 1

More than half the days =2 Nearly every day = 3

▪0-4-Possible Minimal Depression

▪5-9 Mild Depression

▪10-14 Moderate Depression

▪15-19 Moderately Severe Depression

▪20-27 Severe Depression

1. PHQ-2 Scoring

Not at all = 0 Several days = 1

More than half the days =2 Nearly every day = 3

PHQ-2 scores range from 0-6If the score is 3 or greater, major

depressive disorder is likely

Positive PHQ-9 = Consider

•C-SSRS Columbia Suicide Severity Rating Scale• https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf

•SBQ Suicide Behavior Questionnaire• https://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/communications/SD

Q-Color.pdf

https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdfhttps://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/communications/SDQ-Color.pdf

1. C-SSRS Columbia Suicide Severity Rating Scale

Follow the instructions on the form for question patterns.• High Risk-YES to

Questions 4, 5 Past Month and YES to 6a

• Moderate Risk-YES to 3 Past month, YES to 4 LIFETIME, YES to 5LIFETIME, YES to 6

https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/

https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/

•

1. Suicide Behaviors Questionnaire-Revised SBQ-R

https://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/communications/SDQ-Color.pdf

Responses receive a point value of 1-6

Q1 –Lifetime Suicidal Ideation or Attempts

Q2- Frequency of Suicidal Ideation (12 mo.)

Q3-Threat of Suicide Attempt

Q4-Likelihood of Future Suicidal Behaviors

Sum of all points totals between 3-18

• Higher the points = greater the risk

• If ≥ to 7-Suicide Risk is High

• Results have high sensitivity and specificity

https://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/communications/SDQ-Color.pdf

2. AAP Sample Questions

https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_AdolescenceVisits.pdf

Worry • Do you worry a lot or feel overly stressed out?

Feelings • Have you been feeling sad, had difficulty sleeping, or frequently feel

irritable?

Substances • Do you ever use any substances to make you feel better?

Self-Harm • Do you harm yourself, such as by cutting, hitting, pinching yourself?

Lethal Means• Do you ever carry a firearm? Can you get a firearm if you want to? Is

there a firearm at home? If so, do you know how to get hold of it? Have you ever carried a firearm for protection?

Suicidal Ideation • Family History - Do you ever feel so upset that you wish you were not

alive or that you want to die? Has anyone in your family had mental health problems or attempted or died by suicide?

https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_AdolescenceVisits.pdf

2. Sample Questions

Over the past two weeks, have you been bothered by:

1.Little interest or pleasure in doing things?

2.Feeling down, depressed, or hopeless?

3.Thoughts that you want to kill yourself, or have you attempted suicide?

Kroenke K., Spitzer R. L., & Williams J. B. (2003). The patient health questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284–1292. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14583691

https://www.ncbi.nlm.nih.gov/pubmed/14583691

2. Sample Questions

•Are you thinking about killing yourself?

•Have you ever tried to hurt yourself before?

•Do you think you might try to hurt yourself today?

•Have you thought of ways that you might hurt yourself?

•Do you have pills/weapons in your home?

3. Positive Now What?3. Identify Risk Factors/Protective Factors

4. Conduct Suicide Inquiry• Ideation•Plan•Behaviors• Intent

5. Determine Risk Level

3. Determine Intervention Needed

4. Treat Depression

5. Follow Up

3. Risk FactorsHISTORY

✓Suicidal Behavior-current/past

✓Mental Health Diagnoses-current/past

✓Alcohol and/or Drug Use

✓History of Trauma

✓Precipitants/Stressors

✓Family History of Suicide

✓Access to lethal means

PATIENT✓Feelings of hopelessness

✓Impulsive or aggressiveness

✓Isolation-feeling cut off from other people

✓Unable to access mental health treatment

✓Unwillingness to seek help because of stigma/shame

US Department of Health and Human Services Substance Abuse and Mental Health Services Administration www.samhsa.govDownload at www.sprc.org https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

http://www.samhsa.gov/http://www.sprc.org/https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

