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Suicide Prevention in Primary Care
Suicide Prevention in Primary Care
Liza Tupa, Ph.D.
WICHE Mental Health Program
Suicide Prevention in Primary Care
Goals: Increase knowledge and confidence re:
suicide preventionEquip practices to implement a doable
suicide prevention approach
Objectives:Learn about the prevalence, risk and
protective factors, and warning signs associated with suicide.Learn practical prevention strategies and
protocols to implement in your office to identify at-risk patients and effectively intervene without disrupting patient flow. Learn how to collaborate with behavioral
health experts in your community to establish referral sources and minimize the disruption of daily operations.
Suicide Prevention in Primary Care
Getting to Know Your Setting
Disciplines?
Behavioral Health on site?
Level of Integration?
Electronic Health Record?
Urban vs rural?
Behavioral Health Screening?
How do referrals generally occur?
Other resources in the community?
Suicide Prevention in Primary Care
Perspective
Suicide Prevention in Primary Care
Why Primary Care?
People who die by suicide are more likely to have seen a PCP in the previous month before their death than any other health care provider.
70% of those who die by suicide in Colorado are not engaged in mental health care at the time of their death
Preventive care focus
PC’s frequent source of psychotropic medications Most psychotropic scrips written
by GP’s
Chronic conditions
Suicide Prevention in Primary Care
WhyPrimary Care?
You’ll see patients with suicide risk factors:
Major depression
Substance use disorders
PTSD/anxiety disorders
Insomnia
Chronic pain
Physical illnesses, especially CNS disorders (TBI)
Elderly
Veterans returning to rural areas (especially National Guard)
44% of U.S. Military recruits are from rural areas Many aren’t service connected
Suicide Prevention in Primary Care
Why Primary Care?
Stigma
Suicide Prevention in Primary Care
Rural Primary Care Issues
Fewer behavioral health resourcesMore than 65% of rural Americans get
their mental health care from their primary care provider
Elderly
Diverse ethnic/racial representation
Veterans returning to rural areas (especially National Guard)
44% of U.S. Military recruits are from rural areas
Many aren’t service connected
Suicide Prevention in Primary Care
Urban vs Rural
CDC https://www.acsh.org/news/2017/03/16/suicides-rural-america-increased-more-40-16-years-11010
Suicide Prevention in Primary Care
Suicide Rates by State,
2001 – 2016All Injury Types, All Races, All
Ages
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
Section 1: Getting Started
Quick Start Guide
Suicide Prevention in Primary Care
Suicide Prevention in Primary Care
Suicide Prevention in Primary Care
Section 2:Toolkit Primer
Module 1: 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 Overview
Suicide Prevention in Primary Care
PrimerModule 2:Epidemiology
Gender
Age
Race/Ethnicity
Special Populations
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
SuicideRisk Factors
Individual Risk Factors:
Previous suicide attempt, especially within the past
year
Major physical illnesses, chronic pain
Some alcohol and other substance use disorders
Personality disorders (such as Borderline PD,
Antisocial PD, and Obsessive-Compulsive PD)
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)
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
Warning Signs
Other warning signs of suicide
Anxiety
Agitation, aggression
Insomnia or sleep disturbance
Increased alcohol or drug use
Withdrawing or feeling isolated
Talking about being a burden to others
Dramatic mood swings
Feeling trapped – like there’s no way out
Talking about being in unbearable pain
Suicide Prevention in Primary Care
Screen for & Manage Depression
Increases prescription rates for antidepressants
Decreases suicidal ideation and completed suicides in their patients
Tools for screening and managing depression in a primary care setting: The MacArthur Initiative on Depression and Primary Care
http://otgateway.com/articles/13macarthurtoolkit.pdf
Best approach - combination of medication and psychotherapy whenever possible
Suicide Prevention in Primary Care
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all Several days More than half the days Nearly every day
1.Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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: 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
Joiner’s Model
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Asking the Tough Questions
Suicide Inquiry:Ask directlyAsk calmlyAsk without dreadBe prepared to follow up if the answer is “yes”Many people feel relieved to be asked
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
Module 5: Safety Planning
Recognizing warning signs
Identifying internal coping strategies
Utilizing friends and family members that can be contacted in order to distract
Contacting friends and family members who may help to resolve a crisis and with whom suicidal thoughts can be discussed directly.
Contacting health professionals or agencies
Making the environment safe- reducing access to lethal means
What it’s not:Political or moral discussionDiscussion of permanent removal of
means
Suicide Prevention in Primary Care
Lethal Means Restriction
For all and for these groups:
Youth
Elderly
Veterans
Suicide Prevention in Primary Care
Referral to Evidence Based Care
The Warm Handoff
Suicide Prevention in Primary Care
Resources24/7 free Crisis Line1-844-493-8255
Walk-in Centers
Crisis Stabilization Units (referral only)
Respite Care (referral only)
www.ColoradoCrisisServices.org
Suicide Prevention in Primary Care
Tracking 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
Developing a Workflow and Office Protocol
Adapt for your Practice and CommunityReview/Complete an Office
ProtocolWalk through a patient
entering your office (Table Top)Staff best positioned to aid in
this effort?Level of integrationWhere are the blanks?
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
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 Management Tools
Pocket Guides
WICHE/SPRC Pocket Guide
SAFE-T Pocket Guide
WICHE/SPRC Safety Planning Guide
Suicide Prevention in Primary Care
Pocket Card Tool
Suicide Prevention in Primary Care
Safety Planning Guide
Suicide Prevention in Primary Care
Patient Safety Plan Template
Suicide Prevention in Primary Care
Section 5: Resources, Policy, & Reimbursement
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
Patient Ed Tools
Suicide Prevention in Primary Care
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
Lean into change
Suicide Prevention in Primary Care
Thank you!
For inviting me
For caring
For working to help impact this health crisis
Liza Tupa, PhD
Western Interstate Commission for Higher education, Mental Health Program WICHE MHP
303-667-7927