ORLANDO — A new Web-based toolkit provides guidance and information for primary care physicians in the screening, management, and referral of patients at risk of suicide.
The overall aim of using the kit is to optimize interactions between physicians and at-risk patients. It includes advice on when and how to question patients about their risks, how to refer them to mental health specialists, and how to find community resources. It also emphasizes the importance of training all practice staff to recognize the relevant signs and risk factors for suicide.
“Our data tell us that primary care is an important setting” for the early detection of suicide risk, said David A. Litts, O.D., associate director of the Suicide Prevention Resource Center (SPRC), at the Education Development Center, Newton, Mass., and one of the developers of the kit.
“Why primary care?” asked session moderator, Guy S. Diamond, Ph.D. “Because 70% of adolescents see a physician once a year for a well visit or school check-up—[that's] an opportunity to touch a lot of lives.”
In addition, most adolescents report a willingness to talk with a primary care physician about emotional distress, particularly with a physician they know well, said Dr. Diamond, who is on the psychiatry and behavioral science faculty at Children's Hospital of Pittsburgh.
Matthew B. Wintersteen, Ph.D., emphasized during another presentation that primary care is “the sole source of mental health treatment for most Americans.”
The Suicide Prevention Toolkit for Rural Primary Care includes a user-friendly starter guide and sections on educating the practice staff; developing partnerships with mental health providers; tools for managing patients; patient education tools; and resources.
Although its title includes the word “rural,” the kit is just as useful and easily applicable in the nonrural primary care setting, said Dr. Peggy West, a senior adviser at SPRC, who was also involved in developing the kit.
Dr. Litts stressed the importance of first developing an office protocol on suicide prevention. “Make sure you have [it] in place” before you implement the rest of the prevention protocol, he said.
The component on initiating collaborative partnerships with mental health service providers includes a template letter that can be easily modified depending on a patient's circumstances, as well as a mental health service locator and information about veterans' services and telemental health services, which is particularly important in remote rural areas.
Other components include universal screening for depression and substance abuse and instructions on safe storage of firearms for all patients, especially adolescents. A safety planning guide helps a physician decide whether patients can manage themselves and when they should call a physician for help.
Although there are considerable challenges in the primary care setting, such as time constraints, reimbursement issues, and knowing how to intervene when a patient endorses suicidal ideation, primary care physicians can make a difference, said Dr. Wintersteen, who is director of research, division of child and adolescent psychiatry, Thomas Jefferson University, Philadelphia.
“Be approachable, flexible, and persistent,” he advised.
Suicidal ideation screening in a busy primary care practice should be brief. “You want to keep it short,” said Dr. Litts. He recommended asking a question such as: “Mr. Jones, a lot of people who have had pain as long as you have sometimes think about killing themselves. Have you had any thoughts like that?”
“The bottom line with screening is: Ask and they will tell,” said Dr. Wintersteen, who recently published findings that demonstrate the effectiveness of screening adolescents for suicide risk in primary care (Pediatrics 2010;125:938-44).
The importance of state-specific information in the toolkit—such as state hospital locations, regional resources, and local hotline numbers—are lessons learned from early adopters of the toolkit, Dr. West said.
The SPRC is a federally funded entity that is managed through the Substance Abuse and Mental Health Services Administration. It supports suicide preventionwto advance the National Strategy for Suicide. Funding for the toolkit came from a grant from the Western Interstate Commission for Higher Education (WICHE) Center for Rural Mental Health Research.
The kit is available at www.sprc.org/pctoolkit/index.asp