3. Protective FactorsInternal

•Coping Ability

• Frustration Tolerance

•Problem-Solving Ability

•Conflict Resolution

•Adaptability

• Self-esteem, Sense of Purpose or Meaning in Life

External-Connectedness•Positive Therapeutic

Relationships

• Social Support

•Parental Skills/Ability to monitor and support

•Cultural, Religious, or Personal Beliefs that discourage suicide

US Department of Health and Human Services Substance Abuse and Mental Health Services Administration www.samhsa.gov Download at www.sprc.org

http://www.samhsa.gov/http://www.sprc.org/

4. Suicide Inquiry❑Ideation-Frequency, Intensity, Duration

❑Plan- Timing, Location, Lethality, Availability, Preparatory acts

❑Behaviors-Past attempts, Aborted attempts, Rehearsals, Self-injurious actions

❑Intent-Extent to which patient expects to carry out plan and believes plan to be lethal vs. self-injurious

US Department of Health and Human Services Substance Abuse and Mental Health Services Administration www.samhsa.gov Download at www.sprc.org

http://www.samhsa.gov/http://www.sprc.org/

4. Suicide Inquiry Questions1) Tell me about a couple of times in the past few months when things were the

worst for you—did you think about suicide?• If yes, then ask: Did you take any specific steps toward an attempt? What methods did

you think about? What kept you alive?

2) Tell me about the last couple of days—how much would you say suicide has been on your mind, if at all?

• If so, then ask: Are there specific methods you’ve thought about?

3) Have you thought about how you'd kill yourself?• If yes, then ask: Have you thought about when or where you'd kill yourself?

• If they mention a specific method of suicide, then ask: What other methods are you thinking about?

4) Is there a specific scenario where you think you would attempt suicide?

5) Have you ever attempted suicide in the past, or started to?https://training.sprc.org/

https://training.sprc.org/

5. Determine Risk

www.zerosuicide.com

Low Risk

• Modifiablerisk factors

• Strongprotective factors

• NO plan

• NO intent or

• NO suicidal behaviors

Moderate Risk

• Multiple risk factors

• Few protective factors

• Ideation withplan but NO intent or

• NO suicidal behaviors inpast 3 months

Severe Risk

• Serious unmodifiablerisk factors

• Psychiatric diagnoses with severe symptoms/ acuteprecipitating event

• NO relevant Protective Factors

• Potentially Lethal Suicide Attempt or Persistent ideationwith Strong intent or Suicidal behaviors in past 3 months

6. Risk Interventions“Universal”

All Patients

•Screened

•Counseled

•Lethal Means Safety

Low/Moderate Risk

•Counseled

•Safety Plans

•Lethal Means Safety

•Mental Health Referral

•Follow Up

Severe Risk

•Require intervention

•CRISISReferral

•Follow Up

6. Intervention

SEVERE RISK continued…

Consider CRISIS Referral/ Hospitalization if:• Psychiatric disorders - Unipolar major depression, bipolar disorder,

psychotic disorders, or substance use disorders• Recent Suicide Attempt included:

• Highly lethal method -Firearm, Overdose, or Suffocation• Steps to avoid detection

• Ongoing suicidal ideation or disappointment that attempt did not lead to death

• Inability to openly and honestly discuss the suicide attempt • Inability to discuss safety planning

6. Intervention based on Risk Level

To the patient: Sometimes people who are strugglingmay have a crisis and suddenly experience strong suicidal feelings. I’m not saying this is likely to happen, but if it does, I want to be sure you make it through safely and get the help you need. Can we talk over a plan, just in case?

What to say To the caregiver: If a child or teenager attempts suicide, it’s usually at home and it’s often a quick decision. Putting time and distance between them and a method that could do serious harm is one of the single most effective steps to protect your child. Pills are the most frequent method of attempt and guns are the most lethal, so let’s start with those.

Talk through each category with the patient Let them direct the ideas whenever possible…

1. What are your warning signs…

2. Internal coping strategies

3. People and setting providing distraction

4. People I can ask for help

5. Professionals I can contact

6. Make environment safe

6. Collaborative Safety Plans

http://www.suicidesafetyplan.com/uploads/Safety_Planning_-_Cog___Beh_Practice.pdf

http://www.suicidesafetyplan.com/uploads/Safety_Planning_-_Cog___Beh_Practice.pdf

