USF Training - Assessing and Managing Suicidal Behaviors in Pediatric Primary Care

and professor of Psychiatry at katton University School of Medicine in Phoenix Arizona and today Dan is going to talk to us about a very timely subject certainly um very much in the news regarding assessment and management of suicidal behavior in pediatric primary care so then go ahead and take it away thank you very much Marie thank you for the opportunity I'm glad to be here coming from Sunny Phoenix Arizona um but as you know having spent the majority of my career in Florida um I wish you all the best in this opportunity um this is an important topic because when these behaviors happen in pediatric Primary Care it usually creates a little bit of disruption of clinical flow it can create a lot of stress and not only in the clinician the pediatrician but also with the staff and we'll also as we know slow things down if you will so this is a an effort to provide this kind of targeted overview of how to best kind of assess these Youth and what the management strategies and not and to go beyond the simple of oh send them all to the ER automatically right um and as part of this program is increasing skills uh at the Pediatric Primary Care level as well as increasing comfort and managing mental health conditions problems Etc I have no relevant disclosures as you can see and and a lot of this comes from what we hear right when you when we talk to the population of Pediatricians pediatric Primary Care to different degrees we hear all these typical things as you could see on here about Comfort um risk management um workflow issues about I'm so busy you know don't ask don't tell because it's gonna it's going to mess up my schedule and um etc etc so um we're going to start by showing a brief video that will hopefully serve as an introduction and a vehicle to our more focused discussion not just feeling down really depressed it might be that your kid is thinking about killing himself it happens more than you think more than it should and people say I had no idea I thought it was just a phase he was going through I never thought she'd do it I wish she'd come to me I wish he'd said something I wish I'd said something when it's too late so if you think your kid's acting different if she seems like a different person say something say what's wrong how can I help and ask straight out are you thinking about killing yourself it doesn't hurt to ask in fact it helps when people are thinking about killing themselves they want somebody to ask they want somebody to care maybe you're afraid you'll make it worse if you ask like you'll put the idea in their head believe me it doesn't work that way it doesn't hurt to ask in fact the best way to keep a teenager from killing herself is to ask are you thinking about killing yourself and what if they say yes or maybe or sometimes well here's what you don't say that's crazy don't be such a drama queen you're making too much of this that boy is not worth killing yourself over that's not going to solve anything you're just trying to get attention you're not going to kill yourself what you do you say is I'm sorry you're feeling so bad how can I help we'll get through this together let's keep you safe A lot of people think about killing themselves adults and kids most of them never try it but some of them do so if your kid says I'd be better off dead I can't live with this I'm going to kill myself take her seriously find someone she can talk to about it someone who knows how to help sometimes kids want to kill themselves because something happened a breakup a failure but sometimes it goes deeper and it's not going to go away by itself get some help talk to your doctor or a counselor at school or your minister but don't just let it drop and make sure that your kid always has someone to turn to someone he trusts make a list together right then three four five names put a suicide hotline number on there so we'll stop there but again this is a um a Mayo Clinic um sponsored um or produced uh video that's more of a PSA for parents but it's um a valuable um video because it addresses a lot of the same topics regarding this important subject I'm trying to Al righty let me escape this real quick there we go and then move on oops no oh let's go back so so in and an effort to provide a little bit of context before we get into some of the more practical things right cuz we wanted to make this um have a lot of clinical applicability is that we provided a little bit of of context and background factors that will serve as the basis for some of your clinical judgment and decisions then typically when we what we know about risk with youth specifically right remember this topic is on Youth and we could even even bring youth up through transitional age youth or college age youth up to 24 right so one is we know that there are certain individual factors right that um starting you can see on the screen that individuals um typically present with some pre-existing mental health disorders we know that from the suicide literature that about over half of individuals who die by Suicide have some pre-existing disorder that is it's less common to to be out of the blue with nothing else going on right um that although self-injurious behavior nonu nonsuicidal self-injury is not the same as suicidal behaviors but that there's a link in the sense of individuals who cut who hurt themselves without an intention of dying or at risk for suicide as well right that the that teens especially with developmental disorders learning issues intellectual and other physical disorders have a higher risk of suicide and as we kind of know te substance use is an individual risk factor and that includes both at the moment of the event and uh use over time so one is more specific cross-sectional and the other is a little bit more longitudinal we know relationship factors can be either a stressor or risk they're not necessarily A Cause right U and they can be protective as well depending on that um but a lot of you are already aware that ases adverse childhood experiences are important