Project 2025—Raising Awareness for Suicide Treatment

Christine Moutier, M.D. Chief Medical Officer AFSPDavid Jobes, Ph.D. The Catholic University of AmericaDiana Cortez Yanez Lived Experience Consultant

February 2, 2021

Continuing Education Credits & Access to the Recording and Slides

• This closed captioned webinar will be recorded• 2 free CEs are available for attending today’s webinar

• American Psychological Association

• NBCC – CEs through CAMS-care, LLC ACEP # 7039

• National Association of Social Workers (Approval # 886455354-6865)

• You will receive an email from CAMS-care.com following the webinar with a link to complete a survey and receive your CE certificate

• Make sure your name and email are correct in Zoom

• A recording of the webinar and a downloadable slide deck will be available on AFSP and CAMS-care’s websites later in the week

• https://afsp.org/hcp

• https://cams-care.com/resources/events/suicide-prevention-healthcare-settings/

• We have 30 minutes at the end for Q&A. Use the Q&A button at any time during this webinar to post your questions

Today’s Presenters

Dr. Christine Moutier. AFSP’s Chief Medical Officer, knows the impact of suicide firsthand. After losing colleagues to suicide, she dedicated herself to fighting this leading cause of death. Dr. Moutier has served as UCSD professor of psychiatry, dean in the medical school, medical director of the VA Psychiatric Unit, and has been clinically active with diverse patient populations, such as veterans, Asian refugee populations, as well as physicians and academic leaders with mental health conditions. She has presented at the White House, testified before the U.S. Congress, presented at the National Academy of Sciences, and has appeared as an expert on Anderson Cooper 360, the BBC, CBS This Morning, The Atlantic, The New York Times, Time, The Washington Post, The Economist and NBC Nightly News.

Today’s PresentersDavid A. Jobes, Ph.D., ABPP. Is a Professor of Psychology, Director of the Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. Dr. Jobes is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. Dr. Jobes has conducted research in clinical suicidology for 35 years. He is a past president of the American Association of Suicidology. Dr. Jobes is currently a Board Member of the American Foundation for Suicide Prevention (AFSP) and serves on AFSP’s Scientific Council and the Public Policy Council. He is a Fellow of the American Psychological Association and is Board certified in clinical psychology (American Board of Professional Psychology). He maintains a clinical and consultation private practice in Washington, DC.

Today’s PresentersDiana Cortez Yanez. After being in the behavioral health system for 30 years, as a patient, and having made multiple attempts on her life, Diana experienced a life changing treatment. She is now a national public speaker, advocate in suicide prevention and peer specialist. Her passion is sharing what she has gleaned from her experiences as to what helped and what was not helpful, in order to help save lives. Diana has had the opportunity to share her story internationally and in many different platforms such as, the White House, Facebook’s launch of suicide prevention feature, Canadian Health Magazine, Washington State Behavioral Health brochure, NPR, Indian Health Services, Cornerstone, Now Matters Now, Live Through This, Jasper Health, and Zero Suicide. She continues to look for and accept more ways to help in suicide prevention, such as this webinar, for sharing the specific details of her journey.

Learning Objectives

The Suicide Problem & the genesis of Project 2025 – goals and critical areas

How emergency departments and health systems clinically manage patients who are suicidal

Systems of care, evidence-based approaches and best practices to reduce suicide rates

Ethical and legal considerations of treating patients who are suicidal

2 CE credits provided for APA, NASW, and NBCC members

Agenda

• Suicide – a mental health care crisis• Project 2025 – reducing suicides in America - Emergency Departments and Health

Systems• Current Practices – Emergency Departments and Health Systems• A System of Care for Inpatient & Outpatient Treatment

• Screening & Assessment• Management of Suicidal Crises• Evidence based psychological treatments• Pharmaceuticals• Caring contact & Lived experience support

• Risk Management – Ethical & Legal Considerations• Q & A• Final thoughts

The Challenge of Suicide in the United States

A Stubbornly Growing Public Health Problem

United States 2018

Ideation vs Attempts vs Completions (2019)

• 47,511 deaths• 1.6 million made suicide attempts• 12 million adults with serious suicidal ideation• Including adolescents that number is closer to 14 million

Project 2025Reduce the suicide rate by 20% by the end of 2025

The focus today is on 2 of these 4 critical areas

Managing Patients Who are Suicidal TodayEmergency Departments & Inpatient Hospitalization

Emergency Departments today – What to expect?

