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Assessment and Management of Suicide Risk May 24, 2007

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1 Assessment and Management of Suicide Risk May 24, 2007
Melissa J. Pence, Psy.D. Licensed Clinical Psychologist Hampton Roads Neuropsychology and Behavioral Medicine

2 Outline Impact Demographics and epidemiology Etiology Risk assessment
Psychological Testing Treatment and prevention Medical-legal concerns Begin 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.

3 A 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

4 Survivors 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 2003 If there is a suicide every 16.7 minutes, then there are 6 new survivors every 16.7 minutes as well Based 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)

5 Suicide Definition 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 Durkheim Requires: Death/lethal outcome Self-inflicted Intentionally inflicted Awareness or consciousness of outcome CDC 1998 Requires judgment based on implicit or explicit evidence; when evidence is not present- certification of accidental death or death of unk cause De Leo 2004

6 Problems in studying suicide
Low base rate No test (biological or psychological) or clinical marker that predicts suicide Requires clinical judgment Numerous false positives in prediction paradigms High risk suicidal patients excluded from most clinical studies

7 Demographics and Epidemiology
A MAJOR Public Health Problem!

8 How is this data gathered?
Death certificate information reported by each state to the National Center for Health Statistics Most recent national data available is 2003 Numbers are generally understood to be a modest underestimation of actual suicide deaths due to difficulties in conclusively determining cause of death Epidemiology 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

9 U.S. National Statistics (2003) (CDC)
31,484 deaths by suicide 86 deaths per day 1 every 17 minutes 11th leading cause of death Approximately 787,000 attempts, ratio 25:1 Twice as many people die by suicide than by homicide There 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 death A person is nearly twice as likely to die by suicide than by homicide in the United States.2 Worldwide, more people die from suicide than from all homicides and wars combined. (WHO)


11 Statistics (2003) (CDC) Number Per Day* Rate % of Deaths
Group (Number of Suicides) Nation 31,484 86.3 10.8 1.3 White Male (22,830) 19.5 Males 25,203 69.0 17.6 2.1 White Female (5,655) 4.7 Females 6,281 17.2 4.3 0.5 Nonwhite Male (2,373) 9.1 Whites 28,485 78.0 12.1 1.4 Nonwhite Female (626) 2.2 Nonwhites 2,999 8.2 5.5 0.9 Black Male (1,597) 8.8 Blacks 1,955 5.4 5.1 0.7 Black Female (358) 1.8 Elderly (65+ yrs.) 5,248 14.4 14.6 0.3 Hispanic (2,007) 5.0 Young (15-24 yrs.) 3,988 10.9 9.7 11.9 Native American (322) 10.4 Asian/Pacific Islander (722) a slight decline from 2002 was seen in 2003, but continues a pattern primarily of stability or slight decline in recent years From John L. McIntosh, Ph.D.Associate Dean, College of Liberal Arts and Sciences & Professor of Psychology

12 LITHUANIA 2003- Males,74.3 Females,13.9
                                                                                                                                                    From WHO LITHUANIA Males,74.3 Females,13.9 RUSSIAN FEDERATION Males,69.3 Females,11.9 CANADA 2001 Males,18.7 Females,5.2 CHINA (Selected rural & urban areas) CHINA (Hong Kong SAR) UNITED STATES OF AMERICA 2001 Males,17.6 Females,4.1 UNITED KINGDOM 2002 Males,10.8 Females,3.1 Among 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)

13 State by State Rate Comparisons
Highest rates are in the western states, specifically mountain states: Wyoming, Montana, Nevada, Alaska, New Mexico, Oregon, Colorado, Idaho, Arizona

14 Firearms are the Leading Method of Suicide (2003)
Suicide Methods: Number Rate Percent of Total Firearm suicides 16,907 5.8 53.7% All but Firearms 14,577 5.0 46.3% Suffocation/Hanging 6,635 2.3 21.1% Poisoning 5,462 1.9 17.3% Cut/Pierce 571 0.2 1.8% Drowning 339 0.1 1.2%

15 Data on Means of Suicide (2001)
Comments- missing methods? MVAs Walking into traffic Suicide by cop

16 Youth Suicide Rates 3rd 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 200:1 In 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”

17 Youth Suicide In 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)

18 Youth Statistics (2003) Age Group Number of Suicides Suicide Rate
10-14 yrs 244 1.2 15-19 yrs 1,487 7.3 20-24 yrs 2,501 12.1

19 Suicide 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

20 Male Suicide Rates 8th leading cause of death (2003)
4 times more likely to die by suicide than females 60% of suicides involve the use of a firearm Rates are relatively constant between ages 20-64, but increase sharply after age 65.

