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Suicide Prevention in Primary Care
Suicide Prevention in Primary Care
Liza Tupa, Ph.D.
WICHE Behavioral Health Program
Suicide Prevention in Primary Care
The Suicide Prevention Toolkit for Colorado Primary Care Practices
Funded by the Colorado Department of Public Health and Environment-CDPHE
Suicide Prevention in Primary Care
Getting to Know Your Setting
Disciplines?
Behavioral Health on site?
Clinic level of Integration?
Electronic Health Record in use?
Behavioral Health Screenings done?
Do you have other behavioral health resources in your community?
Suicide Prevention in Primary Care
Why Primary Care?
For a patient at risk for suicide, a visit with the PCP may be the only chance to access needed care - STIGMA
70% of those who die by suicide in Colorado are not engaged in mental health care at the time of their death
Risk Factors seen in Primary Care:Mental illnesses
Substance use disorders
Insomnia
Chronic pain
Physical illnesses, especially CNS disorders (TBI)
Suicide Prevention in Primary Care
Suicide Prevention in Primary Care
Sections:
1. Getting Started2. Toolkit Primer3. Developing Mental Health Partnerships4. Patient Management Tools5. State Resources, Policy, and
Reimbursement6. Physician self-care7. Patient Education Tools/Other
Resources
Toolkit Contents:Overview
Suicide Prevention in Primary Care
Toolkit Section 1:
Getting Started
Quick Start Guide
Suicide Prevention in Primary Care
Suicide Prevention in Primary Care
Toolkit Section 2:Educating Clinicians and Staff
Primer Module 1 & 2: Prevalence and Comorbidity
Tenth leading cause of death in the U.S.
Sixth leading cause of death in CO.
In Colorado, suicide is the 2nd leading cause of death for ages 10-44.
Mental illness is neither a necessary nor sufficient condition for suicide but…Approximately 66% of adults who
consider suicide and nearly 80% of those who attempt suicide had a prior mental health disorder.
Suicide Prevention in Primary Care
Colorado Overview2011-2016
Suicide Prevention in Primary Care
Primer Module 3:Effective Prevention Strategies
Suicide Prevention Strategies in Primary Care
1. Train staff to recognize and respond to warning signs of suicide
2. Screen for and treat depression
3. Screen all patients for suicide risk
4. Educate patients about warning signs for suicide
5. Safety Plan/Temporarily restrict means for lethal self-harm
Suicide Prevention in Primary Care
Joiner’s Model
Suicide Prevention in Primary Care
Warning Signs
Warning signs of suicide
Anxiety
Agitation, aggression
Acting reckless
Insomnia or sleep disturbance
Increased alcohol or drug use
Withdrawing or feeling isolated
Talking about being a burden to others
Rage or seeking revenge
Dramatic mood swings
Feeling trapped – like there’s no way out
Talking about being in unbearable pain
Suicide Prevention in Primary Care
Screen for Suicidal Risk
Zero Suicide says Universal Screening!
Screening Tools:
PHQ-9
PHQ-9 A
C-SSRS
SPRC’s Decision Support Tool
Suicide Prevention in Primary Care
Module 3, cont’d: Prevention
Educate Patients and their loved ones about Suicide
Warning Signs
Suicide Prevention in Primary Care
Module 4: Suicide Risk Assessment
Key Components1. Assess for risk factors
2. Suicide Inquiry: The Big Four
a. Thoughts
b. Plan
c. Intent
d. Means
3. Assess for protective factors
4. Use your clinical judgment
5. Document, document, document
Suicide Prevention in Primary Care
Individual Risk Factors
Previous suicide attempt, especially within
the past year
Major physical illnesses, especially with
chronic pain
Central nervous system disorders, incl TBI
Mental illnesses, particularly:
Mood disorders
Schizophrenia
Anxiety disorders (including, PTSD)
Some alcohol and other substance use
disorders
Personality disorders (such as Borderline PD,
Antisocial PD, and Obsessive-Compulsive PD)
Suicide Prevention in Primary Care
Individual Risk Factors
In youths: bullying, ADHD and conduct
disorders (antisocial behavior, aggression,
impulsivity)
Psychiatric symptoms/states of mind:
anhedonia, severe anxiety/panic, insomnia,
command hallucinations, intoxication, self-
hate
Impulsive and/or aggressive behavior
History of trauma or abuse
Family history of suicide, exposure to suicide
in social network, community, media
Precipitants/triggering events leading to
humiliation, shame, or despair
Suicide Prevention in Primary Care
Social/ Environmental Risk Factors
Chaotic family history Lack of social support and increasing
sense of isolation Easy access to/familiarity with lethal
means (e.g., guns, illicit drugs, medications)
Local clusters of suicide that can have a contagious influence
Legal difficulties/contact with law enforcement/incarceration
Barriers to accessing health care, especially mental health and substance abuse treatment
Suicide Prevention in Primary Care
Societal Risk Factors
Certain cultural and religious beliefs
Exposure to, including through the media, and influence of others who have died by suicide
Suicide Prevention in Primary Care
Protective Factors
Sense of responsibility to family
Life satisfaction
Social support; belongingness
Coping skills
Problem-solving skills
Strong therapeutic relationship with a trusted provider
Reality testing ability
Religious faith
Suicide Prevention in Primary Care
Module 4, cont’d:Suicide Risk Assessment
Key components of a suicide risk assessment,
1. Assess warning signs and risk factors
2.Assess protective factors
3.Suicide Inquiry: thoughts/intent/plan/access to means
4.Clinical judgment
Suicide Prevention in Primary Care
Asking the Tough Questions
Suicide Inquiry: You can’t find the fever if you don’t take the temperatureAsk directly
Ask calmly
Ask without dread
Be prepared to follow up if the answer is “yes”
Many people feel relieved to be asked
Suicide Prevention in Primary Care
Suicide risk inquiry questions
Sometimes people in your situation lose hope; I’m wondering if you may have lost hope, too?
