Suicide Risk Management for Primary Care

Dr Louisa WalkerWalker Psychology& Consulting

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The QPR Chain of Survival(Think CPR)

4 links…1. Early recognition of warning signs 2. Early application of QPR3. Early referral to professional care4. Early assessment and treatment

Knowledge + Practice = Action

Question: When to ask and what to say

Persuade: Influence another to seek help

Refer: Help another to get to a professional for assessment

Training: On-line or Face-to-face

Gatekeeper – Foundational TrainingAdvanced – Suicide Risk Management and TriageAvailable online or face-to-faceTailored for populations – organizations

Primary CareIn Patient Hospital and EDNGOs – Social Service AgenciesAdolescent MH – Youth Suicide RiskMaori and Pacific – Whanau OraSchools – secondary and tertiaryLaw Enforcement – NZ Police, Corrections, ProbationProfessional Groups, e.g. Attorneys

QPR Training Options

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522 deaths (2010 – MOH Suicide Facts)

Rate: 11.5 per 100,000/year

10 New Zealanders each week (4 commercial jet crashes every year)

More than one New Zealander every day

The Scope of the Problem

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Of the 522 deaths2.7 x male completions to female2 x females to male attempts

Total Maori rate (13 per 100,000) 23 per cent higher than non-MaoriAmong OECD NZ sits in the middle of the range Rates are just ahead of the US and Canada

New Zealand Data 2010

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Current youth suicide rate - at 18 per 100,000

More than a quarter of all youth deaths (15-24yo) are from suicide

Suicide is the second leading cause of death for youth

More teens and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease, COMBINED.

Youth Suicide Rates 2010

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Maori male youth suicide rate – highest in the OECD

28.7 per 100,000 population80% higher than non-Maori youth

Female youth suicide is fifth highest in OECD – behind Korea, Japan, Finland and Switzerland

Youth Suicide Rates 2009

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Those who die account for a small number of those affected by suicidal behavior…

Youth: 100 - 200 attempts per 1 completion

Females 15-19yo had highest rate of hospitalization for intentional self-harm

Suicide Attempts

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Elder: 4 attempts per 1 completion

Adults over 60 after a non-fatal attempt at most risk that next attempt will be fatal

Suicide Attempts

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60 percent of all self-harm hospitalisation data has been excluded - due to inconsistencies in the way DHBs report data.

Data exclude patients who were only seen in an emergency department and those who were discharged within two days. (???)

Suicide Attempts 2009

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People who knew someone who died of suicide in the past year:

1.6 x more likely to have suicidal ideation2.9 x more likely to have made suicidal plans3.7 x more likely to have made a suicide attempt

(Crosby and Sacks 2002)

Survivors of Suicide

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Six months after exposure to suicide youth are:

At increased psychiatric risk4 x more likely to develop a psychiatric disorder6 x more likely to develop a major depressionYouth who knew someone who died by suicide were 3 x more likely to die by suicide than teenage peers who did not know someone who died by suicide

Youth Survivors of Suicide

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Suicide as a Public Health Problem in Primary Care

Tetanus is rare, serious, preventable

Screen, tetanus shots

Suicidal ideation/behavior more common

3 – 8.4% of ED visitors for other reasons also report suicidal ideation

The Perfect Depression Care Initiative

Dept of Psychiatry – Henry Ford Health System

Goal: No suicides

Debate: If zero is not the right number of suicides, then what is? One? Four? Forty?

Acceptable Failure Rate?

Programme resulted in 75% reduction in suicides

Results sustained over four years

Programme now prototype for redesign of outpatient mental health care

Acceptable Failure Rate?

Medical illnesses contribute to suicidal behavior in several ways: by precipitating a severe depression making an existing psychiatric illness worse, impairing judgment.

Between 25% and 70% of completed suicides were physically ill at the time of death, with physical illness believed to be a major contributing factor in some 11% to 51% of the cases.

