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, MPHAssistant Professor

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

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

Suicide Risk Management

Identify Patients at Risk Assess

Level of Risk

Make Clinical Risk Management

DecisionPerform Risk Management

Tasks

Assessing Risk

• Relies on subjective reporting

• Requires discussing stigmatized topic

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

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

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?

1. Kravitz et. al, JAMA 2005; 2. Feldman et al. Annals of Family Medicine 2007

Background

• Patients’ Requests for Direct-to-Consumer Advertised Antidepressant1

– Standardized Patients (SPs)• Carpal tunnel syndrome/depression• Low back pain/adjustment disorder• Requesting antidepressant

• Family and Internal Medicine PCPs

• Suicide discussion in 36% of encounters2

Analyses of the SP DataMethod

• Text based search of keywords– suicid* hurt*, harm*, kill*, death, dying, etc.

• Coding into suicidal behavior categories

• Evaluating for “pre-contextualizing”

• Evaluating “post-contextualizing”

298 transcripts

91 suicide dialog

6 truncated

Coding scheme

11 mislabeled

Frequency

Range

108 SPs reported suicide inquiry

Inductive review

Model of Suicide Inquiry

Inquiry

Context Follow-up

3 PCP utterancespreceding

inquiry

3 PCP utterancesfollowing

inquiry

Key word search

(suicid*, hurt*, harm*, kill*,

death, dying), transcript

review

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?”

N %1 69 75%2 19 22%3 3 3%4 0 0%

In how many ways was the inquiry phrased?

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…”

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?

Preparing the Patient for Sensitive Questions

Frequency of Multiple Contextualizing Statements

Context Preceding 2 removed 3 removed

in/mixed 80 (88%) 79 (87%) 73 (80%)

Preceding Statements (N = 91)

0 1 2 3

9 (10%) 4 (4%) 6 (7%) 72 (79%)

Do physicians respond with a context relevant statement

Follow-up Statements - in context? (n = 91)

Context Proximal 2 removed 3 removed

in/mixed 89 (98%) 78 (86%) 74 (81%)

0 1 2 3

2 (2%) 23 (26%) 8 (9%) 79 (70%)

Frequency of Contextualized Follow-ups

What is “follow-up context”?

Category N %

Direct Suicide follow-up 32 35%

Supportive 25 27%

Depression 39 45%

Mental Health/Psychosocial 10 11%

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

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.

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.

Analysis of the SP DataDiscussion

• “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

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

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?

Thank You