Suicide Risk Assessment

Provider Realization #2: Suicidal crises can be overcome Explain.

- Acute suicidality is a transient state - Even individuals at high, long-term risk spend more time being non-suicidal than being suicidal. - The majority of individuals who have made serious suicide attempts are relieved that they did not die after receiving acute medical/psychiatric care - The challenge is to help clients survive the acute, suicidal crisis period until such time as they want to live again. - Interventions that successfully address major risk factors also have the potential to reduce suicidal behavior.

Decision to Hospitalize d/t SI

- Depends on diagnosis, depression severity and suicidal ideation - The patient's and the family's coping abilities - The patient's living situation - Availability of social support - Absence or presence of risk factors for suicide

Determining suicide intent

- Determine the extent to which the patient expects to carry out the plan and believes the plan or act to be lethal vs. self-injurious. - Also explore the patient's reasons to die vs. reasons to live. - Inquire about aborted attempts, rehearsals (such as tying a noose or loading a gun), and non-suicidal self-injurious actions, as these are indicators of the patient's intent to act on the plan. - Consider the patient's judgment and level of impulse control. - Look for disagreement between what you see (objective findings) and what the patient tells you about their suicidal state (subjective findings).

Suicide Risk Factors: Physical Disorders

- Diseases of the CNS --> epilepsy, tumors, Huntington's Chorea, DAT, MS, spinal cord injuries - TBI - Sequelae: motor disturbances, sensory deficits, psychiatric symptoms including impulsivity - Cognitive dysfunction --> Impaired attention, concentration, processing speed, memory, language/communication problem solving, concept formation, judgment - Cancers: especially head and neck - Autoimmune diseases - Renal disease - HIV/AIDS Chronic pain syndromes - a substantial risk

Statistics in para-suicidality behaviors: - Females:Males - Incidence of self-injury in psychiatric patients is estimated to be more than ______ times that in the general population - Self-injury is found in about _____% of all abusers of oral substances and _____% of all intravenous users admitted to substance treatment centers - Patients are usually in their _____s

- Female-to-male ratio is almost 3 to 1 - 50 times the general population - 30% oral drug abuse; 10% IV drug abuse - in their 20s (single or married)

Suicide Risk Factors: Specific psych Dx and symptoms

- Hopelessness - Personality disorder - Depression - Repression (turn aggression inward) - Early separation - Anxiety disorders - Akathisia - Increased / Chronic stress - Severe/chronic insomnia - Substance abuse - Command hallucinations/delusions - Previous attempts / Lethality of attempt

Suicide Risk Factors: Concerning Symptoms/Actions

- Hopelessness - Stopping medication - Lack of future plans - Disposing of personal property

Patient Suicide: Clinician Grief Trajectories Psychoanalytic analysis of clinician response

- Initial narcissistic injury sustained in relation to their patient's actions - The subsequent potential for melancholic, atonement, or avoidance reactions - Eventual capacity for the resolution of those reactions

Suicide Risk Documentation: Ethical / Legal issues

- Is there documentation of reassessment of a patient's suicide risk? - Have appropriate precautions been taken to protect a patient from self-harm? - If prescribed an antidepressant, is it one with low-risk for death by overdose or of an amount not sufficient for the person to kill himself? - Have family and friends been advised of the risk of suicide and what to do if risk increases? - Has the patient been provided resources if desire to kill self increases? - Has the patient been scheduled as an outpatient at intervals sufficient to pick up increased risk?

