Emergent Trends in Suicide Prevention: Implications for Provider Organizations

1. Emergent Trends in Suicide Prevention: Implications for Provider Organizations Paul Quinnett, Ph.D. QPR Institute U of Washington School of Medicine

2. Surgeon General of the United States “Suicide is our most preventable form of death.” David Satcher, MD

3. A brief developmental history • Politically active survivors of the death by suicide of a family member • Congressional appeal – house/senate resolutions • Senator Harry Reid (D – Nevada) • Senator Gordon Smith (R – Oregon) • 2001 first national meeting – NSSP 2001 • IOM report: Reducing Suicide: A National Imperative

4. Who are the players? • AAS • AFSP • SPRC • NIMH • CDC • SAMSHA – SPRC/AFSP BPR • National Action Alliance for Suicide Prevention http://actionallianceforsuicideprevention.org

5. Mission of the National Alliance? • Championing suicide prevention as a national priority • Catalyzing efforts to implement high-priority objectives of the NSSP • Cultivating the resources needed to sustain progress

6. National Alliance Actions so far? • National Strategy 2012 Revision (done) • Research Prioritization: Reduce suicide by 20% in five years or 50% in 10 years. • Clinical Care and Intervention:Released a task force report, Suicide Care in Systems Framework, laying out recommendations for national leaders, health and behavioral health providers, and health plans.

7. NSSP 2012 revision - Chaired by the Honorable John McHugh, Secretary of the Army, and the Honorable Gordon H. Smith, President and CEO of the National Association of Broadcasters • 200 organizations participated • Chaired by Surgeon General Regina M. Benjamin and SPRC Director Jerry Reed Public-private all the way……..

8. Emerging standards… • AFSP/SPRC Best Practices Registry • NREPP • Role of BPR in emerging state healthcare law Implications for practice from the National Violent Death Surveillance System (NVDRS) Example: • 41% adult suicides occur while in active care of a health professional (49% in Dane CO.) • 23 EMS professionals in CO over 4 years

9. Why NSSP 2012? • An increased understanding of the link between suicide and other health issues • New knowledge on groups at increased risk • Evidence of the effectiveness of suicide prevention interventions • Increased recognition of the value of comprehensive and coordinated prevention efforts

10. NSSP 2012 Selected Recommendations Objective: Encourage health care providers and health and safety officials caring for individuals with suicide risk to routinely assess for the presence of, or access to, lethal means as part of their patient safety plans, and to educate those individuals and their support networks about actions to reduce risk.

11. Selected Recommendations GOAL: Encourage the training of community and clinical service providers on the prevention of suicidal self-directed violence, including training on how to address the needs of those affected or bereaved by suicide deaths and attempts

12. Continued… Objective: Deliver training on suicide prevention to community groups that have a role in the prevention of suicidal self-directed violence and related behaviors

13. Continued… Objective: Develop core education and training guidelines for the recognition, assessment, and team-based management of at-risk behavior, and the delivery of effective clinical care for people with suicide risk.

14. Continued… Objective: Promote the adoption of core education and training guidelines on the prevention of suicidal self-directed violence and related behaviors by all health professions, including graduate and continuing education.

15. Continued… Objective: Develop and implement protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and others on how to implement effective strategies for communicating and collaboratively managing suicide risk.

16. Continued… GOAL 8 Promote suicide prevention as a core component of behavioral health services using systems level strategies that provide coordination and continuity of care.

17. Continued… Objective: Promote the adoption of “zero suicides” as an aspirational goal by health care and community support systems that provide services and support to defined patient populations.

18. Continued… GOAL: Develop and promote effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal self-directed violence.

19. Continued… Objective: Encourage all specialty mental health and substance abuse treatment programs to have policies and procedures designed to assess suicide risk and intervene to promote safety and reduce suicidal self-directed violence among their patients.

