Transcript Slides - CT-AAP

“WHAT DO I DO NOW?”
Assessment, Triage and Referral of
Behavioral Crises in Primary Care
Richard J. Miller, MD, FAACAP, Director
ACCESS Mental Health CT Wheeler Clinic Hub
Kimberly Hoylst, LCSW
Wheeler Clinic EMPS
Disclosure: Richard J. Miller, MD
Financial disclosure:
• Employed by Wheeler Clinic
• ACCESS Mental Health CT, Hub Medical Director
• No commercial conflicts of interest
Disclosure: Kimberly Hoylst, LCSW
• Financial disclosure:
• No commercial conflicts of interest
• Employed by Wheeler Clinic, EMPS program
Learning Objectives
After attending this session the participants will be able to:
• Describe some of the different ways risk of harm to self or
others can present in the pediatric office.
• Outline strategies to assess and triage risk of harm to self or
others.
• Identify resources for treatment and guide families through
the decision-making process regarding level of care and
treatment options.
AAP – Behavioral Health “Practice Readiness”
As part of the AAP Mental Health Initiative, the academy urges
pediatricians to increase their scope of practice to expand their
comfort and skills in diagnosing and managing mental health
disorders.
They note: “Mental health care is mainstream pediatrics. Primary
Care clinicians, if trained and supported, are ideally positioned to
identify children with mental health problems, to triage for
emergencies, to initiate care and to collaborate with MH/SA
specialists in facilitating a higher level of care when needed.”
Mental Health Initiatives. Advocacy and Policy, AAP health initiatives
However…
Providers concerns about how to deal with crises and
behavioral safety issues may create discomfort and
present barriers to integrate mental health assessment
and treatment into primary care practice.
Here are a few of the things we heard in ACCESS
Mental Health when talking with some of our PCPs
• “I’m afraid to screen for depression or suicide because I don’t
know what to do if they score too high”
• “We weren’t trained in behavioral health. I know how to evaluate
a medical issue, but this is much different.”
• “While in medical school I was taught in surgery “not to cut until
you were sure you knew how to handle what you find and how
to close.” “When it comes to mental health, I don’t”
To Help Address These Concerns Today We Will:
• Consider some of the statistics and presentations of danger to
self or others as they may present in your practices.
• Discuss how you may identify and assess behavioral safety
issues in your primary care setting.
• Review treatment options available and how to refer based on
the assessed level of risk.
• Where and how to obtain timely assistance and supports for
you and your patients when addressing these issues.
• Review some practice changes that you may consider to better
address behavioral crises in the office.
The Scope of the Problem
• Nationwide, 17.0% of high school students had seriously
considered attempting suicide (22.4% female, 11.6% male)
• 13.6% made a plan about how they would attempt suicide
(16.9%F,10.3%M)
• And 8% had attempted suicide (10.6F,5.4%M)
• 2.7% made a suicide attempt that required medical treatment
(3.6%F, 1.8%M)
• MMWR 2013
More Statistics
• While suicide is rare for prepubertal children, it is the 3rd leading
cause of death in 10-24 year olds (15%)
CDC Mortality Data for 2010
• Females are more likely to consider and attempt suicide, but
males are more than 5 times more likely to complete suicide.
• 25-50% of visits to the primary care office are behavioral health
related (Chun et al).
Components of Safety Assessment
1. SCREENING
2. EVALUATION/Interview
• History of Presenting Problem
• Conduct Suicide/Homicide Behavior Inquiry
• Identify Risk Factors
• Signs, symptom and behaviors related to injury to self or others
• Identify Protective Factors
3. RISK ASSEMENT, TRIAGE & PLAN
• Determine Risk Level
• Referral to Level of Care, Based on Risk Level
4. DOCUMENTATION and FOLLOW UP
Adapted from :SAMHSA SAFE-T (Suicide Assessment Five-step Evaluation and
Triage) www.sprc.com
Presenting Problem
• Some patients present with chief complaints of self injury, suicidal or
homicidal ideation or behaviors.
• But many do not, and may not have told parents or other adults.
• Others may present with:
• Mood symptoms
• Substance abuse or acute intoxication
• Accidents (MVA (especially single car), falls, high risk taking
behaviors.
• Acute psychosocial stressor or trauma (family, peer issues,
bullying, academic, sexual or physical abuse, sexual identity
issues, loss, etc.).
• Changes in school functioning (attendance, grades, peer conflict,
social engagement, etc.)
Chun, et al
“Don’t Ask, Don’t Tell”
• You need to ask about safety and suicidal or homicidal
thoughts.
