Article

Managing Suicide Risk in Primary Care: Practice Recommendations for Behavioral Health Consultants

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Abstract

Psychologists working in primary care clinics can have a significant positive impact on preventing suicide. For psychologists working within the behavioral health consultant (BHC) model in primary care, however, the issue of how to appropriately manage suicide risk within this model has yet to be adequately addressed. Given the time-limited and focused nature of the BHC model, it is important to establish a framework for psychologists to provide adequate care that is practical within this model of health care. This article offers 26 empirically supported recommendations for suicide screening, accurate and time-efficient risk assessment, and effective risk management strategies, as well as suggestions for consultation with primary care physicians, all of which are consistent with the BHC model. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

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... Two common misconceptions about suicide risk assessment and management are that (a) they must intrinsically be lengthy or time-consuming, and (b) they can only be accomplished by a behavioral health provider (Bryan, Corso, Neal-Walden, & Rudd, 2009). However, judicious use of screening measures and deliberate sequencing of clinical questioning to prioritize those clinical factors most robustly linked to suicidal behaviors can maximize accuracy in a practical length of time Bryan & Rudd, 2011). ...
... For instance, past suicidal behaviors and objective indicators of suicidal intent (e.g., specificity of plan, access to lethal means, opportunity to act) are much stronger predictors of future suicidal behavior and therefore should be emphasized relative to other common suicide risk factors (see Figure 1; cf. Bryan, Corso, et al., 2009;. Similarly, algorithms that tie risk assessment to management interventions, such as the flowchart displayed in Figure 2, can save time, increase reliability of clinical decisions, and improve practice risk management. ...
... Such team approaches are not only becoming more common in primary care (i.e., the PCMH), but are particularly important in cases where tertiary behavioral health care is indicated but not yet accessed. The case of Jayne illustrates a real-world case whereby outpatient behavioral health care that is focused on the reduction of risk for suicidal behaviors was most appropriate (e.g., Bryan, Corso, et al., 2009;Bryan & Rudd, 2011), but the primary care team nonetheless had to continue monitoring and managing Jayne's risk during the transfer of care. Managing suicide using a chronic disease management model in primary care settings was essential to this success and is important for behavioral health consultants and PCPs practicing in the PCMH. ...
Article
Primary care is a critical setting for suicide prevention because it is often the first and only source of mental health care for the U.S. general population. It is also important because suicidal patients report a greater number of somatic complaints and make more frequent medical visits compared to nonsuicidal patients. Models for managing suicide within primary care have recently arisen, yet no models have been proposed for use within the patient-centered medical home (PCMH), a primary care model that integrates behavioral health into its practice. The authors suggest a chronic disease model for the management of suicide risk in the PCMH along with collaborative strategies that may include suicide screening and targeted assessment, warm hand-offs, cognitive-behavioral interventions, routine collaborative medication management, and means restriction counseling. The current paper advises how those within the PCMH can adapt and implement evidence-based practices to manage suicide. Finally, the authors discuss a case example illustrating these evidence-based and collaborative methods.
... Department of Veterans Affairs & U.S. Department of Defense, 2013). Patients at low acute risk for suicide may be within an IBHC's scope of care, but should be offered a referral to specialty mental health (Bryan et al., 2009;U.S. Air Force, 2014). ...
... Correct decision making regarding a possible referral is critical, as it has been found that suicidal patients presenting to primary care providers have been referred to specialty mental health services in only about one third of cases (Hepner et al., 2007). One possible explanation for this is the difficulty in identifying appropriate thresholds for referral (Bryan et al., 2009). When patients refuse a referral to specialty mental health care, bridging care can be provided by the IBHC, but "the primary goal in such cases is to address barriers to accepting the referral for specialty mental health treatment and facilitating the patient's movement into that level of care" (U.S. Navy, 2013). ...
... If this occurs, the provider is then faced with decisions regarding the particulars of treatment. Bryan, Corso, Neal-Walden, and Rudd (2009) noted the "ambiguity of the appropriate management of suicidal patients within the IBHC model, which can lead to inconsistencies in clinical care" (p. 149). ...
Article
Internal Behavioral Health Consultants (IBHCs) in primary care settings are on the frontline of suicide risk assessment, management, and treatment within military healthcare. In this capacity, IBHCs must quickly determine the following: (1) the patient's suicide risk level; (2) the treatment setting most suitable for the patient; and (3) brief intervention strategies appropriate to the primary care setting. The decisions required of IBHCs by Department of Defense healthcare policies are considered. Two prominent historical methods of medical decision making are reviewed, and these models are applied to the treatment of suicidal patients in military primary care settings.
... In the management of patients threatening suicide in our protocol, verbal intervention is the basis of treatment in line with other protocols [21,47]. As in previous studies, it has been seen that many suicide threats are in fact a kind of protest against the conditions. ...
... Available and requesting a change and requesting assistance. Empathy and empathy for the patient's condition and, if necessary, intervention in the crisis can be very helpful [47] Respect for the patient is very important and behaviors that induce the patient to be a failure or a sinner should be avoided. Attitudes that send the patient the message that "he does not know what is right?" ...
Article
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Background Suicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in the treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation. Method We reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks. Results The basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient (behavioral and pharmacological) management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered. Conclusion A locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians.
... In the management of patients threatening suicide in our protocol, verbal intervention is the basis of treatment in line with other protocols (25,26). ...
... Available and requesting a change and requesting assistance. Empathy and empathy for the patient's condition and, if necessary, intervention in the crisis can be very helpful (26)Respect for the patient is very important and behaviors that induce the patient to be a failure or a sinner should be avoided. Attitudes that send the patient the message that "he does not know what is right?" ...
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Background: Suicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation. Method: We reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks. Results: The basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient (behavioral and pharmacological) management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered. Conclusion: A locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians.
... A significant infrastructure was developed to implement the suicide screening process at NEUSH, including updated policies and procedures, for maintenance of patient safety, a clinical response protocol for patient screening positive at different levels of risk, an electronic version of the C-SSRS Screener inserted in the "Clin-Doc" electronic nursing record for administration by the primary nurse (embedded in the initial nursing assessment for all admissions), and a systematic education process for all nurses and consultation psychiatrists (C-SSRS Screener, full C-SSRS, and the clinical protocol). The clinical response protocol that was developed in association with the implementation of systematic suicide screening was consistent with recommendations by Dr. Posner and supported by the robust predictive findings regarding ideation severity of 4 and 5 and suicidal behavior predicting short-term risk of suicidal behavior [43,44] (See Appendix 1, Figure 1 for the scale and response protocol). ...
... The protocol developed by the NEUSH was also consistent with many empirically based recommendations for managing suicide risk in primary care. [43] This study reports on the feasibility and initial outcomes of systematic screening. Inherent limitations, given its real-world setting, include lack of concurrent measures for external validity; limited numbers of consultation patients not rated with the full C-SSRS; and the typical challenges (particularly clinician variability) around adherence to a systematic practice in a clinical setting. ...
Article
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Background: Suicide is one of the leading causes of death across all age groups globally and poses a significant public health burden. In response to the United States Joint Commission National Patient Safety Goals, a tertiary hospital in the Northeast U.S. developed a suicide risk assessment and response protocol, consisting of systematic screening of patients for suicidal ideation/behavior with a screening version of the Columbia Suicide Severity Rating Scale (C‑SSRS) and a response algorithm based on risk levels derived from the screen. Methods: A total of 837 nurses were trained and 24,168 patients ages 12 and above were screened with the C‑SSRS Screener. Results: Posttraining interrater reliability on the C‑SSRS Screener definitions of ideation and behavior was high and independent of level of education or mental health experience. Of the patients screened, only 144 patients (0.93%) were in the highest risk category, and they were assigned patient safety monitors until a follow‑up consultation. The highest risk levels from the C‑SSRS Screener reasonably identified subsequent attempts at self‑injurious behavior during hospitalization. Screening resulted in lower burden due to reduction in the rate of psychiatric consultations and one‑to‑one observation shifts. Conclusions: These findings suggest that a systematic screening and clinical response protocol using the C‑SSRS Screener can potentially enhance the ability to identify suicide risk in the general hospital population and focus services on patients with the most need. Open Access of article can be found at: http://www.worldsocpsychiatry.org/text.asp?2020/2/1/31/281135
... Both fatherhood and motherhood (Cantor & Slater, 1995;Conejero et al., 2016;Qin et al., 2003) were associated with a reduced risk of suicidal behavior. Suicidal individuals who are able to identify reasons for living are significantly less likely to engage in selfinjurious behavior (Bryan, Corso, Neal-Walden, & Rudd, 2009;Harris, McLean, Sheffield, & Jobes, 2010). Children may provide an important incentive for living. ...
... These results also support ongoing efforts to screen returning members for risk, improve the referral process for service members with alcohol problems, and strengthen the services available to families (Department of Defense Task Force on Mental Health, 2007;Milliken, Auchterlonie, & Hoge, 2007). Improving access to care, providing services in nonstigmatization locations (Bryan et al., 2009;Seal, Bertenthal, Miner, Sen, & Marmar, 2007;Zamorski, 2011), and using programs that change social norms about help-seeking may also aid suicide prevention efforts across the military (Hoge et al., 2004;Knox et al., 2003). ...
