Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care

CPIC was a group-level randomized comparative effectiveness trial designed to compare two depression collaborative care implementation approaches (23). Participants were enrolled from 93 participating programs, including primary care clinics, outpatient mental health clinics, substance outpatient and residential treatment programs, homeless and housing services, social services, and other community-based services (faith-based organizations, hair salons, exercise centers, and park and recreation senior centers) in two Los Angeles communities. Potential participants were screened for eligibility in program waiting rooms and at events. Study surveys were completed by telephone at baseline, 6 months, and 12 months from April 2010 through March 2012. The project was approved by the institutional review board (IRB) of RAND Corporation and by Los Angeles County and other agencies requiring separate review. All participants provided informed consent.

Study eligibility was limited to adults (ages ≥18 years) speaking English or Spanish, with at least moderate depressive symptoms indicated by an 8-item PHQ (PHQ-8) (27) score of ≥10 at screening. The analytic sample included 1,018 enrolled individuals who completed at least one survey (baseline, 6 months, or 12 months). Participant demographic characteristics have been previously described (28). Briefly, the study sample was 58% female (N=595); was 48% Black (N=487), 40% Latino (N=409), and 8% White (N=43); and had a mean±SD age of 46±13 years. Relevant social characteristics included 53% (N=536) having multiple risk factors for homelessness, 74% (N=750) meeting federal poverty criteria, 20% (N=205) working for pay, and 54% (N=545) being uninsured. Additional details on recruitment, enrollment, and outcomes can be found in previous publications (23, 28).

Using a CPPR framework (25, 26), a workgroup comprising academic and community partners, including a community health advocate, a nurse from a local mental health clinic, a clinical administrator in the Los Angeles County Department of Mental Health, a substance abuse agency administrator, a public health nurse, and the director of a safety-net primary care clinic developed the CPIC SRMP. The workgroup modified the SRMP described in the study grant proposal on the basis of the Partners in Care study (29) during biweekly meetings over 4 months. The revised SRMP was reviewed at a community forum attended by >80 local stakeholders, including representatives from community groups, consumer and faith-based organizations, local health clinics, and social services agencies, and was subsequently reviewed and approved by the CPIC Executive Committee. The SRMP content and modifications are described in the Results section.

Participants self-reported gender and race-ethnicity at screening. Suicidality screening was conducted by telephone at baseline and at the 6- and 12-month follow-up surveys. Qualitative data included meeting notes from the SRMP development workgroup and study clinicians’ e-mails summarizing contact with study participants endorsing suicidal ideation. E-mail text was abstracted into Microsoft Excel and included participant study identification; event date; study data collection phase (i.e., screening, baseline, or 6- or 12-month survey); study clinician; assessment of imminent risk; intervention, such as referral to a clinic or emergency room or a 911 call; and narrative comments.

Screening for suicidality with the baseline survey utilized the following Mini-International Neuropsychiatric Interview (MINI) (30) item: “Over the past 2 weeks, when you felt depressed or uninterested, did you repeatedly consider hurting yourself, feel suicidal, or wish that you were dead? Did you attempt suicide or plan a suicide?” At 6 and 12 months, screening utilized the following PHQ-9 (31) item: “In the past 2 weeks, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” In the modified SRMP, participants responding affirmatively to the PHQ-9 suicidality item were asked the follow-up question: “Are these thoughts bothering you now?”

A chi-square test of independence was performed to examine the relationship between demographic characteristics (race-ethnicity and gender) and cumulative prevalence of suicidal ideation. We ran these analyses with SAS, version 7.4, software.

Workgroup meeting notes were summarized to describe the process of SRMP development and adaptation. For analysis of outreach call notes, three study team members drafted codes based on both a priori areas of interest (e.g., “problems with access to care” and “referral provided”) and emergent themes (e.g., “knows how to get help”). After several rounds of analysis in which e-mails were independently coded and reviewed for agreement, a final codebook was developed and applied.

During initial workgroup meetings, several broad themes emerged that guided the SRMP development, adaptation, and implementation. Community partners emphasized the importance of ensuring participant safety over and above IRB requirements, with a high priority placed on suicide prevention. At the same time, community partners were conscious of the stigma of mental illness and of potential distrust of law enforcement involved with mental health crisis interventions. Both community and academic partners shared concerns about ensuring the feasibility of timely implementation of SRMP procedures within the constraints of study resources. Finally, the group agreed that an iterative process, based on CPPR principles, would be used during study implementation to modify the SRMP if necessary. Community feedback and subsequent modifications are summarized in Table 1.