in your assessment of a lot of issues in the mental health world but they're especially important as risk factors for suicidal behaviors in teen right and it we' be remissive didn't talk about social media right social media has a lot of benefits it can be supportive it can be a good venue for information but that we know once it becomes excessive and unhealthy that that can be a risk factor for these behaviors as well and then regarding larger more cultural structural community and societal based factors um we talk about suicide clusters which are not that common but when but when you do have a suicide death among teens you know we look at the community we look at postvention plans that is what to do for that school for that Community Etc to prevent those suicide clusters um we know that where you live whether you live in a rural area or an urban area can present a differential in Risk um and then we know culture plays a factor right and we're going be into in more depth of that goes beyond today's discussion about either if you're an immigrant or if you're new to the country or language barriers and how those present could present as risk factors specific populations can be a risk like the child welfare population we know the Juvenile Justice population and then especially what we call the Dual population kids that are in foster care and in the Juvenile Justice System present these unique risks that are problems as well and although the literature the information is not clear about suicide deaths it is clear about kids with suicidal thoughts and attempts that as you can see gay lesbian bisexual and gender nonconforming youth or higher risks so these are more and you could say either that's an individual risk factor or more how that interfaces with societal and and Community factors it's an issue so so that just forms a little bit of a basis and overview of these factors to take into account and the levels that they um they Encompass um as with everything in either in this program in other programs we talk about the focus assessment you should always try to have validated tools but clearly the tools do not replace having a talk a conversation the interaction and or the relationship with the teen and that your judgment's important including your gut feeling and there's an emerging literature on that and we'll get back to that in a second but that it should not be based just on that I don't feel good I don't like this I don't feel comfortable with this but that should be factored in as well um there's a lot of elegant work right and I and it would be ideal to do this right but and clearly as we go around the country we hear about how difficult some of these challenges are in and lenting these screening Pathways into real clinical practice which some of it you're doing already right everyone every child that comes in into our Clinic gets a PSC 17 the screen for issues and then if they tickle if they meet the threshold for um internalizing issues like depression and anxiety Then you do a more Focus screening like a phq9 for the teens and then oh my gosh if they score question nine or if they they meet the threshold on that we need to do a more focused assessment uh or screening for suicide risk in this case it would be the asq and then if that comes up positive then you do a more brief but Focus assessment of safety right because you would say Hey you met you have some Flags indicators of suicide risk now let's look at safety assessment and then my determination for full suicide assessment so that's all very elegant and that would be ideal to do that then if at some point Point your practices can Implement these protocols that would be great but in reality it's a little bit of modification of these and this is another um even more brief kind of version of what we just said about about your steps right uh well we don't do Universal screenings we do only if they come in and start we think they maybe depressed we'll we'll have them fill out a phq9 and start there with the second diamond the American Academy of Pediatrics has this other assessment I'm not going to go over it today but just be aware that there's other screening examples and this one's the s shades right so um it's there for your reference as well but we were not going to cover that as a as a process today either you most in most practitioners and most groups are familiar with the phq9 right the CH the teenagers this is Norm for teens Right comes in and why is that important because we know although suicide and suicidal behaviors in pre-adolescent teens exist suicide is much less common in prepubertal kids right but suicidal behaviors are that the risk really starts increasing um in in adolescence and so you do your screen you have them completed you do your screening it's a quick scoring the thresholds are pretty clear here by convention and and and best practice or anything over 10 some places use over 15 right to make it more moderately severe to take steps but anything over 10 really warrants further screening right an assessment if you will um and so yes if the teen completes that then you go oh my gosh they scored a 16 and then it's like okay now I have to assess further what's going on well that's the purpose of the of the more targeted um screening instrument right to kind of say let me see we're focusing on depression right but it's not all about depression um let's see what's going on with the this teenager how depressed they really are how situational it is how how long this has been going on and we'll get into some even some scripts and questions in a second right and as part of that is assessment of risk some general kind of sometimes I call them foundational principles but some general principles during an encounter when you're looking at assessing a youth for suicide and you many of you may be doing this naturally but it's really important is stay and calm rather than the oh my God reaction like this this teenager is said that they're thinking about killing themselves so one is clearly um messaging and conveying about remaining calm remaining demonstrating