21 Female Suicide Rates Women 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.


23 Breakdown by Race Caucasians 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.


25 Etiology


27 Familial 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.9 Centers for Disease Control and Prevention (n.d.) Suicide Fact Sheet. CDC

28 Familial 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)

29 Studies 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

30 Serotonergic 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,”

31 Noradrenergic System Reduced 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 depletion This may be due to increased stress response preceeding suicide resulting in excessive release of norephinephrine. (Mann, 2002)

32 The 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".

33 The Diathesis-Stress Model

34 Beck’s Cognitive Model (1967)
Schema: tacit beliefs and memory structures that serve to organize the encoding, retrieving, and processing of information Latent much of the time May be activated by specific life events Develop from an early age Reinforced and consolidated by life events Schema 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

35 Beck’s Cognitive Model, Continued
Cognitive distortions most frequently associated with suicidal ideation: Cognitive constriction or tunnel vision Polarized or all or nothing thinking Selective recall of past failure and overlooking past success These 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?


37 What 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

38 Who 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.

39 Two Components of Assessment
PART 1: The elicitation and elaboration of suicidal ideation PART 2: The identification and qualification of risk factors for completed suicide Ultimate 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)

40 Part 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

41 Assessing 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

42 Assessing 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.1 Moscicki EK. Identification of suicide risk factors using epidemiologic studies. Psychiatr Clin North Am 1997;20:

43 Assessing 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:

44 Assessing 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.

45 Assessing 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 important During this evaluation, mood, affect, motor behavior, level of cooperation, thought organization- should all be assessed and documented.

46 Part 2: Assessing Risk Factors

47 “Risk Factor” Defined Leading to or being associated with suicide
Individuals possessing the risk factor are at greater potential for suicidal behavior Some 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,

48 Presence of a mental disorder
Present in over 90% of completed suicides. High risk diagnoses are: Depression (unipolar and bipolar) Alcohol/substance abuse or dependence Schizophrenia Borderline Personality Disorder GENERAL RISK FACTORS BORDERLINE OR SOME REEARCH ALSO SAYS CLSUTER B PD: ANTISOCIAL,BORDERLINE,HISTRIONIC, NARCISSISTIC

49 Co-morbidity increases risk!
Psychological autopsy studies of 229 suicides: 44% had 2 or more Axis I diagnoses 31% had Axis I and Axis II diagnoses 50% had Axis I and at least one Axis III diagnosis 12% had an Axis I diagnosis with no co-morbidity From Henriksson et al, 1993

50 Recent psychiatric hospitalization
Within the last year Acute exacerbation of illness Highest risk within the first week of d/c

51 The presence of depression
Including hopelessness, guilt, loss Global insomnia Note: 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 not Hopelessness is a chronic AND acute risk factor

52 Recent or impending loss
Loss of job Loss of relationship Loss of loved one, grief Recent 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

53 Substance 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-medicating Predisposing biological or psychological factors are similar Ambivalently conceived self-destructive act Decreasing judgment and disinhibition, risk taking

54 History History of impulsive or dangerous behavior, and/or history of suicide attempts Severe self-mutilation A 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, 1998:867-72 Nearly 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.

55 Access 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 1994 Compared to 78% by CO2 and hanging 67% by drowning 23% by poisoning 4% by cutting Moscicki, 1995 Brent 1991 In a study by Connel, 1995, adults perceptions of medical personel’s advice via guns in the home was explored. 47% would follow advice 37 % would think it over 6% would ignore or be offended No differences found in level of risk with respect to type of gun or whether weapon and ammunition were stored in separate places.

56 Family history of suicide
First degree relatives = more than 2x the risk of the general population For 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.

