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ADDRESSING THE INTERSECTION OF SUBSTANCE USE AND SUICIDE: STRATEGIES FOR PREVENTION,
INTERVENTION, AND TREATMENT
HOSTED BY:ADOLESCENT SBIRT PROJECT, NORC AT THE UNIVERSITY OF CHICAGO, THE BIG
SBIRT INITIATIVE AND THE UNIVERSITY OF CINCINNATI
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Public Health DepartmentNORC at the University of Chicago
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Acknowledgement
¨ This presentation is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $397,935 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
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Webinar Presenter
Brett Harris, DrPHClinical Assistant ProfessorSchool of Public HealthUniversity at [email protected]
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Addressing the Intersection of Substance Use and Suicide: Strategies for Prevention, Intervention, and Treatment
Section 1
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Outline
¨ Suicide as a public health problem
¨ Intersection of substance use and suicide
¨ Substance use and suicide prevention in communities
¨ Suicide safer care protocols for health care settings
¨ Integrating suicide prevention into the SBIRT model
10
Percent Change in Age-Adjusted Death Rates since 2003 by Cause of Death, US, 2003-2016
-40%
-30%
-20%
-10%
0%
10%
20%
30%
2003 2005 2007 2009 2011 2013 2015Sui cide Heart di sease Cancer Stroke Al l-cause
Source: National Center for Health Statistics
11 12
3
Leading Causes of Death by Age Group, US, 2018
Source: CDC W ISQARS Fatal Injury Datahttps://www.cdc.gov/injury/wisqars/fatal.htm l
13
Suicide by Age
14.3
17.5 18.0
20.219.1
15.6
18.0
20.1
0
5
10
15
20
25
15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Cru
de
rate
per
10
0,0
00
Suicide rate by age, US, 2017
0
5
10
15
20
25
1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
Ag
e-a
dju
sted
ra
te p
er 1
00
,00
0
Age-adjusted suicide rate by age, US, 1999-2017
10-24 25-39 50-59 TOTAL
Source: CDC W ISQARS Fatal Injury Datahttps://www.cdc.gov/injury/wisqars/fatal.htm l
14
Percent Change in Age-Adjusted US Suicide Rate by Age
-1 0
0
10
20
30
40
50
60
199 9 200 1 200 3 200 5 200 7 200 9 201 1 201 3 201 5 201 7
Perc
ent
Since 1999
10- 24 25- 39 50- 59 A ll ages
0%
10 %
20 %
30 %
40 %
50 %
60 %
20 10 20 12 20 14 20 16
Since 2010
10 -2 4 25 -3 9 50 -5 9
Source: CDC W ISQARS Fatal Injury Data
https://www.cdc.gov/injury/wisqars/fatal.htm l
15
Suicide by Age and Gender
22.0%
78.0%
Suicide Deaths by Gender, US, 2017
Female Male
22.627.6 27.4
30.2 29.826.2
35.8
50.6
5.8 7.1 8.5 10.4 8.96.2 4.3 3.5
0
10
20
30
40
50
60
15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Age
-ad
just
ed p
er 1
00
,00
0
Suicide death rate by age and gender, US, 2017
Male Female
Source: CDC W ISQARS Fatal Injury Data
https://www.cdc.gov/injury/wisqars/fatal.htm l
16
Suicide by Means and Gender
13.9%
27.8%50.6%
7.7%
Suicide Deaths by Means, US, 2017
Pois oning Suf focatio n Fire arm Ot he r
9.0%
27.7%
56.1%
7.2%
31.4%27.9%
31.2%
9.5%
0%
10 %
20 %
30 %
40 %
50 %
60 %
Pois oning Suf focatio n Fire arm Ot he r
Suicide Deaths by Means and Gender, US, 2017
Ma le Female
Source: CDC W ISQARS Fatal Injury Datahttps://www.cdc.gov/injury/wisqars/fatal.htm l
17
Age-adjusted Suicide Death Rate by Age and Race/Ethnicity, US, 2017
15.4
19.520.8
23.522.0
17.4
20.1
22.0
10.311.9
9.2
7.2
5.1 4.5 4.2
22.7
25.9
18.3
15.5
8.6
11.5
8.4
6.57.6 7.1
7.9 7.7
12.8
8.79.9
8.5 8.27.5
5.9
8.19.4
0.0
5.0
10.0
15.0
20.0
25.0
30.0
15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Ag
e-a
dju
sted
ra
te p
er 1
00
,00
0
White Bla ck A merican Ind ian/A las ka Nat ive A sian/ Pac ific Is la nder H ispa nic
Source: CDC W ISQARS Fatal Injury Datahttps://www.cdc.gov/injury/wisqars/fatal.htm l