that you're confident and having this discussion rather that well I don't really do this well I'm not really sure what to do but I need to ask well you know um they say I need to do this right and these are these are part of a script that you should not be saying that you need to come across as confident hence hence presentations like this to help with the comfort in doing it and hopefully a little bit of the tools on how to do it that you should be consistent in how you manage things rather than oh my gosh this is a oneof and this and we're going to do all these things differently right that you want to stick to as many of your evidence-based protocols and your usual practices as as much as possible whether it's this whether it's something related to HIV or STI or anything else but you do want to remain consistent in what you do and you want to come across as either compassionate or empathetic as opposed to more punitive as opposed to more judgmental um like how could you kind of think so so these are the four C's of the kind of foundational approach and the process right this is a this is part of process when you're doing that so important to validate yes I know yes this happened yes you have these stressors yes you're feeling this way um I understand that and and and I um and you validate rather than trivialize the individual's experiences remember this is the individuals the teenagers lived experiences right so you want to show your validating that um and at some point in the messaging at some point in the interaction is this communication that suicide is never the answer that no matter how bad things seem taking one's life should not be the answer that there should be other options and you'll see when we get to a little bit of a framework in a few minutes about how how that can be hard depending on the stage you're in but that's an important message that there should be alternatives to Suicide always and then lastly be yourself right if you have a relationship with that teenager and you've known them and you're your style is a certain way you want to use incorporate your same style and you modify some of the content and some of the language but that your repertoire may change some but that the way you are in these interactions is an important message that um you are doing what you do in these interactions so these are just some some important guidance in in the process of the interaction right and and in general this is again another General overview of general principles before we get into something a um a um a framework a little bit more specific is that yes and that and that brief interaction right you want to identify strengths right you just don't want to say get right into it into all these negatives right which includes looking for past successes which which is part of getting an idea of what kind of coping strategies or what kind of things have helped in the past as well rather than just focusing on negative negative negative right you're going to hear the word praise right you're going to hear that a lot in the literature you're going to see that a lot from experts and talk about clinical practice that it's part of it and thank you for bringing that up I appreciate you're sharing with that I know it's difficult but it's important right and how to and how that comes across in your in your Brief Encounter that it's non-judgmental right like oh that's so bad that you did that right yes you got drunk and then you you're thinking you're feeling this and that and you got in trouble and you're want to kill yourself but not to have it come across as judgmental right um and then be reflective and share your concerns which are some of the very maybe even intuitive things that we do in practice but it's important to um to take into account so in the um ask suicide screening protocol which there is a should be a reference at the end for you to to further access in a more elegant way right because again these these sessions do not permit a full training on that right so in the ask or the ask suicide screening protocol you start by praising the patient we just heard that right like thank you for thank you for for disclosing thank you for sharing this important information I know it can be difficult at times but it takes a lot of Courage etc etc and and it's a six step model right the second step is about more formally or specifically assessing the individual right and that includes things like is the frequency of these thoughts right because it's a little bit different if an individual has these denovo thoughts that just started that they had only been going on for a day versus someone who's had these intermittent thoughts for a while versus someone who is thinking about death and suicide almost daily over time right um but you know a thought doesn't necessarily mean an action so it it's a little bit of assessing also whether there is this translation of this these thoughts into plan so you inquire about and what have you thought about doing right it's again you want to be culturally impatient and developmentally and family appropriate in your questions right so you could say well do you have a suicide plan or what do you thinking what have you thought about doing and what getting into the details as an opening question with that as well um and we talk about past Behavior because as you heard earlier the risk factors include things like previous suicide attempts and then a history of nonsuicidal self-injury or self-injurious behaviors are are important kind of risks for suicide and suicidal behaviors as well um and then it leads into your brief assessment of your symptoms right if you've already done a phq9 you will have an idea of depression but we know suicide is delink is not owned by any one disorder right you can have anxiety and be an anxiety disorder and be suicidal a substance use disorder and more than that you can have multiple disorders comorbidities and and present with risk for suicide so you want to look at symptoms to do a little bit more of a screening and if you've done your phq9 or they've completed the gad7 