Provider Education Suicide Prevention GNUR 8610 Stacey Lambour

Provider Education & Suicide Prevention GNUR 8610 Stacey Lambour, RN, BSN

Health Problem: Teen Suicide 3 rd leading cause of death from ages 1024 years. In 2004, the suicide 7. 32 per 100, 000 In 2010 it was 12. 1 per 100, 000 For adolescents the rate of attempted suicide in 2011 was 2. 4 per 100, 000 There are over 25 million adolescents in the US That means over 250, 000 suicide attempts will be made per year by adolescents (Healthy People, 2013; Forum on Child and Family Statistics, 2012)

Health Problem: Teen Suicide Children and adolescents experience suicidal thoughts Children 15 and over act on these thoughts more often that younger adolescents Males complete suicide more often; they are 6 times more likely to use lethal means Females attempt suicide 2 -3 times more often but use less lethal means (CDC, 2013; Cutler, 2001; Cash & Bridges, 2009; Waldvogel et al. , 2008)

Health Problem: Teen Suicide White Males have higher rates that White Females Minorities have lower rates that Whites, but they are increasing (CDC, 2013; Mackin et al. , 2012) American Indians & Alaska Natives have the highest risk of suicide of any race As high as 31 per 100, 000 for males & 10 per 100, 000 for females

Risk Factors: Teen Suicide Multifactorial Problem Presence of Mental Health Condition 90% have history of MI Mood disorder, Anxiety, Personality & Substance Abuse highly prevalent (Waldvogel et al. , 2008; Mann et al. , 2005) Family History of Suicide May be heritable up to 45% 5 times greater risk Previous attempt suicide Increased risk 30 fold for male and 3 fold for female

Risk Factors: Teen Suicide Impaired Parental Relationships More prevalent in single parent, divorced families More prevalent in dysfunctional parental relationships versus absentee relationships Exposure to Physical or Sexual Abuse Factor, not predictor Stressful Life Events Poor coping skills Economically disadvantaged Poor Academic Performance LGBT Contagion (Waldvogel et al. , 2008; Mann et al. , 2005)

Impact of Providers From 2003 -2004 the was a 18. 2% increase in the suicide rate in adolescents This jump is largely attributed to the SSRI FDA black box warning about increased risk of suicide in adolescent and the subsequent dramatic decrease in depression treatment and prescribing of SSRI’s for adolescents during this time. (Shain, 2007)

Provider Education Due to the shortage of Mental Health professionals, Primary Care Providers (PCP)and other Care Providers are diagnosing and treating a large portion of the mental health population. Unfortunately, assessment, diagnosis and treatment of mental illness is not extensively covered as part of most primary care or specialist (except MH) education.

Provider Education Identification and treatment of Mental Health conditions in Primary Care has been identified as a key concept in suicide prevention Identification and treatment has been found to significantly reduce suicidal behavior in adolescents Diagnosing, treatment, monitoring and referral are considered part of appropriate care.

Provider Education 70 % of the adolescent population are seen by PCP Most are not regularly screened for mental health conditions (Fallucco et al, 2012) Many mental health conditions begin show symptoms in adolescents Several Medical Advisory Committees recommend regular mental health screening, diagnosing & treatment in Primary Care

Health Belief Model Asserts that many factors are involved in an individuals motivation to change a behavior Factors Involved Perceived Susceptibility Perceived Severity Perceived Benefit Perceived Barriers Cue to Action Self Efficacy

Using the Health Belief Model to Influence Physicians Behavior Overall Goal Decrease rates of adolescent suicide and suicide attempts by increasing Provider screening and treatment of mental health conditions Goal 1: Increasing Provider mental health screening by 20% Goal 2: Increase the treatment of mental health conditions by increasing provider mental health education.

Using the Health Belief Model to Influence Physicians Behavior Goal 1 a: Increase provider perceived susceptibility vis à vis client’s susceptibility Goal 1 b: Increase provider perceived severity vis à vis client population severity Goal 1 c: Increase provider perceived benefit vis à vis client’s benefit Goal 1 d: Decrease provider barriers Goal 1 e: Increase provider cues to action Goal 1 f: Increase provider self efficacy

Goal 1 a: Increase provider perceived susceptibility Perceived Severity refers to the degree to which an individual feels he of she is susceptible to the health condition This must be addressed via patients (Lutifiyya, et al, 2012) 1: 5 children have a mental health condition (MHC) 34%-41% of Primary care patients have diagnosed MHC Over 40% originally seek treatment with PCP 80% of children who need mental health services do not receive them

Goal 1 b: Increase provider perceived severity Perceived Severity refers to how severe the provider perceives the health outcome to be (Dumont & Olsen, 2012) Median age of onset for depression is 14 Median age of anxiety is 11 In one PC office 8. 5% of adolescents had one of the disorders Only 22% of the 8. 5% where screened or treated

Goal 1 c: Increase provider perceived benefit Perceived benefit refers to the positive outcome that occurs if and when the individual decides to implement a preventative action (Jackson, 2011) 50 % of lifelong MI start by age 14. Missing the first signs & symptoms can result in lifelong disability The average adult is diagnosed 10 years after the mental illness began

Goal 1 d: Decrease provider barriers Perceived barriers are what the individuals believes is preventing them from adapting a different behavior (Cabana et al. , 1999) Perceived barriers to implementing guidelines include: Lack of awareness Lack of familiarity Lack of agreement Lack of self efficacy Lack of outcome expectancy Inertia of previous practice

Goal 1 e: Increase provider cues to action The cue to action is the external event that motivates an individual to act Providing clinicians information and education Importance of the issue Their ability to impact the issues Tools to incorporate skills into practice.

