1. Preventing Youth Suicide: Does Access to Care Matter? John V. Campo, MD Nationwide Children’s Hospital Ohio State University Medical Center Email John.Campo@nationwidechildrens.org

2. 5/9/2015 2 Objectives n To review pediatric suicide as a preventable public health problem n To explore the relationship between suicide and access to care n To discuss a few novel efforts designed to improve access to care for youth at risk

3. 5/9/2015 3 Suicide and Access to Care Main Points n Youth suicide rate ↑ since 2004 n Suicide risk associated with psychiatric disorder, especially mood disorder n Suicide risk negatively correlated with access to quality mental health care n Improving access to effective care has potential to reduce youth suicide risk

4. 5/9/2015 4 Pediatric Suicide A Public Health Challenge n 3 rd leading cause death ages 15-24 yrs –Only accidents and violence kill more… –Among top ten causes of death worldwide n U.S. deaths for ages 15-24 years (2006) –4,189 deaths due to suicide –More than following causes COMBINED Cancer (1644) + cardiovascular disease (1376) + stroke (210) + HIV (206) + influenza and pneumonia (184) + diabetes (165) + septicemia (139) + asthma (135) + meningitis (47)

5. 5/9/2015 5 Pediatric Suicide A Public Health Challenge n After a decade of decline, the U.S. youth suicide rate ↑ ’ed ~20% in 2004 –Responsible for > 300 additional deaths –Only ↑ ’ing cause of pediatric death n Increase appears to be persistent Bridge et al. JAMA 2008; 300(9):1025-1026

6. 5/9/2015 6 Copyright ©2008 BMJ Publishing Group Ltd. Bridge et al. JAMA 2008; 300(9):1025-1026

7. 5/9/2015 7 Bridge et al. JAMA 2008; 300(9):1025-1026 Annual Rate of Suicide U.S. Males and Females Aged 10 to 19 Years 1996 through 2005*

8. 5/9/2015 8 Pediatric Suicide A Public Health Challenge (cont.) n Prevalence of suicidal ideation –~ 15% of U.S. high school students annually n Prevalence of suicide attempts –~7% of U.S. high school students annually n 15 to 24 year age range vulnerable –Age of ↑ risk for mood and other disorders, –May “fall between the cracks” of the health system (transition to adulthood…) Important to campus suicide prevention efforts

9. 5/9/2015 9 Pediatric Suicide Psychiatric Disorder and Risk n Untreated psychiatric disorder the most substantial remediable risk factor –~90% of completers have a psychiatric d/o –Risk especially strong for mood disorders Depression the main predictor of suicidal ideation Depression ↑ risk of completion and attempts –2-7% of MDD youth complete suicide later in life –40-80% of attempters suffer from depression Bipolar disorder, particularly mixed, confers ↑ risk –Comorbidity, chronicity, severity ↑ risk

10. 5/9/2015 10 Pediatric Suicide Depression and Suicide Risk Odds Ratio Suicide completion Brent et al., 19997.5 - 12.9 Shaffer et al., 199616 - 20 Suicide attempt Andrews et al., 199212.0 - 14.7 Beautrais et al., 199627.3

11. 5/9/2015 11 Pediatric Suicide Adult Pharmacotherapy RCTs n Meta-analyses of antidepressant RCTs have not shown clear protective effects n Persuasive meta-analytic evidence that lithium reduces suicide risk in adults n Some evidence that clozapine reduces suicide risk in adults with schizophrenia

12. 5/9/2015 12 Forest Plot Showing Meta-Analysis of Suicides Plus Deliberate Self-Harm in Randomized Trials Comparing Lithium with Placebo or Active Comparators Cipriani et al., 2005

13. 5/9/2015 13 Pediatric Suicide Adult Psychotherapy RCTs n Dialectical Behavior Therapy –Reduced rate of repeat suicide attempts in adults who attempted suicide n Cognitive Behavioral Therapy –Some evidence that CBT may reduce suicide attempts and suicidal behaviors –May be most effective when includes specific elements focused on reducing suicidality

