Beyond gun control: practical tools to prevent suicide

Whether suicide occurs in a notorious shooting like Newtown, Connecticut, or as a quiet family tragedy, the question is always the same: Was there anything we could have done to prevent this? Now scientists at Group Health Research Institute are finding practical ways to identify and help people who are at risk for trying to kill themselves.

“Until recently, we lacked two key factors for effective suicide prevention: an accurate method of identifying those at risk and effective interventions that can be delivered to many people,” said Greg Simon, MD, MPH, Group Health Research Institute senior investigator and a Group Health psychiatrist. Dr. Simon and coworkers found an effective and surprisingly simple way to assess suicide risk.

“Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead?”

This is one question on PHQ-9, a questionnaire that Group Health Behavioral Health Services and 10 primary care clinics started using in 2011 to assess patients with depression. In early 2012, analysis by Dr. Simon, GHRI Research Associate Ursula Whiteside, PhD, and Assistant Investigator Rob Penfold, PhD, found that a person who answers “nearly every day” to the question is nine times more likely to attempt suicide than is one who responds “not at all.” The researchers have submitted these results for publication, but Dr. Simon and colleagues wanted to put their findings to work right away to improve clinical care. “When we learn something here, we act,” he said. “We don’t wait for stuff to be published.”

A doctor who finds that a person is likely to attempt suicide must determine if the risk is urgent enough to recommend hospitalization. To help develop a standard, evidence-based process for making this determination among Group Health providers, Drs. Whiteside and Simon collaborated with Group Health Behavioral Health Services Assistant Medical Director Bradley Steinfeld, PhD, its Regional Manager Sarah Stuckey, MA, and others.

The team’s work at a June 2012 Lean management system workshop resulted in adding an evidence-based suicide-risk assessment tool (the Columbia Suicide Severity Rating tool) to the workflow of Group Health Behavioral Health clinics. Dr. Whiteside recommended the new tool, which guides a provider-patient conversation about suicide, based on her research funded by the American Foundation for Suicide Prevention and the National Institute of Mental Health. So far, it has been used about 3,000 times at Group Health. “This is a dramatic new way of suicide risk assessment that could change the mental health world,” said Dr. Simon.

The next step after identifying people with suicide risk is helping them. Previous research by Dr. Simon, GHRI Senior Research Associate Evette Ludman, PhD, and others found that secure messaging and other online communications are effective ways to provide mental health treatment to many people. Based in part on these results, Dr. Simon is now leading a major national study, currently in pilot-project phase, comparing the effectiveness of two therapies for people at risk for suicide. One therapy focuses on correctly diagnosing mental illness and assigning proper treatment to those at risk for killing themselves. To ensure consistent care, the program uses online tools for outreach and follow-up. The second therapy is based on the idea that regardless of mental-health diagnosis, people who attempt suicide are overwhelmed by strong emotions and need help. Dr. Whiteside is developing an online program with coaching support that teaches people specific skills for managing these emotions to reduce their suicide risk.

After the pilot project, the national study will include about 16,000 adults from at least three large health care systems in the HMO Research Network’s Mental Health Research Network—Group Health, HealthPartners in Minnesota, and Kaiser Permanente Colorado. Funding for both the pilot and larger study comes from the Health Care Systems Research Collaboratory, a National Institutes of Health endeavor that supports large, practical clinical studies by health systems, using their information databases.

“Suicide is solvable,” said Dr. Whiteside. “The solution is managing suffering, and we have evidence-based interventions that work for that.”

by Chris Tachibana