Article
Objective: Differentiating suicide attempters from suicide ideators has been named a critical suicidology frontier (Klonsky & May, 2013). Per Bronfenbrenner's (1977, 1994) ecological systems theory, risk/protective factors from four ecological levels (individual, family, workplace, and community) were used to predict last year suicide attempt status among active duty service members expressing suicide ideation. Method: Active duty U.S. Air Force members (N = 52,780, 79.3% male, 79.2% non-Hispanic White, M age = 31.8 years) anonymously completed an online community assessment administered biennially at 82 bases worldwide. Last year suicide ideation and attempts were concurrently measured, as were an array of co-occurring risk and protective factors. Results: Among the 1,927 (approximately 4%) service members self-reporting suicidal ideation, 152 also reported a last year suicide attempt (7.9% of the ideators, 8.7% of men vs. 6.1% of women). However, in multivariate models, military member sex was not a significant moderator. In bivariate models, numerous individual, family/spouse/parent, and community factors were associated with suicide attempt status. In the final multivariate model for the whole sample, risk for a last year attempt was associated with years in the military, social support, and alcohol use problems, but not depression. Among active duty military in relationships, attempt status risk was associated with years in the military, social support, and intimate partner violence victimization. However, the effect sizes for these models were small. Conclusions: Beyond a focus on depression, addressing alcohol misuse, facilitating resilient and nonviolent couple/family relationships, and increasing social support may enhance suicide attempt prevention efforts among military members. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... Seventy-five percent of victims have had contact with their primary care physician in the year preceding suicide and 45% have had contact within the month (Luoma, Pearson, & Martin, 2002). Involvement of a psychologist in the treatment of a patient considering suicide may provide assistance in assessing, monitoring, and appropriately referring a suicidal patient to inpatient care if needed (Bryan, Neal-Walden, Corso, & Rudd, 2009). The treatment of anxiety, phobias, and panic disorders has also been shown to benefit from collaboration between physicians and mental health practitioners (Lang, Norman, & Casmar, 2006). ...
... While many forms of collaboration exist, the traditional referral to counseling is the most common form of collaboration and typically involves the physician sending the patient to the psychologist for management of a problem (McDaniel, 1995). Previous research has illuminated numerous barriers commonly engrained in the referral system (Barsa, Toner, Gurland, & Latigua, 1986; Bray, Enright, & Rogers, 1997; Clark, Linville, & Rosen, 2009; Crane, 1986; Freeling & Kissel, 1988; Kainz, 2002; Koening, 2007; Kushner, Diamond, Beasley, Mundt, Plane, & Robbins, 2001; Marvel, Doherty, & Baird, 1993; McDaniel, 1995; McElheran, Eaton, Rupcich, Basinger, & Johnson, 2004; Miller, Hall, & Hunley, 2004; Pereira & Smith, 2004; Tai-Seale, McGuire, Colenda, Rosen, & Cook, 2007), as well as the benefits to patients when referrals are provided and followed (Barsa, Toner, Gurland, & Lantigua, 1986; Bray & Rogers, 1995; Bryan, Neal-Walden, Corso, & Rudd, 2009; Enright & Blue, 1989; Katon et al., 2002; Knight & Houseman, 2008; Koening, 2006; Lang, Norman, & Casmar, 2006; Luoma, Pearson, & Martin, 2002; Roy-Byrne et al., 2005; Segal, Kennedy, & Cohen, 2001; Unutzer et al., 2002). Despite the known benefits of collaboration and the challenges inherent in the referral process, few studies have attempted to clarify the counseling referral process. ...
Article
The advantages to collaborative care between physicians and mental health care providers have been known for many decades. Rural primary care physicians (RPCPs) are the first professionals that most patients contact when they have a mental health concern, particularly in rural communities. It is therefore important to understand the process that occurs when a referral for counseling is made from a RPCP and the subsequent collaboration that occurs. The purpose of this qualitative study was to generate a model that provides a better understanding of the counseling referral process from the perspective of RPCPs in private practice in the Midwest. A grounded theory approach was used to analyze the data obtained through semi-structured interviews with twelve RPCPs and to construct a model that explains the process that RPCPs engage in when making counseling referrals. The Counseling Referral Evolution emerged from the interviews containing nine categories including: Perceived Mental Health Expertise of Physicians, Relationships with Mental Health Providers, Understanding of Counseling, Mental Health Complaint or Diagnosis, Referral Decisions, Method of Referral, Schedule Follow-up, Outcome, and Barriers. Additionally, the RPCPs suggested improvements for better collaboration between mental health practitioners and primary care physicians. Implications for mental health practitioners and primary care physicians are discussed.
... Often times, the first contact a suicidal patient has with a clinician will be their only contact with that particular clinician. Despite receiving considerable attention and discussion in practice guidelines, textbooks, and training curricula (Bryan, Corso, Neal-Walden, & Rudd, 2009;Bryan & Rudd, 2010;Jobes, 2006;Rudd, Joiner, & Rajab, 2004;Schmitz et al., 2012;Shea, 2002;Stanley & Brown, 2012;Suicide Prevention Resource Center, n.d.), interpersonal dynamics with acutely suicidal patients have received virtually no empirical attention. In the absence of such investigation, recommendations about effective clinical strategies are largely based on opinion and anecdote. ...
... The association of emotional bonding with affective dysregulation during the risk assessment interview aligns with clinical observations that suicidal patients are often "closed off" during suicide risk assessments but are more likely to be expressive and emotionally engaged when clinicians express warmth and understanding, thereby conveying a sense of safety (Bryan & Rudd, 2006;Jobes, 2006;Shea, 2002). When patients are emotionally aroused, however, warmth, empathy, and perceived safety may conversely serve to emotionally deactivate the patient (Bryan et al., 2009;Jobes, 2006;Shea, 2002). To our knowledge, no prior studies examining the correlation of synchrony with emotional bonding (and other related constructs) have explicitly considered regulatory and/or dysregulatory processes. ...
Article
Objective: To determine if synchrony in emotional arousal and affective regulation between patients and clinicians reflect emotional bonding during emergency behavioral health appointments. Method: Audio recordings of suicide risk assessment interviews and crisis intervention planning with 54 suicidal active duty soldiers presenting to an emergency department or behavioral health clinic were analyzed. Emotional arousal was assessed using mean fundamental frequency. Patient-rated emotional bond was assessed with the Working Alliance Inventory, Short Form (Hatcher & Gillaspy, 2014). Actor-partner interdependence modeling was used to identify moment-to-moment patterns of covariance among clinician and patient emotional arousal. Results: Greater synchrony in clinician and patient emotional arousal was positively associated with higher emotional bond ratings during the crisis intervention but not the risk assessment interview. During the risk assessment interview, higher emotional bond was associated with a dysregulating effect of the clinician on the patient's emotional arousal (i.e., larger fluctuations in the patient's emotional arousal). The reverse pattern was seen during the intervention: Higher emotional bond was associated with a regulating effect of the clinician on the patient's emotional arousal (i.e., smaller fluctuations in the patient's emotional arousal). Emotional bond during the intervention was also positively associated with a regulating effect of the patient on the clinician's emotional arousal. Conclusion: Emotional bonding during emergency clinical encounters is associated with patient-clinician synchrony in emotional states. During crisis interventions, emotional bonding is also associated with mutual down-regulation of emotional arousal among patients and clinicians. (PsycINFO Database Record
... As proof, thoughts of death are listed among diagnostic criteria for depression in the Diagnostic and Statistical Manual (4th ed., text rev.; American Psychiatric Association, 2000), much clinical literature is devoted to assessing and preventing suicide (e.g., Bryan, Corso, Neal-Walden, & Rudd, 2009;Cukrowicz, Wingate, Driscoll, & Joiner, 2004;Kleespies & Dettmer, 2000;Wingate, Joiner, Walker, Rudd, & Jobes, 2004), and numerous organizations (i.e., American Association of Suicidology, American Foundation for Suicide Prevention, and International Association for Suicide Prevention) are committed to preventing suicide (Silverman, 2000). Furthermore, the implication that suicidal ideation indicates incapacitating pathology extends into the legal arena and is used to justify involuntary commitment and mental health treatment (Sullivan et al., 1998). ...
Article
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Physician assisted suicide (PAS) poses complex legal and ethical dilemmas for practicing psychologists. Since the passage of the Oregon Death with Dignity Act in 1997, Montana and Washington have passed similar legislation. Despite the law requiring competence evaluations by medical and psychological professionals, existing psycholegal literature inadequately addresses the role of psychologists in the PAS process. This article reviews legal statutes and analyzes ethical dilemmas psychologists may face if involved. We consider competence both generally and in the context of PAS. Suggestions are made for psychologists completing competence assessments and future directions to improve competence assessments for PAS are provided.
... 27 Further, given the present findings, it may be prudent to make oneself familiar with recommendations for treating suicide risk. 28 Such treatment plans have been more successful than no-suicide contracts in preventing suicidal behaviours. 29 What is clear, given the present data, is that depression/suicide screening should be a standard domain in patient evaluations. ...
Article
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Introduction: We sought to evaluate psychosocial factors as predictors of suicidal ideation (SI) in a tertiary care outpatient sample of women suffering from interstitial cystitis/bladder pain syndrome (IC/BPS). Methods: The patients are women managed at tertiary care centres (n=190). Controls were recruited from the community (n=117). Both groups completed questionnaires on demographics, pain (McGill Pain Questionnaire), IC/BPS symptoms, and psychological variables. Univariate and multivariate hierarchical regression modelling was conducted to examine the strength of associations and unique effects of psychosocial variables on patient SI. Results: Compared to 6% in healthy controls, 23% of patients endorsed SI in the past two weeks. Correlations between SI, depression, and catastrophizing across controls and cases show that for controls, SI is associated with greater pain (0.31; p<0.01) and depression only (0.59; p<0.01). For tertiary care centre cases, SI is associated with pain (0.24; p<0.01), depression (0.64; p<0.01), and catastrophizing (0.35; p<0.01). Regression analyses indicated that psychosocial variables accounted for a significant amount of variance over and above IC/BPS symptoms. Catastrophizing (i.e., helplessness) about pain and depression were significant univariate predictors of SI, but only depression predicted SI in multivariable analyses. Conclusions: Limitations of this study include its cross-sectional design and primarily correlation-based statistics. The present study is the first to implicate multiple psychosocial risk factors over and above IC/BPS-specific symptoms and patient pain experience in SI in women with IC/BPS. Depression in particular is uniquely important in predicting suicidality. These results support a multidisciplinary, proactive approach to IC/BPS involving not only treatment of disease symptoms, but also early detection/treatment of associated psychosocial problems.
