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Suicide in America “Suicide is a national public health problem.” David Satcher, M.D. Surgeon General of the United States Instructor bullet points: Dr.

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Presentation on theme: "Suicide in America “Suicide is a national public health problem.” David Satcher, M.D. Surgeon General of the United States Instructor bullet points: Dr."— Presentation transcript:

1 Suicide in America “Suicide is a national public health problem.” David Satcher, M.D. Surgeon General of the United States Instructor bullet points: Dr. Satcher is the former Surgeon General, the one who started the National ball rolling Frame suicide as a public health problem, not just a mental health problem NOTE: Because of the high number of slides, licensed instructors may edit out or add a limited number of slides related to statistics, clinical findings, etc. to better address a particular audience, e.g., Native American healthcare providers, substance abuse counselors, and others. However, all quiz-related slides must be taught --- if you have questions about removing what you consider to be unrelated or non-essential slides, please send your final slide set to the Institute for review and approval. All slides added must be sourced to responsible, scientific sources.

2 QPRT Agenda Introductions Scope of the problem
Introduction to risk/protective factors Mental illness and suicide Suicide Risk Rating Exercise Lunch Avoiding suicide malpractice Introduction/use of the QPRT protocol Role plays and practice Managing risk over time Review the day’s work Read though and add comments as you like Encourage people to jot down questions and save them for Q&A If lunching in, day can be shorted by 30 minutes – be sure to get some sort of consensus Post-training knowledge exams can best be administered online, as distribution, scoring and reporting results is not possible in anything but a very small group

3 Training goals Describe the scope of the problem
Address social policy/impact on practice Relationship of mental illness and substance abuse to suicide Current status of suicide risk assessment Describe limitations of the clinical interview and how to improve suicide risk assessment and management decisions Read Highlight: Patient safety is everyone’s goal Expectations for suicide prevention are rising If you learn this stuff, demonstrate competence, and document well, claims of suicide malpractice are avoidable

4 General approach for today…
Address clinical core competencies to reduce medical errors and help ensure patient safety Emphasis is knowledge gain and skill acquisition verses interesting statistics Teach a tested suicide risk assessment documentation protocol Address strategies for suicide risk reduction in clinical practice If you are teaching inpatient or residential staff you will be focusing on risk stratification decisions as they are reflected in monitoring and observation decisions. Much of this material is the QPRT Suicide Risk Management Inventory user’s manual, Hospital Version. You may create slides from the manual if you so choose. JACHO and other slides are available from the Institute.

5 From the Surgeon General
“Suicide is our most preventable form of death.” Optional - too many clinicians do not believe this…. David Satcher, MD, National Strategy.. Optional: Challenge commonly held clinical myth that, “If they really want to kill themselves, you can’t stop them.” Open discussion to adjust attitudes and correct myths about suicide.

6 Why now? National movement has begun…
National Strategy for Suicide Prevention Institute of Medicine report (Reducing Suicide: A National Imperative) Public health is marketing “suicide is preventable” Public expectations that suicide is a preventable form of death are rising Self-explanatory – Sources for original reports can be Googled… Basically – the world is changing and clinicians must ready themselves for greater expectations.

7 Why us? Clinical providers and their employers are charged with doing a better job (Goal 6). Families are being taught suicide is preventable, so “Why did my brother die after I brought him to your hospital, mental health center or substance abuse treatment program?” Lawsuits against us are on the rise (?) Goal 6 is from the National Suicide Prevention Strategy, 2001 – quoted in the next slide. It is actually quite difficult to determine rate and frequency of suicide malpractice lawsuits since insurance companies do not release this data…. But an inside informant from one of the major companies in the US – personal communication, 2006 – said that they (the insurance company) was settling a increasing number of claims..

8 1. Who is qualified to conduct a suicide risk assessment?
Goal 6 from the National Strategy: “Implement training for recognition of at-risk behavior and delivery of effective treatment” 1. Who is qualified to conduct a suicide risk assessment? 2. What are these qualifications? 3. When is the risk assessment done? How often? 4. Where are staff trained in recognition of at-risk behavior? 5. How is this risk assessment documented? From the national strategy Ask the questions of the audience, since these are being explored in developing patient safety strategies You will find these questions create a lot of confusion… which is good.

9 JCAHO and Suicide 2007 National Patient Safety Goals # 15
The organization identifies patients at risk for suicide. (M) C 1: The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide. (M) C 2. The patient’s immediate safety needs and most appropriate setting for treatment are addressed. (M) C 3. The organization provides information such as a crisis hotline to individuals and their family members for crisis situations. Evidence of social policy changes and why now – multiple Joint Commission papers are available on suicide and patient safety – Read these and make sure everyone “gets it” For JCAHO approved hospitals, suicide is now a “never event” meaning, it should never happen.

10 How big is the problem? Global Violence-Related Deaths
1 million people die by suicide 10-20 million attempt Leading cause of death in 1/3 of all countries 54% of all violence-related deaths Global rates are climbing, esp. men More die by suicide each year than from all armed conflicts around the world Source: World Health Organization 2009 – Global snap shot – These figures are from the WHO – and the Institute of Medicine. Check their websites if asked for citations, as the figures change from time to time. A new violence prevention initiative is underway and among all forms of violent death (wars, homicides, terrorism, etc.) suicide accounts for 54% of the total….

11 Scope of the problem USA
Range: ideations, attempts, deaths 36,909 completed suicides in US (2009) Attempts: 922,725 Estimated 25 attempts to one completion Rates vary widely by race, gender, geography, ethnicity, but all deaths have commonalities Source: AAS – These numbers change and are updated annually by Dr. John McIntosh…. Numbers matters, but these are real lives lost… Note: trends are not established except on the basis of 10-year horizons… Tell audience that for most recent statistics, and for their personal state, visit

12 Big picture adult numbers
Think, plan, attempt, die 10 million adults think about suicide each year 1.2 million plan a method (gun, MVA, etc) 750,000 attempt (minimum count). Approximately 30,000 die Suicide is 11th cause of death overall - 3rd for young people (rate has almost tripled since 1950s – unexpected upturn - first for young people in some states source: National Co morbidity study, CDC and NIMH These numbers are from Crosby, et. al. 2001, CDC study This was a random health-risk telephone interview of adult Americans over age 18. Suicide questions asked: 1. Have you had serious thoughts of suicide in the past 12 months (two or more weeks of ideation?) Did you make a plan about how you would kill yourself? A new suicide ideation rates by states is now available from CDC INSTRUCTOR NOTE: Do not get bogged down in too many stats or your audience will nod off. Did you actually attempt suicide one or more times? The figures are prorated from the wide and valid sample: 10 million think about suicide, 1.2 million plan an attempt, and 750,000 report an attempt Major point for this slide (I often asked the audience to name the most common method of suicide people plan to use). They are usually wrong (drugs, cutting, gun, etc.) and note that the study found the most common method planned was a motor vehicle accident. Then I ask WHY? Answers: to avoid stigma, to collect insurance, to make it easier on survivors. Then I report the highlights from the San Diego Suicide Study, which found that roughly ½ of all single car crashes not involving another passenger or driver (based on psychological autopsy) are probable suicides…. Thus, the true suicide rate is probably much higher than report. Survey’s of medical examiners and coroners have found a tendency to under report suicide where proof positive, e.g., a suicide note, is unavailable, often to protect family and friends. Note that the National Violent Death Surviellence System is likely to impact reported figures.

13 American Numbers (averaged over past 10 years)
35,000 + die each year Rate: per 100,000/Year 90+ per day (1 commercial jet every other day) One person every minutes Of the 35,000+ deaths 4 X male completions to female 3 X females to male attempts Suicide is no respecter of age, race, religion, social or economic status; its an equal opportunity mode of death. Rates per year vary, using 35K+ is a good way capture the “glimpse” they need Run through the figures Add whatever you like that would interest your audience, but don’t tarry of figures; people generally hate statistics You are free to add a slide of your own choosing here for a specific audience, but it must be sourced to a reliable government or non-profit agency, or be a personal slide of a single death by suicide – stories work better than stats

14 States with highest rates for past decade (not ordered)
The following states have completed suicide rates above 15/100,000 Nevada - New Mexico – Montana – Wyoming – Colorado – Alaska – Idaho What do these states have in common? Source: AAS – these ranks change frequently These are averaged findings over several years. Wherever you teaching, know the most current statistics for that state (available at Discussion questions to audience (next two slides): Why are some states high, some low? How might explain the differences? Note the availability of mental health services, per capita funding for mental health, differential attitudes toward help-seeking, etc.

15 States with the lowest rates for the past decade
The following states (and DC) have completed suicide rates below 9/100,000 Rhode Island - California - Connecticut - District of Columbia - New Jersey – Massachusetts - New York What do these states have in common? These numbers don’t change much, although state rankings do because a few more deaths can change the ranking… don’t fuss about it. Among interesting researchable questions: Does access to competent mental health services reduce suicide rates? Would access to web-delivered mental health services in rural areas reduce rates? If remote tribal reservations had access to services and broadband, what might we expect?

16 Would access to care save lives?
Over 90% of all people who die by suicide are suffering from a major psychiatric illness or substance abuse disorder, or both. More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease, COMBINED. Effective, accessible, competent care could save thousands of lives. Compare states with low rates to states with high rates and their per capita funding for mental health and the whether services can be gotten: Source: NIMH web pages and, specifically, Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. The British Journal of Psychiatry, 125, doi: /bjp

17 Intention and Suicide “There are ways of killing yourself without killing yourself.” Tony Manero, Saturday Night Fever, on the “suicide” of his friend. ILTB = Intentional life threatening behavior This slide is about what has been called “sub-intentional suicide” or “intentional life-threatening behavior.” After his suicidal friend falls from a NY city bridge, John Travolta says, “There are ways of killing yourself without killing yourself.” Ask for audience participation here and hope to elicit some of the following: - Older people stopping their life-saving medications - High speed driver under the influence with alcohol on board - Russian roulette - Drug addicts overdosing on known lethal substances, e.g., powerful heroin - Texting while driving under the influence? I often ask if people if they have seen Dances with Wolves (with Kevin C) and ask them to recall the opening scene in which the hero is wounded in the leg during a battle and, rather than lose his leg to a surgeon, rides out in front of the Confederate soldiers with a plan to die of a gunshot wound. This is clearly suicidal behavior as solution to an unacceptable psychological wound, e.g., becoming a one-legged man.

18 Need for surveillance data
We really do not know the full scope of suicidal behaviors, self-inflicted injuries, risk-taking activities that lead to premature morbidity and mortality. New! National Violent Death Surveillance System is now in place in 17 states and is collecting critical data on 50,000 violent deaths per year, including suicide. We do know where those identified end up…. In our care and we must do the best we can to keep them safe. The new NVDSS is proving most helpful in getting a handle on the size of the suicide problem. In 2010, advocates are pushing for federal funding to install this system in all states – doing so would greatly increase our knowledge about suicide, and likely lead to greater efforts to prevent it.

19 Suicide Attempt “Any potentially self-injurious action, with a nonfatal outcome, for which there is evidence, either explicit or implicit, that the individual intended to kill himself or herself.” From Carol, Berman, Maris, et. Al., Journal of Suicide and Life-Threatening Behavior, 1996 Note that this definition is not perfect, and that defining this behavior has been a challenge to the field for many years, and remains so today. Another group is working on a new definition, Lanny Berman, Mort Silverman and others, as regards the VA hospitals need for a competent surveillance system

20 Lethality of Suicide Attempts
Suicide attempts vary in lethality. Death can be an impossible result of some action, or almost a certainty. Smith et. al., The Menninger Foundation, scales from 1 to 10 (good inter rater reliability). Examples: 0.0 Death is an impossible result of “suicidal behavior,” e.g., light scratches to the skin Wounds that do not require suturing. Swallowing paper clips, coins, 10 or fewer aspirins or clearly ineffective acts which are shown to others. This slide is used to describe levels of lethality in suicide attempts. I read through it with some care, and explain that clear definitions of suicidal behaviors are key to clear clinical communications about relative risk. I stress the importance of describing the behavior in detail to reduce the risk of calling every self-inflicted injury, a “suicide gesture.” Note: In the June 2010 issue of Professional Psychology: Research and Practice vol. 4 no 3., Heilbron et. al. call for the discontinued use of the term gesture in their article “The Problematic Label of Suicide Gesture: Alternatives for Clinical Research and Practice.” Basically, the term has no good operational definition and leads to confusion and poor clinical communication about assessed risk…. Encourage your audience to stop using it. The inter-rater reliability for this scale is quite good. The entire scale is available in a number of places, e.g., Bruce Bongar’s books. We use it here to make a point, not to recommend it for clinical practice.