Suicide Risk Factors in Primary Care

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High rates of depression are reported for patients with:

DiabetesCVDCOPDChronic pain Cancer, Lupus, Rheumatoid arthritis

Henk, Katzelnick, Kobak, Griest and Jefferson, 1996

Chronic Conditions

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80% of the time, people experiencing a first psychiatric illness see a general physician, not a mental health professional.

It has been estimated that between 25% and 30% of all ambulatory patients in general medicine have a diagnosable psychiatric condition.

Suicidal thoughts and feelings are one of the most common complications of untreated psychiatric illness. In general, psychiatric illness increases the risk of suicide 10 fold.

Suicide Risk Factors in Primary Care

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Untreated depression has been found in 60% of suicides worldwide.

Suicide occurs only rarely in the physically ill where a psychiatric illness is not also present.

Suicide Risk Factors in Primary Care

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Multiple studies reveal increased rates of depression in medical populations.

In patients with some chronic illnesses, prevalence rates are between 25% and 50%.

(Nesse and Finlayson, 1996)

Patients with chronic illnesses have been found to be at elevated risk for suicidal behaviours.

(Hughes & Kleepsies, 2001).

Depression in Primary Care

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Reduced serotonin function:Particularly suicides of high lethality or with considerable planning

Common clinical pathway for suicidal thinking, feeling and behaviours:

Depletion essential neurotransmitters DopamineSerotonin

General Neurobiology of Suicide

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Not functioning within normal limits

Diminished capacity for complex decision-making

Seriously impairedStrategic thinkingProblem-solvingGeneral executive function

More workdays lost to depression than back pain

Leading cause of absenteeism, poor performance and

decreased productivity

The Depressed Brain

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Highest co-occurring diagnosis in completed suicides: Alcohol addiction and MDD

Suicide risk for alcoholics equal to risk of MDD

Treatment significantly reduces suicide attempts

Alcohol Abuse and Suicide

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Suicide Risk in Primary Care

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Physicians detect only one in six patients who go on to kill themselves, yet warning signs of suicide crisis are known by others (family members, friends, co-workers, etc.).

One study of suicide risk detection found the odds of being asked if you were having thoughts of suicide by a GP was one in 20 (these were patients who made a suicide attempt within 60 days of their visit).

What Happens When You Don’t Ask

No query - suicide ideation, current planning or history?

“There’s no help here, they can’t even talk about it.”

Or failure to reassess?

“They know I’m suicidal but don’t really care.”

Multiple surveys of practicing clinicians found most lacked comprehensive suicide assessment training in graduate and professional programmes

“On-the-job training” results in lack of coherence in approaches to assessment and risk management

Most lack training in a multi-factor ecological model of suicide risk

Risk assessment mistakenly believed to be achieved by a summation of risk factors!

The Training Gap!

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Time (lack of – real or perceived)

Attitude

Stigma

Privacy (lack of)

Discomfort

Barriers to Suicide Assessment

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Failure to screen amounts to risk denial or risk blindness.

Suicide screening questions are direct questions that, if asked correctly, should lead to disclosure of suicidal thoughts, feelings, intent, and desire.

Further questioning will establish capacity to inflict self injury.

Don’t Ask, Don’t Tell

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As people become suicidal they also may become less self-disclosing about their suicidal thoughts and feelings, and also become less able to ask for help.

Yakunina,et al, 2010

The idea that if a patient is suicidal, "they will tell you" is no longer a safe clinical assumption.

Suicidal Communication

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Fear that full disclosure will lead to voluntary or even involuntary hospitalization

Fear that full disclosure of suicidal desire and intent will lead to humiliation and/or rejection.

Fear that the interviewer is neither benevolent nor trustworthy

Self-disclosure and suicide risk:Why not “tell all?”