• If you DON’T ASK, They WON’T TELL.
• For those who tuned in to last month’s CT-AAP Webinar by
ACCESS Mental Health CT. Dr. Kim Brownell and Dr. Barbara
Ward-Zimmerman reviewed the use of scales to screen for
mental health issues in the primary care office. Including:
• Broad screens (ex PSC 17 or 35)
• Problem specific screens (ex. PHQ-9)
Why Screen?
Because You Can’t Tell How Kids are Feeling Just By Looking At Them
Angry
Depressed
Happy
Anxious
Bored
SCREENING
• When to Screen
• The American Academy of Pediatrics recommends that
pediatricians routinely screen adolescents for behavioral
issues and suicide risk factors. (Shain, BN)
• Especially important to screen patients who present with any
of the significant risk factors.
• Most teens visit their PCP annually and many visit their
primary care provider within a month preceding suicidal
behavior. (Owens)
When To Screen, continued
• “For the suicidal patient, a visit with the primary care provider (PCP)
may be the only chance to connect with the health care system and
access effective treatment.
• Consider: Only 32% of the individuals who died by suicide had
contact with mental health services in the year before their deaths,
but 75% of them saw their PCP.”
• So screening for safety can save lives.
(Suicide Prevention Resource Center, http://www.sprc.org/for-providers)
How to Screen
BEHAVIORAL SCREENING TOOLS
• This was covered in detail in last months CT-APP/ ACCESS
Mental Health Webinar.
• BROAD SCREENS
• These can be incorporated into general health appointments as
well as patients who may present at risk. Some examples are:
• PSC-17 and PSC-35, they are free, easy to score and available in
many languages.
• Even the Vanderbilt ADD scales include anxiety and depression
screening questions.
• Items endorsed as positive, facilitate the evaluation and help to
target follow up questions and further discussion.
Targeted Screens for Depression and Suicide
These are sensitive in identifying risk and can be very helpful in
initiating assessment. Here are some examples of the more
common and easy to use screening tools.
• PHQ-9
• PHQ-9A (modified for adolescents)
• ASQ – Ask Suicide-Screening Questions (NIMH)
• Columbia Suicide Severity Scale – Screener
PHQ - 9
• Patient Health Questionnaire (PHQ)
• Over the last 2 weeks, how often have you been bothered by
any of the following problems?
Checkbox Ratings: Not at all, Several days, More than half the
days, Nearly every day
• 1. Little interest or pleasure in doing things
• 2. Feeling down, depressed, or hopeless
• 3. Trouble falling or staying asleep, or sleeping too much
• 4. Feeling tired or having little energy
Available at phqscreeners.com
PHQ – 9 continued
• 5. Poor appetite or overeating
• 6. Feeling bad about yourself—or that you are a failure or have
let yourself or your family down
• 7. Trouble concentrating on things, such as reading the
newspaper or watching television
• 8. Moving or speaking so slowly that other people could have
noticed. Or the opposite- being so fidgety or restless that you
have been moving around a lot more than usual
• 9. Thoughts that you would be better off dead, or of hurting
yourself in some way
PHQ-9A
The PHQ-9 A adds these additional questions specifically
targeted at adolescent suicide risk.
• Has there been a time in the past month when you have had
serious thoughts about ending your life?
□Yes □No
• Have you ever, in your whole life, tried to kill yourself or made a
suicide attempt?
□Yes □No
Modified with permission from the PHQ (Spitzer, Williams & Kroenke, 1999) by J.
Johnson (Johnson, 2002)
ASQ (Ask Suicide-Screening Questions)
• Not to be confused with “Ages and Stages Questionnaires”
• 4 simple questions marked Yes, No. or No Response.
• 96% Sensitivity! (Horowitz, et al, 2012)
1. In the past few weeks have you wished you were dead?
2. In the past few weeks, have you felt that you or your family
would be better off if you were dead?
3. In the past week, have you been having thoughts about
killing yourself?
4. Have you ever tried to kill yourself?
Available Free @ nimh.nih.gov
Columbia Suicide Scale Screener
Another brief scale
6 Yes or No items
1. Have you wished you were dead or wished you could go to sleep and not
wake up?
2. Have you actually had any thoughts about killing yourself?
3. Have you thought about how you might do this?
4. Have you had any intention of acting on these thoughts of killing yourself,
as opposed to you have the thoughts but you definitely would not act on
them?
5. Have you started to work out or worked out the details of how to kill
yourself?
Do you intend to carry out this plan?