21 Lethality of Attempt Scale
3.5 Death is improbable so long as first aid is administered by victim or other agent. No effort to hide attempt. Rescue is likely. 5.0 Death is a probability directly or indirectly. Severe cutting with sizable blood loss. Hanging efforts with chance of discovery high. Vague drug overdose. 7.0 Death is the probable outcome unless there is immediate and vigorous first aid or medical attention. Large doses drugs with fifth of whisky and suicide note. Hanging attempt, with patient found cyanotic. 10.0 Death almost certain. Use of shotgun. Drowning self at midnight in a lake. Survival is accidental. Read The reason a rating of lethality is needed is that too often clinicians communicate about suicide attempts as if one attempt is like any other… thus, the severity of the attempt-behavior is not fully communicated and levels of monitoring may be less than needed to assure safety.

22 Suicide Attempts Most don’t die in their attempt
Youth: attempts per 1 completion Elder: 4 attempts per 1 completion Average: 25 attempts per 1 completion 5 million Americans have attempted (est.) Reporting problem - under reporting - unknown (don’t ask, don’t tell) Source: and AMA… This slide pretty much speaks for itself. Note: a prior suicide attempt remains the most powerful predictor of later death by suicide. Too often, clinicians a) don’t ask about prior attempts, and b) don’t drill down for the details to determine the lethality of the attempt. I note the ratios of attempts to completion regarding the elderly, as this every attempt in this group has a high intention to die, and if the person does not die it is not because they didn’t want to, but because their method failed.

23 More homicides or suicides per year in the US?
Suicide and Homicide More homicides or suicides per year in the US? Is there any overlap between homicide and suicide? You should know the answers to these by heart

24 Facts you Need to Know If a man calls, take him seriously, he may have a gun in his hand.. Boys, teenaged boys, young men 18-25 Highest tally of total death: men in middle years Old white males are the highest risk group - 79% use a firearm (lethal planners) They know how to do it and plan carefully They avoid rescue “If a woman calls about a man, take her even more seriously.” Please cover the high rates for men and boys; 6-1 male to female in the early years, 4-1 male to female over the life span Focus on highest risk group and the role of careful planning. Impulsive males tend to die young, so when older males become depressed and suicidal they represent a huge risk to themselves. A story here is helpful… I tell the one about the 70+ veteran who was taken to an ER with an interrupted overdose on Nyquil. After being re-hydrated, he was sent home with the following comment: “Sir, you can’t drink enough Nyquil to kill yourself.” Upon arrival in his home he pushed an ice pick through his heart. That worked. But tell you own story if you have one. Point: older males, and males in general, do not make idle suicide threats and are most likely to tell someone close them – especially a woman (clinical practice lore).

25 Cold Sober Suicide Where alcohol and other drugs on board contribute to greatly to suicide risk in younger people, among men over 65 only 9% had a BAC greater than .8 Source: National Violent Death Surveillance System This is an interesting recent finding re. late life suicide. We tend to associate alcohol abuse and suicide, especially in younger age cohorts, and assume this is true in late life. Apparently not. More research is needed in this area….

26 Facts you need to know… Suicide risk rises with age for white males, not for men of color Responsibility for one or more children is a powerful protective factor against suicide in women (Sweden) Contact with a healthcare provider does not confer protection…. and neither does recent psychiatric hospitalization. Most suicides occur with weeks to months of last contact AND risk rises after discharge! The Swedish study compared # of live births with suicide completions; the more children a woman had the lower her risk for suicide (a perfect correlation). You should be familiar with the “recent healthcare contact” literature. Point? Are these missed opportunities? Probably, as suicide ideation is infrequently queried for and is not the current standard of practice among PCPs.

27 References on Primary Care and Suicide
Andersen, S.M., and Harthorn, B.H. (1989). The recognition, diagnosis and treatment of mental disorders by primary care physicians. Medical Care, 27: Coombs, D.W, et al. (1992). Presuicide attempt communications between parasuicides and consulted caregivers. Suicide and Life Threatening Behavior, 22: Hirschfeld, R., et al. (1997). The national depressive and manic depressive association consensus statement on the under treatment of depression. Journal of the American Medical Association, 277(4): Miller, M.C., Paulsen, R.H. (1999). Suicide assessment in primary care settings. In Jacobs, D.G. (ed.). The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass. Orleans, C.T. (1985). How primary care physicians treat psychiatric disorders: a national survey of family practitioners. American Journal of Psychiatry, 142(1): Rand, E.H., Badger, L.W., and Coggins, D.R. (1988). Toward a resolution of contradictions. Utility of feedback from the GHQ. General Hospital Psychiatry, 10: Moscicki, E.K. (1999). Epidemiology of suicide. In Jacobs, D.G. (ed.). The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass. Gliatto, M. F. and Rai, A. K. (1999). Evaluation and treatment of patients with suicidal ideation. American Family Physician 59: Katon, W., and Schulberg, H.C., (1992). Epidemiology of depression in primary care. General Hospital Psychiatry. 14: Kaplan, M.S., Adamek, M.E., and A. Calderon. (1999). Managing Depressed and Suicidal Geriatric Patients: Differences Among Primary Care Physicians. The Gerontologist: 39(4): Uncapher, H., Arean, P.A. (2000). Physicians are less willing to treat suicidal ideation in older patients. Journal of the American Geriatric Society 48: This slide contains references on how primary care physicians deal, or don’t deal, with suicidal patients in terms of detection of risk, assessment of risk, and management and treatment of suicidal patients. Just show them the slide, and say, “These studies are only a few of those published in this area.” The question goes back to goal six of the NSPS – Who is trained, ready, and willing to diagnose and treat suicidal people? NOTE TO INSTRUCTOR: If you are teaching Primary Care Providers you will need another slide set – get them from the Institute – they are designed just for physicians and PAs

28 Suicide Prevention is Violence Prevention
DOMESTIC VIOLENCE, SUICIDE AND HOMICIDE * DV victims make more suicide attempts (20 to 26%). * Violent families contribute to youth suicide. * Violent people have a history of self-destructive behavior (30%). * Double suicides are often motivated by the couples fear of separation and the fantasy that they can remain together in death. * Abusive men who kill their wives and lovers usually do so in response to the woman’s attempt to leave. Overlap of violence to suicide. If you do not have my executive summary of this literature you can find it on the instructor area of the web site. The data here are also from the Washington State Consortium on Domestic violence. From other studies, about 1/3 of the males who kill their wives or lovers, then kill themselves. Point? We could stop some homicides by stopping the suicides planned as part of a murder-suicide dynamic.

29 Intimate Partner Violence
Males who threaten suicide in an intimate partner violence situation are at greater risk for murder-suicide. WSDVFR finding: “Abusers were suicidal in 35% of domestic violence fatalities overall (this includes cases where no homicide occurred), and in 31% of the cases in which a homicide was committed.” US AIR FORCE: Suicide rate down 33%, Homicide rate down 52% Serious DV rate down 54% Suicide Prevention IS violence prevention! * This data is from the Washington State DV Consortium + the US Air Force study… - BMJ – Knox, et. al. - if people want more have them for research summaries and a paper, or they can Google the study.

30 Survivors of Suicide 6 blood relatives directly affected by each suicide 1 of every 62 of us is a survivor This number does not include colleagues, co-workers, friends, team or school mates and ex spouses One suicide every 18 minutes = 6 new survivors Suicide risk is greater in survivors (e.g., 4-fold increase in children when a parent dies by suicide) If roughly 30,000+ Americans die by suicide each year leaving 180,000 blood relative survivors, how many have died by suicide since 9/11, and how many new survivors are there? This is AAS data… Ask the audience to do the math… add up 30,000 each year since 9/11 (3,000 lost), and then multiply by 6 – very powerful figures …This is an easier figure to grasp that the exact number. There is a lot going on just now with building survivor support groups and beginning prevention with this high risk group. New figures are emerging that the total number of persons impacted is closer to 100 – six immediate blood relatives, 16 close relatives, 60 to 100 friends, coworkers and colleagues. More research is needed to determine the various impacts of suicide.

31 GOOD NEWS! A national suicide prevention movement has begun
Research, medicine and political will are building Stigma, funding, and lack of awareness remain Leadership has emerged: NIMH, CDC, National Council for Suicide Prevention, AAS, AFSP, SPRC, SAVE, etc. U.S. Air Force success story is out The majority of Americans believe we should fund more research and believe many suicides are preventable (SPANUSA research) Point out that since the national strategy was published, good things are beginning to happen Read the list (note that teen rates are dropping now) Research is being funded (including for QPR) New medicine are being tested and suicidal people are likely to be included in future trials Cognitive Behavioral therapy is also being evaluated in random clinical trials Review highlights of the Air Force study (British Medical Journal/Kerry Knox and company)

32 Suicide Risk and Risk Management
What you need to know…. NOTE TO INSTRUCTOR: These next few slides are designed to challenge clinicians into rethinking what they think they know about suicide….

33 Suicide Risk Assessment
Prediction is complex and difficult Prognosis vs. prediction Challenge of a low probability event Behavior is threshold sensitive Behavior is context sensitive Behavior relationship sensitive Summation of risk factors not helpful Screening tools can get you in trouble (prediction is best done in reverse) This slide will take a few minutes to discuss. It is here to frame in the complexity of predicting suicide, especially on an individual basis. Research has shown individual prediction is not possible based upon a summed risk factor approach. Prognosis is a probability statement not a prediction. Clinically, we work to enhance prognosis Suicide is a low probability event, but the world is filled with dangerous low probability events: volcanoes, plane crashes, nuclear power plant melt downs. The point is that risk management is about reducing risks, and this is something we all do every day. Buckle up before driving, taking an aspirin a day, etc. etc. Suicidal behavior is “threshold sensitive” because we are less in control of our behavior and impulses when we are “hungry, angry, lonely or tired.” Therapists can help reduce suicide risk by helping suicidal people with “relapse prevention” techniques. I used “relationship sensitive” to highlight that a) most suicides are dyadic in nature – a hetero or homosexual relationship is in conflict – and that b) about 1/6th of all suicides occur in a therapeutic relationship… If this relationship is in trouble, so is the suicidal person. You may expand on this as you see fit. Summation of risk factors is not helpful in predicting suicide. The example I use is the VA hospital system, where almost all patients meet criteria for elevated risk (male, psychiatric disorder, familiar with firearms, alcohol abuse, etc. etc.). If you use screening tools and patients report “positive” e.g., endorse suicidal ideation, you must follow up with a timely and comprehensive suicide risk assessment interview, or your are terribly exposed to suicide malpractice if the patient dies by suicide.

Attempts Completions Seasonal Variations Unknown Jan-Feb, March Peak Weekly Unknown High Midweek Geography High on both Same War Unknown Inverse Unemployment: Chronic Unknown No Association Sudden Direct Direct * Source: Harvard School of Public Health, 1998 OPTIONAL SLIDE – If you need time, cut this one as it does not add much to risk assessment, but is interesting. The inverse relationship re. war is from (original citation) Suicide and War: a case study and theoretical appraisal, authored by Pat O’Malley in the British Journal of Criminology, Vol. 15, No 4, in October This article provided an analysis of this relationship down through decades of war in multiple countries in a test of an earlier theory by Durkheim that in times of war people bind together against a common enemy and have fewer reasons to kill themselves. Things could be quite different now with our more recent wars since there is – in my opinion – less integrated pro-war feeling in the country (America) and the “connectedness” issue may be moot….

