Although psychiatrists may be better trained to treat suicidal patients, most patients with suicidal ideation are receiving care outside of specialty psychiatric settings and can benefit from interventions in primary care.
SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS
Although psychiatrists may be better trained to treat suicidal patients, most patients with suicidal ideation are receiving care outside of specialty psychiatric settings and can benefit from interventions in primary care. Many individuals see their primary care provider in the months leading up to suicide death.1 Therefore, primary care clinicians may have important opportunities to identify and treat suicidal patients. Recommendations about assessing suicidal risk in primary care settings are mixed, however. The Joint Commission now recommends asking patients about suicidal ideation routinely in ambulatory settings.2 The United States Preventive Services Task Force (USPSTF) does not make a recommendation for or against screening for suicide risk in a primary care setting due to insufficient evidence regarding the accuracy of screening tests and the effectiveness of suicide prevention interventions.3 The USPSTF does, however, recommend routine depression screening for adolescents and adults seen in the primary care setting when adequate systems are in place to ensure accurate diagnosis and appropriate follow-up.4 Depression-assessment instruments such as the nine-item Patient Health Questionnaire (PHQ-9) often include questions about suicidal ideation.5 Moreover, health care systems are increasingly implementing screening for depression as part of behavioral health integration (BHI) in primary care to provide patients with better access to needed care and address the well-known inefficiencies of siloing care for mental health in specialty settings.6,7
Integrating behavioral health into primary care
Kaiser Permanente Washington, a regional health care system, piloted a BHI program in three primary care clinics in 2015. Rollout across the system’s remaining 22 clinics began in 2016.8,9 The BHI program was designed by clinical operations leaders, including a psychiatrist and researchers to support care for depression, suicidality, alcohol, cannabis, and other drug use.
The BHI team used three main implementation strategies:
• Enabling primary care teams by using external practice coaches who partnered with local implementation teams that included providers, medical assistants (MAs), and clinical social workers (trained as integrated behavioral health clinicians).10,11 This strategy addressed attitudes about depression and substance use, including stigmatization, and gave local clinics ownership of their BHI implementation.
• Supporting primary care teams with decision-support tools embedded in the electronic health record (EHR) that prompted screening, follow-up assessments, and follow-up care.12
• Performance monitoring for site leaders and teams who reviewed routine data reports on screening and assessment during routine quality improvement meetings.13
Workflow for depression and suicide care
The process designed and implemented at each clinic included annual screening for adult patients coming into primary care. Following receipt of an electronic reminder for annual screening, MAs or clinic front-desk staff gave patients a seven-item paper screen. The screen included the PHQ-2 for depression, three questions about alcohol use (AUDIT-C), one question about cannabis use, and one question about other drug use or nonmedical use of prescription medication.14-17 Data from the screen were entered into the EHR while patients were roomed by MAs, and additional EHR decision-support tools prompted assessment and follow-up for symptoms that patients endorsed, such as suicidal ideation.
For example, for patients with scores of 2 or higher on either PHQ-2 question, the EHR prompted MAs to ask the patient to complete the PHQ-9 to help assess depressive symptoms (Figure). If patients answered, “more than half the days” or “nearly every day” to the ninth PHQ-9 question about “thoughts that you would be better off dead, or of hurting yourself” in the last 2 weeks, the EHR prompted MAs to give the patient a brief version of the Columbia Suicide Severity Rating Scale (C-SSRS) modified for patients to complete on paper.18,19 For patients with C-SSRS scores indicating some level of suicide attempt planning in the past month (eg, “yes” to question 3), an EHR “Best Practice Alert” prompted the provider to initiate a same-day referral to a clinical social worker for crisis response planning. Crisis response plans were developed collaboratively with patients to identify warning signs of a suicidal crisis and coping strategies, reduce access to lethal means (ie, firearms and medications), and create a list of resources available for emergency support. A customizable EHR template, based on prior suicide prevention research, was used to document this plan for patients and care providers.20,21
Psychiatrists were available, via telephone consult service, to provide a “real time” consultation to primary care providers, clinical social workers, and other members of the care team. Psychiatrists either answered the phone directly or returned calls within 30 minutes during regular business hours (Monday–Friday 8 AM–5 PM). Primary care providers often contacted psychiatrists to help make decisions about psychiatric hospitalization, initiating psychotropic medications, or about treatment options for suicidal patients with comorbid substance use disorders and/or serious mental illnesses. Clinical social workers at all primary care clinics were also invited to join a weekly 1-hour conference call with a psychiatrist and social work manager to discuss BHI-related challenges such as best practices for handling difficult encounters with suicidal patients.
