I am going to go ahead and get started. We have a lot to cover today, so I want to welcome people to the Suicide Prevention Resource Center's webinar, Adolescent Suicide Prevention and Medical Settings. I'm Julie Goldstein Grumman. I am the Senior Healthcare Advisor to the Suicide Prevention Resource Center and the Director of the Zero Suicide Institute, with wonderful presenters for you today. Suicide Prevention Resource Center is at the University of Oklahoma. The views, opinions, and content expressed in this product don't necessarily reflect the views or opinions of CMHS, SAMHSA, or HHS, and SPRC is funded by SAMHSA. None of our presenters have any financial relationships or conflicts of interest to report. Next slide. The Suicide Prevention Resource Center is the only federally funded resource center that's really devoted to the National Strategy for Suicide Prevention, which was revised in 2012. As I said, SPRC is funded by SAMHSA. SPRC is really a clearinghouse for all of your resources for effective suicide prevention, all settings across the lifespan, and all different types of training and best practices for how to really embed suicide prevention in the setting in which you work. I really encourage you to look more closely at SPRC at their website, sprc.org. I just want to frame today's webinar a little bit about what is zero suicide. As I said, the National Strategy was released. It was updated in 2012 by the U.S. Surgeon General and the National Action Alliance for Suicide Prevention, but Goals 8 and 9 really talked about suicide prevention being a core component of healthcare. We have to improve professional and clinical practices. You would think that that happens, but it doesn't. Most systems, they're not well-trained, they don't have system-wide approaches, so we really have to have clear workloads in place. Zero suicide is a framework that healthcare systems can adopt that will transform how they identify people at risk for suicide and how they care for them. It embeds evidence-based practices, and it really dovetails nicely with other safety and continuous quality improvement approaches because it thinks about what is your wide approach to safety? How do you focus on process improvements? It's not meant to be one more thing that you do, but rather your system and how you transform your system to identify and care for people at risk. The zero suicide framework, it's comprised of seven elements that when used consistently and when you measure fidelity, it can save lives. Zero suicide is the use of this entire framework. It's not one or two pieces of care, but it's how do we use these components, these evidence-based practices seamlessly? How do we weave them together to transform how the system thinks about suicide care? That's going to include things like how do we care for staff? What happens if there is a suicide loss? How do we incorporate the voice of lived experience? How do we ensure that staff are compassionate and using patient-centered care? How do we install hope for people at risk? What we're going to talk a lot about today are the pieces of care that we know that are evidence-based, and those are really the building blocks of good suicide care. They're absolutely critical, but where they differentiate from what zero suicide is is because zero suicide is the glue that holds all those pieces of care together, that really transforms the system, that allows you to measure if you're doing what you say you're doing, if you're doing it with fidelity, if you're doing it well, and if you're truly transforming care, then that should come across to your patients and to your staff who work in that system. Zero suicide is more than just what you're doing, but it's sort of the how you're doing it and why you're doing it. There's a lot more information on our website, zerosuicide.edc.org, but I do want those of you after today's webinar to really appreciate that zero suicide is applicable across the entire healthcare spectrum. We know that most people at risk for suicide don't go to see mental health providers, but they are being seen in the healthcare system. They go into the emergency department for a broken ankle. They go in for well visits or strep throat. They're often seen in the weeks and months before their death, and these are missed opportunities, but that means that all of healthcare has to be the right door for somebody coming in at risk for suicide. We can't just wait and say they'll go to somebody who's in the behavioral health department. Zero suicide is applicable in primary care, in emergency departments, in entire hospital systems, inpatient psychiatry, medical surge units, outpatient community mental health, crisis, so we just need to kind of keep thinking about suicide care as really everybody's responsibility in healthcare, and our speakers today are going to talk about primary care and youth in particular as well as how to embed effective suicide care in collaborative care settings. Next slide. As I said, this is the Zero Suicide Toolkit. It's a wealth of information. It's an evolving toolkit. There is information about primary care in particular and about youth. There's a lot of information and tools. We have a self-study for you to take a look at. How do you assess what your current practices are, where your needs lie? What is the workforce that you have, and how is it that your workforce feels prepared and trained to do the work that we're going to be talking about? A lot of information to help you get started. There's also access to our Zero Suicide Listserv, which has about 3,000 people on it. That includes researchers, people with lived experience, people implementing zero suicide healthcare leaders, the people that are presenting on today's call, and it's an incredible resource because people genuinely want to share their practices. Nobody wants to reinvent the wheel, and people can post any question about, do you have a resource on how to get started here, or have you encountered this challenge? I really encourage you, after today's webinar, to take a look at zerosuicide.edc.org to find more information about how to get started. Today's webinar is really to think about, how do we identify suicide risk among youth? What are the tools that we can use to screen youth who may be at risk for suicide? If we do identify them as at risk, then what are the clinical pathways that we should follow? We can't just refer everybody to the emergency department. What does it mean if somebody's at risk? What is your system approach that everybody should be trained in to ensure that that youth is immediately cared for and determine their level of risk, and what kind of care are you going to provide for them? Suicide prevention is applicable in pediatric primary care, and in fact, is a really important setting to identify kids at risk, but in a system that is prepared. Collaborative care is really an important model, and really a setting in which we think suicide care can absolutely be embedded, and those who work in collaborative care can utilize the tools that we're going to talk about today. Next slide. I'm going to turn it over to our speaker, Dr. Lisa Horowitz, in just a moment. Dr. Lisa Horowitz is a pediatric psychologist and staff scientist at the National Institute of Mental Health Intramural Research Program at NIH. The major focus of Dr. Horowitz's research has been in the area of suicide prevention with an emphasis on detection of suicide risk in medical settings. She's lead principal investigator on five NIMH suicide prevention protocols that involve validating and implementing the ASQ, suicide screening questions, the ASQ, in the emergency department, inpatient, medical surge, and outpatient primary care settings. I'm going to turn it over to Lisa. Thank you, Julie, for that introduction, and thank you so much to SPRC for inviting me to talk. It's such a privilege and an honor to be speaking to you today about something that I care so passionately about, and that I know you all do too. Before I start, because I work for the government, I need to put this slide up. I have no financial conflicts to disclose. I will tell you that I am a co-creator, as Julie said, of the ASQ, which is one of the tools I'm going to discuss today. I always like to start my presentation with my takeaway message. My bottom-line takeaway message is that universal screening is a feasible practice for all patients in all medical settings, and that the best way to do this is to ask directly about suicide. Clinicians with the help of population and site-specific validated screening instruments can really make a difference in identifying and managing patient service. I'm going to propose a three-tiered youth suicide clinical pathway. You're going to hear a lot about this, but it starts with a brief screen, and that could be any screener that I'll talk about. Then the most critical step is this second tier, this brief suicide safety assessment, which should take about 10, 15 minutes. That second step determines what happens next. Does the patient need a full mental health safety evaluation? Do they need an outpatient referral? Do they need to go to the emergency department or not? Or maybe it was a false positive and no further action is necessary. And then anybody who's thinking about suicide should really be discharged with a safety plan and resources like the National Suicide Prevention Lifeline and the Crisis Text Line and lethal means safety and counseling, because these are really important interventions that you can do at the site. So before I start, I just want to start with a brief epidemiology of suicide and suicide in the medical setting. So let's go back in time and skip over the COVID-19 pandemic and go back to 2018, where we have some better statistics. So what were our major public health problems at that time? Well, one of the public health problems that killed people were flu and pneumonia. And so