18
4
Urban vs. Rural Classification
Source: NCHS Data Brief No. 330, Nov. 2018 https://www.cdc.gov/nchs/data/databriefs/db330-h.pdf
19
Means in Rural vs. Non-rural Areas
13.2
1.1
6.3
3.9
1.9
19.1
0.8
10.9
5.3
2.0
0 5 10 15 20
TOTAL
Other
Firearm
Suffocat ion
Poisoni ng
Age-adjusted suicide rate per 100,000
Age-adjusted suicide rate by geography and means, US, 2017
Rural Urban/Suburban
Source: CDC Wonderhttps://wonder.cdc.gov/controller/datarequest/D76;jsessionid=5A36BC05F1C9647D83F98CB3C6C0613E
60.2%24.7%
10.8%
4.3%
Means of suicide in rural areas, US, 2017
Firearm Suffocat ionPoisoni ng Other
20
Self-Harm by Age and Gender
433.2
303.9
235.8
206.6186.5
164.1 159.0142.9
110.2
69.944.2
27.4 33.8 28.5
0
50
100
150
200
250
300
350
400
450
500
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84
Age-
adju
sted
rate
per
100
,000
Rate of self-harm by age, US, 2017
125.64
189.96
0
50
100
150
200
Age-
adju
sted
rate
per
10
0,00
0
Rate of self-harm by gender, US, 2017
Ma le Female
• 25 attempts for every death• 100-200:1 for youth• 4:1 for older adults
• 3 female attempts for each male attempt
• For each suicide, ~147 exposed
Source: CDC W ISQ ARS Non-fatal Injury Datahttps://www.cdc.gov/injury/wisqars/nonfatal.html
Source: American Association of Suicidology https://suicidology.org/wp-content/uploads/2019/04/2017datapgsv1-FINAL.pdf
21
Past-12-month Self-reported Depression, Suicidal Ideation, And Behavior, US High School Students, 2017
S ource : C D C Y ou th R isk B ehav io r S urvey h ttps ://w w w .cdc .gov /hea lthyyou th /da ta /y rbs /resu lts .h tm
31.5%
17.2%13.6%
7.4%
21.4%
11.9%9.7%
5.1%
41.1%
22.1%
17.1%
9.3%
0%
5%
10 %
15 %
20 %
25 %
30 %
35 %
40 %
45 %
Felt Sad or Hopeless Seriously Consi deredAtt empt ing Suicide
Made a P lan Att empted Suicide
Tota l Ma le Female
22
Suicidal Thoughts/Behaviors among Youth, by Sexual Orientation
7.4%
13.6%
17.2%
31.5%
5.4%
10.4%
13.3%
27.5%
18.6%
33.2%
41.4%
53.1%
0% 10% 20% 30% 40% 50% 60%
Att empted Suicide
Made a P lan
Seriously Consi dered At tempt ing Suicide
Felt Sad or Hopeless
Depressed mood, suicidal thoughts and behaviors in the past 12 months by sexual orientation, US high
school students, 2017
Ga y or Lesb ian H eter osex ual Tota l
S ource : C D C Y ou th R isk B ehav io r S urvey h ttps ://w w w .cdc .gov /hea lthyyou th /da ta /y rbs /resu lts .h tm
23
Intersection of Substance Use and Suicide
24
5
Source: CDC Vital Statistics Reports, 2003-2016
Percent Change in Age-Adjusted Death Rates since 2003 by Cause of Death, 2003-2016
-5 0%
0%
50 %
10 0%
15 0%
20 0%
20 03 20 05 20 07 20 09 20 11 20 13 20 15
Suicide Heart di sease Cancer Stroke Drug Overdose All-cause
25
Suicide and Unintentional Drug Overdose Rates per 100,000, US, 1999-2017
Source: CDC WISQARShttps://webappa.cdc.gov/cgi-bin/broker.exe
02468
101214161820
1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
Age
-adj
uste
d ra
te p
er 1
00,0
00
Unintentiona l Dr ug Overdose Suic ide
26
Deaths of Despair: White Non-Hispanic Mortality, 50-54, by Cause of Death and Education Class
Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Papers on Economic Activity. 2017. Available at https://www.brookings.edu/wp-content/uploads/2017/03/6_casedeaton.pdf
27
Deaths of Despair: Drug, Alcohol, and Suicide Mortality, Ages 50-54
Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Papers on Economic Activity. 2017. Available at https://www.brookings.edu/wp-content/uploads/2017/03/6_casedeaton.pdf
28
Substance Misuse and Suicide Are Closely Linked
• Suicide rate among those with OUD 6 times the rate of the general population (87/100,000 vs. 14/100,000)
• People who misuse opioids 40-60% more likely to have thoughts of suicide
