Psychology Exam I: Assessing Clients Who Are At-Risk for Suicide
*-Most depressed patients do not kill themselves.* -The 2002 national suicide rate in the general population was 11.1 per 100,000. -The suicide rate for people with *bipolar or other mood disorders* was 193 per 100,000, or a relative risk of 18 times greater than the general population. -The suicide rate for *schizophrenia, alcohol and drug abuse* was also 18 times that of the national suicide rate.
Actuarial Analysis
___________ is a sentinel behavioral risk factor for suicide when in the context of: -Depression -Manic and mixed states -Psychosis -Panic attacks -Anxiety -Irritability -Melancholic features -Diminished concentration -Hopelessness
Agitation
Demographic risk factors; age, gender, race, and marital status: -Highest suicide rates for white males over age __ -Suicide rates for white males over age 65 are elevated -____ are 3 times more likely to commit suicide than females. -____ make suicide attempts 3-4 times more frequently than males. -Suicide rates are higher among Caucasians and Asians (with the exception of young adults) than among African Americans.
85 Males Females
Patient Education: ________________ -Alliance Building: "We're in this together" encourages clients to call during a crisis. -Thorough explanation of how a psychiatrist or covering clinician may be reached in an emergency -Clients may leave a message with their phone number saying that he/she has gone to a safe holding place until their call is returned, (e.g., home, friend's home, commander, first sergeant, etc.). -Provide with hotline numbers. -Document all pre-arranged plans in the client's records.
A Pre-arranged Safety Plan
++++Feigned Improvement *Clinical Pearls* -Spend sufficient time with the client to do an adequate clinical evaluation and suicide risk assessment. *-Obtaining client information from collateral sources is critical when collecting behavioral observation data.* *-Sudden improvement, also known as "mood lightening," can result from the client's resolve to complete suicide.* -Pressure to have clients improve quickly due to command requests may lead to overlooking feigned improvement. -Real improvement of the suicidal client is a process, even when it occurs quickly. Feigned improvement is an event. *-Behavioral risk factors help the clinician assess suicide risk in the guarded or dissimulating client.*
Feigned Improvement
????________ features play an important role in suicide: -Clinical and Biologic markers associated with melancholic depression: --Psychomotor changes nearly always present --Less likely to have a clear precipitant --Less likely to respond to medication --Elevated cortisol levels --Alterations of sleep EEG profiles
Melancholic
________ features play an important role in suicide: -Either of the following: --Loss of interest or pleasure in all, or almost all, activities --Lack of reactivity to pleasurable stimuli -Three or more of the following: --Distinct quality of mood (e.g., different from bereavement sadness) --Depression worse in the morning --Early morning awakening --Marked psychomotor retardation or agitation --Significant anorexia or weight loss --Excessive or inappropriate guilt
Melancholic
Psychiatric Disorders and Suicide Risk *-More than 90% of suicides in the United States are associated with _____ ______.* -Every psychiatric disorder is associated with suicide except mental retardation. *-What disorders are associated with the highest suicide risk?* -There are high rates of suicide for clients with Anorexia Nervosa (not as problematic with Bulimia Nervosa).
Mental Illness, *Major Depressive Disorder, Bipolar Disorder, Schizophrenia, and Substance Use Disorders*
*++++Clinical Pearls* -Every psychiatric disorder, with the exception of ______ ________, is associated with suicide risk. -*Mental health diagnosis is an important risk factor.* Making the correct diagnosis is crucial. -Comorbid diagnosis of _______ _______ and medical conditions increases the risk of suicide. -The clinician must spend sufficient time with the client to acquire enough information for a reasonable diagnosis and suicide assessment.
Mental retardation Personality Disorders
*++++Clinical Pearls* -Observational data can be used to identify behavioral risk factors that inform treatment and safety management, thus avoiding total reliance on patient reporting. *-Identification of behavioral suicide risk factors is an important component in systematic suicide assessment of all clients.* *-Behavioral risk factors can facilitate early identification of the guarded, deceptive client.*
Preventing Client Suicide
*++++Clinical Pearls:* -Patients may disclose more information about suicidal behaviors and thoughts on self-report measures than during the clinical interview. However, self-report measures should not displace competent suicide risk assessment. *-The suicide assessment of the guarded or deceptive client should include, when possible, input from significant others.*
Preventing Client Suicide
++++Preventing Patient Suicide *Clinical Pearls* -Families and other caretakers play an important role in safety management of the client, especially when educated about their appropriate role. Most families, however, cannot provide constant supervision of the client. Hospitalization may be necessary until the client is stable. -Do not worry alone. Consultation is always an option.