Depression screening and suicide risk assessment
Our research team is still evaluating BHI in our health care system. Preliminary results from analyses of a single month of performance metric data, however, show that of 50,703 visits when BHI screening was due, the PHQ-2 was completed for 89% and 17% of these scored positive for depressive symptoms (Figure). A full PHQ-9 was completed for 96% of visits when the PHQ-2 was positive, with 6% indicating frequent suicidal ideation (in the last 2 weeks). Of those with suicidal ideation, the C-SSRS was completed for 86% of visits and 37% of C-SSRS scores prompted a crisis response plan. These preliminary data illustrate the potential reach of BHI, which translated into a need for crisis response planning in 24 per 10,000 screening visits (107 of 45,235 visits with PHQ-2 completed).
Barriers, facilitators, and positive stories
During the pilot phase of this project, the main barrier to implementation of the workflow for depression and suicide care was the fear associated with identifying patient needs without the time or resources to address them. Primary care providers worried that they did not have the capacity to address the needs of suicidal patients without compromising care provided to other scheduled patients. Another important barrier was the initial lack of an EHR alert to prompt the use of the C-SSRS for patients with frequent suicidal ideation, which was later added.
Facilitators of this workflow included familiarity with the PHQ-9, which was previously used in the primary care clinics to monitor patients diagnosed with depression. Another critical facilitator was the focus on team-based care, which included psychiatrist consultants, clinical social workers, primary care providers and their support staff. Primary care providers routinely identified the clinical social workers, who were available for same-day referrals, as key to overcoming their fear of routinely screening for depression and assessing patients with suicidal ideation. They also expressed appreciation for the psychiatrist consultants available by phone for providing supportive care to their patients at the time it was needed.
Another major facilitator of suicide risk assessment, and BHI overall, was the number of positive stories shared about suicidal patients being seen for routine medical needs who were identified and then received needed care. One clinical social worker shared the following brief Case Vignette.
A young man came in to seek care for cold symptoms. As the clinical social worker on staff, I was paged to come talk with this patient after he scored high on our behavioral health screening tools. I learned that not only was this patient severely depressed but also that he had attempted suicide twice in the past couple of weeks.
Next, we talked about his immediate safety, and I discovered that he had limited outside supports. Because his safety couldn’t be guaranteed if he went home, we talked about inpatient psychiatric treatment, which he agreed was a good idea. I coordinated his follow-up care, and the patient was authorized for psychiatric admission within 4 hours. I also talked with his parents, who waited with him and later drove him to his psychiatric placement.
Thanks to BHI, we had systems in place that let us know this young man was in immediate danger, and we were able to intervene and help him right away.
Implications for practice
Based on our experiences implementing care for suicidality as part of a behavioral health integration package, our conclusions are:
• Psychiatrists can play key roles supporting real-time care for patients with suicidal ideation by educating primary care providers about the wide range of treatment options available and providing consultative support in the development of tailored plans of care for individual patients.
• Implementing screening for depression followed by suicide risk assessment is feasible in primary care settings, particularly when tools to guide clinical decision making for suicidal patients are embedded into EHR systems. Moreover, the brief, self-administered suicide risk assessment tool we used was highly valuable to primary care clinicians who used the information to guide their decisions about follow-up care.
• Most importantly, developing a team-based approach to providing care for suicidal patients, including psychiatrists, clinical social workers, and other primary care staff, takes the burden off individual primary care providers and alleviates fear about identifying patient needs for which they do not have resources to address themselves.
