Our focus is suicide risk assessment across a range of settings. Our objective is to save lives.
Clinical Assessment
In clinical care, ability to accurately assess treatment response is limited not only by clinician variability but by time constraints. In our mind’s eye, we may imagine an idealized Oslerian assessor with unlimited time using only open-ended questions (“Ask no leading questions, never suggest. Give the patient’s own words in the complaint[JG1] .”). But poke-in-the-eye reality provides many patients with 15 minutes of Warholian fame with a primary care clinician hard-pressed by ever growing non-clinical demands that distract from clinical care – including assessment. Many patients have limited or no opportunity for quality assessment.
What can be done? Patients are willing to testify about their symptoms to permit clinicians to make the best recommendations and decisions regarding care. Given clinician constraints, systematically gathering information from patients before clinician-patient face time is a way forward. For example, the nine-item Patient Health Questionnaire (PHQ-9) is the gold-standard self-report assessment in clinical care for depression symptom severity. Providing monthly PHQ-9 scores to primary care physicians (PCPs) over 6 months made it 1.59 times more likely that patients would achieve remission of depression than if PCPs did not receive PHQ-9 scores for patients.¹
A recent New England Journal of Medicine article confirmed rapidly growing recognition that patient-reported outcomes have substantial and broad-scale value in clinical care:
“Measuring patient-reported outcomes (PROs) with standardized questionnaires is one way of getting this information. PRO collection has proliferated in oncology, where it has been linked to improved symptom management, enhanced quality of life, and longer survival. Given these benefits, payers have started to encourage providers to incorporate PRO collection into routine care. For example, the Medicare Comprehensive Care for Joint Replacement model includes financial incentives for hospitals to collect and submit PRO data for patients undergoing elective hip or knee replacement."²
Suicide Risk Assessment
Suicide is an eternal and growing problem with enormous family, social and economic consequences and costs. The tragedy is greatest with youth, doubly dead as they die so young.
Clinician costs of patient suicides are heavy and personal. Pursuit of Zero Suicide is the goal, admirable but unreachable. Healthcare system costs of suicide are also inevitable and substantial including staff burden and time meeting Joint Commission requirements, liability risk and litigation costs. The Columbia-Suicide Severity Rating Scale (C-SSRS) is recognized as the gold standard assessment for suicidal ideation and behavior and has been widely used in regulatory registration drug development programs since 2009. It is also recognized by CDC, WHO and Joint Commission which issued, effective July 1, 2019, new and revised elements of performance applicable to all Joint Commission-accredited hospitals and behavioral health care organizations. These new National Patient Safety Goal (NPSG) 15.01.01 requirements are designed to improve the quality and safety of care for those who are being treated for all behavioral health conditions and those who are identified as high risk for suicide. Hospitals that fail to meet the Joint Commission National Patient Safety Goal for suicide risk assessment risk losing reimbursement from the Centers for Medicare and Medicaid for all services provided, not just behavioral health care.
“Patients being evaluated or treated for behavioral health conditions often have suicidal ideation. Brief screening tools are an effective way to identify individuals at risk for suicide who require further assessment and steps to protect them from attempting suicide. Screening tools should be appropriate for the population to the extent possible (e.g., age-appropriate). When using validated screening tools, organizations should not change the wording of the questions because small changes can affect the accuracy of the tools.
Examples of validated screening tools include the ED Safe Secondary Screener, the PHQ-9, the Patient Safety Screener, the TASR Adolescent Screener, and the ASQ Suicide Risk Screening Tool. The Columbia-Suicide Severity Rating Scale is the only assessment that can be used for both screening and more in-depth assessment of patients who screen positive for suicidal ideation using another tool.”³
Inevitable C-SSRS clinician administration limitations (clinician interview variability including failures to ask about suicidal ideation and behavior and patient reticence about directly disclosing stigmatized suicidal ideation and behaviors) are largely eliminated by the electronic eC-SSRS.
The eC-SSRS also reduces direct and opportunity costs associated with clinician-led suicide risk assessment, freeing clinical staff to focus on patient care and activities that generate revenue for healthcare systems.
eC-SSRS provides clinicians with the best available suicidal ideation and behavior data so they can provide comprehensive suicide risk assessment and subsequent care. Complementary digital assessments of other important suicide risk factors including depression, anxiety, and substance use buttress the eC-SSRS.
Forewarned is forearmed.
Universal Screening in Schools
Meret is providing universal Screening Linked to Care with eC-SSRS, PHQ-A, GAD-7 and other indicated assessments in 6th through 12th grades in schools in Montana. Assessment completion rate has been 100% and those at high risk are seen clinically on the screening day. The eC-SSRS has enabled school staff to identify students who are at high risk of suicide but who were unknown to schools and family, potentially saving student lives.
Patient-Rated Global Impression of Change
The MERET assessment, from which we take our name, refines the fundamental question asked of a patient by a clinician: “How are you doing?” MERET stands for Memory-Enhanced Retrospective Evaluation of Treatment. MERET is an ePRO global change measure ideally suited to address FDA PRO Guidance across most disorders and in clinical care.
MERET captures each individual’s experience of his/her disorder, in their voice, vernacular and affect. Participant recordings are collected at treatment baseline and played back at subsequent assessment points to document change. Seconds listening to a parent, child, sibling or spouse on the telephone immediately inform us of their emotional state and permit useful inference about functioning. This fidelity also occurs when, during treatment, patients hear their baseline recordings including information about their emotions, physical state, and functioning in important life roles. Evidence is strong that voice conveys more vital meaning than other senses.⁴ Playback of baseline recordings anchors recall of baseline status and improves accuracy of global change reports. Effect size increased 16% in one randomized-controlled trial.⁵