Presentation on theme: "Assessment and Management of Suicide Risk May 24, 2007"— Presentation transcript:
1Assessment and Management of Suicide Risk May 24, 2007 Melissa J. Pence, Psy.D.Licensed Clinical PsychologistHampton Roads Neuropsychology and Behavioral Medicine
2Outline Impact Demographics and epidemiology Etiology Risk assessment Psychological TestingTreatment and preventionMedical-legal concernsBegin with impact of suicidal thoughts on the person.We will be discussing a lot of numbers, risk factors, and clinical information this morning. Before we begin, I would like to take a moment to consider how suicide impacts individuals and families on a more personal level.I had a very wise mentor/supervisor who helped me with this issue. Early in my grad school career, I was in the process of evaluating a young man who was decompensating and most likely in the middle of his first psychotic break. He was tormented with hearing voices and was engaging in some very bizarre behavior. I found it fascinating to delve into this case. But before we began, my supervisor kindly and wisely cautioned me. He stated that he wanted me to always remember, no matter how interesting a patient’s behavior may be, or how rudimentary this analysis may become; that this situation is some family's tragedy. He reminded me that this young man was someone’s son and someone’s brother.I have never forgotten those words, and I hope that as we study this tragic circumstance today we can all remember that each of these numbers represent a person experiencing unbearable emotional pain.I think a good place to begin is by discussing Dr. Kay Jamison and her work.
3A personal account of the impact of suicide A personal account of the impact of suicide" His light, through me, will grow as a beacon for others." John C. Gibbs
4Survivors of Suicide (Schneidman, 1969) Long been accepted that each suicide intimately effects at least 6 people.Each suicide intimately affects at least 6 other people (estimate - Shneidman, 1969, On the Nature of Suicide)Based on 6 survivors per suicide, the resulting number of survivors was 188,904 in 2003If there is a suicide every 16.7 minutes, then there are 6 new survivors every 16.7 minutes as wellBased on the 749,337 suicides from 1979 through 2003, it is estimated that the number of survivors of suicides in the U.S. is 4.5 million (1 of every 65 Americans in 2003)
5SuicideDefinition of suicide: “Suicide is the death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result.” Emile DurkheimRequires:Death/lethal outcomeSelf-inflictedIntentionally inflictedAwareness or consciousness of outcomeCDC 1998Requires judgment based on implicit or explicit evidence; when evidence is not present- certification of accidental death or death of unk causeDe Leo 2004
6Problems in studying suicide Low base rateNo test (biological or psychological) or clinical marker that predicts suicideRequires clinical judgmentNumerous false positives in prediction paradigmsHigh risk suicidal patients excluded from most clinical studies
7Demographics and Epidemiology A MAJOR Public Health Problem!
8How is this data gathered? Death certificate information reported by each state to the National Center for Health StatisticsMost recent national data available is 2003Numbers are generally understood to be a modest underestimation of actual suicide deaths due to difficulties in conclusively determining cause of deathEpidemiology stats are from CDC, NIH, and WHO(i.e. crashing car into a tree; was this because the individual was asleep at the wheel or suicidal?)Ruled accidental when there is no evidence to meet criteria of Self-inflicted, Intentionally inflicted, Awareness or consciousness of outcome
9U.S. National Statistics (2003) (CDC) 31,484 deaths by suicide86 deaths per day1 every 17 minutes11th leading cause of deathApproximately 787,000 attempts, ratio 25:1Twice as many people die by suicide than by homicideThere are twice as many deaths in the US from suicide than HIV/AIDS.Based on these numbers, 7 people in the US will die by suicide while we are in this forum this morning.Homicide- 15th leading cause of deathA person is nearly twice as likely to die by suicide than by homicide in the United States.2Worldwide, more people die from suicide than from all homicides and wars combined. (WHO)
11Statistics (2003) (CDC) Number Per Day* Rate % of Deaths Group (Number of Suicides)Nation31,48486.310.81.3White Male (22,830)19.5Males25,20369.017.62.1White Female (5,655)4.7Females6,28126.96.36.199Nonwhite Male (2,373)9.1Whites28,48578.012.11.4Nonwhite Female (626)2.2Nonwhites2,99188.8.131.52Black Male (1,597)8.8Blacks1,95184.108.40.206Black Female (358)1.8Elderly (65+ yrs.)5,24814.414.60.3Hispanic (2,007)5.0Young (15-24 yrs.)3,98810.99.711.9Native American (322)10.4Asian/Pacific Islander (722)a slight decline from 2002 was seen in 2003, but continues a pattern primarily of stability or slight decline in recent yearsFrom John L. McIntosh, Ph.D.Associate Dean, College of Liberal Arts and Sciences & Professor of Psychology
12LITHUANIA 2003- Males,74.3 Females,13.9 From WHOLITHUANIA Males,74.3 Females,13.9RUSSIAN FEDERATION Males,69.3 Females,11.9CANADA 2001 Males,18.7 Females,5.2CHINA (Selected rural & urban areas) CHINA (Hong Kong SAR)UNITED STATES OF AMERICA 2001 Males,17.6 Females,4.1UNITED KINGDOM 2002 Males,10.8 Females,3.1Among countries reporting suicide, the highest rates are found in Eastern Europe and the lowest are found mostly in Latin America, in Muslim countries and in a few of the Asian countries. There is little information on suicide from African countries. There are estimated to be times the number of deaths in failed suicide attempts, resulting in injury, hospitilization, emotional and mental trauma, although no reliable data is available on its full extent. Rates tend to increase with age, but there has recently been an alarming increase in suicidal behaviours amongst young people aged 15 to 25 years, worldwide. With the exception of rural China, more men than women commit suicide, although in most places more women than men attempt suicide. (WHO)To put these #s into perspective, more people die by suicide than in all of the armed conflicts around the world. In many places, the rate is about the same or more than those dying in traffic accidents. In all countries, suicide is now one of the leading causes of death in yr olds. (WHO, 1999)
13State by State Rate Comparisons Highest rates are in the western states, specifically mountain states:Wyoming, Montana, Nevada, Alaska, New Mexico, Oregon, Colorado, Idaho, Arizona
14Firearms are the Leading Method of Suicide (2003) Suicide Methods:NumberRatePercent of TotalFirearm suicides16,9075.853.7%All but Firearms14,5775.046.3%Suffocation/Hanging6,6352.321.1%Poisoning5,4621.917.3%Cut/Pierce5710.21.8%Drowning3390.11.2%
15Data on Means of Suicide (2001) Comments- missing methods?MVAsWalking into trafficSuicide by cop
