Collaborative Care as an Effective Intervention for Primary Care Patients at Risk for Suicide
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In the United States, suicide is the 10th leading cause of death with more than 47,000 deaths by suicide and an estimated 1.4 million attempts annually. Suicide is comparable to other leading causes of death, including diabetes, heart disease, and stroke (AFSP, 2019). Approximately 45% of people who die by suicide visit a primary care provider (PCP) 30 days before their death.
—JB Luoma, et al. 20021
Most people who die by suicide have contact with a medical professional within three months of their death date. In 2019, 12 million American adults seriously thought about suicide, 3.5 million made a plan, and 1.4 million attempted suicide.2 For individuals aged 10–34 years old, death by suicide was the 2nd leading cause of death in 2019.3 80% of suicidal youth visited their health care provider three months prior to their death by suicide. 38% of these adolescents had contact with a health care system within four weeks; and 50% of youth had been to an emergency department within one year prior to the date they died by suicide.2 Older adults (ages 65 and older) account for 18% of all suicides.4
Primary care practices and other medical practices are in powerful positions to reduce the number of deaths by suicide through expanded identification of patients at risk for suicide and safety planning. Traditionally, primary care providers make referrals to emergency departments or therapy services for their patients at risk for suicide. Many patients do not receive specialty mental health care services, and only 50% of patients who do receive referrals for such services reportedly follow through with them. Among those who do, many do not make more than one visit.5 The Collaborative Care Model offers an evidence-based, patient-centered, high-touch approach for caring for patients at risk of suicide in primary care.6
Collaborative Care is an evidence-based model that identifies and treats behavioral health conditions such as anxiety and depression. Treatment involves the primary care team who patients are familiar with and have established relationships. Collaborative Care focuses on defined patient populations tracked in a registry, measurement-based practice, and treatment. Trained primary care providers and behavioral health professionals [End Page x] provide evidence-based interventions supported by regular psychiatric case consultation for primary care providers and treatment adjustment for patients who are not improving as expected.5 Collaborative Care has been widely adopted by primary care organizations across the country and supplies an opportunity to expand access and appropriate treatment for patients at risk for suicide. In Collaborative Care, patients have options for treatment. Collaborative Care allows for the frequent, even daily contact, that patients at risk for suicide might need for both safety and support. Additionally, Collaborative Care allows for psychiatric consultations for a patient at risk within the first week of initiating services, compared to longer wait times in community settings.
Concert Health is a behavioral health medical group and provider of Collaborative Care to hundreds of primary care providers nationally. A typical episode of Collaborative Care lasts about six to eight months and is designed to be delivered either virtually or in person, even prior to COVID. Other behavioral health services typically last for four weeks, 28 days.7 Collaborative Care is widely supported and is now a Medicare benefit, a Medicaid benefit in 20 states, and is recognized as effective by most commercial health plans.
In many primary care practices, patients are screened for depression with the Patient Health Questionnaire (PHQ9), which has a specific question ("Have you had thoughts that you would be better off dead or of hurting yourself in some way?") that addresses suicide.8 Patients who respond that they have these thoughts nearly everyday are more likely to die by suicide.5 Subsequently, many practices will then specifically ask about suicide risk with the Columbia Suicide Severity Rating Scale (CSSRS) or the Ask Suicide-Screening Questions (ASQ). This pathway is how a majority of patients at risk for suicide are identified in primary care...