57 Social isolation or withdrawal
Having a strong preference for being alone (change from previous behavior) Withdrawing from family, social, or volunteer activities Not keeping appointments Recent moves- again a risk (CDC, 2002) 4x higher in divorced than married people (Maris, 2002)

58 Concurrent medical disorder
Characterized by: chronicity, poor prognosis, disfigurement and/or persistent pain. Young men with medical conditions were more than 4 times more likely to attempt suicide than those without such conditions. CDC, 2002 Medical problems contributing in approx 70% of elder suicides. Harris & Barraclough (1994) Blumenthal 1990 Brent and Kolko 1990

59 Medical illness, continued
Diagnoses most associated with completed suicide: Huntington’s Chorea Malignant Neoplasms Multiple Sclerosis Renal disease Peptic Ulcers Spinal Cord injuries Lupus HIV/AIDS Epilepsy (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 aformentioned HIV/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 risk 1. Directly after diagnosis is made- panic guilt hopelessness helplessness 2. Later in course of illness with CNS complications (delirium/dementia)

60 Severe 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)

61 From Jacobs (2003), Harvard Medical School

62 Depression: 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

63 Major Depression Factors to consider:
The concurrent presence of anxiety Substance abuse or dependence Command hallucinations Irritability or anger associated with impulsivity Severe insomnia, especially global insomnia Presence 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, impulsivity May be found in psychotic states and are thought to increase risk, though this has not been proven conclusively May be prone to self-destructive action Along with states of hopelessness this may increase risk and should be treated immediately Should be inquired about routinely, more than ½ suicides are committed w/ handguns, esp. elderly and adolescents

64 Bipolar Disorder (Goodwin & Jamison, 1990)
Risks: Severe depression with anxiety, agitation Global insomnia Substance abuse Transition periods/early recovery phase Impulsive or violent behavior

65 Bipolar 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)

66 Alcohol/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 intoxication Co-morbid psychopathology such as MDD Risk with recent or anticipated interpersonal loss Late 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 yrs Comorbis depressive disorder greatly increases risk 70-80% (Moscicki, 2001)

67 Schizophrenia (Tsuang, Fleming, & Simpson, 1999)
Risk Factors for suicide in psychotic patients: Young age (<30) #1 cause of death for young people Dx with Schizophrenia Good intellectual functioning Disillusion with treatment Good premorbid functioning Early stage of illness Communication of intent Frequent exacerbations and remissions Painful awareness of the likely degree of chronic disability in the future Periods of clinical improvement following relapse Supervention of a depressive episode and increased hopelessness 20-40% of those diagnosed with Schizophrenia attempt at least once. Bongar (1992) Paranoid subtype has greatest risk (Fenton et al 1997) up to 8x other types Negative or deficit symptoms associated with lower risk Amador 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.

68 Timeline of Risk The 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 1999 Ho, 2003

69 Borderline 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 1994 Zosook et al 1994 Behaviors 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

70 Identify Chronic vs. Acute Risk
New, acute presentation Presence of significant stressor Emergent response to acute crisis of mood and despair Possible co-morbid Axis I disorder Chronic: Recurrent and persistent suicidal thoughts that provide an ongoing psychological mechanism for coping with distress Frequent, usual response to life stresses and disappointments Patient may be aware of chronicity In 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 ACUTE Harvard Risk management Foundation, 2003 A 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.[30] A similar study found higher levels of suicidal intent among borderline patients compared to depressed patients without personality disorder.[31] 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:

71 Protective Factors Protective factors are believed to enhance resilience and serve to counterbalance risk factors. An individual's genetic/neurobiological make-up Attitudinal/behavioral characteristics Family/community support Effective and appropriate clinical care for mental, physical and substance abuse disorders Pregnancy or children in the home, except for post-partum illness U.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

72 Protective Factors, continued
Easy access to effective clinical interventions and support Restricted access to highly lethal methods of suicide Cultural and religious beliefs that discourage suicide and support self-preservation instincts Support from ongoing medical/mental health care , positive therapeutic relationship Acquisition of learned skills for problem solving, conflict resolution and non-violent management of disputes.