16Youth Suicide Rates3rd leading cause of death in those aged 15-24, behind only accidents and homicide.2nd leading cause of death in college students.6th leading cause of death in 5-14 year olds.Ratios of attempts to completions estimated to range between 100:1 to 200:1In 2001, firearms were used in 54% of youth suicides.More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic disease, combined .King, 2004 Before the Subcommittee on Substance Abuse and Mental Health Services U.S. Senate Committee on Health, Education, Labor and Pensions Hearing on “Suicide Prevention and Youth: Saving Lives”
17Youth SuicideIn 1999, 20% of HS students reported seriously considering suicide and 8% attempted.Frequent drug and alcohol abuse was found to be the most common characteristic in young people who attempted suicide (Department of Education)The mean proportion of adolescents reporting they had attempted suicide at some point in their lives was 9.7% (95% CI, ), and 29.9% (95% CI, ) of adolescents said they had thought about suicide at some point. Females were significantly more likely than males to report most suicidal phenomena. Evans et al (2005)
18Youth Statistics (2003) Age Group Number of Suicides Suicide Rate 10-14 yrs2441.215-19 yrs1,4877.320-24 yrs2,50112.1
19Suicide in the Elderly Higher Completion rates (1:4) over age 65. Medical illness a significant factor in 70% of suicides over age 70.Most saw a physician within a few months of their death and 1/3 within the previous week.Rate of suicide is 14.8 per 100,000 when compared to 10.8 per 100,000 in general population.Older white males: 32/100,000.Over age 85: 51.4/100,000
20Male Suicide Rates 8th leading cause of death (2003) 4 times more likely to die by suicide than females60% of suicides involve the use of a firearmRates are relatively constant between ages 20-64, but increase sharply after age 65.
21Female Suicide RatesWomen attempt suicide twice as often as men. Some studies suggest the rate is closer to 3:1.One woman attempts suicide every 78 seconds in the U.S.Rates peak between the ages of (around time of menopause) and again after age 75.
23Breakdown by RaceCaucasians are over 2x more likely to complete suicide than African Americans (AA).AA males comprised 84% of suicide deaths in that racial group.Firearms predominant method among AAs, regardless of gender.American Indian and Alaskan native men have the 2nd highest rate of suicide after Caucasians.
27Familial and Genetic Factors There is a transmission of familial and genetic factors that contribute to risk for suicidal behavior.Major psychiatric illnesses, such as MDD, schizophrenia, and alcoholism have genetic component in etiology.The relationship between suicide and family history is complicated and not fully understood.People with a parent, sibling or child who has died by suicide have a six-fold increased risk of doing the same.However, it is important to remember that most people who have had a close relative die by suicide do not attempt to kill themselves.Having a supportive family can protect people from suicide and self-harm.9Centers for Disease Control and Prevention (n.d.) Suicide Fact Sheet. CDC
28Familial and Genetic Factors Several studies have found genetic and familial transmission risk is independent of transmission of psychiatric illness.First degree relatives of individuals (including dizygotic twins) who have completed suicide have more than 2x the risk of the general population.For monozygotic twins, risk increases to 11x. (Quin, Agenbo, & Mortensen, 2002)Recent study could not find genetic effect on suicidal ideation. (Farmer et al, 2001)
29Studies on the Serotonergic System Difficult area to study, numerous methodological problems.There is evidence of modest reductions in in brain stem/prefrontal cortex serotonin or its marker 5-HIAA (metabolite).Lower CSF (cerebral spinal fluid) 5-HIAA levels has been reported by most studies in patients with a history of suicide attempt and a diagnosis of MDD, Schizophrenia, or PD compared to control groups of patients with these diagnoses.Another team member, neuroscientist Mark Underwood (ph), is looking at a different part of the brains of suicide victims, at the back, an area called the brain stem. Enlisting the power of the computer, Underwood counts the number of serotonin nerve cells. There too, the serotonin system looks faulty.MARK UNDERWOOD, NEUROSCIENTIST, NEW YORK STATE PSYCHIATRIC INSTITUTE: We have found hat there are approximately 30 percent more of these serotonin neurons in the suicide victims than in the controls. To find more neurons would suggest something very fundamental, such that you may in fact be born with your biological risk for suicide behavior.That's because you're born will all the neurons you'll ever have, and not only are there more serotonin neurons in the brain stem than there should be, but, they're smaller, and they don't work right.serotonin dysregulation is associated with suicidality regardless of psychiatric disorder, suggesting that it may be a biological trait that predisposes someone with a mental illness to suicide.King, 2004
30Serotonergic system, continued Low CSF 5-HIAA level predicts higher rate of past and future suicidal acts as well as seriousness of suicidal acts over the lifetime.PET scans can map serotonin-induced changes in brain activity.Size of abnormality in anterior cingulate and prefrontal cortex is proportional to lethality.(Oquendo et al., 2003)Arango (1998) has discovered a malfunction in the pre-frontal cortex, the place where executive decisions are made dictating what feelings we will act upon and what feelings we will inhibit.there is an area of abnormality that distinguished depressed suicide attempters. “The size of the abnormality is proportional to the suicidal intent and thereby enforces suicidal lethality. The more lethal the suicidal behavior, the less activity we found in the anterior cingulate and in the lateral prefrontal cortex. area of the brain right above the eyes. On the other hand, activity was higher when impulsivity was higher. These particular brain changes explain how intent and impulsiveness determine how lethal suicidal behavior is,”
31Noradrenergic SystemReduced noradrenergic functioning is suggested, however the evidence is not as strong as in the serotonergic system.The conclusion: there is a period of noradrenergic over-activity (which may be a stress response and state dependent) prior to suicide which contributes to NE depletion.Dopaminergic System: CSF and postmortem studies indicate involvement, but more research is required to confirm this.The conclusion: that best fits the bulk of the findings is that there is a period of noradrenergic over-activity (which may be a stress response and state dependent) prior to suicide which contributes to NE depletionThis may be due to increased stress response preceeding suicide resulting in excessive release of norephinephrine. (Mann, 2002)