• Those who regularly use opioids are 75% more likely to make suicide plans and twice as likely to make a suicide attempt
• 20% of suicides in US involve opiates
• 20-30% of overdose deaths are actually suicides
¤ Hard to determine intent in the absence of a suicide note
¤ Many overdoses among individuals without an explicit intent to die but not caring about the risks
• Up to 40% of lethal or non-lethal attempts involve alcohol intoxicationSAMHSA. Substance use and suicide: A nexus requiring a public health approach. 2016. https://store.samhsa.gov/system/files/sma16-4935.pdf. Accessed October 31, 2019.Oquendo MA, Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. N Engl J Med. 2018;378(17):1567-1569. doi:10.1056/nejmp1801417.
29
Connection between Substance Use and Suicide
¨ Individuals with SUDs twice as likely to have mood/anxiety disorders
¨ Half of individuals with mental illness will have SUD in their lifetime
¨ Chronic pain sufferers prescribed opioids may also have comorbid depression
¨ Disinhibition during intoxication¨ Increasing depressed mood
¨ Alcohol increases proximal risk¤ Increases aggressiveness
¤ Constricts cognition, impairing the generation and implementation of alternative coping strategies
Substance Abuse and Mental Health Services Administration. Substance use and Suicide: A nexus requiring a public health approach. 2016. Available at: http://store.samhsa.gov/shin/content//SMA16-4935/SMA16-4935.pdf. Accessed April 21, 2017. National Institutes of Mental Health https://www.nimh.nih.gov/about/director/messages/2019/suicide-deaths-are-a-major-component-of-the-opioid-crisis-that-must-be-addressed
30
6
Jointly Address Substance Use and Suicide
• “Self-injury mortality”-117,338 in 2017
• Suicide prevention as substance use/opioid overdose prevention
• June 2019 – minimum required standard for suicide care in addiction treatment, Commission on Accreditation of Rehabilitation Facilities
https://store.samhsa.gov/product/In-Brief-Substance-Use-and-Suicide-/sma16-4935
Vestal C. Opioid Treatment Programs Gear Up to Provide Suicide Care. The Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/04/11/opioid-treatment-programs-gear-up-to-provide-suicide-care. 2019. Accessed October 31, 2019.
https://www.tfah.org/report-details/adsandadolescents/
31
Prevention in Communities
Substance Use and Suicide
32
A Public Health Approach
Community awareness
Promotion of Crisis Text Line and other hotlines
Community and school education and trainings
Postvention
Accessing and using data to inform local efforts
Linkages to care
Collaboration between community coalitions and task forces
Local health and mental hygiene directors
33
Community Collaboration Study
Objectives
• To identify opportunities for community-level collaboration among key NYS stakeholders by:• Exploring attitudes and
perceptions regarding suicide and overdose
• Identifying facilitators/barriers to collaboration
• Assessing current practices for suicide prevention
• Identifying populations and areas of need
Methods
• Electronic Survey Monkey distributed to Directors of Community Services and substance use and suicide prevention coalition leads
• Response Rate: 54% (160/299)
34
Results: Attitudes and Perceptions
• The majority of respondents agreed that suicide and opioid overdose are problems for their counties
¤ Few believe their counties have the necessary funding to prevent these deaths, 17% and 25% respectively
% of Respondents that agree/strongly agree with the following,
SU Coalitions
SP Coalitions
DCS Totaln=150
Suicide is a problem for my county. 77%* 94% 92% 86%
Opioid overdose is a problem for my county. 92% 94% 92% 93%
Those with an OUD are at greater risk of suicide. 88% 84% 81% 85%
There’s value in collaborating on suicide and opioid overdose prevention.
