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Suicide Prevention in Primary Care Suicide Prevention in Primary Care Bethany Rigles, Ph.D. WICHE Behavioral Health Program

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Page 1: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Suicide Prevention in Primary Care

Bethany Rigles, Ph.D.

WICHE Behavioral Health Program

Page 2: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Getting to Know Your Setting

Disciplines?

Behavioral Health on site?

Clinic level of Integration?

Electronic Health Record in use?

Behavioral Health Screenings done?

Do you have other behavioral health resources in your community?

Page 3: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Why Primary Care?

For a patient at risk for suicide, a visit with the PCP may be the only chance to access needed care - STIGMA

70% of those who die by suicide in Colorado are not engaged in mental health care at the time of their death

Risk Factors seen in Primary Care:Mental illnessesSubstance use disordersInsomniaChronic painPhysical illnesses, especially CNS

disorders (TBI)

Page 4: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Suicide by county

• Red

http://www.cdc.gov/ncipc/maps/default.htm

Page 5: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Page 6: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

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

Page 7: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Toolkit Section 1:

Getting Started

Quick Start Guide

Page 8: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Page 9: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Toolkit Section 2:Educating Clinicians and Staff

Primer Module 1 & 2: 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.

Page 10: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Colorado Overview2011-2016

Page 11: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

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

Page 12: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Warning Signs

Warning signs of suicideAnxietyAgitation, aggressionActing reckless Insomnia or sleep disturbanceIncreased alcohol or drug useWithdrawing or feeling isolatedTalking about being a burden to othersRage or seeking revengeDramatic mood swingsFeeling trapped – like there’s no way outTalking about being in unbearable pain

Page 13: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Screen for Suicidal Risk

Zero Suicide says Universal Screening!

Screening Tools:

PHQ-9

PHQ-9 A

C-SSRS

SPRC’s Decision Support Tool

Page 14: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Module 3, cont’d: Prevention

Educate Patients and their loved ones about Suicide

Warning Signs

Page 15: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Module 4: Suicide Risk Assessment

Key Components1. Assess for risk factors2. Suicide Inquiry: The Big Four

a. Thoughtsb. Planc. Intentd. Means

3. Assess for protective factors4. Use your clinical judgment5. Document, document,

document

Page 16: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Individual Risk Factors

Previous suicide attempt, especially within the past year

Major physical illnesses, especially with chronic pain

Central nervous system disorders, incl TBI Mental illnesses, particularly: Mood disorders Schizophrenia Anxiety disorders (including, PTSD)

Some alcohol and other substance use disorders

Personality disorders (such as Borderline PD, Antisocial PD, and Obsessive-Compulsive PD)

Page 17: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Individual Risk Factors

In youths: bullying, ADHD and conduct disorders (antisocial behavior, aggression, impulsivity)

Psychiatric symptoms/states of mind: anhedonia, severe anxiety/panic, insomnia, command hallucinations, intoxication, self-hate

Impulsive and/or aggressive behavior History of trauma or abuse Family history of suicide, exposure to suicide

in social network, community, media Precipitants/triggering events leading to

humiliation, shame, or despair

Page 18: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

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) Local clusters of suicide that can have a

contagious influence Legal difficulties/contact with law

enforcement/incarceration Barriers to accessing health care,

especially mental health and substance abuse treatment

Page 19: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Societal Risk Factors

Certain cultural and religious beliefs

Exposure to, including through the media, and influence of others who have died by suicide

Page 20: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Protective Factors

Sense of responsibility to familyLife satisfactionSocial support; belongingnessCoping skills Problem-solving skillsStrong therapeutic relationship

with a trusted providerReality testing ability Religious faith

Page 21: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Module 4, cont’d:Suicide Risk Assessment

Key components of a suicide risk assessment,

1. Assess warning signs and risk factors

2.Assess protective factors 3.Suicide Inquiry:

thoughts/intent/plan/access to means

4.Clinical judgment

Page 22: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Asking the Tough Questions

Suicide Inquiry: You can’t find the fever if you don’t take the temperatureAsk directlyAsk calmlyAsk without dreadBe prepared to follow up if the

answer is “yes”Many people feel relieved to be

asked

Page 23: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Suicide risk inquiry questions

Sometimes people in your situation lose hope; I’m wondering if you may have lost hope, too?Have you ever thought about killing yourself?You’re not thinking of killing yourself, are you?

Page 24: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Pocket Card Tool

Pocket Card assessment questions

Pocket Card decision tree

Page 25: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Module 5:Intervention

1. PCP Treatment2. Collaborative Safety Planning3. Referral to Evidence Based

Treatment4. Documentation and Follow-up

Care

Page 26: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

1. PCP Treatment

More Americans receive psychiatric medications from PCPs than from psychiatristsAntidepressants are typically

the first line choice for treating depressionMonitor frequently for efficacy

and side effectsEncourage patients to

use/form a support network

Page 27: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

2. Collaborative Safety Planning

This is a crucial step in the process!

Safety plan should include:1. Recognizing warning signs2. Identifying a variety of

coping strategies3. Utilizing friends and family

members4. Utilizing other resources like

hotlines5. Making the environment

safe- restarting lethal means

Page 28: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Patient Safety Plan Template

Page 29: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Safety Planning:Lethal Means Restriction

Stronger the collaboration between the provider and the patient = greater the likelihood the patient will relinquish access to lethal means

With the patient’s permission, contact family members /support persons to assist with temporarily limiting access.

What it’s not:Political or moral discussionDiscussion of permanent removal of

means

Page 30: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Lethal Means Restriction

. Reducing access to lethal means

saves lives. 80% of Colorado firearm deaths

are suicides. Firearms used in youth suicide

usually belong to a parent Putting time and distance

between someone who is at risk for suicide and a firearm

Medications are also a common means

www.meansmatter.org

Page 31: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Safety Planning Guide

Page 32: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

3. Referral to evidence-based care

Crisis/Suicide Prevention Hotlines

www. coloradocrisisservices.orgText or Call

1-844-493-8255

Page 33: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

4. Documentation and Follow-up

1. Chart level of risk and interventions, response to interventionsFlag chart

2. Phone call within 24-48 hours3. Schedule a follow-up visit4. Always follow-up quickly upon

discharge from hospital

Page 34: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Messaging and Stigma

We talk about this stuff herePublic awareness materials- Many

are free!Communicate comfort with the topicProviders are not aloneRally all staff levels in your clinicIdentify natural helpers/resources

in the community

Page 35: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Section 3:Building Mental Health Partnerships

Page 36: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Section 4:Patient Manage-mentTools

Pocket Guides

WICHE/SPRC Pocket Guide

SAFE-T Pocket Guide

WICHE/SPRC Safety Planning Guide

Page 37: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Section 5: Resources, Policy, & Reimbursement

Page 38: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Section 6:Provider Self Care

Provider Suicide

Tips for self-care1. Awareness2. Connections3. Balance4. Help

Page 39: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Section 7:Patient Ed Tools, Other Resources

Page 40: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Section 7:Patient Ed Tools, Other Resources

Patient Ed Tools

Page 41: Suicide Prevention Training for Primary Care · Suicide Prevention Strategies in Primary Care. 1. Train staff to recognize and respond to warning signs of suicide. 2. Screen for and

Suicide Prevention in Primary Care

Thank you!

For inviting meFor working to help impact

this health crisis

Bethany Rigles, PhDWestern Interstate Commission for Higher education, Behavioral Health Program WICHE [email protected]@wiche.edu

https://wiche.edu/mentalHealth/suicide-prevention-toolkits