Assessment and Management of Suicide

RiskMay 24, 2007

Melissa J. Pence, Psy.D.Licensed Clinical Psychologist

Hampton Roads Neuropsychology and Behavioral Medicine

Outline 1. Impact

2. Demographics and epidemiology

3. Etiology

4. Risk assessment

5. Psychological Testing

6. Treatment and prevention

7. Medical-legal concerns

A personal account of the impact of suicide

• " His light, through me, will grow as a beacon for others."

John C. Gibbs

http://www.INeedALighthouse.com/index.html

                                                           

             

Survivors of Suicide (Schneidman, 1969)

Survivor

Survivor

Survivor

Survivor

Survivor

Survivor

Suicide Victim

Suicide• Definition of suicide:

“Suicide is the death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result.” Emile Durkheim

• Requires:

1. Death/lethal outcome

2. Self-inflicted

3. Intentionally inflicted

4. Awareness or consciousness of outcome

Problems in studying suicide

• Low base rate

• No test (biological or psychological) or clinical marker that predicts suicide

• Requires clinical judgment

• Numerous false positives in prediction paradigms

• High risk suicidal patients excluded from most clinical studies

Demographics and Epidemiology

A MAJOR Public Health Problem!

How is this data gathered?

• Death certificate information reported by each state to the National Center for Health Statistics

• Most recent national data available is 2003

• Numbers are generally understood to be a modest underestimation of actual suicide deaths due to difficulties in conclusively determining cause of death

U.S. National Statistics (2003) (CDC)

• 31,484 deaths by suicide

• 86 deaths per day

• 1 every 17 minutes

• 11th leading cause of death

• Approximately 787,000 attempts, ratio 25:1

• Twice as many people die by suicide than by homicide

Statistics (2003) (CDC)

NumberPer

Day* Rate % of Deaths Group (Number of Suicides) Rate

Nation 31,484 86.3 10.8 1.3 White Male (22,830) 19.5

Males 25,203 69.0 17.6 2.1 White Female (5,655) 4.7

Females 6,281 17.2 4.3 0.5 Nonwhite Male (2,373) 9.1

Whites 28,485 78.0 12.1 1.4 Nonwhite Female (626) 2.2

Nonwhites 2,999 8.2 5.5 0.9 Black Male (1,597) 8.8

Blacks 1,955 5.4 5.1 0.7 Black Female (358) 1.8

Elderly (65+ yrs.)

5,248 14.4 14.6 0.3 Hispanic (2,007) 5.0

Young (15-24 yrs.)

3,988 10.9 9.7 11.9 Native American (322) 10.4

Asian/Pacific Islander (722) 5.5

                                                                                                                                              

     

State by State Rate Comparisons

Firearms are the Leading Method of Suicide (2003)

Suicide Methods: Number RatePercent of Total

Number Rate Percent of Total

Firearm suicides 16,907 5.8 53.7%All but Firearms

14,577 5.0 46.3%

Suffocation/Hanging 6,635 2.3 21.1% Poisoning 5,462 1.9 17.3%

Cut/Pierce 571 0.2 1.8% Drowning 339 0.1 1.2%

Data on Means of Suicide (2001)

Youth Suicide Rates• 3rd leading cause of death in those aged

15-24, behind only accidents and homicide.

• 2nd leading cause of death in college students.

• 6th leading cause of death in 5-14 year olds.• Ratios of attempts to completions

estimated to range between 100:1 to 200:1• In 2001, firearms were used in 54% of

youth suicides.

Youth Suicide

•In 1999, 20% of HS students reported seriously considering suicide and 8% attempted.•Frequent drug and alcohol abuse was found to be the most common characteristic in young people who attempted suicide (Department of Education)

Youth Statistics (2003)

Age Group

Number of Suicides

Suicide Rate

10-14 yrs 244 1.2

15-19 yrs 1,487 7.3

20-24 yrs 2,501 12.1

Suicide in the Elderly–Higher Completion rates (1:4) over age 65.–Medical illness a significant factor in 70% of suicides over age 70.–Most saw a physician within a few months of their death and 1/3 within the previous week.–Rate of suicide is 14.8 per 100,000 when compared to 10.8 per 100,000 in general population.