32The Diathesis- Stress Model Proposed by Zubin and Spring (1977)An individual has unique biological, psychological and social elements. These elements include strengths and vulnerabilities for dealing with stress.In the diagram above person "a" has a very low vulnerability and consequently can withstand a huge amount of stress, however solitary confinement may stress the person so much that they experience psychotic symptoms. This is seen as a "normal" reaction. Person "b" in the diagram has a higher vulnerability, due to genetic predisposition for example. Person "c" also has genetic loading but also suffered the loss of mother before the age of 11 and was traumatically abused. Therefore persons "a" and "b" take more stress to become "ill".
34Beck’s Cognitive Model (1967) Schema: tacit beliefs and memory structures that serve to organize the encoding, retrieving, and processing of informationLatent much of the timeMay be activated by specific life eventsDevelop from an early ageReinforced and consolidated by life eventsSchema of depressed individuals thought to be rigid, negativistic toward self and others, future is bleak, lack control over outcomes.Contributes to cognitive vulnerability to depression and suicide
35Beck’s Cognitive Model, Continued Cognitive distortions most frequently associated with suicidal ideation:Cognitive constriction or tunnel visionPolarized or all or nothing thinkingSelective recall of past failure and overlooking past successThese are believed to play a role in development and maintenance of dysfunctional attitudes and irrational beliefs.Question: Are these simply co-occurring w/ depressed mood or unique and independent contribution to suicidal behavior?
37What is a Suicide Risk Assessment? “Refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail.”“More than a guess or intuition- it is a reasoned, inductive proceess.”“A necessary exercise in estimating probability over short periods.”From Jacobs, 2003
38Who should receive a suicide assessment? ANY patient who meets criteria for DSM-IV mental or substance use disorder(s).Should initially occur at the point of entry into treatment (i.e. initial visit or intake) and periodically as clinically indicated.If the patient meets criteria for a depressive disorder and/or manifests any degree of suicide lethality, they should be assessed each session.
39Two Components of Assessment PART 1:The elicitation and elaboration of suicidal ideationPART 2:The identification and qualification of risk factors for completed suicideUltimate judgment in suicidality must be made by the clinician in light of clinical data presented by the patient and information from outside sources.Am journal of psychiatry (1993)
40Part 1: Assessing Suicidal Ideation Begin with general questions about self-harm, such as asking whether the patient has had thoughts of death or suicide. Ask them to elaborate in their own words and describe what these thoughts are like. Use open ended questions.Thoughts should be characterized as active (“When I am walking, I get the impulse to jump out into traffic”) or passive (“Everyone would be better of if I was dead”).Asking patients about suicide will not give them the idea or the incentive to commit suicide. Most patients who consider suicide are ambivalent about the act and will feel relieved that the clinician is interested and willing to talk with them about their ideas and plans.6 Unfortunately, some patients are not so forthcoming about psychiatric symptoms or thoughts of suicide. In these cases, the clinician can make an introductory statement followed by specific questions (Table 3) such as: "Sometimes when people feel sad or depressed or have problems in their lives they think about suicide. Have you ever thought about suicide?"6,16,17 Some patients will make indirect statements suggesting suicidality (e.g., "I've had enough," "I'm a burden," or "It's not worth it."). These statements mandate follow-up with specific questions about suicidal intent.16,17
41Assessing Suicidal Ideation, Continued If suicidal thoughts are present, assess how often and in what context they occur.Are they fleeting, periodic, or persistent? Are the situation specific? Are they increasing or decreasing in intensity?Note: denied SI can be misleading in light of other evidence and/or risk factors. For example, in an NIMH study of 76 suicides of recently discharged inpatients, 77% expressed denial of SI in the last week. 28% had formal no-harm contracts. Busch et al, 2003
42Assessing Suicidal Ideation, Continued The patient should be asked if they have a plan, or if they have thought of a means in which they would use to carry out suicide.Method (availability, lethality)Suicide notes, final acts in preparation for death (i.e. will preparation)Has mental rehearsal taken place? Is there a plan for a time or place?Have any attempts been made thus far?Use of firearms is the most common method of suicide in both sexes.1 In men, the second most common method is hanging; in women, it is overdosing on medications.1Moscicki EK. Identification of suicide risk factors using epidemiologic studies. Psychiatr Clin North Am 1997;20:
43Assessing Suicidal Ideation, Continued History of similar thoughts, impulses, plans, aborted attempts and/or attempts should be obtained.Corroborating report from family or providers should be obtained (if possible).Aborted attempts, examples are putting gun to head, making noose, driving to the bridge, etc.Studies indicate that suicidal communications are most often made to family and/or significant others rather than to a health care professional.Patients who eventually commit suicide are more likely to tell their families of their suicidal plans than they are to tell their physicians.7 In patients who have denied suicidal ideation, the clinician should ask the family member if the patient has made direct or indirect statements about suicide to them. Nearly-lethal suicide attempters more often sought help from family and friends than from professionals. (CDC, 2002)7. Fawcett J, Clark DC, Busch KA. Assessing and treating the patient at risk for suicide. Psychiatr Ann 1993;23:
44Assessing Suicidal Ideation, Continued Confidentiality can legally be broken to obtain appropriate care if you have evidence to suggest the patient is acutely a danger to himself or others.Usually necessary information can be obtained by simply listening to the family members and it may not be necessary to reveal private or confidential information to the family.However, in some situations you may be obligated to break confidentiality to protect the patient. Remain sensitive to family issues and disclose necessary information to protect the patient.Helps to discuss this during informed consent at the beginning of the process.
