Effects of Patient Suicide on Professional Practice Among Mental Health Providers.

INTRODUCTION: The loss of a patient to suicide has an enormous impact on clinicians, but few studies have examined its effects. METHOD: In this retrospective study, we compared clinicians who have and have not experienced a patient suicide using a survey of 2157 outpatient clinicians from 169 New York clinics to determine differences in their suicide prevention knowledge, practices, training, and self-efficacy. RESULTS: Approximately 25% of the clinician respondents lost patients to suicide; psychiatrists, nurses/nurse practitioners, and those with more years of experience were disproportionately affected. After controlling for these demographic/professional differences, clinicians who had experienced patient suicide reported feeling that they had insufficient training, despite actually having more suicide prevention training, greater knowledge of suicide prevention practices, and feeling more comfortable working with suicidal patients than clinicians who had not lost a patient to suicide. There were no differences in self-efficacy or utilization of evidence-based clinical practices. CONCLUSIONS: Controlling for demographic/professional differences, clinicians who experienced a patient suicide had more training, knowledge, and felt more comfortable working with suicidal patients. It is critical that sufficient training be available to clinicians, not only to reduce patient deaths, but also to help clinicians increase their comfort, knowledge, skill, and ability to support those bereaved by suicide loss.

Predictors of Intentional Self -Harm Among Medicaid Mental Health Clinic Clients In New York.

BACKGROUND: Behavioral health outpatients are at risk for self-harm. Identifying individuals or combination of risk factors could discriminate those at elevated risk for self-harm. METHODS: The study population (N = 248,491) included New York State Medicaid-enrolled individuals aged 10 to 64 with mental health clinic services between November 1, 2015 to November 1, 2016. Self-harm episodes were defined using ICD-10 codes from emergency department and inpatient visits. Multi-predictor logistic regression models were fit on a subsample of the data and compared to a testing sample based on discrimination performance (Area Under the Curve or AUC). RESULTS: Of N = 248,491 patients, 4,224 (1.70%) had an episode of intentional self-harm. Factors associated with increased self-harm risk were age 17-25, being female and having recent diagnoses of depression (AOR=4.3, 95%CI: 3.6-5.0), personality disorder (AOR=4.2, 95%CI: 2.9-6.1), or substance use disorder (AOR=3.4, 95%CI: 2.7-4.3) within the last month. A multi-predictor logistic regression model including demographics and new psychiatric diagnoses within 90 days prior to index date had good discrimination and outperformed competitor models on a testing sample (AUC=0.86, 95%CI:0.85-0.87). LIMITATIONS: New York State Medicaid data may not be generalizable to the entire U.S population. ICD-10 codes do not allow distinction between self-harm with and without intent to die. CONCLUSIONS: Our results highlight the usefulness of recency of new psychiatric diagnoses, in predicting the magnitude and timing of intentional self-harm risk. An algorithm based on this finding could enhance clinical assessments support screening, intervention and outreach programs that are at the heart of a Zero Suicide prevention model.

Is the outpatient mental health workforce ready to save lives? Suicide prevention training, knowledge, self-efficacy, and clinical practices prior to the implementation of a statewide suicide prevention initiative.

OBJECTIVE: Many public health approaches to suicide prevention emphasize connecting at-risk individuals to professional treatment. However, it is unclear to what degree the outpatient mental health workforce has the requisite knowledge and skills to provide the evidence-based care needed to help those at risk. In this project, prior to the implementation of a statewide suicide prevention initiative, we assessed the baseline suicide prevention training and clinical practices of the New York State outpatient mental health workforce, a group likely representative of the broader U.S. clinical workforce. METHOD: A workforce survey of suicide prevention training and clinical practices was administered to 2,257 outpatient clinicians, representing 169 clinics serving approximately 90,000 clients. Clinicians were asked to complete the survey online, and all responses were confidential. RESULTS: Clinicians reported substantial gaps in their suicide prevention knowledge and training. The vast majority reported moderate self-efficacy working with suicidal clients and endorsed using evidence-based assessment procedures, but varied in utilization of recommended intervention practices. CONCLUSIONS: This study highlights gaps in clinicians' training and clinical practices that need to be overcome to provide evidence-based suicide care. Promisingly, positive associations were found between training and clinician knowledge, self-efficacy, and use of evidence-based practices.

