Suicide Risk In Primary Care Research Articles

Adolescent, Parent, and Provider Perceptions of a Predictive Algorithm to Identify Adolescent Suicide Risk in Primary Care

ObjectiveTo understand adolescent, parent, and provider perceptions of a machine learning algorithm for detecting adolescent suicide risk prior to its implementation primary care. MethodsWe conducted semi-structured, qualitative interviews with adolescents (n = 9), parents (n = 12), and providers (n = 10; mixture of behavioral health and primary care providers) across two major health systems. Interviews were audio recorded and transcribed with analyses supported by use of NVivo. A codebook was developed combining codes derived inductively from interview transcripts and deductively from implementation science frameworks for content analysis. ResultsReactions to the algorithm were mixed. While many participants expressed privacy concerns, they believed the algorithm could be clinically useful for identifying adolescents at risk for suicide and facilitating follow-up. Parents’ past experiences with their adolescents’ suicidal thoughts and behaviors contributed to their openness to the algorithm. Results also aligned with several key Consolidated Framework for Implementation Research domains. For example, providers mentioned barriers inherent to the primary care setting such as time and resource constraints likely to impact algorithm implementation. Participants also cited a climate of mistrust of science and healthcare as potential barriers. ConclusionsFindings shed light on factors that warrant consideration to promote successful implementation of suicide predictive algorithms in pediatric primary care. By attending to perspectives of potential end users prior to the development and testing of the algorithm, we can ensure that the risk prediction methods will be well-suited to the providers who would be interacting with them and the families who could benefit.

Thwarted Belongingness and Suicide Risk in Primary Care: Perceived Burdensomeness and Psychache as Mediators.

Suicide is a significant public health concern, particularly among primary care patients, given that many individuals who die by suicide visit their primary care provider in the months prior to their death. We examined constructs from two prominent theories of suicide, the interpersonal and psychache theories, including thwarted belongingness, perceived burdensomeness, and psychache. Among our sample (n = 224) of patients, perceived burdensomeness and psychache, individually and in serial, mediated the relation between thwarted belongingness and suicidal behavior. Thwarted belongingness was associated with greater perceived burdensomeness and, in turn, with more psychache and increased suicide risk. Our results elucidate the associations between the interpersonal and psychache theories of suicide. Clinical strategies that may reduce thwarted interpersonal needs and psychache, and which are appropriate for medical settings, are discussed.

Acoustic Analysis of Speech for Screening for Suicide Risk: Machine Learning Classifiers for Between- and Within-Person Evaluation of Suicidality

Assessing a patient's suicide risk is challenging for health professionals because it depends on voluntary disclosure by the patient and often has limited resources. The application of novel machine learning approaches to determine suicide risk has clinical utility. This study aimed to investigate cross-sectional and longitudinal approaches to assess suicidality based on acoustic voice features of psychiatric patients using artificial intelligence. We collected 348 voice recordings during clinical interviews of 104 patients diagnosed with mood disorders at baseline and 2, 4, 8, and 12 months after recruitment. Suicidality was assessed using the Beck Scale for Suicidal Ideation and suicidal behavior using the Columbia Suicide Severity Rating Scale. The acoustic features of the voice, including temporal, formal, and spectral features, were extracted from the recordings. A between-person classification model that examines the vocal characteristics of individuals cross sectionally to detect individuals at high risk for suicide and a within-person classification model that detects considerable worsening of suicidality based on changes in acoustic features within an individual were developed and compared. Internal validation was performed using 10-fold cross validation of audio data from baseline to 2-month and external validation was performed using data from 2 to 4 months. A combined set of 12 acoustic features and 3 demographic variables (age, sex, and past suicide attempts) were included in the single-layer artificial neural network for the between-person classification model. Furthermore, 13 acoustic features were included in the extreme gradient boosting machine learning algorithm for the within-person model. The between-person classifier was able to detect high suicidality with 69% accuracy (sensitivity 74%, specificity 62%, area under the receiver operating characteristic curve 0.62), whereas the within-person model was able to predict worsening suicidality over 2 months with 79% accuracy (sensitivity 68%, specificity 84%, area under receiver operating characteristic curve 0.67). The second model showed 62% accuracy in predicting increased suicidality in external sets. Within-person analysis using changes in acoustic features within an individual is a promising approach to detect increased suicidality. Automated analysis of voice can be used to support the real-time assessment of suicide risk in primary care or telemedicine.

Addressing Suicide Risk in Primary Care: Cost Savings Associated with Diverting Patients From Emergency Departments.