Available at http://www.cssrs.columbia.edu/scales_practice_cssrs.html
Question# 6 is an important question that is not on
most other screeners…
6)
Have you done anything, started to do anything, or prepared to
do anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a
will or suicide note, took out pills but didn’t swallow any, held a gun but
changed your mind or it was grabbed from your hand, went to the roof
but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself,
tried to hang yourself, etc.
In your entire lifetime, how many times have you done any of
these things?
EVALUATION – INTERVIEW, SETTING
• Where possible, patients and parents/caregivers should be
interviewed alone and together. Collateral information is imperative.
• Patients and families need to feel respected, taken seriously and that
the provider is concerned and acting in their best interest.
• Explain confidentiality. When imminent risk is concerned the usual
rules of confidentially do not apply. Providers may disclose
information or obtain information to or from collaterals in the service
of safety.
• Providers need to maintain safety during the assessment including
not leaving patient alone, and if possible away from dangerous
equipment.
INTERVIEWS
• Obtain a history of how the events and symptoms evolved over
time.
• Note history of previous treatment. What helped, what didn’t?
• Make note of acute and chronic precipitating factors, risk
factors, and protective factors in individual, family, social,
academic and health domains. (We will discuss this in more
depth later)
SUICIDE/HOMICIDE INQUIRY
General Guidelines
• Ask Patients (and caregivers) about Risk Directly.
• Asking patients about suicidal thoughts and behaviors does not increase
risk. It actually decreases risk
• Use a non judgmental, matter of fact approach
• Don’t Ask Leading Questions (“You’re not thinking of hurting anyone are
you?”)
• Do ask in supportive non threatening manner. For example:
• “ When people have strong feelings like you described they sometimes
feel they cannot handle it anymore, has that happened to you?”
• Have you ever seriously though about death or suicide?
• (think of those questions on the ASQ or other screener)
SUICIDAL IDEATION
Have you ever had impulses or thoughts about harming yourself or
others?
• Have you ever felt hopeless, felt you can’t handle things anymore?
Have you ever had suicidal thoughts?
• Have you ever wished you were dead or wondered what it would be like if
you were gone?
• Have you had any of these thoughts recently? When was the last time?
• Ask about when the thoughts or behaviors occurred, what precipitated
them and what did they actually do?
• When was it the worst?
• Passive ideation: “It wouldn’t bother me if I died”
• vs. Active: “I want to die” or “I wish I was dead”
(higher risk)
SUICIDAL PLANS
• If suicidal thoughts were present, ask about plans.
• Did you think about how you might do it?
• Did you actually make plans?
• Where and when?
• Means:
• Do they have access to the means to carry out the plan?
• Do you know where you would get a (gun, drugs, etc.)?
• Intent: Do they wish or expect to carry out the plan & what would
happen?
• Lethality: How dangerous is the plan or behavior and how
dangerous does the patient think it is?
SUICIDAL BEHAVIOR/INTENT
Preparations made
• Ask about the extent the patient if they want to die, expect to
carry out the plan and if they expect it to be lethal?
• What have they done so far to carry out the plan?
• What do they expect would happen?
• Past attempts, rehearsals or aborted attempts?
• Very high risk for repeat attempts
• What stops/would stop you?
NSSI- NON SUCIDAL SELF INJURY
• Intentional Self mutilation, infliction of pain or self harm to one’s body
• Very common (Girls>Boys). Check for signs on PE
• Injuries are usually superficial, low lethality and without suicidal
intent
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•
•
•
•
•
•
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Cutting (esp. arms , thighs , abdomen)
Burning
Branding
Scratching
Picking scabs or wounds that are healing
Punching self or objects
Bruising or breaking bones
Some forms of hair pulling
Excessive piercings or tattoos
Other forms of bodily harm
NSSI continued
• Many reasons.
• Ask why they do it. “It’s different for everyone, what does it do for
you?”
• Punishment (self or others)
• To “Bring the pain to the outside”
• An attempt to externalize and control emotional pain, anger or anxiety.
• “It makes me stop feeling.”
• An attempt to suppress pain, anger or anxiety. (release of endorphins)
• A cry for help
• Re-enactment of abuse or trauma
• Do you know anyone else who does this?
There is often a friend or relative
NSSI continued
• Patient does not have suicidal intent, but:
• But it can be accompanied by suicidal ideation.
• Can be to suppress or rehearse suicidal impulses
• Can lead to suicidal behavior if not treated
• Can be impulsive and reactive, or methodical and repetitive,
even ritualized.
