On the Road to Prevention: Identification & Triage Using the Columbia-Suicide Severity Rating Scale (C-SSRS) Increas

1. On the Road to Prevention: Identification & Triage Using the Columbia-Suicide Severity Rating Scale (C-SSRS) Increasing Precision, Improving Care Delivery and Redirecting Scarce Resources Administration Training Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; Zelazny, J.; Fisher, P.; Burke, A.; Oquendo, M.; Mann, J. Kelly Posner, Ph.D. Principal Investigator Columbia/FDA Classification Project for Drug Safety Analyses Principal Investigator Center for Suicide Risk Assessment Columbia University 1

2. Suicide: A Major Public Health Crisis in the U.S. • Every 15 minutes someone dies by suicide in the U.S. • 2nd leading cause of death in youth 10-24 passing homicide for the first time in last decade • 8-10% of High School students attempt suicide each year • 4th leading cause of death: adults • Rate DOUBLED for African American males 15-19 1980-1996 • #1 cause of injury mortality in U.S.; more people die by suicide than motor vehicle crashes • 1st or 2nd leading cause of death in law enforcement officers • In 2012, nearly as many died by suicide as were killed in the line of duty • Rate comparable to that in US Army • Most common cause of death in incarcerated persons • Suicide rates 3x general population • 50-75% of those in need receive no treatment or inadequate treatment • 45% who die by suicide see their doctor in the month prior to their death “The under-recognized public health crisis of suicide”- Thomas Insel, Director of NIMH Suicide is a preventable public health problem – prevention efforts depend upon appropriate identification and screening. .

3. Youth Suicidal Ideation and Behavior IN HIGH SCHOOLERS Attempt: 8-10% Attempt requiring medical attention: 2-3% Within any typical classroom, it is likely that three students (one boy and two girls) have attempted suicide in the past year. IN DEPRESSED TEENS • Ideation: 60% • Attempt: 30% 3 02/12/2005; CDC WISQARS 2004-2011 (3/3/2013), Gould et al., 1998, Grunbaum et al., 2004 Shaffer, 2005

4. Relationship to School Violence(Safe Schools Initiative, 2002) • 78% of attackers exhibited a history of suicide attempts or suicidal thoughts at some point prior to their attack • 27% reported suicide as a motive in their attack • Only 1/3 of attackers had received a mental health evaluation and YET 60% had a documented history of extreme depression or desperation - a suicide in disguise -

5. Suicide Rates on the Risein the U.S. Military… • Almost 20% of all U.S. suicides are active duty or veterans • Suicide has surpassed combat deaths in active duty military • Suicide of army reservists and national guardsmen Doubled in 2010 • Active duty troops: 1 suicide every day • Air Force: approx first 15 days of 2012 – 9 suicides • Veterans: 21 suicides per day; 1000 attempts/month – many connected to systems of care

6. Suicides in Rural Areas Highest rates of suicide Large populations, spread out across great distances Less consistent access to primary care Closest physicians may be several hours away and overburdened (Ricketts, 2000) High rates of poverty and gun ownership 6

7. Public Health Burden….. 2 million adolescents attempt suicide annually, resulting in 700,000 ER visits Attempters constitute high proportion of all emergency referrals to child, adolescent, and adult psychiatric services and subsequently command disproportionate level of resources 7

8. Economic Burden of Suicide Worldwide (2008) $141 billion US (2010): $45 billion, $6 billion non-fatal attempts Within corporate family consisting of 100,000 employees (average of 4 blood relatives per employee): Every 7 days, one employee or family member will die by suicide Every day, 3 attempts, some resulting in significant medical injury and disability, which directly impacts health care costs, particularly for self-insured companies. $1.2 million potentially saved for every suicidepreventedin the U.S. medical care and years of life lost Does not account for future medical costs or psychological pain and suffering of survivors 8 Centers for Disease Control and Prevention 2011,Suicide Prevention Resource Center, 2012

9. Scope of the Problem:Depression Depression will be the world’s most burdensome disease by the year 2030 and is already the most burdensome disease in middle and high income countries (WHO, 2008)

10. Unfortunately… 90% of individuals who die by suicide have untreated mental illness, 60% depression Under-treatment of mental illness is pervasive 50-75% of those in need receive no treatment or inadequate treatment (Alonso et al., 2007; Wang et al., 2005) 70% of children and teens with depression go untreated < 20% of adolescents and college students who die by suicide receive any consistent treatment prior to their death 79% of college students who die by suicide never received any campus-based services Highest among seniors and graduate students

11. Furthermore, Expect to See It Across All Medical Disorders and beyond… Suicidality prevalent across all medical disorders 25.5% have ideation 8.9% make an attempt Druss and Pincus, 2000 Cancer patients population based ideation 17.7% independent of depression Schneider & Shenassa, 2008 So need to get it right…..