Psychiatric Co-morbidity as a Suicide Risk Factor

- Psychiatric co-morbidity increases risk for suicide and especially when substance abuse and depressive symptoms coexist - Risk increases significantly when greater than one psychiatric disorder is present at the same time

Freud's Theory of Suicide

- Suicide represents aggression turned inward against an introjected ambivalently cathected love object. - Freud doubted that there would be a suicide without an earlier repressed desire to kill someone else (Mourning and Melancholia)

Patient Suicide: Clinician Grief Trajectories Clinician reactions

- The guilt and self-blame that may accompany the suicide - Self-doubts about one's skills and clinical competence - The fear of (and actual) blame of colleagues and family members - The real or imagined threat of litigation - Consider leaving the field - At least temporarily, stop treating patients who are potentially suicidal

Assessment of risk among children age 6 to 12 should focus on

- degree of depression - family communication patterns, and - state of ego functioning

Suicide Statistics in Adolescents: - 0.5-1% of individuals suicide each year with a ____________ increase among adolescents. - About ____________ of all adolescent deaths are due to suicide. - Suicide is the __________ leading cause of death among American youth. - Rates of suicidal behavior are as high at _____% among child psychiatric inpatients.

- two- to three-fold increase among adolescents - 1/4 of all adolescent deaths d/t suicide - 2nd leading cause of death (after accidents) -79% among child psychiatric inpatients

Provider Realization #5: Suicide contracts are not recommended and are never sufficient Explain.

-Contracts for safety are often used as a stand-alone intervention, but they are never sufficient to ensure the client's safety - Contracts for safety are widely used to reduce legal liability, but there is no evidence that such contracts offer any protection from litigation; In fact, they may make litigation more likely if suicide prevention efforts appear to be hinged on the contract or if they provide the therapist with a false sense of security It is misguided to predicate decisions on whether the client "can" or "can't" or "will" or "won't" contract for safety. Several studies have shown that there is a higher incidence of suicidal attempts in clients who have contracted for safety vs. those who have not. - Counsel will question therapeutic alliance and will challenge contract - if they can prove to the jury that there really wasn't a good therapeutic alliance with the patient you would lose the case

Preventing suicide outcomes are best when...

... family and individual therapy is used in combination with psychopharmacotherapy and hospitalization when indicated.

If a person is suicidal due to social factors, it is ____________ to instill hope and reduce risk.

... is possible to instill hope and reduce risk

If a person is profoundly depressed, it is _____________ to instill hope until the depression has been adequately treated.

... not possible to instill hope until the depression has been adequately treated

Adolescents tend to attempt suicide more frequently in... and by...

...in the winter - after school, or - in the evening with someone nearby ...and by overdose

Provider: Loss of a patient by suicide

1 in 5 mental health professionals will lose a patient to suicide Often ignored and unsupported (socially reinforced stigma), despite their own considerable suffering and sense of guilt and compounded by the specter of litigation. Loss is considered traumatic, and is often accompanied by intense confusion and existential questioning, reflecting a negative impact on one's core beliefs. - "the tyranny of hindsight" refers to the implicit guilt for "sins of omission or commission." Clinicians are likely to experience posttraumatic stress disorder symptoms such as intrusive thoughts, avoidance, and dissociation. Clinicians commonly experience significant guilt and shame

Key Components of a Suicide Risk Assessment

1. Assess risk factors 2. Suicide inquiry: thoughts/plan/intent/access to means 3. Assess protective factors 4. Clinical judgment/formulation

Evaluation of the patient with SI includes

A complete psychiatric history Thorough examination of the patient's mental state An inquiry about depressive symptoms, suicidal thoughts, intents, plans and attempts - A lack of future plans, giving away personal property, making a will, having recently experienced a loss all imply increased risk of suicide

Suicide Risk: Prior Attempts

A history of a prior attempt is the strongest predictor of future suicidal behavior. Always ask if the patient has attempted suicide in the past, even if there is no evidence of recent suicidal thinking. If the patient initially denies suicidal thoughts but you have a high degree of suspicion or concern due to agitation, anger, impaired judgment, etc., ask as many times as necessary in several ways until you can reconcile the disagreement about what you see and what the patient says

The Clinician Survivor Task Force

A service of the American Association of Suicidology (1987) - "clinicians who have lost patients to suicide need a place to acknowledge and carry forward their personal loss ... to benefit both personally and professionally by talking with other therapists who have survived the loss of a patient through suicide." The CSTF provides opportunities to participate in video support groups, and a web site that provides information about the clinician-survivor experience, the opportunity to read and post narratives about one's experience with suicide loss, an updated bibliography, a list of clinical contacts, and a link to several excellent postvention protocols.

