Presentation on theme: "Suicide Risk Assessment"— Presentation transcript:
1Suicide Risk Assessment Nazanin Bahraini, Ph.D.VISN 19 Mental Illness Research Education and Clinical Center,University of Colorado, Denver,School of Medicine
2Take care of our patients We assess risk to…Identify modifiable and treatable risk factors that inform treatmentSimon 2001Take care of our patientsHal Wortzel, MD
3Is a common language necessary to facilitate suicide risk assessment? Do we have a common language?
4The Language of Self-Directed Violence Identification of the Problem Suicidal ideationDeath wishSuicidal threatCry for helpSelf-mutilationParasuicidal gestureSuicidal gestureRisk-taking behaviorSelf-harmSelf-injurySuicide attemptAborted suicide attemptAccidental deathUnintentional suicideSuccessful attemptCompleted suicideLife-threatening behaviorSuicide-related behaviorSuicideThis list makes it difficult to accurately & reliably talk about & understand suicide and related behaviors & communications. Do you notice any terms that might be considered pejorative? Are there any that you are not familiar with? Are there some that seem synonymous with others?
5The Language of Suicidology Implications of the Problem ClinicalResearchPublic HealthBenefits to clinicians (Rudd, 2000) include:(1) improved clarity, precision, and consistency of a single clinician’s practice of risk assessment, management, and treatment over time for an individual patient & across suicidal patients;(2) improved clarity, precision, and consistency of communication among clinicians regarding issues of risk assessment, ongoing management, and treatment;(3) improved clarity in documentation of risk assessment, clinical decision making, related management decisions, and ongoing tx;(4) elimination of inaccurate and potentially pejorative terminology;(5) improved communication between clinician and patient;(6) elimination of the goal of prediction by recognizing the importance and complexity of implicit and explicit suicide intent in determining ultimate clinical outcome.
6The Language of Self-Directed Violence Implications of the Problem Example from Research
7The Language of Self-Directed Violence A Solution to the Problem Nomenclature (def.):a set of commonly understoodwidely acceptablecomprehensiveterms that define the basic clinical phenomena (of suicide and suicide-related behaviors)based on a logical set of necessary component elements that can be easily appliedSilverman et al 2006
8Nomenclature: Essential Features enhance clarity of communicationhave applicability across clinical settingsbe theory neutralbe culturally neutraluse mutually exclusive terms that encompass the spectrum of thoughts and actionsWhereas a nomenclature is a taxonomy of terms and definitions related to a particular topic, a classification system is a more exhaustive categorization and breakdown of subtypes of related phenomenon. In relation to suicide, a classification system would be used to help organize subtypes of behaviors, for example, via the use of modifiers that help to differentiate one behavior from another.Peter Brueghel the Elder, 1563Silverman et al 2006
9Classification System Essential Features “Exhaustive”Builds upon a nomenclatureFurther differentiates between like phenomenaWhereas a nomenclature is a taxonomy of terms and definitions related to a particular topic, a classification system is a more exhaustive categorization and breakdown of subtypes of related phenomenon. In relation to suicide, a classification system would be used to help organize subtypes of behaviors, for example, via the use of modifiers that help to differentiate one behavior from another.Silverman et al 2006
10Self-Directed Violence Classification System Lisa A. Brenner, Ph.D.Morton M. Silverman, M.D.Lisa M. Betthauser, M.B.A.Ryan E. Breshears, Ph.D.Katherine K. Bellon, Ph.D.Herbert. T. Nagamoto, M.D.
11Type Sub-Type Thoughts Behaviors DefinitionModifiersTermsThoughtsNon-Suicidal Self-Directed Violence IdeationSelf-reported thoughts regarding a person’s desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent.For example, persons engage in Non-Suicidal Self-Directed Violence Ideation in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention).N/ASuicidalIdeationSelf-reported thoughts of engaging in suicide-related behavior.For example, intrusive thoughts of suicide without the wish to die would be classified as Suicidal Ideation, Without Intent.Suicidal Intent-Without-Undetermined-WithSuicidal Ideation, Without Suicidal IntentSuicidal Ideation, With UndeterminedSuicidal Ideation, With Suicidal IntentBehaviorsPreparatoryActs or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away).For example, hoarding medication for the purpose of overdosing would be classified as Suicidal Self-Directed Violence, Preparatory.Non-Suicidal Self-Directed Violence, PreparatoryUndetermined Self-Directed Violence,Suicidal Self-Directed Violence, PreparatoryNon-SuicidalSelf-Directed ViolenceBehavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent.For example, persons engage in Non-Suicidal Self-Directed Violence in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention).Injury-FatalInterrupted bySelf or OtherNon-Suicidal Self-Directed Violence, WithoutInjury, Interrupted by Self or OtherNon-Suicidal Self-Directed Violence, With InjuryNon-Suicidal Self-Directed Violence, With Injury,Interrupted by Self or OtherNon-Suicidal Self-Directed Violence, FatalUndeterminedBehavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based upon the available evidence.For example, the person is unable to admit positively to the intent to die (e.g., unconsciousness, incapacitation, intoxication, acute psychosis, disorientation, or death); OR the person is reluctant to admit positively to the intent to die for other or unknown reasons.Undetermined Self-Directed Violence, WithoutUndetermined Self-Directed Violence, With InjuryUndetermined Self-Directed Violence, WithUndetermined Self-Directed Violence, FatalBehavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent.For example, a person with a wish to die cutting her wrist with a knife would be classified as Suicide Attempt, With Injury.Suicide Attempt, Without InjurySuicide Attempt, Without Injury, Interrupted bySuicide Attempt, With InjurySuicide Attempt, With Injury, Interrupted by Selfor OtherSuicide
13Now that we are using a common language How should we beassessing risk?