93% 96% _ 94.5%
*Significantly lower than suicide prevention coalitions and DCS' (p<.05)
35
Populations Most in Need of Suicide Prevention
58.6%
60.9%
67.7%
70.7%
72.2%
74.4%
LGBTQ+
Veterans
Men in Middle Years
Young Adults
Adolescents
Persons with risky substance use
Populations Most In Need Of Suicide Prevention(Selected By Respondents Out Of 12 Options)
36
7
Results: Familiarity of Prevention Practices
• DCSs were more aware of prevention best practices for both suicide and overdose
64%
39%
53%
41%
78%
16%
6774
88
76
94
67
95 97
65
92 95
62
0
20
40
60
80
100
SBIRT Va lid ated s uic ideris k s cr eening s
Cr isis Text Brief int erventionsfor individ ua ls atris k f or s uic ide
(Saf ety Planning )
National SuicidePrevention Lif eline
Post vention (af ter adea th by suicid e)
% of Respondents that are familiar/very familiar
Sub sta nce Us e C oalitio ns Suic ide Prevent ion Co alitions D irec tor s o f C ommunity Se rvices
37
Opportunities for Collaboration Identified by Substance Use Coalitions
1. Distributing materials on respective trainings (89%)
2. Combining short trainings, i.e. Naloxone and QPR (80%)
3. Educating substance use providers on importance of suicide safer care protocols (76%)
4. Participation in joint learning collaborative (79%)
38
Facilitators and Barriers to Collaboration for Substance Use Coalitions
Facilitators Funding (79%)
Improved Data Collection (66%)
Barriers Lack of Staff Time (66%)
Scope of Work Limitations (55%)
39
Conclusions
• This study identifies specific areas in which to provide education, training, and technical assistance to communities:
¤ How suicide prevention is a key element of opioid overdose prevention
¤ Free 24/7 resources: Suicide Prevention Lifeline, Crisis Text, and HOPEline (help with addiction NYS)
¤ Best practices for addressing specific populations identified in the survey
¤ How to strategically braid funding
• State agency collaboration and support may influence county and community level collaboration
40
Population-based primary care and specialized behavioral health settings
Suicide Prevention in Health Care Settings
41
Suicide Safer Care in Behavioral Health Settings
A comparative analysis of perceptions and practice between mental health and substance use disorder treatment providers
42
8
Objectives and Methods
Objectives
• Assess suicide safer care practices and confidence in behavioral health settings
• Explore differences between mental health and substance use disorder (SUD) treatment providers
Methods
• Electronic survey distributed to clinicians at 9 large health systems across New York State• Beliefs about suicide• Perceived self-efficacy • Perceived effectiveness in
working with suicidal clients• Frequency of suicide
prevention practice• Surveys were completed
between November 2018 and January 2019
43
153
648
1,015
0 200 400 600 800 1000 1200
SUD treatment providers
Com pleted survey
Invited to partic ipate
Number of individuals
64% participation rate
24%
Survey Results
• Among SUD providers:
¤ 34.6% have worked with clients who died by suicide
¤ 79.7% with clients who attempted suicide
44
Self Efficacy
46.0
39.1
37.1
24.5
27.6
27.6
*Screening clients for suicide risk.
*Conducti ng a comprehensive suicide riskassessment.
*Manag ing cli ent suic idal thoughts orbehaviors i n treatment.
*Developing a collabora tive, multi -stepStanley-Brown safety p lan with suicidal…
Treating cl ients with suicidal thoughts orbehaviors with a suicide-specifi c approach.