Intentional Misclassifications of Suicide

Accidents of undetermined cause Chronic suicide --> Deaths through alcohol and substance abuse - Consciously poor adherence to medical regimens for: Addiction, Obesity, Hypertension, Smoking, etc Victim-Precipitated Homicide ("Suicide by Cop")

Durkheim's Theory: Anomic Suicide

Applies to persons whose integration into society is disturbed so that they cannot follow customary norms of behavior - A drastic change in economic situation makes persons more vulnerable than they were before their change in fortune - Also refers to social instability and a general breakdown of society's standards and values

Durkheim's Theory: Altruistic Suicide

Applies to those stemming from their excessive integration into a group - Those who sacrifice their lives in battle/war

Durkheim's Theory: Egoistic Suicide

Applies to those who are not strongly integrated into any social group - Lack of family integration (unmarried more vulnerable) - Couples with children are the best protected group - Rural communities have more social integration than urban areas - Roman Catholicism > Protestantism

Around _____% of those who attempt suicide see their clinician in the _____ months preceding the act. Half of these see their prescriber within ____ week(s) of an attempt!

Around 50% of those who attempt suicide see their clinician in the 2 months preceding the act Half of these see their prescriber within 1 week of an attempt!

Questions to uncover suicidal thinking

Ask patients you suspect may be feeling suicidal about thoughts or feelings related to suicide: - "Sometimes, people in your situation (describe the situation) lose hope; I'm wondering if you may have lost hope, too?" - "Have you ever thought things would be better if you were dead?" - "With this much stress (or hopelessness) in your life, have you thought of hurting yourself?" - "Have you ever thought about killing yourself?"

Administrative Considerations in Telehealth Psychiatric Emergencies

Aspects of telehealth require additional considerations for managing the safety of patients who are, or become, high risk for suicidal behavior while under care: - Have a preplanned process in place. - Obtain information on local regulations and emergency resources (must be tailored to Pt's specific state/geographic location regardless of where you're telehealth calling from) - Identify potential local collaborators to help with emergency management if needed - The clinic should have emergency protocols with clear explanation of roles and responsibilities in emergency situations including the determination at what point other staff and resources should be brought in to help manage emergency situations

Suicide Risk: Documentation

Be sure to document your findings along with your formulation (summary statement about the patient's risk) Include the patient's behavior, mood/affect, verbalizations including thought content Document any interventions each time an assessment is done If there are risk factors identified, document how they have been addressed - What risk management/mitigation steps were taken? BE SURE TO READ AND UNDERSTAND THE FACILITY'S SUICDE PREVENTION POLICY AND PROCEDURE

Menninger's Theory of Suicide

Built on Freud's ideas Suicide is inverted homicide because of a patient's anger toward another person - Either turned inward or used as an excuse for punishment Menninger also described a self-directed death instinct (Freud's concept of Thanatos) plus three components of hostility in suicide: - The wish to kill - The wish to be killed - The wish to die (Man Against Himself)

Common deliberate self-harm actions

Burning, scratching, self-hitting, or biting

Children who are assaultive or suicidal tend to exhibit _______________________ and have histories of parental __________ and __________ behavior.

Children who are assaultive or suicidal tend to exhibit intense aggression and have histories of parental suicidal and assaultive behavior

Provider Realization #4: Suicide prevention actions should extend beyond the immediate crisis. Explain.

Clients who have long-term risk factors for suicide (e.g., depression, child sexual abuse history, marital problems, repeated substance relapse) require treatment of these issues, whether or not they show any indication of current risk for suicide. Individuals with a history of serious suicidal thoughts or suicide attempts, but with no recent suicidal thoughts or behaviors, should be monitored to identify any recurrence of suicidality.