the generalized anxiety disorder 7 questionnaire you will have that information already to integrate into this um into your assessment of risk remember this is very focused um a focus assessment this is not a full mental health or psychiatric assessment um and the last portion of that involves the context of the social support and or ongoing stressors and why is that important because kids none of us live within a vacuum right so if there are identified stressors and then individuals going back to that um environment where there's interpersonal violence we know that the coping strategies and the individual no matter what they're going to go back to may still be taxed and the risk May remain if that individual is going back to a very supportive family where there's supervision there's a lot of healthy and pro-social relationships then those are considered protective right and supportive and you help guide and you can be pulled in and they can help in your decision making when you get to this position as well so it's not just the individual it's individual within the context of the social environment the social support than the ongoing stressors and this for example another example be substance use and whether they're going back into an environment where that exposure and the likelihood would continue again versus not then we all sometimes joke it's true what our mothers have said that we are who we hang out with kids are who they hang out with right so we know that vulnerable predisposed youth if they hang out with individuals that have these not healthy behaviors whether it's conduct delinquency substance use the likely they will engage in those are higher than if they hang out with more pro-social youth that are more positive with different values and behaviors Etc praise the patient assess the patient and then bring together with the parents and Guardians to kind of go over some of this remember we've we've discussed this in many many meetings with pediatricians over the years is like oh my gosh how are we going to do all this right I the rest of my clinic how can I do this in 15 minutes how can how long is this going to take we we heard that at the beginning right of some of the concerns right but then we really do need to bring them together to see how how this aligns with what each day view because parents may not be aware or the parents may not accept or the parents May minimize these things oh yeah that's because they got this black bad grade oh yeah that's because they're angry at the boyfriend girlfriend and therefore they're they're doing that a little bit of reductionism right taking these complicated processes and reducing it to this one thing right so you do need to bring them together praise the patient assess the patient interview them together and then after all that is you go like oh my gosh do I make a safety plan will you kind of do unless the police is going to escort them directly from your office in that moment there should be a safety plan um with not only the patient but obviously the parent and or Guardian right and we'll talk a little bit of that in a few minutes of what that could entail um which which is more than just saying do you promise you're not going to try to kill yourself but kind of thing right um but clearly all this is leading to your disposition right a lot of it's a andd assessment and disposition um rather than doing any major interventions right you're not there to necessarily treat in those settings if you have the time and the relationship yes you can engage in that but typically it's more the assessment and the disposition of what to do and so in your assessment if you think there may be some risk or there was risk then yes obviously that generates a non-urgent mental health referral right sure let's try to get you an appointment let's try to make it as soon as possible it's not crucial it doesn't need to be today or tomorrow but let's get that referral if there's an assessment of some risk and that um but that the individual doesn't either meet the involuntary criteria to go to the hospital or even think that maybe they need to go to the hospital for example if they have some some thoughts that they have a really supportive um family and supports and the stress have been eliminated whatever it is the the individual or other stressors were eliminated or managed um then you can consider an urgent referral and saying hey let's try to get this person in they're already seeing a therapist or a psychiatrist let's get them back in um to to do that um or even a tella Health consultation if you're part of the program um Department of Health program the USF program you can get something like that accomplished to help better to help do the full mental health um psychiatric assessment right and then lastly if you think it's IM imminent danger and emergency then you send them right away so that that we know right that's an easy one right the non-emergent one's easy the emergent one emergency referral is easy it's that middle category of individuals where a lot of the wh ifs come up for the individual providers right and then if not you provideed your link them to resources anyway right but um that's important so again but you know if that just what you see on the screen there right why because some individuals will ask in a very dichotomous or binary fashion or are you are you happy or or sad and I always joke with the teens like your honor is that my only two choices um so why because you can be unhappy and be mad you can be unhappy be sad you can be unhappy and be anxious you can be what we call mad sad as you'll see it in a second right it can be both um angry and irritable and sad so when you're doing back to your assessment of your patient right so that's the framework under ask right those six steps right um when you're when you're let's focus on the assessment so one of the things that's been used over the years years both in clinical practice and in um in research as well is this the feeling thermometer or the subjective units of distress scale the studs and it it's a crude barometer or