*Conducti ng struc tured phone follow-upwith clients i n the days after di scharge…
* Significantly lower than MH providers, p < 0.05 % Strongly Agree
45
Jointly Address Substance Use and Suicide
77.1
82.4
71.9
60.8
6.5
0 20 40 60 80 100
With all new cl ients
Whenever I suspect a cli ent may be atelevated ri sk
When a client's record indicates anyhi story of suicida l thoughts or behaviors
At every vi sit with c lients at elevatedrisk for sui cide
At every vi sit with a ll clients
Percent of SUD providers
46
1=never; 2=rarely; 3=sometimes; 4=often; 5=always
Practice Frequency among SUD Providers
3.94
3.55
3.86
3.24
0 1 2 3 4 5
*Screen new clients for suicide risk with astandardized measure
*Screen existing clients for suicide risk witha standardized measure
*Conduct a standardized suic ide riskassessment for those suspected of being a t
elevated ri sk
*Develop a col laborati ve, multi-stepStanley-Brown safety p lan with suicidal
cli ents
* Significantly less frequent than MH providers, p < 0.05
47
Conclusion
• Providing suicide safer SUD treatment not only important but required for accreditation
¤ Providers seeing patients at high risk for suicide but:
n Not confident in their ability to provide suicide safer care
n Not routinely providing best practices in suicide safer care
• Results suggest areas for education and training of the SUD workforce
48
9
Suicide Safer Care Practices and Protocols
49
The Zero Suicide Model: Seven Elements
¨ Zero Suicide implemented in health and behavioral health settings:
¤ Primary care
¤ Emergency departments
¤ Hospitals
¤ Inpatient and outpatient mental health
¤ Substance use disorder treatment clinics
50
Pre-screen: PHQ-3
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Thoughts that you would be better off dead or of hurting yourself in some way
¤ Trigger C-SSRS or ASQ
PHQ-9: Kroenke et al., 2001
51
Full Screen: C-SSRS
Columbia Suicide Severity Rating Scale
¨ Commonly referred to as the C-SSRS or the Columbia screen.
¨ 6-item scale; full range of ideation and behavior including intensity, frequency, and changes over time.
¨ Categorizes different types of lifetime and recent suicidal behavior, such as actual, interrupted, aborted suicide attempts and preparatory behaviors;
¨ Passive, Active, Method, Plan, Intent
¨ Available in over 100 languages.
52
Scoring the C-SSRS
All items on the C-SSRS are “Yes/No” questions
¨ First 2 questions assess general ideation:
¤ 1st question: passive ideation, or the wish to be dead
¤ 2nd question: active ideation, or having any thoughts of killing oneself
¨ A “yes” response to having any thoughts of killing oneself triggers the remainder of the questions
¤ These assess for the presence of a plan, intent upon acting on thoughts, having both a plan and intent on carrying out the plan, and actual suicidal behavior (both lifetime and recent)
53
C-SSRS
Source: Columbia Lighthouse Project http://cssrs.columbia.edu/
For use with both adolescents and adults
This version copied from a pocket card designed for adolescents
Method
Intent
Plan + Intent
Lifetime vs. recent
54
10
Using and Interpreting the C-SSRS
Question Intent: Thoughts and Behaviors
Response
Q1. Wish to be dead Behavioral Health Referral
Q2. Suicidal thoughts Behavioral Health Referral
Q3. Suicidal thoughts with method (w/o specific plan or intent)
Behavioral Health Consult (Psychiatric Nurse/Social Worker) and consider Patient Safety Precautions
Q4. Suicidal intent (without specific plan)
Behavioral Health Consultation and Patient Safety Precautions
Q5. Suicidal intent with specific plan
Behavioral Health Consultation and Patient Safety Precautions
Q6. Suicidal behavior not within the past 3 months
Behavioral Health Consult (Psychiatric Nurse/Social Worker) and consider Patient Safety Precautions
Q6. Suicidal behavior within the past 3 months
Behavioral Health Consultation and Patient Safety Precautions
55
Source: National Institute of Mental Health https://www.nimh.nih.gov/labs-at-nimh/asq-toolkit-materials/asq-tool/screening-tool_155867.pdf
Designed for use with adolescents
56
Even patients who screen negative for suicide risk should be provided with the Lifeline and Crisis Text Line numbers as well as warning signs and the fluctuating nature of suicide risk
