Rob Steele, MD: Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode, and you can do so by visiting cmkc.link/CMEpodcast,

And then just click the claim CME button. Today we are joined by Dr. Danielle DeVille to discuss addressing suicide risk in the primary care setting. Dr. DeVille is currently a Clinical Assistant Professor of Pediatrics at the UMKC School of Medicine and a Psychologist at the Eating Disorders Center at Children's Mercy.

She completed her Ph.D. at the University of Tulsa and the Laureate Institute for Brain Research. Her clinical internship and postdoctoral fellowship were at the University of California, San Diego, where she specialized in eating disorders, family based treatment, and dialectical behavior therapy, or DBT.

Dr. DeVille's research has focused on eating disorders and suicidal behavior. She received an Injury Prevention Grant through the American Psychological Foundation to conduct her dissertation research on the application of machine learning algorithms to detect suicidal thoughts and behaviors in pre adolescent children.

In clinical practice, Dr. DeVille integrates family based interventions with mindfulness based interventions and enjoys working with teens who have eating disorders, mood disorders, and anxiety disorders. Dr. DeVille, thank you for joining us today.

Danielle Deville, PhD: Thank you for having me.

Host: Before we get started, you grew up in the D.C. area, is that correct?

Danielle Deville, PhD: I did.

Host: And then you did training out in San Diego and now you're in Kansas City. So you have run the gamut of the US at this point.

Danielle Deville, PhD: Yeah. And I went to grad school in Oklahoma, so I slowly made my way west, and I'm making my way slowly back.

Host: Yeah. So, before we get started, I'll do as teens like to do. I have a number of teens at home. It's the, would you rather game? Not sure if you know this, so would you rather be on the beltway in D.C. At 1 PM or rush hour traffic in Kansas City at 5 p.m?

Danielle Deville, PhD: Okay. Rush hour traffic in Kansas City at 5, hands down. I was recently back in the D.C. area, and I drove on the beltway for the first time in a while, and I was like, how do people do this?

The traffic is bad, but the roads themselves are very overwhelming, so Kansas City, hands down.

Host: That beltway is intimidating. I'm with you.

Danielle Deville, PhD: It is rough.

Host: Very good. Well, let's, jump right on into it. Can you talk about some of the key suicide risk factors and warning signs that the primary care physician in particular should be looking out for as those children come through, their office?

Danielle Deville, PhD: So I think that I'm going to answer this question a little backwards and start with the warning signs. So, warning signs are the red flags that tell us that for suicidal behaviors may be more imminent. And those are things we really need to stop everything, slow down, and pay attention to.

So if a person is talking about wanting to die or having no reason to live, or if they exhibit sudden changes in their behavior like withdrawing or isolating, or new or increased substance use or, self injury; we need to pay attention, ask questions, and get them help. As far as risk factors go, I'll give you the easy answer, and then I'll give you my caveat as a suicide risk measure. Feel free to rein me in if you need to though, um, cause this is something I can talk a lot about.

So generally when we want to consider suicide risk factors, we want to think about things like mental health conditions, depression, anxiety, PTSD, psychosis, chronic physical illness, chronic pain, recent life stress, minority stress or being a member of a marginalized group, problems in family relationships, trauma, access to lethal means, so do you have a way to kill yourself if you were to want to? The main four that I like to think about are hopelessness, disconnectedness, feeling like you're a burden, and importantly, a sense of fearlessness around the physical pain of death.

So, now, taking a step back and kind of giving you my caveat; we talk about these things, we use the term risk factors. These are actually correlates of suicidal behavior. So, something to always remember is that they don't necessarily predict behavior, they definitely don't cause or explain behavior. And lots of people in the population, I mean there's so many factors, will have one of these or, you know, even several of these at a given point in time, and many of them won't experience suicidality. And this is kind o, the sticking point with suicide research is we've been studying suicide since like the 1800s. And, we really haven't settled on a way of predicting suicide. All of this is more theoretical and none of it really explains suicidal thoughts and behaviors.