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

Female Suicide Rates

•Women attempt suicide twice as often as men. Some studies suggest the rate is closer to 3:1.•One woman attempts suicide every 78 seconds in the U.S.•Rates peak between the ages of 45-54 (around time of menopause) and again after age 75.

60

50

40

30

20

10

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SUICIDE MORTALITY – 2000

National Center For Health Statistics. National Vital Statistics Reports.

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eath

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00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

White MaleFemale

Breakdown by Race

• Caucasians are over 2x more likely to complete suicide than African Americans (AA).

• AA males comprised 84% of suicide deaths in that racial group.

• Firearms predominant method among AAs, regardless of gender.

• American Indian and Alaskan native men have the 2nd highest rate of suicide after Caucasians.

Etiology

Cognitive Psychology

Diathesis-StressModel

Neurobiology

THE NEUROBIOLOGY OF SUICIDAL BEHAVIOR

Familial and Genetic Factors•There is a transmission of familial and genetic factors that contribute to risk for suicidal behavior. •Major psychiatric illnesses, such as MDD, schizophrenia, and alcoholism have genetic component in etiology.

Familial and Genetic Factors• Several studies have found genetic and

familial transmission risk is independent of transmission of psychiatric illness.

• First degree relatives of individuals (including dizygotic twins) who have completed suicide have more than 2x the risk of the general population. – For monozygotic twins, risk increases to 11x.

(Quin, Agenbo, & Mortensen, 2002)

• Recent study could not find genetic effect on suicidal ideation. (Farmer et al, 2001)

Studies on the Serotonergic System

• Difficult area to study, numerous methodological problems.

• There is evidence of modest reductions in in brain stem/prefrontal cortex serotonin or its marker 5-HIAA (metabolite).

• Lower CSF (cerebral spinal fluid) 5-HIAA levels has been reported by most studies in patients with a history of suicide attempt and a diagnosis of MDD, Schizophrenia, or PD compared to control groups of patients with these diagnoses.

Serotonergic system, continued•Low CSF 5-HIAA level predicts higher rate of past and future suicidal acts as well as seriousness of suicidal acts over the lifetime. •PET scans can map serotonin-induced changes in brain activity.

–Size of abnormality in anterior cingulate and prefrontal cortex is proportional to lethality.

(Oquendo et al., 2003)

Noradrenergic System

• Reduced noradrenergic functioning is suggested, however the evidence is not as strong as in the serotonergic system.

• The conclusion: there is a period of noradrenergic over-activity (which may be a stress response and state dependent) prior to suicide which contributes to NE depletion.

The Diathesis- Stress Model

•Proposed by Zubin and Spring (1977)

•An individual has unique biological, psychological and social elements. These elements include strengths and vulnerabilities for dealing with stress.

The Diathesis-Stress Model

Beck’s Cognitive Model (1967)

• Schema: tacit beliefs and memory structures that serve to organize the encoding, retrieving, and processing of information– Latent much of the time– May be activated by specific life events– Develop from an early age– Reinforced and consolidated by life

eventsSchema of depressed individuals thought to be rigid, negativistic toward self and others, future is bleak, lack control over outcomes.

Beck’s Cognitive Model, Continued

• Cognitive distortions most frequently associated with suicidal ideation:– Cognitive constriction or tunnel vision– Polarized or all or nothing thinking– Selective recall of past failure and

overlooking past success

These are believed to play a role in development and maintenance of dysfunctional attitudes and irrational beliefs.

CONDUCTING A SUICIDE RISK ASSESSMENT

What is a Suicide Risk Assessment?• “Refers to the establishment of a

clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail.”

• “More than a guess or intuition- it is a reasoned, inductive proceess.”