... Target areas are most germane to serious head injuries, and include the development and promotion of compensatory cognitive strategies and emotional coping skills, enhancing access to and use of substance abuse services and general behavioral healthcare, increasing patient insight into symptoms and personal limitations, teaching patients to separate themselves from specific problems that may be due to TBI (impaired memory, for example), addressing feelings of burdensomeness , and reinforcing protective supports, such as spirituality, family, and a sense of personal meaning. As in other populations, explicit safety planning is recommended according to risk level and individuals at acute risk may warrant inpatient hospitalization for psychiatric stabilization (Bryan et al., 2009 ...
Article
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Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.
... Initial screening for suicidal ideation in PC may also sometimes take place via measures associated with depression (e.g., PHQ-9 item #9, BDI-II item #9). Positive screens must be followed up with more thorough assessment (e.g., see Bryan, Corso, Neal-Warden, & Rudd, 2009, for a thorough overview). ...
... An independent screen, such as the 5-item Paykel questionnaire, can also be used to probe for suicidal ideation and attempts over the past year (Paykel, Myers, Lindenthal, & Tanner, 1974). If these items are positive, the clinician must focus attention to further evaluating these areas (Bryan, Corso, Neal-Walden, & Rudd, 2009;LeFevre, 2014). For example, if the patient reports feeling hopeless, the next step of assessment might include items specifically addressing this domain (e.g., Beck Hopelessness Scale). ...
Article
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Full implementation of the patient-centered medical home requires the identification and treatment of patients with behavioral health concerns, leading to improved patient outcomes and reduced health care costs. Measurement-based care (MBC) for mental health conditions is an essential step in achieving these goals. Integrated primary care (IPC) administrators and providers are key leaders in MBC that spans initial screening for conditions to monitoring clinical outcomes over time. The purpose of this article is to assist IPC leaders, in partnership with their primary care team, in developing standard operating procedures for screening and follow up evaluations in order to lay a foundation for assessing program outcomes and improving quality of care in their unique settings.
... Despite growing interest in integrated care, studies examining the effectiveness of brief interventions for suicidal ideation delivered by BHCs in integrated primary care are lacking. Whereas the prevailing recommendation is that suicidal patients should be connected with specialty mental health services when suicide risk is identified (Bryan, Corso, Neal-Walden, & Rudd, 2009), some argue patients at mild risk for suicide can be effectively managed in primary care through PCP-BHC collaboration (Schulberg, Bruce, Lee, Williams, & Dietrich, 2004). Recommended approaches to suicide prevention in primary care include PCP education, improved screening, and indirect management of suicide risk through treatment of depression (McDowell, Lineberry, & Bostwick, 2011). ...
Article
Objective: We examined whether brief behavioral health visits reduced suicidal and self-harm ideation among primary care patients and compared the effectiveness of interventions that targeted ideation directly (i.e., safety planning) with those that targeted ideation indirectly through management of underlying mental illness (e.g., behavioral activation). Method: We examined first- and last-visit data from 31 primary care patients with suicidal or self-harm ideation seen by behavioral health consultants. Results: Patients reported significantly lower frequencies of suicidal and self-harm ideation at their final visit than at their initial visit. Patients whose ideation was targeted directly showed greater improvements than patients whose ideation was targeted indirectly. Discussion: Although preliminary, results suggest mild to moderate suicidal ideation could be addressed in primary care through integration of behavioral health consultants into the medical team. (PsycINFO Database Record
... Despite the probable link between anxiety and suicide risk, anxiety is often overlooked during suicide risk assessment in primary care. The focus tends to be on MDD and other mood disorders (23), and identification of risk often occurs through depression screening (24). For example, the VHA conducts universal screening in primary care patients, with follow-up suicide risk assessments based on positive screens for MDD and PTSD, but does not screen for any anxiety disorders (25). ...
Article
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Background: Although anxiety is prevalent in primary care, the association between anxiety symptoms and suicide risk remains understudied. Objectives: This cross-sectional study aimed to (i) assess the prevalence of suicide risk among Veteran primary care patients with anxiety symptoms and (ii) compare suicide risk between patients with a positive (versus negative) depression screen. Methods: Participants were 182 adult primary care patients (84.6% male, Mage = 58.3 years) with current anxiety symptoms, but no psychotherapy in specialty care in the past year, at a Veterans Health Administration medical center in New York. Participants completed self-report measures of anxiety, depression and suicide risk via telephone. Results: Forty percent endorsed ≥1 suicide risk item. Suicide risk was more common among those screening positive (versus negative) for depression (50.5% versus 26.5%, χ2 (1) = 10.88; P = 0.001). Participants with a negative depression screen constituted 31% of all those with any suicide risk. Logistic regression revealed that anxiety symptom severity was not associated with suicide risk (P = 0.14) after controlling for age, sex and depression screen status (P = 0.01). Conclusions: A substantial proportion of primary care patients with anxiety was classified as at risk for suicide, even in the absence of a positive depression screen. Primary care providers should assess suicide risk among patients with anxiety symptoms, even if the patients are not seeking specialty mental health treatment, the anxiety symptoms are not severe or do not rise to the level of an anxiety disorder, and comorbid depressive symptoms are not present.
... A conceptual "cousin" of the SPI is the "Crisis Response Plan" (CRP), which was first developed by Rudd, Joiner, and Rajab [25] and further elaborated and rigorously studied by Bryan and colleagues [26][27][28][29][30]. The CRP has the patient note on an index card, in their own written words, various triggers, coping strategies, resources, and oftentimes their reasons for living. ...
Article
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While the existence of mental illness has been documented for centuries, the understanding and treatment of such illnesses has evolved considerably over time. Ritual exorcisms and locking mentally ill patients in asylums have been fundamentally replaced by the use of psychotropic medications and evidence-based psychological practices. Yet the historic roots of mental health management and care has left a certain legacy. With regard to suicidal risk, the authors argue that suicidal patients are by definition seen as mentally ill and out of control, which demands hospitalization and the treatment of the mental disorder (often using a medication-only approach). Notably, however, the evidence for inpatient care and a medication-only approach for suicidal risk is either limited or totally lacking. Thus, the “one-size-fits-all” approach to treating suicidal risk needs to be re-considered in lieu of the evolving evidence base. To this end, the authors highlight a series of evidence-based considerations for suicide-focused clinical care, culminating in a stepped care public health model for optimal clinical of suicidal risk that is cost-effective, least-restrictive, and evidence-based.
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Integrated primary care research in the Patient-Centered Medical Home (PCMH) presents unique challenges not found in other behavioral health or medical care settings. The PCMH service delivery principles and supporting systems are designed to maximize quality and outcomes of care while controlling health care costs. Conducting ethical research in this setting requires following processes and procedures established by federal statutes that threaten to disrupt this delicate balance. In addition, clinical researchers must consider the ethical requirements and guidance from their respective professional organizations to ensure they adhere to guidelines for conducting ethical research and practice. Given the setting, there is a high likelihood researchers from various disciplines who may adhere to different ethical standards will be collaborating. We present a case example of an ethical concern to illustrate the tension between research and clinical care, discuss federal and professional research guidelines, and propose recommendations for balancing ethical and effective research and clinical care in integrated primary care research in the PCMH. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
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Approximately 20% of the two million troops who have deployed to Iraq and Afghanistan may require treatment for posttraumatic stress disorder (PTSD). We review treatment outcome studies on individual outpatient therapy for military-related PTSD, and consider the extent to which veterans initiate and complete available PTSD treatments. We conclude with considerations for future research.
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Posttraumatic stress disorder (PTSD) is common in primary care but it is frequently not detected or treated adequately. There is insufficient evidence to recommend universal screening for PTSD in primary care, but clinicians should remain alert to PTSD among patients exposed to trauma, and among those with other psychiatric disorders, irritable bowel syndrome, multiple somatic symptoms and chronic pain. A two-stage process of screening (involving the PC-PTSD), and, for those with a positive screen, a diagnostic evaluation (using the PTSD-Checklist), can detect most patients with PTSD with few false positives. Evidence-based recommendations are provided for treatment in primary care or referral to mental health.