Zero suicide implementation-effectiveness trial study protocol in outpatient behavioral health using the A-I-M suicide prevention model.

BACKGROUND: The treatment of suicidal patients often suffers owing to a lack of integrated care and standardized approaches for identifying and reducing risk. The National Strategy for Suicide Prevention endorsed the Zero Suicide (ZS) model, a multi-component, system-wide approach to identify, engage, and treat suicidal patients. The ZS model is a framework for suicide prevention in healthcare systems with the aspirational goal of eliminating suicide in healthcare. While the approach is widely endorsed, it has yet to be evaluated in a systematic manner. This trial evaluates two ZS implementation strategies statewide in specialty mental health clinics. METHODS/STUDY DESIGN: This trial is the first large-scale implementation of the ZS model in mental health clinics using the Assess, Intervene, and Monitor for Suicide Prevention (A-I-M) clinical model. Using a hybrid effectiveness-implementation type 1 design, we are testing the effectiveness of ZS implementation in 186 mental health clinics in 95 agencies in New York State. Agencies are randomly assigned to either: "Basic Implementation" (BI; a large group didactic learning collaboratives) or "Enhanced Implementation" (EI; participatory small group learning collaboratives; enhanced consultation for site champions). Primary outcomes include suicidal behaviors, hospitalizations and Emergency Department visits; implementation outcomes include protocol adoption, protocol fidelity and barriers/facilitators to implementation. DISCUSSION: This project has the potential to have a significant public health impact by determining the effectiveness of the ZS model in mental health clinics, a setting where suicide attempts and suicides occur at a higher rate than any other healthcare setting. It will also provide guidance on the implementation level required to achieve uptake and sustainability of ZS. TRIAL REGISTRATION: N/A.

Most Individuals Are Seen in Outpatient Medical Settings Prior to Intentional Self-Harm and Suicide Attempts Treated in a Hospital Setting.

The objective of this quantitative retrospective study is to understand healthcare patterns prior to self-harm, which may inform prevention efforts and identify intervention sites. Medicaid claims within 30, 60, 90, and 365 days prior to hospital-treated self-harm between 11/1/2015 and 11/1/2016 in New York State (N = 7492) were examined. Numbers and proportions were calculated for all service types. Participants were predominately 15-34, female, and White. Most (97%) had prior-year services, 94% outpatient care (73% behavioral health, 90% medical), 69% emergency department (37% behavioral health, 59% medical), and 42% inpatient services (34% behavioral health, 20% medical). About 86% received services within 90 days and 80% within 60 days. Utilization was high within 30 days prior, with 69% having one or more services. Medical services were more common than behavioral health (94% versus 79% in prior year); outpatient (94%) was more common than emergency (69%) and inpatient (42%) care. Given that most patients received health services within 30 days and almost all saw providers within the year prior, the findings indicate that improved prevention efforts within the healthcare system can reduce the incidence of self-harm.

"Zero Suicide" - A model for reducing suicide in United States behavioral healthcare.

Suicide is a serious public health concern in the US, especially for those served in outpatient behavioral health. Over the past decade, there has been a dramatic increase in US suicide rates, and a significant proportion of those dying by or attempting suicide were treated in outpatient behavioral healthcare within the prior year. In response, the US Action Alliance released the National Strategy for Suicide Prevention in 2012, a key tenet of which is the "Zero Suicide" (ZS) model. ZS provides resources for administrators and providers to create a systematic approach to quality improvement for suicide prevention in healthcare systems via seven essential elements (Lead, Train, Identify, Engage, Treat, Transition, Improve). In this paper, we describe the ZS model, as well as our operationalization of the model in an NIMH-funded study in ~170 free-standing New York State outpatient behavioral health clinics, serving >80,000 patients. This study is the largest implementation and evaluation of the ZS approach ever conducted in outpatient behavioral health. Evaluation of ZS implementation in "real-world" clinical settings will provide crucial insight regarding broader dissemination and inform how to best adopt empirically-supported care for suicidal patients in outpatient behavioral health, thereby reducing tragic and preventable loss of life.