Goal 1 f: Increase provider self efficacy Self efficacy is the measure of one’s own ability to complete task Provide education and training to increase the clinicians self efficacy Video Examples Face to Face practice Scripts Feedback

Intervention Develop Education program via you tube & Power. Point to increase and address goals 1 a 1 f Education and Training will focus on Mental Health Assessment, Diagnosis and Treatment Educational Program will use HBM factors to educate provider Reach out to Provider community to encourage participation in Educational Training

Evaluation Clinician To Testing determine Providers knowledge, comfort and current practice related to mental health screening and treatment Review of Records, to determine rate of mental health screening and treatment before and after training.

Evaluation Screening questionnaire for adolescents in practices Evaluate and compare the number of adolescents reporting mental health symptoms to the numbers being screened All evaluations should be done Prior to Intervention for comparison 3 & 6 months after intervention to evaluate short term effect 12 months to evaluate sustain effectiveness

Cost Estimate Time & resources spent soliciting providers Time & resources spent making Educational Program Time spent reviewing records Time spent analyzing clinical pre and post test Time spent reviewing adolescent surveys

Intervention Resources Examples of Primary Care Mental Health Screenings http: //www. youtube. com/watch? v=qbyb-B 6 sv 00 http: //www. youtube. com/watch? v=LA 4 Wea 3 Sa. E

Intervention Resources GLAD- PC Toolkit http: //www. glad-pc. org AACAP Guidelines http: //www. aacap. org/App_Themes/AACAP/docs/clinical_practice_c enter/systems_of_care/Collaboration_Guide_FINAL_approved_610. pdf NICHM- Mental Health Primary Care Integration http: //www. nihcm. org/pdf/Pediatric. MH-FINAL. pdf PHQ-9 http: //www. integration. samhsa. gov/images/res/PHQ - Questions. pdf Beck Depression Scale http: //www. thecommunityhouse. org/wpcontent/uploads/2012/01/Beck-Depression-Inventory-and-Scoring. Key 1. pdf

References Cabana, M. , Rand, C. , Powe, N. , Wu, A, . Wilson, M. , Abboud, P. , Rubin, H. , (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association. 1999; Oct 20; 282 (15); 1458 -1465. Cash, S. , Bridge, J. , (2009). Epidemiology of youth suicide and suicidal behaviors. Current Opinions in Pediatrics. 2009; 21(5): 613 -619. doi: 10. 1097/MOP. 0 b 013 e 32833063 e 1. Center for Disease Control and Prevention. (2013). Suicide rates among persons ages 10 -24, by race/ethnicity and sex in the United States, 2005 -2009. National Suicide Statistics at a Glance. Retrieved from http: //www. cdc. gov/violenceprevention/suicide/statistics/rates 03. html Cutler, D. , Glaeser, E. , Norberg, K. , (2001). Explaining the rise in youth suicide. Gruber, J. Risky behavior among youth: an economic analysis. 219 -270, University of Chicago Press. Retrieved from http: //www. nber. org/chapters/c 10690. pdf Dumont, I. , Olson, A. , 2012, Primary Care, Depression, and anxiety: exploring somatic and emotional predictors of mental health status in adolescents. Journal of American Board of Family Medicine, Fallucco, E. , Conlon, M. , Gale, G. , Constantino, J. , Glowinski, A. (2012). Use of a standardized patient paradigm to enhance proficiency in risk assessment for adolescent depression and suicide. Journal of Adolescent Health. 2012; 51(1): 66 -72. Forum on Child and Family Statistics. (2012). Pop 1 child population: number of children (in millions) ages 1 -17 in the United States by age, 1950 -2011 and projected 2012 -2050. Retrieved on June 25, 2013 from http: //www. childstats. gov/americaschildren/tables/pop 1. asp Healthy People 2020. (2013). Mental Health and Mental Disorders- Objective 2 Reduce suicide attempts by adolescents. Retrieved from http: //www. healthypeople. gov/2020/Data/Search. Result. aspx? topicid=28&topic=Mental%20 Health%20 and%20 Mental%20 Disorders&objective=MHMD-2&anchor= 125 Jackson Allen, P. , Mc. Guire, L. , (2011). Incorporating mental health into primary care visits. Pediatric Nursing, 37(3), 137 -140 Lutifiyya, M. , Bianco, J. , Quinlan, S. , Hall, C. , Waring, S. , (2012). Mental health and mental health care in rural America: the hope of a redesigned primary care. Disease a month, 58(11), 629 -638 Mackin, J. R. , Perkins, T. , & Furrer, C. J. (2012). The power of protection: A population-based comparison of Native and non-Native youth suicide attempters. American Indian and Alaska Native Mental Health Research , 19(2), 20 -54. doi: 10. 5820/aian. 1902. 2012. 20 Mann, J. , Apter, A. , Bertolote, J. , Beautrais, A. , Currier, D. , Haas, A. (2005). Suicide prevention stratagies: a systematic review. The Journal of the American Medical Association. 2005; 294 (16): 2064 -2074. Shain, B. , (2007). Suicide and suicide attempts in adolescents. Pediatrics. 2007; 120: 669 -676 Retrieved from http: //pediatrics. aappublications. org/content/120/3/669. full. pdf+html Waldvogel, J. , Rueter, M. , Oberg, C. (2008). Adolescent suicide: risk factors and prevention strategies. Current Problems in Pediatric and Adolescent Health Care. 2008; 38(4): 110 -125.