April 27, 2020
National Institute of Mental Health (NIMH)
This Request for Information (RFI) seeks input from providers (all disciplines) in primary care--the entry point for patients’ medical and health care needs (Family Medicine, Internal Medicine, Pediatrics, Obstetrics/Gynecology, School-based Health Centers). Specifically, this RFI seeks information on clinical experience in screening for suicide risk, and consequent actions, such as patient suicide risk assessment, brief interventions, the use of telehealth for behavioral health consultation, and referral to specialty care. In addition to detecting risk in patients, primary care providers often receive referrals for follow-up care after emergency, trauma, inpatient and other types of specialty care, where on- going monitoring of suicide risk may be warranted. In the current coronavirus crisis, receiving input on how primary care settings have modified their practice (e.g., expanded telehealth use) to addressing patient mental health challenges and suicide risk are also of interest.
The primary care setting is an essential, but unrealized opportunity for suicide prevention and intervention. Approximately 80% of US suicide decedents had a primary care visit in the year before death, around 50% in the month before, and about 20% in the week prior. These visits reflect often missed opportunities for identifying suicide ideation and/or history of self-injury that are major suicide death predictors. As such, implementing effective methods to identify individuals with suicide risk in Primary Care settings is an important initial step in the effort to reduce the national suicide rate.
A growing body of evidence from emergency care and post inpatient discharge records indicates that focused suicide preventive practices in healthcare settings can decrease rates of re-attempts in the 12-month period following the index event. These practices include suicide-risk screening, brief within-encounter interventions such as safety planning, post-discharge interventions such as caring communications and telephone follow-up, and referral to indicated psychotherapy. The uptake of these practices in primary care remains unclear. One key barrier may be the limited access primary care providers have to mental health specialists who could further evaluate individuals identified with suicide risk. The Collaborative Care model has been a successful approach to efficient use of mental health specialty consultation; it approximately doubles the effectiveness of usual primary care for common mental health conditions, and it has been found among geriatric patients to reduce suicidal ideation and overall mortality risk. Similarly, telehealth has been used for pediatric psychiatric consultations, but its impact on clinical workflows and effectiveness for reducing suicide risk is not fully known.
NIMH is seeking input to better understand and address implementation issues and research gaps in the delivery of suicide risk identification and risk mitigation efforts in primary care settings.
Through this RFI, the NIMH seeks to better understand the opportunities and barriers in the primary care community regarding efforts to care for individuals with suicide risk. Examples of potential topics that may be relevant in response to this RFI include but are not limited to:
With regard to detecting incident and actionable suicide risk, input on the following topics is sought:
Describe how your practice deploys suicide screening; for example, if universal suicide risk screening is provided, describe the frequency of the screening (e.g. twice a year in routine care; each visit for patients with depression). If suicide risk is assessed only in certain cases, describe the protocol for assessment and follow-up. If your practice does not deploy universal suicide screening, please provide the reasons.
Describe the primary care service delivery setting with regard to type of provider discipline/training, and patient population served (e.g., pediatric, adolescent, general adult, geriatric, obstetrics/ gynecology etc.), solo or group practice; a part of a network of practices. Additional descriptive information about your practice (e.g., if in-house behavioral health experts are available), and how it affects your suicide prevention practices, are of interest. Additional information regarding characteristics such as: urban/rural setting, health disparity populations reached, types of insurances used by your patients, and your practice’s estimated annual patient visits, are of interest.
Describe any efforts to address cultural sensitivity and linguistic needs of patients identified with suicide risk; describe how family members are engaged in safety monitoring, including safe storage of lethal means.
Describe whether/how your practice serves active duty military service members, their families, and/or Veterans eligible for VA health care (e.g., consultation with and/or referral to military service or VA providers).
Describe the challenges in your practice’s use of suicide risk screening, including subsequent clinical decision making such as referral for emergency setting/hospitalization versus community treatment discharge.
If your practice does conduct suicide screening, describe the workflow used, including where screening administration outcomes are documented, use of telehealth or other consultation, and the use of crisis lines. If behavioral health consultation is used, describe the types of professionals who are engaged in this aspect of care (e.g., psychiatrists, psychologists, social workers, nurse practitioners, mental health counselors, etc.) and the strategy used to cover the costs of these services.
Describe feedback you have received from patients/family members about their experience completing the screening process. Describe patients’ perceptions of screening for suicide risk Describe the communicated perceived barriers to completing screening and/or answering in a valid manner. Describe the extent that prior negative experiences have impacted patients’ willingness to complete screening in your clinic.
With regard to receiving patients for follow-up after their acute treatment for suicide ideation and/or behavior, input on the following topics is sought:
Describe how your practice facilitates transitions back to your care, including average wait times for follow-up care. Describe the nature of the follow-up services offered within your practice and your approach for recommendations/referrals for patients if there is a long wait time.
Describe your practice’s efforts to work with the discharging specialists to determine the patients’ frequency of risk screening and assessments, safety plans, and crisis intervention plans. Describe if in-house behavioral health expertise is used, and/or a collaborative care model is used to maintain consultation with a mental health specialist.
Describe whether your practice has working/active referral relationships with local community-based outpatient mental health or office-based treatment providers for ongoing assessment and/or treatment of suicide risk. Provide information on how relationships with local entities were established, and how they function.
Summarize the greatest challenges in identifying suicide risk in your patients, and the consequent practices and services (e.g. safety planning and specialist referrals) provided to mitigate their suicide risk.
Describe the most important research questions for primary care providers implementing suicide prevention practices.
Submitting a Response
All comments must be submitted via email as text or as an attached electronic document. Your responses should be addressed to: ResearchRTF@mail.nih.gov by August 7, 2020. Due to the coronavirus emergency, if a response is likely after the due date, please inform the NIMH contact below. Please include the Notice number in the subject line. Response to this RFI is voluntary. Responders are free to address any or all of the categories listed above. The submitted information will be reviewed by NIH staff.
This request is for information and planning purposes only and should not be construed as a solicitation or as an obligation on the part of the Federal Government. The NIH does not intend to make any awards based on responses to this RFI or to otherwise pay for the preparation of any information submitted or for the Government's use of such information.
The NIH will use the information submitted in response to this RFI at its discretion and will not provide comments to any responder's submission. However, responses to the RFI may be reflected in future funding opportunity announcements. The information provided will be analyzed and may be aggregated in reports. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s).
Jane Pearson, Ph.D.
National Institute of Mental Health