Primary Care Intervention Might Reduce Suicide Attempts

Following the launch of an integrated suicide prevention program across Washington state, researchers observed a 25% drop in the rate of attempted suicides in secondary analysis of a randomized stepped-wedged trial.

Once a suicide screening and safety planning program was introduced to 19 primary care practices in the state, rates of safety planning within 14 days increased by a significant 14%, from 32.8 to 38.3 per 10,000 patient visits, Julie Angerhofer, PhD, MPH, of Kaiser Permanente Washington Health Research Institute in Seattle, and co-authors reported in the Annals of Internal Medicine.

Notably, suicide attempts within 90 days of a primary care visit fell from 6.0 to 4.5 per 10,000 patient visits, which was also significant for the intervention compared with usual care.

“We know that most people seek primary care prior to suicide attempts. So, we know that there are potentially a lot of opportunities for suicide prevention in that setting,” Angerhofer told MedPage Today.

Some health systems already screen for depression in primary care, but the findings suggest that going a step further to address suicidality in clinical practice could be potentially life-saving, Angerhofer said.

Given that suicide is fortunately “pretty rare,” researching suicide-related outcomes can be challenging, she said. For that reason, Angerhofer said she was surprised to see such a marked impact. To her knowledge, this is the first real-world experiment to demonstrate the effectiveness of this kind of suicide prevention work in primary care.

Some primary care teams expressed concerns about having the time and resources to address suicide during routine visits, Angerhofer said, but that’s where the team-based element of the program came in.

“Having integrated mental health specialists available for warm hand-offs was really integral to the whole design, because we don’t want it to be a box-checking exercise” without adequate follow-through, she said.

A patient may have visited the doctor planning to get a wart removed or some other non-mental health-related issue. But if thoughts of suicide in the last month are noted during screening, then that becomes the primary issue — one for which patients are ideally connected to mental health specialists the same day, Angerhofer explained.

Curiously, rates of newly initiated psychotherapy appeared to fall slightly by 8.5 encounters per 10,000 visits during the suicide care period compared to usual care periods. Angerhofer and team suggested this may be due to short-term counseling conducted by clinical social workers offsetting demand for specialized mental healthcare.

The study was conducted at Kaiser Permanente Washington and originally funded to examine the integration of alcohol-related care in primary care. Upon request, Angerhofer and her team added a focus on suicidality and other drug use disorders. Following the development of a more holistic program, the team conducted a secondary analysis of the original trial.

From January 2015 to July 2018, 255,789 patients received usual care during 953,402 primary care visits, and 228,255 patients made 615,511 visits during the suicide care period. Both clinical processes in the study and patient outcomes were tracked through the electronic medical record and insurance claims data.

The intervention involved annual screening with the two-item Patient Health Questionnaire for depression, the three-item Alcohol Use Disorders Identification Test–Consumption, a cannabis use frequency question, and a question about illegal drug or nonmedical use of prescription medications frequency. Positive screens were followed by symptom assessment with further questionnaires and connection with designated members of the care team for same-day safety planning as needed. The trial was divided into a usual care period before the intervention launch date, while the intervention period after the launch date included the 4-month period of active practice facilitation.

The mean age of participants was 49.3 for usual care and 50.2 for suicide care; 58.5% of participants were female; 71.8% were white non-Hispanic/Latinx, 10.9% were Asian or Asian American, 6.7% were Black or African American, and 6% Hispanic/Latinx; and 17% had depression, 12.8% had anxiety, and 1.9% had alcohol use disorder.

With regard to alcohol use, 84.5% in the suicide care and 19.9% in the usual care group were screened for alcohol misuse, with 21.7% compared with 19.9% screening positive. In all, 0.67% versus 0.79% received an alcohol use disorder diagnosis, and 0.51% and 0.14% received brief alcohol counseling for the suicide care and usual care groups, respectively, the authors noted.

Patient characteristics during the first visit of the usual care period and suicide care periods were “overall similar,” except for “slightly lower rates of commercially insured patients” in the suicide care group (61% vs 56.3%) and a greater share of private pay patients (9.4% vs 13.5%, respectively).

While the real-world study design makes the findings more meaningful, it is also the study’s biggest limitation, given the difficulty of parsing which program elements were most effective in preventing suicide, Angerhofer said.

“We think that safety planning was probably a really important ingredient in this whole intervention, but … addressing substance use could have been really helpful for people too,” she said.

As for future research, Angerhofer and her team are studying ways to optimize firearm suicide prevention and hope to explore ways to implement suicide prevention in virtual care settings.

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”