14. 5/9/2015 14 Pediatric Suicide Pediatric RCTs n Few pediatric RCTs specifically address suicide as an outcome –Suicidal youth often excluded from RCTs –Mixed results for psychotherapy studies –TADS and TORDIA studies showed reductions in suicidality for all groups TADS showed greatest reduction in suicidality in fluoxetine + CBT group TORDIA study found no meaningful differences between groups

15. 5/9/2015 15 Pediatric Suicide Pharmacoepidemiologic Studies n Coincident ↓ pediatric suicide rates with ↑ SSRI prescribing since late 1990s –Similar findings in US and Europe –Geographic trends for ↓ suicide with ↑ Rx –1% ↑ in adolescent antidepressant use associated with a ↓ of 0.23 suicide per 100 000 adolescents per year Olfson et al., Arch Gen Psychiatry 2003 n Longer antidepressant Rx may reduce suicide risk –Rx > 180 days vs. Rx < 55 days n Studies of completed suicide –< 10% completed suicides who had been prescribed antidepressants + at autopsy

16. 5/9/2015 16 Pediatric Suicide Primary Care Based Studies n Primary care based education for PCCs in recognition and management of depression may be a very promising approach –PROSPECT study Collaborative care for depressed suicidal elders was more effective than TAU for reducing suicidality –Gotland study Improved PCC ability to treat depression resulted in decreased suicide rate –Youth Partners in Care (Asarnow et al. 2005) Suggest that improved treatment of adolescent depression in primary care may reduce suicidality risk

17. 5/9/2015 17 Pediatric Suicide Other Interventions n Promising interventions include those maintaining long term contact with at risk individuals and offering psychoeducation –Use of technology as simple as the telephone may be especially helpful

18. 5/9/2015 18 Pediatric Suicide Population Based Studies n Negative correlation between suicide rate and access to health and MH services Tondo et al., J Clin Psychiatry 2006 n Type of service availability matters –Multifaceted services protective –> outpatient to inpatient ratio advantageous –24 hour emergency services useful Pirkola et al., Lancet 2009 n Rural residence associated with  risk

19. 5/9/2015 19 Pediatric Suicide Treatment Realities n Most youth at risk for suicide receive inadequate treatment or no treatment –Only 7 to 20% of suicide completers had seen a MH profession in prior 1 to 3 months –Antidepressants rarely found in toxicological studies after completed youth suicides –Some studies correlate low SSRI prescription rates with higher rates of youth suicide Gibbons et al., Am J Psychiatry 2006, Olfson et al., Arch Gen Psychiatry 2003

20. 5/9/2015 20 The Access to Care Challenge Shortage of Pediatric Psychiatrists* n Current US average is 8.7 pediatric psychiatrists per 100,000 youth –Range 3.1 (Alaska) to 21.3 (Massachusetts) –Estimated need ~ 14.4 per 100,000 –Ohio ranks 30 th (6.7 per 100,000) n Number of training programs is decreasing and number of trainees static n Average age of practitioners increasing n Shortage will grow worse at current levels of training and support * Thomas and Holzer, JAACAP 2006

21. 5/9/2015 21 Child and Adolescent Psychiatry Number per county in U.S. (2009)

22. 5/9/2015 22 Child and Adolescent Psychiatry Ohio Rate per 100,000 youth (2009)

23. 5/9/2015 23 Meeting the Need Transformational Change n To improve access to care n To improve care quality n To challenge stigma n To improve efficiency of care

24. 5/9/2015 24 Access to Effective Treatment Need for a System of Care n Stepped care –Different levels of care depending on type of disorder, its severity, complexity, and/or persistence in the face of intervention Primary care/general medical care Outpatient specialty MH care Intermediate specialty MH care Acute inpatient psychiatric care Long term residential treatment –Collaboration across disciplines the key

