Primary Care Recognition and Management of Suicidal Behavior in

JuvenilesJeffrey I. Hunt, MDJeffrey I. Hunt, MD

Alpert Medical School of Brown UniversityAlpert Medical School of Brown University

The Scope of the Problem

33rdrd leading cause of death among 10-14 and leading cause of death among 10-14 and 15-19 year olds. 15-19 year olds. (Anderson, 2002)(Anderson, 2002)

1 out of 5 teenagers in the US seriously 1 out of 5 teenagers in the US seriously considers suicide. considers suicide. (Grunbaum et al., 2002)(Grunbaum et al., 2002)

1600 US teenagers die by suicide each year.1600 US teenagers die by suicide each year.

Rates of Suicidal Behaviors

Youth risk behavior study (YRBS) Youth risk behavior study (YRBS) conducted by CDC indicated:conducted by CDC indicated: 19% of HS students contemplate suicide19% of HS students contemplate suicide 15% made specific plans15% made specific plans 8.8% attempted suicide8.8% attempted suicide 2.6% made medically significant attempts2.6% made medically significant attempts

Overall, decrease in youth suicides in past Overall, decrease in youth suicides in past decade. decade. (JAACAP April, 2003)(JAACAP April, 2003)

The Challenge for Primary Care

Many suicidal young people seek medical care in the month Many suicidal young people seek medical care in the month preceding their suicidal behavior, fewer than half of doctors preceding their suicidal behavior, fewer than half of doctors reported that they routinely screen for suicide risk reported that they routinely screen for suicide risk (Pfaff, 1999; (Pfaff, 1999; Frankenfield, 2000)Frankenfield, 2000)

Need for trainingNeed for training 72% of 600 family physicians and pediatricians in 72% of 600 family physicians and pediatricians in

NC had prescribed an SSRI but only 8% had NC had prescribed an SSRI but only 8% had adequate training and only 16% said they were adequate training and only 16% said they were comfortable treating depression comfortable treating depression (Voelker, 1999)(Voelker, 1999)

Educational approaches for primary care MDs have led to Educational approaches for primary care MDs have led to reductions in suicide rate in adult studies reductions in suicide rate in adult studies (Rutz, 1992)(Rutz, 1992)

Clinical Characteristics of Teens Who Commit Suicide Most Common DiagnosesMost Common Diagnoses

Mood Disorder 60%Mood Disorder 60% Antisocial Disorder 50%Antisocial Disorder 50% Substance Abuse 35%Substance Abuse 35% Anxiety Disorder 27%Anxiety Disorder 27%

Gould et al., 1996

Clinical Features of Suicide Attempt vs. Completed Suicide

Completers more likely than attempters:Completers more likely than attempters: have bipolar disorderhave bipolar disorder have firearm in the homehave firearm in the home have high suicidal intenthave high suicidal intent have dual diagnosis of mood and non-have dual diagnosis of mood and non-

mood disordermood disorderBrent et al, 1993; Gould et al., 1996

Onset of Any Psychiatric Symptoms Before a Suicide Time before deathTime before death > 12 months 63%> 12 months 63% 3-12 months 13%3-12 months 13% < 3months 4%< 3months 4%

Shaffer et al., 1996

Most suicides preceded by a stressful event disciplinary crisisdisciplinary crisis relationship problemrelationship problem humiliationhumiliation contagioncontagion

Gould et al., 1996

Onset of Ideation Before a Teen’s Suicide Attempt(N=29)

< 30 minutes 69%< 30 minutes 69% 39-119 minutes 24%39-119 minutes 24% > 2 hours 7%> 2 hours 7%

Negron et al., 1997

SuicideFacts

AgeAge Uncommon in childhood, early adolescents.Uncommon in childhood, early adolescents. Increases markedly in late teens to 20Increases markedly in late teens to 20’’s.s.

GenderGender Suicide attempts more common among Suicide attempts more common among

femalesfemales Completed suicides 5X more among males.Completed suicides 5X more among males. Firearm and strangulation in males vs. OD in Firearm and strangulation in males vs. OD in

females.females.

Suicide Facts

Ethnicity Ethnicity More common among Caucasians than African-More common among Caucasians than African-

Americans.Americans. Highest among native Americans and lowest among Highest among native Americans and lowest among

Asians/ Pacific- Islanders.Asians/ Pacific- Islanders. Motivation and Intent Motivation and Intent

Expression of extreme distressExpression of extreme distress 2/3 attempt suicide for reasons other than to die.2/3 attempt suicide for reasons other than to die. Result of an impulsive act, desire to influence others, Result of an impulsive act, desire to influence others,

gain attention and escape a noxious situation.gain attention and escape a noxious situation.