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Suicidal Communications

Suicidal people send warning signs to people in their existing social network of relationships

Failure to respond to suicidal communications may accentuate a crisis

Steven Pinker – The Stuff of Thought

The need for indirect speech – the speaker says something he/she doesn’t mean literally knowing the hearer will interpret what was intended and correctly interpret what was meant.

All humans know how to “read between the lines” See, Politeness Theory (Politeness: Some Universals in Language Use – Brown & Levinson, 1987)

Context is everything….

Steven Pinker – The Stuff of Thought

Which of the following is a suicide warning sign?

Suicide warning signs require understanding the context in which they are observed

“I’m going to blow my brains out.”

“I just can’t stand it anymore.”

If either is a suicide warning sign, which statement requires immediate and urgent intervention?

Content vs. Context“I’m going to blow my brains out!”

Is sitting in your office in a psychiatric hospital

“I just can’t stand it anymore.”

Is standing well out of arm’s reach on the edge of 10-story building

Now… which person needed immediate and aggressive

intervention?

Indirect Suicidal CommunicationsProblem gambler caller: “I know it’s too late for me, but can you recommend a counselor for my wife?”

Crisis line caller: “Is 24 aspirins and a bottle of vodka lethal?”

Older woman: “I can’t take care of my two cats anymore, and where I’m going they can’t come. Could you tell me where the nearest animal shelter is?”

Teenager: “Everyone would be better off if I wasn’t around.”

Our Job?

To make hearers of suicidal communications, polite requests for rescue or for help understood so that positive actions can follow.

Practice/rehearsal with means (habituating to pain)

Verbal (written) threats & “dire warnings”

Non-fatal attempts/risky behavior/suspicions injuries

3rd party fear-for-safety reports

The road to suicide is festooned with warning signs…

What people sayDirect suicidal communicationsIndirect suicidal communications

What people doBehaviours indicating distressMood changes from baseline (increased anger, isolation, flat or depressed affect)

What people endureSituational stressorsSignificant lossUnwanted change in circumstancesLoss of freedom or independence

Clues and Warning Signs

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Official suicide warning signs

Consensus and literature based:Suicide threatsSeeking access to meansVerbal or written statement revealing desire to dieIncreased alcohol or drug useNo sense of purpose in lifeFeeling trapped with no way outWithdrawing from friends and familyGiving away prized possessions

Suicidal DesireNo reason for livingNo wish to carry onPassive suicide attempts

Not eatingNot taking needed meds

Wishing to make a suicide attemptFeeling trapped or hopelessFeeling intolerably alone

- Beck et al., 1997; Joiner et al., 1997, 2003

Outward expression of suicidal desire includes: Thinking about suicide Experiencing serious psychological pain Feeling hopelessness Feeling helplessness Feeling like a burden on others Feeling trapped with no way out Feeling intolerably alone

Suicidal Desire

Capacity for self-injuryPreparing for attempt Practicing behaviours at sub-lethal levelVia repeated exposure to self-inflicted injury or vicarious experience of painful injury, suicide capable people develop a kind fearlessness about dying by suicide.

- Tomas Joiner (2005)

Suicidal Capability

Suicidal capability is characterized by the following factors:

History of suicide attempts History of/current violence to others Exposure to/impacted by someone else’s death by suicide

Suicidal Capability

Available means of killing self/othersCurrent intoxication and frequent intoxication Acute symptoms of mental illness, e.g. dramatic mood change or psychotic symptomsExtreme agitation/rage, e.g. increased anxiety and/or decreased sleep

Suicidal Capability

Acquired Capacity for Self-Harm

Journey to SuicideAcquired Capacity for Self-Injury

Lethality of method and seriousness of intent increase with attempts.

Those with a history of suicide attempt have higher pain tolerance than others.

People who have experienced or witnessed violence or injury have higher rates of suicide – prostitutes, self-injecting drug abusers, people living in high-crime areas, veterans, physicians.

