Description
As a social worker, you will likely at some point have a client with a positive suicide risk assessment. Many individuals with suicidal ideation also have a plan, and that plan may be imminent. Even when the risk is not urgent at a given moment, current research shows that most suicides occur within 3 months of the risk being assessed within a formal appointment. Ideation can quickly become a suicide.
For this Discussion, you view an initial suicide risk assessment. As you evaluate the social worker’s actions, imagine yourself in their place. What would you do, and why?
To prepare:
- Explore an evidence-based tool about suicide risk assessment and safety planning. See the Week 3 document Suggested Further Reading for SOCW 6090 (PDF) for a list of resources to review.
- Watch the “Suicide Assessment Interview” segment in the Sommers-Flanagan (2014) video to assess how it compares to your findings.
- Access the Walden Library to research scholarly resources related to suicide and Native American populations.
Post a response in which you address the following: ( Be detailed in response, Use 3 APA peer reciewed references, Use sub-heading)
- Identify elements of Dr. Sommers-Flanagan’s suicide risk assessment.
- Describe any personal emotional responses you would have to Tommi’s revelations and reflect on reasons you might experience these emotions.
- Describe the elements of safety planning that you would put in place as Tommi’s social worker in the first week and in the first months.
- Identify a suicide risk assessment tool you would use at future sessions to identify changes in her risk level. Explain why you would use this tool.
- Explain any adjustments or enhancements that might be helpful given Tommi’s cultural background. Support your ideas with scholarly resources.
References
Dillard, D. A., Avey, J. P., Robinson, R. F., Smith, J. J., Beals, J., Manson, S. M., & Comtois, K. A. (2017). Demographic, Clinical, and Service Utilization Factors Associated with Suicide-Related Visits among Alaska Native and American Indian Adults. Suicide & Life-Threatening Behavior, 47(1), 27–37. https://doi-org.ezp.waldenulibrary.org/10.1111/slt…
Laureate Education (Producer). (2018b). Psychopathology and diagnosis for social work practice podcast: The diagnostic interview, the mental status exam, risk and safety assessments [Audio podcast]. Baltimore, MD: Author.
Sommers-Flanagan, R. (Poduces). (2014). Clinical INterviewing: Intake, assessment and Therapeutic alliance [Video file]. Retrieved from http:www.psychotherapy.net.ezp.waldenulibrary.org/strea…
U.S. Department of Veterans Affairs. (2013). Assessment and management for
patients at risk for suicide. Retrieved
from https://www.healthquality.va.gov/guidelines/MH/srb…
Suicide and Life-Threatening Behavior 47 (1) February 2017
© 2016 The American Association of Suicidology
DOI: 10.1111/sltb.12259
27
Demographic, Clinical, and Service Utilization
Factors Associated with Suicide-Related Visits
among Alaska Native and American Indian
Adults
DENISE A. DILLARD, PHD, JAEDON P. AVEY, PHD, RENEE F. ROBINSON, PHARMD,
JULIA J. SMITH, MS, JANETTE BEALS, PHD, SPERO M. MANSON, PHD, AND
KATHERINE ANNE COMTOIS, PHD, MPH
Alaska Native and American Indian people (AN/AIs) are disproportionately affected by suicide. Within a large AN/AI health service organization,
demographic, clinical, and service utilization factors were compared between
those with a suicide-related health visit and those without. Cases had higher
odds of a behavioral health diagnosis, treatment for an injury, behavioral health
specialty care visits, and opioid medication dispensation in the year prior to a
suicide-related visit compared to gender-, age-, and residence- (urban versus
rural) matched controls. Odds of a suicide-related visit were lower among those
with private insurance and those with non-primary care ambulatory clinic visits.
Many people who die by suicide seek health
care just prior to their death. Nationally,
77% of suicide decedents contact a primary
care provider in the year before death; 32%
see a behavioral health (BH) provider
(Luoma, Martin, & Pearson, 2002). The
U.S. Surgeon General recommends screening for suicide risk in health care settings
(U.S. Public Health Service, 1999); however,
understanding the most efficient and effective way to assess and intervene remains an
DENISE A. DILLARD, JAEDON P. AVEY,
RENEE F. ROBINSON, and JULIA J. SMITH, Southcentral Foundation, Anchorage, AK, USA;
JANETTE BEALS and SPERO M. MANSON, University of Colorado-Anschutz Medical Campus,
Aurora, CO, USA; KATHERINE ANNE COMTOIS,
University of Washington, Seattle, WA, USA.
This project was supported by grant
UL1RR025014 from the NIH National Center
for Research Resources.
*Address correspondence to Denise A.