thermometer way of measuring emotions right and that's and why why did I have that previous slide because it's like if aunds a best you felt and zero is the worst it isn't for hundreds the happiest and zero the most sad you felt because then you miss individuals if you make it happy sad versus happy and unhappy and then that unhappiness gets clarified whatever all that means right and you start with today why because teens can be very reactive and then we talk about the last two weeks and and a little bit of that is because um two weeks is like the threshold for major depressive disorder changes right more than that it's hard to summarize some people go over the past year number and it's hard to reduce emotions to one number over a year because they can vary so much unless you're that that one individual where you have this steady emotional state God bless you but you're that one individual who is most of us AR it varies over time and then once you do that then you go then you get into a little bit more description right about hey tell me what is a what is a 40 right what's your Baseline your Baseline yes I'm at 85 90 most of the days remember if anyone says they're at 100 all every single day I would I would consider that they're not being honest and truthful um but you want to get now after that you want to get a little bit of descriptive of what a 40 a 30 is and keeping in mind just what it says there that it could be a mixture yes I've been I've been mad sad mad sad sometimes is a description for irritable sad right which is frequently more common with teens rightless instead of being just only melancholic it's I'm I'm unhappy irritable or sometimes people call it dysphoric so this is one tool you can use to do a quick assessment of emotions and then you'll see in a second how we put that in context and this is a little bit of what we just said um and so as part of that if the if the if the Adolescent has completed a phq9 you do want to review that especially because they could meet the threshold of a of 10 or above or 15 or above and not Endor question nine about suicidal thoughts about being dead Etc um but you still want to assess that further um question nine if they have if they have rated anything more than a zero right and then as you heard in that promotional video at the at the front by Mayo Clinic is that then you want to then more specifically ask it is okay to ask it's a myth to say hey if I ask directly I'm going to put the thoughts into their mind it's the assessment of that thoughts and it's the assessment of suicidal ideation so caveat reminder self harm is one thing do you think about harming yourself no but I think about killing myself so what makes what defines it as suicidal ideation it's the intention to die or death to be a consequence of an action so it's important to how you ask it and how as you heard the frequency or how recent or how proximal now that's really important right because by the time someone sees you um in in the Paradigm you'll see in a second um that could have been yesterday a week ago and they're not either feeling or thinking that today and that that happens not infrequently if you have parents that are reluctant to address this don't want to address this you know one possible script that's out there especially in the ask U protocols is like you know your child's safety is my priority it's my number one priority I have to I'm going to go now and inquire about this so um it's important to to be upfront with the parents and get their engagement and buy in this many years ago we've gone all over the place on this but many years ago there was this uh movement away from the gut feeling the impression right like well I feel that this is more serious right because it isn't just based on endorsement or denial do you want to kill yourself no oh okay it's over right do you want to kill yourself yes oh okay it must be true right it's it's your impression of this that gets factored in in the moment but clearly as we said earlier it's not just your gut feeling it's the integration of that in here no I especially if you have an ongoing relationship no they're saying this and yes you're right it is the context right yes they're saying this and I know this individual and I know what's going on and this doesn't seem to make sense or it's not consistent and I've tried three different ways then they're still saying this but everything suggests that there may be more risk than that they're disclosing or willing to disclose here Etc so that does get factored in and you do want to value that and it is bidirectional you're absolutely right it is a dialogue right um but during your pediatric Primary Care visit you focus you you got to focus on the here and now right what am I going to do right there's a lot of issues and a lot of problems but in your hierarchy of your medical decision making is like what am I going to do right now as a consequence of this encounter right and you saw the three types of dispositions that we talked about earlier so one framework in understanding acute suicidal Behavior now again there are different models this is just one framework for you to think about is is kids come in with their Baseline State and certain kids come in with either these chronic risk factors or a predisposition for that yes I've been depressed in the past yes I've been using substances um over time yes I have these a have these psychosocial stressors at home my you know I'm witnessing this interpersonal VI exposure to interpersonal violence I have been a of sexual trauma and on and on so this kind of Baseline predisposition is important to know right call it this diathesis right um and then there's a stressor right but it isn't just a diathesis stress it isn't just a predisposition stress right it's it is the interaction with the individual and this is again for acute assessment right and the stressor by far the most common stressors are interpersonal I had something with either my best friend my boyfriend my girlfriend my partner or it could be more vertical with my teacher my coach how could they do that