• “A necessary exercise in estimating probability over short periods.”

From Jacobs, 2003

Who should receive a suicide assessment?

• ANY patient who meets criteria for DSM-IV mental or substance use disorder(s).

• Should initially occur at the point of entry into treatment (i.e. initial visit or intake) and periodically as clinically indicated.

• If the patient meets criteria for a depressive disorder and/or manifests any degree of suicide lethality, they should be assessed each session.

Two Components of AssessmentPART 1:

The elicitation and elaboration of suicidal ideation

PART 2:

The identification and qualification of risk factors for completed suicide

Part 1: Assessing Suicidal Ideation• Begin with general questions about

self-harm, such as asking whether the patient has had thoughts of death or suicide. Ask them to elaborate in their own words and describe what these thoughts are like. Use open ended questions.

• Thoughts should be characterized as active (“When I am walking, I get the impulse to jump out into traffic”) or passive (“Everyone would be better of if I was dead”).

Assessing Suicidal Ideation, Continued

•If suicidal thoughts are present, assess how often and in what context they occur. •Are they fleeting, periodic, or persistent? Are the situation specific? Are they increasing or decreasing in intensity?

Assessing Suicidal Ideation, Continued• The patient should be asked if they

have a plan, or if they have thought of a means in which they would use to carry out suicide. – Method (availability, lethality)– Suicide notes, final acts in

preparation for death (i.e. will preparation)

– Has mental rehearsal taken place? Is there a plan for a time or place?

– Have any attempts been made thus far?

Assessing Suicidal Ideation, Continued

• History of similar thoughts, impulses, plans, aborted attempts and/or attempts should be obtained.

• Corroborating report from family or providers should be obtained (if possible).

Assessing Suicidal Ideation, Continued

– Confidentiality can legally be broken to obtain appropriate care if you have evidence to suggest the patient is acutely a danger to himself or others.

• Usually necessary information can be obtained by simply listening to the family members and it may not be necessary to reveal private or confidential information to the family.

• However, in some situations you may be obligated to break confidentiality to protect the patient. Remain sensitive to family issues and disclose necessary information to protect the patient.

• Helps to discuss this during informed consent at the beginning of the process.

Assessing Suicidal Ideation, Continued

• Determine if there are any barriers to suicide.– What are the patient’s reasons for

living and reasons for dying? – How has the patient managed to

evade the act of suicide thus far?

• Assess level of current supports (family, significant other, friends, employer, therapist, etc.)

Part 2: Assessing Risk Factors

“Risk Factor” Defined• Leading to or being associated with

suicide

• Individuals possessing the risk factor are at greater potential for suicidal behavior

• Some risk factors can be changed or reduced (i.e. providing Lithium treatment for Bipolar Disorder), others are static (The patient’s father completed suicide)

• From Suicide Prevention Resource Center, www.sprc.org

Presence of a mental disorder•Present in over 90% of completed suicides.•High risk diagnoses are:

–Depression (unipolar and bipolar)–Alcohol/substance abuse or dependence–Schizophrenia–Borderline Personality Disorder

Co-morbidity increases risk!• Psychological autopsy studies of 229

suicides:– 44% had 2 or more Axis I

diagnoses– 31% had Axis I and Axis II

diagnoses– 50% had Axis I and at least one

Axis III diagnosis– 12% had an Axis I diagnosis with

no co-morbidity

From Henriksson et al, 1993

Recent psychiatric hospitalization•Within the last year•Acute exacerbation of illness

The presence of depression•Including hopelessness, guilt, loss•Global insomnia

Note: Hopelessness has been found to be co-occurring with depression as well as a predictor of suicidal ideation and behavior.

Recent or impending loss– Loss of job– Loss of relationship– Loss of loved one, grief– Recent move (CDC, 2002)

– Humiliating events, such as financial ruin due to a scandal, being arrested or being fired, can lead to impulsive suicide (Hirschfeld and Davidson, 1998)

Substance or alcohol use• Up to 50% of those completing

suicide drinking alcohol at time of death.