Risk Imminent Crisis Peaks Crisis Begins RISK LEVEL Crisis Diminishes Hazard Encountered Note that suicide crises tend to be short lived. Either the person survives the crisis and returns to a “normal baseline” or he or she dies. Point? Quick, positive action should save lives. Just as in a cardiac crisis. Note: This slide was developed by QPR Institute, but is made available without copyright protection for others to use. Stable Stable Years Days Hours Days Years Plus or minus three weeks

36 When these three are present-the risk of violence is high.
THE LETHAL TRIAD UPSET PERSON * Reduce or remove any of these risk factors quickly, and the risk of suicide drops dramatically. This slide was developed by QPR Institute, but is made available without copyright protection for others to use. FIREARM ALCOHOL When these three are present-the risk of violence is high.

37 Dr. Tom Joiner’s Interpersonal Theory of Suicide
Two major components associated with suicide and serious attempts The desire to die and the capacity for self harm Two elements within the desire to die Perceived burdensomeness A sense of thwarted or low belongingness These concepts and next few slides have emerged in recent years and are generating a lot research… See books by Tom Joiner – “Why People Die by Suicide” Harvard University Press, Dr. Joiner has provided the graphic slide for our use by personal permission.

38 Serious Attempt or Death by Suicide
Sketch of the Theory Those Who Desire Suicide Those Who Are Capable of Suicide Note that this graphic helps define the large population of people who develop suicidal desire and ideations, but that of these, only a much smaller number are actually capable of suicide attempts. Current research is focusing on further testing this theory. Serious Attempt or Death by Suicide

39 Acquired Capacity for Suicide
Suicidal behavior is not just about the desire to die It requires the capacity to inflict self injury Read and move quickly

40 The Acquired Capability to Enact Lethal Self-Injury
This capacity is acquired over time Accrues with repeated and escalating experiences involving pain and provocation, such as Past suicidal behavior, but not only that… Repeated injuries Repeated witnessing of pain, violence, or injury (e.g., physicians, EMS, ED nurses, law enforcement personnel, and combat soldiers) Any repeated exposure to pain and provocation. Determining capacity to enact lethal self-injury is critical to suicide risk assessment, so make sure people understand what this term means.

41 The Acquired Capability to Enact Lethal Self-Injury
According to Joiner, with repeated exposure, one habituates – the “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated with self-harm Read this… and ask folks to follow work in this area. For example, has this patient been exposed to trauma, when, how much, for how long, etc. etc. These dimensions of a) not belonging, b) feeling a burden on others, and having c) developed a capacity for self-injury have great significance in the assessment of immediate risk for a suicide attempt.

42 The Many Paths to Suicide
Cause of Death Fundamental (distal) Risk Factors Acute (proximal) Risk Factors: triggers/last straw Biological Crisis in Relation Poison Genetic Load Sex GLTB Loss of Freedom Gun Race Age Personal/Psychological Increasing Hopelessness Contemplation of Suicide as Solution Hanging Fired/ Expelled Values Religion Beliefs Drugs or Alcohol Child Abuse Loss of Parent Culture Shock/ Shift WALL OF RESISTANCE Illness Autocide This slide took years to develop and I cannot do it justice with a few bullet points. This slide was developed by QPR Institute, but is made available without copyright protection for students in this course. Reframe these talking points in life of Dr. Joiner’s theory Focus on risk as well as protective factors in your coverage. GLTB literature for youth shows sexual orientation by itself is not a risk factor, what is a risk for this group is the social, psychological environment and the use of drugs and alcohol to combat stress, anxiety, depression that may develop (see Maddy Gould’s 10-year review article on youth suicide risk for citations). Differentiate between fundamental or distal risk factors Note: as crisis worsens, communications of suicidal planning increases Wall of Resistance is one protective factor list Model for Suicide Environmental Urban vs. Rural Geo-graphy Major Loss Jumping Season of year ? All “Causes” are real. Hopelessness is the common pathway. Break the chain anywhere = prevention. ?

43 Counselor or therapist Medication Compliance Support of significant
Wall of Resistance to Suicide Counselor or therapist Duty to others Others? Good health Medication Compliance Fear Job Security or Job Skills Responsibility for children Support of significant other(s) Difficult Access to means A sense of HOPE Positive Self-esteem Religious Prohibition Calm Environment AA or NA Sponsor Pet(s) Sobriety is the foundation for safety, as everything rests on a non-intoxicated state of mind. Directly enhancing connectedness and reducing burdensomeness are implied in many of these “bricks in the wall” Read through these and add your own stuff as you see find. Literature supports most, but not all, of these concepts. Do not get into a lengthy discussion of safety agreements or no-suicide contracts, as this is covered in the QPRT language. This slide was developed by QPR Institute, but is made available to students in this course without copyright protection. Best Friend(s) Safety Agreement Treatment Availability -- Sobriety -- Protective Factors and Buffers Against Suicide

44 Nature of the suicide Psychic suffering (Psychache) Hopelessness
Unbearable mental anguish Cognitive constriction Grossly impaired problem solving ability Feeling a burden to others Thwarted belongingness Acquired capacity for self-injury “Psychache” is from Schneidman, Hopelessness from Aarron Beck’s work, and the last three – again- from Tom Joiner – the most popular theorist right now… Let me know if you are not familiar with this content well enough to highlight it and talk briefly about it. Schneidman’s book “Autopsy of a Suicidal Mind” by Oxford Press is as good as any to source this, but many of his books cover the subject. He was, by the way, the Founder of the American Association of Suicidology and just died in 2009.

Suicide is always multi-determined. Suicide prevention must involve multiple approaches. Most suicidal people do not want to die. Suicidal people want to find a way to live. Ambivalence exists until the moment of death. The final decision rests with the individual. Reduce risk factors and you reduce risk. Enhance protective factors and you reduce risk. This one should be clear. I typically tell the story of those who have jumped to almost certain death from the Golden Gate Bridge and did not die, and how all but one every jumped again… … see my lecture or see Wikipedia for an excellent review about the bridge and bridge stories.

46 End Module Questions Q&A

47 The Relationship of Mental Illness and Substance Abuse to Suicide…
This is your segue slide into the foundation lecture on mental illness, substance abuse and suicide. Both MI and SA should get equal play in your emphasis and remarks. You can note that the relationship of mental illnesses to suicide is largely a study in Western, first world countries, and that other countries, for example, China, do not see things the way we do in a medical model approach…

48 Preventing suicide is largely about identifying and treating mood disorders, alcoholism and co-occurring disorders WHO aims to target: - Mood disorders - Schizophrenia - Alcoholism World evidence for treatment effectiveness suggests suicide rates can be substantially reduced in all these categories… if we can find them before they die Source: In a world view, the vast majority of suicides can be attributed to MDD, Bi-polar, booze and drugs…. Finding and treating these problems in the World Health Organizations primary focus … personality disorders are not targeted in large part because there are few or no known effective treatments for them

49 Is Suicide Primarily: “Mental Health Territory?”
Lifetime Suicide risk for Schizophrenic, Affective and Addiction Disorders: Method: review of 83 mortality studies: Schizophrenia…………4% Affective Disorders……6% Addiction Disorders…...7% Inskip HM: Br J Psych 1998 Notes: Schizophrenia often has co-occurring depression/substance abuse Addictions take more lives than mood disorders (as best we can estimate) Note: Databases for these lifetime risk estimates vary widely, are often calculated differently by different researchers and some data sets are county specific. These figures are widely quoted now, but are challenged by other researchers with different data sets and selection rules. To get an idea of about the controversy, see The Lifetime Risk of Suicide in Schizophrenia A Reexamination by Brian A. Palmer, MD, MS, MPH; V. Shane Pankratz, PhD; John Michael Bostwick, MD Arch Gen Psychiatry. 2005;62: , in which their figures are 5.6% lifetime risk for schizophrenia. Also, see Am J Psychiatry 157: , December 2000 Reviews and Overviews Affective Disorders and Suicide Risk: A Reexamination John Michael Bostwick, M.D., and V. Shane Pankratz, Ph.D. These folks found different lifetime risks associated with a number of variables, including hospitalized with and without suicidality, etc. etc. Point to students: It’s hard to get good data on the risk of psychiatric illness and death by suicide and, the research continues…

50 Epidemiology: Interesting but not clinically useful…
Suicide rates vary across cultures, racial groups, age groups, time and by geography. Major risk factors: Mental disorders, hopelessness, impulsive and/or aggressive tendencies, history of trauma or abuse, major physical illnesses, previous suicide attempt, family history of suicide, etc. (see NSSP for complete lists of risk and protective factors) What you need to know: 90-95% of all completed suicides have an Axis I disorder…BUT – most people with these illnesses DO NOT die by suicide. This is a read slide… emphasis last line, as this is a quiz item Source for this 90-95% is from Kay Redfield Jamison, Night Falls Fast, and Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. The British Journal of Psychiatry, 125, doi: /bjp

51 General Neurobiology of Suicide
Reduced serotonin function in suicide, especially in suicides of high lethality or with considerable planning Depletion of essential neurotransmitters (including dopamine and serotonin) may be the common clinical pathway for suicidal thinking, feeling and behaviors Genetic studies inconclusive to date Familial patterns of suicide suggest biological factors may influence risk. This is from a lecture by Dr. Coyle, delivered at Harvard in 97. There have been no major breakthroughs since Not much has changed. At least one quiz item comes from this slide, so be sure your audience “gets it” that depleted neurotransmitters are the likely culprit in many suicides. From Joseph Coyle, MD, Harvard Medical School, 1997

52 Specific neurobiological changes in severe suicidal depression
Loss of gray matter Impaired prefrontal cortical response to serotonin release Dopamine deficit Serotonin hypofunction in the PFC correlates to higher suicidal intent and planning and lethality of suicide attempt Read – but note that this research is always iffy, since there is not a one-to-one relationship between neurotransmitters and suicide – far from it. Much work needs to be done. * One thing we do know is the compliance with treatment is key to feeling better and recovery, and that non-compliance is a huge risk factor.

53 MDD AND SUICIDE Lifetime risk: 2- 6% (lifetime risk)
98 % of completers are seriously depressed Most die while off medication. Adherence to meds is essential to safety. For severe, agitated and suicidal depressions, electroconvulsive therapy may be the best choice. Family/patient education: MMD is a potentially fatal illness and death is a possible result of not following medical advise. Benzodiazepines are often underutilized (more later) Note: earlier studies said 15% of depressed folks died by suicide, but these were based on hospital studies of patient so sick they were inpatients. This whole area is thoroughly reviewed now in a number of areas, including the new book “Evidence-Based Suicide Prevention” --

54 Pharmacotherapy for depression
PET scan depicts a depressed patient’s brain prior to treatment, after successful treatment , scan reveals greatly increased activity in the prefrontal cortex Optional

55 Warning, do not use the brain on the left to make a life or death decision….
Please make clear that the relationship of serotonin to depression is far from clear, and it is not a matter of adding a quart to bring fluid levels back to normal. Recent research shows a very complex relationship of neurotransmitters and mood and, more to the point, we have no evidence that the SSRIs are effective in treating suicidal depression --- since suicidal people have been excluded from almost all clinical trials.

56 A note on antidepressants
TCAs deadly in overdose SSRI’s not deadly in overdose Lot’s of TCAs prescriptions = more suicides Lot’s of SSRIs prescriptions = fewer suicides (EU, Australia, Scandinavia, USA) Sources: Grunebaum, et al, J. Clin. Psychiatry, 2004 Gibbons, et al, Arch Gen Psychiatry, 2005 Gibbons, et al, Am J. Psychiatry, 2006 These are large geographical studies of counties, provinces, countries, etc. They basically look at prescription rates and suicide rates --- SSRIs are safer in overdose.