that was about 55,000 deaths a year, 150 per day. And for young people, that was about four per week. Another one was motor vehicle accidents, and that was 39,000 deaths a year, about 108 deaths a day. And for young people, that was 19 deaths a day from motor vehicle accidents. And then we get to suicide, and that was 48,000 deaths. So that's 132 people dying of suicide every day in the United States. And for young people, that was 18 deaths a day. So what did we do about this from a public health perspective? Well, in 2018, you couldn't walk into a grocery store or a pharmacy without seeing signs about get your flu shot, cover your cough, symptoms of the flu. There was a big public outreach, and it reduced cases of the flu and death by flu. And for motor vehicle accidents, there was a big campaign about wearing seat belts. It's a law to wear a seat belt. Their kids need to go to driving school before they get their license. And there's drunk driving laws, there's laws in place. So another big public health outreach that reduced death by motor vehicle accidents. But what happens when we get to suicide, which is right up there with these other two? Many of you probably haven't even seen this suicide prevention lifeline sign. So there's still a lot of stigma around mental health problems, but especially when it comes to suicide. We have so much more to do. So suicide is a second reason why kids die. And if you look at all youth deaths in the United States, you see that over a quarter of them are from suicide. And suicide is preventable. Now you see over here a little bit, we saw 2019 data. So there's maybe like a tiny downturn in the suicide rate, but we really haven't made much progress. This is over time. And in fact, more kids die of suicide than the seven other leading medical causes of death combined. So there's a myth that younger children actually don't really think about suicide. And that's a myth because kids under 12 plan, attempt, and die by suicide. And in fact, the 10 to 14 age group is the fastest increasing age group. I think in the last 10 years, that age group has increased the suicide rate by 225%. So there's been some studies published about preteen suicide and the importance of screening preteens for suicide. So we found this in our emergency department study, 29% of the 10 to 12 year olds we screened in the emergency department were at risk for suicide. And then there was an important study that came out by Burstein et al, and they found that between 2007, 2015, there was a significant increase in visits to the emergency department for suicidal behavior and suicidal ideation. And 43% of those visits were kids under the age of 12. And then another study showing the trends of elementary school, five to 11 year olds. And I'm going to talk a little bit about this because I was part of this study. And what we found was when we looked at the suicide rate for kids under 12, it looked like it was very stable until you parsed it out by race. And then we found a significant racial disparity with a decrease for white children and an increase in the suicide rate for black children. So we don't know all the reasons why, or we don't have a good answer of why this increase is occurring, but this is under study now. And I just wanted to show you, if you look, and this is over the age range of five to 17, and you can see an increase in suicide risk for black children, and then it completely reverses at age 13, where white teenagers have a higher rate of suicide. Now I say that, but I also want to point out that there are some very disturbing trends going on. And in fact, the black teenagers are showing the highest increase in the suicide rate of any other racial group. And there has been an emergency task force put out by the Congressional Black Caucus with this Ring the Alarm report, which I encourage everybody to read, which is really a call to action. How do we help make sure that our tools and our interventions are not just good for the majority of kids, but also BIPOC youth? And what we see here is American Indians, Alaskan Natives, who actually have the highest rates of suicide of any racial or ethnic population. And so this is, again, over the lifespan, and you see this just incredibly, you know, this high, high rate of suicide for American Indians, Alaskan Natives. So there are many populations at risk, and we really need to pay attention to minoritized youth who are at the highest risk now, LGBTQ, individuals with autism, spectrum disorder, neurodevelopmental disorders, kids in the child welfare system, and kids in rural areas. And what our hope is is that screening can help identify minoritized youth at risk for suicide and then link them with the proper care. So suicide is still a relatively rare event. What's more common than suicide is suicidal behavior and suicidal ideation. And so if you look at the Youth Risk Behavior Survey, what you see is 8.9% of your average high school student has self-reported that in the past year they have attempted suicide, and 18.8% self-report that they seriously considered attempting. So these numbers are just staggering and really require attention. These are the risk factors for suicide. I'm not going to go through them all. I highlighted the most potent, which the most potent is previous attempt. So in psychology, we have a saying, any past behavior is best predictor of future behavior. This is absolutely true for suicide. Anyone who's done it in the past is more at risk for doing it in the future. Mental illness is also a high risk factor for suicide. And one that we often overlook is medical illness. So kids with medical illness are at greater risk for suicide. Now these are risk factors, and most people who have these risk factors are not going to die by suicide because they're risk factors. What's more important is warning signs. So if you think about it as if you were a triage nurse in an emergency department and someone came in with the risk factors for a heart attack, and let's say they had a family history of heart attack, they were a smoker, they were obese, they had high cholesterol, hypertension. If they walked up to your desk at the triage desk, you wouldn't think they were having a heart attack. But if they came in clutching their chest in pain and sweating profusely and pain radiating down their left arm, you might think they're having a heart attack because that's a warning sign. And so the same goes for suicide. So talking about wanting to die or kill oneself, that seems like an obvious warning sign, but often that warning sign's ignored. Looking for a way to kill oneself, feeling hopeless, trapped, or like you're a burden, acting recklessly, the signs of depression, sleeping too little, too much, withdrawing, displaying extreme mood swings. These are all signs that someone might actually be at imminent risk for suicide. Okay, so I laid some pretty heavy sobering statistics on you, but this is really a presentation about hope because we believe that you can actually save lives by screening for suicide risk in all these different medical settings. So there's a lot of support for this now. The American Academy of Pediatrics, for example, the American Medical Association, the Joint Commission, there's a lot of support now for using medical systems to leverage suicide risk screening and be partners in suicide prevention. So one of the issues, as Dr. Goldstein mentioned, was that if you look at death registry studies, the majority of people who died by suicide had visited a healthcare provider months, sometimes weeks before they died. And this goes for adolescents too, right? So they're coming in and the problem is, is they don't walk into a doctor's office and say, I'm thinking of killing myself. They frequently present with whatever kind of medical illness they're having. So if someone doesn't ask them directly, are you thinking of killing yourself? They most likely aren't going to talk about it. So the majority of suicide attempters go unrecognized because the majority of settings don't screen for suicide risk. So the fact that we know that people who die by suicide have visited a healthcare provider so close to their death is really not only an opportunity, but a responsibility to detect and then manage suicide risk in the medical setting. So this is one of my favorite New Yorker cartoons. It's the elephant in psychoanalysis, right? The elephant in the room. We believe that suicide risk is the elephant in the room. And if we just gave providers tools to detect and manage suicide risk, then it could be prevented. So what are the valid questions that we can ask medical patients in order to screen for suicide risk? So before I talk about that, I just want to talk about the difference between screening and assessment, because this is really important. A screening tool just identifies someone who might be at risk and needs further evaluation. The assessment is a much more comprehensive evaluation that confirms the risk and guides the next steps. But these are two different things, right? So many times you can't go from a screening tool to knowing exactly what to do. You need this interim step of a suicide risk assessment. So we're going to talk about both of those. Now, there are many suicide risk screeners, and the one thing I would caution you is to use one that has research behind it, because the problem that happens is sometimes people make up suicide screening questions. And the problem with making up questions, while they might have some face validity, is that you don't know what they're really measuring. So screeners like these that have been tested through research, you have a better idea that they're measuring what you want to measure. So, again, many screeners. I put up three of the most commonly used ones that I'm familiar with, and that's the Columbia Suicide Severity Rating Scale, the CSSRS, the PHQ-A, the adolescent version of the PHQ-9, and the