• Do they try to resist? If so can they?
• It is a desperate, mal-adaptive coping skill and needs
intervention.
HOMICIDALITY
Ask about:
• IDEATION: Have you ever had thoughts or wishes to hurt others.
• PLAN: Planned ahead or reactive to the moment then regretted.
• Lethality of plan
• Access to means (especially firearms)
• BEHAVIORS
• Previous episodes
• INTENT
• Extent of intention to harm. Superficial, serious injury or to kill?
• Intent to scare off threat (as in a bully)
• Level of risk
RISK FACTORS
• Let’s go over some of the many factors that contribute to Risk
so you can be aware of them while you interview patient and
parent.
• It is important to screen for risk factors as they can have a
major impact on outcome and treatment recommendations.
Including whether or not if they are modifiable.
• Age is a risk, Children and teens do not yet have the long view
perspective that things eventually will pass or get better. This
comes with experience. In fact, temporary setbacks feel like
permanent loss. Now = Forever.
RISK FACTORS TO BE AWARE OF
• Categories
• Individual
• Family
• Psycho/Social
• Environmental
RISK FACTORS - INDIVIDUAL
• Previous attempts to harm self or others
• One of the strongest predictors, although most people who die by suicide die on their
first attempt. (SPRC Suicide Prevention Primer)
• Gender
• Females more likely to make attempts. Males 4-5 times more likely to be lethal.
• Mood Disorders
• Depression & Bipolar Disorder
• Anhedonia, hopelessness, insomnia
• Mood swings
• Psychosis, especially if command hallucinations
• Anxiety
• Severe panic (escape!)
• Impulse Control Disorders
• Aggression
• Can shift from verbal to property to self or others.
RISK FACTORS – INDIVIDUAL Continued
• Substance Abuse
• Very High Risk (increase impulsivity, decreased inhibition,
dysphoria)
• PTSD/History of Trauma or Abuse
• Always check for current or Past Trauma
• Can cause unpredictable reactivity
• Physical Illness
• Pain, loss of function (ex. athlete)
• Concussion
• Gender Identity
• LGBTQIA individuals present significantly are at
increased risk.
RISK FACTORS - Family
• Family History of:
• Suicide or Attempt
• Violence/Abuse
• Mental Illness and Substance abuse
• Death or Loss of Significant Family Member
• Severe or Terminal Illness of Family Member
• Family Conflict
• High Risk behaviors are often precipitated by family conflict
• Other Family Stressors (legal, financial, etc.)
RISK FACTORS - Psychosocial
• Peer conflict
• Bullying, including cyber-bullying
• Loss of close friend
• Betrayal
• Break up Romantic Relationship
• Social Isolation
• Academic Difficulties or Failure
• Legal Difficulties
RISK FACTORS - Environmental
• ACCESS TO WEAPONS
• Very High Risk, Especially Firearms.
• ACCESS TO POTENTIALLY LETHAL MEDICATIONS OR
DRUGS
PROTECTIVE FACTORS
Individual
• Willingness to seek and accept help
• Ability to cope with Stress, Resilience
• Hopefulness
• Future Oriented
• Connection to others, caring how harming self or others
would affect them.
• Religious affiliation
PROTECTIVE FACTORS
Environmental
• Supportive Family
• Nuclear Family
• Extended Family
• Supportive Peers
• Caution if patient only shares risk issues with friends
• Connection to Other Supportive Adults
• Therapists, School Counselors, Teachers, Mentors, Clergy
• Religion/Spirituality
ASSESSMENT & TRIAGE
ASSESS RISK LEVEL: Putting it all together
• Risk assessment is a judgment based upon:
• History
• Level of Suicidality/Homicidality
• Risk Factors
• Protective Factors
• Available Interventions can then be matched based on the
assessed level of risk.
LOW RISK - example
Suicidal/Homicidal Ideation
• Thought or ideation without plan, intent or behavior
Risk Factors
• Mild, modifiable or non-continuing
• Protective Factors
• Strong protective factors
• Accepting of treatment
MODERATE RISK - example
Suicidal/Homicidal Assessment
• Ideation, with plan, but no intent, rehearsal, or behavior; past
or present.
Risk Factors
• Multiple risks some modifiable and some continuing non
modifiable risk factors
Protective Factors
• Few protective factors, supports
HIGH RISK - example
Suicidal/Homicidal Assessment
• Persistent ideation, expressed intent and means to harm self
or others. Previous self or other injurious behaviors, attempts
or rehearsal.
Risk Factors
• Severe behavioral illness with acute symptoms such as
hallucinations, mania. Substance abuse. Access to means.
