Identifying Common and Unique Barriers and Facilitators to Implementing Evidence-Based Practices for Suicide Prevention across Primary Care and Specialty Mental Health Settings

Abstract

Objective

We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts.

Method

Twenty-six clinicians and practice leaders from behavioral health (n = 2 programs) and primary care (n = 4 clinics) settings participated. Participation included a semi-structured qualitative interview on barriers and facilitators to implementing evidence-based suicide prevention practices. Within that interview, clinicians participated in a chart-stimulated recall exercise to gather additional information about decision making regarding suicide screening. Interview guides and qualitative coding were informed by leading frameworks in implementation science and behavioral science, and an integrated approach to interpreting qualitative results was used.

Results

There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging.

Conclusion

Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.

HIGHLIGHTS

• We examined barriers and facilitators to suicide prevention across health settings.

• Common and unique barriers and facilitators across health-care settings emerged.

• Findings can enhance suicide prevention implementation across health-care settings.

Keywords:

• Implementation
• prevention
• primary care
• specialty mental health
• suicide

AUTHOR NOTES

Molly Davis, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA.

Jennifer Siegel, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Emily M. Becker-Haimes, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, PA, USA.

Shari Jager-Hyman, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Rinad S. Beidas, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA, USA.

Jami F. Young, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA.

Katherine Wislocki, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Anne Futterer, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Jennifer A. Mautone, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA.

Alison M. Buttenheim, PhD, MBA, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.

David S. Mandell, ScD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

Darby Marx, Weill Cornell Medical College of Cornell University, New York, NY, USA.

Courtney Benjamin Wolk, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

ACKNOWLEDGMENTS

We wish to thank the participating primary care and specialty mental health programs, clinicians, and leaders for their contributions to this project. Clinical research was facilitated through the Pediatric Research Consortium (PeRC) at The Children’s Hospital of Philadelphia.

DISCLOSURE STATEMENT

The authors declare that there is no conflict of interest. Dr. Rinad Beidas receives royalties from Oxford University Press and has provided consultation to the Camden Coalition of Health Care Providers. She provides consultation currently to United Behavioral Health. She also serves on the Clinical and Scientific Advisory Board for Optum Behavioral Health. Dr. Jami Young receives royalties from Oxford University Press.

DATA AVAILABILITY STATEMENT

Data will be made available upon request. Requests for access to the data can be sent to the Penn ALACRITY Data Sharing Committee. This committee is comprised of the following individuals: Rinad Beidas, PhD, David Mandell, ScD, Kevin Volpp, MD, PhD, Alison Buttenheim, PhD, MBA, Steven Marcus, PhD, and Nathaniel Williams, PhD. Requests can be sent to the committee’s coordinator, Kelly Zentgraf, at [email protected], 3535 Market Street, Third Floor, Philadelphia, PA 19107, 215-746-6038.

Additional information

Funding

This project was funded by an administrative supplement to a National Institute of Mental Health (NIMH) P50 grant [P50 MH113840; Principal Investigators: Beidas, Mandell, & Buttenheim/Volpp]: Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness (ALACRITY; supplement grant number: 3P50MH113840-03S1; Principal Investigators: Beidas, Mandell, & Buttenheim/Volpp; supplement title: Transforming Mental Health Delivery through Behavioral Economics and Implementation Science). Molly Davis was supported by a National Institute of Mental Health Training Fellowship [T32 MH109433].

Notes on contributors

Molly Davis

Molly Davis, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA.

Jennifer Siegel

Jennifer Siegel, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Emily M. Becker-Haimes

Emily M. Becker-Haimes, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, PA, USA.

Shari Jager-Hyman

Shari Jager-Hyman, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Rinad S. Beidas

Rinad S. Beidas, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA, USA.

Jami F. Young

Jami F. Young, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA.

Katherine Wislocki

Katherine Wislocki, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Anne Futterer

Anne Futterer, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Jennifer A. Mautone

Jennifer A. Mautone, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA.

Alison M. Buttenheim

Alison M. Buttenheim, PhD, MBA, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.

David S. Mandell

David S. Mandell, ScD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

Darby Marx

Darby Marx, Weill Cornell Medical College of Cornell University, New York, NY, USA.

Courtney Benjamin Wolk

Courtney Benjamin Wolk, PhD, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.