#1 cause of death, 1 to 2% per year. 30 studies 9 to 46% x = 19%. Attempts Major Depressive Disorder = 20% Bipolar Disorder = 25%-50% General Population = 1% Highest risk windows Early in illness In denial phase During mixed states While experiencing depressive mania K. R. Jamison, 1997 John Hopkins University This content has not changed recently. A frequent question is why does Lithium work best for those who won’t take it. Basically, what we know clinically is that folks early in the illness, and still in denial about their illness, tend to respond well to Li once you can get them to take it. Cite “Night Falls Fast” by Kay Redfield Jamison, as a good source for this data, as well as perhaps the best resource for this area….

58 1st line intervention for suicidal bi-polar patients
Lithium appears to decrease aggression and impulsivity Psychotherapy and mood stabilizers prevent suicide better than mood stabilizers alone. Lithium has pronounced anti-suicide effect (600 fold impact) Lithium works best for those who won’t take it; when they do take it, therapeutic impact is significant Read – Again from Jamison TEST QUESTION

- Ten to 15% complete suicide (best estimated of Lifetime risk: 5%). Leading cause of death in patients under 35. - Negative symptoms associated with increased risk. - 20 to 40% make a suicide attempt. - Finland National Study (1997) - 7% of all suicides met DSM-IV criteria for schizophrenia (N=92). Of these 92, 64 were also depressed. - Suicides occur during active phases of the illness Read… note that depression, again, seems to be the major co-occurring disorder that raises suicide risk – Finnish study. NOTE: Seems that the more we look at co-morbidity, it always that killer clinical depression that accounts for so much of variance in risk factors for suicide… M.T. Tsuang, MD, Harvard Medical School, 1998

60 Suicide and Schizophrenia
Inadequate pharmacotherapy contributes to higher suicide rates for schizophrenics. Major risk factors: young age, early stage of illness, substance abuse present, college education, multiple episodes of psychosis, living alone, history of previous attempt. Improving on medications is the most dangerous time. Suicides occur after discharge and in the first year of follow-up from index illness. * Nothing to note here.

61 A note on Clozapine Most effective for negative symptoms
Best for Rx resistant, has antidepressant and mood stabilizing effect Clozapine reduced suicide events by 25% compared to olanzapine Clozapine 2 yr NNT of 13 to prevent 1 attempt Source: Meltzer et. al. 2003/Health study research NEJM,1989. Optional slide – you may skip this one or delete it. There is growing evidence for Clozapine having an anti-suicide effect… NNT means number needed to treat to prevent a suicide event, e.g., attempt or completion.

62 Or is Suicide also: Addictions Territory?
Alcohol strongest predictor of completed suicide over years after attempt, OR= 5.18…vs. demog or psych disorders ( Beck J Stud Alc 1989) 40-60% of completed suicides across USA/Europe are alcohol/drug affected (state variable). Editorial: Dying for a Drink: Brit Med J. 2001 Higher suicide rates (+8%) in 18 vs. 21yo legal drinking age states for those ages (Birckmayer J: Am J Pub Health 1999) Note: OR = odds ratio - in general alcohol in the patient or its availability in a society increases suicide risk NOTE TO INSTRUCTOR: Many of the following slides were contributed by psychiatrist Rick Ries, MD, the QPR Institute’s Medical Director. Rick is a world class expert in addictions, mental illness and suicide. Rick is a professor at the University of Washington School of Medicine.

63 Alcohol Abuse and Suicide
Major risk factors: male, long-term drinker, co- morbid psychiatric disorder. Intoxication impairs judgment and increases impulsivity and aggressiveness Co-morbidity increases risk Highest risk group: MDD and alcoholism. Alcoholism erodes protective factors: loss of job, health, home, money, family & friends Alcohol myopia: inability to access the consequences of one’s actions (the stupid effect) Sources: NIMH, Dying for a Drink, BMJ Oct 2001 Test item imbedded here: co-occurring depression and alcohol addition – Am. J. Psychiatry, summer 1998…. This finding is repeated ad nausea. Compared with the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk for suicide; people who inject drugs are at about 14 times greater risk for suicide (Wilcox, et al., 2004).  Source: Wilcox, H. C., Conner, K. R.., & Caine, E. D. (2004). Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug and Alcohol Dependence, 76, Supplement 1, S11-S19 doi: /j.drugalcdep

64 Lifetime Suicide Thoughts/Attempts ASI data, TRI database-04
N=60,952 This one explains itself. Basically, draw a line through the graphs and you find an average of roughly 20 ideators and 14% attempters. Do substance abuse treatment patients actually receive treatment that match their needs when it comes to suicide risk? If the lack of training in the detection, assessment and management of suicide risk in mental health is less than perfect, imagine what it must be like in substance abuse treatment field. For a breakthrough document attempting to change this situation, please refer interested students to: Treatment Improvement Protocol 42.. Authored by Waddell et. al. in the Journal of Groups in Addiction & Recovery, Volume 3, Issue 3 & 4 November 2008 , pages Of note, the QPRT method you are teaching is mentioned as one example of a “best practice” in the assessment of suicide risk in TIP 42.

65 Skip the booze and junk Optional slide
No, these are blobs of warm Swiss cheese. Tell your children, “Do not date a boy with a brain in this condition.”

66 What do we know about Suicide in Prospective Age-Matched Alcoholic Populations
4.5% of alcoholics attempted suicide within 5 years of DX ( age 40.. n=1,237) 0.8% in non-alcoholic matched comparison group ( age 42..n=2,000)… p< .001………..7X increased risk Preuss/Schuckit Am J Psych 03 Note: A large body of literature indicates that serotonin plays a major role in behavioral regulation, and that alcohol has an inverse relationship between impulsive aggression and the serotonergic function – at least in adults. One frequently quoted article on this subject is Tauscher, et. al, “Inverse Relationship Between Serotonin 5-HT1A Receptor Binding and Anxiety: A [11C]WAY PET Investigation in Healthy Volunteers Am J Psychiatry 158: , August 2001 © 2001 American Psychiatric Association

67 Methamphetamine Users (n= 1,016) LIFETIME SUICIDE ATTEMPTS and BEHAVIOR PROBLEMS
ASI Item Overall Males Females Test Statistic* Attempted Suicide (%) 27% 13% 28% 35.42** Violent behavior problems (%) 43% 40% 46% 3.29*** Assault Charges (mean number) 0.29 0.46 0.15 4.46** Weapons charges (mean number) 0.13 0.21 0.07 4.09** *Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; Student’s two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df=1013. **p < ***0.1 < p <0.05 Because meth is such a huge problem, just highlight the number of attempted suicides in the population – nothing the 27% (in red) overall suicide attempt rate. Zweben, et al., 2004

68 Skip the Meth Optional slide –

69 Substance Induced Depression: Severity/Dangerousness
Henriksson, et al (1993)- 43% of completed suicides had alcohol dependence. 48% of these were also depressed. 42% had a personality disorder. Elliot, et al (1996)- patients with medically severe suicide attempts had a statistically higher prevalence or substance-induced mood disorder. Pages K et al (1997)- Higher degrees of Sub + Dep related to higher severity suicide ratings Optional slide: The combination of depression and drugs alcohol is more deadly, even if it may be shorter in duration. NOTE TO INSTRUCTOR: This slide can be a challenge to teach – but the main point is that some substance induce severe agitated and acute depressions which can lead to highly lethal suicide attempts.

70 Transient acute depression
Intense, short-lived depression is prevalent among treatment-seeking people who abuse cocaine, methamphetamines, and alcohol. Does this depression increase suicide risk? Brown et al., 1995; Cornelius, Salloum, Day, Thase, & Mann, 1996; Husband et al., 1996). Optional slide, but clinically important. Depression is the – perhaps – major risk factor for suicide as noted just about everywhere. Sources: Brown SA, Inaba RK, Gillin JC, Schuckit MA, Stewart MA, Irwin MR. Alcoholism and affective disorder: Clinical course of depressive symptoms. American Journal of Psychiatry. (1995); 152: 45–52. Cornelius JR, Salloum IM, Day NL, Thase ME, Mann JJ. Patterns of suicidality and alcohol use in alcoholics with major depression. Alcoholism, Clinical and Experimental Research. (1996); 20: 1451–1455. Husband SD, Marlowe DB, Lamb RJ, Iguchi MY, Bux DA, Kirby KC. et al. Decline in self-reported dysphoria after treatment entry in inner-city cocaine addicts. Journal of Consulting & Clinical Psychology. (1996); 64: 221–224.

71 Traumatic brain injury
Blast is the most common wounding etiology our returning war fighters 50-60% of those exposed to blasts sustain a brain injury (Walter Reed Army Medical Center) Depression, PTSD and alcohol use common Simpson & Tate post-injury TBI community sample study (2002): - 23% had significant suicidal ideation - 18% made a suicide attempt Life time risk of suicide 3-4 times higher This new slide address special needs of our returning war fighters – and elevated risk for suicide following TBI, P TSD, and co-morbid, often coping strategy, alcohol use. Source: J Nerv Ment Dis Oct;193(10):680-5. Clinical features of suicide attempts after traumatic brain injury. Simpson G, Tate R.

72 PTSD and Suicide Research: Positive correlation between PTSD and suicide Some studies suggest that suicide risk is higher due to the symptoms of PTSD; others claim risk is higher due related psychiatric conditions Intrusive memories, high arousal & low avoidance increase risk of suicide ? Source on next slide NOTE TO INSTRUCTOR: If you have extra slides on PTSD, use them. We will update annually.

73 PTSD Or, is it the co-occurring depression and/or alcohol use?
Risk factors: male, alcohol abuse, older, family history of suicide, homeless, single, with firearm Highest risk: multiple combat wounds and/or hospitalized for injury + guilt over combat behavior Source: The Relationship Between PTSD and Suicide, William Hudenko, Ph.D. VA – National Center for PTSD Much research is underway – stay tuned and clinicians need to stay up with this literature

Severe psychic anxiety/turmoil Incessant rumination Global insomnia Delusions of gloom and doom Recent alcohol use (with or without alcoholism) Jan Fawcett, M.D., 1997 (replicated in 2003 with 76 inpatient deaths) This is an important slide on those symptoms most associated with inpatient suicide and immediate risk. These symptoms were reported in the medical records by observers on the units… they have implications for outpatient management as well…. And place emphasis on alcohol use here, as it appears highly distressed patients unable to sleep, stop their ruminations, etc. etc., use alcohol as a method in decrease distress associated with brain dysfunction… Source: Fawcett, J “Inpatient Management of Suicide.” Paper presented at the Harvard Medical School conference on Suicide: Critical Issues in Assessment and Management.

PSYCHIATRIC COMORBID TRANSIENT ILLNESS PSYCHOLOGICAL STATES Schizophrenia Agitation Depressive Disorder Perturbation Bipolar Disorder Psychic Pain Panic Disorder Hopelessness Substance Abuse Disorder Dopamine Deficit Personality Disorder Serotonin Deficit Co-morbid Physical Illness Alcohol Myopia Another long-considered slide that spells out the relationship of diagnosis to symptoms – all of which we know how to treat. This slide was developed by staff at the QPR institute is a copyrighted original WALL OF RESISTANCE SUICIDAL BEHAVIORS

76 Common Chemical Pathways for Suicidal Acts?
Alcohol in the bloodstream Low serotonin levels Impaired dopamine function Quiz item – stress it

77 What can we do? Do we know how to sober people up?
Do we know how to treat anxiety? Do we know how reduce psychic pain? Are there effective treatments for agitation? Do we know what to do about serotonin deficits? CBT for depressive hopelessness? DBT for Axis II consumers Engage audience with these questions. E.G. 10 sessions of CBT with adolescent attempters reduced future attempts by 50% Marsha Linehan’s work has been replicated several times and is in NREPP. BOTTOM LINE: Treatment works – provided people use things known to work!