12. Suicide prevention efforts depend upon appropriate identification & screening 12

13. …Consequences The Problem… Field of medicine challenged by lack of conceptual clarity about suicidal behavior and absence of well-defined terminology (research and clinical) Variability of terms referring to same behaviors (threat, gesture) “Slap in the face” 16 different terms for the same behavior • Negative implications on appropriate management of suicide and research - if suicidal behavior and ideation cannot be properly identified, it cannot be properly understood, managed or treated in any population or diagnosis • Furthermore, comparison across epidemiological or drug safety data sets is compromised, decreasing confidence in data 13

14. The Need for Consistent Definitions & Data Elements • “ Research on suicide is plagued by many methodological problems… Definitions lack uniformity,…reporting of suicide is inaccurate…” Reducing Suicide Institute of Medicine 2002 Alex Crosby, CDC

15. How to Fix the Problem…Columbia - Suicide Severity Rating Scale Developed by leading experts (collaboration with Beck’s group) for National Adolescent Attempter’s Study in response to need for a measure to: Assess both behavior and ideation together Look at density/severity Track change Evidence-based and supported Feasible, low-burden – short administration time (average is a few minutes) includes only the most essential, evidence-based items needed in a thorough assessment Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; Zelazny, J.; Fisher, P.; Burke, A.; Oquendo, M.; Mann, J. 15

16. C-SSRS Requests/Uses The Joint Commission Best Practices Library World Health Organization-Europe: 100 Best Practices for Adolescent Suicide Prevention AMA Best Practices Adolescent Suicide U.S. Army, U.S. Navy, U.S. Air Force, U.S. Marines, and National Guard Health Canada Hospitals and Community Clinic Settings Inpatient and ERs; general medical and psychiatric, Crisis services, Special Needs Clinics, VA’s A county-wide Suicide cluster in New York Japanese National Institute of Mental Health and Neurology Israeli Defense Forces and Israeli National Suicide Prevention Program Korean Association for Suicide Prevention Planned statewide dissemination in Victoria, Australia – Health and Law Enforcement agencies Managed Care Organizations/Mobile Crisis Teams Tribal Nations International Mission Organizations Drug and Alcohol Addiction Centers National Institute on Alcohol Abuse and Alcoholism: NIAAA Commissioned by VA to do online training for clinical trials Center of Excellence for Research on Returning War Veterans Fire Departments Police Departments Judges/legal/police – to help reduce unnecessary hospitalization Primary care Worker’s Compensation Administration Surveillance Efforts; CDC Definitions are Columbia Definitions Prisons / juvenile justice Suicide Section of SCID Clinical Practice, nationally and internationally Crisis negotiation teams Schools (Middle Schools, High Schools, and College Campuses) Homeless populations Claims/HMOs Clergy (ex: Hindu priests and priestesses) EAPs Counties…States…Countries Linking Systems Inpt  Bridge  Outpt Enables quicker response to those who need it due to precision of communication 16

17. How the C-SSRS is Making an Impact… Linking Systems “The C-SSRS has made a big difference. Historically, the issue of lethality was “turfed out” to their psychologist. However, after the entire ACT team began using the C-SSRS, the discussions about suicide became more team wide and robust. Everyone was now providing observations and ideas about suicide risk management and wanting to take responsibility for client care. The greater clarity provided by the C-SSRS has been tremendously helpful” – OMH, NY

18. National Implementation Efforts in the Military/VA: The National Guard Psychological Health Program Air Force - Guide for the Management of Suicidal Behaviors Navy – Primary Care Marine Corps– “total force Rollout” use by all support workers (family advocacy workers, substance abuse specialists, victim advocates, attorneys, and chaplains ) VA – Engaged in a collaborative empirical process while supporting simultaneous national implementation Already used or requested in 30-40 VA hospitals Army – Behavioral Health Data Platform Tri-Service – Inpatient/Outpatient 18

19. National Implementation Efforts in the Marines • Intended use in all support workers: • Family advocacy workers • Substance Abuse Specialists • Victim Advocates • Attorneys • Chaplains • Mandated for use in Marine Corps Defense Services • Force Preservation • Train 16 installations including Okinawa

20. C-SSRS Used in Education School Districts School Clergy Autism, Intellectually Disabled, BOCES School-based Wellness Centers Suicide Clusters College Campuses and Counseling Centers Graduate Schools Medical Schools International Universities – e.g. University of Victoria, South Africa, National University of Ireland Nursing Schools As Intervention and to Assess Outcome e.g. Turnaround for Children, SAMSA, Garret Lee Smith Grant Elementary  High School Education Nurses Physicians Counselors Coaches Social Workers Teachers One-to-One Aides Higher Education RAs Gatekeepers Incoming Student Screening Physicians Counselors Research