57
What to Do after Screening
¨ If imminent risk, do what needs to be done to keep client safe¤ Emergency evaluation and/or hospitalization
¨ Not at imminent risk:
¤ Review crisis information (clinic after hours/emergency numbers, local ED/CPEP, local and national crisis hotlines/Lifeline, Crisis Text Line)
¤ Treatment plan that addresses suicidality directly, reduces risk factors, and improves protective factors
¤ Increase clinical contact
¤ Follow-up and monitor between sessions
¤ Safety Planning Intervention before the end of the risk assessment session
58
Safety Planning Intervention (SPI)
¨ There are lots of “safety plans,” “coping plans,” “relapse prevention plans” and “crisis plans” - SPI is different
¨ SPI is a clinical intervention for those with suicidal thoughts and behavior explicitly for the purpose of helping them make it through a time-limited suicidal crisis
¤ Not really applicable to people who are not experiencing suicidal crises
¤ Becomes just a form to complete if you do not explain how and why it works
¤ Warning signs, means restriction, etc. become hypothetical if the client does not have ideation with method/plan
¨ You want to be careful not to have a overly-general crisis plan, as triggers and coping responses for substance use, aggression, domestic violence, etc. vs. suicidal thoughts may not be the same
59
Safety Planning Intervention
¨ Clinical intervention that results in a plan for when a suicidal crisis emerges
¨ Idea is that suicide risk fluctuates over time
¤ Plan for managing suicidal feelings and staying safe when these feelings emerge
¤ Provides a simple format as problem-solving diminishes during a crisis
n Improves coping/problem-solving over time
¨ Determine cognitive and behavioral strategies to use during suicidal crises
¤ Clinician guides patient and family in generating their own ideas
n Research: Patients who received SPI as part of an ED visit for a suicide-related concern were half as likely to exhibit suicidal behavior and twice as likely to attend at least 1 outpatient mental health visit than the comparison group who did not receive SPI (Stanley et al., 2018)
60
11
Safety Planning Intervention: Six Steps
Environment Making the environment safe (reducing access to lethal means)
Mental Health Contacting mental health professionals/agencies
Family Members/Friends Contacting family members or friends to help resolve crisis
Socializing Socializing with others as a way of distraction
Internal Coping Strategies
Employing internal coping strategies (without contacting another person)
Warning Signs Recognizing warning signs
61
Safety Planning Intervention: Steps 1-3
1. Warning Signs¤ “What do you experience when you start to think about suicide or feel
extremely depressed?”¤ “How will you know when the safety plan should be used?”
¤ List warning signs using patient’s own words
2. Internal Coping Strategies¤ “What can you do, on your own, if you become suicidal again, to resist acting
on your thoughts or urges?”
¤ “How likely is it that you would do this in a time of crisis?”¤ [If doubt is expressed] “What might prevent you from doing these activities?”
3. Social Contacts Who May Distract from the Crisis¤ “Who may help you take your mind off of problems at least for a little
while?” “Who helps you feel better when you talk with them?”
Source: Suicide Prevention Resource Center http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf
62
Safety Planning Intervention: Steps 4-6
4. Family Members or Friends Who May Offer Help¤ “Among your family or friends, who do you think you could contact for help
during a crisis?” “Who do you feel you can talk with when you’re under stress?”
5. Professionals and Agencies to Contact for Help¤ “Who are the mental health professionals that we should identify to be on
your safety plan?” “Are there other health care providers?”
¤ List name, numbers and/or locations of clinicians and local urgent care services
6. Making the Environment Safe¤ “Do you own a firearm, such as a gun or rifle?” “What other means do you
have access to and may use to attempt to kill yourself?”¤ “How can we go about developing a plan to limit your access to these
means?”