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Active duty veterans increasingly access primary care for needed mental health services, but the relationship among depression, PTSD, and suicidal ideation in this subpopulation remains unclear. The relationship is explored in 120 active duty members treated in a military integrated primary care behavioral health service. Logistic regression analyses resulted in a significant relationship between PTSD and suicidal ideation, but this relationship was fully explained by depression symptoms. The interaction between depression and PTSD symptoms was likewise unrelated to suicidal ideation, and it did not improve overall model fit, suggesting that depression independently explained increased risk for suicidal ideation in the current sample. The authors discuss the differences between suicidal ideation and suicidal behaviors, and how depression and PTSD symptoms might differentially relate to each. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Posttraumatic stress disorder (PTSD) is common among Veterans Affairs (VA) primary care patients and may be managed via multiple treatment pathways. Using the Behavioral Model of Health Service Use (Anderson, 1995), this retrospective study based on medical chart review examined factors associated with three types of mental health treatment: intervention by a 1) primary care provider (PCP), 2) primary care-mental health integration (PC-MHI) provider, and 3) specialty mental health (SMH) provider. A second goal was to describe PTSD treatment services for patients not receiving SMH by detailing the content of mental health treatment provided by PCPs and PC-MHI providers. Electronic medical record data for a five year time period for 133 Veterans were randomly selected for review from a population 6,637 primary care patients with PTSD. Results indicated that the evaluated needs of participants (i.e., number of unique medical and psychiatric disorders) were associated with Veterans receiving more intensive services (i.e., SMH). PCPs commonly addressed patients' mental health concerns, but patients often declined referrals for mental health treatment. PC-MHI consultations most often focused on medication management and supportive psychotherapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The study presents early findings from an ongoing pilot study of a cognitive–behavioral treatment for assisting active-duty military members with deployment-related posttraumatic stress disorder (PTSD) designed for use by psychologists working in an integrated primary care clinic. Treatment protocol is based primarily on Prolonged Exposure but also includes elements of Cognitive Processing Therapy that were adapted for use in primary care. Individuals were recruited from the population of patients consulted to the psychologist by primary care providers during routine clinical care. The 15 participants include active-duty or activated reserve Operation Iraqi Freedom and Operation Enduring Freedom veterans seeking help for deployment-related PTSD symptoms, with a PTSD Checklist-Military Version score 32, and interest in treatment for PTSD in primary care. Baseline and 1-month posttreatment follow-up evaluations were conducted by an independent evaluator. Five participants (33%) dropped out of the intervention after one or two appointments. Using the last observation carried forward for intent-to-treat analyses, the results showed that PTSD severity, depression, and global mental health functioning all significantly improved with the intervention. Fifty percent of treatment completers no longer met criteria for PTSD. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Abstract: Little information about suicidal ideation and behavior in long-term care (LTC) facilities is available. Nonetheless, the implementation of the Minimum Data Set 3.0 requires that LTC facilities screen their residents for suicide risk and have protocols in place to effectively manage residents’ responses. In this article, the authors briefly discuss the risk factors of suicide in the elderly and the problems that suicidal ideation and behavior pose in the LTC environment. The authors explain issues that arise when trying to manage suicide risk in the elderly LTC population with general, traditional approaches. These inherent issues make it difficult to develop an effective protocol for managing suicide risk in LTC facilities, leading the authors to propose their own framework for assessing and managing suicide risk in the LTC setting.
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The primary aim of the current study was to obtain information about the longitudinal clinical functioning of primary care patients who had received care from behavioral health consultants (BHCs) integrated into a large family medicine clinic. Global mental health functioning was measured with the 20-item self-report Behavioral Health Measure (BHM), which was completed by patients at all appointments with the BHC. The BHM was then mailed to 664 patients 1.5 to 3 years after receipt of intervention from BHCs in primary care, of which 70 (10.5%) were completed and returned (62.9% female; mean age 43.1 ± 12.7 years; 48.6% Caucasian, 12.9% African American, 21.4% Hispanic/Latino, 2.9% Asian/Pacific Islander, 10.0% Other, 4.3% no response). Mixed effects modeling revealed that patients improved from their first to last BHC appointment, with gains being maintained an average of 2 years after intervention. Patterns of results remained significant even when accounting for the receipt of additional mental health treatment subsequent to BHC intervention. Findings suggest that clinical gains achieved by this subset of primary care patients that were associated with brief BHC intervention were maintained approximately 2 years after the final appointment.
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There is a clear relationship between suicide risk and chronic pain conditions. However, the exact nature of this link has been poorly understood, with risk attribution often limited to comorbid depression. Perceived burdensomeness has already been confirmed as a risk factor for suicidal ideation (SI) and suicide attempt in the general population. Self-perceived burden, studied among medically and terminally ill medical populations, has begun to receive a great deal of attention as a suicide risk factor. However, this risk has not been considered in an outpatient chronic pain population, a group likely to experience perceived burdensomeness as a particular problem. Guidelines recommend routine suicide risk screening in medical settings, but many questionnaires are time-consuming and do not allow for the assessment of the presence of newly identified risk constructs, such as perceived burdensomeness. This retrospective study examined the relationship between depression, perceived burdensomeness, and SI in a patient sample seeking behavioral treatment for chronic pain management. A logistic regression model was developed, with preliminary results indicating perceived burdensomeness was the sole predictor of SI, even in the presence of other well-established risk factors such as age, gender, depressive symptoms, and pain severity. Findings highlight the potential utility of a single-item screening question in routine clinical care as an incrementally superior predictor of SI in a chronic pain population.
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To evaluate critically whether treatment models existed in the literature to treat a soldier with multiple psychiatric and other comorbidities and propose a mental health model consisting of an integrated multidisciplinary treatment team for use in military outpatient settings. A case example was described to demonstrate the complexity of presentation including depression, anxiety, insomnia, post-traumatic stress disorder, chronic pain, substance abuse, relationship problems, and suicide attempts. Literature search was conducted for the period 2004-2009. Articles that referred to collaborative/integrated care were examined in detail. Seven articles described collaborative care. Of these, five described collaboration with only primary care and 2 with other specialties including pain, substance abuse, and vocational rehabilitation services. Most articles gave a broader description of the collaborative model. Some postulated a theoretical framework. One described collaborative care in detail but was coordinated by only one professional. None described integration of providers involved in the patient's care. The process of implementation was not sufficiently described. Because of limitations in the published literature, a mental health model consisting of a multidisciplinary integrated treatment team is proposed to treat the soldiers in the military outpatient setting.
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The current study investigated therapeutic alliance and clinical improvement within an integrated primary care behavioral health model. Participants included 542 primary care patients seen in two large family medicine clinics. Mental health symptoms and functioning were assessed using the 20-item Behavioral Health Measure (Kopta & Lowery, 2002) at the beginning of each patient appointment. Therapeutic alliance was measured with the Therapeutic Bond Scale (CelestHealth Solutions, 2008) following an initial appointment with one of 22 behavioral health consultants (BHCs). Primary care patients rated their therapeutic alliance following a first appointment with a BHC as statistically stronger than alliance ratings from a previously reported sample of outpatient psychotherapy patients after the second, third, and fourth psychotherapy sessions (Kopta, Saunders, Lutz, Kadison, & Hirsch, 2009). Results of a bootstrapped linear regression analysis indicated that therapeutic alliance assessed after the first primary care behavioral health appointment was not associated with eventual clinical change in mental health symptoms and functioning. A strong therapeutic alliance was able to be formed in a primary care behavioral health modality. This exceeded the magnitude found in outpatient psychotherapy alliance ratings. Early therapeutic alliance was unrelated to overall clinical improvement in primary care.
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Suicide is the third leading cause of death in college students, but there is limited consensual evidence to guide clinicians' assessment and management of suicide. The aim of the current study was to assess the capability of a simple and practical measure, the Beck Depression Inventory (BDI) suicide item, to identify college students at high risk of suicide. Exploration of this research question could have important implications in this vulnerable population for identifying those at risk for suicide. Six-hundred-and-fifty-seven college students participated in a mental health screening and completed the BDI and the Suicidal Behaviors Questionnaire-Revised (SBQ-R), which is a detailed measure of suicide risk. We dichotomized the BDI suicide item, which measures suicidal ideation within the past week (presence vs. absence of suicidal ideation) as well as the SBQ-R total score (low vs. high risk of suicide). We computed the kappa statistic for the examination of agreement between these two measures. The kappa coefficient for the BDI suicide item and the SBQ-R was 0.57 for dichotomized scores. The BDI suicide item had a positive predictive value of 74 %, and a negative predictive value of 93 %. In a hierarchical linear regression, the BDI suicide item alone significantly predicted elevated scores on the SBQ-R [Chi square (1) = 128.427, p < 0.001]. These results suggest that affirmative responses on the single BDI suicide item indicate elevated suicide risk. However this single item screening approach will miss some at-risk students.
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The Behavioral Health Measure (BHM) is a brief self-report measure of general psychological distress and functioning developed for the tracking of mental health outcomes in outpatient psychotherapy settings (Kopta & Lowry, 2002). Although the BHM is used in integrated primary care behavioral health clinics, the scale's psychometric properties have not been evaluated in these settings. The current study investigated the BHM's psychometric properties, including its factor structure and reliability, and presents normative data from 3 large integrated primary care clinics. Mean scores for each of the BHM's 4 scales were significantly lower (i.e., more distress) for women than men, with scores being stable across the 3 primary care samples. Confirmatory factor analysis demonstrated adequate fit for the 3-factor and 1-factor models, with fit improving when 3 items were omitted. Internal consistency estimates for the BHM's 4 scales ranged from adequate to very good (α range: .72-.93). The 4 scales were highly intercorrelated, suggesting they measure similar constructs. Results suggest a revised, 17-item version of the BHM has adequate structure and reliability estimates, and is appropriate for use in primary care settings. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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This study is the first to evaluate evidence for measurement invariance and the psychometric properties of the Suicide Resilience Inventory-25 (SRI-25; Osman et al., ) in college-age samples in both the United States and China. We found strong support for full measurement invariance of the three-factor structure of the SRI-25 in the U.S. (113 men and 238 women) and Chinese (121 men and 205 women) samples. In addition, we found that the U.S. sample scored significantly higher than the Chinese sample on all the individual scale scores. Composite scale reliability estimates ranged from moderate (ρ = .83) to high (ρ = .93) across the groups. Although not an aim of the current study, we examined estimates of internal consistency of the SRI-25 scales for men and women within each sample. Differential correlates of the SRI-25 scales were explored further for each sample. These results provide support for the use of the SRI-25 in U.S. and Chinese student samples.