Firearms

Best Option - Remove from the home

Options: Trusted person, Law Enforcement, Self-storage Unit, Shooting

Range Locker, Pawn Shops, Gun Shop

Safely Store FirearmsLocked and unloaded; ammo stored separately

• Disassemble guns; lock a critical component

Medication

Dispose of old/ unneeded

Lock in steel toolbox

Prescribe and/or keep only limited

quantities

Belts & Ropes

Search, remove, lock up and/or monitor items that could be

used for harm

Sharp Objects

Search, remove, lock up and/or monitor items that could be

used for harm

6. Lethal Means Safety

6. Lethal Means Safety - Medications• Opioids - most frequently involved in

overdose suicides• Prescription pain medications-oxycodone,

methadone, morphine

• Other drugs: • Benzodiazepines-anxiolytics/muscle relaxants

are abuse-prone • Antipsychotics• Antidepressants• Sleeping pills-Prescription • OTC like diphenhydramine-Benadryl • OTC pain relievers like acetaminophen-Tylenol

For Safe Quantities call:

Poison Control Hotline - 800-222-1222COUNSELING ON ACCESS TO LETHAL MEANS https://training.sprc.org/course/view.php?id=20

• As Prescribers: Use lower-toxicity medications• Selective serotonin reuptake inhibitor (SSRI)

• Serotonin and norepinephrine reuptake inhibitor (SNRI)

• NOT tricyclic (TCA) antidepressant

• Limit quantities and combinations to avoid serious harm if taken all at once

• Consider weekly refills to reduce lethality

• Remember patient’s use of alcohol/other drugs including over-the-counter medications

• Some combinations are more deadly than others

COUNSELING ON ACCESS TO LETHAL MEANS https://training.sprc.org/course/view.php?id=20

6. Lethal Means Safety - Medications

7. Depression Treatment

Exercise

Therapy

Medications

3 Parts of Depression Treatment

7. Depression TreatmentAntidepressant Initiation:

• Explain box warning • Explain length of time to efficacy• Ensure patient and caregiver understand instructions• Avoid Tricyclics: therapeutic levels and toxic levels

In terms of adolescent confidentiality,

SAFETY TRUMPS PRIVACY

Shain B and AAP COMMITTEE ON ADOLESCENCE. Suicide and Suicide Attempts in Adolescents. Pediatrics. 2016;138(1):e20161420

7. Depression TreatmentAfter Antidepressant Start if:

➢New or more frequent thoughts of wanting to die

➢Self-destructive behavior

➢Signs of increased anxiety/panic, agitation, aggressiveness, impulsivity, insomnia, or irritability

➢New or more involuntary restlessness such as pacing or fidgeting

➢Extreme degree of elation or energy

➢Fast, driven speech

➢New onset of unrealistic plans or goalsShain B and AAP COMMITTEE ON ADOLESCENCE. Suicide and Suicide Attempts in Adolescents. Pediatrics. 2016;138(1):e20161420

7. Mental Health Treatment Options• Cognitive Therapy for Suicide Prevention (CT-SP)

• Dialectical Behavior Therapy (DBT)

• Collaborative Assessment and Management of Suicidality (CAMS)

• Motivational Interviewing (MI)

• Brief Cognitive Behavioral Therapy (BCBT)*

• Teachable Moment Brief Interventions (TMBI)*

• Attempted Suicide Short Intervention Plan (ASSIP)*

*Still being studied http://zerosuicide.edc.org/toolkit/treat#quicktabs-treat=1

https://missmaryliberry.files.wordpress.com/2012/02/photo531.jpg?w=335&h=445

http://zerosuicide.edc.org/toolkit/treat#quicktabs-treat=1https://missmaryliberry.files.wordpress.com/2012/02/photo531.jpg?w=335&h=445

8. Follow Up

•Continue Follow Up after Referral

•Collaborative care is important•Results in greater reduction of depressive symptoms in a primary care setting*

•Use HELLPPP**

*Richardson LP, Ludman E, McCauley E, et al. Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA. 2014;312(8):809–816**Foy JM, Green CM, Earls MF , AAP COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, MENTAL HEALTH LEADERSHIP WORK GROUP. Mental Health Competencies For Pediatric Practice. Pediatrics. 2019; 144(5):e20192757

Prevention Smartphone Apps

https://scyspi.org/

Virtual Hope Box

My3 Stop, Breathe & Think

There is Hope

Stay Alive Calm in the Storm

Let’s Talk (Caregivers)

https://suicidepreventionlifeline.org/

Crisis Lines - 911 833-DMH-CCRI or 833-364-2274

(CCRI ~ 24/7/365 crisis response team to meet the mental needs of SC Residents)

https://suicidepreventionlifeline.org/https://scyspi.org

Everyone Specific to SC

HOPE4SC to 741741

Trans Lifeline

1-877-565-8860

LGBTQ+

1-866-488-7386

https://suicidepreventionlifeline.org/