A recent study published in the Annals of Internal Medicine reveals that integrating suicide screening and safety planning into primary care practices can significantly reduce suicide attempts. The intervention, implemented across 19 Kaiser Permanente clinics in Washington State, led to a 25% decrease in suicide attempts within 90 days following a primary care visit.
The research, a secondary analysis of a randomized stepped-wedge trial, demonstrated a reduction in suicide attempts from 6.0 to 4.5 per 10,000 patient visits during the specified period. Furthermore, documented safety plans within two weeks of a primary care visit for patients with elevated suicide risk increased by 14% after the integrated suicide care model was introduced.
Intervention Details
The suicide care intervention incorporated the 2-item Patient Health Questionnaire for depression, the 3-item Alcohol Use Disorders Identification Test-Consumption, a cannabis use frequency question, and a question about the frequency of illegal drug or nonmedical prescription medication use. Positive screening results triggered further assessment, and primary care clinicians were instructed to immediately connect patients with designated care team members for same-day safety planning, short-term counseling, and referrals to specialized mental health and substance use treatment.
The trial compared a usual care period with an intervention period, supported by practice facilitation, electronic medical record (EMR) decision support, and performance monitoring. Clinical decision support included pre-visit screening and assessment reminders, as well as prompts to support suicide risk identification and mitigation during clinic visits.
Key Findings
From January 2015 to July 2018, the study analyzed 953,402 primary care visits from 255,789 adults during the usual care period and 615,511 visits from 228,255 adults during the suicide care period. The mean age of participants was approximately 50 years, with over half being women and a majority identifying as white non-Hispanic/Latinx. Mental health assessments indicated that 17% of the cohort had depression, 12.8% had anxiety, and 1.9% had alcohol use disorder.
The rate of safety planning was significantly higher in the suicide care group (38.3 per 10,000 patients) compared to the usual care group (32.8 per 10,000 patients), representing a rate difference of 5.5 plans (95% CI 2.3 to 8.7). Suicide attempts within 90 days were lower in the suicide care group (4.5 per 10,000 patients) than in the usual care group (6.0 per 10,000 patients), indicating a rate difference of 1.5 fewer attempts (95% CI -2.6 to -0.41).
Limitations and Future Directions
The study's primary limitation is the real-world setting, which involved overlapping care for suicidality and substance abuse. This overlap makes it challenging to isolate the most effective components of the intervention. Researchers suggest that future studies should examine the independent and combined effects of clinical practices supporting care for depression, suicidality, alcohol, cannabis, and other drug use.