45Assessing Suicidal Ideation, Continued Determine if there are any barriers to suicide.What are the patient’s reasons for living and reasons for dying?How has the patient managed to evade the act of suicide thus far?Assess level of current supports (family, significant other, friends, employer, therapist, etc.)This information should be obtained from the patient, rather than as a 3rd party observer.(i.e. You may look at a patient’s situation and think “She has her child to live for” but the patient may not see this as a deterrent to suicide.PERCIEVED barriers are what is importantDuring this evaluation, mood, affect, motor behavior, level of cooperation, thought organization- should all be assessed and documented.
47“Risk Factor” Defined Leading to or being associated with suicide Individuals possessing the risk factor are at greater potential for suicidal behaviorSome risk factors can be changed or reduced (i.e. providing Lithium treatment for Bipolar Disorder), others are static (The patient’s father completed suicide)From Suicide Prevention Resource Center,
48Presence of a mental disorder Present in over 90% of completed suicides.High risk diagnoses are:Depression (unipolar and bipolar)Alcohol/substance abuse or dependenceSchizophreniaBorderline Personality DisorderGENERAL RISK FACTORSBORDERLINE OR SOME REEARCH ALSO SAYS CLSUTER B PD:ANTISOCIAL,BORDERLINE,HISTRIONIC, NARCISSISTIC
49Co-morbidity increases risk! Psychological autopsy studies of 229 suicides:44% had 2 or more Axis I diagnoses31% had Axis I and Axis II diagnoses50% had Axis I and at least one Axis III diagnosis12% had an Axis I diagnosis with no co-morbidityFrom Henriksson et al, 1993
50Recent psychiatric hospitalization Within the last yearAcute exacerbation of illnessHighest risk within the first week of d/c
51The presence of depression Including hopelessness, guilt, lossGlobal insomniaNote: Hopelessness has been found to be co-occurring with depression as well as a predictor of suicidal ideation and behavior.Note- Young (1996) found trait, or baseline level of hopelessness predicts future suicide attempts, whereas incremental increase and total score did notHopelessness is a chronic AND acute risk factor
52Recent or impending loss Loss of jobLoss of relationshipLoss of loved one, griefRecent move (CDC, 2002)Humiliating events, such as financial ruin due to a scandal, being arrested or being fired, can lead to impulsive suicide (Hirschfeld and Davidson, 1998)Moving in the past 12 months was associated with an increased risk for a nearly lethal suicide attempt. Frequency of moving, distance moved, recency of move, and difficulty staying in touch were all factors that increased the likelihood of nearly lethal suicide attempts.CDC 2002
53Substance or alcohol use Up to 50% of those completing suicide drinking alcohol at time of death.Drinking within three hours of the attempt was the most important alcohol-related risk factor for nearly lethal suicide attempts, more important than alcoholism and binge drinking. (CDC, 2002)CNS depressants increase risk. (Wines et al, 2004)Murphy et al (1992)No unfying theory as to mechanism as to why etoh increases risk:Self-medicatingPredisposing biological or psychological factors are similarAmbivalently conceived self-destructive actDecreasing judgment and disinhibition, risk taking
54HistoryHistory of impulsive or dangerous behavior, and/or history of suicide attemptsSevere self-mutilationA history of serious suicide attempts may be the best single predictor of completed suicide; the greatest risk occurs within 3 months of the first attempt.HOWEVER, the majority of suicides are in individuals with no prior attempts.especially self destructive behavior;13. Moscicki EK. Identification of suicide risk factors using epidemiologic studies. Psychiatr Clin North Am 1997;20(3):14. Roy A. Suicide. In: Kaplan HI, Sadock BJ, eds. Kaplan and Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry. 8th ed. Baltimore: Williams & Wilkins, 1998:867-72Nearly 1 in 4 of those who made nearly lethal suicide attempts reported that less than 5 minutes passed between their decisions to attempt suicide and their actual attempts, indicating impulsive attempts.
55Access to firearms 92% of suicide attempts by firearm are successful Keeping firearms in the home increases the risk of suicide for both genders even after other factors, such as depression and alcohol use, are controlled for.Mosicki 1994Compared to 78% by CO2 and hanging67% by drowning23% by poisoning4% by cuttingMoscicki, 1995Brent 1991In a study by Connel, 1995, adults perceptions of medical personel’s advice via guns in the home was explored.47% would follow advice37 % would think it over6% would ignore or be offendedNo differences found in level of risk with respect to type of gun or whether weapon and ammunition were stored in separate places.