Further research on this model of care is needed to know if the suicide care we implemented as part of BHI in primary care improved patient health outcomes (eg, suicide attempts). Additionally, adaptations may be required to implement this model of care in a fee-for-service environment. For psychiatrists working in these settings, however, it is important to note that team-based care is possible because consultation and care management services are reimbursable by Medicare and other payers as part of a collaborative care program. Finally, it is outside the scope of this article to provide guidance on issues related to legal liability when patients die by suicide, despite their health care providers best attempts to provide high-quality care. We recognize, however, that providers who have lost patients to suicide may make decisions about patient care based on these experiences.22 We also recognize that current laws may incentivize “over-hospitalization” and coercive treatment.23,24 A core ethical challenge to working with suicidal patients is that interventions intended to increase short-term safety in the short run may not be the best long-term solution.25 The best protection for patients and providers who care for suicidal patients, in primary care and specialty care settings, may be collaborative crisis response planning and documentation.20,21,26
Health care systems are increasingly addressing depression through behavioral health integration in primary care to improve the well-known inefficiencies and inferiority of siloing mental health care in psychiatric specialty settings. Provider stories about the integration of care for suicidality in primary care, including depression screening and suicide risk assessment, indicate that primary care staff value the ability to provide the care to suicidal patients when needed. Integrated social workers trained as behavioral health clinicians, as well as psychiatrist leadership and ongoing consultative support, provide a system to help primary care teams be successful.
Ms Richards is Research Associate, Kaiser Permanente Washington and a PhD candidate in Health Services, University of Washington, Seattle, WA; Ms Parrish is Social Work Manager and Integrated Behavioral Health Clinical Consultant, Kaiser Permanente Washington; Ms Lee is Research Associate, Kaiser Permanente Washington Health Research Institute and a practice coach; Dr Bradley is Senior Investigator, Kaiser Permanente Washington and Affiliate Professor, Departments of Medicine and Health Services, University of Washington, Seattle, WA; Dr Caldeiro is Chief, Chemical Dependency and Consultative Psychiatry and an addiction psychiatrist, Kaiser Permanente Washington.
The authors report no conflicts of interest concerning the subject matter of this article.
1. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29:870-877.
2. Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;56:1-7.
3. LeFevre ML. Screening for suicide risk in adolescents, adults, and older adults in primary care: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:719-726.
4. Siu AL; US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315:380-387.
5. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.
6. Crowley RA, Kirschner N; Health and Public Policy Committee of the American College of Physicians. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Ann Intern Med. 2015;163:298-299.
7. Institute of Medicine (US) Committee on the Future of Primary Care; Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, DC: National Academies Press; 1996.
8. Bobb JF, Lee AK, Lapham GT, et al. Evaluation of a pilot implementation to integrate alcohol-related care within primary care. Int J Environ Res Public Health. 2017;14.
9. Glass JE, Bobb JF, Lee AK, et al. Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial). Implement Sci. 2018;13:108.
10. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10:63-74.
11. Kirchner JE, Ritchie MJ, Pitcock JA, et al. Outcomes of a partnered facilitation strategy to implement primary care-mental health. J Gen Intern Med. 2014;29 (Suppl 4):904-912.
12. Damiani G, Pinnarelli L, Colosimo SC, et al. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. BMC Health Serv Res. 2010;10:2.
13. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012:CD000259.
14. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284-1292.
15. Bradley KA, DeBenedetti AF, Volk RJ, et al. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31:1208-1217.
16. Lapham GT, Lee AK, Caldeiro RM, et al. Frequency of cannabis use among primary care patients in Washington State. J Am Board Fam Med. 2017;30:795-805.
17. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170:1155-1160.
18. The Columbia Lighthouse Project. The Columbia Scale (C-SSRS): About the protocol. 2016. http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/. Accessed November 8, 2018.
19. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-1277.
20. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19:256-264.
21. Bryan CJ, May AM, Rozek DC, et al. Use of crisis management interventions among suicidal patients: results of a randomized controlled trial. Depress Anxiety. 2018;35:619-628.
22. Hendin H, Haas AP, Maltsberger JT, et al. Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry. 2004;161:1442-1446.
23. Stefan S. Rational Suicide, Irrational Laws: Examining Current Approaches to Suicide in Policy and Law. New York, NY: Oxford University Press; 2016.
24. Appel JM. “How hard it is that we have to die”: rethinking suicide liability for psychiatrists. Camb Q Healthc Ethics. 2012;21:527-536.
25. Howe E. Five ethical and clinical challenges psychiatrists may face when treating patients with borderline personality disorder who are or may become suicidal. Innov Clin Neurosci. 2013;10:14-19.
26. Packman WL, Pennuto TO, Bongar B, Orthwein J. Legal issues of professional negligence in suicide cases. Behav Sci Law. 2004;22:697-713.