Suicide Facts

Highest in western states and AlaskaHighest in western states and Alaska Firearms most common method Firearms most common method

rural: firearmsrural: firearms urban: jumping from a heighturban: jumping from a height suburban: asphyxiation by COsuburban: asphyxiation by CO

Ingestions in 15-24 year olds: 16% of Ingestions in 15-24 year olds: 16% of female suicides, 2% of male suicidesfemale suicides, 2% of male suicides

Risk Factors

Psycho-pathologyPsycho-pathology 90% of youth suicides have at least one 90% of youth suicides have at least one

major psychiatric disorder. major psychiatric disorder. (Beautrais, 2001)(Beautrais, 2001)

Depression, substance abuse and aggressive Depression, substance abuse and aggressive or disruptive behaviors very common.or disruptive behaviors very common.

49% – 64% of all adolescent suicide victims 49% – 64% of all adolescent suicide victims have depressive disorders.have depressive disorders.

10% - 15% of all patients with bipolar 10% - 15% of all patients with bipolar disorder commit suicide.disorder commit suicide.

Risk Factors Immediate Risk elevated by severe anxiety Immediate Risk elevated by severe anxiety

or agitation or agitation Prior suicide attempt is a strong predictor of Prior suicide attempt is a strong predictor of

completed suicide.completed suicide. Serotonin function abnormalities.Serotonin function abnormalities.

Reduced serotonin metabolites in the Reduced serotonin metabolites in the brain and CSF of suicide victims.brain and CSF of suicide victims.

Risk Factors

Family factorsFamily factors Parental psycho-pathology particularly Parental psycho-pathology particularly

depression and substance abuse.depression and substance abuse. Family history of suicide.Family history of suicide. Parental conflicts / divorce.Parental conflicts / divorce. Parent – child relationshipParent – child relationship

Risk Factors

Socio-environmental factors.Socio-environmental factors. Life stressors (interpersonal losses).Life stressors (interpersonal losses). Physical / Sexual abuse.Physical / Sexual abuse. School / Work problems.School / Work problems. Lack of meaningful peer relationships.Lack of meaningful peer relationships. Access to firearms.Access to firearms. Chronic / Multiple physical illness.Chronic / Multiple physical illness.

Protective Factors

Family cohesionFamily cohesion ReligiosityReligiosity Ability to form therapeutic allianceAbility to form therapeutic alliance

Secular Trends

Suicide rate decliningSuicide rate declining Possible reasons:Possible reasons:

Increase in prescriptions of antidepressantsIncrease in prescriptions of antidepressants firearm legislationfirearm legislation Firm conclusions not possibleFirm conclusions not possible

Suicide Risk Assessment One of the most complex, difficult One of the most complex, difficult

and challenging clinical tasks in and challenging clinical tasks in psychiatry psychiatry

Forecasting the weather as Forecasting the weather as metaphor for suicide risk metaphor for suicide risk assessment (Simon, 1992) assessment (Simon, 1992)

suicide risk is time suicide risk is time driven assessmentsdriven assessments

short term short term assessments more assessments more

accurateaccurate Like a weather forecast suicide Like a weather forecast suicide

risk assessments need to be risk assessments need to be updated frequentlyupdated frequently

Suicide Risk Assessment

Needs to be systematicNeeds to be systematic Checklists helpful but not sufficientChecklists helpful but not sufficient ““Contracting for safetyContracting for safety”” does not eliminate does not eliminate

need for risk assessmentneed for risk assessment Documentation of clinical decision making Documentation of clinical decision making

is importantis important

Assessment of Suicidal Behavior

Assessment of the AttemptAssessment of the Attempt type of method type of method potential lethality potential lethality degree of planning involveddegree of planning involved degree of chance of interventiondegree of chance of intervention previous suicide attemptsprevious suicide attempts pervasive suicidal ideationpervasive suicidal ideation availability of firearms or lethal medicationsavailability of firearms or lethal medications motivating feelingsmotivating feelings

Assessment of Underlying Conditions Psychiatric diagnosesPsychiatric diagnoses Social/environmental factorsSocial/environmental factors Cognitive distortionsCognitive distortions Coping styleCoping style History of family psychopathologyHistory of family psychopathology Family discord or other life event stressesFamily discord or other life event stresses