78 Good news! Treatment works
Cognitive therapy reduces youth suicide attempts by 50% (Brown, et al, Aug 3, 2005 JAMA). Youth Suicide Rates Lower in Counties with High SSRI Use (Gibbons, et al, Am. J. Psychiatry 2006) Several therapies are being adapted specifically for suicidal patients.. MI, CBT, IMPACT and Problem Solving Therapy Limitations: 18-month follow up and correlational data only

79 Good news The Gotland Study: PTD
A primary care physician training program to increase early recognition and treatment of depressive disorder; suicide rates went down in the follow up years… “This finding strongly suggests that the significant decrease in the suicide rate after the PTD programme is a direct result of the robust decrease in depressive suicides of the area served by trained GPs.” Source: Rihmer Z, Rutz W, Pihlgren H., J Affect Disord Dec PTD – Prevention and Treatment of Depression Small Island off Sweden – post graduate training program for primary care doctors in how to recognize, diagnose and treat mood disorders - Quote is from the article abstract in J of Affective Disorders Much cited article showing the relationship of untreated mood disorders and how treatment could reduce suicide rates.

80 Depression/suicide screening in the Henry Ford Health Systems
Zero is perfect number of patient suicides Perfect Depression Care initiative Relies on a “shift in thinking, rather than on costly resources or a surge in clinical staff” Six steps: set goal, engage patients, improve quality, monitor, report, etc. (read) If you build it, they will come…

81 Results? 75% reduction in suicide
: baseline 87/100K suicides 4 years in: baseline dropped to 22/100K In the past two years, or the last 10 consecutive quarters, the department has not seen one patient suicide. U-Tube: Source, Ed Coffey, MD, CEO and Joint Com. Instructor! Do watch this U-Tube video – and show it in your program if you have internet access… makes a powerful point that suicide is preventable…

82 Dr. Ed Coffey… "There's nothing unique about the strategies. Everyone would say they're doing the same thing. We assess the risk and do everything we can do to lessen that risk.” Everyone gets training and must be competent (100%) on exams. Note – nothing unusual was done except to identify risk, assess it, monitor it and require staff excellence…

83 More good news! Addiction treatment works
Cohort suicide attempts year prior year after Adults > 25 yo (n=3,524) 23% % 18-24 yo (N=651) % % Adolescents (n=236) % % Karageorge: National Treatment Improvement Evaluation study 2001 This is a very positive finding…. NOTE TO INSTRUCTOR: Substance abuse counselors actually more time in face-to-face therapy than to most mental health professionals, at least in the public sector. And, they work to remove one of the most dangerous risk factors for suicide (booze and drugs).

84 Take home messages…. Most dangerous diagnosis: alcoholism and major depressive disorder… Am. Journal of Psychiatry, 1998. 3 Common clinical pathways: serotonin deficit, dopamine deficit, and alcohol in blood stream Co-occurring disorders kill There is no safety without sobriety… Treatment works! Treatment works in many cases We know much more about the clinical treatment of suicidal behavior than we did 10 years ago What we don’t know greatly outweighs what we do know MUCH RESEARCH IS NEEDED!

85 Discussion Questions?

86 Risk Rating Exercise Compare yourself with other judges
Rate each of the following on a scale of 1 to (1= no risk; 7 = high risk) Stelmachers & Sherman This exercise is designed on Stelmachers and Sherman’s work with rating suicide risk from clinical scenarios. The subjects in his study were mental health professionals (like your audience). “Use of Case Vignettes in Suicide Risk Assessment, Suicide and Life-Threatening Behavior, Vol 20(1), Spring 1990. Read the cases out loud and get the audience involved. Tell them they must work alone (no consultation) and make a severity rating. One goal is to raise their anxiety so that they do not do this kind of work without consultation.

87 CASE #1 A 21 year old male, foreign graduate student was brought to Crisis Intervention Center by friends and a pastor. After informing his friends that he planned to jump off a bridge, he actually went there and had to be physically restrained from jumping. He had written several suicide notes, one willing his computer to a friend, another to a different friend stating that the patient would be dead by the time his note was opened. * This case takes two slides, read them both.

88 CASE # 1 Continued The patient described himself as being quite depressed, with low energy, poor sleep and appetite, and persistent suicidal ideation. The precipitant seems to have been his girlfriend’s breaking off their engagement four days ago. He has a psychiatric history of several years, but refuses to reveal any details. He exhibits some grandiosity, paranoid mentation, anger, agitation and irritability. He appears somewhat manic but not depressed. He denies any acute plan to commit suicide and is threatening to sue the CID for having been detained. When you have finished reading the slide, give them only a couple of minutes to write down a risk rating number 1 to 7. Then invite someone to say their rating score out loud. Then ask others, or ask the audience. People are initially reluctant, but warm up quickly. This case scares everyone, which is the negative anchor point for future ratings. When you have exhausted their response, click to the next slide and show them how their colleagues rated the case.

89 Risk Rating Rating: High Risk Mean 6.21 SD. 0.86 Points to make…
1. The ratings is high. Fear for the patient’s safety is justified because… 2. I then click the slide back and have them sing out the risk factors. 3. I have them acknowledge their “felt fear” for this persons safety. 4. I note that fear drives clinicians together, thus the standard deviation is extremely low. Point? There should be little disagreement among clinicians when they know and share a comprehensive evaluation of risk, including all the ones highlighted in this case.

90 Case # 2 A 16-year-old Native America female presented as a self-referral following an overdose of 12 aspirin tables. Patient reports that she could not tolerate the rumors at school that she and another girl are sharing the same boyfriend. The patient denies being suicidal at this time (“I won’t do it again; I learned my lesson.”) She reports that she has always had difficulty expressing her feelings. In the interview she is quiet, guarded and initially reluctant to talk. Diagnostic impression: adjustment disorder READ Discuss, ask questions. Get the audience engaged. What should come out is: They don’t have enough data to make a rating If they are culturally competent, they will recognize this girl is not giving them much What little is learned is determined, in part, on the quality of relationship – Ask, is Adjustment Disorder justified. The answer should be no, since the interviewer did not determine: a) history of prior attempts b) R/O of depressive disorder, substance abuse, family history, etc. etc. Lesson: You can’t understand risk you haven’t explored thoroughly

91 Risk Rating Rating: Low Risk Mean: 2.25 SD: 1.29 Note:
Many will disagree with the low rating (it may not be justified because an incomplete evaluation was done) Note the large standard deviation – which means where there is little data there is a lot of disagreement Note: the Dx of Adjustment Disorder will not lead to a carefully considered risk management plan.

92 Case # 3 A 39 year old white male was referred from the Emergency room. Patient was in the process of overdosing when he was called by a friend, who arranged for the ambulance to bring him to the CIC. The patient took 10 or 15 aspirin tablets and 72 over the counter sleeping pills. He had written a long suicide note bequeathing belongings, expressing guilt about not doing well on his job and feeling hopeless about a “hereditary thinking disorder.” Read this slide and the next as one case

93 Case # 3 continued He feels that no one can help him and suffers from low self esteem. Says, “I’m a misfit.” Three nights ago he had also made a suicide attempt with Navane and aspirin but woke up by himself in the morning. He lives by himself. There was no obvious immediate precipitant, but the patient’s mother had died six months ago. He is currently in therapy and has a psychiatrist. Read both slides

94 Risk Rating Rating: High Risk Mean: 6.58 SD: 0.61
This one is a slam dunk. I use it to reinforce their growing sense of competence to recognize high risk when all the pieces are there. Note the very low SD --- and discuss

95 Case # 4 A 38-year-old man with a chronic and persistent, severe infection in his right hand is evaluated to be moderately depressed. Prognosis for his infection is not good and he has been struggling with feelings of hopelessness regarding his hand. There is no family history for suicide, mental illness, mood disorders or alcoholism. This man is neither alcoholic nor drug dependent, has a high IQ and has never been in trouble emotionally. He is cooperative during the interview, but distant. His family remains greatly concerned. * This is trap question to capture the concept that while 90% of those who die by suicide are mentally ill, 10% are not. This fellow falls in the 10% who do not have an Axis I disorder I remind them that context matters (per the threshold slide) Then I say, “You are permitted to ask this man one question. What is that question?” What he does for a living sets the context in which is ruined hand becomes the basis for an egoistic suicide. If someone calls out, is he a pianist, I give them a reward (a free book or something) If no one calls it out, I ask, “What does this man do for a living?” The first person to get it right gets the reward Then I show them the next slide.

96 What you need to know…. This troubled man has been training to be a concert pianist for the past 25 years. What we want here is MAJOR INSIGHT into what some people will not live life on terms other than their own, and these can be narrow and narcissistic.

97 Case # 5 A 30-year-old married female is discovered to be having an affair by her husband (a minister). After her husband’s learning of her indiscretions, she requests an emergency evaluation for treatment. She states she has not been depressed, but does feel panicky. She states her husband has a history of losing his temper and she is afraid of him. However, she seems resourceful, intelligent and articulate. There are no children in the family. She does not have a history of prior suicide attempts, but reports she is now thinking about it. She reports she and her husband have continued having sexual relations throughout the period of her affair. This slide is, again, to highlight the importance of context in assessing suicide risk. After they have completed a rating, I ask them to set the next appointment. Outpatient? Immediate hospitalization? Often a discussion of potential domestic violence will come up. When they have complete this discussion, I click to the next page (the rest of the story) and let them read it and weep. Point out: a) how context drives risk, b) the need for anticipation of risk increasing, and b) this is not a true case as Dr. Quinnett was home ill with the flu one day and forced to watch the Soap Operas and made this up…..

98 What you can’t know, but should always plan for….
Two days before her scheduled counseling appointment, her lover tests positive for HIV and calls her husband to inform him of his exposure…. Context changes and context matters…

99 Things to Keep in Mind The absence of SI does not equal no suicide risk The denial of SI does not equal no suicide risk Once suicide been considered a solution, the problem it would solve can suddenly become much bigger Always determine the psychological, social, emotional, and environmental context and crisis in which a suicidal person is trapped, or feels about to be trapped. Read

100 Things to keep in mind…. Wall, Platt and Hall, 1999 study of 100 successive suicide attempters: - 83 had been seen within one month by healthcare providers (PCP and mental health), yet only 28 had be asked about suicide. You can’t assess risk you don’t know is there, and your referral source PROBABLY hasn’t asked! Don’t ask, don’t tell, don’t work…. * This is a widely cited study, but I don’t spend much time on it, except to point out the missed opportunities.

101 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 10: My schedule is already full next week if they need extra sessions. These 10 top reasons may or may not play to your audience, so you can use them as an elective. There are a few points however: We don’t ask about suicide because if frightens us Because we were never trained If we don’t ask before the half hour mark in an interview, we may be dealing with a crisis in the last 10 minutes Not asking could be costing lives.

102 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 10: My schedule is already full next week if they need extra sessions. Reason # 9: If they were really suicidal, they would say so. * False belief – the way it used to be years ago.

103 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 10: My schedule is already full next week if they need extra sessions. Reason # 9: If they were really suicidal, they would say so. Reason# 8: There’s no room on the form. I’ve reviewed hundreds of mental health intake documents…. Very little or no space is provided for suicide risk assessment

104 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 10: My schedule is already full next week if they need extra sessions. Reason # 9: If they were really suicidal, they would say so. Reason# 8: There’s no room on the form. Reason # 7: I’m not sure I like this patient very much. * This is actually a clinical matter of some concern as it involves what Maltzberger calls “Malevolent Countertertransference” which means, there is something about this patient I detest. Clinical response? Find another therapist, quickly.