Ask Suicide Screening Questions, which I'm going to use the Ask as an example because I was part of the research team that developed that, so I know the most about that. So, just to tell you briefly, we developed the Ask using these three children's hospital emergency departments in Boston, in Washington, D.C., and nationwide in Columbus, Ohio. We sampled both medical patients and patients presenting with psychiatric chief complaints because we weren't sure what we were going to find, and we wanted to make sure there were kids with suicide risk in the sample, and we looked at 10- to 21-year-olds. So, this is the Ask, and I'm going to show it to you in more detail, but it had a good sensitivity. Now, sensitivity is a true positive rate, so it captured almost 97 percent of the kids at risk for suicide, and it has a strong specificity, which is the true negative rate, and this limits false positives. Negative predictive value was really good, and that means that when the test says the youth is negative, that they most likely are negative. So, here's the Ask. In the past few weeks, have you wished you were dead? In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past week, have you been having thoughts about killing yourself, and have you ever tried to kill yourself? If the patient answers yes to any one of these four questions, they're given a fifth acuity question. Are you having thoughts of killing yourself right now? So, there's two ways to screen positive on the Ask. You can screen acute positive or non-acute positive. So, I have some pretty big data sets now that other hospitals have shared with us so that we see. I have the Parkland Health and Hospital Systems out of Dallas. They just published a paper on 90,000 encounters with screening with the Ask, so I can tell you that about somewhere in the 90s, some places 97 percent, some places 90 percent will screen negative when you give them this tool, so most patients are going to screen negative when you screen them for suicide. Now, this is different whether or not they're presenting for a medical chief complaint or a psychiatric chief complaint. So, when I say about 97 percent of the kids will screen negative, those are kids presenting with medical chief complaints, but this is part of universal screening. So, let me just show you the two ways. So, for that, you know, three percent from this 90,000 encounter data set that we have, and I've also seen as high as 15 percent, so it depends what age range you're screening. Is it the emergency department? Is it an outpatient primary care clinic? They have lower rates than the emergency department. So, in the percentage that's screened positive, 99.5 percent of your patients that are presenting with medical chief complaints are going to screen non-acute positive. So, let's say a patient said yes to one, no to two, yes to three, no to four. You ask that fifth acuity question. Are you having thoughts of killing yourself right now? They say no. That's a non-acute positive, and I'm going to talk a lot about the non-acute positives because that's the majority of the patients that you're going to screen. If they say yes to five, that's an acute positive. Someone who says yes to five, and this is on the ask, but on any screening tool, if they're having thoughts of killing themselves right then and there, that's an emergency. That's making sure that they're safe, that they don't have anything dangerous that they can hurt themselves with in your medical setting. So, just to go back to the ask study, about four percent in our study of the medical patients screened positive for suicide risk, 18.7 percent of the patients presenting with psychiatric chief complaints, we felt that that four percent made it feasible for universal screening. This was in the emergency department. It was non-disruptive to the ED workflow. It takes about 20 seconds to administer the ask, and it was acceptable to parents and the patients as well. We asked the patients, do you think nurses should screen for suicide risk? We asked in the primary care setting. We asked in the emergency department, and the majority of patients are in favor of it. The ask is now available in the public domain. We have validated it in inpatient medical surgical units. We have validated in the outpatient primary care and specialty clinics, and it has also now been validated in adults, so that hospitals can have one tool to use for kids and adults. These other places in black, that's ongoing research. We're very excited about our collaboration with the Indian Health Service. We are trying to train and implement suicide risk screening in the IHS medical system, which is about 170 medical settings throughout the country. We're also testing the ask and how it works in kids with neurodevelopmental disorders, NASD, in a study we have with Kennedy Krieger Institute and Nationwide Children's Hospital. We have some global initiatives, and ask has been translated into 16 different languages. This is all available on the ask toolkit. If you want to know more, we have the tool, we have a brief suicide safety assessment guide, scripts for staff for how do you introduce the ask when you're screening? How do you train your nurses, the medical technicians? How do you screen them, the doctors? How do you train them to give the screener? We have templates of flyers for parents. No matter what tool you use, it's important to tell the parents that you're screening for suicide risk now. I think it's more important to tell them than I don't think it's something you have to ask them. If it's okay to do, it should be like any other medical test, like taking a blood pressure or taking a temperature. We have some educational videos. I do want to talk about something that comes up often. In 2016, and I believe Dr. Little is going to talk more about the Joint Commission, but in 2016, the Joint Commission recommended suicide risk screening for all medical patients. That was a really big thing to happen to suicide prevention in the medical setting. Now, it wasn't a mandate. It was just a recommendation. A lot of places, especially primary care clinics, were screening for depression. The AAP puts out a strong recommendation that all primary care docs should screen for depression. A lot of places were doing that and said, oh, well, we're screening for depression, and that's probably the same thing as screening for suicide risk. We weren't sure that this was right, and so we wanted to test this. We looked in our studies. We embedded the PHQ-9, which is an excellent depression screen. It's really good at screening for depression. It's in nine items. There's a ninth item that is often used as a suicide risk screen, and that item says, how often have you been bothered by the following symptoms during the past two weeks? Thoughts that you would be better off dead or hurting yourself in some way. The problem with this question is there's two issues with it. One, it has an or in it. Whenever a question has an or in it, you don't know. When someone answers yes to it, you don't know which side of the question they're responding to. The other problem is it says hurting. It doesn't say killing, and especially for kids, hurting yourself and killing yourself and wanting to do those two things are very different. We had some questions, and there's also been a lot of research now showing that the PHQ actually might not be adequate to capture suicide risk. Again, really good depression screen, but how does it function with suicide risk? We did a little study looking at depression screening versus suicide risk screening. This was a study that we embedded the PHQ in our inpatient medical surgical units validation study. This was 600 medical inpatients in a hospital, kids age 10 to 21. When you look at the amount of kids that screened positive for suicide risk, there was 81, and then 103 screened positive on PHQA, and then 42 endorsed item nine. When we put that all together, what we found was that had you only screened with the PHQA, you would have missed about a third of the kids at risk for suicide because it didn't capture them. Had you only used item nine, you would have missed 56 percent of the kids at risk for suicide. I think the bottom line of this study was that by all means, screen for depression and use a depression screen, but if you want to screen for suicide risk, use a suicide risk specific screen. Now, is the PHQ-9 item nine or the whole PHQ-9 better than not screening at all? Absolutely, yes, because you're going to capture kids at risk for suicide, but if you want to capture as many kids as you can at risk for suicide, then you should use the suicide risk screen. There's many people that I hear that do this sequential kind of screening for suicide risk. They screen, they give the PHQ-2 because it's just two items, and then if the patient screens positive, they give the PHQ-9, and if that's positive, then they administer a suicide risk screen. What's the problem with this? One of the problems is there's actually no research that supports that this is a valid way to screen for suicide risk, and why make the patient jump through all those hoops? We don't know that that matters, and if someone says no to PHQ-2, if they don't make it, they still could be positive on the suicide risk screen, but you missed them because they didn't say yes to one of those two questions. One of the things, we know people are screening for a lot of different conditions, and so one of the things we did was we stuck the ask on the bottom of the PHQ-A so that pediatricians would have just one piece of paper to hand out to patients. Okay, so when you're screening for suicide risk, one of the main worries is that you're going to put the idea into somebody's head, right, and so that is a really common concern, and we call that iatrogenic risk. Like, did we make the patient suicidal by asking them about suicide? So I'm here to tell you that there's