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University health centers provide an opportune setting in which psychology graduate students can obtain training in integrated primary care (IPC). The purpose of this article is to describe an advanced practicum experience for psychology doctoral students, who serve as integrated behavioral health providers (BHPs) in a university primary care clinic. First, we describe aspects of our IPC practicum, including planning and development; the theoretical model; implementation of behavioral health screening; structure of patient visits; use of evidence-based practice; management of risky patients; communication with specialty mental health and primary care providers (PCPs); issues related to practicum eligibility, training, and supervision; evaluations; and program maintenance. Then we report on characteristics of 347 patients seen by BHPs over 3 semesters; the most common reasons for referral were sleep, depression, and anxiety. Lastly, we surveyed 7 graduate students who completed the practicum to obtain their views on aspects of the training experience; students reported that they developed new skills and would recommend the practicum to others. Our experience suggests that an IPC practicum in a university health center has the potential to benefit psychology graduate students, primary care providers (PCPs), and patients. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Article
Little is known about general practitioners' (GPs') perspectives, management of and interactions with suicidal patients prior to the patient's suicide. The aims of the study were to explore GPs' interpretations of patient communication and treatment in primary care leading up to suicide and to investigate the relationship between GPs and mental health services prior to a patient's suicide. Thirty-nine semi-structured interviews with GPs of people who had died by suicide were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using a thematic approach. The following themes emerged from GP interviews: (i) GP interpretations of suicide attempts or self-harm; (ii) professional isolation; and (iii) GP responsibilities versus patient autonomy. GPs recruited for the study may have different views from GPs who have never experienced a patient suicide or who have experienced the death of a patient by suicide who was not under the care of specialist services. Our findings may not be representative of the rest of the United Kingdom, although many of the issues identified are likely to apply across services. This study highlighted the following recommendations for future suicide prevention in general practice: increasing GP awareness of suicide-related issues and improving training and risk assessment skills; removing barriers to accessing therapies and treatments needed in primary care; improving liaison and collaboration between services to provide better patient outcomes; and increasing awareness in primary care about why patients may not want treatments offered by focusing on each individual's situational context. © 2015 John Wiley & Sons Ltd.
Article
The current study examined demographic, psychosocial, and substance use factors associated with distinct patterns of past 12-month suicide thoughts, plans, and attempts among adolescents drawn from a nationally representative sample of high schoolers. Data were from the 2015, 2017, and 2019 National Youth Risk Behavior Survey. Four mutually exclusive 12-month suicidal behavior patterns were identified: suicide thoughts only (pattern 1), suicide thoughts and plans without suicide attempt (pattern 2), suicide attempt with thoughts and/or plans (pattern 3), and suicide attempt without thoughts or plans (pattern 4). Multinomial logistic regression analyses were conducted to examine factors correlated with these distinct patterns. Psychosocial and substance use factors were modeled as independent predictors, controlling for demographic characteristics, as well as simultaneously to represent the potential for co-occurrence. The analytic sample included 7491 respondents. About 24% (n = 1734) of youth endorsed pattern 1, 38% (n = 2779) pattern 2, 35% (n = 2716) pattern 3, and 3% (n = 262) pattern 4. All psychosocial and substance use factors measured were individually associated with greater odds of suicide attempts with thoughts or plans (pattern 3) than patterns 1 or 2. Black and male youth were at greater odds of suicide attempts without thoughts or plans (pattern 4) than all other patterns. When modeled simultaneously, respondents who were bullied online, sad or hopeless, had a history of sexual violence, used cigarettes, and misused prescription opiates retained greater odds of suicide attempts with thoughts or plans (pattern 3) than patterns 1 or 2. Findings suggest screening for suicidal behaviors should include factors that differentiate between varying suicidal expressions and that may cue providers to intervene in the absence of suicide thoughts and plans.
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Purpose – The purpose of this paper is to fully consider the potential changes in clinical suicide prevention that may evolve after the passing of the Patient Protection and Affordable Care Act (ACA). The authors argue that it is wise to anticipate demand for suicide-specific evidence-based treatments (EBTs) moving forward. The authors outline current best practices in clinical suicide prevention, and describe the Collaborative Assessment and Management of Suicidality (CAMS) as an example of how a suicide-focussed EBT can adapt to some predicted changes. Design/methodology/approach – This conceptual paper first presents an overview of the main effects of ACA within the behavioral health care (BHC) system. Next, the authors review contemporary approaches to the treatment of suicidal patients, as well as current treatment limitations. The authors present CAMS as a model of a suicide-focussed EBT that holds promise for use in the post-ACA era. To close, the authors discuss anticipated changes in suicide treatment and illustrate that CAMS is adaptable to these changes. Findings – ACA mandates several changes: implementation of EBTs, better preventative care, integrated treatment models, and improved healthcare administration. A central effect of ACA in BHC is the increased use of EBTs. Therefore effective EBTs for suicide prevention are described. Originality/value – Anticipating how ACA will affect clinical suicide prevention is necessary, as it is historically a very challenging area of treatment within BHC and a significant public health concern. This paper highlights the importance of the use suicide-specific EBTs.
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Whereas the first edition focused mainly on ethical reasoning and decision making, this new edition draws more explicitly on all components of James Rest's model of moral/ethical behavior, including moral/ethical sensitivity, moral/ethical decision making, moral/ethical motivation, and the ego strength to follow through on the decision.
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The wars in Iraq and Afghanistan are producing a new generation of veterans at risk for the chronic mental health problems that result, in part, from exposure to the stress, adversity, and trauma of war-zone experiences. Military returnees are experiencing posttraumatic stress disorder (PTSD) and other mental health problems in numbers not seen since the war in Vietnam. Beyond the treatment efforts offered by the Veterans Administration, other rehabilitation and mental health providers will be needed to provide ongoing services. The intent of this article is to focus on the symptomatology and treatment approaches related to PTSD. Although most military personnel returning from deployments will readjust successfully, a significant number of soldiers will exhibit PTSD or some other psychiatric disorders. Qualified professionals are and will be required to work with this population.
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Treating suicidality is one of the most challenging situations managed by college and university counseling centers. The first edition of Bongar’s (1991) The Suicidal Patient: Clinical and Legal Standards of Care, a compendium of empirical knowledge and clinical research regarding standard of care in the treatment of suicidality, was soon considered a valuable resource in the field. The volume was pivotal in the arena of clinical practice because, in addition to compiling state of the art information, it also positioned itself as a benchmark for determining whether standard of care has been met in treatment of suicidal people. Now in its third edition (Bongar & Sullivan, 2013), this resource continues to inform clinical practice. This article examines several noteworthy changes across the three editions of this seminal work. What has changed, possible trends suggested by the changes, and resulting implications of these changes are examined. Of particular importance are changes that represent significant developments in the field or make relatively new assertions of what constitutes sound practice. These trends, changes, and assertions regarding standard of care are discussed in terms of their relevance to the counseling center setting. In the third edition there are several instances in which Bongar and Sullivan (2013) clearly extended beyond reporting observations about clinical practice and arguably moved into the realm of attempting to set norms for standard of care. Even though these new assertions may essentially be the authors’ opinions, they may be treated as fact by regulators, expert witnesses, attorneys, and others in determining whether standard of care has been met in specific cases.
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The increase in service member and veteran suicides within the military has garnered considerable attention over the past decade, especially once the rate of military members surpassed that of demographically-matched civilians. Dr. Peter J. N. Linnerooth, a former Army and Department of Veterans Affairs psychologist, was concerned about Service Member and Veteran suicide and wrote this paper prior to his own tragic suicide in 2013.In honor of Dr. Linnerooth's memory, this paper was updated by former friends, colleagues, and peers to review in detail the problem of suicide in the military including issues related to epidemiology, assessment, treatment, and potential causal factors.
Chapter
The goal of the following chapter is to serve as a primer on suicidality presenting in primary care and how integrated care can support improvements in practice. The state of current screening and treatment for suicidality within primary care will be reviewed, including current training of primary care providers and needed areas of additional training and support. The ways in which integrated care can be utilized to improve practice in primary care as related to suicidality will be addressed, and a brief overview of the Primary Care Behavioral Health (PCBH) model will be provided. Finally, the specifics of the PCBH program in which the authors practice will be discussed as an example of how care is provided in a Federally Qualified Health Center.
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Posttraumatic Stress Disorder (PTSD) is common among primary care patients and is associated with significant functional impairment, physical health concerns, and mental health comorbidities. Significant barriers to receiving adequate treatment often exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. While good PTSD screening and assessment measures are available for the primary care setting, there are currently no empirically supported primary care-based brief interventions for PTSD. This article reviews early research on the development and testing of primary care-based PTSD treatments and also reviews other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Cognitive and behavioral therapies currently have the strongest evidence base for establishing an empirically supported brief intervention for PTSD in primary care. Recommendations are made for future research and clinical practice.
