QPR for Non-Psychiatric Medical Providers We at the QPR Institute are fully aware of the demands on medical care professionals to treat large numbers of patients in short periods of time. We also feel that routine screening of high risk populations will lead to the detection of suicide risk otherwise missed in routine medical practice and that a brief intervention and referral should fall within the scope of practice. Background In 2006 the Joint Commission on the Accreditation of Healthcare Organizations targeted the identification of suicidal patients as a patient safety goal for 2007. Requirement 15A states, “The organization identifies clients at risk for suicide.” Identification and assessment of potentially suicidal patients is also recommended by the Institute of Medicine in its key 2002 report, Reducing Suicide: A National Imperative and specific training in detection and assessment of suicidal patients is recommended in the 2001 National Strategy for Suicide Prevention. These initiatives are in keeping with the goals of Healthy People 2010. Routine screening of high risk groups will increase institutional adoption and maintenance of suicide screening, brief intervention and referrals to specialty care providers. Detecting suicide risk and proper referrals will decrease the number of subsequent emergency department visits for suicide-related events, as well as decreasing morbidity and mortality in the populations served. As noted in the QPR Introductory Video, physicians recommend the use of QPR in their practice to facilitate detection of potentially suicidal patients. Why screen for suicide? Multiple studies have shown increased rates of depression in medical populations and in patients with selected chronic illnesses, with prevalence rates between 25 and 50 percent (Nesse and Finlayson, 1996) and the medically ill have been found to be at elevated risk for suicidal behaviors (Hughes & Kleepsies, 2001). High rates of depression are reported for patients with AIDS, chronic pain syndromes, central nervous disorders such as multiple sclerosis, chronic renal failure, cancer, lupus, rheumatoid arthritis and acute burn victims (Henk, Katzelnick, Kobak, Griest and Jefferson, 1996). Moreover, numerous studies show that the majority of individuals who later go on to attempt or complete suicide have recently visited a physician (Links et al., 1999 and Luoma et al., 2002), thus placing physicians in a unique role to affect suicide rates, especially for older adults. Dhossche et al.(2001) reported that the suicide rate in patients recently discharged from the hospital is three times higher than that of the general population, even though a large proportion do not voluntarily disclose their suicidal intent, even on the day of their death (Isometsä et al., 1995).

Still other studies indicate that at least one half of all patients who receive mental health care obtain it from their PCP (e.g., Narrow et al., 1993), yet 50% of practitioners miss the presence of suicidal ideation in their patients (Beaudin et al., 2004). The fear that inquiry into suicidal thoughts and feelings may precipitate an adverse outcome is not supported (Hirschfeld & Russell, 1997) and there appears to be a general hesitance or lack of training in how to conduct a suicide risk inquiry (Feldman et al., 2007). No list of medical illnesses and associated risks for suicide can be exhaustive because each patient has a unique reaction to his or her diagnosis, injury or medical crisis. The accidental loss of an index finger may prove inconvenient to a truck driver, but career ending to a concert pianist. Therefore, a psychological perspective is necessary to understand suicide potential in any given patient and an increased index of suspicion is required if undetected suicidal patients are to be identified. Who should be screened? In addition to all patients exhibiting suicide warning signs, the QPR Institute and its multidisciplinary faculty recommends a suicide risk probe is indicated when there is:

• A positive screen for depression or other psychiatric illness • A positive screen for substance abuse

• A current episode of admitted or suspected deliberate self-harm such as cutting,

self-poisoning, including alcohol poisoning and drug overdose

• A known history of a previous suicide attempt or deliberate self-harm behavior

• A recent suicide of a family member or significant other

• A current or known history of trauma or abuse, including elder abuse and domestic violence

• An existing or current diagnosis of major physical illness, especially if it is

terminal or involves serious chronic pain

• Hopelessness about the consequences of a significant injury or traumatic loss, especially if patient is socially isolated

• The patient has experienced recent, relational or social loss such as the death of a

loved one or unwanted or unexpected unemployment Youth Because of their elevated risk for suicidal behaviors we further recommend a routine QPR screen for all patients 15 to 25 years old. In an emergency, parental consent is not required for assessing or treating youth.

QPR probes In addition to those QPR inquiries recommended in the Gatekeeper training, these probes are suggested for medical providers.

• “Have you had any recent thoughts about death or suicide? • “Were you feeling suicidal when this injury occurred?”

• “Have you attempted suicide in the past?”

• “Are you feeling suicidal now?”

If the answer to any of the above questions is yes, the patient should receive a brief intervention that succeeds in persuading the individual to seek help or accept a referral for further evaluation. If the provider is competent to conduct a suicide risk assessment, the assessment interview should follow immediately. Assisting friends and families Patient safety following detection and assessment of suicide risk may be improved by providing emergency numbers, directions to referral sources and similar informational interventions to the patient and his or her family. The QPR Institute publishes a booklet for the family members and loved ones of persons known to be at risk of suicidal behaviors. The Tender Leaves of Hope: Helping Someone Survive a Suicide Crisis can be purchased from the Institute’s web site bookstore at http:://www/qprinstitute.com. Advanced training For those interested, you may wish to explore advanced training programs in suicide risk assessment offered by the QPR Institute and its educational partners, Eastern Washington University and Essential Learning. References

• Beaudin, C. L., Virgil, V. J. & Weber, S. (2004). Suicide risk assessment in an MCO. Managed Care Interface, 17, 39-44

• Dhossche, D. M., Ulusarac, A. & Syed, W. (2001). A Retrospective Study of

General Hospital Patients Who Commit Suicide Shortly After Being Discharged From the Hospital. Archives of Internal Medicine, 161(7), 991-994

• Feldman, M.D., Franks, P., Duberstein, P.D., Vannoy, S., Epstein, R. and Kravitz,

R.L. (2007). Let’s not talk about: suicide inquiry in primary care. Annals of Family Medicine 5:412-418

• Harris, E.C. & Barraclough, B. (1994). Suicide as an outcome for medical

disorders. A meta-analysis. British Journal of Psychiatry, 73 (6), 281-396

• Henk H.J., Katzelnick D.J., Kobak K.A., et al. (1996). Medical costs attributed to depression among patients with a history of high medical expenses in health maintenance organization. Archives of General Psychiatry, 53:899-904

• Hirschfeld, R. M. A., & Russell, J. M. (1997). Assessment and treatment of

suicidal patients. New England Journal of Medicine, 337(13), 910-915 • Hughes, D. & Kleepsies, P. (2001). Suicide in the medically ill. Suicide and Life-

Threatening Behavior, 31 (Supplement), 48-59 • Isometsä, E. T., Heikkinen, M. E., Marttunen, M. J., Henriksson, M. M., Aro, H.

M., & Lonnqvist, J. K. (1995). The last appointment before suicide: is suicide intent communicated? American Journal of Psychiatry, 152(6), 919-922

• Luoma, J. B., Martin, C. E. & Pearson, J. L. (2002). Contact with mental health

and primary care providers before suicide: A review of recent studies. American Journal of Psychiatry, 159(6), 906-916

• Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R. W. & Locke, B. Z.

(1993). Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, 50(2), 95-107

• Nesse R.E. & Finlayson R.E. (1996) Management of depression in patients with

coexisting medical illness. American Family Physician; 54:468