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

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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."— Presentation transcript:

1 Suicide in America “Suicide is a national public health problem.” David Satcher, M.D. Surgeon General of the United States

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

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

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

5 From the Surgeon General “Suicide is our most preventable form of death.”

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

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 (?)

8 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?

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.

10 How big is the problem? Global Violence-Related Deaths 1 million people die by suicide 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 –

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 –

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 11 th cause of death overall - 3 rd 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

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.

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

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?

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. 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. 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. Effective, accessible, competent care could save thousands of lives.

17 Intention and Suicide “There are ways of killing yourself without killing yourself.” Tony Manero, Saturday Night Fever, on the “suicide” of his friend. on the “suicide” of his friend. ILTB = Intentional life threatening behavior

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.

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

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.

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 Death almost certain. Use of shotgun. Drowning self at midnight in a lake. Survival is accidental.

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…

23 Suicide and Homicide More homicides or suicides per year in the US? Is there any overlap between homicide and suicide?

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 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.”

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 Source: National Violent Death Surveillance System

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!

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:

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.

29 Intimate Partner Violence Males who threaten suicide in an intimate partner violence situation are at greater risk for murder-suicide. 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%, Suicide rate down 33%, Homicide rate down 52% Homicide rate down 52% Serious DV rate down 54% Serious DV rate down 54% Suicide Prevention IS violence prevention!

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?

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)

32 Suicide Risk and Risk Management What you need to know….

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)

34 ENVIRONMENTAL RISK FACTORS AttemptsCompletions Seasonal VariationsUnknownJan-Feb, March Peak WeeklyUnknownHigh Midweek GeographyHigh on bothSame WarUnknownInverse Unemployment: ChronicUnknownNo Association SuddenDirectDirect * Source: Harvard School of Public Health, 1998

35 SUICIDE CRISIS EPISODE Stable Days Hours Days Years Crisis Peaks Crisis Begins Hazard Encountered Risk Imminent Crisis Diminishes Plus or minus three weeks

36 THE LETHAL TRIAD UPSET PERSON 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

38 Serious Attempt or Death by Suicide Those Who Desire Suicide Those Who Are Capable of Suicide Sketch of the Theory

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

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.

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

42 The Many Paths to Suicide Fundamental (distal) Risk Factors Acute (proximal) Risk Factors: triggers/last straw Cause of Death Crisis in Relation Loss of Freedom Fired/ Expelled Illness Major Loss ? Poison Gun Hanging Autocide Jumping ? Increasing Hopelessness Contemplation of Suicide as Solution WALL OF RESISTANCE Genetic Load Sex GLTB Race Age Drugs or Alcohol Biological Child Abuse Loss of Parent Culture Shock/ Shift Values Religion Beliefs Season of year Geo- graphy Model for Suicide Personal/Psychological All “Causes” are real. Hopelessness is the common pathway. Break the chain anywhere = prevention. Environmental Urban vs. Rural

43 -- Sobriety -- Best Friend(s) Safety Agreement Treatment Availability Pet(s) Calm Environment Religious Prohibition AA or NA Sponsor Difficult Access to means A sense of HOPE Positive Self-esteem Fear Job Security or Job Skills Support of significant other(s) Counselor or therapist Medication ComplianceGood health Responsibility for children Others? Wall of Resistance to Suicide Protective Factors and Buffers Against Suicide Duty to others

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

45 BASIC CONCEPTS ABOUT SUICIDE  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.

46 End Module Questions

47 The Relationship of Mental Illness and Substance Abuse to Suicide…

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:

49 Is Suicide Primarily: “Mental Health Territory?” 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 Inskip HM: Br J Psych 1998

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.

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. 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

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)

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

55 Warning, do not use the brain on the left to make a life or death decision….

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

57 BIPOLAR DISORDER & SUICIDE  # 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

58 1 st 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

59 SUICIDE AND SCHIZOPHRENIA - Ten to 15% complete suicide (best estimated of Lifetime risk: 5%). Leading cause of death in patients under Negative symptoms associated with increased risk 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 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.

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.

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 Higher suicide rates (+8%) in 18 vs. 21yo legal drinking age states for those ages (Birckmayer J: Am J Pub Health 1999)

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

64 Lifetime Suicide Thoughts/Attempts ASI data, TRI database-04 N=60,952

65 Skip the booze and junk

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 Preuss/Schuckit Am J Psych 03

67 Methamphetamine Users (n= 1,016) LIFETIME SUICIDE ATTEMPTS and BEHAVIOR PROBLEMS ASI Item OverallMalesFemales Test Statistic* Attempted Suicide (%) 27%13%28%35.42** Violent behavior problems (%) 43%40%46%3.29*** Assault Charges (mean number) ** Weapons charges (mean number) ** *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 Zweben, et al., 2004

68 Skip the Meth

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

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).