Lack of available supports.
Protective Factors
• Probably not relevant.
INTERVENTIONS- Available Levels of Care
• 911
• ED/Hospital
• 211-1-1 EMPS – Emergency Mobile Psychiatric Services
• Outpatient Services
• Enhanced Care Clinics
• Community Based Clinicians
• Primary Care Provider
• Other Community Resources
• ACCESS MENTAL HEALTH CT
911- High Risk
Dialing 911 Will call emergency responders Police & Ambulance
• Police will assess the situation and act to provide safety.
• They may possibly decide to press charges or arrest the
child based on their judgment (particularly in the case of an
assaultive or threatening individual).
• Ambulance may be called to provide safe and or involuntary
transfer to a hospital emergency room for assessment and
treatment.
• Use in high risk situations where risk to self or others is
imminent.
Hospital – Emergency Department (ED) – High Risk
Emergency Department
• Provides:
• Medical Physical (and Laboratory) Assessment or Treatment
• Ability to medicate or sedate, if indicated
• Provide Behavioral Health Assessment
Conducted by clinical master’s level staff
• Consultation with APRN’s, Psychiatrists, may be available. Some
EDs have child trained staff others do not.
• Can facilitate admission to hospital level of care.
• Ability to restrain if necessary for safety.
• Provide a safe holding environment and observation
Hospital ED
• Consider if:
• Imminent Risk to self or others.
• Very High Risk, if admission to a hospital is likely indicated
• Involuntary
• Medical work up needed (such as due to ingestion or injury)
• Needs continued observation or acute stabilization in safe
environment.
• Note: Will not provide follow up after discharge.
• But may refer to EMPS or recommend other outpatient
treatment.
EMPS – Emergency Mobile Psychiatric Services
• Emergency Mobile Psychiatric Services (EMPS) offers an immediate
response to children and youth, ages 3 - 17, or 18 if still enrolled in
school, experiencing behavioral health emergencies in the home,
school and other community or hospital settings.
• The EMPS team is available 24 hours a day, seven days a week, all
year long
• Mobile response hours are between the hours of 8 a.m. and 10 p.m.
(1 p.m. to 10 p.m. weekends and holidays)
• This response helps to maintain youth safely in the community and
often eliminates unnecessary emergency department visits or
subsequent inpatient admissions.
EMPS- Emergency Mobile Psychiatric Services
• EMPS Provides
• Immediate access by dialing 2-1-1 and pressing “1”
• In-home or community response from a Masters Level
clinician on our EMPS team, usually within 45 minutes of the
initial call
• Clinical assessment and crisis safety planning
• Stabilization of the immediate crisis in the child’s home,
school or other community locations
• Brief in-home or community-based stabilization services and
linkage to treatment and other community resources
EMPS - Continued
• Engagement of family members and caregivers in the
treatment process
• Integration with community-based services, including
outpatient treatment, intensive family preservation, in-home
treatment, specialized education, substance abuse
treatment, sexual abuse treatment and parental training
• Ongoing collaboration with multiple community providers to
ensure appropriate care
• Can be appropriate for low to high risk situations.
OUTPATIENT TREATMENT (low to moderate risk)
• ECC (Enhanced Care Clinic)
• Multiple levels or care available
• Outpatient. Intensive outpatient/Partial Hospital
• Specialized treatments (CBT,DBT, intensive in home or other outpatient treatment
• Often provide same day or rapid intake
• Outpatient Community Based Treatment
• Community based, Private practitioner, group or clinic.
• May provide continuity of care
• Hours, services available and insurance participation vary
between practices and practitioners.
PRIMARY CARE PROVIDERS
Primary Care Providers
• Provide initial assessment and follow up
• Have trusted, often long term history with family and patient.
• Treatment monitoring and case management
(Medical Home)
• Provide needed Support for Patient and Family.
• Encouragement, hope, education (verbal, handouts and resources)
• Follow up
• Can Establish Interim Safety Plan
• If not being referred to 911 or Hospital or EMPS
Make a Plan for Safety
• Don’t - Suicide contracts (“I promise not to hurt myself”) are not
effective.
• Do- Make a Plan for Safety when feeling distressed
• Individual
• Coping skills, distractions- Friends (for distraction not support), music, movies,
etc.
• Family
• Discuss and list who they can talk to and when to seek them out.
• PROVIDE A SAFE ENVIRONMENT (Remove firearms, sharps, dangerous
medications , etc.)
