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The Nurse Practitioner Blog

A forum for discussion on recent news and developments in healthcare and the NP field.

Wednesday, June 2, 2021

Nurse Practitioners as Gatekeepers for Suicidality: Asking Can Save a Life

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According to the Centers for Disease Control and Prevention (CDC), death by suicide is the 10th leading cause of death in the United States when viewed across the lifespan. Additionally, while the impact of the COVID-19 pandemic on suicidality rates has not been fully ascertained, an early report in EClinicalMedicine, published by The Lancet, suggests that the prevalence of suicidality may be increasing in racial and ethnic minority populations disproportionately driving rates.

The growing issue of suicidality is further compounded by the maldistributed access to psychiatric care in many communities. This is largely due to the increase in demand for specialty psychiatric services combined with a shrinking psychiatric workforce. Inadequate numbers of practitioners are being trained to replace those leaving/retiring from community practices. This workforce shortage is being partially mitigated by the increased number of  Psychiatric Mental Health Nurse Practitioners (PMHNP) in the field, less restrictive advanced nursing practice regulations nationally, and the use of innovative patient access modalities to psychiatric care, such as telehealth. Despite these best efforts, there remains a shortage of available providers to meet the growing need of people for psychiatric services.

Advanced Practice Registered Nurses (APRNs) in primary care and other community-based practice settings have the potential to be effective stop-gaps to meet this disparity in psychiatric access. While it would not be wholly advisable to shift all psychiatric care to non-psychiatric providers, it is feasible to provide non-psychiatric providers the skills to identify and treat low or moderate acuity mental health conditions.

While mild depression and anxiety symptoms are already widely treated outside of the traditional psychiatric specialty care, is suicidality a condition that can be managed without immediate access to acute psychiatry? A recent analysis from Vanderbilt University Medical Center (VUMC) written by Ketel, et al. (April, 2021) may suggest that it can. In 2018, a nurse practitioner-led, interprofessional primary care practice implemented universal suicidality screening at every patient visit. After analyzing 2 years of quality improvement data, they found that, out of 1,733 unique patients, 149 patients (8.6%) had some level of suicidality. Remarkably, a majority (62%) of patients that screened positive for suicidal ideation came into the practice for only medical complaints. 

VUMC practice was able to effectively manage 112 patients (75%) without elevating the patient to specialty psychiatry. They accomplished this through the use of standardized, evidence-based screening and triage tools accompanied by regular follow-up and counseling by an embedded licensed master social worker (LMSW). In fact, out of the 149 patients screened, only 8 patients (5%) required referral/elevation to acute specialty psychiatry settings. On the downside, 29 patients (20%) who initially screened positive for suicidality were “lost to follow-up” or refused to accept care. In general, however, of the 112 patients that engaged with care, there were no suicide attempts or deaths. Additionally, the practice achieved complete resolution in suicidality in 84 patients (75%).

How was this possible? Suicidality, like most other physical and mental health conditions, has a range of acuities and is associated with both protective factors (factors that decrease acuity or prevalence) and risk factors (factors that increase acuity or prevalence). Both protective and risk factors can generally be quantifiably accessed and stratified. Protective factors that work preventatively against suicide or self-harm include a strong social support network, responsibility for the well-being of another person/animal (i.e. child/pet), and religious beliefs that prohibit suicide. On the other hand, risk factors are traits or situations that increase a person’s likelihood to complete suicide or self-harm. They may include being unemployed, experiencing a recent loss, experiencing psychological or physical trauma, and having immediate access to deadly means (i.e. firearms or medications).

While considering these protective and risk factors in individual patients can appear intimidating at first glance, it aligns with the course of care for most other clinical conditions encountered within the scope of primary care or community-based care.