the judge said this I had an argument in court but there's an a stressor that's typically psychosocial but it could be other other stressors as well I failed I'm not going to get into that college Etc and then that triggers this intense emotion this kind of Tim limited intense emotion that has this ramp up up and that's important right because Baseline may be yeah chronically depressed irritable anxious but in these acute States it's this intense emotion and that could be anything as we've said it could be rage anger could be anxiety it could be guilt could be sadness depression could be a mixture of everything what happens to thinking when there's an intense emotion in general well the changes we call it cognitive distortions a lot of people say we don't think but what it really is is that your thinking changes to where when you're calm you may think one way when you're really upset you think say and do things that you typically would not do and yes that's when the highest risk for teens when you when you look at this kind of model is for these suicidal behaviors why because you'll see if they coming in five days after an incident they're going to look calm and put together and go yeah I know that was five days ago but right now not and so we don't minimize that trivialize that but we know the risk the more imminent risk may be less unless there's going to be that stressor when they walk out the door and go back home that the the risk there may be more of an urgent followup whether you can get them connected or if they're already connected to to get be seen sooner because the that wave of emotion and therefore all those thinking about suicide being an option has kind of settled down we don't talk about going away or being present or not we just talk about it settling down right and in that moment what it's like I can't believe it you're letting me go out I can't believe it I'm so angry and one of the most common distortions we call them attributions at that time oh my God if I can't go to the prom I'm only using prom as an example because it is it is prom time at this time of year is my that's my life would be so bad that suicide becomes an acceptable option in that moment remember remember these are momentary distortions of with being so enraged upset nervous angry Etc it's an Escape from an unbearable situation my life the oh my gods right oh my life is so bad that I'd rather be dead in the moment the second is Revenger retaliation oh yes you did this to me you'll see when you get home you're going to find me dead in the bed you're going to see I'm going to get back at you because you did this to me you left me you dumped me you did this to me I'm going to get back Revenge retaliation is the the way of thinking these first two the first one especially is viewed a lot with anger and rage Revenge retaliation can be with anger and rage but also with other feelings as well another one's atonement and that's usually with a lot of severe guilt much less common right by far escape is the most common revenge and retaliation next and then atonement is when like oh my gosh I feel so bad the only option I have is to kill my I didn't get a chance to go see my grandma oh I didn't get I didn't do this I feel so bad I need to make up for it and a tone for it so I am going to kill myself and the last one is reunification which is not as common you may see that a little bit with the rare pre-adolescent kids with a different concept of death but you know what I'd rather be in heaven with blank with my grandmother oh yes my best friend did it I'm we're going to reunite in heaven together after we die and we kill each other we kill ourselves right and so that means the suicide risk is like we just talked about is reaches a peak and then it starts going down remember it doesn't necessarily go back to zero right but that the risk is a peak right in these acute situations and that's what you're assessing be and so if obviously if the teen comes in with very charged very emotionally very upset the risk is a lot higher than if it happened a week ago then the risk is more chronic or maybe but it's not as acute and these are things you factor in your decision the asq we were referring to earlier is a screening tool that's really easy to do but whether you and we always recommend implementing it into your protocols but if you can or not these are the questions right that they ask about um in the screening um it's online the as you'll see the toolkit and the resources will be attached at the end right but it's it gives way a framework to do a screening to see what you're going to do next as far as um as far as safety plan right so you you praised you did your focus assessment including the assessment of risk and then you make your safety Plan and there's all kinds of examples of safety cont if you have your protocol and your folders with it you could bring this out but this takes time and and it go through all the steps and again typically it goes beyond the scope of a lot of what happens in pediatric primary care but these are really good examples right because they address each of those steps of what we talked about about oh my gosh it's your coping strategies it's not just your stressors it's like what are you going to do next time when you start feeling like this how do you take your mind to somewhere else and then if you've got got people you trust right who can you call and what's the number and how do you blank blank blank right um during the crisis right and if and then on a professional level who do you blink and blame and blink right and then how do you do safety planning as far as means right if there's Firearms if there's other means Etc right this Firearms still make up a little over half of the deaths here in the US and the next being as fixi which is hanging hanging um the safety planning Road map you can see it's there right and in and on the on the light blue bars on the left are the possible questions and scripts you could ask and and the the light blue on the right hand side is the domains the air things that you're assessing right so if