This document discusses self-harm and suicide among children and young people, and the role of primary care. It notes a 70% increase in under-14s attending A&E for self-harm and that 1 in 10 young people will self-harm at some point. It also discusses suicide rates among young women and those under 25 in England. The document proposes developing an electronic clinical decision support system (e-CDSS) to help GPs assess and manage suicide risk in young patients. Feedback from qualitative research with GPs, patients, and mental health experts was incorporated into the prototype e-CDSS to ensure it is clinically relevant, integrated with workflows, and provides actionable decision support.

1. Dr Maria Michail, PhD
Senior Research Fellow
Institute for Mental Health
School of Psychology
University of Birmingham
Self-harm and Suicide in
Children and Young People:
The role of primary care.

2. The scale of the problem
 70% increase in 10-14 year olds attending A&E for self-
harm related reasons (RCPsych, 2014).
 1 in 10 young people will self-harm at some point,
but it can happen at any age.

6. Suicide among young women
General population
 15,634 general population suicides by females -- an average of
1,421 deaths per year.
 In England, there was an increase in female suicide rates in
those aged under 25.
 38% were in contact with mental health services 12 prior to
suicide (compared to 24% of males in contact with services.
Female patient suicides
 15% increase between 2006 and 2015 in England
 < 25 years and 45-54 years
 74% previous history of self-harm

7. Self-harm and Suicide Research Programme
To create a transformational change in our
understanding, conceptualisation and response to self-
harm and suicide prevention in research, clinical
practice, policy-making and community practices.

8. Suicide Prevention in Primary Care

9. Policy Context

10. Suicide Prevention in Primary Care

11. Why primary care?
• GPs are 1st point of contact for people in distress and
gatekeepers to specialist services (Goldberg, 2002).
• 23% of those under the age of 35 had contact with a
primary care provider in the month prior to suicide,
and 62% in the year prior (Luoma et al, 2002).
• 58% of young people who had self-harmed, had seen
their GP in the past 6 months (Sayal et al 2014).
48.5%
Teachers
33.4%
Primary Care
25.2%
Mental Health Specialists
22.6% Educational
Support Services

12. Our Questions:
1. What are the challenges that GPs face
in managing suicide risk among young
people in primary care?
2. What are the challenges that young
people face when seeking help from
primary care?
3. How could we address those
challenges?

14. I think that’s something that a lot of GPs empathise
with.[laughter] The sort of the long waiting times and
those phone calls to the crisis, (…) and obviously,
although we do whatever we can but they are
(referring to crisis team) the specialism, isn’t it,
psychiatry? So then we want some specialist help
sometimes, there can be a bit of a resistant (there),
you know, taking the patient over. (GP FG4)
It’s very difficult to find who’s really suicidal because, as
I said, we do, most of the time, they will not come here
and say I’m suicidal. Yes, there are a few of them, again,
I don’t know how much (…) they’re young people but
they’re (…) the one if they are depressed, they do use it
as, you know, this cry for help, whether they’re actually,
most of the time it happens, they’re actually not going
to do anything about it, and, but they just trying to get
some attention, or some help at the time. (GP FG4)

15. What GPs want?
 Specialist education and training that extends beyond
the provision of micro-skills.
 Enhancing competencies and capabilities in
conducting a holistic, psychosocial needs-based
assessment with young people (NICE, 2012).
 In-house support with assessing and managing young
people at-risk of suicide during consultations:
• support decision making
• facilitate clinical judgement

16. Suicide in Children and Young people: Tips for GPs.

17. Dissemination and Implementation
Scaling up
National roll-out

18. Electronic Clinical Decision Support System
(e-CDSS)
Framework for structured decision making,
guiding the consultation, and providing a
standardised way of recording and documenting
clinical assessment.
Health
IT
system
Decision
prompts
Suicide risk
assessment
scales
Published
guidelines
Safety
planning
resources

19. NOT a risk assessment scale
NOT a risk prediction tool

20. • Positive Predictive
Value (PPV) < 5%
• This means 95% are
inaccurate!
• They miss suicide
deaths in the “low risk”
group – which most
people are in!
1.
I. No “high risk” classification was clinically
useful.
II. No risk scales perform sufficiently well so as
to be recommended for routine clinical use.
III. Risk scales should not replace a full
psychosocial assessment (NICE, 2012).

21. CDSS in primary care
• Improve decision making and preventative care.
• Use patient specific information to generate
assessments / recommendations.
• Present options to the GP for consideration.
• “cognitive forcing function” – switch from “non
analytical” to “analytical” thinking.

22. E-CDSS for suicidality
in primary care.

23. Phase 1
• Qualitative interviews with GPs
• Service User Advisory Group meetings
• Mental health professionals consultations
Phase 2
• Participatory co-production workshops
Phase 3
• Building the e-CDSS prototype.
Phase 4
• Usability testing with 3 primary care practices
• Non-live testing & live testing
• Refinement of prototype

24. What GPs want:
 Brief, quick and easy to use, minimal
screen interaction, maximise ‘being’ with
patient
 Flexible – don’t want to have to use the
whole thing for every patient.
• Fits with variable consultation styles - can
be used in different ways (with patient /
after patient has left / as an aide memoire)
 Mixture of questions: binary (Yes / No) and
open ended
 Populates an entry in the clinical notes
(captures the details and outcomes of the
consultation)
 Gives us a framework for referral to
secondary care teams (eg CRHTs)
-and-
 Satisfies “Bolam test” – we have done
what is reasonable and appropriate for
patients needs, and which is defendable at
coroners, protects ourselves

25. MENTAL HEALTH PROFESSIONALS
• Dig deeper
• Get more of a sense of risk, explore warning
signs, coping resources etc.
SERVICE USER ADVISORY GROUP
• To be listened to and have experiences validated
• Help me think about times when I have coped before
• Signpost me to appropriate support
• Don’t take away my sense of agency / control
SUICIDOLOGY EXPERTS
• Capability
• Means
• volition
• Perceived burdonsomeness /
hopelessness

26. Phase 1
• Qualitative interviews with GPs
• Service User Advisory Group meetings
• Mental health professionals consultations
Phase 2
• Participatory co-production workshops
Phase 3
• Building the e-CDSS prototype.
Phase 4
• Usability testing with 3 primary care practices
• Non-live testing & live testing
• Refinement of prototype

27. Usability testing
Using an established framework for the
development of the e-CDSS (Kannry et al.,
2015) - key considerations:
o Relevance / clinical appropriateness
o Actionable decision support?
o Impact on workflow / time efficiency
o Integration with existing IT systems
Non Live testing
 Dummy data entry, vignettes, cognitive
walkthrough.
 Usability (System Usability Scale – SUS;
bespoke evaluation questionnaire).
Live testing
 4 GP practices (East and West Midlands) -
variable demographics.
 Usability (SUS; GPs views on acceptability,
relevance; service user views.

28. PRESENTATION DEMOGRAPHICS CLINICAL RISK MARKERS DYNAMIC FACTORS
“Do you want to run the e-CDSS?”
Main Template
Section1 Static risk factors
Section 2 Dynamic risk factors
Section 3 Urgency of support needs /
management options
Section 4 Co-produce safety plan

33. Thankyouforyourtime.
Dr Maria Michail
Institute for Mental Health
School of Psychology
University of Birmingham
Tel: 0121 414 6795
Email: m.michail@bham.ac.uk
@mariamichail2