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Suicide Prevention in Primary Care Suicide Prevention in Primary Care Liza Tupa, Ph.D. WICHE Behavioral Health Program

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Page 1: Suicide Prevention Training for Primary Carecoruralhealth-wpengine.netdna-ssl.com/wp-content/... · Suicide Prevention in Primary Care Toolkit Section 2: Educating Clinicians and

Suicide Prevention in Primary Care

Suicide Prevention in Primary Care

Liza Tupa, Ph.D.

WICHE Behavioral Health Program

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Suicide Prevention in Primary Care

The Suicide Prevention Toolkit for Colorado Primary Care Practices

Funded by the Colorado Department of Public Health and Environment-CDPHE

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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?

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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 illnesses

Substance use disorders

Insomnia

Chronic pain

Physical illnesses, especially CNS disorders (TBI)

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Suicide Prevention in Primary Care

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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

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Suicide Prevention in Primary Care

Toolkit Section 1:

Getting Started

Quick Start Guide

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Suicide Prevention in Primary Care

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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.

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Suicide Prevention in Primary Care

Colorado Overview2011-2016

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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

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Suicide Prevention in Primary Care

Joiner’s Model

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Suicide Prevention in Primary Care

Warning Signs

Warning signs of suicide

Anxiety

Agitation, aggression

Acting reckless

Insomnia or sleep disturbance

Increased alcohol or drug use

Withdrawing or feeling isolated

Talking about being a burden to others

Rage or seeking revenge

Dramatic mood swings

Feeling trapped – like there’s no way out

Talking about being in unbearable pain

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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

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Suicide Prevention in Primary Care

Module 3, cont’d: Prevention

Educate Patients and their loved ones about Suicide

Warning Signs

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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

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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)

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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

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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

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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

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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

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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

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Suicide Prevention in Primary Care

Asking the Tough Questions

Suicide Inquiry: You can’t find the fever if you don’t take the temperatureAsk directly

Ask calmly

Ask without dread

Be prepared to follow up if the answer is “yes”

Many people feel relieved to be asked

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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?

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Suicide Prevention in Primary Care

Pocket Card Tool

Pocket Card assessment questions

Pocket Card decision tree

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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

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Suicide Prevention in Primary Care

1. PCP Treatment

More Americans receive psychiatric medications from PCPs than from psychiatrists

Antidepressants are typically the first line choice for treating depression

Monitor frequently for efficacy and side effects

Encourage patients to use/form a support network

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Suicide Prevention in Primary Care

2. Collaborative Safety Planning

This is a crucial step in the process!

Safety plan should include:1. Recognizing warning signs

2. Identifying a variety of coping strategies

3. Utilizing friends and family members

4. Utilizing other resources like hotlines

5. Making the environment safe- restarting lethal means

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Suicide Prevention in Primary Care

Patient Safety Plan Template

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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 discussion

Discussion of permanent removal of means

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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

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Suicide Prevention in Primary Care

Safety Planning Guide

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Suicide Prevention in Primary Care

3. Referral to evidence-based care

Crisis/Suicide Prevention Hotlines

www. coloradocrisisservices.org

Text or Call1-844-493-8255

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Suicide Prevention in Primary Care

Referral to Evidence Based Care

The Warm Handoff

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Suicide Prevention in Primary Care

4. Documentation 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

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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

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Suicide Prevention in Primary Care

Section 3:Building Mental Health Partnerships

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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!!

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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

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Suicide Prevention in Primary Care

Section 5: Resources, Policy, & Reimbursement

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Suicide Prevention in Primary Care

Section 5: Resources, Policy, & 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

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Suicide Prevention in Primary Care

Section 6:Provider Self Care

Provider Suicide

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

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Suicide Prevention in Primary Care

Section 7:Patient Ed Tools, Other Resources

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Suicide Prevention in Primary Care

Section 7:Patient Ed Tools, Other Resources

Patient Ed Tools

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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!

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Suicide Prevention in Primary Care

Thank you!

For inviting meFor working to help impact

this health crisis

Liza Tupa, PhD

Western Interstate Commission for Higher education, Behavioral Health Program WICHE BHP

[email protected]

[email protected]

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