Source: Suicide Prevention Resource Center http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf
63
Apps
MY3 Stanley-Brown Safety Plan
http://my3app.org/#stay-connected https://itunes.apple.com/us/app/safety-plan/id695122998#?platform=iphone
64
Follow-up and Monitoring: Structured Phone Follow-Up
¨ Assess mood and current risk¤ Administer C-SSRS (since last visit) to determine level of risk¤ If imminent risk detected, contact crisis line
¨ Review and revise safety plan¤ Remove unhelpful items and identify more helpful ones¤ Review access to means and whether there is a need to remove them
¨ Treatment engagement/motivation¤ Review treatment plan options and problem solve obstacles to treatment¤ Provide information on available community supports, Lifeline and Crisis Text Line
¨ Obtain consent/willingness for additional follow-up¤ Assess need for further calls and problem solve resistance¤ Set call time¤ Let client know how to initiate future care
Occurs 24-48 hours after initial contact to provide support during a time of elevated risk
Training module available from the Center for Practice Innovations http://zerosuicide.sprc.org/resources/structured-follow-and-monitoring-suicidal-individuals
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Follow-up, Monitoring, and Referral
¨ Non-Demand Caring Contacts¤Postcards, letters, emails or text messages
containing brief expressions of caring
¤Patients who refuse further care but receive these contacts had a lower suicide rate than those in the comparison group who did not receive these contacts (Motto & Bostrom, 2001)
Source: Zero Suicide Toolkit https://zerosuicide.sprc.org/toolkit/treat/interventions-suicide-risk#footnote3_6nqa0ya
• Warm hand-off to other levels of care, suicide-specific treatment• Cognitive Behavioral Therapy for Suicide Prevention• Dialectical Behavioral Therapy• Collaborative Assessment and Management of Suicidality
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Postvention for Clinicians who Lose Patients to Suicide
¨ Most clinicians in the behavioral health field have lost patients to suicide
¨ In a survey of psychiatrists by Erlich et al. (2018):
¤ Half changed their practice patterns after a patient suiciden 1/3 sought increased supervision
n 1/4 began using formal measures to assess suicidal thoughts and behaviors
n 9.1% began using a formal postvention protocol or standardized toolkitn 9.8% stopped accepting patients they deemed at risk of suicide
¨ Postvention interventions are rare, variable, and underutilized
¨ Burden and risk of burnout
¨ Lack of standardized approach in training and preparation for managing in the aftermath of a suicide
¨ AAS Clinician Survivor Task Force and information: http://cliniciansurvivor.org/
Erlich MD et al. Why we need to enhance suicide postvention: Evaluating a survey of psychiatrists’ behaviors after the suicide of a patient. J Nerv Ment Dis. 2017 July; 205(7): 507–511. doi:10.1097/NMD.0000000000000682.
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Suicide Prevention and the SBIRT Model
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What is SBIRT?
Screening
Brief Intervention
Referral to Treatment
An evidence-based prevention and early intervention model to address the full continuum of substance use
Goal: Identification of those misusing substances in non-SUD treatment settings and provision of appropriate services
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The Current Model:A Continuum of Substance Use
Abstinence
Addiction
Responsible Use
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The SBIRT Model:A Continuum of Substance Use
Abstinence
Experimental Use
Social Use
Binge Use
Problem Use
Substance Use
Disorder
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5%
20%
75%
Substance Use Disorder
Low Risk orAbstinence
No Intervention or screening and Feedback
Brief Intervention and Referral for additional Services
Source: Babor, T.F. & Higgins-Biddle, J.C. (2001). Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf.
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Integration into the SBIRT Model: Commonalities
• Substance use – AUDIT, DAST-10, CRAFFT, S2BI• Suicide – PHQ-3, PHQ-9, C-SSRS
Screening
• Substance use – Brief Negotiated Interview (BNI)• Suicide – Safety Planning Intervention (SPI)
Brief intervention
• Return visits for additional brief intervention• Structured phone follow-up
Extended Brief Intervention
Referral
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Thank You and Summary
Brett Harris, DrPHClinical Assistant ProfessorSchool of Public HealthUniversity at [email protected]
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In Our Last Few Moments…
sbirt.webs.com/substance-use-and-suicide
¨ PowerPoint Slides
¨ Materials and Resources
¨ On Demand Access 24/7
¨ Certificate of Attendance
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SBIRT Technical Assistance
Do you have questions about SBIRT implementation, evaluation, or training?
Schedule a free telephonic Technical Assistance session with Tracy McPherson, SBIRT Training, Technical Assistance, and Evaluation Lead.
Email Dr. McPherson at [email protected]
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Using SBIRT to Talk to Adolescents about Substance Use 4-part Webinar Series
¨ Substance Use Screening Tools for Adolescents
¨ Brief Intervention for Adolescents Part I: BNI Using MI Strategies
¨ Brief Intervention for Adolescents Part II: BNI Using MI and CBT Strategies
¨ Discussing Options and Referring
Adolescents to Treatment
sbirt.webs.com/webinars
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Thank You for Attending!
www.sbirt.webs.com [email protected]
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