Preventing Patient Suicide
Preventing Patient Suicide *Clinical Pearls* -Effective treatment and safety management of the suicidal client require the full commitment of time and effort from the clinician. -Suicide risk management is a process, not an event. It is key to determining informed, ongoing treatment and safety management. It is performed on all clients at risk of suicide.
Preventing Patient Suicide
Preventing Patient Suicide *Clinical Pearls* -Suicide prevention contracts should not take the place of adequate risk assessment. Reliance on suicide prevention contracts with new, unknown clients is unwarranted. Suicide prevention contracts can provide the illusion of safety where none exists. -The entire treatment team participates in the supervision of the client at suicide risk. The proper supervision for clients at risk for suicide in rapid-turnover settings cannot be the responsibility of only one or two people.
Preventing Patient Suicide
Preventing Patient Suicide Gun Safety Management of Suicidal Patients -Access to guns is associated with a significant increase in suicide compared to homes without guns (Brent 2001). -Regions with higher rates of gun ownership have higher rates of suicide, after other factors associated with suicide have been controlled (Barber 2005). -In 2003, of the 31,484 suicides in the United States, 16,907 were by firearms (American Association of Suicidology 2006). -Firearm suicide attempts end in death in approximately 85% of cases (Kellerman and Waecker 1998).
Preventing Patient Suicide
Preventing Patient Suicide Gun Safety Management of Suicidal Patients -When lethal means of committing suicide are less available, suicide rates decline by that method, and, often overall suicide rates decline as well (Harvard School of Public Health 2010). -Method of storage and the number of guns in the home influence suicide risk. -Impulsivity and guns are a lethal mixture. -Suicide rehearsal with a gun reinforces the belief that a firearm suicide is quick and easy. -It takes less time to reach for a loaded gun that most other methods of suicide.
Preventing Patient Suicide
Psychiatric Disorders and Suicide Risk *Persons with Personality Disorders are at seven times greater risk for suicide than the general population.* *-Cluster B personality disorders, especially borderline and antisocial personality disorders, place people at greater risk for suicide.*
Risk Factors
-Clients with *depression and anxiety have higher levels of suicidal ideation when compared to depressed clients who are not anxious.*
Risk Factors of Suicide
-Depressed clients with comorbid *panic attacks* may find their lives unbearable, and may quickly escalate to a suicide attempt. -Rapid and effective treatment for depressed and anxious clients may prevent suicidal ideation. -Secondary effects, such as work impairment and disrupted relationships often lead to despair, demoralization, and increased risk of suicide. -Clients from diagnostic groups such as major depressive disorder, chronic alcoholism and substance abuse are at increased risk of suicide.
Risk Factors of Suicide
Under physical disorders, the following conditions are associated with increased risk of suicide: *-AIDS, Epilepsy, Spinal Cord Injury, Brain Injury, Huntington's Chorea, and Cancer*
Risk factors
*-The risk of suicide is doubled when a patient engages in self-mutilation.* -Persons intent on committing suicide are usually ambivalent until the last moment.
Risk factors of Suicide
-Individuals who complete suicide after prior attempts have experimented with at least two different methods. *-High risk factors associated with attempted suicide in adults are depression, prior suicide attempts, hopelessness, suicidal ideation, alcohol abuse, cocaine use, and recent loss of an important relationship.* -In youths, the strongest factors associated with a suicide attempt are depression, alcohol or other drug use disorder, and aggressive or disruptive behaviors.