Acute Management

Identify all risk factorsIdentify all risk factors Identify resources that potentially reduce Identify resources that potentially reduce

riskrisk If risk outweighs available resources If risk outweighs available resources

consider increased level of careconsider increased level of care

Factors Indicating Hospitalization GenderGender: All males over : All males over

age 12age 12 Mental StateMental State: Depression, : Depression,

psychosis, hopelessness, psychosis, hopelessness, social withdrawal, social withdrawal, persisting SI, Intoxicationpersisting SI, Intoxication

Nature of AttemptNature of Attempt: : Potentially lethal attemptPotentially lethal attempt

Past History: Past History: previous previous suicide attempts and/or suicide attempts and/or history of volatile and history of volatile and unpredictable behaviorunpredictable behavior

Home Background:Home Background: absence of caring or absence of caring or responsible settingresponsible setting

Shaffer et al., 2000

Minimum Steps to Take Before Discharge from Office or ED Always talk to the parent or caregiver to Always talk to the parent or caregiver to

corroborate the adolescentcorroborate the adolescent’’s history and to s history and to establish treatment alliance and plan to maintain establish treatment alliance and plan to maintain safetysafety

Secure any firearms and medicationSecure any firearms and medication Concrete and precise follow-up appointment with Concrete and precise follow-up appointment with

emergency telephone numbersemergency telephone numbers No-suicide contract (helpful but not sufficient)No-suicide contract (helpful but not sufficient)

Shaffer, et al., 2000

Treatment: Inpatient & Partial Hospitalization No evidence that exposure to other suicidal No evidence that exposure to other suicidal

psychiatric inpatients increases the risk of psychiatric inpatients increases the risk of suicidal behaviorsuicidal behavior

Stabilize mood Stabilize mood Address environmental stressesAddress environmental stresses Address clearly dysfunctional family Address clearly dysfunctional family

patterns or parental psychiatric illnesspatterns or parental psychiatric illness

Treatment Approaches

Problem oriented Problem oriented Cognitive Behavior TherapyCognitive Behavior Therapy Dialectical Behavior TherapyDialectical Behavior Therapy MedicationMedication Family TherapyFamily Therapy Group TherapyGroup Therapy

Suicide Prevention

Crisis ServicesCrisis Services Educational approachesEducational approaches Case FindingCase Finding Professional educationProfessional education

Community-Based Suicide Prevention Crisis hot linesCrisis hot lines

little research fails to show impactlittle research fails to show impact Method restrictionMethod restriction

gun-security laws little impactgun-security laws little impact raised minimum drinking age significant impactraised minimum drinking age significant impact

Indirect case finding through educationIndirect case finding through education fails to increase help-seeking behavior and fails to increase help-seeking behavior and

activates SI in previously suicidal adolescentsactivates SI in previously suicidal adolescents

Community-Based Suicide Prevention Direct case findingDirect case finding

cost-effective and highly sensitive cost-effective and highly sensitive screening in a non-threatening way at risk youth in high screening in a non-threatening way at risk youth in high

schools, detention centers, etc.schools, detention centers, etc. www.teenscreen.orgwww.teenscreen.org

Media CounselingMedia Counseling CDC and AFSP guidelines regarding risk of prominent CDC and AFSP guidelines regarding risk of prominent

coverage of youth suicidecoverage of youth suicide TrainingTraining

educating primary care providers regarding identification educating primary care providers regarding identification and treatment of mood disordersand treatment of mood disorders

Legal Issues in Suicide

Assessment versus predictionAssessment versus prediction No standard of exists for the No standard of exists for the predictionprediction of of

suicidesuicide standard exists requiring standard exists requiring adequate assessment of adequate assessment of

suicidesuicide Courts analyze suicide cases to determine whether Courts analyze suicide cases to determine whether

suicide was suicide was foreseeableforeseeable Contemporaneous Contemporaneous documentation documentation of suicide risk of suicide risk

assessment is vital assessment is vital

Team approach

Know the mental health clinicians with whom you Know the mental health clinicians with whom you are workingare working

Establish regular means of communicating about Establish regular means of communicating about your mutual patientsyour mutual patients

Identify with the patient and parents who is to be Identify with the patient and parents who is to be first point of contactfirst point of contact

Document discussions with collaboratorsDocument discussions with collaborators

Summary

Suicidal behavior in adolescents is very Suicidal behavior in adolescents is very commoncommon

Primary care clinicians often have contact Primary care clinicians often have contact with suicidal adolescents prior to them with suicidal adolescents prior to them making attemptsmaking attempts

Systematic and timely risk assessments can Systematic and timely risk assessments can reduce morbidity and mortality reduce morbidity and mortality