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The health care system in the United States, plagued by spiraling costs, unequal access, and uneven quality, can find its best chance of improving the health of the population through the improvement of behavioral health services. It is in this area that the largest potential payoff in reduction of morbidity and mortality and increased cost-effectiveness of care can be found. A review of the evidence shows that many forms of behavioral health services, particularly when delivered as part of primary medical care, can be central to such an improvement. The evidence supports many but not all behavioral health services when delivered in settings in which people will accept these services under particular administrative and fiscal structures. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The psychometric properties of the Scale for Suicide Ideation—Current (SSI-C; Beck, Kovacs & Weissman, 1979, Journal of Consulting and Clinical Psychology, 47, 343–352) and the Scale for Suicide Ideation—Worst (SSI-W; Beck, Brown, Steer, Dahlsgaard & Grisham, 1997, in press) were explored. These 19-item clinician-administered scales measure current suicide ideation (SSI-C) as well as suicide ideation at its worst point in the patient's life (SSI-W). For a sample of 4063 outpatients, both scales were positively correlated with a diagnosis of a principal mood disorder, a diagnosis of a personality disorder, and measures of depression and hopelessness. The relationship between the SSI-W and a history of suicide attempts was stronger (r = 0.50, P < 0.001) than the relationship between the SSI-C and previous suicide attempts (r = 0.31, P < 0.001). For 444 current and 1764 past suicide ideators, the SSI-C and the SSI-W had high internal consistencies (coefficient αs = 0.84 and 0.89, respectively). The SSI-C and the SSI-W were moderatedly correlated with each other (r = 0.51, P < 0.001). Iterated maximum-likelihood principal-factor analyses identified comparable Preparation and Motivation dimensions underlying both scales.
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Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play. A systematic review of the literature. Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up to 9% may commit suicide within one day of discharge. The corresponding figures are 11 and 4% for community-based psychiatric care and 83 and 20% for general practitioners. Among those who die by suicide, contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.
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Excessive mortality of suicide attempters has emerged from many follow-up studies. Completed suicide is the main cause of excess deaths, but the increased risk of deaths from other unnatural and natural causes is also of major public health concern. We lack follow-up studies of the different causes of death in cohorts of suicide attempters. The present study aimed to determine the mortality by suicide and other causes of death and to investigate risk factors. This mean 5.3-year follow-up study was based on an unselected cohort of suicide attempts by both violent and non-violent methods, treated in hospitals in a well-defined urban catchment area in Helsinki. In total, 2782 patients aged 15 years and over admitted to the emergency rooms after suicide attempt between 1989 and 1996 were included in the follow-up analysis. Standardised mortality ratios (SMR) for suicide, disease, accident, homicide, and undetermined death were calculated. Mortality from all causes was 15 times higher than that expected among men and nine times higher in women. SMRs in men were 5402 (95% CI 4339-6412) for suicide, 2480 (95% CI 925-4835) for homicide, and 11,139 (95% CI 6884-16,680) for undetermined cause, and for women 7682 (95% CI 5423-9585), 3763 (95% CI 52-5880) and 15,681 (95% CI 6894-22,294), respectively. Fifteen percent of all suicide attempters died during the average 5.3-year follow-up of the index attempt. Deaths from suicide accounted for 37% of all excess deaths in men and 44% in women. The mortality ratio was highest during the 1st follow-up year. The total number of lost years of life among the 413 suicide attempters who died during follow-up was 13,883. The risk factors for all causes of death were male sex, single, retirement, drug overdose as a method, an index attempt not involving alcohol, and a repeated attempt. A suicide attempt indicates a severe risk of premature death, and suicide is the main cause of excess deaths. However, it appears that concentrating efficient treatment only on the most suicidal patients could prevent no more than two of five premature deaths. More effort is therefore needed to prevent the excess mortality of suicide attempters by also addressing causes of death other than suicide.
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There are few firm data to guide the clinician in identifying individual depressed patients who may be at high risk for completing suicide. In particular, there have been few prospective studies of well-characterized depressed patients to determine indicators of such future events. Eight hundred thirteen patients with a major depressive episode (DSM-III, DSM-III-R, or DSM-IV criteria) were assessed in detail in a specialist Mood Disorders Unit (MDU) over a 10-year period. Follow-up at the end of that period (mean = 5.1 years) confirmed that 31 patients (3.8%) had completed suicide. The suicide completers were compared on a broad range of clinical and demographic variables obtained at baseline with (1) the total remaining depressed sample, (2) 31 age- and sex-matched subjects who were confirmed to be alive and had never attempted suicide, and (3) 24 age- and sex-matched living subjects who had made at least 1 suicide attempt. The most consistent finding, across all 3 comparisons, was that the suicide completers were more likely to have been inpatients at the time of the index MDU assessment. Other characteristics of completers were a greater number of prior admissions for depression, being older and in a relationship, and being male and married or female and single. Somewhat paradoxically, suicide completers also evidenced fewer previous suicide attempts and less suicidal ideation compared with living subjects who had attempted suicide at the time of index assessment. Overall, we were able to find few predictors of later suicide in this sample. Those who completed suicide demonstrated evidence of more severe illness over a lifetime (for example, having more admissions). but revealed less suicidal ideation at the time of the index MDU assessment. While these features were statistically significant, they are of limited usefulness in predicting suicide in an individual patient.
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This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide. The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects. Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults. While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.
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Few depressed older adults receive effective treatment in primary care settings. To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. Randomized controlled trial with recruitment from July 1999 to August 2001. Eighteen primary care clinics from 8 health care organizations in 5 states. A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care. Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life. At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group. The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.
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Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings. To evaluate the effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices. Randomized controlled trial conducted between 1999 and 2003 enrolling 418 primary care patients with current depressive symptoms, aged 13 through 21 years, from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States. Usual care (n = 207) or 6-month quality improvement intervention (n = 211) including expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients' depression, training for care managers in manualized cognitive-behavior therapy for depression, and patient and clinician choice regarding treatment modality. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment. Depressive symptoms assessed by Center for Epidemiological Studies-Depression Scale (CES-D) score. Secondary outcomes were mental health-related quality of life assessed by Mental Health Summary Score (MCS-12) and satisfaction with mental health care assessed using a 5-point scale. Six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (mean [SD] CES-D scores, 19.0 [11.9] vs 21.4 [13.1]; P = .02), higher mental health-related quality of life (mean [SD] MCS-12 scores, 44.6 [11.3] vs 42.8 [12.9]; P = .03), and greater satisfaction with mental health care (mean [SD] scores, 3.8 [0.9] vs 3.5 [1.0]; P = .004). Intervention patients also reported significantly higher rates of mental health care (32.1% vs 17.2%, P<.001) and psychotherapy or counseling (32.0% vs 21.2%, P = .007). A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.
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T. E. Joiner's (2004, in press) theory of suicidal behavior suggests that past suicidal behavior plays an important role in future suicidality. However, the mechanism by which this risk is transferred and the causal implications have not been well studied. The current study provides evaluation of the nature and limits of this relationship across 4 populations, with varying degrees of suicidal behavior. Across settings, age groups, and impairment levels, the association between past suicidal behavior and current suicidal symptoms held, even when controlling for strong covariates like hopelessness and symptoms of various Axis I and II syndromes. Results provide additional support for the importance of past suicidality as a substantive risk factor for later suicidal behavior.
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This study attempted to assess whether an index of the difference between the wish to die and the wish to live constitutes a risk factor for suicide. A study group of 5,814 patients, including 44 who committed suicide (0.8%), were recruited from a psychiatric outpatient clinic. Structured diagnostic interviews and clinician ratings of the wish to live and wish to die were conducted. The outcome variable was the occurrence of suicide, as indicated on death certificates. A dichotomized index score of the difference between the wish to live and the wish to die yielded a hazard ratio of 6.51 for suicide. This index contributed a unique risk for suicide after the authors controlled for age, psychiatric hospitalization, suicide attempts, bipolar disorder, major depressive disorder, and unemployment status. The difference between the wish to die versus the wish to live is a unique risk factor for suicide.
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We investigated the prevalence, severity, and course of passive and active suicidal ideation occurring in primary care patients with an uncomplicated depressive disorder. We studied suicidal ideation experienced by patients recruited in 60 primary care practices participating in a randomized controlled trial of depression management. Risk levels associated with suicidal ideation and plans were determined by a 2-stage procedure using pertinent items of the Patient Health Questionnaire-9, the Hopkins Symptom Checklist-20, and the Cornell structured assessment interview and management algorithm. Of the 761 patients whom physicians judged in need of treatment for a clinical depression, 405 (53%) were experiencing uncomplicated dysthymia, major depression, or both. Among these depressed patients, about 90% had no risk or a low risk of self-harm based on the presence and nature of suicidal ideation; the rest had an intermediate risk. Almost all patients who were initially classified at the no or low risk levels remained at these levels during the subsequent 6 months. The incidence of suicidal ideation at a risk level requiring the physician's immediate attention in this no- or low-risk subgroup was 1.1% at 3 months and 2.6% at 6 months. Almost all patients with uncomplicated dysthymia, major depression, or both acknowledging suicidal ideation of the minimal risk type when initially assessed maintained this minimal risk status during the subsequent 6 months.
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In late 2006, a U.S. Food and Drug Administration advisory committee recommended that the 2004 black box warning regarding suicidality in pediatric patients receiving antidepressants be extended to include young adults. This study examined the relationship between antidepressant treatment and suicide attempts in adult patients in the Veterans Administration health care system. The authors analyzed data on 226,866 veterans who received a diagnosis of depression in 2003 or 2004, had at least 6 months of follow-up, and had no history of depression from 2000 to 2002. Suicide attempt rates overall as well as before and after initiation of antidepressant therapy were compared for patients who received selective serotonin reuptake inhibitors (SSRIs), new-generation non-serotonergic-specific (non-SSRI) antidepressants (bupropion, mirtazapine, nefazodone, and venlafaxine), tricyclic antidepressants, or no antidepressant. Age group analyses were also performed. Suicide attempt rates were lower among patients who were treated with antidepressants than among those who were not, with a statistically significant odds ratio for SSRIs and tricyclics. For SSRIs versus no antidepressant, this effect was significant in all adult age groups. Suicide attempt rates were also higher prior to treatment than after the start of treatment, with a significant relative risk for SSRIs and for non-SSRIs. For SSRIs, this effect was seen in all adult age groups and was significant in all but the 18-25 group. These findings suggest that SSRI treatment has a protective effect in all adult age groups. They do not support the hypothesis that SSRI treatment places patients at greater risk of suicide.
