Project 2025—Raising Awareness for Suicide Treatment
Transcript of Project 2025—Raising Awareness for Suicide Treatment
Project 2025—Raising Awareness for Suicide Treatment
Christine Moutier, M.D. Chief Medical Officer AFSPDavid Jobes, Ph.D. The Catholic University of AmericaDiana Cortez Yanez Lived Experience Consultant
February 2, 2021
Continuing Education Credits & Access to the Recording and Slides
• This closed captioned webinar will be recorded• 2 free CEs are available for attending today’s webinar
• American Psychological Association
• NBCC – CEs through CAMS-care, LLC ACEP # 7039
• National Association of Social Workers (Approval # 886455354-6865)
• You will receive an email from CAMS-care.com following the webinar with a link to complete a survey and receive your CE certificate
• Make sure your name and email are correct in Zoom
• A recording of the webinar and a downloadable slide deck will be available on AFSP and CAMS-care’s websites later in the week
• https://afsp.org/hcp
• https://cams-care.com/resources/events/suicide-prevention-healthcare-settings/
• We have 30 minutes at the end for Q&A. Use the Q&A button at any time during this webinar to post your questions
Today’s Presenters
Dr. Christine Moutier. AFSP’s Chief Medical Officer, knows the impact of suicide firsthand. After losing colleagues to suicide, she dedicated herself to fighting this leading cause of death. Dr. Moutier has served as UCSD professor of psychiatry, dean in the medical school, medical director of the VA Psychiatric Unit, and has been clinically active with diverse patient populations, such as veterans, Asian refugee populations, as well as physicians and academic leaders with mental health conditions. She has presented at the White House, testified before the U.S. Congress, presented at the National Academy of Sciences, and has appeared as an expert on Anderson Cooper 360, the BBC, CBS This Morning, The Atlantic, The New York Times, Time, The Washington Post, The Economist and NBC Nightly News.
Today’s PresentersDavid A. Jobes, Ph.D., ABPP. Is a Professor of Psychology, Director of the Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. Dr. Jobes is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. Dr. Jobes has conducted research in clinical suicidology for 35 years. He is a past president of the American Association of Suicidology. Dr. Jobes is currently a Board Member of the American Foundation for Suicide Prevention (AFSP) and serves on AFSP’s Scientific Council and the Public Policy Council. He is a Fellow of the American Psychological Association and is Board certified in clinical psychology (American Board of Professional Psychology). He maintains a clinical and consultation private practice in Washington, DC.
Today’s PresentersDiana Cortez Yanez. After being in the behavioral health system for 30 years, as a patient, and having made multiple attempts on her life, Diana experienced a life changing treatment. She is now a national public speaker, advocate in suicide prevention and peer specialist. Her passion is sharing what she has gleaned from her experiences as to what helped and what was not helpful, in order to help save lives. Diana has had the opportunity to share her story internationally and in many different platforms such as, the White House, Facebook’s launch of suicide prevention feature, Canadian Health Magazine, Washington State Behavioral Health brochure, NPR, Indian Health Services, Cornerstone, Now Matters Now, Live Through This, Jasper Health, and Zero Suicide. She continues to look for and accept more ways to help in suicide prevention, such as this webinar, for sharing the specific details of her journey.
Learning Objectives
The Suicide Problem & the genesis of Project 2025 – goals and critical areas
How emergency departments and health systems clinically manage patients who are suicidal
Systems of care, evidence-based approaches and best practices to reduce suicide rates
Ethical and legal considerations of treating patients who are suicidal
2 CE credits provided for APA, NASW, and NBCC members
Agenda
• Suicide – a mental health care crisis• Project 2025 – reducing suicides in America - Emergency Departments and Health
Systems• Current Practices – Emergency Departments and Health Systems• A System of Care for Inpatient & Outpatient Treatment
• Screening & Assessment• Management of Suicidal Crises• Evidence based psychological treatments• Pharmaceuticals• Caring contact & Lived experience support
• Risk Management – Ethical & Legal Considerations• Q & A• Final thoughts
The Challenge of Suicide in the United States
A Stubbornly Growing Public Health Problem
United States 2018
Ideation vs Attempts vs Completions (2019)
• 47,511 deaths• 1.6 million made suicide attempts• 12 million adults with serious suicidal ideation• Including adolescents that number is closer to 14 million
Project 2025Reduce the suicide rate by 20% by the end of 2025
The focus today is on 2 of these 4 critical areas
Managing Patients Who are Suicidal TodayEmergency Departments & Inpatient Hospitalization
Emergency Departments today – What to expect?