25. 5/9/2015 25 Pediatric Suicide The Relevance of Primary Care n The primary care setting may prove to be critical to meaningful prevention –80% of completers had contact with a primary care clinician in the prior year –40-60% had contact with PCC in prior month –Shortage of pediatric mental health professionals is deep and persistent –Treatment of geriatric depression in primary care demonstrated to ↓ suicide risk

26. 5/9/2015 26 Pediatric Suicide Identifying At Risk Youth n Medical Settings –Primary Care –Specialty Care –Emergency Departments/Crisis Centers –Hospitals n Schools n Juvenile Justice/Courts n Child Welfare Settings

27. 5/9/2015 27 Suicidality Screening in Primary Care Health eTouch n Developed by Drs. Bill Gardner and Kelly Kelleher and colleagues n Portable with little space requirement n Automatically scored and stored n Little imposition on office work flow n Confidential and secure n Potential to integrate with EMR

28. 5/9/2015 28 Youths are given the tablet in the primary care waiting room.

29. 5/9/2015 29 A stylus is used to select responses to multiple-choice questions. For privacy, the system moves to the next question as soon as a response is entered.

30. 5/9/2015 30 Report is clipped to patient’s chart so that it is available to the clinician during the visit.

31. 5/9/2015 31 Health eTouch Screening Results High levels of mental and behavioral risk found in patients at nine urban primary care clinics serving a predominantly Medicaid population.

32. 5/9/2015 32 The clinician can follow-up on issues identified by screening. The report form includes contact information for referrals to enhance efficiency.

33. 5/9/2015 33 Access to Effective Treatment Use of Novel Technologies n Health eTouch –Screening –Case finding –Assessment  Decision support for PCCs  Access to informal psychiatry consultation n Telepsychiatry (Rural areas especially) n Interactive voice response technology –PhaST study

34. 5/9/2015 34 Pharmaceutical Safety Tracking PhaST n Study funded by AHRQ (Gardner, PI) n In wake of “Black Box Warning” –FDA recommends intensive f/u monitoring Weeks 1, 2, 3, 4, 6, 8, then monthly until stable No research support for recommendation Infeasible for clinicians and families –Pediatric antidepressant prescriptions ↓ n Need for feasible safety monitoring

35. 5/9/2015 35 Pharmaceutical Safety Tracking PhaST (cont.) n Interactive voice response technology (IVR) –“Robotic phone calls” n Medication AEs monitored on FDA schedule n 8 questions answered using phone pad n Positive response triggers study clinician call n AEs classified as routine, urgent, or emergent n Prescribing physician contacted accordingly and/or emergency response activated

36. 5/9/2015 36 Pharmaceutical Safety Tracking PhaST (cont.)

37. 5/9/2015 37 Pediatric Suicide Prevention Strategies n Effective treatment for psychiatric d/os –Consensus is growing that untreated psychiatric disorders are the most substantial remediable risk factor for suicide n Reduce access to lethal means n Screening to identify high risk individuals n Education and awareness programs n Influence media reports of suicide

38. 5/9/2015 38 Pediatric Suicide Selected References n Bridge JA, Greenhouse JB, Weldon AH, Campo JV, Kelleher KJ. Suicide trends among youths aged 10 to 19 years in the United States, 1996-2005. JAMA 2008; 300(9):1025-1026. n Campo JV. Youth suicide prevention: Does access to care matter? Current Opinion in Pediatrics 2009; 21:628-634. n Campo JV. Suicide prevention: time for ‘zero tolerance’ [Editorial]. Current Opinion in Pediatrics 2009; 21:611-612. n

39. 39 Nationwide Children’s Hospital Physician Decision Support During business hours (M–F, 8 am – 5 pm) Page (614) 690-1887 or Call (614) 355-8080 Select option 2 for doctor’s office, then 2 Email BHDecisionSupport@NationwideChildrens.org BHDecisionSupport@NationwideChildrens.org For urgent questions after hours, Call (614) 722-2000 - ask for psychiatrist on-call