Integrating behavioral health into primary care ambulatory clinics can improve management of patients presenting with suicidality in medical practices. To date, financial outcomes associated with managing suicidality in integrated care have not been documented. This study sought to evaluate both course of treatment (e.g., the patient is discharged home and referred to emergency departments [EDs]) and financial outcomes (e.g., cost to medical center) for patients presenting with suicidality in integrated pediatric primary care. Medical record review was conducted across a 6-month period. Demographics, course of treatment, and financial data were collected. Financial data were extracted using EPSi software using a cost accounting model. We documented the amount in dollars billed to the patient/insurance company and the amount reimbursed to the medical center and then calculated net margins associated with each course of treatment. Participants were 103 youth (aged 7-24 years). The results demonstrate that the integrated model of care diverted 93% of participants from the ED and that the highlighted model of care yielded cost savings for the medical center. After reimbursement, patients seen in the ED for suicide evaluations cost the medical center an average of 16 times more than patients who were managed in the primary care setting. The results document the magnitude of cost savings associated with an integrated care model for treating high-risk youth.

Managing suicide risk in primary care.

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Initial assessment and management of the suicidal ideation and suicide attempts in primary care

Suicide and suicidal behaviors are a significant public health problem, for which several prevention modalities have been implemented. The identification and treatment of suicidal risk is a critical step in prevention, especially in primary health care, a level where most of the population consults. This article focuses fundamentally on the research on suicide risk in primary care by proposing an action guide for the assessment and management initial of suicide ideas and attempts.

Épidémiologie descriptive du risque suicidaire dans le système médical français de médecine générale.

Suicide prevention certainly includes a better knowledge of suicide risk in primary care. A number of international publications have shown interest in assessing this risk, but mostly through specific consultant populations: young patients, old patients, anhedonic, depressive, etc. Our study analyses suicide risk prevalence in patients consulting in general medicine for any somatic or psychiatric reason, their pathology or their age. This cross-sectional study was conducted with adult patients (827 subjects included) who were consulting a French generalist doctor panel randomly selected. They filled a validated self-questionnaire (aRSD) assessing their suicide risk in the 15 preceding days and providing professional and personal data. The totally operable 757 files (483 female; 274 male) show that close to a quarter of consultants (24.3%) presents with a positive suicide risk in the 15 days preceding their consultation and 6.3%, reveal a severe risk (aRSD ≥ 7) with ideas and impulses to commit the act. When the reason to consult is psychiatric, 64.6% of these consultants have aRSD positive. One time out of two, the risk is even severe. This data shows how important the suicide risk prevalence is in general medicine. It confirms the main role played by primary care patricians in acting to prevent suicide risk. This data also shows the contribution represented by a self-questionnaire that would rapidly assess the suicide intent while screening, it.

WHO-mhGAP Training in Mexico: Increasing Knowledge and Readiness for the Identification and Management of Depression and Suicide Risk in Primary Care

In order to reduce the treatment gap of mental disorders, the World Health Organization (WHO) has proposed the mhGAP guidelines to be implemented globally. To examine the effectivity of a training course based on the WHO-mhGAP guidelines to increase knowledge and readiness for identification and management of depression and suicide risk in primary care (PC) in Mexico. PC clinicians were invited to participate in a traning course; before and after it, all completed an evaluation of knowledge of mhGAP and depression (0-10 points), and self-efficacy in suicide risk management (0-40 points), and were classified according to Prochaska and Diclemente transtheorical model in their particular stage of readiness for identification and management of these conditions. The sample included 60 health professionals. Before training, clinicians had adequate knowledge of depression and its treatment (8.1±1.66), but not on the mhGAP model and/or suicide risk management, which increased by the end of training (mhGAPpre:7.91±2.19 vs. mhGAPpost:8.77±1.34, p=0.01; SuicidePRE:29.16±9.35 vs. SuicidePOST:39.24±6.83, p=0.0001). Before training, most clinicians were at the contemplation stage (42.6% vs. 37.7% at the action and 19.7% at the precontemplation stage). By the end of the training, a decrease in the number of clinicians at both the contemplation and precontemplation stages (to 36.1% and to zero, respectively) and a significant increase of clinicians at the action stage (to 63.9%) was observed. A training course based on the WHO-mhGAP could be an effective tool for increasing PC clinicians' willingness to implement mental health services.

Suicide interventions in primary care: A selective review of the evidence.