• A long wait
• 15-minute watch
• Doctors and nurses are focused on medical rather than mental treatment• Some sort of screening or assessment
• Most likely an immediate hospitalization in urban communities and a patient being sent home in a rural community
• Variations in the experiences for all involved
• Some progress• EDs adopting tools like Jaspr, ICAR²E – a rich domain for innovation with an AFSP award
• Move towards universal screening
• Programs like Reaching Everyone Preventing Suicide where patient is referred to outpatient treatment
For a person who enters an ED with suicidal ideation – stats?
Jaspr Health Project from ED to home use?
https://www.youtube.com/watch?v=l9zbM8jEsvY&feature=youtu.be Jaspr at Home
Hospitalization:
Source: Luxton, D.D., June, J.D., Comtois, K.A. (2013) Can postdischarge follow-up contacts prevent suicide and suicidal behavior? Crisis 34(1) 32-14
Not Always a Good Intervention for Patients Who are Suicidal
The majority of suicides post-hospitalization occur within the
first month after discharge
Rates of suicide after discharge is more than 100 times the rate of
the general population
Compliance with routine treatment after discharge has been found to be
less than 40%
Only 25-50% attend an appointment for outpatient treatment
Outpatient Management of Suicidal Crises
Safety Plan Intervention(Stanley & Brown)
Crisis Response Plan(Rudd & Bryan)
Virtual Hope Box (Bush)
Caring for Patients Who are
Suicidal A Systems Approach
Suicide System of Care–Inpatient & Outpatient
Well established screening tools include ASQ & PHQ-9
Assessment is a process and useful tools include C-SSRS, SSI,SHBQ, SBQ-R…
CAMS
DBT
CT-SP & BCBT
Caring Follow-Up(e.g., calls/emails)
Platforms -e.g.,NeuroFlow, WellTrack
Psychosocial Services
Evaluation of Suicidal Risk
Evidence Based Suicide-Specific Assessment &
TreatmentNon-Demand Caring Contacts
CLINICAL CARECommunity Awareness
QPR
ASIST
Umatter
Sources of Strength
CALM
Postvention
Build Awareness that help & treatment is available
70% of people who die by suicide are not engaged in mental health treatment at the time of their death
Public Awareness
Ideally in an outpatient setting for all but the most extreme cases – most patients do not want to be locked up
Screening
Assessment
Screening & Assessment for Suicidal Risk
Effective Clinical Treatments
for Suicidal States
Evidence-Based Treatments for Suicidality
• 90+ RCT’s with suicidal ideation and behavioral outcomes
• No support for inpatient hospitalization
• Increased risk of suicide post-discharge
• Handful of treatments with single RCT support (e.g., ASSIP)
• Suicide-specific interventions with replicated and independent RCT support:
• Dialectical Behavior Therapy (DBT)
• Two types of suicide-specific CBT (CT-SP & BCBT)
• Collaborative Assessment and Management of Suicidality (CAMS)
• Non-demand follow-up “caring contact”
Dialectical Behavior Therapy (DBT)
Source: DeCou, C.R., Comtois, K.A., Landes, S.J. (2019) Dialectical Behavior Therapy is effective for the treatment of suicidal behavior: A meta-analysis Behavior Therapy. 50(2019) 60-72
DBT is an Outpatient Treatment with Four Modalities:
Group Skills Training1
Individual Psychotherapy2
Out-of-session Phone Coaching3
Therapist Consultation Team Meeting4
Dialectical Behavior Therapy (DBT)
Meta-analysis of 18 controlled trials of DBT
Source: DeCou, C.R., Comtois, K.A., Landes, S.J. (2019) Dialectical Behavior Therapy is effective for the treatment of suicidal behavior: A meta-analysis Behavior Therapy. 50(2019) 60-72
DBT Reduced Self-Directed Violence
DBT Reduced Frequency of Psychiatric
Crisis Services
Suicidal Ideation was not significantly impacted by DBT in most of the studies
Cognitive Therapy for Suicide Prevention (CT-SP)
