Youth Suicide Prevention and Intervention in Primary Care Settings: An Exploration of Integrated Behavioral Health Stakeholder Perspectives

Background: Preventing suicide is an immense public health challenge. Suicide is currently the 2^nd leading cause of death in youth ages 10-24 (CDC, 2016). Research shows that nearly 90% of suicidal youths are seen in primary care during the 12 months preceding a suicide attempt (McCarty et al., 2011). Primary care providers who detect the presence of suicidality in patients typically refer them directly to the Emergency Department (ED), often resulting in extensive wait times followed by inpatient admission (Plemmons et al., 2018). While behavioral health integration within primary care settings presents an opportunity to expand access to evidence-based preventive mental health treatment for suicidal adolescents, possibly avoiding ED visits altogether, little is known about primary care providers’ perspectives on suicide risk or their experiences of working with suicidal patients and their families. This study explores multidisciplinary perspectives, experiences, and practices related to working with suicidal adolescents and families in the primary care setting.

Methods: Data are drawn from the first phase of a multiyear study designed to adapt and test the Family-Based Crisis Intervention for Suicidal Adolescents, a brief ED-based intervention for suicidal adolescents and their families, for use in Primary Care (FBCI-PC). In Phase 1, the investigative team conducted qualitative interviews with N=25 integrated behavioral health (IBH) stakeholders (primary care physicians, nurses, and social workers), all of whom are primary care providers, from four geographically unique primary care practices located across the state of Massachusetts to explore their experiences of working with suicidal patients in primary care settings, current practice protocols and processes related to suicide screening and assessment and intervention in the primary care setting). All interviews were audiorecorded and transcribed verbatim.  Data were analyzed using thematic analysis (Braun & Clarke, 2006), utilizing conceptually clustered matrices for comparative analyses (Miles, Huberman, & Saldana, 2014).

Results: Findings revealed variability in practices related to suicide screening, prevention and intervention across the four primary care settings. These approaches were influenced substantially by the following four domains: a) availability of internal and external resources (e.g., staffing, protected time allocated for crisis management, supervision, proximity to additional supports), b) stage of IBH rollout and quality of relationship with behavioral health team, c) IBH clinician experience and comfort with working with suicidal adolescents and their families, and d) the degree to which practice leadership, which in all cases were primary care physicians without behavioral health specialized training, were knowledgeable about suicide risk assessment and treatment.

Implications: This study provides new knowledge about the experiences of primary care physicians, nurses and social workers in integrated behavioral health settings with respect to detecting and treating suicide risk in adolescents. Findings suggest intervention targets for providers (e.g., knowledge of best practice with suicidal youth) and primary care clinics (e.g., detection and referral to behavioral health clinicians) that would promote provider delivery of a primary-care setting based intervention. Such considerations are critical to inform the adaptation of EBP for suicidal adolescents for use in primary care settings.