Dillard, Research Department, 4105 Tudor Centre Drive, Suite 200, Anchorage, AK 99508;
E-mail: dadillard@southcentralfoundation.com
important area for investigation (U.S.
Preventive Services Task Force, 2014).
The average annual suicide death rate
among Alaska Native and American Indian
people (AN/AIs) in Alaska’s southcentral
region is more than 50% higher than the
U.S. all races rate. Indeed, suicide is the
leading cause of injury death among AN/
AIs aged 15 to 24 in Alaska. Moreover, significant morbidity has been incurred: 17.7
versus 5.3 per 10,000 were hospitalized
after suicide attempts for AN/AIs in the
southcentral region versus non-Native people statewide, respectively (Injury Prevention Program and the Alaska Native
Epidemiology Center, 2014).
Two Alaska-wide studies of service
utilization associated with suicide have been
conducted with mixed samples of nonNative people and AN/AIs. In one, most
people (64%) sought health care from a
doctor in the 6 months prior to their death.
Thirty-nine percent saw a BH counselor or
therapist in the last year of life (Perkins,
28
FACTORS ASSOCIATED
Sanddal, Howell, Sanddal, & Berman,
2009). In the second, a greater proportion
of people attempting suicide were single,
unemployed, and had less than a high
school education as compared to the 2000
U.S. Census general population. Fatal versus nonfatal attempts were more likely
among males, people 25 years of age or
older, and people with a substance abuse
history (Wexler, Hill, Bertone-Johnson, &
Fenaughty, 2008). The only comprehensive
investigation of service utilization specific
to AN/AIs occurred in one rural northern
region (Hill, Perkins, & Wexler, 2007). In
the year prior to death by suicide, AN
males (n = 30) were 2.8 times more likely
to receive hospital treatment and 22.2 times
more likely to be treated for an alcoholrelated injury than controls (n = 30).
To better understand how the tribal
health care system in Alaska could respond
to this increased risk of suicide, we retrospectively examined the demographic, clinical, and service utilization characteristics of
AN/AIs with a suicide-related visit.
METHOD
Setting
Southcentral Foundation (SCF), a
tribally owned and operated health care facility in Anchorage, Alaska, provides primary
health care services to more than 65,000 AN/
AIs residing in southcentral Alaska. The primary care clinic (PC) is staffed by 36 clinical
workgroups, each composed of a lead physician, advanced nurse practitioner or physician assistant, a registered nurse, and one
or more Certified Medical Assistants or
Licensed Practical Nurses. A master’s level
Behavioral Health Consultant (BHC) is
shared among several PC workgroups and
supports routine screening and management
for depression and substance abuse, including interventions when questions about suicide potential arise.
In addition to PC services, SCF
offers other specialty care including outpa-
WITH
SUICIDE-RELATED VISITS
tient and residential BH services. SCF BH
services are also offered to the Alaska
Native Medical Center (ANMC) emergency/urgent care and inpatient units.
Comanaged by SCF and the Alaska Native
Tribal Health Consortium, ANMC is 150bed hospital providing secondary and tertiary services for approximately 136,000
AN/AIs in all regions of Alaska. Inpatient
psychiatry services are provided at private
hospitals or a state-run public facility.
Project approval was granted by the
Alaska area institutional review board and
governing tribal organizations. Both SCF
and ANMC used the Resource and Patient
Management System (RPMS) as the electronic medical record and SIGNATURE as
their billing software package at the time of
the study (Gartner, 2002; Indian Health
Service, 2015).
Participants
Cases comprised all AN/AIs seen at an
SCF clinic or ANMC between January 1,
2005, and December 31, 2009, with a diagnostic code for a self-inflicted injury or death
(ICD-9-CM codes e-950 to e-959). The
sample was restricted to adults because of
special considerations for research involving
children and because only adults receive
depression and substance abuse screening in
the SCF PC clinics. As explained later, data
were abstracted for a year before the index
visit; thus, only those 19 and older at this
visit were included. Cases were matched with
AN/AIs who were the same age in years on
the date of the suicide-related index visit,
gender, and residence type (urban vs. rural).
The most recent visit was used as the index
visit if more than one suicide-related visit
was present.
Measures
For all cases and controls, additional
demographic, clinical, and service use factors were extracted and then categorized
according to the distribution, with particular
attention to the avoidance of small cell sizes
DILLARD
ET AL.
that could inadvertently identify individual
AN/AIs.
Other demographic factors included
marital status, insurance status, religious
affiliation, and zip code to estimate median
income.
