Suicide attempts fall sharply after screening initiative during primary care visits

Key takeaways:

• Most individuals see PCPs in the year preceding death by suicide.
• Combining depression, substance use and suicide screening and connecting patients with counselors significantly reduced suicide attempts.

A study combining suicide care with depression and substance use care decreased suicide attempts after primary care visits, according to the results of research published in Annals of Internal Medicine.

Julie Angerhofer Richards, PhD, MPH, an assistant investigator with Kaiser Permanente Washington Health Research Institute, and colleagues wrote that, in the year preceding death, more than 75% of people who died by suicide saw a primary care provider.

“Therefore, primary care teams may have important opportunities to engage at-risk patients in early intervention efforts to prevent suicide attempts and deaths,” Richards, who is also an affiliate assistant professor at the University of Washington School of Public Health, and colleagues wrote.

The researchers conducted a stepped-wedge, cluster randomized implementation trial and evaluated the impact of an intervention integrating suicide care into primary care visits on 228,255 patients (615,511 visits) compared with 255,789 patients who experienced usual care (953,402 visits) at 19 practices in Washington state.

The intervention, which they wrote was designed to support suicide and depression care in combination with substance use care, included depression screening based on population, assessment of suicide risk and collaborative safety planning.

It involved the three-item Alcohol Use Disorders Identification Test-Consumption, the two-item Patient Health Questionnaire (PHQ-2) for depression, a question about frequency of illegal or nonmedical prescription drug use and a question about frequency of cannabis use, according to the study. When the PHQ-2 was positive, the PCP assessed depression symptoms with the PHQ-9. Then, for patients who reported thoughts about self-harm, PCPs offered a self-administered variation of the Columbia-Suicide Severity Rating Scale (C-SSRS).

If a patient said on the C-SSRS that they had planned for a suicide attempt in the last month, PCPs connected them with designated care team members for safety planning on the same day of the visit, the researchers wrote.

“Licensed independent clinical social workers, who had previously functioned as medical social workers doing case management, were trained to function as integrated mental health clinicians, specifically to prioritize engaging at-risk patients in safety planning, as well as provide short-term counseling and linkage to specialty mental health and substance use treatment,” Richards and colleagues wrote.

They found that the intervention led to a 25% reduction in the rate of suicide attempts that occurred 90 days after visiting a PCP.

Compared with the usual care group, the rate of safety planning trended higher among those in the intervention group (32.8 vs 38.3 per 10,000 patients; rate difference = 5.5; 95% CI, 2.3-8.7). Additionally, fewer suicide attempts within 90 days occurred among those in the intervention group compared with the usual care group (4.5 vs. 6 per 10,000 patients; rate difference = 1.5; 95% CI, 2.6-0.4).

“Strategies to improve suicide risk identification and mitigation in primary care implemented alongside a substance care program are effective in reducing suicide attempts,” Richards and colleagues wrote. “Future work might consider examining both the independent and bundled effects of clinical practices supporting care for depression, suicidality, alcohol, cannabis and other drug use.”