Suicide attempts decreased after adding suicide care to primary care

Safety planning and risk screening improved outcomes for adult patients

After suicide care was integrated into routine primary care visits, researchers saw a 25% decrease in the rate of suicide attempts in the 90 days after these visits, according to a new study from Kaiser Permanente Washington Health Research Institute (KPWHRI).

The study, published in the Annals of Internal Medicine, is the first to show that suicide risk screening in primary care, followed by safety planning, improved suicide prevention efforts in a health care setting. The trial took place at Kaiser Permanente clinics in Washington state, which provide care for approximately 700,000 people statewide.

“Our findings are important because we know many people seek primary care prior to fatal and nonfatal suicide attempts,” said Julie Angerhofer Richards, PhD, MPH, the lead author of the paper and an assistant investigator at KPWHRI. “Many health care systems in the U.S. and abroad now routinely ask patients about suicidal thoughts, and this study provides evidence to support this practice, in combination with collaborative safety planning among people identified at risk of suicide attempt.” 

The researchers looked at about 1.5 million visits to primary care between January 2015 and July 2018. Clinics began implementing the suicide care model in waves in January 2016, and usual care data was gathered prior to implementation. After implementation, documented safety plans within 2 weeks of a primary care visit increased by 14%. Combined nonfatal suicide attempts and suicide deaths decreased by 25% within 90 days of a primary care visit. Overall, more people were screened and assessed for suicide risk, depression, and alcohol and drug use after implementation, compared to usual care.

The suicide care model included screening for all adult patients using the Patient Health Questionnaire. Patients who said they had relatively frequent thoughts about self-harm were screened further for suicide risk. Those at high risk were referred to members of the care team for same-day safety planning, a collaborative practice that helps empower people to manage painful emotions and situations.

Prior to implementation of the new care model, only patients with a known mental health condition received mental health monitoring. 

The addition of suicide care in primary care was part of a larger behavioral health integration project, which included care for depression, alcohol use, and cannabis and other drug use. Practice facilitators met with local implementation teams at each clinic every 1 to 2 weeks for 4 months. The project also included clinical decision-support tools in the electronic health record, like reminders and prompts for care teams, and regular performance monitoring.

“This work required strong leadership support and active participation by primary care teams including integrated mental health social workers,” Richards said. “We were lucky to partner with amazing leaders, clinicians, and staff across our organization.”

The researchers wrote that the results provide important evidence for care teams when thinking about how to address suicidal thoughts reported during routine depression screening. 

“We hope these findings can be used by other health systems,” Richards said, “both as a possible road map for how to deliver suicide care in primary care, and as further evidence that this type of approach leads to better outcomes for patients.”

The study was funded by the National Institute of Mental Health.

KPWHRI coauthors included Maricela Cruz, PhD; Christine Stewart, PhD; and Gregory Simon, MD, MPH.

By Amelia Apfel