CIPC Blog

Talking Suicide Prevention with Dr. Boudreaux, part 1 of 4

This is the first of a 4-blog post series where Dr. Edwin Bourdreaux chats with us about his work recently highlighted by NIH: HEAL Research Spotlight, Taking Suicide Prevention into Primary Care Settings. 

About Edwin D. Boudreaux, PhD:

Dr. Boudreaux approaches the challenge associated with solving seemingly intractable barriers to deliver high-quality behavioral healthcare by working with interdisciplinary teams who have complementary expertise and perspectives and figuring out the right balance between human-centered approaches and the use of technology to facilitate workflow.

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Thank you so much for taking the time to chat with us about the important work you’re doing, highlighted by NIH. Could you share with us your insights regarding the role of primary care in suicide prevention?

I’d be happy to. I think the first thing we need to establish is why is suicide prevention important. When we roll out our efforts into settings like primary care, the questions are why do we even care about this? Why do we need to pay attention to suicide prevention in primary care? Is it a problem? We have to address these questions first. 

What I usually appeal to is the literature that looks at people who die by suicide and then goes backwards and looks at whether those individuals had encountered a health care system or health care visit in the year before they died. The researchers look closely at the 365 days before death. 

What we learn when we do this is that a significant proportion of these patients, in fact 83%, have seen some health care provider in the year before they died. This includes primary care; at least half had seen a primary care provider before they died. What's most intriguing is most of these patients aren’t seen for mental health disorders and haven’t been diagnosed with mental health disorders. So most of the patients dying by suicide are seen in a health care setting including primary care, and their mental health problems are not recognized. 

This is what motivates us to try to improve our screening and prevention efforts in primary care. We’re missing these individuals and missing an opportunity to potentially save their lives by doing better screening. Primary care already does a lot of treatment of mental health problems; in fact most psychotropic medications are prescribed by primary care providers, not by psychiatrists. Primary care is already treating patients with mental health disorders - depression, anxiety, ADHD, substance use problems, in children and younger adults, and these patient populations have a primary risk factor for suicide. We need try to focus on how to best treat these patients who have a known risk factor for suicide. 

There has been a lot of work recently on how we should do that; how we should improve our screening and treatment or mitigation of suicide risks for patients who have a primary risk factor. That's really the motivation behind what we’re doing. It's rooted in the literature, it's also rooted in the interviews that we’ve had with primary care providers including those here at UMass. 

At UMass, we have done lots of in-depth interviews to find out how primary care providers are currently screening and managing patients with suicide risk, and frankly many of them don’t feel very comfortable. Many of them actually feel very uncomfortable - especially if they’re treating patients in a clinic that doesn’t have an integrated primary care approach so they don’t have behavioral health providers on board. 

Those individuals who are uncomfortable have asked for clearer guidance. They want something they can read and follow when they’re in a concerning patient interaction. This doesn’t happen very often but when it does happen it can be stressful for the provider. They are often worried about what the next step is, is there a liability concern, and this typically leads to variability in practice. 

Some providers might not do anything, they might just let the patient go and not take any actions to address the suicide risk. On the other hand, the primary care provider might send the patient directly to the emergency department. This may not be a good thing either because of the process of getting care in the emergency department; this whole experience is usually pretty uncomfortable for patients. 

What we try to do is try to figure out how can we inform the providers and give them some structure while still providing autonomy in their decision-making so they are less stressed about screening and identifying suicide risk and can channel patients to the most appropriate treatment path. We don’t want to under treat or over treat a patient. 

So in a nutshell this is why we are implementing suicide prevention screening and personal safety plans in our primary care sites rollout. 

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In our next blog post from this series, Dr. Boudreaux talks with us about personalized safety plans for suicide prevention. 

Resources: 

https://zerosuicide.edc.org/

https://zerosuicide.edc.org/sites/default/files/suicidesafercareguideforprimarycareproviders.pdf