56Family history of suicide First degree relatives = more than 2x the risk of the general populationFor monozygotic twins, risk = 11x.Maris (1987) 11% of completed suicides had a first degree relative complete suicide, while none of the matched non-suicidal controls had such a family history.Tsang (1983) also shown genetic link for suicide in adult twins and increased rates in the relatives of suicide completers.
57Social isolation or withdrawal Having a strong preference for being alone (change from previous behavior)Withdrawing from family, social, or volunteer activitiesNot keeping appointmentsRecent moves- again a risk (CDC, 2002)4x higher in divorced than married people (Maris, 2002)
58Concurrent medical disorder Characterized by:chronicity,poor prognosis,disfigurementand/orpersistent pain.Young men with medical conditions were more than 4 times more likely to attempt suicide than those without such conditions.CDC, 2002Medical problems contributing in approx 70% of elder suicides.Harris & Barraclough (1994)Blumenthal 1990Brent and Kolko 1990
59Medical illness, continued Diagnoses most associated with completed suicide:Huntington’s ChoreaMalignant NeoplasmsMultiple SclerosisRenal diseasePeptic UlcersSpinal Cord injuriesLupusHIV/AIDSEpilepsy (only medical diagnosis documented to increase risk in children and adolescents)IT IS NOT CLEAR WHETHER THESE MEDICAL DIAGNOSES (ASIDE FROM EPILEPSY) ARE INDEPENDENT RISK FACTORS OR INCREASE RISK DUE TO HIGH PREVALNCE OF CO-MORBID PSYCHIATRIC DX. (MOSCICKI 1997)Epilepsy in children (Brent 1996)- not clear if association is due to underlying brain pathology, medical stress, other unk factors, or a combination of the aformentionedHIV/AIDS: Rates vary…in 1988 Marzuk et al found rate 36x general pop. In young men w/ AIDS. New treatments, less stigma currently, risk has declined.2 periods of high risk1. Directly after diagnosis is made- panic guilt hopelessness helplessness2. Later in course of illness with CNS complications (delirium/dementia)
60Severe agitation/anxiety Panic attacks, severe psychic anxiety, and global insomnia all significantly associated with suicide at one year follow up. (NIMH)Behavioral signs: pacing, wringing hands, rocking, severe restlessness, etc.Assess for treatment responsive acute risk factors, such as askathsia.Akathisia is a common and unpleasant side effect of many psychotropic medications. consequences for the patient include reduced compliance, exacerbation of psychotic symptoms and an increased risk of suicide and violence. The word akathisia comes from the Greek meaning literally “not to sit’ and was initially used by Haskovec in 1921 to refer to restless patients with hysteria and neurasthenia. Akathisia is a relatively common side effect of antipsychotic medication, although other drugs including antidepressants, metoclopramide, some calcium channel blockers, dopamine agonists, amphetamine and buspirone have all been shown to cause it. The symptoms consist of objective and subjective components. Subjectively there are symptoms of dysphoria including tension, panic, irritability and impatience2 and objectively there are movements usually taking the form of shuffling of feet while sitting and pacing or rocking while standing. Fidgety leg movements may occur while lying down.3 The differential diagnosis includes agitation secondary to psychotic symptoms, the restless legs syndrome, anxiety, drug withdrawal states and a number of neurological disorders. (Nelson, 2001)
62Depression: Unipolar and Bipolar The lifetime risk for suicide in patients with mood disorders (major depressive disorder and bipolar disorder) is approximately 15-19%, and the risk is highest in the early stages of the illness.11. Hawton K. Assessment of suicide risk. Br J Psychiatry 1987;150:DSM-IV TR (15% for MDD)Jacobs 2003
63Major Depression Factors to consider: The concurrent presence of anxietySubstance abuse or dependenceCommand hallucinationsIrritability or anger associated with impulsivitySevere insomnia, especially global insomniaPresence of or access to a gun(Jones et al, 2000)Comorbid anxiety d/o diagnosis, agitation, turmoil/perturbation, akathisia (inner agitation, motor restlessness- can occur alone or as a side effect of medication)Contributes to poor judgment, disinhibition, impulsivityMay be found in psychotic states and are thought to increase risk, though this has not been proven conclusivelyMay be prone to self-destructive actionAlong with states of hopelessness this may increase risk and should be treated immediatelyShould be inquired about routinely, more than ½ suicides are committed w/ handguns, esp. elderly and adolescents
64Bipolar Disorder (Goodwin & Jamison, 1990) Risks:Severe depression with anxiety, agitationGlobal insomniaSubstance abuseTransition periods/early recovery phaseImpulsive or violent behavior
65Bipolar Disorder, continued Assess current mood:Typically rates < 2% during psychotic mania (Dilsaver, 1997)11% directly after remission from mania (Goodwin, 2002)Approximately 79% during major depressive episode (Goodwin, 2002)11% during mixed state (Goodwin, 2002)
66Alcohol/Substance Abuse or Dependence The suicide risk among patients suffering from alcoholism is similar to that in patients with mood disorders, but they tend to commit suicide late in the course of alcoholism and are frequently depressed at the time of death.Two factors affecting risk (Weiss & Hufford, 1999)Effects of acute intoxicationCo-morbid psychopathology such as MDDRisk with recent or anticipated interpersonal lossLate in the course of illness, I.e. 2nd or 3rd decade (HRM 1996)11. Hawton K. Assessment of suicide risk. Br J Psychiatry 1987;150:10x more reseach on ETOH than any other substance (maris 2002)Roy (1986) Estimates 18% of alcoholics will die by suicide, mean age 47 – mean length of alcoholism 25 yrsComorbis depressive disorder greatly increases risk 70-80% (Moscicki, 2001)
67Schizophrenia (Tsuang, Fleming, & Simpson, 1999) Risk Factors for suicide in psychotic patients:Young age (<30)#1 cause of death for young people Dx with SchizophreniaGood intellectual functioningDisillusion with treatmentGood premorbid functioningEarly stage of illnessCommunication of intentFrequent exacerbations and remissionsPainful awareness of the likely degree of chronic disability in the futurePeriods of clinical improvement following relapseSupervention of a depressive episode and increased hopelessness20-40% of those diagnosed with Schizophrenia attempt at least once.Bongar (1992)Paranoid subtype has greatest risk (Fenton et al 1997) up to 8x other typesNegative or deficit symptoms associated with lower riskAmador et al 1996-Awareness of delusions (moderate to severe) asociality, and anhedonia were associates with suicidality. Interestingly, awareness of hallucinations or dx of thought d/o was not predictive.