14Elements of Useful Assessment Tools Clear operational definitions of construct assessedFocused on specific domainsDeveloped through systematic, multistage processempirical support for item content, clear administration and scoring instructions, reliability, and validityRange of normative data availableAlso consider:Context specificschools, military, clinical settingsAvailable resourcestime, money, staffingInfrastructure to support outcomesavailable referralstrained clinical staff in-houseGutierrez and Osman, 2008
15Evidence-Based Measures Suicidal Ideation - Beck Scale for Suicide IdeationDepressive Symptoms – Beck Depression Inventory IIHopelessness - Beck Hopelessness ScaleThoughts about the future - Suicide Cognitions ScaleHistory of Suicide - Related Behaviors - Self-Harm Behavior QuestionnaireProtective Factors - Reasons for Living InventoryA Review of Suicide Assessment Measuresfor Intervention Research with Adults and Older Adults-Greg Brown“The purpose of this review is to provide a systematic examination of the psychometric properties of measures of suicidal ideation and behavior for younger and older adults.”“Many of these measures have demonstrated adequate internal reliability and concurrent validity. …It is therefore a serious problem that the predictive validity for most suicide measures has not been established. In fact, only a few instruments, such as the Scale for Suicide Ideation and the Beck Hopelessness Scale, have been found to be significant risk factors for completedsuicide.”
16“Although self-report measures are often used as screening tools, an adequate evaluation of suicidality should include both interviewer-administered and self-report measures.”
17Important Domains of a Suicide- Focused Psychiatric Interview Current presentation of suicidalitySpecifically inquire about suicidal thoughts, plans and behaviorsPsychiatric IllnessHistoryPsychosocial situationIndividual strengths and vulnerabilitiesAPA Practice Guidelines (2003)
18Identify Suicide Risk Factors Specific factors that may generally increase risk for suicide or other self-directed violent behaviorsA major focus of research for past 30 yearsCategories of risk factorsDemographicPsychiatricPsychosocial stressorsPast historyDemographic (e.g., male gender, age over 65, Caucasian)Psychiatric (e.g., diagnosed serious mental illness)Psychosocial (e.g., loss of significant relationship, impulsivity)Past history (e.g., suicide attempt, sexual or physical abuse)What risk factors do:Overall level of clinical concern about an individualGuide screening and assessment effortsDeveloping models to explain suicideDistal to suicidal behaviorRisk factors do not predict individual behavior
19Determine if factors are modifiable Non-modifiable Risk FactorsFamily HistoryPast historyDemographicsModifiable Risk FactorsTreat psychiatric symptomsIncrease social supportRemove access to lethal means
20Warning SignsWarning signs – person-specific emotions, thoughts, or behaviors precipitating suicidal behaviorProximal to the suicidal behavior and imply imminent riskThe presence of suicide warning signs, especially when combined with suicide risk factors generates the need to conduct further suicide risk assessmentThoughts of suicideThoughts of deathSudden changes in personality, behavior, eating or sleeping patternsRudd et al. 2006
21Warning Signs of Acute Risk: Threatening to hurt or kill him or herself, or talking of wanting to hurt or kill him/herself; and/or,Looking for ways to kill him/herself by seeking access to firearms, available pills, or other means; and/or,Talking or writing about death, dying or suicide, when these actions are out of the ordinary.
