Dr. Saman Yousuf 17 June 2011

 Risk assessment and crisis management (if there is suicide risk) are covered in the same interview  Crisis management: Keeping a person safe in short term (usually the next 72 hours)  Crisis prevention: Enabling a person to stay safe in the future (i.e long term)

Aims  Reduction of immediate risk of suicide by: - Diffusing emotional distress - Addressing immediate problems - Ensuring safety - Providing immediate support - Identifying and employing coping mechanisms

Diffusing emotional distress  Explore feelings and emotions  Encourage hopefulness  Bolster self-esteem  Build trust and confidence to ensure effective management of crisis

Ensuring safety  Identify likely means of lethality – the ‘A-test’ What is acceptable to the person What is available to the person  Removing or restricting the means of lethality Safety and with least distress  Utilising safety protocols for removal or restriction of dangerous weapons

Providing appropriate support  Identify who is best able to provide support Professionals Family and friends Community network Is the person comfortable with the kind of support being suggested?  Ensure support is available and accessible During the night At weekends On holidays

Family, friends and community support  Can provide better support than professionals IF - Agreeable to become involved - Informed of the risk / offered support - Given guidance when/if situation worsens  Careful consideration before engaging teenagers and immature people  Parents of teenagers and children may become overprotective and judgmental

Coping mechanisms  What has worked in the past?  What stopped the person from committing suicide?  New self-help coping mechanisms IMPORTANT: Working on coping mechanisms should not take place until the patient is safe, supported and no longer in distress

Revisiting assessment  Suicidal intent (frequency and severity of thoughts)  Plan  Measures to prevent detection

CASE SCENARIOS

 A structured action plan to be formed with the patient  Modifiable risk factors  strategies  Psychiatric illness  referral to psychiatrist for treatment  Psychosocial stressors  Social worker  Regular follow-up: frequent till suicidal ideation / behavior subsides and then interval between follow-ups can be gradually increased Crisis prevention

Example of a positive action plan (structured plan)  When I am upset and thinking about suicide, I’ll take the following steps:  Do not drink, or, if I am drinking, stop drinking  Sit down and take 50 deep breaths  Try to do things that help me feel better for at least 30 minutes (e.g., taking a walk, listening to music)  Contact one of my significant others and talk to them about our joint interests  If the thoughts persist, I will call someone I can trust and seek for help at xxxx-xxxx  If nothing has improved, I can ring up 999 or go to the A&E department

What doesn’t work…  Hospital admission vs. discharge  Inpatient behavior therapy vs. Inpatient insight-oriented therapy  9 antidepressants vs. placebo  10 long-term therapies vs. one short term therapy  2 intensive intervention plus outreach vs. Standard aftercare  Problem-solving therapy vs. standard aftercare  Home-based family therapy vs. standard aftercare

What seems to work…

Cognitive model for suicide mode:

Replication in Australia Carter GL et al 2005 BMJ;331:805; Carter GL et al 2007 Br J Psychiatry;191:

No effect found: New Zealand Ref: Beautrais et al 2010 Br J Psychiatry 197, 55–60

Summary  There are relatively few randomized clinical trials for treatments for suicidal behavior.  Standard of care interventions such as inpatient and anti-depressants do not have strong support.  Psychotherapy – particularly CBT and DBT seems to have some supportive findings.  Simple and basic interventions. i.e., caring letters, alone have support.

When a suicide occurs… Despite best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice Approximately, 12,000-14,000 suicides per year occur while in treatment To facilitate the aftercare process:  Ensure that the patient’s records are complete  Be available to assist grieving family members  Remember that confidentiality still exists  Seek support from colleagues / supervisors