been at least four research studies that have debunked this myth. This is not true, and in fact, the opposite is true. The best way to keep a young person or even any person from killing themselves is to ask them directly, are you thinking of killing yourself, and then to listen to the answer and to really listen and maybe even brace for what that answer might be and then be the bridge to getting them some help. Okay, so some additional considerations with screening and, again, screening with any screening tool. This is not just screening with the ask, but any screening tool you use. Who can screen? So anybody who's trained to use the screening tool can screen, and being trained to use a screening tool is really easy, so it ideally would be a nurse, a medical technician, but it could be a physician. It could be a nurse practitioner. It could be a physician's assistant. We have some places in the Indian Health Service where pharmacists are screening. It really could be anybody. What if the patient refuses to answer the question? Well, sometimes patients refuse to answer questions, and for kids, we decided that that's going to be a non-acute positive screen, and the reason is that actually in one of our studies, what we found is that patients that refuse to answer, over 85 percent of them had significant mental health histories, so they were at higher risk. Do I contract for safety? So we don't do safety contracts anymore. What we do instead are safety plans, so it used to be that if you were worried about a person being suicidal and you were a provider, you said, sign this piece of paper that says you're not going to hurt yourself, and then you went home and slept better at night, but there's no validity to this, so instead, you make a safety plan. What are you going to do if it's 2 o'clock in the morning and you start thinking about suicide and there's no one around? Who are you going to call? What are you going to do to distract yourself? Asking the patient about suicide, make them suicidal. We talked about that's a myth. What if the patient does not seem like they're suicidal? Do I still need to ask? So this needs to be every patient every time because you can't see suicide risk, and you have to ask. What if the patient starts talking to the nurse or the medical technician about suicidal thoughts in detail? What do you do then? So it is fine to train the people who are screening to say, I am so glad you're talking about this. I'm going to get someone who's trained to talk to kids about suicide to come talk to you. So we don't want to put that burden on people who aren't trained to manage when people start talking about suicide. What if a parent refuses to leave the room? Because it's really best to screen kids and to tell the parent to step out for a moment, but if the parent refuses to leave the room, you can screen anyway because it's a great way to model how to ask kids about suicide. What if the parent or guardian won't cooperate with the disposition plan? Because sometimes this happens. I see in some places that are screening, the child screens positive, maybe on every question of the screening tool, and then the parent says, nope, I came in for a broken leg. My child's not seeing psychiatry for that, or my child's not getting the mental health assessment. So you have to go according to laws of your state and the hospital. Sometimes some of the things I've seen were attending physicians come in and then try to convince the parents, but sometimes, again, according to laws, sometimes people can refuse medical tests. If it's an acute positive, they can't refuse. Then other things have to happen that are complicated. So we can talk about that during the question and answer period. What happens when the patient screens positive? So here's what should not happen, and Julie mentioned this when she started her intro. We cannot treat every positive screen or every young person who has a thought about suicide like it's an emergency. Is it something we should pay attention to? Absolutely, but there's some hospitals that have been screening, and every positive screen is treated the same way. They are put into a paper. The child's put into a paper gown. Their phone's taken away. They're given a one-to-one sitter, and they're there for hours. This is a very punitive way to screen for suicide, and it's untenable. So the fastest way to shut down a screening program is to have every positive screen become an emergency. So again, depending on the tool you use, and different tools have different criteria, with the ask, only the acute positives require the one-to-one sitter because you can't overuse resources. There has to be a little toleration for patients that might be thinking about suicide. Most of them are not at imminent risk, especially the patients that present with medical chief complaints. They need attention. They need someone to talk to, but they need that next step of someone assessing, is this imminent risk or not? It's not always so obvious, and you need to talk to them, but they should not just automatically be given full-on safety precautions. So we put forward this three-tiered clinical pathway. This pathway, it includes using the ask, but you could really use any suicide screening tool. Any screening tool can be subbed in for the brief screen. So it starts with the brief screen, should take about 20 seconds, and then this middle step, the brief suicide safety assessment, so important. This is the most critical step of the pathway because this is what decides the next step. Does this child need a full mental health evaluation? Do they need an outpatient referral or no further actions required? So this is the pathway. It's published by Brombat et al. It's really just what I told you. It looks complicated because it's fleshed out and there's some text that goes with it, but it's, you know, administer a screening tool, then give the brief suicide safety assessment, which helps you determine, you know, which bucket is this. Does the child need a full, you know, is this imminent risk? Is this high risk and needs a further evaluation, or is this low risk and they can be seen outpatient and even in a few weeks from now? So this is the one for out. So we have these pathways. It's on the ASQ toolkit website, and we have one for outpatient, we have one for inpatient med-surg, and we have one for emergency department. This one is for the brief suicide safety assessment in outpatient should be, is this an imminent risk? Is further evaluation needed, or is it low risk? Also, just very briefly, a lot of the screening tools ask, have you ever tried to kill yourself, right? So what if the patient says they tried to kill themselves, and then they come into your office next year, or a few months from now, they're always going to be positive, right? Because they screen positive on that. So it's okay to add, since last visit, have you tried to kill yourself? And if they answer no, and they were no to the other questions on the screening tool, then maybe no further action is needed. And then here are some things to consider. Was the attempt more than a year ago? Has the patient received or is currently receiving mental health care already? Is the patient, is the parent aware of the suicidal behavior, and is the suicidal behavior not an active concern? So if it's yes to all those, then it's a low risk choice for action. Okay, and then there's safety planning, which it fleshes out a bit. So for the brief suicide safety assessment, you can use the Columbia Suicide Severity Rating Scale that Columbia makes, actually is probably easier to use on the patients who screen positive. So it makes a good second tier assessment. We also created the Ask Brief Suicide Safety Assessment, which is a guide. And it basically helps you determine disposition. So this looks long, and you might say, how can I do that in 10 or 15 minutes? And the truth is, as soon as you get to your disposition, you can stop, because what you're really trying to figure out is one of these four things. So it's helping you make the next step. And that's what any brief suicide safety assessment should do. Is this an emergency? Does this patient need further evaluation? Or it's not the business of the day. They came in for belly pain, and they screen positive, but it's not urgent, or they're already in mental health treatment, someone knows about it, and no further intervention is necessary at this time. We also adapted the pathway for COVID and telehealth. And what that focuses on is safety planning. So how do you avoid the emergency department? How do you avoid sending patients? Because remember, as Julie said in the beginning, especially with pediatric practices, outpatient, every positive screen should not be sent to the emergency department. In fact, hardly any of them will need to go to the emergency department. But you do need to help them come up with a safety plan. So we could spend hours on how you do a safety plan, but the nuts and bolts are really what are the warning signs, the trigger points for that particular patient? What coping strategies can you help them put on board? Who are their social contacts, their emergency contacts? And then what lethal means that they have access to that you can help a parent remove? So just a word about lethal means safety. This is so important. Parents don't realize that the Tylenol and the Advil in their medicine cabinet can be used to kill, that kids can use that to kill themselves. And so it's so important, you know, have the talk about guns in the home, and can they be locked up safely so the child doesn't have access to them? The pills, the knives, the ropes, if a child's in crisis, getting rid of the means could really save their life. And that's because when people are feeling suicidal, they're in a state where they're not thinking clearly. They're just in so much pain that they aren't thinking clearly. And I can't tell