1. Comprehensive Suicide Risk Assessment Andrea Bradford MD MMM Medical Director, ValueOptions Inc.

2. Comprehensive Suicide Risk Assessment Suicidal ideation and intent only a small part of the suicide risk assessment Factors related to suicide risk frequently documented in several places and not included in final formulation of risk Modifiable risk factors for suicide frequently not addressed in treatment plans Clinical formulation of suicide risk decreases potential liability if suicide occurs

3. Comprehensive Suicide Risk Assessment Sources of information other than the patient important Identifying protective factors an important part of decision making when suicide risk is present A safety contract with respect to suicide is not an effective tool. It only has validity when the patient refuses to contract. An agreement to contract for safety is a potential legal liability unless it’s importance is discounted in a formulation

4. Comprehensive Suicide Risk Assessment Having all suicide risk factors and protective factors co-located for ease of review is important Documenting a suicide risk formulation based on all risk and protective factors using clinical judgment is important Documenting a treatment plan which is responsive to potentially modifiable suicide risk factors is important

5. Comprehensive Suicide Risk Assessment Using the Form ValueOptions makes available to practitioners a comprehensive suicide risk assessment form based on the Catawba Hospital form, which is copyrighted and used with permission. The form includes predictive risk factors for completed suicide, protective factors, and space to identify sources The form includes space to document a formulation of risk and treatment planning considerations

6. Comprehensive Suicide Risk Assessment Using the Form Patient Name: __________________________ Clinician: ______________________________ Date: _________________________________ Current Mental Status  Suicidal ideation by consumer  Suicidal ideation alleged by others  Realistic plan in community  Realistic plan in hospital  Suicidal intent alleged by others  Suicidal intent expressed by consumer

7. Comprehensive Suicide Risk Assessment Using the Form Clinical Factors  Severe anxiety and/or agitation  Anorexia Nervosa  Bipolar Disorder  Bipolar II  Mixed state  Depressive phase of illness  Depression  Severe  Anhedonia or hopelessness  Anxiety, agitation, or panic  Aggression or impulsivity  Delusional thinking  Global or partial insomnia  Recent sense of peace/well-being  Co-morbid alcohol abuse/dependence

8. Comprehensive Suicide Risk Assessment Using the Form Clinical Factors Continued  Dysthymia  Post Partum Depression  Alcohol/Substance Abuse/Dependence  Co-morbid Axis I Disorder  Mixed Drug Abuse Obsessive-Compulsive Disorder  Schizophrenia  Paranoid or Undifferentiated Type  Depressive State  Command Hallucinations  More than a high school education  Less than 40 years old  Personality Disorders  Cluster B or Cluster C  Co-morbid depression  Co-morbid alcohol abuse/dependence

9. Comprehensive Suicide Risk Assessment Using the Form Clinical Factors Continued  Epilepsy  Temporal lobe epilepsy  Chronic Pain  More than one psychiatric diagnosis  Currently psychotic  Unstable or poor therapeutic relationship

10. Comprehensive Suicide Risk Assessment Using the Form Cognitive Features that Contribute to Risk  Loss of executive function  Thought constriction (tunnel vision)  Polarized thinking  Closed-mindedness  Inability to adapt to a dependent role

11. Comprehensive Suicide Risk Assessment Using the Form Loss Factors  Decrease in vocational status  Loss of significant relationship  Decline in physical health  Loss of freedom due to legal status

12. Comprehensive Suicide Risk Assessment Using the Form Historical Factors  Prior suicide attempts  Family history of suicide  Anniversary of important loss  Impulsivity  Family of origin violence  Victim of physical or sexual abuse  Domestic partner violence

13. Comprehensive Suicide Risk Assessment Using the Form Demographic Factors  Male  65 years or older  85 years or older  Low socioeconomic status  Living alone  Currently divorced  Caucasian or Native American  Unemployed  Access to/history of use of firearms  Lack of structured religion

14. Comprehensive Suicide Risk Assessment Using the Form Risk Reduction Factors  Pregnancy  Responsible for children under 18 years old  Sense of responsibility to family  Catholicism or Judaism is religion of choice  Employed  Living with another person, especially a relative  Positive social support  Positive therapeutic relationship

15. Comprehensive Suicide Risk Assessment Using the Form Individual Risk Reduction Factors and Individual Risk Factors: For hospitalized consumers, this should include an assessment of the risk of elopement. Clinician’s Formulation of Risk: Using the risk factors and risk reduction factors identified above, describe your estimation of the consumer’s imminent and long term risk for suicide, as well as necessary interventions to assure consumer’s safety and facilitate stabilization. Describe your clinical reasoning in detail. Interventions: Document interventions which directly address mitigating those risk factors which are identified and can be addressed either clinically or with the help of natural supports. For consumers where a formal crisis plan is developed, that may serve to complete this section by attaching a copy of that plan.