68Timeline of RiskThe risk is most elevated in the month following D/C and about ½ of all post D/C suicides occur in the week following D/C. (All Dx post D/C)Appleby et al 1999Ho, 2003
69Borderline Personality Disorder Most likely associated with parasuicidal rather than suicidal acts:HOWEVER approximately 8.5% of patients eventually commit suicide, usually after multiple attempts or gestures.Nearly 75% of patients make one attempt in lifetime.With alcohol problems=19%Per Stone (1993) with alcohol + major affective D/O=38%Usually qualify for a co-morbid Axis I diagnosis at the time of death.Hx of childhood sexual abuse increases the amount and lethality of parasuicidal behaviors.67-76% have made at least one attempt. 43% at least one attempt with high medical lethality.(Isometsa et al, 1996)(Soloff et al 1994)(Wagner & Linehan, 1994)Solof et al 1994Zosook et al 1994Behaviors often seen as “in your face”- such as threats, freq. gestures. Interestingly, a study by Runeson, Beskow, and Waern (1996) found that 44% of suicides completed by pt dx w/ BPD were witnessed, while the rate is 17% for other diagnoses combined.Stone, 1993
70Identify Chronic vs. Acute Risk New, acute presentationPresence of significant stressorEmergent response to acute crisis of mood and despairPossible co-morbid Axis I disorderChronic:Recurrent and persistent suicidal thoughts that provide an ongoing psychological mechanism for coping with distressFrequent, usual response to life stresses and disappointmentsPatient may be aware of chronicityIn the absence of confirmation of current presentation as part of a chronic or repetitive pattern or with absence of historical data and or unavailability of treating providers- risk should be assumed to be ACUTEHarvard Risk management Foundation, 2003A study of 81 inpatients with Borderline personality disorder compared the suicide histories with 77 age-matched patients with major depression alone. No statistically significant difference in characteristics of suicide histories or risk was found between the groups, including lifetime number of attempts, degree of lethal intent, objective planning, medical damage, or degree of violence in the suicide methods. Borderline patients with co-morbid major depression had the highest suicide histories. A similar study found higher levels of suicidal intent among borderline patients compared to depressed patients without personality disorder.Soloff PH, Lynch KG, Kelly TM, et al. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry 2000; 157:Cheng AT, Mann AH, Chan KA. Personality disorder and suicide: a case-control study. Br J Psychiatry 1997; 170:
71Protective FactorsProtective factors are believed to enhance resilience and serve to counterbalance risk factors.An individual's genetic/neurobiological make-upAttitudinal/behavioral characteristicsFamily/community supportEffective and appropriate clinical care for mental, physical and substance abuse disordersPregnancy or children in the home, except for post-partum illnessU.S. Public Health Service (2001). National strategy for suicide prevention: Goals and objectives for action. Rockville, MD: U.S. Department of Health and Human Services, PHS.Jacobs, 2003
72Protective Factors, continued Easy access to effective clinical interventions and supportRestricted access to highly lethal methods of suicideCultural and religious beliefs that discourage suicide and support self-preservation instinctsSupport from ongoing medical/mental health care , positive therapeutic relationshipAcquisition of learned skills for problem solving, conflict resolution and non-violent management of disputes.
73Prevention and Treatment Strategies Therapeutic Treatment StrategiesNo Suicide ContractsPharmcotherapyHospitalization
74Prevention/Treatment Strategies ASSESS, ASSESS, ASSESSAssess acute vs. chronic risk24 hour access to crisis careStrong therapeutic alliance is ESSENTIAL!Work with family and other support systemsUse multiple resources, multidisciplinary approach
75Access to Services Crisis services by phone 1(800) 273-TALK National Hotline1(800) 273-TALKEmergency DepartmentNational hotline funded by federal gov’t. Will direct patients to local suicide resources and crisis centers
76Prevention/Treatment Strategies Short term coping strategies, behavioral treatmentsDeep breathingRelaxation trainingImagery trainingGroundingSpecific, concrete, written safety plan in place and frequently renewed and reviewedAccess to means removed immediatelyIntervention will need to be tailored to patient- think of risk to resources ratio- i.e. the higher the risk and lower the resources, the more intervention is required. Low risk high resource patients probably require less intervention. Beardslee & Goldman 1999DBT: Developed specifically for chronically suicidal individuals
77Dialectical Behavioral Therapy (Linehan, 1993) Developed by Linehan for patients Dx w/ BPD and engaging in self-harm behaviorsPhilosophical orientation focuses on dialecticsMove from dichotomous thinking to balancePatients learn to observe and describe, be non-judgmental and focus on the present, and focus on current activity
78What is a no-suicide contract? Also known as no-harm contract or safety contract.Involves an agreement in which a patient makes a verbal or written promise not to harm or kill themselves.Commonly used by mental health practitioners, including: psychiatrists, psychologists, nurses, social workers, and therapists.Originally used as a tool in established therapeutic relationships to assess risk and allow the patient to participate in treatment planning.