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Individuals with a differing number of past suicide attempts are generally considered a homogeneous group, despite emerging evidence to the contrary. The current study aimed to test the hypothesis that multiple suicide attempters would exhibit a more severe clinical profile than single suicide attempters. A series of self-report batteries and clinical interviews was administered to 39 single attempters and 114 multiple attempters who came to an urban hospital emergency room after a suicide attempt. The participants were predominantly poor and nonwhite. Multiple suicide attempters versus single attempters exhibited a greater degree of deleterious background characteristics (e.g., a history of childhood emotional abuse, a history of family suicide), increased psychopathology (e.g., depression, substance abuse), higher levels of suicidality (e.g., ideation), and poorer interpersonal functioning. Profile differences existed even after control for borderline personality disorder. Results indicate that multiple attempters display more severe psychopathology, suicidality, and interpersonal difficulties and are more likely to have histories of deleterious background characteristics than single attempters. Moreover, these differences cannot be explained by the diagnosis of borderline personality disorder. Results suggest that the identification of attempt status is a simple, yet powerful, means of gauging levels of risk and psychopathology.
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Objective: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. Measurements: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. Results: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. Conclusion: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
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It is now well accepted that the assessment, management, and treatment of suicidality in clinical practice is one of the most challenging and stressful tasks for any clinician (Jobes, 1995). The literature in suicidology routinely differentiates among treatment, treatment outcome, and risk assessment (e.g., Rudd, Joiner, & Rajab, 2000), with no clear theoretical link across the three areas. Additionally, there has been limited work addressing content versus process issues in each area specific to suicide risk assessment. The current theory being offered focuses specifically on the risk assessment process, not treatment outcome. Furthermore, its focus is not on the specific content of risk assessment (i.e., what questions to ask across what content domains). A considerable amount is known about the content of risk assessment (e.g., Rudd et al., 2000). This is a fairly significant departure from the routine in suicidology, but it is one I believe to be important for a number of reasons that are emphasized in this chapter. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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There exists a very large and growing demand for behavioral health care, and all too often the responsibility for such care falls not on mental health clinics but on primary care clinics. The mental health professions have been slow to respond to this problem, but an emerging and promising strategy has been to improve collaboration between mental health and primary care by integrating the two services. This book provides practical advice to those interested in integrating primary care and behavioral health services. The authors describe a specific model, the Primary Care Behavioral Health (PCBH) model, that they believe offers a great deal of promise for improving both mental and physical health outcomes. In doing so, they hope to contribute to the standardization of primary care behavioral health integration efforts. The PCBH model is in widespread use around the USA, but has never before been detailed in a book. The model represents a radically different approach to treating behavioral problems, relative to the traditional specialty mental health model. It is also dramatically different from other approaches to integration. Scientific literature is reviewed in some parts and cited as needed, but this work is first and foremost a "nuts and bolts" guide for behavioral health providers who want to work in primary care and for the administrators who seek to hire them. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Provides practical guidance to psychologists and psychology students working or considering working in a primary care setting. The authors begin with an overview of clinical health psychology in primary care that includes a review of several models for integrating into a medical practice, a discussion of the differences between specialty health psychology services and primary care health psychology services, and a listing of skills necessary for success in the primary care setting. Chapter 2 is devoted to suggestions for establishing and maintaining a clinical health psychology practice in the primary care setting. The subsequent chapters are devoted to common health complaints and diseases seen in primary care, and the collaborative role a clinical health psychologist can play in managing these patients within the primary care setting. The chapters on diabetes, hypertension, cardiovascular disease, asthma, acute and chronic pain, insomnia, obesity, and gastrointestinal disorders begin with a description of the conditions and their common medical treatments to help psychologists work collaboratively and in an informed manner with physician colleagues. The book concludes with a discussion of future trends and opportunities in health psychology and integrated primary care. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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"The Practical Art of Suicide Assessment" is a concise guidebook on how to assess suicidal risk no matter how complicated the clinical presentation. The text contains sample questions, effective strategies, case histories, and excerpts from actual suicide assessments. Dr. Shea helps the reader understand the complex inner worlds of both the client contemplating suicide and the clinician trying to prevent it, showing how these worlds invariably interact with and change one another. Dr. Shea highlights the elusive nature of suicidal ideation and demonstrates the current limitations of prediction. Through examination of the etiology and phenomenology of suicide, the author explains how to recognize its many faces, enhancing the interviewer's ability to uncover danger that others might miss. This book focuses on the art of eliciting suicidal ideation, introducing an interviewing strategy to determine lethal risk—the Chronological Assessment of Suicide Events (the CASE approach). An actual clinical transcript of the CASE approach is included. In addition, Dr. Shea also explores critical issues such as contradictory data, client deceit, clinician burnout, the role of corroborative sources of information, and forensic liability. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Emerging research has provided empirical support for a number of cognitive-behavioral strategies designed to reduce suicidal behaviors. In this case study of "John," I describe the application of a combination of these strategies in treating a suicidal patient who recently returned from stressful military duty in Iraq. Focusing on assisting the patient to develop problem-solving and distress tolerance skills, treatment was centered in a collaborative model emphasizing the importance of the therapeutic relationship and involvement of social support networks. Interventions were guided by continual monitoring of suicidal symptoms and general distress level using standardized outcome measures, including Lambert's Outcome Questionnaire (OQ-45) and Jobes' Suicide Status Form (SSF). The treatment involved 21 sessions and resulted in eventual resolution of the suicidal crisis and in significantly reduced emotional distress.
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A state dependence model of serial behavior suggests that each occurrence increases the subsequent likelihood of that behavior being repeated. A heterogeneity model, by contrast, suggests that the likelihood of a behavior occurring is predetermined, and uninfluenced by intervening occurrences. We have applied the random-effects probit model of Gibbons and Bock (1987) to examine the fit of the state dependence and heterogeneity models to longitudinal data on suicide attempts by 928 patients with affective disorder. Heterogeneity but not state dependence was required to model these data. The findings suggest that when considering patients with moderate to severe major affective disorder, the clinician should not interpret the absence of any recent suicide attempts to mean that the patient is at relatively low risk for attempting suicide in the future. An implication of the heterogeneity model is that suicide attempts made many years ago may have equal value to recent attempts when estimating an individual's "predisposition" to nonlethal attempts in the future.
Article
An exploratory analysis of the Suicide Intent Scale was performed on a sample of 98 psychiatric inpatients who had made suicide attempts. The factor analysis was performed using a method for polychotomous data, and resulted in a two-factor solution. The Lethal Intent factor contained items pertaining to the subjective level of lethal intent, while the Planning factor contained items largely related to objective planning for the attempt. Preliminary analysis of these factors suggest that the Suicide Intent Scale can be used to evaluate two separate aspects of suicidal behavior.
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This study evaluated the effectiveness of a time-limited, outpatient intervention targeting suicidal young adults. Participants (N = 264) were randomly assigned to either the experimental treatment or the control condition (i.e., treatment as usual). In addition to intake assessments, participants completed follow-ups at 1, 6, 12, 18, and 24 months. Both treatment and control participants evidenced significant improvement across all outcome measures throughout the follow-up period. Reductions were reported in suicidal ideation and behavior, associated symptomatology, and experienced stress, along with marked improvement in self-appraised problem-solving ability. Results also indicated that the experimental treatment was more effective than treatment as usual at retaining the highest risk participants. Available data demonstrate the efficacy of a time-limited, outpatient intervention for suicidal young adults. Implications of current findings for intervention with and treatment of this population are discussed.
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The authors conducted the 1st large-sample factor-analytic study of the Modified Scale for Suicidal Ideation (MSSI; I. W. Miller, W. H. Norman, S. B. Bishop, & M. G. Dow, 1986) on a sample of 330 suicidal young adults. Factor analyses revealed 2 MSSI factors: Suicidal Desire and Ideation (ongoing thoughts or desires about suicide) and Resolved Plans and Preparation (intense thoughts, plans, and courage and capability to commit suicide). The Resolved Plans and Preparation factor was more related to Attempt versus Ideator status than was the Suicidal Desire and Ideation factor. The Suicidal Desire and Ideation factor was more highly related to depressotypic indicators than was the other factor, suggesting that level of depression, although predictive of ideation, may not be as strong a correlate of preparation. Comparison of depression- and anxiety-related diagnostic groups on the MSSI factors revealed little difference, consistent with previous work highlighting the occurrence of suicidality across diagnostic groups. These findings have implications for the structure of suicidality, as well as its clinical assessment.
