Patient perceptions shed light on unexpected suicide attempts

Julie Richards, motivated by clinical practice needs and lived experience, is researching suicide-related care

By Julie Richards, MPH, research associate at Kaiser Permanente Washington Health Research Institute and PhD candidate, University of Washington Department of Health Services

The usual way to start a story about suicide research is to state where suicide ranks in the hierarchy of U.S. causes of death (10th), how many people die by suicide each year (more than 47,000), and how the numbers continue to rise. The usual way the mainstream media introduce the topic is to name famous people who recently died by suicide (e.g., Anthony Bourdain, Kate Spade).

These statistics and stories are important. But at KPWHRI, we are also learning that we must go beyond “business as usual” in suicide prevention. I want to tell you about the work we’re doing with Kaiser Permanente Washington health care providers to integrate mental health into everyday care. I also want to tell you what we learned by talking to patients who made an “unexpected” suicide attempt. I’ll share some of my own “lived experience” to explain why this research is meaningful to me, but also requires that I keep my assumptions in check.

Integrating help for suicidal patients into primary care

My current research is possible because in 2014, Kaiser Permanente Washington began including suicide-related care into routine primary care as part of the Behavioral Health Integration (BHI) initiative. This is an important step in suicide prevention because we know that siloing mental health care in psychiatric specialty settings means that most patients who could benefit from this care never receive it. We also know that many individuals see their primary care provider in the months leading up to death by suicide, which means primary care teams may have opportunities to help prevent suicide.

All adult patients at Kaiser Permanente Washington primary care locations are now screened at least annually for depression and substance use. Patients reporting frequent suicidal thoughts as part of this process are further assessed for suicide risk. This assessment helps providers make decisions about which patients have more immediate needs, including who may need to meet with a behavioral health specialist and who may need collaborative safety planning provided the same day as the assessment.

Why patients may not report suicidal ideation

Making suicide-related care part of BHI means that more Kaiser Permanente Washington patients are likely to get access to the help they need when they need it. However, we know that some patients do not report suicidal ideation prior to suicide attempt. We wanted to learn from those patients how to improve suicide care, so in a project funded by the American Foundation for Suicide Prevention, we found patients who, in 2016 and 2017, reported having no thoughts of self-harm yet attempted suicide within the next 60 days. My collaborator Ursula Whiteside, PhD (recently featured in Huffington Post), interviewed 26 patients who shared that they either were not having suicidal thoughts at the time of the visit or did not report them because of the fear of stigma, overreaction, and loss of autonomy. Our results, with details about what health systems can do to prevent suicide, are now published in Psychiatric Services.

I’m now building from both BHI and this research among suicide-attempt survivors. With help from collaborators, I interviewed 37 primary care patients who reported varying frequency of thoughts about self-harm (from “not at all” to “nearly every day”) during BHI screening at a recent primary care visit. I wrote a manuscript (now under review) describing what we learned. Findings include how provider expressions of active listening without overreaction may bolster patients comfort with disclosing stigmatized information about suicidality that they fear may compromise their autonomy.

Separately, I’m finalizing a related evaluation of these patients’ perceptions of a standard question about firearm access, which is now included on a questionnaire used to monitor depression in primary care. This will be helpful for understand the limitations of patient-reported information about firearms (and relatedly, limitations of interventions based on how patients answer).

My 'lived experience' informs my research

I want to acknowledge that I have some personal experience with suicide. I intentionally chose not to lead with this information, because suicide deaths have a way of captivating our attention and arousing a lot of competing emotions. I wanted you to hear about the research first, but I should tell you that my mom died by suicide in 2010. She shared many of the same experiences with the participants in our recent study with suicide-attempt survivors, including a bad experience with psychiatric hospitalization, lack of coordinated care among her health care providers, and fear of stigma. However, she did not survive her attempt, because part of her narrative included a love of firearms, which are a highly lethal means of suicide attempt, making it fatal in most cases (and my mom was not an exception).

The experiences my mom and I lived through together — including those that likely contributed to her suicide death — are a big reason I pursued this line of research. These experiences also create a lens through which I do this work; or said another way, I care more about this topic because of my “lived experience.” But this also means I need to constantly check my assumptions and not presume participants in my research share my experiences. I also collaborate with colleagues who are comfortable challenging assumptions — mine and others’. I hope our work together continues to change “business as usual” in suicide prevention and accomplishes my ultimate goal of putting us suicide researchers out of business and making the suicide-prevention research field obsolete.

BHI at Kaiser Permanente Washington is led by Ryan Caldeiro, MD, chief of Consultative Psychiatry and Chemical Dependency Services for Kaiser Permanente Washington and a clinical associate at KPWHRI; and Rebecca Parrish, LICSW, integrated behavioral health clinical consultant and social work manager.

Julie Richards’ work is also supported by her dissertation chair, Emily Williams, PhD; and committee members Susan Shortreed, PhD; Greg Simon, MD, MPH; and Rob Penfold, PhD. Other mentors/collaborators on the work described include Ursula Whiteside, PhD (who was principal investigator on the American Foundation for Suicide Prevention grant); Kathy Bradley, MD, MPH (whose Agency for Healthcare Research and Quality funding and leadership supported BHI implementation); Evette Ludman, PhD, David Grossman, MD, MPH; Joe Glass, PhD, MSW; Amy Lee, MPH; Casey Luce, MSPH; Mary Shea, MA; Chester Pabiniak, MS; Beth Kirlin; Sarah Hohl, MPH; Courtney Segal, and Rianna Hidalgo.

Watch for this work, with an emphasis on points relevant to psychiatrists, to be featured in an upcoming issue of Psychiatric Times. Julie will also be presenting her dissertation research, including evaluation of self-reported alcohol use as a predictor of subsequent suicide attempt, at a KPWRI research seminar in February.