• Professionals
• Who they can talk to, when to seek them out and contact information
• (pediatrician, therapist, guidance counselor, help line, etc..)
PRIMARY CARE - Co-management of Patient
• Levels of co-management:
• Family + PCP monitoring and support
• Provide Education, supportive counseling and Case management
• Mental Health Practitioner + PCP monitoring
• Refer for therapy, consider medication
(I almost always recommend non medical Tx first)
• Mental Health Practitioner+ Prescribing PCP
• With or without consultative support of psychiatrist ( ACCESS-MHCT, Co-located
or community APRN or Psychiatrist)
• Mental Health Practitioner + Prescribing Specialist + PCP
monitoring and follow up.
OTHER COMMUNITY RESOURCES
• SCHOOL SYSTEM
• Establish collaborative COMMUNICATION
• School-based assessment
• Helpful additional collateral observers
• Accommodations and specialized services
• Counseling-individual and group
• SUPPORT GROUPS (CAMI, etc)
• RELIGIOUS INSTITUTIONS/ORGANIZATIONS
ACCESS Mental Health CT
• Mission: to support pediatric primary care providers in meeting
the needs of children and adolescents with mental health
problems
• The ACCESS Mental Health program consists of
3 expert pediatric behavioral health consultation teams
• Teams consist of a Child Psychiatrist, Licensed Behavioral
Health Clinician, Coordinator and Family Peer Specialist
• Geographically located to cover the entire state
61
ACCESS Mental Health CT
 Hartford Hospital 855.561.7135
 Wheeler Clinic, Inc. 855.631.9835
 Yale Child Study Center 844.751.8955
ACCESS Mental Health – What we do
• Free telephone consultation to primary care providers
concerning their patients ages 0–18 often immediately, but at
least within 30 minutes of the initial call
• Assistance with finding community behavioral health
services
• Ongoing education about pediatric mental health assessment
and treatment
• Where indicated, a one-time non-emergency diagnostic
evaluation to provide diagnostic clarification and treatment
recommendations
ACCESS Mental Health CT
In a Crisis Situation ACCESS MH-CT can help:
• You can call us for guidance and support around risk
assessment and triage issues, even while the patient and family
are still in the office
• We can assist with helping to link with treatment resources for
this patient.
• We can perform a one time non-emergency face to face consult
with the patient to help you with level of care or treatment
decisions.
• We can assist with practice readiness to handle behavioral
health issues.
DOCUMENTATION & FOLLOW UP
Document
• Risk Assessment
• Level of Risk
• Reasons for
• Interventions
• Referral
• Level of Care
• Family agreement and understanding of plan
• Risk Reduction
• Family Steps to assure safety (supervision, treatment
• Removal of Firearms, dangerous drugs or other means.
• Follow Up
• When is next appointment?
• Other clinicians & collaterals (get releases signed if indicated)
• Screening tools as indicated.
Intro to Vignettes
To see how this all fits together and can be applied in real time in
your office, let’s look at a few examples of patients as they may
present in your practice.
• We’ll look at how they initially presented, what we found in our
assessment of:
• History
• Suicidal/Homicidal Behavior Inquiry
• Risk Factors
• Protective Factors
• Then look level of risk and treatment options
Case Vignette 1 – MARTIN
• Martin is a 15 year old male who you are meeting with today in
your office due to his school contacting you. Martin has a
history of being diagnosed with Autism Spectrum Disorder.
• You have set up a symptom focused patient appointment
MARTIN - Interview
• In speaking with Martin, he reports that he has been very upset
at school because peers have been calling him names and is
also upset with his teacher due to feeling that they are not
helping him with this situation. He makes comments that he
feels “they should pay for what they’ve done” and states that he
is so mad that he “wants to do something.” Martin denies any
current suicidal or homicidal thoughts but does report feeling
increased sadness, tearfulness and increased anger.
• He has occasional meetings with counselors at school but no
outpatient therapy supports in place.
MARTIN
• Identified Problem: Martin expresses feelings of anger,
sadness, tearfulness
• SI/HI Inquiry: Passive homicidal ideation without identified
plan/intent/means. Martin does not have any history of attempts
or threats to harm or kill himself/others.
• Risk Factors: Martin struggles with peer relational concerns,
Affective regulation and has had recent changes within his
mood, and increased anger.
• Protective Factors: Martin has a supportive family who is
invested in keeping him safe, seeking help for him and he likes
seeing the school counselor.
MARTIN - Risk Assessment and Outcome
Risk Assessment:
• Martin presents as Low to Moderate Risk due to denying suicidal or
homicidal ideation currently. However he is unpredictable and still angry.