73 Prevention and Treatment Strategies
Therapeutic Treatment Strategies No Suicide Contracts Pharmcotherapy Hospitalization

74 Prevention/Treatment Strategies
ASSESS, ASSESS, ASSESS Assess acute vs. chronic risk 24 hour access to crisis care Strong therapeutic alliance is ESSENTIAL! Work with family and other support systems Use multiple resources, multidisciplinary approach

75 Access to Services Crisis services by phone 1(800) 273-TALK
National Hotline 1(800) 273-TALK Emergency Department National hotline funded by federal gov’t. Will direct patients to local suicide resources and crisis centers

76 Prevention/Treatment Strategies
Short term coping strategies, behavioral treatments Deep breathing Relaxation training Imagery training Grounding Specific, concrete, written safety plan in place and frequently renewed and reviewed Access to means removed immediately Intervention 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 1999 DBT: Developed specifically for chronically suicidal individuals

77 Dialectical Behavioral Therapy (Linehan, 1993)
Developed by Linehan for patients Dx w/ BPD and engaging in self-harm behaviors Philosophical orientation focuses on dialectics Move from dichotomous thinking to balance Patients learn to observe and describe, be non-judgmental and focus on the present, and focus on current activity

78 What 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.

79 No-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.


81 When the patient doesn’t agree….
No Suicide Contracts When 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.

82 History of NSCs First 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

83 No Suicide Contracts: Potential Pitfalls

84 Pitfall #1 BELIEVING THAT A SIGNED SUICIDE CONTRACT ELIMINATES SUICIDE RISK Suicide 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.

85 Pitfall #2 CONTRACT: THE LEGAL TERM Clinicians 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.

86 Pitfall #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.

87 Who may or may not be capable of giving informed consent?
Diagnosis Cited in… Cerebral Impairment Drye et al (1973) Psychosis Goulding (1979) Egan (1997) Under the influence of drugs/alcohol Impulse control deficiencies Davidson et al (1995) Motto (1979) Severe Depression Simon (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.

88 Informed Consent: Farrow & O’Brien (2003)
VERY limited data in this area Their 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.

89 Pitfall #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

90 No Suicide Contracts: Potential Benefits

91 Benefits 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 situation An adjunct to comprehensive evaluation and treatment In the context of a sound and positive therapeutic relationship The 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

92 Bottom line about NSCs Use 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

93 Pharmcotherapy There 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 depression The 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 psychiatry Malone 1997 Molcho & Stanley (2002) The SSRI antidepressant medications carry the specific benefit of having low lethality in overdose. Lambert 2003 Disadvantages of lithium- blood levels, contraindicated in pregnant women In 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, 1999 Fatalities 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

94 Pharmcotherapy Patients 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) Amitriptyline Amoxapine Clomipramine Desipramine Doxepin Imipramine Nortriptyline Note: Tylenol also highly lethal

95 From Jacobs (2003) Harvard Medical School

96 Medical-legal Concerns

97 Litigation Bereaved 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)

98 A Shift in the Law (Gutheil, 2000)
Before 1940: Suicide was considered an independent intervening cause of death After 1940: But for the provider or physician’s negligence, the patient would not have committed suicide (negligence as a proximate cause)

99 Medical-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.

100 Medical- 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.

101 Risk Management Realistically, 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, and inadequate patient supervision. Harvard risk Management Foundation (2003)

102 Documentation In 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 assessment Contacts with family members Contacts with other treatment providers Phone calls, letters Responses to failed appointments Non-compliance with treatment to 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.

103 Risk Management: Key Points (Lee & Bartlett, 2005)
Keep abreast of current legal and ethical standards Develop and implement a policy for handling crisis situations 24 hour availability of services Increasing frequency or duration of sessions Bring in supportive family/friends Refer where appropriate for multidisciplinary Tx Follow up for compliance and disposition Monitor medication allocation, access, and use Establish check-in system with the client 24 hour coverage includes vacation/holiday periods!

104 Risk Management: Key Points (Lee & Bartlett, 2005)
Maintain clinical competency (continuing education, supervision, consultation) Ensure accurate and thorough documentation Develop relevant resources, such as a network to consult with, community programs, etc.

105 Postvention Immediately provide support to the family
Consider attending funeral or writing letter of condolence Serves both humanitarian and risk management goals Care for yourself Understand your feelings (guilt, grief, anger, fear, etc.) Discuss/consult/debrief with trusted colleague or supervisor Family will likely need intervention, high rates of complicated grief, depression, PTSD especially if they were initial person on scene May need opportunity to tell their story multiple times and grapple with situation (Goldman & Beardslee, 1999)

106 Provider self-care Caring for suicidal patients can be very taxing- emotionally and physically! Remember to care for yourself: Eat a balanced nutritional diet, get adequate sleep, exercise Seek personal counseling formally or informally Consult appropriately with colleagues and supervisors May wish to share personal emotional reactions, burnout, and counter-transference issues (Shea, 2002)

107 Questions or comments….

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