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Zero Suicide Academy
Reducing Suicide for Those in Care
Spokane March 10, 2015
#zerosuicide
Ursula Whiteside, PhD
#ZeroSuicide #LivedExp #SPSM
@UrsulaWhiteside
www.NowMattersNow.org
A Fledgling Movement and a Mission
Zero Suicide Academy
LIVED EXPERIENCE
Lived Experience
 Lived Experience – describes those with
suicidal experiences willing to share their
expertise in order to improve suicide
prevention
 Lived Experience consultants are active
participants in the guidance of suicide care
Team Now
Matters Now
Hack Suffering
Zero Suicide Academy
GROUP HEALTH EXAMPLE
Group Health Example
 Screening
 PHQ at every Behavioral Health visit
 PHQ annually for Primary Care
 Assessment
 If PHQ item 9 score <=2, complete Columbia
Suicide Severity Rating Scale
 Public health statement for Lethal Means
 Quality Improvement
Patient Health Questionnaire (PHQ-9)
Patient Health
Questionnaire
(PHQ)
“Thoughts you
would be
better of dead
or thoughts of
hurting
yourself in
some way”
Does Response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or
suicide death? Psychiatric Services, 64, 1195-1202. PMID: 24036589 (2013)
PHQ Item 9 Predicts Suicide Attempt
“Thoughts you
would be better
of dead or
thoughts of
hurting yourself
in some way”
Nearly every
More than half
Several days
Not at all
Days
Since
PHQ
PHQ Item 9 Predicts Suicide Death
“Thoughts you
would be better
of dead or
thoughts of
hurting yourself
in some way”
Nearly every
More than half
Several days
Not at all
Days
Since
PHQ
Columbia Suicide Severity Rating Scale
Risk-specific follow-up protocol:
• Low: Routine follow-up
• Moderate: Create crisis plan
• High: Create crisis plan, refer to
acute-care coordination path
• Severe: Consider hospitalization
© Simon 2014
Public Health Approach to
Lethal Means Reduction
“This is a public health safety issue, like wearing
motorcycle helmets and knowing the signs of a stroke…
We universally recommend that people who are
experiencing depression and/or significant stress, and
especially people experiencing suicidal thoughts, DO NOT
HAVE EASY ACCESS TO GUNS (or pills, etc.) – just like we
would for your mother, brother or sister if they were
experiencing these symptoms”
-Ursula Whiteside, 2012
Quality Improvement
Learning Healthcare System
“Each patient care experience naturally reflects the
best available evidence, and, in turn, adds
seamlessly to learning what works best in different
circumstances.”
IOM Roundtable on Evidence-Based Medicine, 2008
© Simon 2014
Quality Improvement
Learning Healthcare System
 All experience contributes to evidence
 Evidence is truly based in experience
 Learning happens continuously, in real
time
 Clinical data = research data
© Simon 2014
Quality Improvement
Percent of Primary
Care visits with
Antidepressants
prescription where
PHQ recorded in
Electronic Health
Record
© Simon 2014
Quality Improvement
© Simon 2014
Quality Improvement
140,000
105,000
2007
2008
2009
2010
2011
2012
70,000
35,000
0
Group Health
HealthPartners
KP Colorado
KP So Cal
© Simon 2014
Quality improvement
SRA Misses 08/2013
Pra Nbr
Fist Name
Csr Number
Encounter Date
043816
Pra Last
Name
xxxxxxx
xxxxxxx
zzzzzz
08AUG2013:15:00:00
PHQ-9 Question
9
2
043816
xxxxxxx
xxxxxxx
zzzzzz
13AUG2013:16:30:00
2
001153
xxxxxxx
xxxxxxx
zzzzzz
26AUG2013:16:00:00
2
002731
Simon
Gregory
zzzzzz
26AUG2013:15:00:00
2
002359
xxxxxxx
xxxxxxx
zzzzzz
15AUG2013:09:30:00
2
002359
xxxxxxx
xxxxxxx
zzzzzz
22AUG2013:13:30:00
2
001996
xxxxxxx
xxxxxxx
zzzzzz
09AUG2013:14:30:00
2
001996
xxxxxxx
xxxxxxx
zzzzzz
19AUG2013:13:30:00
3
© Simon 2014
Quality improvement
 How do you measure impact on suicide
attempts and deaths?
 How is the numerator calculated?
 How is the denominator calculated?