About half of people who die by suicide visit their primary care provider (PCP) within 1 month of doing so, compared with fewer than 1 in 5 contacting specialty mental health. Thus, primary care is an important setting for improving identification and treatment of suicide risk. This review identifies and summarizes evidence for the effectiveness of intervention components for suicide risk in primary care. We searched the PsycINFO database to identify relevant articles. We considered publications reporting the effectiveness of a packaged intervention for management of suicide risk in primary care or any other brief (i.e., single-session) intervention for suicide risk in the present review. Four major components to suicide interventions in primary care emerged: (a) educating practitioners, (b) screening for suicide risk and/or mood disturbance, (c) managing depression symptoms, and (d) assessing and managing suicide risk. Although practitioner education and screening for suicide risk are important, they are insufficient for effective suicide prevention programs. Collaborative treatment of depression by multidisciplinary teams can reduce rates of suicidal ideation in primary care patients. Recent evidence also indicates a single-session crisis response planning intervention may be effective at reducing suicidal ideation and attempts. Integration of behavioral health specialists trained in suicide risk assessment and management could be important for improving suicide prevention in primary care patients. This condensed review of the evidence serves as a resource for practitioners who are hoping to implement brief, effective interventions for suicide risk to better serve their patients. (PsycINFO Database Record

Addressing suicide risk in primary care: A next step for behavioral health integration.

Comments on two articles by A. R. Dueweke et al. (see records 2018-24944-001 and 2018-24945-001). The first article reviews evidence for interventions in primary care and the second assesses the ubiquitous two-question "prescreen" of the Patient Health Questionnaire-9 (PHQ-9) for detecting patients with thoughts of self-harm. In the second article the authors assess the ability of this measure to identify thoughts of self harm, the ninth question on the full PHQ-9, and show that a substantial number of patients would be missed. These two articles provide excellent starting points for thinking through how to ensure that risk of suicide is identified and addressed in a systematic and useful way. Any clinician working in primary care can use these two articles and the resources they contain to inform efforts at systemic change to reduce suicide risk. (PsycINFO Database Record

Improving pediatricians’ knowledge and skills in suicide prevention: Opportunities for social work

Primary care physicians are key gatekeepers for detecting suicidal intent. However, research indicates training gaps for these providers. Standardized screening for suicide risk in primary care can...

Factors Influencing Suicide Risk Assessment and Management in VA Primary Care Clinics: A Qualitative Study of Provider Perspectives

ABSTRACTThis study obtained the perspectives of 11 providers employed in Veteran Affairs (VA) primary care clinics across 4 states regarding the factors that influence the assessment and management of suicide risk. Qualitative data was analyzed using a hybrid inductive-deductive thematic analysis approach. Themes highlighted the impact of a trusting patient–provider relationship, multidisciplinary team-based care, education about suicide prevention from integrated behavioral health providers, reliable access to mental health care, and VA system-wide suicide prevention efforts in supporting generalists' ability to effectively assess and manage veterans' suicide. Recommendations for enhancing evidence-based care for suicide risk in primary care are discussed.

Comprehensive Screening for Suicide Risk in Primary Care

Suicide is a major public health problem and a complex clinical challenge. Assessment and early identification could be enhanced with screening tools that look beyond depression. The purpose of this study was to identify profiles of risk behaviors and social stress associated with suicidal ideation and behavior using the Behavioral Health Screen. The study used screening data from 2,513 primary care patients (aged 14-24 years). Data were collected between 2008 and 2012, and were analyzed in 2016. Latent class analysis identified a high and low risk profile. Domains of primary influence included substance use, sexual assault, same-sex behavior, and unsafe sex. The high-risk group was 11 times more likely to have made a suicide attempt, five times more likely to report a history of suicidal ideation and behavior, and three times more likely to report recent suicidal ideation and behavior. Risk behaviors and social stress contribute to the risk for suicide above and beyond depression and should be assessed during routine primary care visits with adolescents. The Behavioral Health Screen can screen all these domains and thus assist primary care providers in assessing for both psychiatric and social stress factors associated with youth suicide.

5 Things to know about screening for suicide risk in primary care

5 Things to know about screening for suicide risk in primary care

Assessment and management of suicide risk in primary care.

Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. Data collection from clinical proformas, case records, and semistructured face-to-face interviews with general practitioners. Primary and secondary care data were available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall κ = .127, p = .10). Depression, care setting (after discharge), suicidal ideation at last contact, and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices, and 33% of staff received training in suicide risk assessments. Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.

Suicide risk in primary care: identification and management in older adults.

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.