21. State-Wide Dissemination • Rhode Island– EMS, Police • New York Suicide Prevention Initiative, inpatient & outpatient psychiatric services, nonprofit behavioral healthcare, youth organizations • GeorgiaDepartment of Behavioral Health – implement in all services, between services, and in systems of care • New Jersey all services that touch youth - schools, social services agencies, juvenile justice facilities, religious organizations, military facilities, primary care, higher education • TennesseeState Crisis Assessment Tool, all divisions & contract vendors used by DOMH, • WisconsinDepartment of Corrections, Crisis Responders • MaineStatewide Health Improvement Plan – all primary care • Utah“All In”

22. Utah “All in” Effort – so far… • Association for Utah Community Health - Federally Qualified Health Centers • Front line personnel and support staff • Street medicine/homeless outreach providers  • University of Utah Department of Emergency Medicine - crisis and social work teams using C-SSRS and S&B Safety Plans.   • Utah Division of Child and Family Services - all new child welfare caseworkers trained in screening, referral and safety planning • Utah Commission on Criminal and Juvenile Justice • Statewide domestic violence sentencing and treatment guidelines. • Law enforcement, judges, prosecutors and state-contracted DV treatment providers • Utah Domestic Violence Coalition • Promoting the C-SSRS at annual DV conference • Staff at state-contracted domestic violence shelters • Utah Department of Commerce/Utah Trafficking in Persons Committee • Utah Association of Domestic Violence Treatment Providers - contracted treatment providers providing court ordered treatment to individuals adjudicated on charges of cohabitant abuse.  • Unified Fire Authority - EMT/Paramedic and Fire Fighters.    • Utah Safety Net - 2014 Safety Net Conference workshop.

23. New York State Suicide Prevention Initiative • Revolutionizing Policy and Care • Eval of recent suicides all same picture: No good risk assessment, no safety plan, no warm hand-off • Comprehensive systems approach to suicide prevention • Organizational vision of zero suicides • All Adult and Youth Behavioral Health Care organizations statewide • *All patients* screened using C-SSRS • C-SSRS and Safety Planning online learning modules to be used in training all staff

24. County-Wide Dissemination One Example: Lapeer County, Michigan • Court workers • Mental health workers • K-12 school staff: teachers, bus drivers, cafeteria workers, etc. • Clergy • Law enforcement • ER staff • Child welfare workers • Police Officers, Sheriff, Road Patrol, Village & State Troopers • * All first responders: EMT, Fire Department, Police Officers, etc. “Complete Blanket Coverage” *Especially critical in rural areas

25. Why is it Helpful? From the Ground… Suicide Screening Tool to be Rolled Out in Rhode Island: “New Suicide Prevention Initiatives in Rhode Island” Released: March 20, 2012 “The scale is an easy way to save lives…Our staff have been trained by Dr. Posner, the creator of the C-SSRS, and have found it easy to use and effective. By tying it to our electronic health records, it becomes that much more streamlined into every day care.” New York State, Office of Mental Health“…the feeling is that the C-SSRS has separated the wheat from the chaff; it focuses attention where it needs to be. This easy to use instrument allows our clinicians to move ahead with confidence and we are similarly confident that we are providing them with the best technology available.” – OMH, NY     

26. National Council Magazine “Ultimately, the C-SSRS serves as an effective mobile crisis tool which gets to the right people at the right time and right place and helps to save lives and save public dollars.”

27. Hope at last to break suicide's silence • March 25, 2012 • Kelly Posner, Ph.D., principal investigator for Columbia’s Center for Suicide Risk Assessment, earlier this month brought this information to Middle Tennessee, in a meeting of health professionals at Nashville’s Oasis Center for troubled teens, and a separate briefing with authorities at Fort Campbell.” • Other methods that use imprecise terminology and have variable concepts of what constitutes suicidal behavior… often hinder communication about an individual that could prevent suicide.” • The new system is gradually being implemented by the Army, Navy, Air Force and National Guard; by police and fire departments; drug and alcohol addiction centers; and public schools and colleges. • Commentary on Article: • “A leading cause of death"? I have my doubts about that assertion.” “Maybe in some third-world, oppressed countries - or among some teenagers, but certainly not in the US.” • “Hope at last to break suicide's silence. I was not aware there was any.” -Retired Mental Health Editor • “Suicide is very much preventable. I applaud the development of an instrument to help identify those in need of help…”

28. Simply…. 1-5 rating for suicidal ideation, of increasing severity (from a wish to die to an active thought of killing oneself with plan and intent) Have you wished you were dead or wished you could go to sleep and not wake up? Have you actually had any thoughts of killing yourself? If answer is “No” to both, no more questions on ideation All relevant behaviors assessed All items include definitions for each term and standardized questions for each category are included to guide the interviewer for facilitating improved identification Two Screen Questions for Ideation

