If you've cared for patients with suicidal ideation, you'll know how valuable this tool can be.
Fam Pract Manag. 2009 Sep-Oct;16(5):17-20.
Most of us have experienced the anxiety, stress and disruption in our daily routine that occurs when we see a patient who has suicidal thoughts. As practices implement systems to routinely screen for and manage depression, more patients with depression and suicidal ideation will be uncovered.1–3 Most of the depression-screening tools4–7 used in primary care practices include questions surrounding two statements: “I would be better off dead” and “I have thoughts of harming myself.” We must be ready to respond when a patient admits to having these thoughts.8
In an ongoing study of postpartum depression screening,9 we asked family medicine practices to screen all postpartum women using the Edinburgh Postnatal Depression Scale. The study found that 7.6 percent – 70 of 922 – of the postpartum women screened reported suicidal thoughts that required further evaluation. To help the practices involved in the study evaluate these patients efficiently and effectively during the course of their busy practice schedules and initiate immediate action when needed, we developed a simple two-page tool called the Immediate Action Protocol, or IAP. Download the IAP here in pdf format.
Using the Immediate Action Protocol
The first page of the IAP lists questions for the physician to ask the patient that are designed to help elicit a more specific assessment of the risk that the patient will act on his or her suicidal thoughts.8,10,11 The tool provides the general content of the questions and suggests ways to engage the patient so that answers can be obtained.
The second page of the tool lists the telephone numbers of local referral sources that can be used to obtain a more detailed assessment of suicide risk or for immediate treatment. The tool also includes a reminder regarding the physician's right and obligation to initiate a legal hold for further evaluation in the event that the patient is considered to be a risk to himself or herself or others but does not agree to further immediate assessment.
The material included in the IAP is simple, and your practice may already have a procedure in place for assessing patients' suicidal thinking. Still, even though many of the practices in our study had experienced the need to evaluate patients for suicide risk, none of the 28 practices had this information easily accessible. Physicians and staff found the tool helpful, easy to update and usable in both electronic and paper formats.
To enhance usability, readability and durability of the form, we typed the resource information and laminated several copies for each practice. The forms were placed in appropriate locations such as near the nurses' telephone line, on physicians' desks and at receptionists' stations. We printed them on colored paper so they would be easy to find among other papers.
Put this tool to use
Adding an unexpected assessment for suicide risk to a full day's schedule of patient visits is challenging no matter how good your tools are, but having a ready-to-use resource available greatly facilitates the process. And if you have cared for a patient who committed suicide, you understand the importance of an effective, efficient system that focuses the assessment and assures quality care.
About the Authors
Dr. Yawn is the director of research and a family physician at Olmsted Medical Center, Department of Research, in Rochester, Minn. Dr. Dietrich is a professor of family medicine in the Department of Community and Family Medicine at Dartmouth Medical School in Hanover, N.H. Dr. Wollan is a biostatistician at Olmsted Medical Center. Ms. Bertram is a registered nurse and study coordinator at Olmsted Medical Center. Ms. Kurland is a registered nurse and research associate at Olmsted Medical Center. Dr. Pace is director of the National Research Network for the AAFP in Leawood, Kan. Ms. Graham is a research associate and Ms. Huff is a research assistant for the National Research Network. Author disclosure: Dr. Dietrich discloses a partnership with 3 CM, LLC, a company that provides mental health treatments to the Department of Defense for the city of New York and others.
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1. Georgiopoulos AM, Bryan TL, Yawn BP, Houston MS, Rummans TA, Therneau TM. Population-based screening for postpartum depression. Obstet Gynecol. 1999;93:653–657.
2. Dietrich AJ, Oxman TE, Williams JW, et al. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. BMJ. 2004;329:602.
3. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272:1749–1756.
4. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry. 1993;163:27–31.
5. Enns MW, Cox BJ, Parker JD, Guertin JE. Confirmatory factor analysis of the Beck Anxiety and Depression Inventories in patients with major depression. J Affect Disord. 1998;47:195–200.
6. Spitzer RL, Kroenke K, Williams JB. Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIMEMD: the PHQ primary care study. JAMA. 1999;282:1737–1744.
7. Miller WC, Anton HA, Townson AF. Measurement properties of the CESD scale among individuals with spinal cord injury. Spinal Cord. 2008;46:287–292.
8. Schulberg HC, Lee PW, Bruce ML, et al. Suicidal ideation and risk levels among primary care patients with uncomplicated depression. Ann Fam Med. 2005;3:523–528.
9. Yawn B, Pace W, Wollan P, et al. Postpartum depression screening: EPDs vs. PHQ-9 J Am Board Fam Med. In press.
10. Gaynes BN, West SL, Ford CA, et al. Screening for suicide risk in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:822–835.
11. Milton J, Ferguson B, Mills T. Risk assessment and suicide prevention in primary care. Crisis. 1999;20:171–177.
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