• Drinking within three hours of the attempt was the most important alcohol-related risk factor for nearly lethal suicide attempts, more important than alcoholism and binge drinking. (CDC, 2002)

– CNS depressants increase risk. (Wines et al, 2004)

History• History of impulsive or dangerous

behavior, and/or history of suicide attempts– Severe self-mutilation– A history of serious suicide attempts

may be the best single predictor of completed suicide; the greatest risk occurs within 3 months of the first attempt.

– HOWEVER, the majority of suicides are in individuals with no prior attempts.

Access to firearms

• 92% of suicide attempts by firearm are successful

• Keeping firearms in the home increases the risk of suicide for both genders even after other factors, such as depression and alcohol use, are controlled for.

Family history of suicide• First degree relatives = more than 2x

the risk of the general population

– For monozygotic twins, risk = 11x.

Social isolation or withdrawal

•Having a strong preference for being alone (change from previous behavior)

•Withdrawing from family, social, or volunteer activities

•Not keeping appointments

Concurrent medical disorder

Characterized by:• chronicity, •poor prognosis,•disfigurement and/or •persistent pain.

Medical illness, continued• Diagnoses most associated with

completed suicide:– Huntington’s Chorea– Malignant Neoplasms– Multiple Sclerosis– Renal disease– Peptic Ulcers– Spinal Cord injuries– Lupus– HIV/AIDS– Epilepsy (only medical diagnosis

documented to increase risk in children and adolescents)

Severe agitation/anxiety•Panic attacks, severe psychic anxiety, and global insomnia all significantly associated with suicide at one year follow up. (NIMH)

•Behavioral signs: pacing, wringing hands, rocking, severe restlessness, etc.

•Assess for treatment responsive acute risk factors, such as askathsia.

RISK FACTORS (blue = modifiable)

family history of suicide, mental illness, or abuseGenetic & Familial

sexual/physical abuse; neglect; parental lossChildhood Trauma

thought constriction; polarized thinkingCognitive Dimensions

impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt

Behavioral Dimensions

hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism

Psychological Dimensions

malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system

Physical Illness

psychiatric diagnosis; comorbidityPsychiatric

lack of social support; unemployment; drop in socio-economic status; firearm access

Psychosocial

male; widowed, divorced, single; increases with age; whiteDemographic

From Jacobs (2003), Harvard Medical School

Depression: Unipolar and Bipolar

•The lifetime risk for suicide in patients with mood disorders (major depressive disorder and bipolar disorder) is approximately 15-19%, and the risk is highest in the early stages of the illness.

Major Depression• Factors to consider:

– The concurrent presence of anxiety– Substance abuse or dependence– Command hallucinations– Irritability or anger associated with

impulsivity– Severe insomnia, especially global

insomnia– Presence of or access to a gun

(Jones et al, 2000)

Bipolar Disorder (Goodwin & Jamison, 1990)

•Risks: –Severe depression with anxiety, agitation–Global insomnia–Substance abuse–Transition periods/early recovery phase–Impulsive or violent behavior

Bipolar Disorder, continued– Assess current mood:

• Typically rates < 2% during psychotic mania (Dilsaver, 1997)

• 11% directly after remission from mania (Goodwin, 2002)

• Approximately 79% during major depressive episode (Goodwin, 2002)

• 11% during mixed state (Goodwin, 2002)

Alcohol/Substance Abuse or Dependence• The suicide risk among patients suffering

from alcoholism is similar to that in patients with mood disorders, but they tend to commit suicide late in the course of alcoholism and are frequently depressed at the time of death.

