Introduction
Suicide is an urgent concern: in 2020, suicide was the twelfth leading cause of death for all ages in the United States — with almost 50,000 recorded suicide deaths (Centers for Disease Control and Prevention, 2020). In adolescents, suicide was the second leading cause of death for ages 10 to 14, and the third leading cause of death for ages 15 to 24 (Centers for Disease Control and Prevention, 2020). As a major provider of behavioral health care, Concert Health has adopted comprehensive care models and pathways for both adult and pediatric patients at risk for suicide.
Collaborative Care, the evidence-based model used by Concert Health, supports patients at risk for suicide through the use of high-touch, evidence-based interventions (Gordon, Avenevoli, and Pearson, 2020; Schoenbaum, 2020). With many of the at-risk patients visiting primary care in the month of death, Concert Health believes their partnership with health care providers can help to reduce suicides nationally (Ahmedani et al., 2014).
Suicide Safer Care
Concert Health understands that patients’ risk and treatment needs can change during the course of care. In order to provide the appropriate care and treatment for patients of all ages, Concert Health has stratified suicide risk into three categories: High Risk, At Risk or Historical. Concert Health understands that individuals can have changes in risk, and utilizes evidence-based screening tools including the Columbia Suicide Severity Rating Scale (CSSRS) and the Ask Suicide Screening Questions (ASQ).
These tools directly ask patients about their risk for suicide which is one of the best preventive practices (Yershova et al., 2016). All Concert Health patients who are identified as at risk are assessed daily or weekly by their primary care team and those closest to them.
Suicide Safer Care for Adults
While interacting with patients, many health care partners who collaborate with ConcertHealth screen for depression using the PHQ-9, the gold standard, validated tool for assessing depressive symptoms (Kroenke, Spitzer, and Williams, 2001; Manea, Gilbody, and McMillan, 2015). Screening for depression is important. Systematic reviews demonstrate high associations between more severe forms of depression and suicide (Hawton et al., 2013).
In addition to the PHQ-9, Concert Health also uses the C-SSRS for patients ages 16 and up. The C-SSRS is a validated tool recommended by the United States Food and Drug Administration for its utility and accuracy of identifying suicidal ideation, plan and intent (Na et al., 2018; Posner et al., 2011). The C-SSRS is to be used at every contact with patients who are classified as At Risk or High Risk. Since many patients at risk for suicide may not present with depression, Concert Health continues to ask all patients about suicide directly.
Multiple versions of the C-SSRS are administered to track patients’ risk by asking about lifetime risk, risk in the past three months, and risk since last contact. This close monitoring allows for more accurate risk-flagging and monitoring. Asking about past suicidal thoughts and/or acts, especially if they are persistent and involve a strong intent to die, is crucial because they are the strongest predictors of who will die by suicide (Sveticic and Leo, 2012).
The Concert Health adult suicide safer care incorporates all evidence-based practices including asking patients directly about suicide, administering evidence-based risk assessments, consistently reviewing risk and placing suicide on the diagnosis list.
Suicide Safer Care for Children and Adolescents
Nationally, 8.9% of high school students attempted suicide one or more times in the past year, and 18.8% of high school students reported “seriously considering attempting suicide” in the past years (Underwood et al., 2019). Suicide is the tenth leading cause of death for 6 to 9 year olds and the second leading cause of death for 10 to 14 year olds (Centers for Disease Control and Prevention, 2020). There is a clear need to address suicide in adolescents, from early identification to treating the first onset of suicidal ideation (Connor and Portzky, 2018).
Concert Health cares for children ages 6 and up. Adopting the widely-used ASQ, a validated tool supported by the National Institute of Mental Health, Concert Health clinicians ask children and adolescents directly about suicide (Horowitz et al., 2012). In primary care settings, the ASQ showed a sensitivity of 100.0% (95% CI: 59.0–100.0%), specificity of 87.9% (95% CI: 82.0–92.3%) and NPV of 100.0% (95% CI: 97.7–100.0) (Aguinaldo et al., 2021).
Since many children and adolescents are not screened for suicide in other settings, Concert Health ensures that all patients ages 10 and up are asked directly about suicide with the ASQ. Children under 10 are assessed with the ASQ if identified or flagged as at risk by themselves or someone caring for them.
Access to Firearms and Lethal Means
Concert Health asks all patients about access to firearms and other lethal means. Regardless of current suicide risk, counseling on access to firearms has proved to be a suicide prevention effort with some of the most robust supporting evidence (Lewiecki and Miller, 2013; Sale et al., 2017; Bandealy et al., 2020).
For males in 2020, the leading means of suicide was firearms with a rate at least twice that of suffocation, the second leading means (Garnett, Curtin, and Stone, 2022). For females in 2020, the rate of firearm-related suicide was higher than the rates of suicide by poisoning and suffocation. Most notably, 90% of suicide attempts with a firearm end in death (Conner, Azrael, and Miller, 2022).
Safety Planning
In addition to counseling on access to firearms and lethal means, Concert Health actively utilizes the evidence-based intervention of interactive safety planning with patients of all ages identified to have risk for suicide. The only evidence-based safety plan, the Stanley-Brown, is developed during initial contact and subsequently reviewed and revised at each and every contact for patients who are high risk or at risk for suicide (Stanley and Brown, 2012). The safety plan is treated as an intervention and is done collaboratively with patients — each patient has a personalized safety plan available to them. Safety plans are shared with patients and placed in the medical record for easy access.
Reducing Risk With Treatment
Throughout the course of treatment, clinicians at Concert Health understand the importance of treating suicide risk directly. Utilizing the dialectical behavioral therapy (DBT) and motivational interviewing (MI), both are effective tools for treating suicide. Comprehensive safety plans, means reduction and treatment provide an opportunity to reduce risk for many patients during the course of treatment.
Since the adoption of risk stratification, Concert Health has been able to track and monitor patients’ risk. Concert Health also supports its staff in receiving specialized clinical supervision, psychiatric consultation and dedicated organizational skills training related to suicide prevention and treatment as part of the onboarding experience. Additionally, Concert Health also provides all health care providers free CME training around identifying and caring for patients at risk for suicide in their settings.
Conclusion
Since January 1, 2022, a total 853 patients were identified as having some risk for suicide during treatment. Of the 853 patients, 395 patients were flagged as high risk, 338 were identified as at risk for suicide, and 120 were flagged as historical risk. Since January 1, 2022, 229 patients have had their risk flag lowered.
Concert Health understands the importance of a comprehensive, evidence-based treatment model and care pathways for pediatric and adult patients at risk for suicide. Concert Health will continue to monitor updates in research and best practices for adoption, as well as a concentrated effort to train and support our health care partners and clinicians.
Concert co-founder and Chief Clinical Officer, Virna Little, an internationally recognized clinician known for her work in developing sustainable integrated delivery systems and suicide prevention, developed the curriculum that has trained more than 3,300 primary care providers and their teams in suicide safer care in more than 29 states. The training is provided to all requesting organizations and included in Concert Health implementations. To learn more, visit https://concerth