We just know that these correlates exist. But really when it comes to your individual patient, you need to focus on the individual in front of you.

Host: Yeah, that's a really great point and it leads really to my next question. It's a good segue into universal screening. So, understanding the difference between causality and correlation, as you've mentioned, not a perfect science by any means. But having said that, we have instituted here at Children's Mercy and I know a number of other areas and certainly, I imagine a lot of the primary care offices have done their part in doing universal suicide screening.

Can you talk about, sort of the strategy behind that and just the mechanics of implementing universal screening?

Danielle Deville, PhD: So the idea behind universal screening is that we want to cast a net that's as wide as possible, hoping that we can identify folks who may be at risk or, who may have had a history of suicidal behaviors who aren't at risk right now, but we can protect them if they become at risk in the future.

In terms of implementation of universal screening, it's relatively simple. It is asking the questions. So with every patient who comes in, in that effort to cast a larger net, rather than only focusing on folks with depression or folks with other mental health conditions that are known; you start by asking every patient who comes in just as regular part of your visit with them, if they've experienced suicidal ideation or suicidal behaviors. That's the general idea behind universal screening.

Host: Yeah, great. As a parent, you know, not just a pediatrician, I've experienced that myself. I've had, our kids have accidents, can end up in the emergency department here at Children's Mercy, and they were, asked those questions without me in the room, which is very helpful. So, I was very thankful for that. They screened fine, but the fact that they were asked, I think, as a parent, I was reassured by that. I appreciated it.

Danielle Deville, PhD: Also, I'm reassured to hear that they were asked with you not in the room, because that is something that often doesn't happen from like a population perspective. Kids will be asked with their parents in the room and we know that they're less likely to be honest. So even younger kids, kids as young as nine and ten, if we have concerns or if we're asking as part of universal screening, generally what I recommend is that you ask the kid privately and then loop the parents back in later if you need to.

Host: There's a whole art to that, of course, so for those that may screen positive or perhaps they're coming in and clearly have had some suicidal ideation, one of the things one has to do is really assess the safety of that child. So, walk us through the basics of a safety assessment and how do you, sort of triage this, teen as to whether this is something in which we really have to have intervention right now versus something that could be followed up later?

Danielle Deville, PhD: So when we are thinking about suicide risk assessment, I think of two things. So we want to gather information about the thoughts and the behaviors. So we want to think about what we're asking, and we also want to think about how to ask it. And I think that often we focus more on the what and less on the how, and I think that they're equally important.

That being said, I'm going to start with the what. So we want to ask about the thoughts. We want to ask as directly and specific as possible and get as many details as we can. So instead of asking kind of vaguely, have you ever wanted to hurt yourself? We want to ask something that's a little bit more specific like have you ever wished that you were dead? Wish that you could go to sleep and not wake up? Have you ever had thoughts about killing yourself?

Often people are afraid to use that language, because it can feel uncomfortable, and it is really important to be specific. And then we want to gather information on, like, the frequency and intensity and duration of the thoughts if they're there. So, how often have you had these thoughts? When the thoughts come, how long do they last?

Is it just, you know, a few seconds out of every day? Or are you having these thoughts all day long? How intense are they? Is there anything that you have been able to do to reduce their intensity? And then you also want to look at the deterrence, or assess for any ambivalence, so you can use that to help motivate the teen or the kid, when you're doing safety planning, which we'll get to later, but is there anything that stopped you acting on these thoughts? You also want to get a sense of, if they've thought about a method for how they would kill themselves, and ask them what that is, which is something that, you know, sometimes people leave out. You want to get a sense if they have a plan, which is distinct from a method. You can think about how, but not think about where or when.

And we want to get a sense of, is there any intent? You can have a plan that you never intend to act on. It's just something you've thought about. But when we have a plan with intent, that's when we get really concerned. And we might need to think about, really what are our next steps here?