79No-Suicide Contracts Usually Contain An explicit statement not to harm or kill oneself.A specific duration of time.Contingency plans if contract conditions cannot be kept.i.e. contacting the therapist via emergency number, presenting to ER/calling 911, or calling a crisis line such as 627-LIFE.
81When the patient doesn’t agree…. No Suicide ContractsWhen the patient doesn’t agree….If the patient can not or will not agree to the terms of the negotiated contract or if non-verbal/historical cues contradict the agreement, he/she is usually considered to be at- risk.In the presence of a strong therapeutic alliance when manipulative behavior is suspected, this should be further explored.In the absence of such an alliance or knowledge of the patient, the risk must be taken seriously and appropriate action taken.
82History of NSCsFirst documentation in 1973 in study by Drye, Goulding, & Goulding.Surveyed 31 counselors reporting on 609 patients, 266 of whom were judged “seriously suicidal”. 24 suicides or serious attempts were reported where their method for assessment was NOT used and 4 deaths occurred where their method was used.Method= When counselor became aware of SI, asked client to repeat, “No matter what happens, I will not kill myself, accidentally or on purpose, at any time” (p.172) Then client discussed his/her reaction to the statement.Objections or alterations were deemed at risk.STUDY HAD SERIOUS FLAWS, WIDELY CRITICIZED FOR POOR RELIABILITY/VALIDITY, little info on selection criteria, details of study such as length, etc.NSCs DESIGNED AS ASSESSMENT TOOL< NOT AS RISK MANAGEMENT OR STAND ALONE PREVENTION TOOL
84Pitfall #1BELIEVING THAT A SIGNED SUICIDE CONTRACT ELIMINATES SUICIDE RISKSuicide cannot be absolutely predicted- False sense of security.There is no data demonstrating its effectiveness or its acceptance in the professional community. (Drew, 2001)In one study, 41 percent of psychiatrists had patients who committed suicide or made serious attempts after entering into a NSC. (Kroll, 2000)An APA study (2003) found almost all patients in treatment at the time of their suicide completions or attempts had no harm contracts in place at the time of the act.Psychiatrists in practice for longer periods of time were less likely than younger colleagues to contract with their patients for safety.
85Pitfall #2CONTRACT: THE LEGAL TERMClinicians may wish to consider avoiding the word “contract” in their medical documentation.The term may also appear to attempt to free the clinician from blame for suicide attempts/completions.Appropriate clinical assessment and intervention, rather than liability prevention, should be the focus of care.Outcomes of legal cases and judgments about clinician’s care are improved by demonstration of comprehensive assessment and treatment.The word “contract” is a legal term and implies exchange of goods.
86Pitfall #3 INFORMED CONSENT??? Informed consent is a legal and ethical doctrine involving the disclosure of risks, alternatives, and facts that allow a patient to make informed and unpressured decisions about treatment options.The competency of a patient to understand what they are signing or to give informed consent to such an agreement during a time of crisis is in question.
87Who may or may not be capable of giving informed consent? DiagnosisCited in…Cerebral ImpairmentDrye et al (1973)PsychosisGoulding (1979)Egan (1997)Under the influence of drugs/alcoholImpulse control deficienciesDavidson et al (1995)Motto (1979)Severe DepressionSimon (1999)Again, clinical judgment is to be used--that is, the patient's agreement to the contract should not be given credence if the patient is intoxicated or psychotic, made a serious suicide attempt in the recent past or is so depressed that he or she cannot comprehend the terms of the contract.
88Informed Consent: Farrow & O’Brien (2003) VERY limited data in this areaTheir study concluded that most patients interviewed were not able to participate in informed consent for a NSC at the time of suicidal crisis.In retrospect, most subjects doubted their competence to enter a NSC at the time of crisis. “My thinking was so confused. I did not understand what they were suggesting.”Participants reported a strong sense of being coerced by clinician.Suggest that paradoxically, persons who are most at risk for suicide and with whom an NSC may be considered are less likely to be truly competent to enter a NSC; while low risk individuals who are probably competent are less likely to need a NSC.
