An alarming development captured my attention last this week. In the wake of the COVID-19 pandemic, there has been an unprecedented—breathtaking, really—move to providing mental health care via telehealth. As I have noted in previous blogs, CAMS-care reacted rapidly to be at the crest of the pandemic wave, moving all of our training to online access and providing early guidance for effectively using CAMS via telehealth modalities. Our on-going clinical trials of CAMS have similarly transitioned into providing care through telehealth, and we will soon be able to provide clinical trial data on this method of CAMS-guided care.
However, in terms of treating suicidal patients remotely via technology, apparently anxiety has increased about whether this can be done effectively. As I have noted in many forums, the fallback position of routinely sending a suicidal person to the emergency department (ED) has suddenly become troubling in this COVID-19 era as EDs are packed with patients who have contracted the debilitating and deadly virus. Moreover, the routine use of inpatient care is now also questionable during the pandemic because it is more difficult to physically distance and follow other science-based public health rules in these environments.
Therefore, routine practices for suicidal people have rather suddenly become suspect, creating both a moral and ethical dilemma: does a provider insist on sending a patient to the ED to save their life from suicide if it means potentially risking that same life by subjecting them to an environment where they may contract the virus? Add to this complex mix another layer of complication—the routine practice of calling 911 to have police conduct a “safety check” or to orchestrate an “active rescue.” Furthermore, if the person at risk is a person of color, local police showing up at their door may not be exactly reassuring as the nation continues to convulse and struggle with racial and social injustices.
A few years ago I had the honor of serving on a small task force under the auspices of the National Action Alliance for Suicide Prevention that generated the first-ever broadly relevant recommendations for working with suicidal patients across the full spectrum of clinical settings. Led by Dr. Mike Hogan, our team generated “Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe.”
The recommendations in that document broadly address sensible suggestions that can be applied across outpatient care, inpatient care, emergency department care, and primary care. We promoted simple ideas— “low hanging fruit,” so to speak—of items that could be readily enacted, such as:
- a willingness to see and treat suicidal patients,
- the need to screen, identify, and assess suicidal risk,
- the use of suicide crisis stabilization plans,
- the importance of lethal means safety discussions and reducing access to lethal means, and
- the routine use of “caring contact” and routine follow-up.
The idea was to provide sensible and affordable recommendations that would not necessarily require a lot of extra professional training or extensive re-tooling across the spectrum of clinical settings. Obvious, simple, and compelling right?
Well, we had to battle to get these recommendations released; they were “embargoed” for almost a year! It seems that powerful organizations and certain members of our field vigorously opposed these recommendations for a variety of reasons, not least among them was maintenance of the status quo of care. A status quo that includes an over-reliance on medication, ED-based interventions, and inpatient admissions, all of which have limited, mixed, or no empirical support for their use.
In contrast, all of our recommendations were built on evidence or at least were evidence-informed. As of this month I have lived in the Washington area for 38 years. After all this time, one might get used politics and the influences of powerful lobby groups to oppose even commonsense efforts for the greater good. But alas, this is not the case, and I found this particular fight to get these recommendations out to public especially exasperating. But, thank God, reason did prevail and the task force document was finally released a couple of years ago.
But while the revolution in the use of telehealth is one of the few silver linings related to the COVID-19 pandemic, an unfortunate related outcome is that healthcare systems have apparently become worried that screening or identifying suicidal risk remotely creates new problems in terms of timely and effective responses (particularly asynchronous screenings where there might be a delay in response). In this regard, some health system leaders have expressed concern that screening for and assessing suicidal risk outside of a face-to-face engagement may create a potential liability risk. The implications? While these concerns are exaggerated, they have led to some systems questioning or even restricting the use of existing screenings or assessment programs. In effect, this amounts to: “don’t ask, don’t tell.”
I am pleased to report that a small team of us from the original task force have quickly developed a draft addendum to the original recommendations in response to COVID-19-related concerns about screening for suicidal risk during telehealth visits. As of this writing, this document is now in draft form and under review, and hopefully it can be quickly released to the public, providers, and health care systems to do the right thing—to stop putting our heads in the sand when it comes to screening and assessment. Instead, we need to screen, identify, and assess suicidal risk to the best of our ability. Needless to say, it is impossible to provide life-saving interventions and clinical care if potential suicide risk remains utterly unknown.
To this end, the draft addendum makes commonsense recommendations as to how to optimally handle remote screening and interventions. Moreover, the addendum notes that fears about malpractice liability related to this issue are not based on reality as there are no cases on record of malpractice liability to date related to this concern. It is thus imperative to follow evidence-based, evidence-informed, best practice guidelines to screen for suicidal thoughts and behaviors and provide indicated care.
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I am mindful that some of my blogs perhaps convey a tone of frustration bordering on exasperation – perhaps that is the point of blogging?
In any case, it may seem like I am aligned against unnamed forces and prominent experts who are determined to undermine the undeniably noble cause of evidence-based clinical suicide prevention. In some blogs I have regaled the reader with various battles with those who criticize the extensive CAMS evidence base, and I frequently note the reluctance of providers to be open to, engage in, and actually use evidence-based, suicide-focused care.
In this blog post I obliquely refer to powerful organizations, lobby groups, or influential voices who seem to undermine and oppose commonsense change. Within our conspiracy-riddled world, I certainly do not mean to add to the mix by suggesting anything cryptic, or that there is some well-organized conspiracy fighting against innovations or the evidence base within contemporary clinical suicidology.
However, I would note the considerable resistance and pointed criticism of such approaches—including our task force recommendations—which can result in an unacceptable default position. The consequent net impact to fighting even sensible innovations and needed changes in clinical care is the perpetuation of the present status quo, which our epidemiological data shows is not working at the public health level to help decrease suicide-related suffering and ultimately deaths.
We must therefore move from a head-in-the-sand attitude to embracing practical recommendations and the clinical evidence-base to improve our ability to save lives and better reduce suicidal suffering for our patients, whether that be in person or remotely through telehealth.
For my part, I say: Do ask and do tell!