16. Using the Form Case Example A 77 year old caucasian male presents to an outpatient clinic accompanied by his wife of 45 years. She reports that he threatened to kill himself today. His history includes a suicide attempt 12 years ago just prior to his treatment for alcoholism, when his wife threatened to leave him. He has also been treated for a major depression 6 and 8 years ago. His father committed suicide at age 65. His wife reported that she is moving out today because of his relapse on alcohol 2 weeks ago. He was diagnosed with disseminated prostate cancer 2 weeks ago, but does not want his wife to know. He denies suicidal ideation or intent. There is a gun in the home.

17. Using the Form Case Example 1 Individual Risk Reduction Factors and Individual Risk Factors: Mr. Patient has serious risk factors to include reported suicide threats today, a history of a prior attempt, a family history of suicide, alcohol dependence with a recent relapse, and a history of major depressive episodes. His wife is leaving him and he has recently been diagnosed with cancer. He is a caucasian male in a high risk age group and also has access to a gun. He has no identified risk reduction factors.

18. Using the Form Case Example 1 Clinician’s Formulation of Risk: Using the risk factors and risk reduction factors identified above, describe your estimation of the consumer’s imminent and long term risk for suicide, as well as necessary interventions to assure consumer’s safety and facilitate stabilization. Describe your clinical reasoning in detail Despite his reports that he is having no suicidal thoughts, Mr. Patient is considered to be at high risk for suicide due to the severity and multiplicity of his risk factors. At his age, either his wife leaving or his medical condition would place him at serious risk if a threat were voiced (as he did, per his wife’s report), but his additional risk factors increase his risk to the point that he needs immediate hospitalization to further assess his depression and plan for risk reduction.

19. Using the Form Case Example 1 Interventions: Document interventions which directly address mitigating those risk factors which are identified and can be addressed either clinically or with the help of natural supports. For consumers where a formal crisis plan is developed, that may serve to complete this section by attaching a copy of that plan. Mr. Patient will be hospitalized immediately. His wife has agreed to participate in therapy sessions while he is hospitalized, where he will be encouraged to share his medical condition with her. Additional supports in his community and social network will be enlisted, including collaboration with his family doctor. His current depressive symptoms and alcohol use will be addressed, and outpatient appropriate outpatient resources identified. His wife has agreed to remove the gun.

20. Using the Form Case Example 2 Ms Disorder is a 32 year old female who presents for her regular therapy appointment complaining that she just can’t go on. She has three children ages 8, 10 and 14 and has been living with her mother for the past 12 years. She has been treated for Borderline Personality Disorder for the past 10 years, and her symptoms include intermittent suicidality, mild psychotic symptoms, cutting on her arms, and frequent family fights. She is currently reporting no psychotic symptoms, but feels she will never “get ahead” and be able to live independently. She has never previously attempted suicide and there is no family history of suicide or abuse. She has never been married, but does have a current boyfriend. Her family is active in the Catholic church. She reports that she is thinking about “ending it all” by taking all of her medications.

21. Using the Form Case Example 2 Individual Risk Reduction Factors and Individual Risk Factors: Ms Disorder has risk factors to include her Personality Disorder, her current suicidal ideation and her impulsivity. Her protective factors include her responsibility for her 3 children, her religion, the fact that she lives with her mother, the support she gets from her boyfriend and her long standing therapy relationship.

22. Using the Form Case Example 2 Clinician’s Formulation of Risk: Using the risk factors and risk reduction factors identified above, describe your estimation of the consumer’s imminent and long term risk for suicide, as well as necessary interventions to assure consumer’s safety and facilitate stabilization. Describe your clinical reasoning in detail Based on the risk factors and risk reduction factors above, and drawing on my 4 year treatment relationship with Ms Disorder, in my clinical judgment, her risk for suicide remains low. She has never attempted suicide, despite episodes of suicidality expressed with more vigor than the current report. Her mother is involved in her treatment and will be engaged to watch her daughter more closely. Ms Disorder is also very engaged with her religion and children and will not engage in behavior she sees as potentially hurtful to them.

23. Using the Form Case Example 2 Interventions: Document interventions which directly address mitigating those risk factors which are identified and can be addressed either clinically or with the help of natural supports. For consumers where a formal crisis plan is developed, that may serve to complete this section by attaching a copy of that plan With permission, Ms Disorder’s mother has been contacted and will talk with her and watch for any signs of escalation. Ms Disorder has agreed to keep her appointment this evening with her priest and has been reminded of her access to the emergency services in her area. She will be enrolled in a DBT group which starts next week to deal with her thoughts of self harm. Her therapy appointments with me will continue to focus on her following through on positive actions in her life and actively managing her symptoms. A peer counselor has been identified who has overcome similar problems.