Martin also has several protective factors in place at this time.
Intervention:
• Refer Martin to EMPS for crisis services at the time of your visit due to his
level of risk. They will assess and provide clinical bridging until connected
appropriate providers. Or consider referral to an ECC for immediate
intake (ACCESS MHCT can help facilitate)
Follow Up:
• Schedule a follow up appointment within the next 3 weeks with Martin.
Collaborate with community providers (including Outpatient clinic or
EMPS) for additional steps.
• Establish or continue to coordinate with school.
TONY - Case Vignette 2
Mrs. Smith has brought her 12 year old son Tony to meet with
you today due to him being more tired and having difficulty
focusing. Mrs. Smith is concerned that something medically is
going on and wanted you to meet with him.
TONY - Interview
In speaking with Tony and his family:
Tony stated that he feels very hopeless about the future and does
not care what happens to him.
TONY - Screening and SI/HI
SCREENING:
• PHQ-9 is administered and Score 16 including “3” on #9
indicating that he had thoughts of hurting himself nearly every
day.
SUICIDAL IDEATION INQUIRY:
• He states that he has been having thoughts about wanting to kill
himself and has already made plans to access a rope he found
in the garage at home. He said that he plans to follow through
with this plan today because he feels like he “just can’t take it
anymore.”
TONY - Risk and Protective Factors
RISK FACTORS:
• Tony revealed that his father yells a lot and parents argue.
• Dad has a history of depression.
• He has access to means to carry out his plan
PROTECTIVE FACTORS:
• Tony has a supportive family
• Does well academically in school
• Has religious affiliation and family is willing to engage in treatment.
• There are no firearms in the home.
TONY – Risk Assessment, Intervention & Follow Up
RISK ASSESSMENT:
• Tony presents as High Risk due to his identified plan/intent and
access to means. Additionally there is increased hopelessness and
a timeline for when the attempt will occur.
INTERVENTION:
• Refer Tony to the hospital emergency department at time of visit due
to high level of risk.
FOLLOW UP:
• Schedule a follow up appointment within 1 week of discharge to see
Tony, obtain further history from school/other collaterals and utilize
behavioral check list with screening tools at next appointment.
RAQUEL- Case Vignette 3
• Raquel is a 13 year old female who comes to you today for her
yearly physical exam. You’ve been Raquel’s Primary Care
Physician since she was 5 years old and know the family very
well.
• When meeting with you, Raquel often comes in very talkative
and smiling. During her physical examination today, you notice
a few superficial cuts on her left and right forearms. You ask
Raquel how she got these, whereas she begins to cry and
reports that she cut herself with a razor blade two months ago,
but denies any desire currently or since then to cut herself
again.
• She denies any substance abuse, sleep or appetite
disturbance.
RAQUEL - Office interview, continued
• You explain that given this is a safety issue you will need to
discuss this with her parent.
• After meeting with them together you are able to meet with
mom and she is upset but very supportive. There is no history
of depression in the family. Parents are divorced but father is
also supportive.
• Raquel has many friends and is a good student and
academically engaged.
• You know from your records that there are no contributing
medical issues.
RAQUEL- ASSESSMENT
Identified Problem: After you found healed scars, Raquel
admitted that she cut herself two months ago due to experiencing
feelings of sadness.
SCREENING:
While talking with mother you give a PHQ- 9
Raquel scores a 5 (Mild Depression)
SUICIDAL IDEATION INQUIRY:
• Raquel reports that she has no desire now or in the future to
cut herself again. Raquel also denies any access to razors,
sharps, etc. She denies ever having suicidal thoughts or plans.
RAQUEL- ASSESSMENT, continued
RISK FACTORS:
• Raquel’s maternal grandmother passed away three months ago
whom Raquel was very close with.
• Raquel has engaged in cutting behaviors 2 months prior.
PROTECTIVE FACTORS:
• Raquel has a supportive family.
• Engages in extracurricular activities.
• Wants help and would like to talk to a therapist.
RAQUEL- Risk Assessment Triage and Outcome
RISK ASSESSMENT:
• Raquel presents as Low/Moderate risk due to her history of
engaging in cutting behaviors. Additionally Raquel has denied any
current thoughts to engage in cutting at the time of your interview.
INTERVENTION:
• Refer to community based provider for individual therapy. Both
parent and child agree with this recommendation.
• Utilize ACCESS Mental Health CT to assist with linkage to services
and informing you of the resulting appointment.