As with other conditions, suicidal ideations present on a wide continuum of acuity. Suicidal thoughts can range from infrequent, passive thoughts of suicide, to  constant, active attempts to do self-harm or kill oneself. The most widely accepted tool to measure suicidal ideation severity is Beck’s Suicidal Ideation Scale. In general, most patients presenting to non-psychiatric settings are not in this latter state of suicidality. When they do, it is obviously a time to engage the most immediate and intense emergency systems available. This would be akin to a patient presenting to a practice with acute chest pain or a person found unresponsive. Another example may be a patient with diabetes with an acute and severe episode of hyperglycemia. The appropriate response in this case would also be to immediately elevate the patient to a higher level of specialty care or emergency setting.

However, in both of these examples, possible cardiac event or severe diabetic hyperglycemia, the better alternative would have been for the APRN to detect and intervene well before the acute event occurred. This is done through detection and management of the patient’s unique set of risk factors and clinical indicators in early stages of disease progression. In the cases of cardiac disease and diabetes, regular and consistent use of evidence-based clinical detection and treatment modalities in the early stages of the disease progression can prevent or postpone the need for higher levels of acute or emergent care.

Early detection and treatment of suicidal ideation can be seen in this same light. If detected early, initial management of suicidal ideation is absolutely possible and appropriate in non-psychiatric settings. This does not imply that patients with persistent suicidal ideations do not require eventual elevation to specialty psychiatric care, but it does allow primary care and other ambulatory clinical settings to intervene at lower acuity levels. This will help shift at least some of the demand for acute psychiatry services and allow greater access to patients in truly acute psychiatric distress. 

At minimum, most primary care practices can act as community “gatekeepers” for suicidal detection. A community suicide gatekeeper is a person or organization that is capable of identifying, approaching, discussing, and referring individuals in psychiatric distress to the appropriate level of care. Generally, gatekeepers have ongoing access to a community or have regular interactions with the public as a part of their normal routine.  It is not a new concept. Originally it was developed in the early 1990’s as a way to engage school age children, adolescents, and young adults in school-based settings. A more updated article in RAND Health Quarterly by Burnette, et al. (2015) provides an excellent description of the scientific underpinnings for community gatekeeping.

Over the past 30 years, gatekeeping has expanded from just schools to include many social service and community organizations. In 2021 and in partnership with the National Action Alliance for Suicide Prevention and the United States Federal Government, the US Surgeon General released a “Call to Action” for the prevention of suicidality in the United States. This call to action is a “broadening of the vision” initiated in the 90’s. This is an expansive call that outlines six actions to decrease the impact of suicidality. It is an excellent plan and worth reading in its entirety, and this brief article could not do it complete justice. With that said, the first action in the statement seeks to encourage and empower every individual and organization to play a role in suicide prevention. That includes primary care practices and the APRN community of providers.

How do you get started addressing suicidality in primary care or as an APRN provider in the community? The first step is to identify partners and resources within your community that can help support your practice once patients are identified with suicidal ideation. This obviously includes traditional mental health service organizations in the community, but it also includes other community organizations who interact frequently with your population. Having a robust community network allows for close collaboration and sense of community togetherness around suicide prevention. An excellent evidence-based model for building community connectedness around suicidality is the CDC’s “Preventing Suicide: A Technical Package of Policy, Programs, and Practices.” The next step is to officially engage with your individual state’s suicide prevention program. A list of contacts by state can be found at the Suicide Prevention Resource Center. At this site, you will also find access to free online and in-person training to get your entire practice prepared to assist patients with suicidality. Other excellent resources to consider would be the American Foundation for Suicide Prevention and SAMHSA. Both of these organizations have copious amounts of resources for overall mental health, as well as the screening tools needed to fully implement suicidality screening effectively. Once your practice has accessed all of its available resources, it is time to take the next step and start confidently asking your patients about suicidal ideations.

 

Christian Ketel, DNP, RN-BC (He/Him/His)

Assistant Professor of Nursing

Director Vanderbilt Primary Care-West End

Co-Director of the Meharry-Vanderbilt Alliance Inter-Institutional Interprofessional Student Program

LEAN for Health Care Trainer and Facilitator

Tennessee ACEs Building Stronger Brains Initiative Trainer

Vanderbilt University School of Nursing