105 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 10: My schedule is already full next week if they need extra sessions. Reason # 9: If they were really suicidal, they would say so. Reason# 8: There’s no room on the form. Reason # 7: I’m not sure I like this patient very much. Reason # 6: The managed care company doesn’t want to know. This is only partially true, as Pacific Behavioral Health is actually screening for suicide risk in all their insured.

106 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 5: Denial in my line of work is underrated, what I don’t know can’t hurt me. Joke – until you realize that while it may not hurt you, you patient could die – and denial is a poor excuse if your on the witness stand defending yourself.

107 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 5: Denial in my line of work is underrated, what I don’t know can’t hurt me. Reason # 4: It’s already 11:45 and I have plans for lunch. Quiz item! We recommend getting to the S question by no later than the ½ hour mark of an intake interview. NOTE TO INSTRUCTOR: This quiz item only pertains to the use of the QPRT, not to the quiz items from the general pool on knowledge about suicide content.

108 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 5: Denial in my line of work is underrated, what I don’t know can’t hurt me. Reason # 4: It’s already 11:45 and I have plans for lunch. Reason # 3: I probably couldn’t get them into a hospital anyway. Point: Too many clinicians are not willing or able to fight, confront or otherwise challenge admission criteria, hospital-based screeners or managed care company gatekeepers…. Thus, at-risk patients who ought to be in hospitals never get admitted… since managed care companies don’t pay death benefits and hospitals can’t be sued for people they never admitted… well, you know the rest.

109 The 10 Top Reasons never to ask your patient if they’re suicidal
Reason # 5: Denial in my line of work is underrated, what I don’t know can’t hurt me. Reason # 4: It’s already 11:45 and I have plans for lunch. Reason # 3: I probably couldn’t get them into a hospital anyway. Reason # 2: Nothing I learned in graduate school says I have to. Point? Ask for a show of hands of those who completed a suicide risk management or risk assessment course.

110 And the # 1 reason not ask our patient if he or she is suicidal?
MY GOD THEY MIGHT SAY YES! Gets to our worse fears! NOTE TO INSTRUCTOR: Suicidal patients frighten clinicians – I have an essay on this, now included in the online QPRT course you have taken. Print it if you like.

111 End Module Questions Q&A

112 Avoiding Suicide Malpractice
Highlights only – full 2-hour course now available online at Taught by lawyer and psychologist You may wish to show my video lecture here if you need a break or do not feel comfortable with this subject area.

113 Common Suicide Malpractice Errors
Type 1: Failure to detect and assess suicide risk Type 2: Failure to manage and treat properly (sub standard care) Type 3: Postvention failure – failure to address survivor needs Speaks for itself. These classifications originated with the QPR Institute

114 Who will sue you? An uninformed family is a potentially litigious one -especially if not comforted after the suicide.” Source: QPR Institute, 2001 This is where the lawsuit will come from.

115 Best Defense? 1. A well-trained, skilled clinician (with documented specific training) 2. Sensitive and caring staff with client and family (they don’t sue you if they like you) 3. Everyone took reasonable and competent steps in providing assessment and care Standard stuff

116 Worst Defense? 1. Untrained, unskilled and unprofessional staff
2. Perceived as uncaring by client and family 3. Evidence of sloppy work Standard stuff

117 Avoid suicide malpractice every time!
Get appropriate training and keep records of same Routinely query about suicide risk Document your risk assessment Carry out a “best practices” treatment plan Team up and chart Document why you did what you did, and why you didn’t do something even your mother would think you should do. Standard stuff

118 Skip Simpson, Attorney at Law
"If the docs took the course, followed the course in their practice, documented their actions, and still had a suicide, they would not need insurance if I reviewed the file. I have never sued a mental health practitioner with a documented file.” Skip Simpson, Attorney at Law (Jedi Knight of Suicide Malpractice – 88%) Our pal Skip (ex US Air Force navigator on a B-52), teaches psychiatric residents at the University of Texas School of Medicine in how to avoid suicide malpractice, and serves as on the QPR Institute’s Advisory Board. He is the co-leader in our new online course called, “Avoiding Suicide Malpractice.”

119 “If it isn’t written down, it didn’t happen.” T. Gutheil, 1980 ***
Twin pillars of defense: Consultation and documentation TEST ITEM!

120 True story My son died by suicide in 1993 and in the process of suing the hospital and the doctor, the last professional to see my son for therapy was a Ph.D. in Psychology. When this person was deposed, he reported that  he never asked him if he was suicidal (Todd was two days post discharge from a suicide attempt) and said that 'he was a bright young adult, if he was suicidal, he would have told me.' Two days later, Todd hung himself.   I won the case out of court without going to a jury! Sherry Bryant, LCSW, CADC, LMFT This story is from a colleague and a QPR instructor.

121 End Module Questions Lunch? Q&A

The greater the number of losses, the greater the risk. Personally humiliating events. No good evidence for sexual orientation as an independent risk factor for suicide. Treatment prevents suicide. Eve Morscicki, NIMH, 1997 Move quickly through these background slides.

123 Suicide Risk Assessment: What you Need to Know…
Screens for suicide produce large numbers of false positives (will not die by suicide) Positive screens require assessments No useful psychological tests or methods to predict suicide attempt (NIMH) Summation of risk factor approach too nonspecific and weak in predicting individual suicide Optional

124 Prediction vs. Standard of Care
You are not required to predict the future, but you are required to try (assess risk). Note: 40% of clinical decisions at major academic medical centers are not based on research evidence (Gray, Evidence Based Psychiatry, APA 2004) Optional

The greater the number of losses, the greater the risk. No good evidence for sexual orientation as an independent risk factor for suicide. Personally humiliating events may trigger suicidal behavior in non-mentally ill people Single greatest risk: untreated mental illness Eve Morscicki, NIMH, 1997 Optional

Necessary condition + trigger(s) push suicide threshold. Distal vs. Proximal & Trait vs. State variables. Halt (hungry, angry, lonely, tired). Absence of a psychiatric diagnosis does not equal mental health. Co-morbidity is the single greatest risk. Straightforward – and only if you have time – - Co-morbidity – e.g., Depression and alcoholism, American Journal of Psychiatry, fall 1998…. Etc. See full reference list Key references: Center for Substance Abuse Treatment. Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 50. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. Brown SA, Inaba RK, Gillin JC, Schuckit MA, Stewart MA, Irwin MR. Alcoholism and affective disorder: Clinical course of depressive symptoms. American Journal of Psychiatry. (1995); 152: 45–52. Cherpitel CJ, Borges GL, Wilcox HC. Acute alcohol use and suicidal behavior: A review of the literature. Alcoholism: Clinical & Experimental Research. (2004); 28: 18S–28S. Conner KR, Britton PC, Sworts LM, Joiner TE Jr. Suicide attempts among individuals with opiate dependence: The critical role of belonging. Addictive Behaviors. (2007); 32: 1395–1404. Cornelius JR, Salloum IM, Day NL, Thase ME, Mann JJ. Patterns of suicidality and alcohol use in alcoholics with major depression. Alcoholism, Clinical and Experimental Research. (1996); 20: 1451–1455.

National Survey: Almost all clinicians rely on clinical interview (Jobes, Eyman & Yufi, 1995). No known test will predict suicide. Screening inventories useful but…. Beck Hopelessness scale the best life long predictor Risk detection is job one. 75% of suicides see a physician within a week to a month before their death (NIMH: opportunities missed) Optional

Current screening methods produce large numbers of false positives. Summation of risk factor approach: -not clinically useful -too nonspecific to be helpful -inefficient and weak in predicting individual suicide 67% - 91% of completers made no previous attempt (Coe, 1963 & Dorpat, 1960). Lot’s of risk goes unrecognized… Give this one a light once over… POINT IS THIS: Estimated 50% of suicidal patients seen in out patient settings are never detected by clinical providers.

129 UNRECOGNIZED RISK 60% of suicide completers had no contact with a mental health professional and no prior suicide attempt. 60% to 90% of all suicide completers had communicated explicit intent to a significant other during the period prior to death. 75% to 80% had a non-psychiatrist physician contact within six months. 93% of completers had an Axis I diagnosis. One-sixth of all completers are in current treatment with a mental health provider Clark and Fawcett 1991 YOU CAN HAMMER THIS POINT HOME: “Too many clinicians don’t know what they don’t know.”

130 What do we know? Get some training….
Surveys show most clinicians use an interview format, not psychometrics There is no consensus practice standard or tool (Simon & Shuman, CNS, 2006) Review the APA’s Practice Guidelines for comprehensive review (Jacobs, et. al, 2004) Get some training…. Optional, but tight summary of the field

131 Raising the bar beyond the current standard of practice
You are required to perform an adequate assessment, not to predict suicide. The standard of care is legally defined, not ideal (statutory language varies state to state). Standards of care are minimum, not maximum Medical custom vs. reasonable & prudent WE CAN DO BETTER… Optional

132 Worst clinician in the world!
- Suicide is not spoken here, so no query was ever made - Assessment appears skimpy, e.g., “Denies SI, HI and CFS.” - Skimpy assessment + reliance on no-suicide contract (“He promised me he wouldn’t.”) - Assessment present but written in Sanskrit (inscrutable handwriting) - Assessment is not communicated to others SI = suicidal ideation – HI = homicidal ideation – CFS = contracts for safety. All evidence of poor practice – See next slide showing root cause analyses for hospital suicides.

133 JCAHO Reported 501 Inpatient Suicides From 1995 To 2004 And 56 In 2005
JCAHO and Suicide JCAHO Reported 501 Inpatient Suicides From 1995 To 2004 And 56 In 2005 Note failures in communications training, assessment and safety – see next slide to reinforce.

134 Where Inpatient Suicide Occurs
Most common sentinel event reported to the JCAHO Since 1996* (14%) Method: 71% Hanging 14% Jumping Factors 87% Deficiencies in physical environment 83% Inadequate assessment 60% Insufficient staff orientation or training Where Inpatient Suicide Occurs Source – note failures in assessment, training, and environment. 83% OF THE SUICIDE DEATHS WERE PRECEEDED BY AN “INADQUATE ASSESSMENT” 60% BY INSUFFICIENT STAFF TRAINING *Sentinal Event reporting begain in Source: Reducing the Risk of Suicide. JCAHO, Joint Commission Resources, Inc. 2005

135 Best clinician in the world!
Treats all threats as genuine (until proven otherwise) Gets all the data and the PINS Understands the CONTEXT Assesses clinical status thoroughly Documents all actions taken and why Documents all actions NOT taken and why Communicates the risk to others PINS are Pre Incident Indicators – from Gavin DeBecker’s work on predicting violence – we are coining a term – Pre Suicide Attempt Indicators… PSAI .. Coming to a theater near you soon… deBecker, Gift of Fear 1997.

136 Limitations of the clinical interview in suicide risk assessment
Update and new research You may wish to spend a few minutes on these slides – the points made here are based on our latest research, not yet published.

137 Current practice standards
Clinicians rely on their clinical interviewing skills to understand the patient’s reality The patient’s reality is often distorted by CNS dysfunction “Facts” elicited from distressed patients may be interesting and useful to plan treatment, but they may not be an accurate reflection of dynamic reality Optional

138 Self-disclosure and suicide risk: Why not “tell all?”
Fear that full disclosure will lead to voluntary or even involuntary hospitalization Fear that full disclosure will prevent discharge from hospital Fear that full disclosure will lead to arrest and possibly incarceration Fear that full disclosure of suicidal desire and intent will lead to unwanted rescue Optional – Source: Quinnett and Baker, unpublished study, 2007 – personal communication – next three slides NOTE: These observations are included in the online course.