Two factors affecting risk (Weiss & Hufford, 1999)1.Effects of acute intoxication2.Co-morbid psychopathology such as

MDD• Risk with recent or anticipated

interpersonal loss

Schizophrenia (Tsuang, Fleming, & Simpson, 1999)

•Risk Factors for suicide in psychotic patients:

–Young age (<30)•#1 cause of death for young people Dx with Schizophrenia

–Good intellectual functioning–Disillusion with treatment–Good premorbid functioning –Early stage of illness–Communication of intent

–Frequent exacerbations and remissions–Painful awareness of the likely degree of chronic disability in the future–Periods of clinical improvement following relapse–Supervention of a depressive episode and increased hopelessness

Timeline of Risk

Borderline Personality Disorder• Most likely associated with parasuicidal rather than suicidal acts:– HOWEVER approximately 8.5% of patients

eventually commit suicide, usually after multiple attempts or gestures.

– Nearly 75% of patients make one attempt in lifetime.

– With alcohol problems=19%– Per Stone (1993) with alcohol + major

affective D/O=38%– Usually qualify for a co-morbid Axis I diagnosis at

the time of death.• Hx of childhood sexual abuse increases the

amount and lethality of parasuicidal behaviors.

Identify Chronic vs. Acute Risk•Acute:

–New, acute presentation–Presence of significant stressor–Emergent response to acute crisis of mood and despair–Possible co-morbid Axis I disorder

•Chronic:–Recurrent and persistent suicidal thoughts that provide an ongoing psychological mechanism for coping with distress–Frequent, usual response to life stresses and disappointments–Patient may be aware of chronicity

Protective Factors

• Protective factors are believed to enhance resilience and serve to counterbalance risk factors.– An individual's genetic/neurobiological

make-up – Attitudinal/behavioral characteristics – Family/community support – Effective and appropriate clinical care for

mental, physical and substance abuse disorders

– Pregnancy or children in the home, except for post-partum illness

Protective Factors, continued– Easy access to effective clinical

interventions and support

– Restricted access to highly lethal methods of suicide

– Cultural and religious beliefs that discourage suicide and support self-preservation instincts

– Support from ongoing medical/mental health care , positive therapeutic relationship

– Acquisition of learned skills for problem solving, conflict resolution and non-violent management of disputes.

Prevention and Treatment Strategies

Therapeutic Treatment Strategies

No Suicide Contracts

Pharmcotherapy

Hospitalization

Prevention/Treatment Strategies

• ASSESS, ASSESS, ASSESS– Assess acute vs. chronic risk

• 24 hour access to crisis care• Strong therapeutic alliance is

ESSENTIAL!• Work with family and other support

systems• Use multiple resources,

multidisciplinary approach

Access to Services• Crisis services by phone

– National Hotline

• 1(800) 273-TALK

• Emergency Department

Prevention/Treatment Strategies

• Short term coping strategies, behavioral treatments– Deep breathing– Relaxation training– Imagery training– Grounding

• Specific, concrete, written safety plan in place and frequently renewed and reviewed– Access to means removed immediately

Dialectical Behavioral Therapy (Linehan, 1993)

• Developed by Linehan for patients Dx w/ BPD and engaging in self-harm behaviors

• Philosophical orientation focuses on dialectics– Move from dichotomous thinking to

balance

• Patients learn to observe and describe, be non-judgmental and focus on the present, and focus on current activity

What is a no-suicide contract?• Also known as no-harm contract

or safety contract.• Involves an agreement in which a

patient makes a verbal or written promise not to harm or kill themselves.

• Commonly used by mental health practitioners, including: psychiatrists, psychologists, nurses, social workers, and therapists.

No-Suicide Contracts Usually Contain

• An explicit statement not to harm or kill oneself.

• A specific duration of time.

• Contingency plans if contract conditions cannot be kept.

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

• If the patient can not or will not agree to the terms of the negotiated contract or if non-verbal/historical cues contradict the agreement, he/she is usually considered to be at- risk.

• In the presence of a strong therapeutic alliance when manipulative behavior is suspected, this should be further explored.