• A long wait

• 15-minute watch

• Doctors and nurses are focused on medical rather than mental treatment• Some sort of screening or assessment

• Most likely an immediate hospitalization in urban communities and a patient being sent home in a rural community

• Variations in the experiences for all involved

• Some progress• EDs adopting tools like Jaspr, ICAR²E – a rich domain for innovation with an AFSP award

• Move towards universal screening

• Programs like Reaching Everyone Preventing Suicide where patient is referred to outpatient treatment

For a person who enters an ED with suicidal ideation – stats?

Jaspr Health Project from ED to home use?

https://www.youtube.com/watch?v=l9zbM8jEsvY&feature=youtu.be Jaspr at Home

Hospitalization:

Source: Luxton, D.D., June, J.D., Comtois, K.A. (2013) Can postdischarge follow-up contacts prevent suicide and suicidal behavior? Crisis 34(1) 32-14

Not Always a Good Intervention for Patients Who are Suicidal

The majority of suicides post-hospitalization occur within the

first month after discharge

Rates of suicide after discharge is more than 100 times the rate of

the general population

Compliance with routine treatment after discharge has been found to be

less than 40%

Only 25-50% attend an appointment for outpatient treatment

Outpatient Management of Suicidal Crises

Safety Plan Intervention(Stanley & Brown)

Crisis Response Plan(Rudd & Bryan)

Virtual Hope Box (Bush)

Caring for Patients Who are

Suicidal A Systems Approach

Suicide System of Care–Inpatient & Outpatient

Well established screening tools include ASQ & PHQ-9

Assessment is a process and useful tools include C-SSRS, SSI,SHBQ, SBQ-R…

CAMS

DBT

CT-SP & BCBT

Caring Follow-Up(e.g., calls/emails)

Platforms -e.g.,NeuroFlow, WellTrack

Psychosocial Services

Evaluation of Suicidal Risk

Evidence Based Suicide-Specific Assessment &

TreatmentNon-Demand Caring Contacts

CLINICAL CARECommunity Awareness

QPR

ASIST

Umatter

Sources of Strength

CALM

Postvention

Build Awareness that help & treatment is available

70% of people who die by suicide are not engaged in mental health treatment at the time of their death

Public Awareness

Ideally in an outpatient setting for all but the most extreme cases – most patients do not want to be locked up

Screening

Assessment

Screening & Assessment for Suicidal Risk

Effective Clinical Treatments

for Suicidal States

Evidence-Based Treatments for Suicidality

• 90+ RCT’s with suicidal ideation and behavioral outcomes

• No support for inpatient hospitalization

• Increased risk of suicide post-discharge

• Handful of treatments with single RCT support (e.g., ASSIP)

• Suicide-specific interventions with replicated and independent RCT support:

• Dialectical Behavior Therapy (DBT)

• Two types of suicide-specific CBT (CT-SP & BCBT)

• Collaborative Assessment and Management of Suicidality (CAMS)

• Non-demand follow-up “caring contact”

Dialectical Behavior Therapy (DBT)

Source: DeCou, C.R., Comtois, K.A., Landes, S.J. (2019) Dialectical Behavior Therapy is effective for the treatment of suicidal behavior: A meta-analysis Behavior Therapy. 50(2019) 60-72

DBT is an Outpatient Treatment with Four Modalities:

Group Skills Training1

Individual Psychotherapy2

Out-of-session Phone Coaching3

Therapist Consultation Team Meeting4

Dialectical Behavior Therapy (DBT)