you think there's any warning signs right like um you want to ask yourself like how will I know how will you know when the safety plan will be used right and that and that means how this we'll look at how the patient the team would be identifying their emotions and things like that again this is a little more elegant if you can or have some collocated services with others they can do it with you um but this is for your information and if you can incorporate it in your practices it would be the most ideal with but recognizing all the potential issues of doing that from a realistic everyday perspective right um and then it goes through all the different um steps like it like you saw on that contract right form as well right of that kind of we know help get through these acute crisises right because yes it's like the next time there's this stressor what new coping strategies are you going to do who are you going to call what are you going to do meditate or what are you going to listen to music or how are you going to blank blank blank blank blank manage it and then clearly when you're determining your disposition right it's it's what we know right you go like oh my gosh what are we doing right and the hope is that it is not just everybody I've been to meetings with pediatricians where several say nope the second I hear that we automatically send off but all of you as participants in the program know that the goal is to see if there are more things within the scope of my practice and the scope of my skill set that I could be assessing better two be more comfortable in assessing and then three deciding in a more nuanced way what can be managed here versus automatically sending to the Ed and that it's that middle group for you that really is where you're going to fall regarding this topic right so these were some of the um issues that clearly we address and hopefully you can incorporate some of these tools into a more time sensitive efficient assessment and management of this now clearly it involves the proverbial Village right the family all your staff as well to help coordinate things but it really is important to hopefully move away from this kind of binary it's either you go off for for regular outpatient or we're sending we're calling the police and we're sending you automatically to the emergency department hence the importance of understanding right that Su subtle behaviors have a certain um flow and that there's certain characteristics and we provided a couple of paradigms to help you better assess the context and the risk at the moment right like how big is this wave or not right and what do I do with that and knowing that it's not unusual to have as a pediatrician to have these wh ifs and some doubts right because remember what ifs are called anticipatory anxiety oh but but what if something happen what if I miss it's a false negative right what if I send somebody out that should be going to the hospital immediately what if I get sued what if this happens or that um and hence the importance of getting a little bit more information and and practicing this and then using your consultations to help refine it and get further support on this it really is important because it's an aspect that as we've seen more and more over time um it's not going away and then your resources right and then just a little bit of touching because this is part of the bigger program it's not as specific to um acute suicidal behaviors but just let's assume youve you in this first box you found that the child the the youngster has okay it's not urgent the the suicide risk is not imminent not urgent but they're depressed and they and and oh my gosh like you know from before right um what do I do with that depression right or do I start medicines remember in general we don't start medications for mild depression or or depression that's that's non-clinical and keep in mind what makes something clinical it's the severity of the symptoms in the mood and the amount of of impairment and functioning right so you go through your you go through your decision tree right well is this is the kid is the child depressed or do do they have a major depressive disorder okay yes they do and then is it a major depressive disorder of at least moderate or moderate to severe severe severity right and as a consequence of that MDD is resulting moderate to severe impairment and if those questions are yes then you're kind of inching towards an anti-depressant right and and all that other training you've had about your protocol right um and then you keep asking right okay do we do we initiate step therapy well if it's more moderate maybe and um versus com combination therapy yes we're going to initiate treatment medications if it's and we're going to generate a referral to a therapist or continue the therapy if not right um and then we you factor in your own your own and personal beliefs and thoughts on whether the anti-depressant is indicated this is what's on your USF website as your resources this is kind of this reduced um synopsis of the entire very elegant protocol but so you're referred back to the USF website for a more detailed and more elegant version of this but you know that medications are either fluoxitine or Citalopram as a first line you're too you're to FDA approved medications and knowing that fluoxitine um is probably more appropriate for pre-adolescent kids and I usually recommend fluoxitine as the first line because the database is um the data is much more robust than SI talopram but um the guidelines both are on the same level um because they FDA approved for this as well and um and attached on the rest of this will be your resources include some some great articles and access to some of the content of these um tools and some of the we've spoken about including more details about implementing a safety planning guide for you to take on in your practices as well

Channel: Florida Program for BH Improvement and Solutions

Views: 139

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Id: 8dSwMwfhItU

Length: 52min 8sec (3128 seconds)

Published: Tue Jun 11 2024