139 Why not “tell all?” Fear that revelation of access to a firearm or drugs may implicate personal or third party illegal ownership of same Fear that the interviewer is neither benevolent nor trustworthy Fear that revelation of a suicide plan may expose a double suicide, suicide pact or planned murder-suicide Fear that disclosure of suicidal desire, intent, rehearsal or past suicide attempts will lead to shame and censure or job denial or loss More fears and why suicidal patients deny suicidal ideation

140 Better solution Do not rely on a single reporter
Do not rely on a single data source Do rely on multiple observers Interview everyone possible (conduct a psychological autopsy in reverse) What you don’t bother to learn now, you have to learn later (in court) It’s what they do, not what they say THINK LIKE A SOCIAL WORKER NOT LIKE A SURGEON! TALK TO THE FAMILY!

141 End Module Please read your QPRT User’s Manual/Handouts carefully….
Always do better on the competency quiz that the lawyer who is suing you….. New slide

142 This is not an MRI of the lawyer about to sue you…

143 End Module Questions Q&A

144 The QPRT Risk Assessment Method

145 QPRT recognition 1998 J.J. Negley Associates, Inc. Presidents Award for Avoiding Suicide Malpractice. $15,000 NCBHC Joint Commission 3 patient safety publications Devereux Foundation adoption (1999) APA Patient Safety Task Force (2002) TIP 42 (2005) Background – optional YOU SHOULD BE FAMILIAR WITH THE EVALUTIONS OF QPRT

146 Developed by clinicians for clinicians Brief and user friendly
QPRT Benefit Summary Developed by clinicians for clinicians Brief and user friendly Standardizes suicide risk data collection Improves triage decision making Reviewed and contributed to by nationally and internationally known suicidologists Heavily field tested in outpatient, emergency and hospital settings Offers adult/older adult, pediatric and hospital versions Snapshot of developmental history – with original work completed at Spokane Mental Health, Spokane Washington by an interdisciplinary team of psychologists, psychiatrists, therapists, and nurses.

147 Nests well with other risk evaluation methods
QPRT Benefit Summary Routinely detects the presence of suicidal ideation, feelings, plans and past attempts Nests well with other risk evaluation methods Generic and fits into any medical or psychological record Integrates risk assessment with risk management Enhances standard of care Is accepted by patients (89% report satisfaction with interviewer’s skill and comfort) Is accepted by clinicians (94% believe it improves their standard of practice) Reduces exposure to suicide malpractice Utility and practicality

148 The QPRT interview is not:
A substitute for psychiatric diagnosis A treatment plan A substitute for a comprehensive mental health examination Straigtforward

149 Follow along…. Please take your sample QPRT or one from your folder and follow along and, if you like, make notes… ASK YOUR PARTICIPANTS TO TAKE OUT A QPRT INVENTORY AND FOLLOW ALONG

150 No relationship, no data
Without a “therapeutic alliance” with the suicidal patient little information of real value will be learned from any interview protocol, including this one The strength of this alliance determines how well this protocol works to assess suicide risk and intervention results Source: Multiple studies cited throughout the about-to-be published book, tentatively titled, “Building a Therapeutic Alliance with the Suicidal Patient.” by APA Books – scheduled for release in 2010…. Edited by Konrad, M and Jobes, D. – As an early reviewer of this much-needed text, we at the QPR Institute wholly support a return to the basic and essential need to reestablish the value of the therapeutic relationship and all that it means to suicidal sufferers.

151 The QPRT interview is: A tactical structured interview protocol designed to obtain critical, dynamic suicide risk and protective factor information A tool to help determine near-term suicide risk A strategic intervention designed to reduce immediate risk of suicide through empathic inquiry and enhance suicide protective factors Note , and emphasize, that without a “therapeutic alliance” with the patient, the odds are not good that you will be told the “patient’s narrative” of their inner view and thoughts about suicide.

152 The QPRT interview may not be useful with:
Actively psychotic patients Patients so depressed they can barely speak, or so manic they cannot be engaged Intoxicated patients Delusional patients Highly impulsive patients, especially if on drugs and/or alcohol Patients suffering from severe dementia or obvious cognitive impairments LIMITATIONS OF THE QPRT Read and take questions

153 Asking the S Question: Samples
“You know, when people are as upset as you seem to be, they sometimes wish they were dead. I’m wondering if you’re feeling that way, too?” “You seem very unhappy. Have you had any thoughts of death or suicide?” “Suicidal thoughts are a common symptom of depression; have you had been depressed lately?” “Have you been suicidal or have you been thinking about suicide?” These are probes to detect suicide risk, ideation and to prepare the patient to begin to tell their story about suicide.

154 Sample S Questions “Are you considering ending your life?”
“Have you ever wished that you were dead?” “Are you thinking about killing yourself?” “Have you thought about suicide in the past two months?” (Sometimes suicidal people will tell you about how they felt last week, but not today.) Sample questions

155 Wrong way to ask S Question
“You’re not thinking of suicide, are you?” …or any variant question which asks for a denial…. Ask for other “wrong ways to ask the S question” – there are many…. NOTE TO INSTRUCTOR: To engage them, and wake up the post-lunch dozers, ask them how they would ask the suicide question to ensure a “No” response to ideation.

Patient Name Case Number Date Questioned the patient about thoughts of death or suicide: Yes No Suicidal thoughts/feelings present: Yes No If no, review and initial statement on following page. If YES, document: WHAT IS WRONG? WHY NOW? WITHWHAT? WHERE AND WHEN? WHEN AND WITH WHAT IN THE PAST? WHO IS INVOLVED? WHY NOT NOW? Q Have participants find their sample copy and proceed with you to cover all the points. Briefly describe what they should learn from each stem question, and have them open their QPRT User Manual so that can skim this part with you.

157 WHAT’S WRONG? What You Should Learn:
Explanation of the reasons for suicide Problem(s) that suicide would solve, such as being a burden on others How this person solves problems Take them through each reason for question – what they should learn, sample Qs and key points Key back to Joiner’s thwarted belongingness and perceived burdensomeness on others.

158 Eliciting the narrative..
There is therapeutic value in telling the story – and we mean the “whole story” behind the ideation or attempt… The clinician must simply say, “Begin wherever you like…” Interrupt the patient’s story only for clarification Source in support of eliciting the full narrative: Michel, K., Maltzberger, J.T., Jobes, D.A., Leenaars, A., Orbach, I., Young, R., & Valach, L. (2002). Discovering the truth in an attempted suicide. American Journal of Psychotherapy.

159 Sample Questions “Okay John, why don’t you tell me what’s wrong with your life right now?” “Audrey, could you tell me what led up to this? Begin anywhere you like.” “We’ve got some time to talk. I’d very much like to hear your version of what’s wrong right now and this crisis came to be.” Leads to open up the patient’s narrative, and to elicit why suicide “makes sense” to this person.

160 Key Points for What’s Wrong?
Most suicidal people need to talk. Others may not be listening, but now you are. Telling their story produces relief. Active listening without interjecting judgments or opinions is essential to encourage full disclosure. Telling one’s story may help restore the person’s ability to think more clearly and cope more successfully. Earlier sources – and very much the basis for the art of healing and psychotherapy… all the way back to the Greeks…

161 Expect Common themes (suicidal desire and intent)
Feels hopeless and depressed (clinical depression is the most common cause of suicide) Feels isolated and alone Has lost job or major relationship or a multiple of losses Feels overwhelmed, angry and upset Joiner theory proved….

162 Common themes Feels like a burden on others
Financial problems with no escape Fears being humiliated, e.g., arrested for a sex crime Has serious problems at work More themes

Patient Name Case Number Date Questioned the patient about thoughts of death or suicide: Yes No Suicidal thoughts/feelings present: Yes No If no, review and initial statement on following page. If YES, document: WHAT IS WRONG? WHY NOW? WITH WHAT? WHERE AND WHEN? WHEN AND WITH WHAT IN THE PAST? WHO IS INVOLVED? WHY NOT NOW? Q Just show them the slide again for orientation

164 WHY NOW? What you should learn
Recent history of recent or anticipated real or imagined losses or rejections. Trigger event(s) - separation from spouse, loss of home, domestic violence, anticipated loss of job, any changes creating a sense of burdensomeness on others, or that causes isolation from one’s primary group. Onset of sleeplessness, depression, loss of appetite, relapse into drug or alcohol use, anxiety, panic attacks, or other symptoms of acute psychological distress. Read

165 Sample Questions “Robin, what has changed such that you are considering suicide now?” “It sounds as though this relationship has been difficult for a long time. What’s different for you now?” “Joe, it sounds like you’ve been unhappy for months and hadn’t contemplated suicide before. Why are things so unbearable now?” Precipitating event questions – final straws? Note: the final straw triggering the suicide attempt may not have happened, but is anticipated, e.g., a story of humiliation about to appear in the newspapers, or being fired from one’s job.

166 Key Points for Why Now? Something unacceptable is about to happen.
Suicide or homicide threats have been made. Ambivalence about living or dying, and both reasons for living and dying may be expressed. Listen for both suicide risk and protective factors. Are suicidal desire and intent present? How is the person’s ability to cope being overwhelmed? Read and discuss

167 WITH WHAT? What You Should Learn:
The means of suicide under consideration (if any) Lethality of means being considered Accessibility to the means selected (this requires a follow up question – where are the means?) Whether more than one method is under consideration Practice or rehearsal with the means selected Exploration of means of suicide and their access and restriction According to Joiner, rehearsal with a means of suicide builds capacity to enact lethal self-injury.

168 Sample Questions “Have you thought about how you would kill yourself? If the person responds with a ‘yes,’ follow up with: - “Can you tell me how you’ve considered ending your life?” - “How would you kill yourself?” - “Do you have a method in mind?” - “Have you practiced with the (means selected)?” Read

169 Redundant Planning? Sample questions:
“Have you had any other thoughts of how you might kill yourself?” “If the first method didn’t work what else might you try?” The cautious interviewer explores alternative means that might be under consideration. NOTE TO INSTRUCTOR: Redundant planning is very different from more impulsive suicide attempts, and much more likely to be lethal if a planned attempt is made.

170 Sample questions to determine the availability of means
“Do you have immediate access to (medications, a gun, a razor blade, etc.)?” “Where is the gun (rope, razor, etc.)?” “Where would you get the medications (gun, rope, razor, etc.)?” Add a clinical story here if you have one… relevant to these matters.

171 Key Points for With What?
Rehearsal suggests suicide capability is present Past self-injury (with any method) Risk increases dramatically with access to means Never suggest another method or means Means selection is often influenced by culture, occupation, social contagion (modeling effect), and availability Multiple methods under consideration = greater risk Read

172 WHERE AND WHEN? What You Should Learn:
A conditional suicide plan contingent on some unacceptable event, “If she leaves me I will kill myself.” “If they fire me, I die.” “If I’m arrested I will have to kill myself.” Possible location of a suicide attempt Plan for rescue or to avoid rescue Degree and details of lethal planning Possible anniversary phenomena Potential for murder-suicide or suicide pact Read– add clinical stories if you like, but be brief…

173 Sample Questions “Have thought about where you might try to kill yourself?” “Have you decided when?” “Is there something that might happen that would put your plan in motion?”

174 Key Points for When and Where?
Many suicide attempts are impulsive and little or no planning will be evident Generally, the more detailed the planning (intent) the greater the risk Specificity of time and place = greater risk Determination of “anniversary phenomena” may open discussion of opportunities and a referral for help, e.g., grief counseling for a major loss Efforts to avoid rescue = greater risk Resistance to disclosure of a suicide plan may indicate higher risk Read and highlight

What You Should Learn Past history of suicidal behaviors Past history of intense suicidal ideation and/or planning Method used in any suicide attempt(s) Whether rescue was avoided Timing and precipitants of past attempts Careful history taking of prior attempts is critical to understanding current risk -- we cannot stress this too much…

Social response to past attempt(s) Treatment, if any, following a suicide attempt or period of severe ideation Degree, if any, of medical injuries Potential protective factors Comparison of current method under consideration vs. prior method used You can see that the response to each lead probe, should lead to several more.