Meta-analysis of 18 controlled trials of DBT

Source: DeCou, C.R., Comtois, K.A., Landes, S.J. (2019) Dialectical Behavior Therapy is effective for the treatment of suicidal behavior: A meta-analysis Behavior Therapy. 50(2019) 60-72

DBT Reduced Self-Directed Violence

DBT Reduced Frequency of Psychiatric

Crisis Services

Suicidal Ideation was not significantly impacted by DBT in most of the studies

Cognitive Therapy for Suicide Prevention (CT-SP)

Source: Brown, G.K., Ten Have, T., Henriques, G.R., Xie, S.X., Hollander, J.E., Beck, A.T. (2005) Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294, 563-370

• Identifying thoughts, images, core beliefs• Emphasis on “suicidal mode”• Develop adaptive ways of coping with

stressors• Relapse prevention task

Methods:

Cognitive Therapy for Suicide Prevention (CT-SP)

Source: Brown, G.K., Ten Have, T., Henriques, G.R., Xie, S.X., Hollander, J.E., Beck, A.T. (2005) Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294, 563-370

CT-SP was twice as effective as

usual care in reducing

suicide attempts

Patients in CT-SP treatment had

significantly lower scores on Beck Depression Inventory (BDI)

Patients in CT-SP treatment had

significantly lower levels of hopelessness

Results of Study

Source: Rudd, D.M., Bryan, C.J. et al (2015) Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015 May;172(5):441-9

Phase I: Brief Cognitive Behavioral Therapy

Methods

Phase II: Assessment of suicidal behaviors and develop strategies

Phase III: Apply strategies to reduce vulnerability to using suicide to cope

Phase IV: Relapse prevention task conducted

Brief Cognitive Behavior Therapy (BCBT)

Treatment of Suicidal States

Brief Cognitive Behavior Therapy (BCBT)Treatment of Suicidal States

Source: Rudd, D.M., Bryan, C.J. et al (2015) Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015 May;172(5):441-9

Soldiers in BCBT 60% less likely than

soldiers in treatment to make a suicide attempt

during the 2 year follow up period

Soldiers in BCBT slightly less likely

to be medically retired than Soldiers in control treatment

Results of Study

The Relative Importance of Suicidal Ideation(as a massive population at risk)

We are understandably preoccupied with attempts and deaths.But why do we not appreciate the largest population who are suicidal—those with serious suicidal ideation?

The Collaborative Assessment and Management of Suicidality (CAMS)

A Treatment Framework that Provides Risk Assessment, Stabilization Planning, and Treatment of Patient-Defined Suicidal Drivers

The Collaborative Assessment and Management of Suicidality (CAMS)

The four pillars of the CAMS framework:

1) Empathy

2) Collaboration

3) Honesty

4) Suicide-focused

Goal: Build a strong therapeutic alliancethat increases patient-motivation; CAMS targets and treats patient-definedsuicidal “drivers”

First session of CAMS—SSF Assessment, Stabilization Planning, Driver-Focused Treatment Planning, and HIPAA Documentation

CAMS Tracking/Update Sessions CAMS Outcome/Disposition Session

CAMS for Suicidal Ideation

• Understand the direct and indirect drivers of suicidal ideation

• CAMS Assessments® - assess what might be the best way to support the patient

• Develop a CAMS Stabilization Plan to provide resources for the patient

• CAMS Treatment® - develop a treatment plan to address the direct and indirect drivers of suicidal ideation

• Provide a framework to shape treatment to target and treat the drivers of suicidal ideation

The CAMS Framework® is an assessment and suicide-focused treatment

Summary of CAMS Research Findings to Date

• Reliably reduces suicidal ideation in 6-8 sessions• Reduces overall symptom distress, depression, hopelessness, and

changes suicidal cognitions• Increases hope and improves clinical retention to care• Patients like CAMS and the process of doing CAMS• Works better with patients who are less severe at baseline presentation • Decreases ED visits among certain subgroups• A promising impact on self-harm behavior and suicide attempts• Relatively easy to learn

Across 8 published non-randomized clinical trials of CAMS, 1 meta-analysis, 5 published randomized controlled clinical trials, and 3 unpublished RCT’s (a total of 90+ publications):

MedicationsAre there medications that work?