Assessed the year prior to and
6 months after index visit, the clinical factors
included depression and substance abuse
screening score(s); ICD-9-CM diagnostic
codes for number of BH conditions, physical
conditions, and injuries; and medications dispensed. Depression screening was conducted
with the Patient Health Questionnaire-2
(PHQ-2; i.e., depressed mood and anhedonia)
with a cutoff score of 3, immediately followed
by the PHQ-9 when cutoff was reached. Substance abuse screening was conducted with a
modified Alcohol Use Disorders Identification Test (AUDIT) with a cutoff score of 7
for women and 8 for men. The score closest
to the date of the suicide-related index visit
was used when more than one depression or
substance abuse screening score was recorded.
ICD-9-CM BH diagnostic codes included
mood, anxiety, impulse control, pain, psychotic, personality, and substance abuse disorders. Psychotropic medications included
antidepressants, benzodiazepines, mood stabilizers, and antipsychotics. Injuries included
fractures, dislocation, sprain, and other. Physical conditions encompassed acute myocardial
infarction, angina, congestive heart failure,
chronic obstructive pulmonary disorder, dementia, diabetes, malignancy, osteoarthritis,
spine disorder, and stroke.
Service utilization included number
and type of visits within PC clinics, BH
care, emergency/urgent care, and other
ambulatory clinics like women’s health. For
PC visits involving a BHC as well as BH
specialty care visits, number of visits was
categorized as none, one, or two or more
visits. Both PC visits and other ambulatory
visits were categorized as none, one or two,
three to six, and seven or more. Number of
ANMC inpatient days was quantified as
none, or one or more.
Among cases only, means of self-harm
were categorized into highly and less lethal
29
levels. Highly lethal means included firearms
or suffocation and less lethal included poisoning, cutting, other means such as drowning and falling, and sequelae (e.g., liver
disease after poisoning). Limited, easily
accessible data were also assembled for all
adult AN/AIs seen at a SCF clinic or ANMC
to depict how cases and controls compared
to the broader service population (referred to
as total service population).
Statistical Analyses
Descriptive analyses of demographic,
clinical, and service utilization data were
conducted for cases, controls, and the total
service population. Fisher’s exact tests
investigated potential differences by degree
of lethality, comparing high and less lethal
means among cases.
Univariable conditional logistic regression estimated the odds ratio (OR) and
95% CI for a suicide-related visit by demographic, clinical, and service utilization factors in the year prior among cases and
controls. All factors with a univariable association of p < .25, with the exception of
marital status and religion, were included in
the multivariable models and interactions
investigated (Hosmer & Lemeshow, 2000).
Cases and controls missing values on one or
more factors were excluded from subsequent multivariable models.
RESULTS
Most of the 890 cases were female
(58%), the mean age was 31.9 years (SD =
11.4), and 65% lived in urban areas (Table 1).
Cases were younger (p < .0001) and more
urban (p < .0001) than the total service population. A substantial proportion of cases
(n = 165, 19%) had more than one suiciderelated visit.
As shown in Table 2, 75% of cases
were not married (never married, divorced,
separated, or widowed) compared to 68%
of matched controls. More than half of
cases (56%) and controls (54%) lived in an
30
FACTORS ASSOCIATED
TABLE 1
Gender, Age, and Residence Characteristics of
Cases and Total Service Population
Casesa
(N = 890)
N
Gender
Female 520
Male
370
Age in yearsc
19–24
310
25–34
279
35+
301
Residence
Rural
315
Urband 575
Total
Service
Populationb
(N = 64,528)
%
N
%
p
58
42
36,225
28,303
56
44
.17
35
31
34
13,106
13,883
37,539
20
22
58
Purchase answer to see full
attachment
© 2016 The American Association of Suicidology
DOI: 10.1111/sltb.12259
27
Demographic, Clinical, and Service Utilization
Factors Associated with Suicide-Related Visits
among Alaska Native and American Indian
Adults
DENISE A. DILLARD, PHD, JAEDON P. AVEY, PHD, RENEE F. ROBINSON, PHARMD,
JULIA J. SMITH, MS, JANETTE BEALS, PHD, SPERO M. MANSON, PHD, AND
KATHERINE ANNE COMTOIS, PHD, MPH
Alaska Native and American Indian people (AN/AIs) are disproportionately affected by suicide. Within a large AN/AI health service organization,
demographic, clinical, and service utilization factors were compared between
those with a suicide-related health visit and those without. Cases had higher
odds of a behavioral health diagnosis, treatment for an injury, behavioral health
specialty care visits, and opioid medication dispensation in the year prior to a
suicide-related visit compared to gender-, age-, and residence- (urban versus
rural) matched controls. Odds of a suicide-related visit were lower among those
with private insurance and those with non-primary care ambulatory clinic visits.