History of NSCs • First documentation in 1973 in study by Drye,

Goulding, & Goulding.• Surveyed 31 counselors reporting on 609

patients, 266 of whom were judged “seriously suicidal”. 24 suicides or serious attempts were reported where their method for assessment was NOT used and 4 deaths occurred where their method was used.

• Method= When counselor became aware of SI, asked client to repeat, “No matter what happens, I will not kill myself, accidentally or on purpose, at any time” (p.172) Then client discussed his/her reaction to the statement.

• Objections or alterations were deemed at risk.

No Suicide Contracts: Potential Pitfalls

Pitfall #1

• BELIEVING THAT A SIGNED SUICIDE CONTRACT ELIMINATES SUICIDE RISK– Suicide cannot be absolutely predicted-

False sense of security.– There is no data demonstrating its

effectiveness or its acceptance in the professional community. (Drew, 2001)

– In one study, 41 percent of psychiatrists had patients who committed suicide or made serious attempts after entering into a NSC. (Kroll, 2000)

Pitfall #2• CONTRACT: THE LEGAL TERM

– Clinicians may wish to consider avoiding the word “contract” in their medical documentation.

– The term may also appear to attempt to free the clinician from blame for suicide attempts/completions.

– Appropriate clinical assessment and intervention, rather than liability prevention, should be the focus of care.

• Outcomes of legal cases and judgments about clinician’s care are improved by demonstration of comprehensive assessment and treatment.

Pitfall #3• INFORMED CONSENT???

– Informed consent is a legal and ethical doctrine involving the disclosure of risks, alternatives, and facts that allow a patient to make informed and unpressured decisions about treatment options.

– The competency of a patient to understand what they are signing or to give informed consent to such an agreement during a time of crisis is in question.

Who may or may not be capable of giving informed consent?Diagnosis Cited in…

Cerebral Impairment Drye et al (1973)

Psychosis Goulding (1979)

Egan (1997)

Under the influence of drugs/alcohol

Goulding (1979)

Egan (1997)

Impulse control deficiencies

Davidson et al (1995)

Motto (1979)

Severe Depression Egan (1997)

Simon (1999)

Informed Consent: Farrow & O’Brien (2003)

• VERY limited data in this area• Their study concluded that most patients

interviewed were not able to participate in informed consent for a NSC at the time of suicidal crisis.

• In retrospect, most subjects doubted their competence to enter a NSC at the time of crisis. “My thinking was so confused. I did not understand what they were suggesting.”

• Participants reported a strong sense of being coerced by clinician.

Pitfall #4• A safeguard against liability???

– A NSC may be used as a means to reduce the evaluator or therapist’s anxiety regarding litigation.

– Frequently charted phrases or shorthand such as “contracted for safety” should be avoided without appropriate ancillary documentation (suicide risk assessment, basis for clinical judgment, plan for managing risk.)

– Providers may believe that securing a NSC completes an assessment of suicidality, this is short sighted and legally precarious.

• Range et al, 2000, Stanford et al, 1994, Weiss, 2001, Miller, 1999, Miller et al, 1998, Lee & Bartlett, 2005

No Suicide Contracts: Potential Benefits

Benefits1. A means of evaluating current suicidality

– One part of a comprehensive suicide risk evaluation.

– Opportunity to discuss suicidal feelings directly.

2. Provision of specific behavioral alternatives to suicidal acts.

– Written behavioral plan for patient in a crisis situation

3. An adjunct to comprehensive evaluation and treatment

– In the context of a sound and positive therapeutic relationship

– The more concrete, the better! (i.e. written vs. oral, specific behavioral strategies tailored to the patient’s needs)

Bottom line about NSCs

– Use NSCs with caution, understanding that they are one part of a comprehensive suicide risk assessment and treatment plan and have not been demonstrated in the literature to reduce suicide risk.

Pharmcotherapy• There are reasons to believe that selective

serotonin reuptake inhibitors (SSRIs) might reduce suicidality.

• SSRIs remain the preferred psychopharmacological treatment for depression.