Acquired Capacity for Self-Injury

Acquired capacity for self-harm

DoctorsNursesAddictsSoldiersPoliceMalesTrauma exposedThose with a history of suicide attempt have higher pain tolerance than others.

The most challenging aspect of assessing immediate suicide riskIntent to act can vary according to a number of variables

The uncontrollable decisions of third parties, e.g., a man is left by a woman or is fired from his job

Suicidal Intent

Suicide intent can best be determined by exploring the following:

Is there…A suicide attempt in progress?A plan to hurt/kill self/other (method is known)? Evidence of preparatory or practice behaviors?Expressed intent to die by suicide?

Suicidal Intent

Social supports Planning for the future Engagement with helper Ambivalence for living/dying Core values/beliefs Sense of purpose (in life)

Buffers against Suicide

A suicide screen is indicated when there is:

A positive screen for depression or other psychiatric illness A positive screen for substance abuse Admitted or suspected deliberate self-harm such as cutting, self-poisoning, including alcohol poisoning and drug overdose A known history of a previous suicide attempt or deliberate self-harm behavior

Who to Screen

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A suicide screen is indicated when there is:A recent suicide of a family member or significant other A current or known history of trauma or abuse, including domestic violence Recent diagnosis of major physical illness, especially if it is terminal or involves serious chronic pain

Who to Screen

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Hopelessness about the consequences of a significant injury or traumatic loss, especially if patient is socially isolated.

The patient who has experienced recent relational or social loss such as the death of a loved one or unwanted or unexpected unemployment

Who to Screen

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Because youth 15-25 years of age represent a high risk group, routine screens are indicated in any setting, but especially in ED and primary care.

Yakunina, E., Rogers,J., Waehler,C. &

Werth, J.L. (2010).

Screening Youth

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Ambivalence exists until the moment of deathThe final decision rests with the individualReduce risk factors and you reduce riskEnhance protective factors and you reduce risk

Basic Concepts About Suicide

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Suicide Crisis Episode

Stable Stable

Days HoursYears Years

Crisis Peaks

Crisis Begins

Hazard Encountered

Risk Imminent

Crisis Diminishes

Plus or minus three weeks60

Risk exists in multiple domains across the life-spanFundamental risks:

BiologicalPersonal/PsychologicalEnvironment

Acute or proximal risk factorsTriggers – the last straw!

We all have a baseline level of riskTriggers tip one into suicidal crisis

Suicide Risk: An Ecological Model

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Environmental

PersonalPsychological

Biological

Risk changes from day to day, often moment to moment

Complex and changing

Defies the use of a check list approach re: determining risk and lethality

Suicide Risk: An Ecological Model

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Psychic suffering (Psychache)Unbearable mental anguishPsychic turmoil

HopelessnessMost common psychological

state for completed suicides

Cognitive constrictionTunnel visionDelusions of gloom and doom

The Nature of Suicide

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Mediate riskCareful weighing of risk versus protections results in lethality profileProtective factors can and should be enhanced!This “Wall of Resistance” is essential to safety planning

Protective Factors

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The absence of suicidal ideation does not equal no suicide risk

The denial of suicide ideation does not equal no suicide risk

Clinical care admission criteria often require specific suicide planning and/or a previous attempt – these requirements for admission are not based on scientific standards

Things to Keep in Mind

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Given extensive research evidence we now know more about who is at especially high risk for attempting or completing suicide. It is high time we apply what we know by routinely screening patients for suicide risk.

Understanding Suicide Risk

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Interview formatGets beyond standard check list approachUncovers full picture of risk and protectionCovers information other assessment systems missBuilds in safety planningFar more accurate assessment of lethality

QPR Triage System

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Questions - Discussion

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Dr. Louisa WalkerWalker Psychology & ConsultingT: +64 9 448 3805F: +64 9 448 3855E: louisa.walker@qpr.org.nz

QPR New Zealand website: www.qpr.org.nz