Risk factors of Suicide
-Completed suicide risk is highest during the first year after an attempt. -Most completed suicides take place among individuals who have never made an attempt. -Recent near-lethal attempts are frequently followed within days by a completed suicide. -*What two risk factors are the single most powerful indicators of completed suicide?*
Risk factors of Suicide, *Prior suicide attempts and HOPELESSNESS*
*Short-term risk factors include:* -Panic attacks -Psychic anxiety -Loss of pleasure and interest -Moderate alcohol abuse -Depressive turmoil (mixed states) *-Diminished concentration* *-Global insomnia* These factors were predominantly severe, anxiety driven, and treatable.
Risk factors of suicide
Circumstantial risk factors may be pertinent (e.g., an individual who is jailed for the first time). Age-related contagion effect is an important risk factor for adolescents who have been exposed to a completed peer suicide.
Risk factors of suicide
Risk Factors *-General risk factors such as a recent suicide attempt, hopelessness, or family history of suicide apply across most clinical settings.* -Individual risk factors are unique and specific to the client *(e.g., the stuttering patient who no longer stutters when suicidal).* -Cultural risk factors may determine risk *(e.g., shame suicides in certain Far East cultures).*
Risk factors of suicide
*Self-administered suicide scales are overly sensitive and lack specificity:* -Suicide risk factors occur in depressed clients who do not commit suicide. -Clients at-risk for suicide may not answer truthfully. -Checklists cannot encompass all the pertinent suicide risk factors present in a given client.
Treatment and Management for Assessing Clients Who Are At-Risk For Suicide
Suicide is the result of multiple factors: -Diagnosis (psychiatric and medical) -Psychodynamic -Genetic -Familial -Occupational -Environmental -Social -Cultural -Existential -Chance factors
Treatment and Management for Assessing Clients Who Are At-Risk For Suicide
The following are what? -Stressful life events have a significant association with completed suicides. -Clients are at varying risk for suicide, and their level of risk can change rapidly. -Single scores of suicide risk assessment scales and inventories should not be relied upon as the sole basis for clinical decision making. -Structured or semi-structured suicide scales can complement, but are not a substitute for, systemic suicide risk assessment.
Treatment and Management for Assessing Clients Who Are At-Risk For Suicide
The following are what? -Suicide is a rare event. -Efforts to predict who will commit suicide lead to a large number of false positive and false negative predictions. -No method of suicide risk-assessment can reliably identify who will commit suicide and who will not.
Treatment and Management for Assessing Clients Who Are At-Risk For Suicide
The Myth of ____ _______ -Voice mail messages advising clients to go to the emergency room or call 911 if they have a 'true emergency' may increase the risk of a suicide attempt. -Suicidal clients may interpret this as "Don't bother me!"
True Emergency
++++Family history of mental illness, particularly of suicide, is a significant risk factor. *The Psychiatric disorders:* -Affective Disorders -Schizophrenia -Alcoholism -Substance Abuse *-Cluster B Personality Disorders (i.e., Antisocial, Borderline, Histrionic, and Narcissistic)*
Yup
The Myth of Passive Suicidal Ideation *-There is no evidence that supports the commonly held belief that "passive" suicidal ideation is less of a risk than "active" suicidal ideation.* -Suicidal ideation, such as the wish to die by passive means, can be as lethal as thoughts of hanging. -Presumably, passive thoughts of wanting to die allows time for intervention, but methods can change without notice. -"Fleeting" suicidal ideation, also requires careful evaluation.
Yup
-Detoxifying clients with substance use disorders can reduce, often dramatically, high suicide risk. *-Adherence to treatment recommendations, allowing access to significant others, and voluntary socializing with others often signal real improvement.* *-Real improvement may be rapid, but it is not sudden and unexpected.*
Evaluation of Authentic Improvement
-Many clients at risk for suicide may improve rapidly after intervention. -Initiation of treatment, effects of medication, peer interactions, and safety measures can promote rapid improvement. -Alleviation of sleep problems can result in rapid improvement in a client's clinical condition. *-____________ reduces feelings of isolation and provides needed support.*
Evaluation of Authentic Improvement, *Group therapy*
-A suicidal patient with agitated depression may leave the emergency department before being seen and then attempt or complete suicide. *-A phone call with a psychiatrist or covering clinician who is informed about suicidal patients within one hour provides clients with access to competent intermediary care to determine a proper course of action.*
Emergency Accessibility
-Calling 911 leaves clients with the image of rescue squads at their door with sirens blaring and inquisitive bystanders. -Patients may be too impaired or unwilling to follow instructions, instead choosing to attempt or complete suicide. -Emergency rooms frequently require that patients endure long periods of waiting to be evaluated.
