Suicide Inquiries in Primary Care Medical Encounters

1. Suicide Inquiries in Primary Care Medical Encounters University of Washington Department of Psychiatry and Behavioral Sciences VA Puget Sound Health Care System 2009 Steven Vannoy, PhD, MPHAssistant Professor

2. Disclosure • No conflicts of interest • Funding sources • NIH/NCRR (National Center for Research Resources) 1 UL1 RR 025014-01 • NIMH NRSA Training Grant (T32MH73553) • National Council for Community Behavioral Healthcare

3. Medical Settings • Most people receive mental health treatment in primary care • 45% of people who die by suicide have seen their PCP within 1 month of death vs 19% having seen MH specialist • Specialty clinics employing chronic disease model are better setup for addressing mental health concerns

4. Identify Patients at Risk Suicide Risk Management Assess Level of Risk Make Clinical Risk Management Decision Perform Risk Management Tasks

5. Assessing Risk • Relies on subjective reporting • Requires discussing stigmatized topic

6. What We DON’T Know • The nature or quality of the discourse • The quality of the risk assessment • The types of interventions initiated • Whether follow-up occurs • Rate of referrals that are completed • How to improve practice as usual • Does any of this save lives

7. Suicide Discourse • Related to mood disorders (depression/anxiety/panic) • Related to psycho-social functioning/stress • Related to “suicidal” thoughts/behaviors • Passive • Thoughts that life isn’t worth living or “I’d be better of dead” • Thinking of death • Active • Thoughts of self-harm • Thoughts of killing oneself “committing suicide” • Behavior • Preparatory • Attempt

8. A Model of Suicide Discourse in Primary Care • How is the “question” asked? • Are patients “prepared” for it? • How is the initial question followed-up?

9. Background • Patients’ Requests for Direct-to-Consumer Advertised Antidepressant1 • Standardized Patients (SPs) • Carpal tunnel syndrome/depression • Low back pain/adjustment disorder • Requesting antidepressant • Family and Internal Medicine PCPs • Suicide discussion in 36% of encounters2 1. Kravitz et. al, JAMA 2005; 2. Feldman et al. Annals of Family Medicine 2007

10. Analyses of the SP DataMethod • Text based search of keywords • suicid* hurt*, harm*, kill*, death, dying, etc. • Coding into suicidal behavior categories • Evaluating for “pre-contextualizing” • Evaluating “post-contextualizing”

11. 298 transcripts 108 SPs reported suicide inquiry 6 truncated 11 mislabeled 91 suicide dialog Inductive review Coding scheme Frequency Range

12. Model of Suicide Inquiry Context Follow-up Inquiry 3 PCP utterances following inquiry 3 PCP utterances preceding inquiry Key word search (suicid*, hurt*, harm*, kill*, death, dying), transcript review

13. Inquiry • Self harm (56%) “…had thoughts of hurting yourself?” • Suicide or killing (48%) “…feeling suicidal at all?” • Indirect (13%) “…any feeling that life is not worth living?” • Death (3%) “…ever thought about death a lot?”

14. In how many ways was the inquiry phrased?

15. How is the Inquiry Framed? • Indication of typical outcome • “Has this stress gotten to the point where you’ve had thoughts about killing yourself?” • Normalizing • “We ask everyone this question…” • Acknowledging awkwardness • “This may sound strange, but…” • Asking permission • “Let me ask you an important question…”

16. Are Some Questions Better Than Others? • “Negative Phrasing” n = 9 (10%) • No thoughts of harming yourself, right? • But yeah I assume you are not suicidal • And what I'd like you to do is I'm going to make a contract. If things get bleaker than this so that you actually feel suicidal-- you haven't done any of that? • I'm going to see you in a couple weeks and I don't get the impression-- are you telling me you're not feeling suicidal?

17. Preparing the Patient for Sensitive Questions Preceding Statements (N = 91) Frequency of Multiple Contextualizing Statements

18. Do physicians respond with a context relevant statement Follow-up Statements - in context? (n = 91) Frequency of Contextualized Follow-ups

19. What is “follow-up context”?

20. Are Some Follow-ups Better than Others? • What does “Okay”, “Good”, “All Right” communicate? • N = 17 (20%) With in-context of follow-up • N = 8 (9%) With off-topic follow-up • What does an apology communicate? • “sorry, just something I have to ask” • N = 6

21. Closing off dialogue? DR: Okay. No thoughts of harming yourself, right? SP: No. DR: Okay. Okay. Alright. Let me take a look at your back and we'll talk a little bit about the insomnia.

22. What about this? • DR: Have you felt like the bridge? • SP: The bridge? • DR: Have you felt like doing away with yourself? • SP: No. • DR: Good then.Well let’s check you over.

23. Analysis of the SP DataDiscussion • “When asked, the majority ask in an apparently effective manner • 22% phrase in more than 1 way • 10% coded as negative • Unlike many other topics in primary care, the question is contextualized • 80% of the time at least 3 preceding statements are relevant to mental health, depression, psychosocial functioning • More than 80% of the time the question is followed with a context relevant statement • 33% follow up with direct suicide related statements

24. Analysis of the SP Data • What are the effects of • Contextualizing • Negative Phrasing • Follow-up Statements • Limitations • All SP’s denied any ideation • Cross sectional, 1st time encounters

25. Suicide Risk Management in Oncology? • How would patients perceive this? • What would their preference be? • Can we get providers to engage? • Does it have a clinical impact?

26. Thank You