Patient Suicide: Navigating the aftermath as a provider

Clinicians who experience optimal support are able to identify many retrospective benefits of their experience. - better able to identify risk and protective factors for suicide - more knowledgeable about optimal interventions - report reduction in therapeutic grandiosity/omnipotence - more realistic appraisals and expectations in relation to clinical competence - likely to retrospectively identify errors in treatment, "missed cues," or things they might subsequently do differently - become more aware of own therapeutic limitations

Provider Realization #8: It is best to ask clients about suicide, and ask directly Explain.

Data does not support the idea that asking about suicide will put this idea in an individual's mind. You may never know about a client's suicidality unless you ask.

Suicidality through the continuum of depression

Depressed persons may attempt suicide just as they appear to be recovering from their depression. Consider: AD's work on the physiologic symptoms (like feeling more energized) well before it's effective in the psychiatric symptoms (like decreased mood) --> this put patients at risk while they're 'physically' feeling better, but they're not mentally there

Provider Realization #3: Although suicide cannot be predicted with certainty, suicide risk assessment is a valuable clinical tool. Explain.

Determining with accuracy who will die by suicide using tests or clinical judgment is extremely difficult, if not impossible. Suicide risk assessment is a valuable clinical tool because it can ensure that those requiring more services get the help that they need.

Biological Theories in Suicide

Diminished central serotonin plays a role in suicidal behavior Significant changes in presynaptic and postsynaptic serotonin binding sites Changes in noradrenergic system Genetic Factors - Suicidal behavior tends to run in families - A family history of suicide increases the risk of attempted suicide and that of completed suicide

Durkheim's Theory of Suicide

Divides suicides into three social categories: 1.) Egoistic Suicide 2.) Altruistic Suicide 3.) Anomic Suicide

Steps in suicide risk management

First: Assess immanent risk --> Does this patient need observation? Then, evaluate risk factors to determine if the patient can be managed outside the hospital or require confinement: - Family may elect to provide constant surveillance. - Alert family to risk and treatment plan and informed of signs of deepening depression. - Give instructions/phone number for crisis center

Child: Loss of a parent by suicide

For children the loss of a parent feels like a shameful abandonment for which the child may blame himself

Parent: Loss of a child by suicide

For parents, their grief is compounded by having failed in what their perceived as their responsibility for the total feelings of their child

GATE: Procedures for Therapists

G: Gather information - Screening and spotting warning signs - Asking follow-up questions - "IDENTIFY THE RISK" A: Access supervision and/or consultation - Can provide invaluable input to promote the client's safety give you needed support and reduce your personal liability T: Take responsible action(s) - "MANAGE THE RISK" E: Extend the action(s) - Continue monitoring (D): Documentation of all actions taken

Prime suicide site in the world: ___________________

Golden Gate Bridge in SF, California (1,600 suicides since the bridge opened in 1937)

Strongest predictor of future suicide attempts and completion

History of a suicide attempt

Why patients self-mutilate

In some instances self-mutilation occurs in patients who feel unreal or depersonalized and is an attempt to make themselves feel that they exist. Most claim no pain and give reasons as anger at themselves or others, relief of tension, and the wish to die. Most cutters have attempted suicide Self-mutilation has been viewed as localized self-destruction with mishandling of aggressive impulses caused by the unconscious wish to punish self or an introjected object.

The 'Right to Die' Conundrum

Individual's right to die creates a particular problem in diagnosis and management. An individual with severe medical illness such as terminal AIDS or cancer may wish to die; If the desire to suicide is not a product of a mental illness, the clinician cannot restrain the person. CAVEAT: In many instances, a person is delusional and thinks he has a terminal illness but does not and is profoundly depressed

Rights of the Patient in Telehealth

Inform the patient of their rights and responsibilities when receiving care at a distance (through telehealth) including the right to refuse to use telehealth Provide patients and providers with a formal process for resolving ethical questions and issues that might arise as a result of a telehealth encounter Incorporate organizational values and ethics statements into the administrative policies and procedures for telehealth Eliminate any conflict of interest to influence decisions made about, for, or with patients who receive care via telehealth.