you how many kids told me that they attempted, they were gonna attempt suicide, but then somebody called on the phone and distracted them, or somebody walked in the door. And distracting someone and making sure they don't have the means can really save their lives. All right, just a brief moment about can we adapt the suicide risk screeners for kids under the age of eight? I'm gonna say we shouldn't, right? And one of the reasons is, first of all, the screeners are, so the ASK is a third grade reading level, that's an eight or nine-year-old. The CSSRS is a fourth grade reading level, that's a nine or 10-year-old. And the PHQA is a 6.5 grade reading level, and that's about an 11 or 12-year-old. So these are tools that have been studied on kids age eight, age 10, age 12, and above. However, that doesn't mean that kids under the age of eight are not thinking about suicide, because there are some, it's rarer, but there are some kids under the age of eight who are thinking about suicide. And so if they come into your office and you see the warning signs, then assess them. You don't need to screen them. A kid under age eight doesn't need, there shouldn't be universal screening for under age eight, but if you see warning signs of suicide, or thinking, or behavior, then they should be assessed. So, and maybe what we should be screening younger kids for is coping strategies. What do you do when you feel bad or sad or mad to get that upstream intervention of early, putting coping strategies on early? So to summarize, again, I'm sure by now you know I'm an advocate for universal screening, that you should ask directly with a suicide-specific screener. 10 years and older for kids presenting with medical chief complaints. Eight years and older for kids presenting with psychiatric chief complaints, because those kids who present with psychiatric chief complaints in every setting are at higher risk for suicide. And then kids under the age of eight recognize the warning signs and assess for risk. Screening should take about 20 seconds, but it requires practice guidelines in place for managing those that screen positive. And so this pathway of the brief screen with any tool, and then the brief suicide safety assessment, and then the next steps are really important. It's also really important that we have more studies and we have a focus on making sure that we are identifying the kids at highest risk and looking, especially to make sure that our tools are good for everybody and it's equal in that way. Instruct patients and families to remove their lethal means like the firearms, the pills. Okay, and so I just wanted to say thank you. There was a lot of people that went into doing all this work and thank you for your attention. Thank you, Lisa. That was so informative and really the kind of things people can start doing today. So what did you learn? Let's use the chat box. We're gonna hold Q&A until after Dr. Little goes, but I know some of you are using the question box, the chat box, both are fine. What is one key takeaway from that presentation or something that you feel like you're gonna go back and share with your team right away that you didn't know before? I'll give you a second to think about it. Hopefully whatever you share might stimulate others. Taking a look, I can see. A couple of comments coming in. One of my key takeaways, and I certainly heard Dr. Horowitz present, I'm always surprised at the number of systems that are still using contracts for safety. I think that's something that people feel, that systems feel like they're really covered, and yet we know that there's no proof to that. There's nothing legal, there's nothing ethical, and you're actually not teaching your clients anything. When I was in grad school, you were sort of taught to use that, but it was to make you feel better. But if you think about it, safety plans teaches sort of a sense of self-efficacy for your patients. I can see some people talking about, they use the PHQA often in our clinic, and now they understand that it is not the most complete way to assess for suicide. So it looks like the system that has some changes, they can start tomorrow. First time I've heard a logical explanation for not using the PHQ-9, so I think that's great. We know it's a great tool, but it's not the right tool for suicide prevention. The importance of screening all patients, I'm amazed at how you did this. Do not treat all positive screens as an emergency. I think we know that our emergency departments have really been flooded. And we have to think about what happens. Most of the time, people are not gonna get admitted, they're gonna get returned right back to your care, or to outpatient care, and so the whole cycle of what are you gonna do with them to reduce their thoughts of suicide is gonna start all over again anyway. So we can avoid the trauma, we can avoid the aggravation for those that are not at acute risk, and use the tools that do exist. So I wanna thank you, Dr. Horowitz, and we'll turn back to you just after Dr. Little's presentation. I wanna introduce, though, Dr. Little. Dr. Verna Little is Chief Operating Officer and Co-Founder of Concert Health, a national organization providing behavioral health services to primary care providers, and Co-Founder of Zero Overdose, a nonprofit addressing the national crisis of unintentional overdoses. Previously, Dr. Little worked for 22 years as a Senior Vice President for a large federally qualified health center, FQHC Network, in New York. I think FQHCs are a really critical location to think about suicide care, and I know Dr. Little is gonna share some of her observations. She's a nationally and internationally known speaker for her work in integrating primary care and behavioral health, developing sustainable integrated delivery systems, and in suicide prevention. So I will turn it over to you. Great, thank you so much. Pleasure to be here. Really glad to share this time with all of you. And I can't imagine after hearing some of the data that we all heard that people just aren't inspired to leave here and do something different. So I wanna thank you, Dr. Hurwitz, because every time I hear you speak, I just get re-inspired, so thank you. We're gonna spend the next couple of minutes talking a little bit more about suicide safer care, particularly in pediatric primary care. Go ahead. So I know that for some of you on the line, you've heard Dr. Hurwitz use certain language, and I think it's really important that we level set around language, particularly when we're in primary care and talking to patients who may be at risk for suicide. So I know that you've heard many of us on this webinar say die by suicide versus committed suicide, really thinking that people commit crimes and really trying to use the language die by suicide. A lot of times I will be reviewing charts or working with organizations, and I still see language around successful or unsuccessful attempts. I was in an emergency room one time, and I often reference, I was working there, and there was a 13-year-old who had tried to die by suicide that morning, and she was introduced to me, and her name, she had an unsuccessful attempt this morning, and thinking about the message that we sent to that 13-year-old, not even being able to be successful, or had she been successful not being with us. Also really describing behavior. Many times, even with the electronic health records, I will see language in the charts and oftentimes in caps and oftentimes in flags or EMR notices that patient is manipulative or patient is attention-seeking. And so one of the things that I think is really helpful for me is that someone who is talking about suicide is more likely to die by suicide, and so I really start there, in that I need to be caring for someone who may be at risk for suicide, and that it's way more helpful for my team and others that work in my organization and the patient to really describe their behavior, what did they say or what did they do, instead of maybe pretending to know their intent. Also trying to use language like working with or caring for versus with dealing with someone who may be at risk for suicide. Go ahead. So we're gonna talk a little bit more about the role of the pediatric primary care provider, what can happen during the course of a routine primary care visit, some little bit more on safety planning that Dr. Horwitz was speaking about, and some things that we might be able to do during the course, again, of a routine primary care visit. And it's really important for those on the line who work in primary care, who are pediatric primary care providers, that a lot of the workflows and the processes that you use for other chronic illnesses can actually be used for suicide safer care, and we'll try to make some of those comparisons and talk a little bit more, and then talk a little bit about collaborative care for pediatric patients and the pediatric population. So why are we focusing on primary care settings? I'm still overwhelmed and inspired by some of the data we heard earlier, but one of the things we know for sure, and I have seen this working in primary care and working in an organization where we had both primary care and behavioral health, I unfortunately had more patients die by suicide in primary care that were not known to specialty mental health, not seen in specialty mental health. And in fact, Julie and I were talking recently about some of the information that came out of a large payer where they actually found that people who were not engaged who had sort of fell out of care actually resurfaced in primary care. And when I think about all of the time that I spent working in and running school-based health centers, how many kids came in to see us that didn't actually connect with any other systems. You know, they came to us for their dental care, their primary care, and didn't touch anywhere else. And so we really have an incredible