PS1-31: Role of Multiple Chronic Conditions in Longitudinal Cognitive Decline

7 HealthPartners Background/Aims: Suicide is the 10th leading cause of death in the United States, warranting public health prevention efforts. Such efforts require accurate risk identification. However, the US Preventive Services Task Force has suggested that there is not enough information available to recommend screening for suicide risk in primary care. While research suggests that many individuals receive services before death, studies have been limited by small samples. This study used the largest US general population sample to date to examine the frequency, types and patterns of health services utilized prior to suicide as well as variations by subgroup. Methods: Health care utilization and demographic data from six health systems of the Mental Health Research Network were pre-matched with official mortality records and census files using the Virtual Data Warehouse. In total, 2237 suicide deaths were identified using ICD-10 codes, X60-X84. Reverse survival curves were calculated estimating weekly utilization for the year prior to death. These data were stratified by age, sex, insurance type, socioeconomic indicators, and cause of death. Results: Suicide death was more common among men (77%; n = 1728) and occurred more frequently by violent means (77%; n = 1730). Approximately 81% (n = 1806) received services in the year before death, with nearly 40% (n = 900) making a visit within a month before death. While 44% (n = 992) made any visit that included a mental health diagnosis in the year before death, most visits occurred in primary care without a mental health diagnosis (59%; n = 1320). Non-mental health primary care visits and outpatient behavioral health visits were most common in the two weeks before suicide. Service use occurred most often among women (87%; 441 of 509), older adults (65+ years; 96%; 386 of 401), and those who died by non-violent means (85%; 422 of 498). The relative frequency of mental health and general medical utilization differed markedly between age groups. Conclusions: Most individuals who died by suicide also used health services within a year before death. Here, over half of these individuals did not have a mental health diagnosis, and were seen for other reasons in primary care.

PS1-30: Examining Health Service Utilization in the Year Prior to Suicide Death

Background/Aims Suicide is the 10th leading cause of death in the United States, warranting public health prevention efforts. Such efforts require accurate risk identification. However, the US Preventive Services Task Force has suggested that there is not enough information available to recommend screening for suicide risk in primary care. While research suggests that many individuals receive services before death, studies have been limited by small samples. This study used the largest US general population sample to date to examine the frequency, types and patterns of health services utilized prior to suicide as well as variations by subgroup. Methods Health care utilization and demographic data from six health systems of the Mental Health Research Network were pre-matched with official mortality records and census files using the Virtual Data Warehouse. In total, 2237 suicide deaths were identified using ICD-10 codes, X60-X84. Reverse survival curves were calculated estimating weekly utilization for the year prior to death. These data were stratified by age, sex, insurance type, socioeconomic indicators, and cause of death. Results Suicide death was more common among men (77%; n = 1728) and occurred more frequently by violent means (77%; n = 1730). Approximately 81% (n = 1806) received services in the year before death, with nearly 40% (n = 900) making a visit within a month before death. While 44% (n = 992) made any visit that included a mental health diagnosis in the year before death, most visits occurred in primary care without a mental health diagnosis (59%; n = 1320). Non-mental health primary care visits and outpatient behavioral health visits were most common in the two weeks before suicide. Service use occurred most often among women (87%; 441 of 509), older adults (65+ years; 96%; 386 of 401), and those who died by non-violent means (85%; 422 of 498). The relative frequency of mental health and general medical utilization differed markedly between age groups. Conclusions Most individuals who died by suicide also used health services within a year before death. Here, over half of these individuals did not have a mental health diagnosis, and were seen for other reasons in primary care. This study may guide targeted public health prevention efforts, including risk identification strategies. Language: en

Standardized Screening for Suicidal Adolescents in Primary Care

To determine if brief standardized screening for suicide risk in pediatric primary care practices will increase detection rates of suicidal youth, maintain increased detection and referral rates, and be replicated in other practices. Physicians in 3 primary care practices received brief training in suicide risk, and 2 standardized questions were inserted into their existing electronic medical chart psychosocial interview. The questions automatically populated for all adolescents aged 12.0 to 17.9 years. Deidentified data were extracted during both intervention trials and for the same dates of the previous year. Referral rates were extracted from social work records. The rates of inquiry about suicide risk increased 219% (clinic A odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.56-2.51]; clinic B OR: 3.20 [95% CI: 2.69-3.71]; clinic C OR: 1.85 [95% CI: 1.38-2.31]). The rate of case detection increased in clinic A (OR: 4.99 [95% CI: 4.20-5.79]), was maintained over 6 months after the intervention began (OR: 4.38 [95% CI: 3.74-5.02]), and was replicated in both clinic B (OR: 5.46 [95% [CI: 3.36-7.56]) and clinic C (OR: 3.42 [95% CI: 2.33-4.52]). The increase in case detection was 392% across all 3 clinics. Referral rates of suicidal youth to outpatient behavioral health care centers increased at a rate equal to that of the detection rates. Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made.

Managing suicide risk in primary care: Practice recommendations for behavioral health consultants.

Psychologists working in primary care clinics can have a significant positive impact on preventing suicide. For psychologists working within the behavioral health consultant (BHC) model in primary care, however, the issue of how to appropriately manage suicide risk within this model has yet to be adequately addressed. Given the time-limited and focused nature of the BHC model, it is important to establish a framework for psychologists to provide adequate care that is practical within this model of health care. This article offers 26 empirically supported recommendations for suicide screening, accurate and time-efficient risk assessment, and effective risk management strategies, as well as suggestions for consultation with primary care physicians, all of which are consistent with the BHC model.