The SRMP was activated in response to suicidality endorsed on the MINI or PHQ-9 or disclosed to survey staff. After the activation, staff immediately paged the on-call study clinician (a licensed physician or psychologist) and shared the participant’s name, telephone number, preferred language, and reason for SRMP activation. Within 30 minutes, the study clinician placed an outreach call to the participant, with ongoing attempts if the initial call was unsuccessful. For Spanish speakers, translation was provided via a three-way call. At least one of six study clinicians was on call during all hours of survey operation, including evenings and weekends, over an 18-month period.

Study clinicians received guidelines for follow-up and resources for referrals. If the clinician determined that a participant was at high risk for self-harm, the clinician would facilitate a referral to an emergency department or, in case of imminent risk and as a last resort, call 911. Participants deemed at low immediate risk, and with a current outpatient provider, were coached in how to discuss suicidality with the provider; if assistance was needed, permission could be obtained for the study clinician to speak to the provider. For participants with no current provider, the study clinician would provide a referral to a partner mental health or primary care agency where the patient would be seen within 2 business days, with a “warm handoff” during which study staff would speak directly to a clinic staff member.

Suicidal thoughts were common, endorsed by 32% of study participants at one or more of the three survey time points, and by 15% of participants at baseline, 24% at the 6-month follow-up, and 20% at the 12-month follow-up (Table 2). Of all participants endorsing suicidal thoughts during the study (N=329), 215 (65%) did so at a single survey time point, 89 (27%) at two time points, and 25 (8%) at all three time points. As shown in Table 3, overall prevalence of suicidal ideation was higher for men than for women (37% vs. 29%; p=0.01); no statistically significant differences were detected among different race-ethnicities.

As the study progressed, we noted that no participants had been deemed to be at high immediate risk of self-harm on the outreach calls, despite the high frequency of SRMP activation; some participants reported passive thoughts of death or hopelessness without intent or plan to act on those thoughts, whereas others reported current resolution of suicidal thoughts. Midway through the 6-month follow-up survey, after discussions involving community partners, research staff, and the RAND IRB, the decision was made to modify the SRMP (Table 1). Subsequently, participants screening positive for recent suicidality on the PHQ-9 (used for the 6- and 12-month surveys) were asked an additional question to assess current suicidality: “Are these thoughts bothering you now?” Outreach was triggered only when a participant answered affirmatively. Before the SRMP modification, this key question was posed by study clinicians during the outreach calls, and its incorporation into the survey limited outreach calls to assessment of ongoing suicidal ideation, reducing burden on the study staff.

Of 1,018 participants surveyed, study clinician outreach was triggered in 318 instances across 253 unique participants during telephone surveys at three time points (Figure 1). Participants were successfully contacted in 300 instances; all of them were found to be at low immediate risk for suicide. In 157 outreach calls, participants were provided one or more referrals, which included mental health clinics (N=83), emergency room recommendations for future reference (N=80), and a suicide hotline number (N=66). Referrals were either declined or deemed unnecessary (e.g., because the participant was already in treatment) in 137 calls. Referral data were missing for six calls. Study clinicians were unable to reach a participant in 18 cases, six of whom were determined to be at low immediate risk on the basis of further discussion with the participant’s study survey administrator or outpatient clinician; the 12 remaining cases were coded as lost to follow-up.

As detailed above, the SRMP was modified midway through the study, leading to a higher threshold for study clinician outreach. Under the original protocol, 244 calls were triggered, representing 17% of telephone surveys (N=1,404). Under the modified protocol, 74 calls were triggered after 225 initial reports of suicidal ideation, representing 7% and 21% of telephone surveys (N=1,069) endorsing current and previous or current suicidal ideation, respectively. Outreach frequency did not vary by CPIC study arm (see online supplement to this article).

In the 4-year follow-up of the CPIC study, which included intensive tracking of all enrolled participants and review of death records, no known suicide deaths occurred among the study participants. One study participant was hospitalized for a nonfatal suicide attempt 3 weeks after the baseline survey, at which time he had endorsed suicidal thoughts, received a study clinician outreach call, and was found to be at low immediate risk for suicide.

Key themes identified from study clinicians’ notes included discussion of participants’ current stressors, such as personal or family illness; housing, financial, or legal problems; trauma history; and difficulty either obtaining or remaining in mental health treatment. Participants often expressed surprise and appreciation in response to the clinicians’ outreach. Quotes from participants included the following: “This program is wonderful—it should be a national resource for communities like ours,” “I wish this project could be available to everyone in the community,” and “You’re the only person who has ever called me just to check on how I’m doing.” Some participants expressed skepticism about treatment: “What would an old person like me do talking to someone about how I feel? I mean, how could it help?” No complaints were noted about violation of privacy.