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

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 ?

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

74 FIVE ACUTE SUICIDE RISK FACTORS  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)

75 PSYCHIATRIC COMORBID TRANSIENT ILLNESSPSYCHOLOGICAL STATES SchizophreniaAgitation Depressive DisorderPerturbation Bipolar DisorderPsychic Pain Panic DisorderHopelessness Substance Abuse DisorderDopamine Deficit Personality DisorderSerotonin Deficit Co-morbid Physical IllnessAlcohol Myopia DISEASE MANAGEMENT MODEL FOR SUICIDAL PATIENTS

76 Common Chemical Pathways for Suicidal Acts? Alcohol in the bloodstream Low serotonin levels Impaired dopamine function

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? CBT for depressive hopelessness? DBT for Axis II consumers

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 Rihmer ZRutz WPihlgren HRihmer ZRutz WPihlgren H

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” 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.

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.

83 More good news! Addiction treatment works Cohort suicide attempts year prior year after year prior year afterAdults > 25 yo (n=3,524)23% % yo (N=651) 28% % Adolescents (n=236) 23% % Karageorge: National Treatment Improvement Evaluation study 2001

84 Take home messages…. Most dangerous diagnosis: alcoholism and major depressive disorder… Am. Journal of Psychiatry, Common clinical pathways: serotonin deficit, dopamine deficit, and alcohol in blood stream Co-occurring disorders kill There is no safety without sobriety… Treatment works!

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

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.

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.

89 Risk Rating Rating: High Risk Mean 6.21 SD. 0.86

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

91 Risk Rating Rating: Low Risk Mean: 2.25 SD: 1.29

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.”

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.

94 Risk Rating Rating: High Risk Mean: 6.58 SD: 0.61

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.

96 What you need to know…. This troubled man has been training to be a concert pianist for the past 25 years.

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.

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….

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.

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….

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.

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.

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.

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.

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.

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.

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.

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.

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.

110 And the # 1 reason not ask our patient if he or she is suicidal? MY GOD THEY MIGHT SAY YES!

111 End Module Questions

112 Avoiding Suicide Malpractice Highlights only – full 2-hour course now available online at Taught by lawyer and psychologist

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 “

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

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

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

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.

118 "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%)

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

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

121 End Module QuestionsLunch?

122 CURRENT THINKING ON SUICIDE AND RISK  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

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

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)

125 CURRENT THINKING ON SUICIDE AND RISK  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

126 CURRENT THINKING ON SUICIDE AND RISK  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.

127 CURRENT STATUS OF SUICIDE RISK ASSESSMENT  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)

128  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… CURRENT STATUS OF SUICIDE RISK ASSESSMENT

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

130 What do we know? 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….

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…

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

133 JCAHO and Suicide JCAHO Reported 501 Inpatient Suicides From 1995 To 2004 And 56 In 2005

134 Inpatient Suicide 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 * Sentinal Event reporting begain in Source: Reducing the Risk of Suicide. JCAHO, Joint Commission Resources, Inc Where Inpatient Suicide Occurs

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

136 Limitations of the clinical interview in suicide risk assessment Update and new research

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

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

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

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

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…..

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

143 End Module Questions

144 The QPRT Risk Assessment Method

145 QPRT recognition 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)

146  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 QPRT Benefit Summary

147  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 QPRT Benefit Summary

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

149 Follow along…. Please take your sample QPRT or one from your folder and follow along and, if you like, make notes…

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

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

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

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?”

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.)

155 Wrong way to ask S Question “You’re not thinking of suicide, are you?” …or any variant question which asks for a denial….

156 QPRT SUICIDE RISK MANAGEMENT INVENTORY 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

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

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

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.”

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.

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

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

163 QPRT SUICIDE RISK MANAGEMENT INVENTORY 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

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.

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?”

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?

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

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)?”

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?”

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.)?”

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

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

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

175 WHEN AND WITH WHAT IN THE PAST? 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

176 WHEN AND WITH WHAT IN THE PAST? 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

177 Sample questions “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

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

179 WHO IS INVOLVED? 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

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?”

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

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 Meaningfulness of life and purpose for living Residual tasks to be completed before the attempt, such as making out a will

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?”

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

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

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:

187 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:

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: - 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

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

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. 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.

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?

192 Low confidence note … The person has been uncooperative and refused to collaborate in the assessment Is suspected of being deceitful in answering questions Is suspected of being deceitful in answering questions Has or may have psychotic symptoms, especially paranoia Has or may have psychotic symptoms, especially paranoia Is or has been recently intoxicated Is or has been recently intoxicated

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????

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

196 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 QPRT

197 SEMANTICS ARE IMPORTANT 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?”)

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.”

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

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.

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

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….

203 THANK YOU! Contact information Free book from website Free book from website The Institute does not provide clinical consultation….


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