Source: Brown, G.K., Ten Have, T., Henriques, G.R., Xie, S.X., Hollander, J.E., Beck, A.T. (2005) Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294, 563-370
• Identifying thoughts, images, core beliefs• Emphasis on “suicidal mode”• Develop adaptive ways of coping with
stressors• Relapse prevention task
Methods:
Cognitive Therapy for Suicide Prevention (CT-SP)
Source: Brown, G.K., Ten Have, T., Henriques, G.R., Xie, S.X., Hollander, J.E., Beck, A.T. (2005) Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294, 563-370
CT-SP was twice as effective as
usual care in reducing
suicide attempts
Patients in CT-SP treatment had
significantly lower scores on Beck Depression Inventory (BDI)
Patients in CT-SP treatment had
significantly lower levels of hopelessness
Results of Study
Source: Rudd, D.M., Bryan, C.J. et al (2015) Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015 May;172(5):441-9
Phase I: Brief Cognitive Behavioral Therapy
Methods
Phase II: Assessment of suicidal behaviors and develop strategies
Phase III: Apply strategies to reduce vulnerability to using suicide to cope
Phase IV: Relapse prevention task conducted
Brief Cognitive Behavior Therapy (BCBT)
Treatment of Suicidal States
Brief Cognitive Behavior Therapy (BCBT)Treatment of Suicidal States
Source: Rudd, D.M., Bryan, C.J. et al (2015) Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015 May;172(5):441-9
Soldiers in BCBT 60% less likely than
soldiers in treatment to make a suicide attempt
during the 2 year follow up period
Soldiers in BCBT slightly less likely
to be medically retired than Soldiers in control treatment
Results of Study
The Relative Importance of Suicidal Ideation(as a massive population at risk)
We are understandably preoccupied with attempts and deaths.But why do we not appreciate the largest population who are suicidal—those with serious suicidal ideation?
The Collaborative Assessment and Management of Suicidality (CAMS)
A Treatment Framework that Provides Risk Assessment, Stabilization Planning, and Treatment of Patient-Defined Suicidal Drivers
The Collaborative Assessment and Management of Suicidality (CAMS)
The four pillars of the CAMS framework:
1) Empathy
2) Collaboration
3) Honesty
4) Suicide-focused
Goal: Build a strong therapeutic alliancethat increases patient-motivation; CAMS targets and treats patient-definedsuicidal “drivers”
First session of CAMS—SSF Assessment, Stabilization Planning, Driver-Focused Treatment Planning, and HIPAA Documentation
CAMS Tracking/Update Sessions CAMS Outcome/Disposition Session
CAMS for Suicidal Ideation
• Understand the direct and indirect drivers of suicidal ideation
• CAMS Assessments® - assess what might be the best way to support the patient
• Develop a CAMS Stabilization Plan to provide resources for the patient
• CAMS Treatment® - develop a treatment plan to address the direct and indirect drivers of suicidal ideation
• Provide a framework to shape treatment to target and treat the drivers of suicidal ideation
The CAMS Framework® is an assessment and suicide-focused treatment
Summary of CAMS Research Findings to Date
• Reliably reduces suicidal ideation in 6-8 sessions• Reduces overall symptom distress, depression, hopelessness, and
changes suicidal cognitions• Increases hope and improves clinical retention to care• Patients like CAMS and the process of doing CAMS• Works better with patients who are less severe at baseline presentation • Decreases ED visits among certain subgroups• A promising impact on self-harm behavior and suicide attempts• Relatively easy to learn
Across 8 published non-randomized clinical trials of CAMS, 1 meta-analysis, 5 published randomized controlled clinical trials, and 3 unpublished RCT’s (a total of 90+ publications):
MedicationsAre there medications that work?