opportunity to identify kids who may be at risk for suicide. So I know we talked briefly about the Joint Commission. For some of you that have the opportunity and the blessing to get visited by the Joint Commission periodically, one of the things that has been really clear is not only this Sentinel event and not only with Joint Commission, but that the regulatory bodies like Joint Commission, CARF, the others are really saying, you know what, you need to think about how you care for people at risk for suicide. You need to have some processes in place. You need to have training. You really need to have a pathway. And so really encouraging you, go ahead, to think about what you're doing around Suicide Safer Care and to think about some of the national patient safety goals and oftentimes, you know, for organizations, especially in Joint Commission years when things may not move so quickly, is to say, hey, wait a minute, if ever we're gonna rally around trying to be a zero suicide and Suicide Safer Care organization, it's really because we need to do some of this in response to what Joint Commission is requiring. And so while I don't always agree with that motivating tool, it can often be a motivating tool in some organizations. So certainly good to know about. Go ahead. So one of the things to really think about also, and this is kind of a famous slide for those of us in the zero suicide world, is really thinking about your organization and creating a system where nobody falls through the cracks and for any of you who have heard me speak before, I always talk about sort of wrapping a warm fuzzy blanket around your patients at risk for suicide and really thinking about how people can fall through the cracks. And so oftentimes, you know, I will give examples and I worked with an organization in the Midwest and they had someone die by suicide and that person had called and canceled an appointment in primary care or canceled an appointment like a WIC appointment and another one. And nobody at the front desk answering the phone knew that she was at risk for suicide and there was no process in place where some flag went up that, hey, this person has canceled three appointments within a week and somebody should really follow up or that didn't get raised to somebody's attention. And so thinking about places like that in your system where you might start to change some processes so that people don't fall through the cracks. So one of the things that I really like to talk about is sort of what we hear in primary care. So I've had the privilege of working with primary care providers around the country and we've trained a little over 2,500 primary care providers now, many of them in pediatric practices around suicide safer care. And there's a couple of things that we always hear. One of them is that I don't really know what to do and so one of the things that I really encourage you to do and to do perhaps at your next staff meetings or the next time you're in a group or with your practices is to do what I like to call storage statements. And so many of us can think about a time in our life where we told someone something and that first couple of seconds really dictated to us, did we regret our decision to say something? Were we glad we said something? Did we tell more? Did we not say anything else? And so thinking about if you have a child or an adolescent who for the first time maybe told you that they're thinking about suicide, that initial response is really important. And so years ago when I was training social work students, I came up with something called storage statements. And in other words, thinking about something in advance so that you actually have a response if you need it. And so thinking about what do we really wanna convey to someone who just told us that they're thinking about suicide. That we heard you, thank you for telling me you're thinking about suicide. You're really important to me, your life matters to me. And so tonight when you're brushing your teeth, maybe think about a response or a sentence or two that you might wanna say to someone, an adolescent who's in your practice that just told you that they're thinking about suicide or answered yes maybe to a screening tool. I think it's really important. And also one of the other things that we hear is I don't really have time, right? I don't have time. And so I've worked in primary care my whole career. One of the things I know for certain is that it is incredibly busy. The other thing that I know for certain is it would be a beautiful day in primary care if what people came in for was actually the most critical need or the most important thing. And so I encourage you to think about how you care for patients who come in, so example, if someone comes in and they're really experiencing asthma, what do you do? You might give them a treatment. You talk to them. You talk to them about emotional triggers, about environmental triggers. You might do some education around how to use a spacer or how to use an emergency inhaler. You might talk to their parents or guardians. You might do an asthma action plan. All of these things are pretty routine to happen in pediatric primary care when a child comes in experiencing asthma. And so think about that same workflow for a patient who may be at risk for suicide. We wanna stop. We wanna get some information. We wanna ask some questions. We wanna determine risk. We wanna give some information. We wanna do a safety plan. And so really a lot of the same workflows that can and do happen during a routine primary care visit can and should happen with someone at risk for suicide. So one of the things that you wanna try to do is of course we don't wanna panic, right? We wanna be careful to listen and reflect and then to give someone hope and remember to use some of the language that we talked about. Go ahead. So there's a couple of pieces that I think are super important in primary care. Oftentimes I'll ask organizations, tell me about how many diabetics you have. And they're really proud to tell me about their registry, how many diabetics and the A1Cs and what they're doing. And then I'll ask, so how many patients do you have at risk for suicide? And I can probably literally count on one hand, I certainly don't think two hands, the number of organizations that have been really able to answer that question. And so it's really important to start to track patients who are at risk for suicide. And one of the things that we are lucky to have is that we live in a world where there's a code for everything. I'm sitting in South Carolina now and if I went outside and a bat fell on my head or my water skis caught on fire, right? I would absolutely, there would be a code for that. So there are codes for risks of suicide. And I really encourage you to use them, to put them on your problem list. They're already in your EMRs, you can put them in right away. And that is incredibly important, not just for tracking your patients at risk for suicide, but also because imagine if someone is covering for you and they see that someone is at risk for suicide on the problem list, they may ask different questions or make different decisions. So it's really important. And I encourage you also to start to think about two populations and having suicide risk on your problem list is really helpful for both populations. So the first population are the kids that we identify because they came in, they score positive, they made a suicidal statement. Oftentimes we have some processes in place, but where we often fall short is that we don't have a process in place for kids or adolescents who come back for routine primary care. And so as an example, there was an adolescent and he was getting care in a school-based health center. He came in to get some forms filled out and he answered yes to the PHQ-9A. And so lots of commotion, I think they actually sent him out. And one of the things is that he came back three weeks later to get those forms filled out, saw a different provider, came in and out, and no one asked him about his suicide risk. Was he safe? Did he have a safety plan? Was he engaged in care? And so those are the kind of falling through the cracks that you can avoid if you put suicide risk on the problem list. And also to really think about what does follow-up care look like for you? And in other words, if someone goes in, and again, to use the asthma example, if a child comes in and they have asthma, you have questions that you ask them right away. You have things that you do. You ask them about their asthma action plan. What do you do for kids who are at risk for suicide? Do you, at a very minimum, ask them if they're safe? Do they have a safety plan to do some sort of follow-up? So really something to think about. So certainly Dr. Horowitz talked a lot about the PHQA, so I think we can go ahead to the other slide. And talk a little bit about collaborative care. So collaborative care is an evidence-based model for the identification and treatment of patients with depression or anxiety in primary care settings. It's actually considered a primary care initiative. It came out of a research project in the late 90s, early 2000s, with 1,800 patients and 400 primary care providers around the country. It initially focused on seniors and depression. It has since morphed to be evidence-based ages 12 and up. And one of the things that is important to know is that this model brings two new individuals onto the primary care team. One is a behavioral health care manager, and the other is a psychiatric consultant. This behavioral health care manager tracks an entire population of patients who have depression or anxiety. And so one of the things that's important to know is, again, the entire population, so not just people who want or need counseling or therapy, but anyone who has a depression or anxiety diagnosis so that there can be a care plan, there can be some follow-up, the