Host:

So what really resonated with me was, you giving voice to the fact that it's uncomfortable to ask those questions. And I can tell you from my personal experience, it was hard at the very beginning. Early in practice, it's hard to ask those questions. Partly you're not sure how to do it, and two, you're a little fearful of what the answer might be, but,

you've got to do that with practice. I think that's really great advice, with respect to the primary care physician being able to jump in there and ask those questions.

Danielle Deville, PhD: And that kind of gets at that second piece, which is the how. So the what do we ask, the how do we ask? In terms of what we want to ask, are you having these thoughts? We also want to assess behaviors. So have you ever made a suicide attempt before? If you're talking to a younger kid, you might not use that language, right? You might ask, have you ever done anything to try and make yourself die? Have you ever done anything to hurt yourself on purpose? Did you want to die when you did this? And then, past suicide attempts, we also want to look at preparatory behaviors. So, have you ever done anything to get ready to kill yourself, like collecting pills or giving belongings away, writing a suicide note?

People are often fearful that having these conversations will put the idea of suicide in someone's head. And so it's important that we all know that that's just not how this works. And there's research to back that. It's okay to talk about these things.

Host: Yeah. So what about the plan? What do you put in the plan?

Danielle Deville, PhD: The suicide safety plan?

Host: Yeah, it's the safety plan. Yeah.

Danielle Deville, PhD: I think of it as like five things. So, we have our coping strategies, and these can be things that might seem really obvious to us in the moment, but you have to keep in mind when someone is in crisis, what is obvious now will not likely be obvious then. So having a written, clear, simple, direct plan can be really helpful. So that might mean coping strategies. Again, even if they seem obvious now, internal things that people can do, to distract themselves, just to get through the moment. This is not going to cure your depression. It's just going to get you through the next hour, help you survive this crisis.

That's sort of the internal coping. Then we have external coping. So, who else can you bring in? You don't need to say, look, I'm suicidal. Look, I'm really needing support right now. But can you go to a friend's house? You don't have to tell them what's going on. Can you go to a park? Go to a public place? Can you text a friend? Just start a conversation about anything. Just get out around others, and then if those two things fail, who can you reach out to? So, if you work through all those coping strategies, you're still not okay. The good news is that that's bought you some time, right?

That's time that you could have been acting on these thoughts and you haven't done that. Now let's bring in other people. So, who can you reach out to? Who's safe? Coaches, parents, friends. And then also professionals in the community, so your therapists, suicide hotlines. And then the last component of a safety plan is just making the environment safe, and I think that that's the most important part.

And we can involve parents in this, but initiating means restriction. So removing weapons, removing access to weapons, for adolescents removing car keys, removing pills, including over the counter pills, vitamins, supplements, cleaning supplies. How do we kind of recreate almost a hospital environment, but at home to keep kids safe.

Host: I have heard other clinicians actually having them sign a, I will not harm myself, or I will call, but is there any data or even anecdotal information to suggest that that is either helpful and or effective?

Danielle Deville, PhD: No, we don't recommend no suicide contracts. There's really no research to support that they're effective. There is research to support that, like, collaboratively coming up with a plan to keep the kids safe is effective, but the no suicide contracts are not supported, not recommended.

Host: Dr. DeVille, thank you so much for your time and your expertise. I think we've learned quite a bit in a short amount of time. You know, before you go, I gave you sort of the East Coast, would you rather? So, since you've spent time in San Diego, I'll give you a West Coast would you rather. We're in the middle of summer, I think it's getting up to 97 this weekend, so, would you rather jump into the Pacific in November, or would you rather go hiking in Kansas City this weekend?

Danielle Deville, PhD: Hiking in Kansas City this weekend. I like the heat. I really do. I didn't think I would. I was worried about it, but I do really like it.

Host: Yeah, I'm the same way. There's no way you're going to catch me jumping into the Pacific at that time of year or almost any time. It's so cold there. Very good. Well, Dr. Deville, thank you again for your time. It has been pleasure to both talk with you and to learn from you. As a reminder, claim your CME credit for listening to our show today.

Visit cmkc.link/CMEpodcast and then click the claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. I'm Dr. Rob Steele. See you next time.