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Identifying suicide on the front lines of health


Screening, intervention in primary care settings provide at-risk patients timely care

By Eric Bottomley
The Permanente Federation

Suicide rates in the United States have increased more than 30% since 2001, and more than 47,000 suicide-related deaths are currently being reported each year, according to the Centers for Disease Control and Prevention. Nearly half of those who die by suicide visited a primary care clinic within a month of their death – presenting a unique opportunity for primary care to be the first point of intervention for those at risk.

Many health systems in the United States don’t yet have primary care workflows in place that spot patients who are thinking about, or have attempted, suicide. For clinicians who do manage to detect suicidal warning signs, it can be difficult for them to know where to start to get their patients on the right path to care.

Kaiser Permanente’s Northwest Permanente and Washington Permanente Medical Group help primary care clinicians be prepared to support at-risk patients by simplifying workflows that universally screen for depression, examining suicidal thoughts and behaviors, and developing safety plans for at-risk patients so they can receive prompt intervention.

Universal screening for depression

First, clinicians universally screen patients for depression with a brief 9-question survey when they come in for a primary care visit. Whether they are visiting their clinician for chronic pain, the common cold, or a routine physical, each patient is screened to identify risk as early as possible. Primary care clinicians also have access to specialized training, clinical decision resources, and consultation with mental health professionals – in person, online, or by phone – to help provide real-time support to patients who show signs of depression that could lead to suicidal thoughts and behavior.

Examining suicidal thoughts, behaviors

If a potential risk is identified, a patient receives the Columbia-Suicide Severity Rating Scale (C-SSRS) – an evidence-based survey that allows any team member to gather more information on the patient’s recent and previous history of suicidal thoughts and behaviors. This survey can be administered by any member of the patient’s care team – not just mental health professionals.

Based on the score, the patient may continue to receive regular intervention and follow-ups in primary care, be referred to specialty behavioral health, or immediately transferred to a mental health professional embedded within the primary care setting to develop a safety plan before they leave the medical offices.

Creating an evidence-based safety plan

Mental health professionals are embedded within primary care to ensure that patients determined to be at risk of suicide have access to intervention as soon as possible. These specialists leverage clinical decision support tools to determine the best course of action to reduce or eliminate risk of suicide before the patient leaves their appointment.

One such tool is the Stanley Brown Safety Plan. The plan’s main approach uses a written list of warning signs, coping strategies, and resources that are developed in partnership between the patient and their clinician. The plan helps the patient identify:

  • Personal triggering events and warning signs
  • Preferred internal coping strategies
  • Social situations that may distract them from the crisis
  • Family members, friends, and professional agencies to contact for help
  • Reasons for living
  • Ways to make their environment safe, specifically restricting access to lethal means such as firearms and prescription medications

The plan is provided to the patient and documented in the electronic medical record for regular monitoring and assessment by the care team.

Integrating safety plans into primary care

To make this possible, Kaiser Permanente’s Care Management Institute – tasked with finding and spreading evidence-based treatments – partnered with internal clinical experts to weave the Columbia-Suicide Severity Rating Scale and the Stanley Brown Safety Plan into Kaiser Permanente’s electronic medical record system.

“Our integrated approach helps patients receive screening, intervention, and monitoring, all during their regular primary care visits,” says Cambria Bruschke, suicide prevention lead at the Care Management Institute. “It speaks to our efforts in prevention to identify and treat conditions before they become worse.”

She says studies confirm safety planning reduces suicidal thoughts and behaviors while increasing patient engagement by equipping them with tools that keep them safe during a crisis. Safety planning also empowers physicians to get their patients on the right path to the most effective treatment.

These evidence-based approaches empower our partners in primary care to save and improve even more lives by helping those who are at risk of suicide before they leave the clinic.

– Pavan Somusetty, MD, Kaiser Permanente’s national leader for suicide prevention


Evidence-based guidelines support physicians who aren’t specialized in treating mental health conditions, enabling them to proactively get the patient on a plan that’s supported by mental health specialists on the patient’s care team.

“Traditionally in medicine, primary care doctors had little training or support in providing mental health care,” says Pavan Somusetty, MD, Kaiser Permanente’s national leader for suicide prevention and assistant chief of Psychiatry at Northwest Permanente. “These evidence-based approaches empower our partners in primary care to save and improve even more lives by helping those who are at risk of suicide before they leave the clinic.”

Looking ahead, the Care Management Institute will continue focusing on ways to expand the reach of safety plan interventions in primary care, Urgent Care, and Emergency Departments at other Kaiser Permanente Regions. In doing so, Kaiser Permanente hopes to position these departments as effective safety nets in preventing suicidal patients from going undetected and receiving the appropriate life-saving treatment.

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