22Additional Warning Signs: Increased substance (alcohol or drug) useNo reason for living; no sense of purpose in lifeRage, uncontrolled anger, seeking revengeActing reckless or engaging in risky activities, seemingly without thinkingDramatic mood changes.Anxiety, agitation, unable to sleep or sleeping all the timeFeeling trapped - like there’s no way outHopelessnessWithdrawal from friends, family and society
23Risk Factors vs. Warning Signs Characteristic Feature Risk Factor Warning SignRelationship to Suicide Distal ProximalEmpirical Support Evidence- Clinically base derivedTimeframe Enduring ImminentNature of Occurrence Relatively stable TransientImplications for Clinical Practice At times limited Demands interventionRudd et al. 2006
24Empirical test of warning signs almost non-existent
29VA ACE CARDSThese are wallet-sized, easily-accessible, and portable tools on which the steps for being an active and valuable participant in suicide prevention are summarizedThe accompanying brochure discusses warning signs of suicide, and provides safety guidelines for each stepFront viewBack view
30VA Risk Assessment Pocket Card The Suicide Risk Assessment Pocket Card was developed to assist clinicians in all areas but especially in primary care and the emergency room/triage area to make an assessment and care decisions regarding patients who present with suicidal ideation or provide reason to believe that there is cause for concern.
32VA Risk Assessment Manual Provides more specific information and the rationale for the sections on the pocket cardSections of the guide correspond with the sections of the cardLook for the warning signsFactors that may increase or decrease suicide riskAsk the questionsRespond to suicide riskThe Reference Guide may also be used as a teaching aid for new providers, residents and students at all levels and disciplines as well as other caregivers.It also includes information regarding immediate psychopharmacological interventions and myths about suicideLink to the guide included
33Additional Considerations for Risk Assessment in Military Personnel At risk for post traumatic stress disorder, traumatic brain injury (TBI), and suicideCan we draw from what we know about these conditions, suicidology, and rehabilitation medicine to identify novel means ofassessing risk?
34Members of the military developing PTSD PTSD and SuicideMembers of the military developing PTSD
35Those with PTSD at Increased Risk for Suicidal Behavior 14.9 times more likely to attempt suicide than those without PTSD(community sample)Davidson et al 1991
36Why? Veteran Population Survivor guilt (Hendin and Haas, 1991) Being an agent of killing (Fontana et al., 1992)Intensity of sustaining a combat injury (Bullman and Kang, 1996)
38Post-Traumatic Symptoms and Suicidality Avoidance/NumbingHyperarousalRe-experiencingRe-experiencing Symptom Cluster Associated with Suicidal IdeationNye et al., 2007
39Substance Abuse and Suicide in Veteran Population CharacteristicsMaleFemaleHazard Ratio95% Confidence IntervalAny Psychiatric Diagnosis2.50(2.38, 2.64)5.18(4.08, 6.58)Any Substance Abuse or Dependence2.27(2.11, 2.45)6.62(4.72, 9.29)Alcohol Abuse or Dependence2.28(2.12, 2.45)6.04(4.14, 8.82)Other Drug Abuse or Dependence2.09(1.90, 2.31)5.33(3.58, 7.94)Bipolar Disorder2.98(2.73, 3.25)6.33(4.69, 8.54)Depression2.61(2.47, 2.75)5.20(4.01, 6.75)Other Anxiety2.10(1.94, 2.28)3.48(2.52, 4.81)PTSD1.84(1.70, 1.98)3.50(2.51, 4.86)Schizophrenia(1.93, 2.28)6.08(4.35, 8.48)Ilgen et al. (2010
40Chronic Risk Increase psychosocial stressors Interpersonal conflictWork or academic related problemsExacerbate co-occurring psychopathologyDepression & AnxietyHopelessnessIncrease potential for injuries associated with suicideTraumatic Brain InjuryOften occur togetherSubstance Use is both a risk factor and warning sign for suicidal behaviorIntoxication from alcohol and other substances may increase the likelihood of an individual acting on suicidal thoughts
41Intoxication & Acute Risk Psychopharmacological effects on the brainImpair problem solvingImpulsivityDisinhibition“Alcohol myopia”Acute alcohol consumption restricts attention to the immediate salient stimuliSteele & Joseph, 1990
42VA Clinical RemindersConsist of specific screening questions to assess for potential deployment-related health risksHelp standardize health careEnsures that Veterans are diagnosed and treated appropriatelyExisting clinical reminders for depression, alcohol abuse, and Post-traumatic Stress Disorder
43PTSD Clinical Reminder The PTSD questions trigger a follow-up evaluation by a mental health care professional when three questions are answered affirmatively
44Risk Factors for those with a History of TBI Individuals with a history of TBI are at increased risk of dying by suicideMembers of the military are sustaining TBIs
45Role of Pre-injury vs. Post-Injury Risk Factors Post-injury psychosocial factors, in particular the presence of post injury emotional/psychiatric disturbance (E/PD) had far greater significance than pre-injury vulnerabilities or injury variables, in predicting elevated levels of suicidality post injury.Higher levels of hopelessness were the strongest predictor of suicidal ideation, and high levels of SI, in association E/PD was the strongest predictor of post-injury attemptsSimpson and Tate 2002
46TBI and Psychiatric Co-morbidity Respondents with a co-morbid history of psychiatric/emotional disturbance and substance abuse were 21 times more likely to have made a post-TBI suicide attempt.Simpson and Tate 2005
47TBI – Symptoms, Functioning and Outcomes Qualitative Analysis of Suicide Precipitating Events, Protective Factors and Prevention Strategies among Veterans with Traumatic Brain InjuryBrenner, L., Homaifar, B., Wolfman, J., Kemp, J., & Adler, L., Qualitative Analysis of Suicide Precipitating Events, Protective Factors and Prevention Strategies among Veterans with Traumatic Brain Injury, Rehabilitation Psychology.