Many people who die by suicide seek health
care just prior to their death. Nationally,
77% of suicide decedents contact a primary
care provider in the year before death; 32%
see a behavioral health (BH) provider
(Luoma, Martin, & Pearson, 2002). The
U.S. Surgeon General recommends screening for suicide risk in health care settings
(U.S. Public Health Service, 1999); however,
understanding the most efficient and effective way to assess and intervene remains an
DENISE A. DILLARD, JAEDON P. AVEY,
RENEE F. ROBINSON, and JULIA J. SMITH, Southcentral Foundation, Anchorage, AK, USA;
JANETTE BEALS and SPERO M. MANSON, University of Colorado-Anschutz Medical Campus,
Aurora, CO, USA; KATHERINE ANNE COMTOIS,
University of Washington, Seattle, WA, USA.
This project was supported by grant
UL1RR025014 from the NIH National Center
for Research Resources.
*Address correspondence to Denise A.
Dillard, Research Department, 4105 Tudor Centre Drive, Suite 200, Anchorage, AK 99508;
E-mail: dadillard@southcentralfoundation.com
important area for investigation (U.S.
Preventive Services Task Force, 2014).
The average annual suicide death rate
among Alaska Native and American Indian
people (AN/AIs) in Alaska’s southcentral
region is more than 50% higher than the
U.S. all races rate. Indeed, suicide is the
leading cause of injury death among AN/
AIs aged 15 to 24 in Alaska. Moreover, significant morbidity has been incurred: 17.7
versus 5.3 per 10,000 were hospitalized
after suicide attempts for AN/AIs in the
southcentral region versus non-Native people statewide, respectively (Injury Prevention Program and the Alaska Native
Epidemiology Center, 2014).
Two Alaska-wide studies of service
utilization associated with suicide have been
conducted with mixed samples of nonNative people and AN/AIs. In one, most
people (64%) sought health care from a
doctor in the 6 months prior to their death.
Thirty-nine percent saw a BH counselor or
therapist in the last year of life (Perkins,
28
FACTORS ASSOCIATED
Sanddal, Howell, Sanddal, & Berman,
2009). In the second, a greater proportion
of people attempting suicide were single,
unemployed, and had less than a high
school education as compared to the 2000
U.S. Census general population. Fatal versus nonfatal attempts were more likely
among males, people 25 years of age or
older, and people with a substance abuse
history (Wexler, Hill, Bertone-Johnson, &
Fenaughty, 2008). The only comprehensive
investigation of service utilization specific
to AN/AIs occurred in one rural northern
region (Hill, Perkins, & Wexler, 2007). In
the year prior to death by suicide, AN
males (n = 30) were 2.8 times more likely
to receive hospital treatment and 22.2 times
more likely to be treated for an alcoholrelated injury than controls (n = 30).
To better understand how the tribal
health care system in Alaska could respond
to this increased risk of suicide, we retrospectively examined the demographic, clinical, and service utilization characteristics of
AN/AIs with a suicide-related visit.
METHOD
Setting
Southcentral Foundation (SCF), a
tribally owned and operated health care facility in Anchorage, Alaska, provides primary
health care services to more than 65,000 AN/
AIs residing in southcentral Alaska. The primary care clinic (PC) is staffed by 36 clinical
workgroups, each composed of a lead physician, advanced nurse practitioner or physician assistant, a registered nurse, and one
or more Certified Medical Assistants or
Licensed Practical Nurses. A master’s level
Behavioral Health Consultant (BHC) is
shared among several PC workgroups and
supports routine screening and management
for depression and substance abuse, including interventions when questions about suicide potential arise.
In addition to PC services, SCF
offers other specialty care including outpa-
WITH
SUICIDE-RELATED VISITS
tient and residential BH services. SCF BH
services are also offered to the Alaska
Native Medical Center (ANMC) emergency/urgent care and inpatient units.
Comanaged by SCF and the Alaska Native
Tribal Health Consortium, ANMC is 150bed hospital providing secondary and tertiary services for approximately 136,000
AN/AIs in all regions of Alaska. Inpatient
psychiatry services are provided at private
hospitals or a state-run public facility.
Project approval was granted by the
Alaska area institutional review board and
governing tribal organizations. Both SCF
and ANMC used the Resource and Patient
Management System (RPMS) as the electronic medical record and SIGNATURE as
their billing software package at the time of
the study (Gartner, 2002; Indian Health
Service, 2015).
