suicide inquiries in primary care medical encounters university of washington department of...
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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
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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
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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
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Suicide Risk Management
Identify Patients at Risk Assess
Level of Risk
Make Clinical Risk Management
DecisionPerform Risk Management
Tasks
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Assessing Risk
• Relies on subjective reporting
• Requires discussing stigmatized topic
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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
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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
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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?
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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
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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”
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298 transcripts
91 suicide dialog
6 truncated
Coding scheme
11 mislabeled
Frequency
Range
108 SPs reported suicide inquiry
Inductive review
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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
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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?”
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N %1 69 75%2 19 22%3 3 3%4 0 0%
In how many ways was the inquiry phrased?
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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…”
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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?
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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%)
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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
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What is “follow-up context”?
Category N %
Direct Suicide follow-up 32 35%
Supportive 25 27%
Depression 39 45%
Mental Health/Psychosocial 10 11%
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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
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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.
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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.
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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
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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
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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?
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Thank You