177 Sample questions “When was that?
“Pat, you’ve been struggling with a lot of different feelings lately and you’re telling me you’ve been considering suicide. Have you ever had thoughts of suicide in the past?” - If Pat responds “yes,” then ask: “When was that? After learning when a previous episode of suicidality occurred, follow up with: “Did you think about suicide seriously for two or more weeks?” “Did you attempt suicide at that time?” Repeat the inquiry until you have the complete history These questions are designed to assess acquired capacity for self-injury.

178 Key Points for When and With What?
Comprehensive history taking is strongly recommended The more detail elicited the better Suicide attempts while in treatment = greater risk and suggests extraordinary precautionary safety measures are indicated Historical response to a past suicide attempt may provide insights into resolution of the current crisis Attempt to avoid rescue? = greater risk New method under consideration? = greater risk This is self explanatory

179 WHO IS INVOLVED? What You Should Learn Role of significant others
Names of potentially helpful third parties Names of potentially harmful third parties Names of persons on whom the suicidal person feels he or she is a burden (a perceived, not necessarily real burden) Possible presence of a suicide pact or murder-suicide plan Who is a burden, who is thwarting the person’s sense of belongingness…. – You will often know this from the patient’s first narrative explanation – provided you took the time to elicit it fully… a la Carl Rogers non-directive interviewing …

180 Sample Questions “Who are the people or the activities that are important to you?” “Who else knows you are in this much pain?” “Who is your main support during times like these?” “Is there anyone who will be hurt if you take you own life?” “If you feel like a burden on others, who are they?” More questions to determine burdensomeness and thwarted belongingness

181 Key Points Most suicidal crises involve at least two people, such as a couple in conflict Suicide threats made to significant others without producing relief or change may suggest higher risk Social isolation = greater risk Feeling a burden to significant others = greater risk Threats of violence toward others may be part of a planned suicide, or murder-suicide plan involving a conflicted relationship, students at school, or co-workers Read

182 WHY NOT NOW? What You Should Learn
One or more protective factors (reasons for living) Spiritual or religious prohibitions against suicide Personal or professional responsibilities to others (connectedness) Plans made for dependent others, such as, “My brother will raise my children.” Meaningfulness of life and purpose for living Residual tasks to be completed before the attempt, such as making out a will Searching for buffers/protective against suicide … and routes to avoid guilt NOTE TO INSTRUCTOR: EMPHASIS TO THE AUDIENCE THE NEED TO SIT AND SPEND TIME WORKING TRHOUGH AND BUILDING UP BUFFERS… THIS IS A MAJOR INTERVENTION IN THE RESTORATION OF MEANING AND PURPOSE TO ONE’S GOING ON LIVING.

183 Sample Questions “Give me some reasons why you may want to live?”
“You’ve shared some reasons why you are considering suicide. What are some reasons that you should not kill yourself?” “Can you give me three reasons to go on living?” “Can you tell me about your core values and beliefs?” “Who are you close to? Who matters in your life” “What are your dreams for the future?” Sources for good reading content on these matters: “Building a Therapeutic Alliance With the Suicidal Patient” edited by Jobes and Michel… 2010 or 2011 – includes literature reviews on hope, purpose and meaning in life as buffers against suicide.

184 Key Points Few or no protective factors = greater risk
Serious isolation or rejection by others = greater risk The offer of treatment, rest, hope, relief from suffering is a powerful protective factor Marshalling protective factors lowers risk Low risk does not equal zero risk Summary and Review

185 Persuading the Person to Get Help
KEY POINTS: Expressed anger at you may mean greater risk Refusal to accept help = greater risk An abrupt or angry withdrawal from the interview may mean greater risk Unwillingness to remove the means of suicide = greater risk Reassessment of risk may be indicated if help is refused Emergency intervention, consultation and/or supervisory input should be readily available Read

186 I agree to continue to see my current provider and/or:
Accept a referral to Community Mental Health Accept a referral to I also agree to the following: to remain clean and sober until crisis passes. to follow medical advice, including medication regime (if prescribed) to remove (or see to the removal of) the means of suicide. to not harm or kill self accidentally or on purpose. to call and talk to office, hotline, mental health provider or other responsible person in case of crisis. to accept responsibility for this safety plan. My agreement to safety is: If no answer to 1st question, and rest of protocol covered without raising suspicion of elevated risk

187 Appropriate releases signed (if necessary).
Patient/family educated about access to (in)voluntary psychiatric hospitalization and community resources. Patient/family accepts literature on suicide prevention and agrees to return for follow up. Appropriate releases signed (if necessary). Disposition and Signed Agreement or Check Here If Verbal Agreement Only I understand that my suicidal thoughts and feelings are the probable result of a current crisis, or of an untreated depressive illness, or of some other medical and/or psychological condition. Understanding this, and that treatment is available, I am willing to accept help. I agree to be safe and will not attempt or complete suicide while my provider and I pursue relief of my symptoms, problems and current distress. I have supplied my provider with names of relatives and/or friends whom he or she may contact about my safety plan. Completed by: Date Patient Signature: Date Witnessed by: READ aloud the disposition statement and be prepared to discuss it. It was reviewed by two mental health lawyers on the development team… you will see it is not a no-suicide contract, but is a statement of informed consent to treatment – although it does request a safety-statement. Since inception and first use in 1996, the QPR Institute is unaware of a single successful action or complaint brought against a clinician or treatment facility using the QPRT Suicide Risk Management Inventory for patient assessment and reassessment. There may have been some, but we are unaware of any such potential negative outcomes.

188 Suicide risk is low to moderate
When: - Few risk factors are present and several or many protective factors are present, and the person agrees to: * Not use drugs or alcohol * Seek help or accept a referral * Remove the means of suicide * Commit to a safety plan Stratification of suicide risk is a difficult challenge and not well researched or even understood. Still, some estimates may need to be made by clinical providers. Based on what we know, the following slides are worth consideration

189 Suicide risk is high When:
many risk factors are present and few or no protective factors are present, and the person: - Has been uncooperative - Has said little or nothing about his or her problems - Has been distant, evasive and aloof - Refuses to go along or agree to the referral and safety plan - Refuses to remove the mans of suicide Read - this high risk decision is based on collective and peer reviewed clinical data presented in various scenarios and role-plays

190 Low confidence note… A progress note indicating a low confidence in the assessment means at least a moderate risk rating is warranted and reassessment is indicated in the near term (not more than 24 hours). A second risk assessment opinion may also be indicated.  Where confidence in the risk rating is low greater vigilance as well as ongoing or more frequent observation and monitoring is indicated. See earlier reasons why full disclosure may not be forthcoming. This note can be made on the QPRT or in the clinical record….

191 Assessment confidence interval
What is low risk = ? What is moderate risk = ? What is high risk = ? How confident are you in the assignment of these levels of risk? What if you’re wrong? New slide – now addressed in the 2nd edition of the QPRT manual/handouts. In the clinician does not wish to use the QPRT itself, any sense of low confidence in their interview data should lead to a consult and second opinion – Stratification of risk decisions have serious clinical monitoring and communication implications for patient care….

192 Low confidence note … The person has been uncooperative and refused to collaborate in the assessment Is suspected of being deceitful in answering questions Has or may have psychotic symptoms, especially paranoia Is or has been recently intoxicated New slide – used to make clinical call about confidence interval

193 Low confidence note when the person…
Has a history of impulsivity Refuses to sign releases to collect or confirm collateral information, such as medical records from other providers. Is faced with an uncontrollable external event which may trigger a suicide attempt, such as the serving of divorce papers or a warrant to appear in court And???? New slide – cautionary note about what risk management strategies will be implemented. Discuss how they (the audience) would manage item 3 above…

194 What else would cause you to have low confidence in your risk rating
Discussion…. Discussion

195 Persuaded patient to accept help/treatment:
Risk low, patient commits to safety plan. Risk moderate, commits to safety & referral plan. Patient not persuaded to accept help/treatment: Risk high, initiate emergency room evaluation/(in)voluntary hospitalization procedure. (NOTE ON CONFIDENCE INTERVAL HERE) Referral. Patient agrees to remain with current provider and/or: Accepts a referral to Community Mental Health Accepts a referral to P R This is the section where a handwritten note of “Low Confidence” should be made according to the guidelines in the User’s Manual, adult version. This is an optional ad on for both hard copy and EMR

196 Suicide Risk Management Inventory
Risk Management Plan. Patient verbally agrees: to remain clean and sober until crisis passes. to follow medical advice, including medication regime (if prescribed) to remove (or see to the removal of) the means of suicide. to not harm or kill self accidentally or on purpose. to call and talk to office, hotline, mental health provider or other responsible person in case of crisis. to accept responsibility for this safety plan. Quote patient's statement of agreement to safety: Patient/family educated about access to (in)voluntary psychiatric hospitalization and community resources. Patient/family accepts literature on suicide prevention and agrees to return for follow up. Appropriate releases signed (if necessary). Suicide Risk Management Inventory  Paul Quinnett, Ph.D., and Kevin Bratcher, M.S., 1996 Completed by: Date White - chart copy, Pink - chart copy, Yellow - client/patient copy T Clinicians reviewing the risk management plan with the patient may experience resistance to safety actions to be taken by the patient…. If such resistance is encountered, reassessment is indicated… QPRT

Poor safety agreement language - “I guess I’ll be okay” (vague) - “I’ll call somebody if things get bad.” (vague, lacks specificity. How will anyone know when things “get bad?” What is “bad” in this context? Who is “somebody?”) Read and discuss VAGUE IS BAD, SPECIFIC IS GOOD

198 Real people safety statements
“If things get this bad again, I’ll call my pastor. Honest, I will.” “I won’t do it. I promise. I wouldn’t put Adam through that. I’ll call you back personally if I need to.” “I can, and do, agree to a safety plan. I don’t want to die. I honor my word.” What’s right or wrong with these – source: Clinical records from patients admitted the outpatient services at Greentree Behavioral Health, a division of Spokane Mental Health, Spokane, Washington, US.

199 KEY POINTS in Safety Agreements
Set specific times and expectations for crisis management action steps (work through safety plan checklist) Recommitment to life; not a “no-suicide contract” Clarity of language in a person’s recommitment to life and safety plan helps confirm risk is now lower Hard copy directions, phone numbers, and how-to steps are helpful and key to avoiding claims of negligence Review

200 USE QUOTATIONS For example, “I just couldn’t do that [suicide] to my family,” illustrates that, in this case, the family is a strong protective factor. Likewise, the phrase, “I have a five-year-old boy and am pregnant right now,” indicates much lower suicide risk than, say, “I have no children and just had my first abortion.” If the statement is not clear and unequivocal, try to help the person make the statement more clearly. The greater the clarity of this commitment, even over the phone to a stranger, the greater the likelihood the person will follow through with the recommended referral. WRITE IT DOWN WHATEVER THE PERSON SAYS, WRITE IT DOWN. REASON? BECAUSE IF THEY GO ON TO KILL THEMSELVES, YOU MAY FIND YOURSELF READING YOUR CHART TO A JUDGE AND JURY. IF ACCEPTED A VAGUE, HALF-HEARTED COMMITMENT TO SAFETY, IT WILL NOT PLAY WELL IN COURT. BUT IF YOU GOT A CLEAR AND CONVINCING STATEMENT OF SAFETY, THEN THE JURY WILL SYMPATHISE WITH YOU, NOT THE PERSON WHO DIED.

201 Role play practice sessions
Allow minutes per role play Complete sample QPRT as part of the practice session Process each experience All questions answered Begin role plays

202 When to use QPRT Managing Risk over Time
At admission At discharge At significant transitions during treatment change in risk factors (health, SA, loss, etc.) change in placement/caregivers Documented in core clinical record Please review your manual for windows of elevated risk…. This is the minimum expected use of the QPRT –

203 THANK YOU! Contact information Free book from website The Institute does not provide clinical consultation…. Your name as a licensed instructor here…

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