48Cognitive Impairment and Suicidality “I knew what I wanted to say although I'd get into a thought about half-way though and it would just dissolve into my brain. I wouldn't know where it was, what it was and five minutes later I couldn't even remember that I had a thought. And that added to a lot of frustration going on.…and you know because of the condition a couple of days later you can't even remember that you were frustrated.”“I get to the point where I fight with my memory and other things…and it’s not worth it.”TBI – Symptoms, Functioning and OutcomesQualitative Analysis of Suicide Precipitating Events, Protective Factors and Prevention Strategies among Veterans with Traumatic Brain InjuryBrenner et al., 2009
49Emotional and Psychiatric Disturbances and Suicidality I got depressed about a lot of things and figured my wife could use a $400,000 tax-free life insurance plan a lot better than….I went jogging one morning, and was feeling this bad, and I said "well, it's going to be easy for me to slip and fall in front of this next truck that goes by…"
50Loss of Sense of Self and Suicidality Veterans spoke about a shift in their self-concepts post-injury, which was frequently associated with a sense of loss"…when you have a brain trauma…it's kind of like two different people that split…it’s kind of like a split personality. You have the person that’s still walking around but then you have the other person who’s the brain trauma."
51Evidence-Based Measures: Suicidality in Those With TBI: 1RESEARCH NEEDED!!!
52Interpersonal-Psychological Theory of Suicide Risk Joiner 2005 Those who desire deathThose capable of suicidePerceived Burdensomeness+Failed BelongingnessAcquired Ability(Habituation)Serious Attempt orDeath By SuicideSuicidal Ideation
53A Qualitative Study of Potential Suicide Risk Factors in Returning Combat Veterans Brenner LA, Gutierrez PM, Cornette MM, Betthauser LM, Bahraini N, Staves P. A qualitative study of potential suicide risk factors in returning combat veterans. Journal of Mental Health Counseling. 2008;30(3): ; 24(1):14-23.
54Themes Combat experiences were a setting for exposure to pain It takes more to be hurt now than in the pastIncreased tolerance for pain in conjunction with a variety of maladaptive coping strategies
55Pain“I think that during the time that I was overseas I ah, kind of lost connection with reality and lost connection with my feelings…if you don’t have any emotions, then you are not scared or afraid either, which really helps you to get through the days in such a dangerous environment.”including avoidance, isolation, anger, substance abuse, and/or self-injurious behaviors
56BelongingnessFeeling disconnection from civilians and/or society in general“I separate myself from society, that part of society. I don’t know how to deal with those people….I just keep myself away.”including avoidance, isolation, anger, substance abuse, and/or self-injurious behaviors“They made me retire when I got back from this one, and it wasn't a choice…I still haven’t redefined who I am.”
57Burdensomeness“I feel like I am burden, 100%, I don’t feel like I belong anywhere … like if I'm out with some friends, I don't feel like I belong. Family, I'm the outsider.”
58The International Classification of Functioning (ICF) Model developed by the World Health Organization (WHO)Means of understanding factors that can impact how people live with TBIREGARDLESS OF INJURY SEVERITY
59Key TermsDisability – impairment in bodily function (e.g., cognitive dysfunction)Activity limitation – “…difficulties an individual may have in executing” a task or action (e.g., not being able to drive)Participation restriction – “…problems an individual may experience in involvement with life situations” (e.g., not being able to work)
60TBI and Suicide Risk Assessment Strategy Assess forAcquired AbilityBurdensomenessFailed BelongingnessIn the context ofDisabilityActivity limitationParticipation restrictionIt is necessary to consider individual functioning and disability post-TBI in the context of personal and environmental factors
61Interpersonal-Psychological Theory of Suicide Risk Joiner 2005 Those who desire deathThose capable of suicidePerceived Burdensomeness+Failed BelongingnessCognitive Dysfunction, Inabilityto Drive, Inability to Work,Loss of Sense of SelfAcquired Ability(Habituation)Injury History, TBI Sequelae(e.g., chronic pain), DepressionSerious Attempt orDeath By SuicideSuicidal Ideation