use of a registry so nobody falls through the cracks. And then the psychiatric consultant, who in the collaborative care model does not see patients and they don't prescribe medications, they actually meet with that care manager once a week, talk about patients that aren't getting better, and make recommendations directly in the chart to the primary care provider. And so what's interesting about collaborative care is that they are a monthly case rate codes. They are a Medicare benefit, means a little less to the pediatric population. However, they are recognized by Medicaid in 19 states. The last was actually Texas just recently and prior to that, California. There's a couple more sort of headed that direction. And it's also recognized by all of the, pretty much all of the commercial payers with the exception of some local providers in certain markets around the country. And so one of the things to know is it again, is a monthly case rate. So it is not by visit. It's the amount of time over the course of a month that that care manager and that team spends caring for that patient. Go ahead. Okay. So one of the things to really know about collaborative care is that it is actually inclusive of telephonic or virtual care, even prior to when it was really fashionable, you know, pre COVID. And so what's nice is that it allows for check-ins with patients and telephonic work as part of the monthly minutes that wouldn't be reimbursed in many other scenarios. Go ahead. So collaborative care is incredibly patient centered. And what that means is that people can really choose what will work for them. So oftentimes, particularly with adolescents, what's something you might do today or tomorrow that might be helpful for you to feel less sad and then actually talking to them in a day or every other day. For patients who are at risk for suicide, it's very common to talk to someone every day, to talk about a safety plan, to talk about if they use their safety plan, what are they thinking to talk with parent or guardians and really think about how you can work with them to choose what would be helpful for them. And that can change. So it's not just a weekly appointment, although it could be, but it can morph and change. So I could talk to you four or five times a week, and then once a week, and then twice a week, it's really based on what would be helpful. And that amount of time can vary and what happens on those calls can vary or happens in those person visits or those video visits. And so incredibly patient-centered. And so one of the nice things about collaborative care for patients at risk for suicide is that it really allows for an immediate connection to care that someone could talk to someone very quickly because these folks are embedded with primary care and then really provide the kind of almost daily support if it's needed or wanted for patients who are at risk for suicide, that there's pretty immediate access within the week to a psychiatric consultation or maybe even sooner, and that there's really some nice wraparound for patients who would be at risk. And it's for your entire population. So anybody who's experiencing depression or anxiety, and it's incredibly treat to target. So collaborative care does use the PHQ-9, PHQ-9A, and the GAD-7, which is the equivalent for anxiety, looking really for a 50% or 10-point reduction in symptoms in the first 90 days. So it's really focused on how do we reduce your symptoms using evidence-based practices, lots of different ones. And then of course, collaborative care in and of itself is an evidence-based practice. So a registry is required so that nobody falls off the radar and tracking the population. There's lots of information on collaborative care. If you literally Google CMS and collaborative care, you will find some of the Medicare Learning Network Sheets that are really helpful. I'm also glad to put my contact information out, and I would be more than happy to talk to you about collaborative care and how it could be helpful for you in caring for your pediatric population. Next slide. So one of the things that we've talked about quite a bit in this webinar is that not everybody needs to go to the emergency room, and I'm really gonna reiterate sort of what Dr. Horowitz said earlier. I worked in an emergency room for 17 years, providing care to patients who were sent there from the community. Many of the people did not need to be there particularly. Many of the adolescents, and oftentimes, when I talk to social workers, providers in the community, they sort of thought that something magical happened in the emergency room, and what I can tell you is there's no magic that happens in the emergency room for sure, but that I would often say, you know this patient, you have a history with them. We could ask some of the same questions. Let's really make sure that people get to where they need to be. Not every child who comes in with asthma needs to go to the emergency room, because what would happen after a while is they'd say, you know what, why would I go there? I'll just go right to the emergency room, or they would say, I don't wanna go to the emergency room. I don't need to go to the emergency room, and they stay home, and then you have kids or individuals with asthma and suicide risk or suicide risk staying home, and we don't want that, so making sure that everybody gets an appropriate level of care. Go ahead. Okay, so I'm gonna turn it back over to Julie, and I really appreciate everyone's time. Thank you both so much, and thank you, Dr. Little. I think it's so important to hear that these tools can be used and how to go about using them in your systems. I wanna go back to any observations using the Q&A box. What is a takeaway, Lisa, if you wanna forward the slide? Again, what is a key takeaway from Dr. Little's presentation? What is it that you can start doing right away? What is something that was not known to you before? And at the same time that you're doing that, you can start to tee up some questions you might have for any of our presenters. I'll give you a moment just to type into the chat, and I've seen a few questions come in, so I will ask our presenters these questions as well. One of the first questions that I saw is also, I'm gonna ask you, Dr. Little, so how do you know all these pieces of care that we were describing? How do you train your staff to utilize both the practices that you want? How do you ensure that they feel comfortable and competent to use these kinds of practices? What do you do to train your team? I think there's a couple of pieces that are really important, is one is really give people the opportunity to talk about suicide and what some of their concerns are. I've talked to so many nurses in the field who have said, I'm really concerned, I'm afraid to ask someone about suicide, and really taking some of those conversations head-on. I also think it's a lot of fun to be at a staff meeting and practice storage statements. What would you say? What do we want someone to know when they tell us they're thinking about suicide? And together, think about storage statements, and to share stories where people maybe thought of something good, and then to think about training. Training is an ongoing process, and to really make sure that we're bringing cases into huddles or into staff meetings and talking about what we could have done better or differently, and where we need to focus. And one of the things that I've been in a lot of trainings, and given a lot of trainings, and people have a tendency, those storage statements need not to be, well, what I would say is, I would ask the person how they're doing, and I would ask them if they're thinking of suicide. People tend to try to give themselves some distance, and not just say, no, no, this is you, say it like I'm your patient. And so I really encourage, if you're gonna practice these storage statements and role plays, to make sure that people are doing that as though they're doing it in the moment. Yeah, we don't let them get away with that in training. So tonight, when you're brushing your teeth, say it into the mirror, like you would say it to a patient. Yep. Exactly. I saw somebody say their key takeaway is changing the language I use around suicide. And I think that's so impactful. So thank you for always bringing that up in presentations. A couple other questions I saw. So I'm gonna direct this to you, Dr. Horowitz. Do you recommend interval screening on mental health inpatient units to capture fluctuating risk like do you screen people every 12 hours for suicide risk on an inpatient unit? So does the question say if it's an inpatient medical unit or an inpatient psychiatric unit? I leave that. They didn't, but I leave that to you. Okay. So I'm gonna guess it's an inpatient psychiatric unit. So I think it's important to continue screening, except to assess. So screening is really meant to detect suicidal thinking, right, that you're not aware of. So once you detect it, a lot of the screeners aren't meant for every 12 hours. So for example, you wouldn't wanna give the ask every 12 hours on the inpatient unit because it wasn't developed to, that wasn't its purpose. So you wanna make sure that what you're doing is assessing safety every 12 hours. So I would be very careful about what tool you were using and I would make it an assessment tool if it was repeated that way. Okay. Great, thank you. What about, I'm gonna go back to you, Dr. Little, to follow up on the earlier question, but certainly Dr. Horowitz, you can respond to this as well. How have you incorporated self-care in your training of your staff? So I think it's really important also to talk about self-care, to be able to give people the opportunity to talk about what would be helpful for them. Also really to make sure that your EAP programs and some of the others are really trained around suicide safer care. We are at a time when it is unbelievable