• Lithium has a strong, and possibly unique protective effect against suicidal acts in patients with bipolar disorder. (Baldessarini & Tondo, 1999)

Pharmcotherapy• Patients being treated with

psychotropic medication should be closely observed for clinical worsening:

–Agitation, irritability, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

SOMATIC TREATMENTS

Evidence for Clozapine reducing suicidality in schizophrenia and schizo-affective disorders

Antipsychotics

Lithium has a demonstrated anti-suicide effect; anticonvulsants do not

Lithium and

Anti-convulsants

A mainstay treatment of suicidal patients with depressive illness / symptoms.

Antidepressants

May reduce risk by treating anxietyBenzodiazepines

Evidence for short-term reduction of suicide, but not long-term.

ECT

From Jacobs (2003) Harvard Medical School

Medical-legal Concerns

Litigation• Bereaved survivors have a unique

grief, often feeling hurt, angry, and possibly guilty.

• May seek compensation for their loss through a claim of negligence.

• Number of lawsuits continues to rise.

• Hospitals are the primary target, however there has been an increase in number of claims against outpatient providers.

A Shift in the Law (Gutheil, 2000) • Before 1940: Suicide was considered

an independent intervening cause of death

• After 1940: But for the provider or physician’s negligence, the patient would not have committed suicide (negligence as a proximate cause)

Medical-legal Concerns• The law recognizes that there are no

standards for the prediction of suicide and that suicide results from a complicated array of factors.

• The standard of care for patients with suicidality is based on the concept of "foreseeability"

• Courts assume that a suicide is preventable if it is foreseeable.

Medical- Legal Concerns (Lee & Bartlett, 2005)

• Forseeability is defined as “A comprehensive and reasonable assessment of risk”

• Reasonable care involves “Developing a comprehensive treatment plan and timely implementation based on the assessment of risk, or forseeability”

• Failure to assess risk and make sound judgments makes the provider a possible target of litigation.

Risk Management• Realistically, a clinician is not always able

to prevent a suicide in a determined patient.

• Common themes identified in liability suits include:– lack of an ongoing, documented

assessment of suicide risk, especially prior to hospital discharge, a change in privileges, or a change in clinical status,

– lack of documentation to reflect a clinical rationale regarding treatment decisions, and

– inadequate patient supervision.

Documentation• In the case of a lawsuit, the chart will be

examined.

• Although most lawsuits arise over inpatients who commit suicide, documentation of encounters with all suicidal patients should include:– Risk assessment– Contacts with family members– Contacts with other treatment providers– Phone calls, letters– Responses to failed appointments– Non-compliance with treatment

Risk Management: Key Points (Lee & Bartlett, 2005)

• Keep abreast of current legal and ethical standards

• Develop and implement a policy for handling crisis situations– 24 hour availability of services– Increasing frequency or duration of sessions– Bring in supportive family/friends– Refer where appropriate for multidisciplinary

Tx– Follow up for compliance and disposition– Monitor medication allocation, access, and use– Establish check-in system with the client

Risk Management: Key Points (Lee & Bartlett, 2005)

• Maintain clinical competency (continuing education, supervision, consultation)

• Ensure accurate and thorough documentation

• Develop relevant resources, such as a network to consult with, community programs, etc.

Postvention• Immediately provide support to the family• Consider attending funeral or writing letter

of condolence– Serves both humanitarian and risk

management goals

• Care for yourself– Understand your feelings (guilt, grief, anger,

fear, etc.)– Discuss/consult/debrief with trusted colleague

or supervisor

Provider self-care• Caring for suicidal patients can be

very taxing- emotionally and physically!

• Remember to care for yourself:– Eat a balanced nutritional diet, get

adequate sleep, exercise– Seek personal counseling formally or

informally– Consult appropriately with colleagues

and supervisors• May wish to share personal emotional

reactions, burnout, and counter-transference issues (Shea, 2002)

Questions or comments….