Patient Suicide: Institutional and Administrative Procedures

It is essential to consult with a legal representative/risk manager Who holds privilege after a patient's death (varies by state) - What may and may not be shared under the restrictions of HIPAA Clarify procedures for chart completion and review The QI inquiry (a/k/a Psychological Autopsy) - Purpose: to facilitate learning, identify gaps in agency procedures and training, improve pre- and postvention procedures, and help clinicians cope with the loss - Should be delayed until the treating clinician is no longer in the "shock" phase of the loss, and is able to think and process events more objectively

Patient Suicide: Clinician Confidentiality Restrictions

Legal counsel may advise a clinician against speaking to consultants or supervisors or even surviving family members for fear that these non-privileged communications are subject to discovery should any legal proceedings ensue. Quality Improvement Committee and the QI Inquiry (If a member of the committee discusses info outside of the committee it becomes fair game for legal counsel)

Suicide Risk Factors: Religion

Lower incidence of suicide among Jewish and Catholics Likely r/t views on ascension to heaven

Suicidal thoughts and behaviors are commonly found at increased rates among individuals with psychiatric disorders. Highest risk disorders include...

MDD Bipolar disorders Schizophrenia PTSD, GAD SUD Personality Disorders (esp. borderline and antisocial (who inflict harm onto themselves to inflict pain on someone else, not r/t depression or desire to die))

Suicide Risk Factors: Age (adult)

Men: risk increases with age Women: increases until age 65 then drops

Patient Suicide: Family Contact

Most authors have recommended that clinicians and/or agencies reach out to surviving families. Although some legal representatives will advise against this, experts in the field of suicide litigation have noted that compassionate family contact reduces liability and facilitates healing for both parties --> "Compassion Overe Caution" Clinicians should ask the family if it would be helpful if they were to attend the funeral/memorial services, and how to introduce themselves if asked by other attendees.

Characteristics of self-mutilation/cutting

Most cut delicately, not coarsely - Usually in private with a razor blade, knife, broken glass or mirror - Wrists, arms, thighs and legs are most commonly cut - The face, beasts and abdomen are cut infrequently

Lethality of suicidal behavior

Objective danger to life associated with a suicide method or action Note that lethality may not always coincide with an individual's expectation of what is medically dangerous.

Aborted suicide attempt

Potentially self-injurious behavior with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage occurred

Suicide survivor

Refers to those who have lost a loved one to suicide (not to someone who has attempted suicide but lived) The toll on suicide survivors appears greater than that by other deaths - Mainly because the opportunities for guilt are so great Survivors are at the mercy of their often merciless consciences; feel that if they had done something differently, the decedent would still be here

Suicide Risk Factors: Race

Risks lower for non-whites

____________ reported most likely to commit suicide as inpatients and ____________ as outpatients.

Schizophrenics reported most likely to commit suicide as inpatients and drugs/alcohol abusers as outpatients.

Suicide

Self-inflicted death with explicit or implicit evidence that the person intended to die

Suicide attempt

Self-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die.

Protective Factors in Suicide Risk Assessment

Strengthening protective factors can be a part of safety planning - Protective factors can mitigate risk in a person with moderate to low suicide risk Protective factors provide a poor counterbalance to individuals who are high-risk for attempting suicide - Someone with strong ideation, intent, a plan, preparatory behaviors, and impaired judgment

Legal issues/considerations in telehealth psychiatric emergencies

Stress and anxiety can be exacerbated by the fear of having less control of the situation, unfamiliarity with safety procedures, technology issues, and concerns about liability. Liability can occur from even the briefest of patient contacts. Clinicians shall be familiar with local civil commitment regulations and have arrangements where possible to work with local staff to initiate/assist with civil commitments (involuntary commitments)

Suicidal intent

Subjective expectation and desire for a self-destructive act to end in death.