Intervention Research: Pragmatic trial of populationbased selective prevention programs (Greg Simon Uh3
funded by NIH Collaboratory)
Outpatients responding
“more than half the days”
or “nearly every day” to
PHQ item 9
Usual Care
Emotion Regulation
Skills Training
(NowMattersNow.org
is DBT Skills)
Risk Assessment /
Care Management
© Simon 2014
What Clients Want from Providers:
From Team Now Matters Now
 Be fully present with me
 Help me hold my pain (feel less alone in my pain)
 I feel helpless, broken, and scared
 Please be aware if you are afraid and acknowledge it
 Be transparent about what you are thinking and feeling
(but communicate in nonjudgmental and non-defensive
way)
What Clients Want from Providers:
From Team Now Matters Now
 I may try to manage your emotions for you
 Discuss with me my diagnosis, as it is in the charts and go
through the DSM criteria with me
 When including family and friends in plan, tell me and let
me decide who and how
 Help me to empower myself
 First I need empathy, a witness (rather than fixing)
What Clients Want from Providers:
From Team Now Matters Now
 Treat my sleep problem
 Gently examine my paranoid thoughts with me
 I might feel like I’m bad or wrong for having these thoughts
 I might feel like I’m “in trouble” for reporting ideation
 Balance trusting me and my innate capabilities AND yourself as a
clinician when what I reveal is potentially unsafe
 Ask, “Would you tell me if you did have [plans, a gun, pills etc]?”
then PAUSE and watch my response and nonverbals
What Clients Want from Providers:
From Team Now Matters Now
 Acknowledge that there is hope AND also that this is a problem
that researchers are still working on finding better cures for
 Give me feedback about the way I am asking you for help
 Know that I am telling you about my suicide ideation/plans
because I want to live, I want help, and I want to work together
 I may be paying very close attention to how you respond to
what I say, and telling you more or less based on how open I
think you are to hearing it and how much I trust you
Designing Messaging to Engage Patients in an Online Suicide Prevention Intervention: Survey
Results from Patients with Current Suicidal Ideation. Journal of Medical Internet Research,
6(2):e42. doi:10.2196/jmir.3173
(2014)
Your Feedback Counts Study
Whiteside et al., 2014
Intervention Content
Whiteside et al., 2014
Intervention Name
Whiteside et al., 2014
Just beginning to scratch the surface
 Most of our research is focused on those already
known to be at risk
 Most of those who die are not known to be suicidal or
at risk for suicide…
© Simon 2014
HealthCare System
Zero Suicides in Health Care:
Population
Targeting Pathways to Suicide and Suicide Attempt
Dr. Ursula Whiteside
Enrolled Consumers
Seeing PC and/or
BHS Provider
Receiving PHQ
Not Enrolled
Not Seeing PCP
Not Receiving PHQ
Reporting Ideation
Medically Treated SelfInjury Coded as a Suicide
Attempt or Suicide Death
Not Reporting
Ideation
Zero Suicides in Health Care
HealthCare System
Targeting Pathways to Suicide and Suicide Attempt
Population
Dr. Ursula Whiteside
50% of suicide attempts
Enrolled Consumers
Seeing PC and/or
BHS Provider
Receiving PHQ
Not Enrolled
Not Seeing PCP
Not Receiving PHQ
25% of suicide
attempts
Reporting Ideation
Not Reporting
25% of suicide
attempts
Ideation
Medically Treated SelfInjury Coded as a Suicide
Attempt or Suicide Death
Zero Suicides in Health Care:
HealthCare System
Targeting Pathways to Suicide and Suicide Attempt
Population
Dr. Ursula Whiteside
Insurance enrollment
includes automatic
Enrolled Consumers
Not Enrolled
registration for secure
messaging with providers
using medical record
Health Profile (including
screening)
Seeing PC and/or depression
Not Seeing
PCP sent
annually via secure messaging
BHS Provider
Online CBT offered
Attempt to schedule PCP visit
Depression Screening and Lethal
Receiving PHQ Means Removal
Not Receiving
PHQ for
Protocol
those with Depression
Online CBT offered
Simon Suicide Risk Identification
Reporting Ideation
Method
Columbia Suicide Severity Rating
Scale
Crisis Planning
Lethal Means Removal Protocol
Unexpected Attempt
Qualitative
Not Reporting
Interviews Ideation
Medically Treated SelfInjury Coded as a Suicide
Attempt or Suicide Death
Safety Planning and Means Restriction
 All persons with suicide risk have a safety plan in
hand when they leave care.
 Safety planning is collaborative and includes:
aggressive means restriction, communication
with family members and other caregivers, and
regular review and revision of the plan.