Emergency Accessibility
-No protective factor is absolute. -The acuteness and severity of symptoms can nullify factors. -Evidence-based studies identify general protective factors that may not apply to individual clients. --Example: A devout, severely depressed client may feel abandoned by God or feel that God will understand and forgive suicide.
General and Individual Protective Factors
-Studies have identified internal core character and personality traits that perfectionistic, high-functioning, successful individuals often possess. When such individuals become depressed, they often despair over the loss of highly valued coping and survival skills; they often feel hopeless and at a high risk for suicide. -Enduring survival and coping traits may be disabled temporarily by severe depression and medication side-effects.
General and Individual Protective Factors
*++++Clinical Pearls* -A dynamic interplay exists between risk and protective factors. -Protective factor should be systematically assessed, as are suicide risk factors. -Any protective factor(s) can be overcome by the severity of the client's painful symptoms. -General evidence-based protective factors should alert the clinician to inquire about whether the client has any uniquely protective factors. -Restoring and enhancing protective factors form an essential therapeutic intervention for the client at risk for suicide.
General and Protective Factors
-Although pregnant women complete suicide at one-third the expected rate, it is not an absolute protective factor. Pregnancy may not be a welcomed event by some women. -Suicide contracts, when utilized as a substitute for competent suicide risk assessment, can become a suicide risk factor.
General and Protective Factors
-An assumed protective factor may represent a stealth suicide risk factor (i.e., suicide prevention contracts). -Family connectedness may be insufficient or actually destructive, (i.e., some families or family members may be more impaired than the client) *-Having a child under the age of 18 is an evidence-based general protective factor. But having an impulsive, acting-out, drug using adolescent can also be a significant risk factor.*
General and Protective Factors
Assessment of the _______ ______. -Some patients may be initially frightened, embarrassed, denying, minimizing, and defensive. -Guarded, deceptive suicidal patients intentionally conceal active suicidal ideation, intent, or plan from clinicians. *-Patients at high risk often communicate suicide intent only to the most important person in their lives, but not necessarily to the clinician, even after direct questioning.*
Guarded Client
Assessment of the _______ _______. -Patients at moderate to mild risk usually communicate their intent to physicians or other family members. -The majority of patients who commit suicide do not communicate their intent during their last therapeutic appointment. *-Assessment of the guarded client should include, when possible, input from significant others.* *-Clinicians may just listen, but not give information, when the client refuses to give permission.*
Guarded Client
++++Gun Safety Management of Suicidal Patients *Clinical Pearls* -The essence of gun safety management is verification. -Gun safety management requires a collaborative, team approach. -Guns in the home are associated with a significant increase in suicide compared to homes without guns. -Impulsivity and guns are a lethal combination. The time between decision and suicide attempt is often a matter of a few seconds or minutes. -The purchase of a handgun is associated with a significant increase in the risk of suicide within a week of purchase.
Gun Safety
The following are what? -Foreseeability must also be distinguished from preventability. -A client's suicide may be preventable in hindsight, but was not foreseeable at the time of the assessment. *-Only the risk of suicide is determinable.* -When suicide risk assessments are not performed or documented, courts are less able to provide evaluate the clinical complexities and ambiguities that exist in the assessment, treatment and management of clients at-risk for suicide.
Standard of Care for Assessing Clients Who Are At-Risk For Suicide
The following are what? -Legal standard is different from professional standard. -Courts evaluate the provider's management by deciding whether the suicide risk assessment process was reasonable and *the client's suicide was foreseeable.* *-Foreseeability should not be confused with predictability, for which no professional standard exists.*
Standard of Care for Assessing Clients Who Are At-Risk For Suicide
Current standards of care do not require that specific psychological tests or checklists be used as part of the systemic assessment of _____ ___
Suicide Risk