FOLLOW UP:
• Schedule a return symptom focused appointment and continue
assessment. It would be beneficial to utilize screening tools,
collateral information with at next appointment.
PRACTICE CHANGE
Routinely Screen for safety
• Ask about thoughts of harm to self or others as you do about other high
risk issues such as drugs, driving, sexual activity.
• Regularly Administer Behavioral Screening Instruments in your
practice.
• Remember “if you don’t ask, they don’t tell.”
Prepare Symptom Focused Packets (ready for you and your patients)
• Pick and include which follow up screens (ASQ, PHQ-9 etc.) your
practice will use.
• Utilize observer questionnaires for obtaining collateral information (you
can develop your own or ask ACCESS MH CT for ours)
• Include Safety Plan Sheet, when indicated.
PRACTICE CHANGE- continued
• Prepare list of referrals and contacts for different levels of care
• Prepare list of resources for patients and families
• Remember, ACCESS Mental Health CT is just a phone call
away to:
• Help you sort through evaluation and options
• Assist with referral and linkage to services
• Provide continuing education on behavioral health issues.
• Provide non emergency one time consultations to help with
treatment and level of care questions.
“UNDERSTANDING SUICIDE”
“When people are suicidal, their thinking is paralyzed,
their options appear spare or nonexistent, their mood is
despairing, and hopelessness permeates their entire
mental domain. The future cannot be separated from the
present, and the present is painful beyond solace.”
Kay Redfield Jameson
Night Falls Fast: Understanding Suicide
REFERENCES
• Fallucco et al. Teaching Pediatric Residents to Assess Adolescent Suicide Risk with a
Standardized Patient Module Pediatrics Volume 125, Number 5, May 29010
• Chun T, Katz E, Duffy S. Pediatric Mental Health Emergencies and Special Care Needs.
Pediatric Clin N America 60 (2013) 1185-1201
• Suicide Prevention Toolkit for Rural Primary Care Practices
http://www.sprc.org/webform/primary-care-toolkit
• Practice Parameter For the Assessment and Treatment of Children and Adolescents with
Suicidal Behavior, JAACAP, 40:7 Supplement, July 2001
• Maslow G, Dunlap K, Chung R. Depression and suicide in children and Adolescents.
Pediatrics in Review, Vol 36 No.7, July 2015
• Mental Health Initiatives. Advocacy and Policy, AAP health initiatives
• Kahn L, Kinchen S, Shanklin S, et al. Youth Risk Behavior Surveillance - United States,
2013, MMWR 2014:63June 13 2014 Vol.63 (4):1-162
References, Continued
• Eaton DK, Kann L, Kinchen S, et al, Youth Risk Behavior Surveillance _ United States,
2011. MMWR Surveillance Summer 2012:61 (4)
• Centers for Disease Control and Prevention. Leading Causes of Death 199-2010. Atlanta
(GA): Centers for Disease Control and Prevention; 2012
• Horowitz L, Bridge J, Teach s, et al. Ask Suicide-Screening Questions (ASQ), Arch Pediatr
Adol Med. 2012; 166(12):1170-1176
• Shain BN, AAP Committee on Adolescence Suicide and Suicide Attempts in Adolescents.
Pediatrics.2007;120(3):669-678
• Owens C, Lloyd KR, Campbell J. Access to healthcare prior to suicide: findings from a
psychological autopsy study, Br J Gen Pract. 2004,54 (501):279-281
• Kay Redfield Jameson, Night Falls Fast: Understanding Suicide. Alfred A. Knopf. 1999
• Foy J, Enhancing Pediatric Mental Health Care: Algorithms for Primary care
Pediatrics, 2010;125;S109-125
RESOURCES
• ACCESS Mental Health CT
• Wheeler 855-631-9835, Hartford
• EMPS – Dial 211 Option 1-1
• Suicide Prevention Toolkit for Rural Primary Care Practices
http://www.sprc.org/webform/primary-care-toolkit
Includes information and tools to implement state-of-the-art suicide prevention
practices in primary care settings. Although designed with the rural practice in
mind, this toolkit is suitable for use in non-rural settings as well.
• National Suicide Prevention Hotline 1-800-273-TALK(8255) or text HI to 741741
to chat
• AACAP.org - Fact for Families & Depression Resource Center
• ASQ: http://www.nimh.nih.gov/news/science-news/ask-suicide-screeningquestions-asq.shtml
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ACCESS Mental Health CT
 Hartford Hospital 855.561.7135
 Wheeler Clinic, Inc. 855.631.9835
 Yale Child Study Center 844.751.8955