89Pitfall #4 A safeguard against liability??? A NSC may be used as a means to reduce the evaluator or therapist’s anxiety regarding litigation.Frequently charted phrases or shorthand such as “contracted for safety” should be avoided without appropriate ancillary documentation (suicide risk assessment, basis for clinical judgment, plan for managing risk.)Providers may believe that securing a NSC completes an assessment of suicidality, this is short sighted and legally precarious.Range et al, 2000, Stanford et al, 1994, Weiss, 2001, Miller, 1999, Miller et al, 1998, Lee & Bartlett, 2005
91Benefits A means of evaluating current suicidality One part of a comprehensive suicide risk evaluation.Opportunity to discuss suicidal feelings directly.Provision of specific behavioral alternatives to suicidal acts.Written behavioral plan for patient in a crisis situationAn adjunct to comprehensive evaluation and treatmentIn the context of a sound and positive therapeutic relationshipThe more concrete, the better! (i.e. written vs. oral, specific behavioral strategies tailored to the patient’s needs)Also, if in context of sound relationship, shows concern and that this is being taken seriously.Common goal to keep client safe
92Bottom line about NSCsUse NSCs with caution, understanding that they are one part of a comprehensive suicide risk assessment and treatment plan and have not been demonstrated in the literature to reduce suicide risk.Jacobs 2003
93PharmcotherapyThere are reasons to believe that selective serotonin reuptake inhibitors (SSRIs) might reduce suicidality.SSRIs remain the preferred psychopharmacological treatment for depression.Lithium has a strong, and possibly unique protective effect against suicidal acts in patients with bipolar disorder. (Baldessarini & Tondo, 1999)because of their potential to reduce irritability, affective response to stress, hypersensitivity, depression and anxiety.Including young adult depressionThe use of medications should always be considered when developing a comprehensive treatment plan for patients with a major depressive disorder, or when a patient expresses suicidal ideation, intent or plans. Refer to psychiatryMalone 1997Molcho & Stanley (2002)The SSRI antidepressant medications carry the specific benefit of having low lethality in overdose.Lambert 2003Disadvantages of lithium- blood levels, contraindicated in pregnant womenIn metaanalysis involving over 16, 200 pts, found 7 fold decrease in risk in pts on lithium maintenance vs mood altering substances other than lithium.Baldessarini and Tondo, 1999Fatalities have been shown to increase after discontinuing lithium-May be cumulative benefits of long term lithium maintenance, as risk was highest during first 3 years and steady afterwards
94PharmcotherapyPatients being treated with psychotropic medication should be closely observed for clinical worsening:Agitation, irritability, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.Monitoring should include daily observation by families/caregivers alerted as to potential side effects and notified when to contact the physician. Should include frequent contact with providers.It is also recommended that prescriptions for antidepressants be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.Psychotropic drug treatment is not a cure for suicidality, but one part of a comprehensive treatment program.Tricyclics: Contrindicated in patients with plan or history of overdosing, as they are LETHAL in overdose. (Kapur et al 1992)AmitriptylineAmoxapineClomipramineDesipramineDoxepinImipramineNortriptylineNote: Tylenol also highly lethal
97LitigationBereaved survivors have a unique grief, often feeling hurt, angry, and possibly guilty.May seek compensation for their loss through a claim of negligence.Number of lawsuits continues to rise.Hospitals are the primary target, however there has been an increase in number of claims against outpatient providers.Lee & Bartlett (2005)
98A Shift in the Law (Gutheil, 2000) Before 1940: Suicide was considered an independent intervening cause of deathAfter 1940: But for the provider or physician’s negligence, the patient would not have committed suicide (negligence as a proximate cause)
99Medical-legal Concerns The law recognizes that there are no standards for the prediction of suicide and that suicide results from a complicated array of factors.The standard of care for patients with suicidality is based on the concept of "foreseeability"Courts assume that a suicide is preventable if it is foreseeable.which includes the reasonable ability of the provider to take a thorough history, to recognize relevant risk factors and to design and implement a treatment plan that provides precautions against completed suicide.
100Medical- Legal Concerns (Lee & Bartlett, 2005) Forseeability is defined as “A comprehensive and reasonable assessment of risk”Reasonable care involves “Developing a comprehensive treatment plan and timely implementation based on the assessment of risk, or forseeability”Failure to assess risk and make sound judgments makes the provider a possible target of litigation.
101Risk ManagementRealistically, a clinician is not always able to prevent a suicide in a determined patient.Common themes identified in liability suits include:lack of an ongoing, documented assessment of suicide risk, especially prior to hospital discharge, a change in privileges, or a change in clinical status,lack of documentation to reflect a clinical rationale regarding treatment decisions, andinadequate patient supervision.Harvard risk Management Foundation (2003)
102DocumentationIn the case of a lawsuit, the chart will be examined.Although most lawsuits arise over inpatients who commit suicide, documentation of encounters with all suicidal patients should include:Risk assessmentContacts with family membersContacts with other treatment providersPhone calls, lettersResponses to failed appointmentsNon-compliance with treatmentto determine whether the provider recognized the risk factors and considered the benefits of exerting greater control over the patient (e.g., hospitalization, calling the family).Patients with a plan, access to a lethal means, recent social stressors and evidence of a psychiatric disorder should be hospitalized.Collaboration/consultation with other providers or qualified colleagues are elements of good treatment and risk management.
103Risk Management: Key Points (Lee & Bartlett, 2005) Keep abreast of current legal and ethical standardsDevelop and implement a policy for handling crisis situations24 hour availability of servicesIncreasing frequency or duration of sessionsBring in supportive family/friendsRefer where appropriate for multidisciplinary TxFollow up for compliance and dispositionMonitor medication allocation, access, and useEstablish check-in system with the client24 hour coverage includes vacation/holiday periods!
104Risk Management: Key Points (Lee & Bartlett, 2005) Maintain clinical competency (continuing education, supervision, consultation)Ensure accurate and thorough documentationDevelop relevant resources, such as a network to consult with, community programs, etc.
105Postvention Immediately provide support to the family Consider attending funeral or writing letter of condolenceServes both humanitarian and risk management goalsCare for yourselfUnderstand your feelings (guilt, grief, anger, fear, etc.)Discuss/consult/debrief with trusted colleague or supervisorFamily will likely need intervention, high rates of complicated grief, depression, PTSD especially if they were initial person on sceneMay need opportunity to tell their story multiple times and grapple with situation (Goldman & Beardslee, 1999)
106Provider self-careCaring for suicidal patients can be very taxing- emotionally and physically!Remember to care for yourself:Eat a balanced nutritional diet, get adequate sleep, exerciseSeek personal counseling formally or informallyConsult appropriately with colleagues and supervisorsMay wish to share personal emotional reactions, burnout, and counter-transference issues (Shea, 2002)