Participants
Cases comprised all AN/AIs seen at an
SCF clinic or ANMC between January 1,
2005, and December 31, 2009, with a diagnostic code for a self-inflicted injury or death
(ICD-9-CM codes e-950 to e-959). The
sample was restricted to adults because of
special considerations for research involving
children and because only adults receive
depression and substance abuse screening in
the SCF PC clinics. As explained later, data
were abstracted for a year before the index
visit; thus, only those 19 and older at this
visit were included. Cases were matched with
AN/AIs who were the same age in years on
the date of the suicide-related index visit,
gender, and residence type (urban vs. rural).
The most recent visit was used as the index
visit if more than one suicide-related visit
was present.
Measures
For all cases and controls, additional
demographic, clinical, and service use factors were extracted and then categorized
according to the distribution, with particular
attention to the avoidance of small cell sizes
DILLARD
ET AL.
that could inadvertently identify individual
AN/AIs.
Other demographic factors included
marital status, insurance status, religious
affiliation, and zip code to estimate median
income.
Assessed the year prior to and
6 months after index visit, the clinical factors
included depression and substance abuse
screening score(s); ICD-9-CM diagnostic
codes for number of BH conditions, physical
conditions, and injuries; and medications dispensed. Depression screening was conducted
with the Patient Health Questionnaire-2
(PHQ-2; i.e., depressed mood and anhedonia)
with a cutoff score of 3, immediately followed
by the PHQ-9 when cutoff was reached. Substance abuse screening was conducted with a
modified Alcohol Use Disorders Identification Test (AUDIT) with a cutoff score of 7
for women and 8 for men. The score closest
to the date of the suicide-related index visit
was used when more than one depression or
substance abuse screening score was recorded.
ICD-9-CM BH diagnostic codes included
mood, anxiety, impulse control, pain, psychotic, personality, and substance abuse disorders. Psychotropic medications included
antidepressants, benzodiazepines, mood stabilizers, and antipsychotics. Injuries included
fractures, dislocation, sprain, and other. Physical conditions encompassed acute myocardial
infarction, angina, congestive heart failure,
chronic obstructive pulmonary disorder, dementia, diabetes, malignancy, osteoarthritis,
spine disorder, and stroke.
Service utilization included number
and type of visits within PC clinics, BH
care, emergency/urgent care, and other
ambulatory clinics like women’s health. For
PC visits involving a BHC as well as BH
specialty care visits, number of visits was
categorized as none, one, or two or more
visits. Both PC visits and other ambulatory
visits were categorized as none, one or two,
three to six, and seven or more. Number of
ANMC inpatient days was quantified as
none, or one or more.
Among cases only, means of self-harm
were categorized into highly and less lethal
29
levels. Highly lethal means included firearms
or suffocation and less lethal included poisoning, cutting, other means such as drowning and falling, and sequelae (e.g., liver
disease after poisoning). Limited, easily
accessible data were also assembled for all
adult AN/AIs seen at a SCF clinic or ANMC
to depict how cases and controls compared
to the broader service population (referred to
as total service population).
Statistical Analyses
Descriptive analyses of demographic,
clinical, and service utilization data were
conducted for cases, controls, and the total
service population. Fisher’s exact tests
investigated potential differences by degree
of lethality, comparing high and less lethal
means among cases.
Univariable conditional logistic regression estimated the odds ratio (OR) and
95% CI for a suicide-related visit by demographic, clinical, and service utilization factors in the year prior among cases and
controls. All factors with a univariable association of p < .25, with the exception of
marital status and religion, were included in
the multivariable models and interactions
investigated (Hosmer & Lemeshow, 2000).
Cases and controls missing values on one or
more factors were excluded from subsequent multivariable models.
RESULTS
Most of the 890 cases were female
(58%), the mean age was 31.9 years (SD =
11.4), and 65% lived in urban areas (Table 1).
Cases were younger (p < .0001) and more
urban (p < .0001) than the total service population. A substantial proportion of cases
(n = 165, 19%) had more than one suiciderelated visit.
As shown in Table 2, 75% of cases
were not married (never married, divorced,
separated, or widowed) compared to 68%
of matched controls. More than half of
cases (56%) and controls (54%) lived in an
30
FACTORS ASSOCIATED
TABLE 1
Gender, Age, and Residence Characteristics of
Cases and Total Service Population
Casesa
(N = 890)
N
Gender
Female 520
Male
370
Age in yearsc
19–24
310
25–34
279
35+
301
Residence
Rural
315
Urband 575
Total
Service
Populationb
(N = 64,528)
%
N
%
p
58
42
36,225
28,303
56
44
.17
35
31
34
13,106
13,883
37,539
20
22
58
Purchase answer to see full
attachment
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