29. Research Supported Items Preparatory Behavior Those with recent preparatory behavior (e.g., collecting pills, razors, or loaded weapon) 8-10xmore likely to die by suicide (Brown & Beck, unpublished) Interrupted Suicide Attempts 3x more likely to die by suicide (Steer, Beck & Lester, 1988) Aborted Suicide Attempts Subjects who made aborted attempts 2xas likely to have made a suicide attempt (Barber et al., 1998)

30. eC-SSRS...Depressed Subjects…ALL Behaviors Are Prevalent and Predictive n = 28,699 administrations .8% .6% .2% .2% .2% No Behavior: 28,303 Each behavior is EQUALLY PREDICTIVE to an attempt Actual Attempt: 70 Interrupted Attempt: 178 Aborted Attempt: 223 Preparatory Behavior: 71 9 8 . 6 % Multiple behaviors = greater risk *Only 1.7% had any worrisome answer *Only .9% with ~50,000 administrations 472 Interrupted, Aborted and Preparatory (87%) vs. 70 Actual Attempts (13%) Mundt et al., 2011

31. Screening Vets with C-SSRS: Only .17% Required Referral to More Acute Care Positive Screen needing Hospitalization: n=5 (0.17%) Positive Screen without Hospitalization: n=9 (0.30%) Negative Screens: n=2948 (99.53%) • Only 14 out of 2962 screened positive (.47%) • Only 5 (.17%) required more acute care

32. C-SSRS Format and Administration…How many questions should I ask? • Semi-structured interview/flexible format • Questions are provided as helpful tools – it is not required to ask any or all questions – just enough to get the appropriate answer • Most important: gather enough clinical information to determine whether to call something suicidal or not

33. Example…. Rater: “Have you made a suicide attempt?” Individual: “Yes, I took 50 pills because I definitely wanted to die.” • You have enough information to classify as an actual attempt, no need to ask additional questions

34. Multiple Sources : Don’t Have to Rely on Individual’s Report Most of time person will give you relevant info, but when indicated…. Allows for utilization of multiple sources of information Any source of information that gets you the most clinically meaningful response (subject, family members/caregivers, records)

35. Examples… • A friend of a student comes to your office and reports that the student posted on Facebook that he wants to die. • A loved one brings a family member into the ER. The patient denies suicidal thoughts, but the family member shares with you that the he has been talking about suicide for the past two weeks and wrote a note yesterday and that is why he is here in the ER. • Client is at intake for outpatient services and denies lifetime suicidal ideation and behavior but medical record sent from inpatient hospital indicates admission for recent attempt.

36. Suicidal Ideation 1. Wish to die • Have you wished you were dead or wished you could go to sleep and not wake up? 2. Active Thoughts of Killing Oneself • Have you actually had any thoughts of killing yourself? *** If “NO” to both these questions Suicidal Ideation Section is finished.*** *** If “YES” to ‘Active thoughts’ ask the following three questions.*** 3. Associated Thoughts of Methods • Have you been thinking about how you might do this? 4. Some Intent • Have you had these thoughts and had some intention of acting on them? 5. Plan and Intent • Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? *Auditory hallucinations qualify as ideation*

37. This is the Full C-SSRS Ideation Page Typical Administration Time=Few Minutes

38. Same Screening Questions *If 1 and 2 are no, ideation section isdone This is the C-SSRS Screener *Minimum of 3 Questions

39. Intensity of Ideation • Once types of ideation are determined, few follow-up questions about most severe thought • Frequency • Duration • Controllability • Deterrents • Reasons for ideation (stop the pain or make someone angry—stop the pain is worse) • Gives you a 2-25 score that will help inform clinical judgment about risk All these items significantly predictive of suicide (on SSI)/minimum amount of info needed for tracking and severity

45. Clinical Monitoring Guidance • For Intensity of Ideation, risk is greater when: • Thoughts are more frequent • Thoughts are of longer duration • Thoughts are less controllable • Fewer deterrents to acting on thoughts • Stopping the pain is the reason Duration found to be predictive in adolescents (King, 2010)

46. Ideation Severity Demo http://youtu.be/2kpB3Tq2mgU

47. Impact on Care Delivery and Service Utilization…

48. Advantages….Operationalized Criteria for Next Steps Allows for setting parameters for triggering next steps whatever they may be (e.g. referral to mental health, one-to-one, etc.) 4 or 5 on recent ideation item to indicate need for immediate action Decreases unnecessary referrals, interventions, etc. • *In the past, people didn’t know what to manage, so they would hear anywish to die and intervene… 48 48

49. Clinical Monitoring Guidance: Threshold for Next Steps Indicates Need for Next Step

50. Thresholds facilitate identification of those at highest, triage, and care delivery 4/5  Psych consult 3  Consult to Care team Example: Streamlining Care in Hospital Policies (Reading Hospital Policy)