Suicide Attempts Reduced by 25% with Integrated Primary Care Intervention

Integration of a suicide screening and safety planning program in primary care practices across Washington State resulted in a 25% drop in the rate of suicide attempts in the 90 days after a primary care visit, according to findings published today in the Annals of internal Medicine.¹

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The study, a secondary analysis of a randomized stepped-wedge trial conducted at 19 Kaiser Permanente clinics in Washington State, found specifically that suicide attempts fell from 6.0 to 4.5 per 10 000 patient visits over the 90-day period. After implementation of the integrated suicide care model, documented safety plans within 2 weeks of a primary care visit that elevated concern for suicide increased by 14%. Overall, reported lead author Julie Angerhofer Richards, PhD, MPH, a collaborative scientist at Kaiser Permanente Washington Health Research Institute, more people were screened and assessed for suicide risk, depression, and alcohol and drug use after implementation compared to usual care.¹

"Our findings are important because we know many people seek primary care prior to fatal and nonfatal suicide attempts," Richards said in a statement.² "Many health care systems in the US and abroad now routinely ask patients about suicidal thoughts, and this study provides evidence to support this practice, in combination with collaborative safety planning among people identified at risk of suicide attempt."²

The original Kaiser Permanente study was designed to evaluate integration of alcohol misuse care into primary care. But Richards and her research team requested that a population-based suicide care component be implemented at the same time as care for substance use as part of the behavioral health initiative. The health system did not have any prior population-based screening or systematic follow-up for these conditions in primary care, according to the study.

Suicide care intervention

The suicide care intervention included use of the 2-item Patient Health Questionnaire for depression, 3-tiem Alcohol Use Disorders Identification Test-Consumption, a cannabis use frequency question, and a question about frequency of the use of illegal drugs or nonmedical use of prescription medications. Any positive screening result was followed by additional assessment, and primary care clinicians were instructed to connect patients immediately with designated care team members for same-day safety planning as well as short-term counseling and linkage to specialty mental health and substance use treatment, as needed, according to the study.

Investigators divided the trial into a usual care period before the intervention launch date (including a 2-month preparatory period) and the intervention period after the launch date that included the 4 months of active practice facilitation. Implementation of the intervention was supported by practice facilitation, electronic medical record (EMR) decision support, and performance monitoring. Clinical decision support included previsit screening and assessment reminders for primary care teams in addition to prompts to support identification of suicide risk and mitigation during clinic visits.

The primary outcomes for the study were safety planning after population-based screening and suicide risk assessment (process outcome) and suicide attempts (nonfatal) or deaths, with self-harm intent, within 90 days of a visit (patient outcome).

FINDINGS

According to the study results, from January 2015 to July 2018, a total of 255 789 adults made 953 402 primary care visits during the usual care period and 228 255 made 615511 visits during the suicide care period. The mean age of participants was 49.3 years for usual care and 50.2 for suicide care; more than half (58.5%) of participants were women; 71.8% self-identified as white non-Hispanic/Latinx, 10.9% as Asian or Asian American, 6.7% as Black or African American, and 6% as Hispanic/Latinx. In terms of mental health assessments, 17% of the cohort had depression, 12.8% had anxiety, and 1.9% had alcohol use disorder.

The researchers reported the median number of visits across both study periods for individuals reporting frequent suicidal thoughts (during any visit) was 3 and for those reporting no suicidal thoughts was 2.

All the screening and assessment process outcome rates were significantly higher in the suicide care group vs usual care group when the 2 care periods were compared, according to the study.

As mentioned, the rate of safety planning was higher in the suicide care group compared with the usual care group (38.3 vs 32.8 per 10 000 patients) for a rate difference of 5.5 plans (95% CI 2.3 to 8.7). Suicide attempts within 90 days were lower in the former than the latter (4.5 vs 6.0 per 10 000 patients) for a rate difference of 1.5 fewer in the former (95% CI -2.6 to -0.41).

The study’s greatest limitation is the real-world setting with the overlap in care for suicidality and substance abuse, making it difficult to tease out which elements of the intervention may have been most effective in preventing suicide. “Findings reflect the effectiveness of implementing suicide care in combination with care for substance use. Addressing alcohol use may have been impactful due to the high prevalence of co-occurring depression, suicidality, and [alcohol use disorders]; additional research is needed to evaluate how care for [alcohol use disorders] may enhance care for suicidality,” Richards and colleagues wrote. Further, they suggest that future research examine “both independent and bundled effects of clinical practices supporting care for depression, suicidality, alcohol, cannabis, and other drug use.”

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting "988."

References

1. Richards JA, Curz M, Stewart C, et al. Effectiveness of integrating suicide care in primary care. Secondary analysis of a step-wedge, cluster randomized implementation trial. Ann Intern Med. Published online September 30, 2024. doi:10.7326/M24-0024 

2. Suicide attempts decreased after adding suicide care to primary care, study finds. News release. Kaiser Permanente. September 30, 2024. Accessed October 1, 2024. https://medicalxpress.com/news/2024-09-suicide-decreased-adding-primary.html