Have you ever thought about killing yourself?
You’re not thinking of killing yourself, are you?
Suicide Prevention in Primary Care
Pocket Card Tool
Pocket Card assessment questions
Pocket Card decision tree
Suicide Prevention in Primary Care
Module 5:Intervention
1. PCP Treatment
2. Collaborative Safety Planning
3. Referral to Evidence Based Treatment
4. Documentation and Follow-up Care
Suicide Prevention in Primary Care
1. PCP Treatment
More Americans receive psychiatric medications from PCPs than from psychiatrists
Antidepressants are typically the first line choice for treating depression
Monitor frequently for efficacy and side effects
Encourage patients to use/form a support network
Suicide Prevention in Primary Care
2. Collaborative Safety Planning
This is a crucial step in the process!
Safety plan should include:1. Recognizing warning signs
2. Identifying a variety of coping strategies
3. Utilizing friends and family members
4. Utilizing other resources like hotlines
5. Making the environment safe- restarting lethal means
Suicide Prevention in Primary Care
Patient Safety Plan Template
Suicide Prevention in Primary Care
Safety Planning:Lethal Means Restriction
Stronger the collaboration between the provider and the patient = greater the likelihood the patient will relinquish access to lethal means
With the patient’s permission, contact family members /support persons to assist with temporarily limiting access.
What it’s not:Political or moral discussion
Discussion of permanent removal of means
Suicide Prevention in Primary Care
Lethal Means Restriction
. Reducing access to lethal means
saves lives. 80% of Colorado firearm deaths
are suicides. Firearms used in youth suicide
usually belong to a parent Putting time and distance
between someone who is at risk for suicide and a firearm
Medications are also a common means
www.meansmatter.org
Suicide Prevention in Primary Care
Safety Planning Guide
Suicide Prevention in Primary Care
3. Referral to evidence-based care
Crisis/Suicide Prevention Hotlines
www. coloradocrisisservices.org
Text or Call1-844-493-8255
Suicide Prevention in Primary Care
Referral to Evidence Based Care
The Warm Handoff
Suicide Prevention in Primary Care
4. Documentation and Follow-up
1. Chart level of risk and interventions, response to interventions
Flag chart
2. Phone call within 24-48 hours
3. Schedule a follow-up visit
4. Always follow-up quickly upon discharge from hospital
Suicide Prevention in Primary Care
Messaging and Stigma
We talk about this stuff here
Public awareness materials- Many are free!
Communicate comfort with the topic
Providers are not aloneRally all staff levels in your clinic
Identify natural helpers/resources in the community
Suicide Prevention in Primary Care
Section 3:Building Mental Health Partnerships
Suicide Prevention in Primary Care
Section 3:Building Mental Health Partnerships
Collaborating with Behavioral Health
Existing Behavioral Health contacts/collaborations
Where is the nearest Community Mental Health Center?www.cbhc.org
Where are the nearest inpatient beds (adults vs. adolescents)?
List of community resources and referral networks
Don’t wait until a crisis!!
Suicide Prevention in Primary Care
Section 4:Patient Manage-mentTools
Pocket Guides
WICHE/SPRC Pocket Guide
SAFE-T Pocket Guide
WICHE/SPRC Safety Planning Guide
Suicide Prevention in Primary Care
Section 5: Resources, Policy, & Reimbursement
Suicide Prevention in Primary Care
Section 5: Resources, Policy, & Reimbursement
ACA: marketplace plans must cover depression screening for adults
Key Medicare Reimbursable Services:Annual Depression
Screening
Alcohol Misuse screening & counseling
SBIRT
Behavioral health counseling and therapy
Suicide Prevention in Primary Care
Section 6:Provider Self Care
Provider Suicide
Tips for self-care1. Awareness2. Connections3. Balance4. Help
Suicide Prevention in Primary Care
Section 7:Patient Ed Tools, Other Resources
Suicide Prevention in Primary Care
Section 7:Patient Ed Tools, Other Resources
Patient Ed Tools
Suicide Prevention in Primary Care
Next Steps
Your challenge: Develop an action plan that involves your entire staff in suicide prevention
Implementing lessons from today’s training
Find more info in the Toolkit!
Suicide Prevention in Primary Care
Thank you!
For inviting meFor working to help impact
this health crisis
Liza Tupa, PhD
Western Interstate Commission for Higher education, Behavioral Health Program WICHE BHP
https://wiche.edu/mentalHealth/suicide-prevention-toolkits