Provider Realization #7: Suicidal individuals generally show warning signs. Explain.

Such warning signs come in many forms and are often repeated; (E.g., expressions of hopelessness, suicidal communication, etc.) The difficulty is in recognizing them for what they are. Direct indications of acute suicidality: - Suicidal communication: Someone threatening to hurt or kill him/herself or talking of wanting to hurt or kill him/herself - Seeking access to a method: Someone looking for ways to kill him/herself by seeking access to firearms, available pills, or other means - Making preparations: Someone talking or writing about death, dying, or suicide

Assessing Suicide Risk Factors

Suicidal behavior is associated with many different types of events, illnesses and life circumstances The strongest predictor of suicide is one or more previous attempts However, most people who die by suicide die on their first attempt The greater number of identified risk factors is suggestive of greater risk (use assessment scales)

Patient Suicide: Litigation

The most common malpractice lawsuits filed against clinicians are those that involve a patient's suicide. - 34% of surviving family members considered brining a lawsuit against the clinician - Of these, 57% consulted a lawyer An institution's concern about protecting itself from liability may compromise its ability to support the clinician or trainee who sustained the loss Reprisals against supervisors and the institution may engender angry and blaming responses toward the treating clinician

Provider Realization #6: Suicide attempts always must be taken seriously Explain.

There is always a mismatch between the intent of the suicidal act and the lethality of the method chosen. - Clients who genuinely want to die (and expect to die) may nonetheless survive because their method was not foolproof and/or because they were interrupted or rescued. A prior suicide attempt is a highly potent risk factor for eventually dying by suicide. Any suicide attempt must be taken seriously, including those that involve little risk of death, and any suicidal thoughts must be carefully considered in relation to the client's history and current presentation.

Clinical judgement of suicide risk: Low-end vs High-end

There is no screening tool or questionnaire that can accurately predict which patients with suicidal risk will go on to make a suicide attempt Low-end of the risk spectrum: - Patients with thoughts of death or wanting to die but without suicidal thoughts, intent or a plan High-end of the risk spectrum: - Highly specific suicide plans - Preparatory acts or suicide rehearsals - Clearly articulated intent - Further exacerbations that heighten risk --> Impaired judgment caused by intoxication, psychosis, TBI, impulsiveness

Suicidal ideation

Thought of serving as the agent of one's own death; seriousness may vary depending on the specificity of suicidal plans and the degree of suicidal intent.

Most serious warning signs for suicide

Threatening to hurt or kill self Looking for ways to kill self - Seeking access to pills, weapons or other means - Talking or writing about death, dying or suicide

Onset: Deliberate self-harm

Typically self-harm commences in late adolescence with multiple episodes of low lethality that continues for years

Deliberate Self-Harm (Parasuicidal Behavior)

Willful self-inflicting of painful, destructive, or injurious acts without intent to die Even though, not 'willful' or intent on suicide, Parasuicidal behavior is not any less serious because this patient might accidentally die

Provider Realization #1: Almost all of your clients who are suicidal are ambivalent about living or not living. Explain.

Wishing both to die and to live is typical of most individuals who are suicidal, even those who are seriously suicidal. - For example, hesitation wounds are commonly seen on individuals who have wounds are commonly seen on individuals who have died by suicide; bruises on a temple indicating that a gun had been placed there several times before pulling the trigger. Take suicidal thinking seriously and think about ways to reinforce realistic hope. Do everything you can to support the side of the client that wants to live but do not trivialize or ignore signs of wanting to die.

Suicide Risk Factors: Gender

Women attempt more than men; however, men succeed more

Self-harm repeaters are at ____________ short-term risk for suicide than first cases.

at greater short-term risk for suicide than first cases.

Self-mutilation, particularly skin cutting and burning, is commonly found in patients with ____________________

eating disorders.

After discussing the character of suicidal thoughts, you should inquire about ________________.

planning