Article
To examine risk for suicide attempts among 180 consecutively referred adolescents during the first 5 years after discharge from an inpatient psychiatry unit. In a prospective naturalistic study, adolescents were assessed at psychiatric hospitalization and semiannually thereafter for up to 5 years with semistructured psychiatric diagnostic interviews and self-report questionnaires. Approximately 25% of the adolescents attempted suicide and no adolescents completed suicide within the first 5 years after discharge. The first 6 months to 1 year after discharge represented the period of highest risk. The number of prior attempts was the strongest predictor of posthospitalization attempts. Affective disorders by themselves did not predict later suicide attempts but were related to posthospitalization attempts when accompanied by a history of past suicide attempts. Independent of psychiatric diagnoses, severity of depressive symptoms and trait anxiety also predicted suicide attempts. Similar to the effect with affective disorders, depressive symptoms were most strongly related to posthospitalization suicidality among adolescents with a prior history of suicide attempts. Particularly among youths with prior suicidal behavior, clinicians should be alert to the above constellation of psychiatric predictors of posthospitalization suicidal behavior.
Article
Among 440 psychiatric outpatients with current suicidal ideation, we examined the empirical distinction between the "plans" vs. "desire" dimensions of suicidality, focusing for conceptual and empirical reasons on a worst-point assessment strategy. Factor analyses were consistent with the distinction, but more importantly, among the current ideators included in this study, the worst-point "plans" dimension was the only predictor significantly related to both of two important indices, history of past attempt and eventual suicide. These findings bear on the trajectory of suicidal behavior over time, as well as inform the clinical assessment of suicidal patients.
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The response of ethnic minorities to mental health care is largely unstudied. To determine the effect of appropriate care for depression on ethnic minorities. Observational analysis of the effects of evidence-based depression care over 6 months on clinical outcomes and employment status is examined for ethnic minorities and nonminorities. Selection into treatment is accounted for using instrumental variables techniques, with randomized assignment to the quality improvement intervention as the identifying instrument. Six managed care organizations across the United States. Patients One thousand three hundred fifty-six depressed adults, including 601 white, 258 Latino, 56 African American, and 24 Asian or Native American patients. Intervention Quality improvement interventions aimed at increasing guideline-concordant depression care. At 6 months, minority patients who received appropriate care, compared with those who did not receive it, had lower rates of probable depressive disorder (20.5% vs 70.5%); the findings were similar for nonminority patients (24.3% vs 71.2%). Nonminority patients who received appropriate care were found to have higher rates of employment than were those who did not receive appropriate care (71.4% vs 52.4%). This was not true of minority patients (68.2% vs 56.5%). Evidence-based care for depression is equally effective in reducing depressive disorders for minority and nonminority patients. However, functional outcomes of care, such as continued employment, may be more limited for minority than nonminority patients. Because minority members are less likely to get appropriate care, efforts should be made to engage minority members in effective care for depression.
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The purpose of this article is to approach topics in suicide risk assessment from a scientifically informed standpoint. We summarize and elaborate a general framework for an empirically supported best practice recommendation in evaluating suicide potential and minimizing risk. This risk assessment framework provides a concise heuristic for assessment of suicidal symptoms, points the way to relatively routinized clinical decision-making and activity, and is compatible with best practices relevant to the legalities of suicide risk assessment. Having established a general and scientifically based framework for risk assessment, we go on to address the other questions noted above, with reference to the framework and to our ongoing scientific work. We conclude by summarizing all the work and providing clear and concise clinical recommendations based thereon.
Article
Suicide is a critical public health problem that primary care physicians potentially can help address given that distressed patients frequently visit them in the weeks and months preceding the successful suicide. This article considers factors placing the patient at high risk for successful suicide and clinical assessment techniques available to the primary care physician. Patients who wish to harm themselves but still lack an articulated plan for doing so can be treated by the primary care physician with the monitoring assistance of a depression care manager and appropriate consultation by a mental health specialist.
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This article reviews the literature on the use of "no-suicide contracts" in clinical practice, including conceptual discussions, patient and clinician surveys, and a few empirical studies on clinical utility. Our primary conclusion is that no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness in the clinical environment. The authors provide and illustrate the commitment to treatment statement as a practice alternative to the no-suicide contract.
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Worldwide, almost a million people die by suicide each year. Intentional, nonfatal, self-inflicted injury, including both suicide attempts and acts without suicide intent, also has very high prevalence. This article provides a practice-friendly review of controlled studies of psychosocial treatments aiming to prevent suicide, attempted suicide, and nonsuicidal self-inflicted injuries. Despite relatively small sample sizes for a low-base-rate outcome such as self-inflicted injury, several psychotherapies have been found effective, including cognitive therapy, dialectical behavior therapy, problem-solving therapy, and interpersonal psychotherapy, as well as outreach interventions, such as sending caring letters. The clinical implications of the review are discussed with the goal of translating the science to service-particularly the importance of outreach and treatment of non-compliance, the assessment and management of suicide risk, and competency in effective psychotherapies. These are critical steps for clinical psychology and psychotherapists to take in their role in suicide prevention.
Article
After regulatory agencies in the United Kingdom and United States recommended severe restrictions on antidepressant use in children, many lessons were learned, although one was not that these drugs cause suicide. We learned that pharmaceutical companies selectively released data that reflected positively on their products and that combining suppressed and published data suggested that most of these medications had questionable efficacy. We also learned that the studies lacked uniformity both in which age groups constituted children and which behavior was considered suicidal. Several recent, large nonindustry studies indicated that rates of suicide and suicidal behavior were actually reduced in children who used antidepressants, despite piteous anecdotal tales in the popular press purporting that selective serotonin reuptake inhibitors (SSRIs) caused children to kill themselves. Patients in pharmaceutical trials probably do not represent typical patients in routine clinical practice. Emerging implications are that suicidal behavior-if it does occur-is most likely soon after starting antidepressant use and that prescribers must be both vigilant in educating patients and families about warning signs and available to manage worrisome behavior.
Article
This article reviews and integrates empirically grounded advances in the assessment of suicidality. The practices discussed are consistent with existing standards of care, practice guidelines, and applicable research. The authors differentiate between risk assessment and prediction and then emphasize the important role of time in risk assessment. We present and illustrate a continuum of suicidality for risk assessment and offer practical recommendations for clinical decision making and treatment.
Article
Given that suicidality is a well-known symptom and outcome of untreated or inadequately treated depressive illness, the United States (US) Food and Drug Administration (FDA) warning of emergent suicidality in children and adolescents based on the antidepressant arm of placebo-controlled randomized trials (RCTs) has created understandable concern in clinical practice. The issues involved are of broader public health importance for all age groups. As in other branches of medicine, psychiatrists must always be vigilant of the rare risk of iatrogenesis when prescribing potent agents like antidepressants for patients with depressive disorders where the risk of suicidality is inherent. The overall evidence we review suggests that the widespread use of antidepressants in the new “SSRI-era” appear to have actually led to highly significant decline in suicide rates in most countries with traditionally high baseline suicide rates. The decline is particularly striking for women who, compared with men, seek more help for depression. Recent clinical data on large samples in the US too have revealed a protective effect of antidepressant against suicide.
To evaluate the effect of UK and US warnings placed in response to reports of suicidal thinking in pediatric patients receiving selective serotonin reuptake inhibitor and selective norepinephrine reuptake inhibitor antidepressants on antidepressant prescribing for children and adolescents. Interrupted time-series analysis of antidepressant prescriptions. Tennessee's Medicaid program, January 1, 2002, through September 30, 2005. A mean of 405,000 children and adolescents aged 2 to 17 years qualified each month. Main Exposure Piecewise linear regression models were used to estimate the cumulative effect of the warnings, which were considered the exposure of interest. Monthly proportions of study children and adolescents who were new users of antidepressants, had discontinuity in antidepressant use, or were users of other psychotropic drugs. During the 2 years preceding the UK warning, there was no trend in the monthly proportions of new antidepressant users, with 23 new users per 10 000 persons per month. This proportion subsequently decreased 33% (95% confidence interval, 23% to 41%; P < .001) by 21 months following the UK warning. The reduction was most pronounced for the nonfluoxetine selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors, where initiations decreased 54% (95% confidence interval, 46% to 62%; P < .001). In contrast, new users of fluoxetine increased 60% (95% confidence interval, 9% to 135%; P = .02). There was no increase in discontinuations of antidepressants, and there was no evidence of substitution of other psychotropic drugs. The regulatory warnings led to decreased use of antidepressants in children and adolescents, but the clinical and public health consequences of this change are unknown.
Article
This study compared the time patterns of suicide attempts among outpatients starting depression treatment with medication or psychotherapy. Outpatient claims from a prepaid health plan were used to identify new episodes of depression treatment beginning with an antidepressant prescription in primary care (N=70,368), an antidepressant prescription from a psychiatrist (N=7,297), or an initial psychotherapy visit (N=54,123). Outpatient and inpatient claims were used to identify suicide attempts or possible suicide attempts during the 90 days before and 180 days after the start of treatment. Overall incidence of suicide attempt was highest among patients receiving antidepressant prescriptions from psychiatrists (1,124 per 100,000), lower among those starting psychotherapy (778 per 100,000), and lowest among those receiving antidepressant prescriptions in primary care (301 per 100,000). The pattern of attempts over time was the same in all three groups: highest in the month before starting treatment, next highest in the month after starting treatment, and declining thereafter. Results were unchanged after eliminating patients receiving overlapping treatment with medication and psychotherapy. Overall incidence of suicide attempt was higher in adolescents and young adults, but the time pattern was the same across all three treatments. The pattern of suicide attempts before and after starting antidepressant treatment is not specific to medication. Differences between treatments and changes over time probably reflect referral patterns and the expected improvement in suicidal ideation after the start of treatment.
Preventive Services Task Force Screening to identify primary care patients who are at risk for suicide: Recommendations from the U.S. Preventive Services Task Force
U.S. Preventive Services Task Force. (2004). Screening to identify primary care patients who are at risk for suicide: Recommendations from the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140, I49.