Medications and CNS Treatments
• Maximize treatment for primary diagnosis AND consider suicide risk as well
• Understand the data re FDA Black Box warning- AD in <24 years old• Medications with evidence for reducing suicidal behavior
• Lithium (1 RCT, numerous secondary outcome)• Clozapine (1 RCT)• Antidepressants (RCTs, pharmaco-epidemiological studies)
• Esketamine (FDA approved for treatment-refractory MDD & MDD with Suicidal Ideation)
• Electroconvulsive therapy (ECT)• Maybe transcranial magnetic stimulation (TMS)• Best in combination with therapy
Caring Contact & Lived Experience Support
The importance of not being forgotten and peer support
Caring Contact Outreach & Lived Experience Peer-Based Support
• Caring letters• Caring postcards• Caring phone calls• Caring emails• Caring texts• ED follow-up calls• Inpatient follow-up
phone calls• Post-discharge home
visits (e.g., VA)
And the power of using technology to reach more people at risk for suicide…
Ethical and LegalConsiderations
Know the three “pillars” for reducing malpractice liability(i.e., malpractice wrongful death tort litigation pursued by a plaintiff):
(Jobes & Berman, 1993)
Malpractice Liability, Competent Practice, and Cases of Suicide
Foreseeability Follow-up/follow-through
Treatment planning
Suicide-Related Malpractice Liability
• Malpractice tort litigation for wrongful death secondary to a patient suicide is pursued by plaintiffs (e.g., surviving family) who assert that the provider breached the “standard of care.”
• The Standard of Care is operationally defined as what a reasonably prudent practitioner who is similarly trained, in a similar setting, with a similar patient would do.
• The Standard of Care is defined by expert witnesses who examine subpoenaed records, interrogatories, and depositions related to the case.
Suicide-Related Malpractice Liability
The plaintiff has the burden of proof to establish that the practitioner:
• Failed to assess the risk (i.e., foreseeability)
• Failed to appropriately treat the risk
• Failed to follow-through on risk over the course of treatment
Enhanced Clinical Documentation—Reducing the Risk of Malpractice • For example, CAMS uses the SSF in every session
Follow SPRC COVID Virtual Environment guidelines
Resources for Therapists and Families
1.For cliniciansa.Action Alliance Recommended Standard Care b.The Joint Commission Suicide Prevention Portalc.Project 2025 SafeSide linkd.Discount of 20% on any CAMS training using code AFSP21 at https://cams-care.com/products/
2.For the publica.afsp.org to learn more about suicide preventionb.To learn more about treatment https://afsp.org/treatmentc.Finding treatment https://afsp.org/find-a-mental-health-professionald.What to do when someone you love is struggling https://afsp.org/what-to-do-when-someone-is-at-riske.https://afsp.org/find-a-local-chapter to find chapter near youf.Tips for parents https://afsp.org/teens-and-suicide-what-parents-should-knowg.Resources for suicide bereavement https://afsp.org/ive-lost-someoneh.If you're worried about someone https://afsp.org/when-someone-is-at-risk
New U.S. Surgeon General Call to Action
Questions and Answers
Continuing Education Credits & Access to the Recording and Slides
• A recording of the webinar and a downloadable slide deck will be available on AFSP and CAMS-care’s websites• https://afsp.org/hcp
• https://cams-care.com/resources/events/suicide-prevention-healthcare-settings/
• 2 free CEs are available for attending today’s webinar• American Psychological Association
• NBCC – CEs through CAMS-care, LLC ACEP # 7039
• National Association of Social Workers (Approval # 886455354-6865)
• Webinar attendees will receive an email with a link to the CE Survey. Completing the survey will result in a CE Certificate
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Final Thoughts