Guest post by Dr. COL (Ret) George Patrin, MD, member of CMHNetwork Advisory Council - In response to our recent post on an opportunity to provide feedback to NIMH on strategies to enhance suicide prevention efforts targeted at children and adolescents within emergency medicine department (ED) settings, where many individuals at high risk for suicide are seen.
The National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), and National Institute on Alcoholism and Alcohol Abuse (NIAAA) are all looking for a new strategy to enhance suicide prevention efforts targeted at children and adolescents within emergency medicine department (ED) settings? Certainly the ER is a place "where individuals at high risk for suicide" present. I understand our collective response needs to be in by Nov 9th. So important, and unheeded by mainstream medical leaders, is the need to address alcohol and other substance-use disorders in mental health care that is currently not integrated into the primary care settings. Equally important is addressing pain management in these same centers - no matter the cause, physical, mental, or spiritual. I worked in the Hennepin County Emergency System in Minneapolis, MN, as a Paramedic for 9 years before med school. I saw the devastation caused by ignoring these healthcare and societal components in the civilian sector and then as a Family Advocate in the military, especially their impact on suicide rates. It is gratifying that the organizers of this effort are emphasizing inclusion of family members who have experienced the fallout of our poor healthcare system up front. Addressing bullying, not only for suicidal youth, but also within the military ranks and in workplaces in our communities is equally timely. Certainly the pharmaceutical industry must become accountable in addressing overuse of medications that ultimately cause suicide without proper monitoring and timely follow-up.
While research is important to ensure we are reaching the end point with our efforts, I am exasperated that we keep repeating research that has already been done, overlooking and delaying programs already in place that are successful in reducing and even eliminating suicide. We continually put transformation on hold until the next round of research and pilot studies are completed. We can and must "reduce the burden of suicidality" now, without delay. "ED-SAFE" was done in 2009. A problem I have with that well-meant effort is the researchers overlooked the concept that the place to "evaluate for a feasible approach to identifying and intervening with adults at-risk for suicide" is within Primary Care settings first and foremost. They didn't tie and associate that research to the patient's primary care home base. We must look at "ED settings" as the patient's 'medical home' when they are there, and emphasize getting the patient seen by their Primary Provider, supported by Family and Friends, the main goal, rather than referred to mental health specialists. Suicide risk factors ("bread crumbs") have already been identified, over and over again, but for the most part, are ignored. Randi Jensen calls it the "Conspiracy of Denial" in her new book "Just Because You're Suicidal Doesn't Mean You're Crazy." We delegate yet more resources to additional research, looking for nuances in risk factors we have already identified. Rather, put resources into supporting program transformation in healthcare and school programs for "implementation of practical screening tools and procedures as well as interventions for children and adolescents." We have identified screening tools as well - why are we not universally screening for anxiety and depression, must less suicide, today? The ER, in crisis, is not the place to implement a screening tool. Get the patient to their Primary Care team to establish a safety need that decrease the need for ER crisis calls trying to get help. Yes, addressing mental health issues are "resource intensive," that's why the Primary Care Team needs to be integrated in the local ERs so holistic interventions can begin there, preventing the next ER visit and crisis. Agree - use of ER assets to address these issues isn't economical, because every ER visit generates one or two additional visits. Rather, staff the ER visit with Primary Care and Integrated Mental Health (with an on-call system) to make the visit more evidence-based for the given patient population.
"EDs are seeing increasing numbers of youth presenting for psychiatric and substance abuse reasons, with suicidal behavior included as a common presenting complaint," because access is an issue in Primary Care, coupled with the fact that when seen, continuity is not practiced. Everything is fee-for-service, band-aid care. We must address the cause of this "increase in demand." I do not believe we need more "empirically-based practices for suicide-specific screening;" rather, conduct depression and anxiety screens and include follow-on questions about suicide when they are positive. But these programs must take place in the primary care setting with a trusted primary care provider team. If we concentrate on identifying at risk youth in ERs, we place a barrier to getting needed care, because the patient must be referred back to primary care and then to mental health specialists. We still think the only "appropriate referral" is to a psychiatrist or psychologist rather than fixing access to Primary Care with integrated behavioral health colleagues who don't need a "referral" to be seen. The "recently revised U.S. National Strategy for Suicide Prevention (http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full_report-rev.pdf)" misses this point entirely, as did President Obama with his Executive Order to Address Mental Health in the Military. "Objective 9.6 to “Develop standardized protocols for use within emergency departments based on common clinical presentation to allow for more differentiated responses based on risk profiles and assessed clinical needs.”
In summary, if the "NIMH, NIDA, and NIAAA are truly seeking perspectives of (their) multiple stakeholders to ensure that the right questions are being addressed related to youth suicide prevention efforts within the ED setting," they need to invite two groups to the table - Primary Care Organizations (FP, Peds, IM, PNPs) and the end-users (Youth and Families). "Begin with the end in mind," ala Covey. Suicide prevention should not be the purview of the Mental Health Specialists. It belongs with prevention in Primary Care. These are the "Research Partnerships" needed to "Transform Services ... by broad scientific and public input."
This response has addressed the following requests -
1. Prioritizing current unanswered research questions for youth suicide prevention in ED settings (e.g., need for screening tools, risk stratification approaches, and/or practical interventions).
2. Discussion of what ED providers (as primary care stand-ins) should be screening for when assessing suicide risk in child/adolescent patients. (e.g., suicide related behaviors, impulsivity, depression, use of alcohol and other substances, other risk factors, etc.).
3. Discuss any existing reliable and valid screening instruments for ED providers (for use by ED nurses in particular) to assess suicide risk and/or related risk factors among youth.
4. The most appropriate approaches for further suicide risk evaluation to optimize appropriate discharge and referral efforts.
8. The patterns of service utilization post discharge from the ED with regard to referral adherence and/or later risk of attempt.
9. Practical, promising, and/or effective brief interventions that can take place in the ED to improve adherence to an appropriate referral after discharge. Interventions (in person, printed materials, electronic resources) that can facilitate continuity of care post discharge from the ED.
10. Interventions that can provide practical strategies to help community providers best serve high-risk youth referred from the ED.
We should all volunteer our services to be on the "scientific working groups (being) convened by the NIH and the National Action Alliance for Suicide Prevention." Send your responses to NIMHsuicideprevention@nih.gov. (Please include the Notice number NOT-MH-12-035 in the subject line)