Medications and CNS Treatments

• Maximize treatment for primary diagnosis AND consider suicide risk as well

• Understand the data re FDA Black Box warning- AD in <24 years old• Medications with evidence for reducing suicidal behavior

• Lithium (1 RCT, numerous secondary outcome)• Clozapine (1 RCT)• Antidepressants (RCTs, pharmaco-epidemiological studies)

• Esketamine (FDA approved for treatment-refractory MDD & MDD with Suicidal Ideation)

• Electroconvulsive therapy (ECT)• Maybe transcranial magnetic stimulation (TMS)• Best in combination with therapy

Caring Contact & Lived Experience Support

The importance of not being forgotten and peer support

Caring Contact Outreach & Lived Experience Peer-Based Support

• Caring letters• Caring postcards• Caring phone calls• Caring emails• Caring texts• ED follow-up calls• Inpatient follow-up

phone calls• Post-discharge home

visits (e.g., VA)

And the power of using technology to reach more people at risk for suicide…

Ethical and LegalConsiderations

Know the three “pillars” for reducing malpractice liability(i.e., malpractice wrongful death tort litigation pursued by a plaintiff):

(Jobes & Berman, 1993)

Malpractice Liability, Competent Practice, and Cases of Suicide

Foreseeability Follow-up/follow-through

Treatment planning

Suicide-Related Malpractice Liability

• Malpractice tort litigation for wrongful death secondary to a patient suicide is pursued by plaintiffs (e.g., surviving family) who assert that the provider breached the “standard of care.”

• The Standard of Care is operationally defined as what a reasonably prudent practitioner who is similarly trained, in a similar setting, with a similar patient would do.

• The Standard of Care is defined by expert witnesses who examine subpoenaed records, interrogatories, and depositions related to the case.

Suicide-Related Malpractice Liability

The plaintiff has the burden of proof to establish that the practitioner:

• Failed to assess the risk (i.e., foreseeability)

• Failed to appropriately treat the risk

• Failed to follow-through on risk over the course of treatment

Enhanced Clinical Documentation—Reducing the Risk of Malpractice • For example, CAMS uses the SSF in every session

Follow SPRC COVID Virtual Environment guidelines

Resources for Therapists and Families

1.For cliniciansa.Action Alliance Recommended Standard Care b.The Joint Commission Suicide Prevention Portalc.Project 2025 SafeSide linkd.Discount of 20% on any CAMS training using code AFSP21 at https://cams-care.com/products/

2.For the publica.afsp.org to learn more about suicide preventionb.To learn more about treatment https://afsp.org/treatmentc.Finding treatment https://afsp.org/find-a-mental-health-professionald.What to do when someone you love is struggling https://afsp.org/what-to-do-when-someone-is-at-riske.https://afsp.org/find-a-local-chapter to find chapter near youf.Tips for parents https://afsp.org/teens-and-suicide-what-parents-should-knowg.Resources for suicide bereavement https://afsp.org/ive-lost-someoneh.If you're worried about someone https://afsp.org/when-someone-is-at-risk

New U.S. Surgeon General Call to Action

Questions and Answers

Continuing Education Credits & Access to the Recording and Slides

• A recording of the webinar and a downloadable slide deck will be available on AFSP and CAMS-care’s websites• https://afsp.org/hcp

• https://cams-care.com/resources/events/suicide-prevention-healthcare-settings/

• 2 free CEs are available for attending today’s webinar• American Psychological Association

• NBCC – CEs through CAMS-care, LLC ACEP # 7039

• National Association of Social Workers (Approval # 886455354-6865)

• Webinar attendees will receive an email with a link to the CE Survey. Completing the survey will result in a CE Certificate

Thank you for watching

CAMS-care is pleased to be providing 2 free CE credits if you are a psychologist, social worker or professional counselor.

To obtain your free CEs, please contact CAMS-care customer support:

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Final Thoughts