to me, or I guess not unbelievable, the rise in suicides among healthcare providers and people in healthcare. And so, are we taking precautions and taking self-care and taking the conversation about suicide to an organizational level sort of across the board? Lisa, do you have anything to add? I mean, I just agree with what you said, Verna. And I just think that there's, suicidal thinking can be really hidden. And one of the most striking things that ever happened during a training I did was that we were training a pediatric practice how to screen kids for suicide risk, but one of the staff members was actually at risk. And that came to light after the training and then her friends and her staff were able to get her help. So I think you just have to be acutely aware that this is not an other kind of problem. This could be anybody. You don't see suicide, but like I said, you don't see suicide risk. And so it's always important, one, to be sensitive and to make sure that there's just an environment that accepts openness about and destigmatizes suicide risk. I think one of the things that touched us as we were going around doing the primary care trainings that is that we did not go to a single residency program where a resident didn't come up to us and talk about someone that they had lost to suicide either in residency or in medical school, not a single one in all of the states that we went to. And so to me, that was troubling and telling. And because of that, there is a AHA, American Hospital Association podcast series about suicide in medical providers that for those of you who might be interested in a little bit more on that topic, I know it came to light a lot during COVID as well on the mental health of our healthcare workforce. And hopefully kind of using the language that Verna described and sort of using tools, I think it hopefully changes the culture, right? That as we care for people, that everybody feels more comfortable sharing their thoughts of suicide, not just patients. So Lisa, another question that came in was about just what you find you talked about. Ideally parents leave the room when you screen kids, but somebody asked if you find a notable difference in kids who are screened in front of parents versus alone with regard to their screening positive. Yeah, really good question. You know, I can't think of a study off the top of my head that shows kids are more frank to answer suicide risk questions when their parents leave the room, but I think it's just intuitive that we believe that kids will, especially adolescents, will tell you more when their parent isn't standing right there. So I think it's ideal to have the parents leave the room with what you don't want to do is turn to the child and say, do you want your mother to stay or go? Because you don't want to put that on the child. So you really want to say it in a, and this is one of the things that I know when we did a lot of the nurse trainings, this was something that worried people. Like, I don't want to ask the parent to leave the room. They're not going to want to leave. But it turns out the majority of parents will step out and it doesn't have to be go to the cafeteria and go get, it's literally, if the screening tool is 20 seconds, it's can you step out for a minute? And if we have concerns about your child's safety, we'll let you know. It's also at that time when the parent steps out that you can ask the domestic violence questions about do you feel safe at home? So there's a lot of places that use that opportunity when the parent steps out to ask the other sensitive questions to the child. Thank you. And Lisa, one other question that came in is about the Computer Adaptive Suicide Scale for Youth, the CASI, and I know Dr. Gordon recently has flagged that. So is that something that you recommend? So the CASI is the first computerized adaptive test and it's an NIMH, it was an NIMH funded study. And what's interesting about, it's an interesting test. You can, so it forces in three of the asked questions. So three out of the four asked questions are actually embedded in the CASI and you can dial up sensitivity or specificity. So it's a tool that I think a lot more computerized adaptive tests like this are becoming a focus and it seems like it's a wave of the future. From a public health perspective, I think maximizing sensitivity is always important. So I think as long as you use a tool that has high sensitivity, and captures the kids at risk, then I think it's a good way to go. And I think this is like the million dollar question and something a lot of communities struggle with, which is what should providers do, primary care providers, pediatric providers who practice in a community with very limited access to mental health services, right? They have a six month wait. What should they do for people who they've identified as being at risk? So I think there's a couple of things and one of them to be honest might be thinking about collaborative care. And I say that because collaborative care can be done partially virtually or completely virtually. You're able to then provide care pretty imminently. It also changes the ability you have and who you can hire. So people with different credentials than you might be able to hire traditionally for a behavioral health role in your practice. It means that somebody could be working remote from another part of the state and really expand access. So I would encourage you to think about collaborative care. I'd also encourage you to think about partnering with the providers that are in the community so that you can have someone on your team that can do some safety planning, do some follow-up for children and adolescents who aren't in that really acute bucket and maybe have them come in more often and then work with your providers to really make sure that you can expedite the kids that you're concerned about and that you have some standardized tools so that they know what the ask is and they know what you're using and you can use the same safety plans. Lisa, do you have anything to add? I think that that's a good answer. I think that pretty much covers it. Yeah, no, I think it's really challenging in a lot of these communities, but being prepared really matters. Also, I think that telehealth has been really much more utilized during COVID and I think that's another option. Maybe actually, Lisa, another thing to speak about and would be sort of like the primary care networks and the opportunities to call for consultation that exist in some states. Yeah, I think, so first of all, I think it's always important to have your plan in place. Like you can't just start screening tomorrow without knowing how are you gonna manage the patients that screen positive. So a lot of people set up a priori relationships with mental health people saying, I'm gonna screen, will you be willing to evaluate my positive screens if I get one? But there are places in different states that I've been hearing about. There's some that have mobile crisis units. So if you have a child who you're really worried about, you can call a mobile crisis unit, you can call a helpline. Like I know a lot of states have a line for primary care docs to call a psychiatrist or a psychologist or a social worker where they can get assistance on each case. So every state is different. And I know there's also a lot of hope behind SAMHSA's working on the 988 number where people will have better access to mental health care through that. So that's still a ways away, but that's coming down the pike as well. I think I'm just gonna add there that sometimes, like I have talked to places that start screening and then their screening rate becomes too high. I just talked to a place a few weeks ago and so they stopped screening. And I would just recommend not doing that because especially with kids, sometimes screening itself could be an intervention because kids come with a parent or a guardian usually. And so you can at least put the parent or guardian on notice. You can at least do some lethal means safety counseling. You could at least try to come up with one or two things that child could do at two o'clock in the morning if they're thinking about suicide. So I don't think that it should just be, don't ask, don't tell. Like, okay, we can't handle it, so we're not gonna ask them. I think there's always something that can be done. And so please, if you start screening and your rates go too high, then figure out how to respond in a way that you can manage rather than just stop screening. I think that's a really great place to stop. So thank you. If you want to advance the slide, actually, it's information about how to get CMEs. Want to make sure everybody gets those. This actually, as I mentioned, is the Zero Suicide website. So want to make sure people know how to access that. The webinar will be archived there as well as on the sprc.org website. There's information about how to join the Zero Suicide listserv, which I encourage all of you to do. We will advance it once more. And I just want to really thank both of our presenters who make this sound easy and accessible and doable. And I know that it's not easy work and it is really challenging, but the tools exist. It helps people at risk. We have lots of wonderful role models out there who are available to ask questions and it's really necessary to do this work to save lives. So there's really no excuse to not use what we know works for reducing suicide. So thank you both so much for doing this webinar with us and joining us. I hope everybody has a great day and see you the next time. Thank you. Thank you. Thank you.

Adolescent Suicide Prevention

Medical Settings

Julie Goldstein-Gramman

Suicide Prevention Resource Center

Zero Suicide Institute

Zero Suicide Framework

Ask Suicide Screening Questions

Screening Tools

Three-Tiered Clinical Pathway

Pediatric Primary Care

Warning Signs

Collaborative Care Models