20. Bottom line? • The 2001 NSSP strategy started the ball rolling • The suicide deaths of soldiers and veterans have ramped up interest and motivation • Professional member organizations, universities, and training institutions did not heed the recommendations of the IOM or NSSP • The suicide prevention community is growing and building political force for change

21. Why the emphasis on training? It is strongly believed by the SP community that stigma and taboo have contributed to the training deficit in suicide prevention education at the professional level…. And that such training could enhance consumer safety and prevent suicide…

22. Old goal 6: “Implement training for recognition of at-risk behavior and delivery of effective treatment” 1. Who is qualified to conduct a suicide risk assessment? 2. What are these qualifications? 3. When is the risk assessment done? How often? 4. Where are staff trained in recognition of at-risk behavior? 5. How is this risk assessment documented?

23. SRMI quiz (1,100+ practicing professionals)

24. Question • Would improved specific knowledge and skill in the “assessment, treatment, and management” of consumers detected to be at elevated risk of suicide reduce morbidity and mortality among behavioral health service customers? • Answer: ???? - We shall see…

25. Case example… • Chart entry from PCP visit with 18-year-old single Hispanic female. “Complains of headache and stomach distress. Drank some poison last week….” (provided medicines for headache, etc.) • Two days later this young woman was dead of an overdose… • No SRA, no referral for a workup by a MHP, even though one was in the building…

26. Goal 6 NSSP Targeted and Struck in Washington State Washington state legislature drafted and passed Engrossed Substitute House Bill No. 2366 – “An act relating to requiring certain health professionals to complete education in Suicide assessment, treatment, and management.” House vote: 92 to 5 Senate vote: 100%

27. Back Story • Matt Adler dies by suicide • Jenn Stuber obtains provider’s record • Begins review – support by U of WA School of Social Work • Champion: Rep. Tina Orwall – SW with experience with suicidal consumers • Review of literature undertaken/BPR review • Agenda: inadequate training costs lives • Stakeholder meetings begin – ownership of failure to train • A gathering of expert eaglets (AAS/AFSP support) • A bill is drafted • Atmosphere: Legislative session where both sides wanted to get a least ‘something passed.’

28. Law requires • All licensed mental health providers to: • Complete a training program in suicide assessment, treatment, and management every six years • Clarifies that training programs in suicide assessment, treatment, and management must include the following elements: Suicide assessment, including screening and referral, suicide treatment, and suicide management.

29. Law relied on several things… • Availability of BPR training options (more than one) • Consensus expert opinion published paper (read from paper in testimony – you have a copy) • Capacity to train an entire workforce – online availability (cost shift to providers)

30. Details • Allows a disciplining authority to approve training programs that do not include all of the elements if the excluded elements are inappropriate for the profession in question based on the profession's scope of practice. • Requires training that includes only screening and referral to be at least three hours in length. Requires all other training to be at least six hours in length.

31. Governor Signs Bill

32. Update June 12, 2013 • Rules are in process • Implementation on schedule • Staff will be impacted by license, age, renewal • Physicians and nurses working to adopt/adapt • DOH evaluation on training status report out in July • Other states “all in” KY+ • WA is ahead of the curve….. FOREFRONT organization lauched

33. Best treatment practices? - Detection - Assessment - Treatment – (limited) - CBT – DBT – Lithium – Clozapine - Follow Up (caring letters/emails) – see complete list of NREPP programs (17 only) - Management of risk over time… good data on continuity as a best practice…

34. Challenges…. • Suicide risk continues to go undetected • Assessment failures account for 70% of “medical errors” associated with patient suicide • Lack of specific training • Lack of specific knowledge • Lack of supporting policies & payments • Reliance on junk science, e.g., no-suicide contracts • Wrong beliefs, e.g., If they really want to kill themselves you can’t stop them. • CEO, “Patient suicides is the ‘cost of business.’”

35. Discussion questions • How can national policy vision be translated into practice settings? • What questions do you (providers) have about current research/evidence re: suicide prevention? • What challenges/barriers do you experience in practice settings?

36. Contact information: Free e-book and apps • Office phone: 509-235-8823 • Institute phone: 1-888-726-7926 • Email: pquinnett@mindspring.com • Website: www.qprinstitute.com